Exercise is 'most effective' method of preventing lower back pain

“Exercise is the best medicine to banish back pain and stop people taking sick days,” reports the Daily Mirror. While this may be true, the research in question did not look at treatments for existing back pain.

In fact, the researchers reviewed previously gathered evidence about what helps prevent, not treat, lower back pain. Also, the evidence that exercise reduced sick leave was judged to be poor quality.

The review found exercise with or without education about the back and back pain was the most likely intervention to prevent lower back pain. This included core muscle strengthening, stretching and aerobic exercise carried out over a period of about 3 to 18 months.

Education alone, back belts, shoe insoles, and ergonomics (changes to objects such as chairs to make them more “back friendly”) were not found to prevent lower back pain. But this finding was based on low-quality studies, so it should be viewed with caution.

Some of these interventions, such as shoe insoles, were only studied in army recruits, so the results may not be applicable to other population groups.

These limitations aside, exercise would seem to be the best option based on the available evidence. Exercise is known to offer a range of benefits. This review suggests preventing lower back pain is another potential benefit. 

Where did the story come from?

The study was carried out by researchers from the University of Sydney and Macquarie University, both in Australia, and the Federal University of Minas Gerais in Brazil. No external funding was reported.

It was published in the peer-reviewed Journal of the American Medical Association (JAMA) Internal Medicine on an open access basis, so you can read it for free online.

The Mirror, the Daily Express and the Daily Mail reported the story inaccurately. All three papers focused on the treatment of back pain, rather than prevention. While exercise may well help treat the symptoms of lower back pain, the study did not consider this issue.

They also did not make it clear the majority of the studies were poor quality, which makes the results less reliable. 

What kind of research was this?

This was a systematic review of all of the relevant randomised controlled trials (RCTs) that have assessed prevention strategies for lower back pain. Statistical pooling of results (meta-analysis) was carried out where possible.

The research was conducted according to international standards for systematic reviews. However, the quality of the results is also dependent on the quality of the underlying studies.  

What did the research involve?

A search was performed of four medical databases, including the Physiotherapy Evidence Database, to look for RCTs on the prevention of lower back pain.

Two reviewers sifted the results according to strict inclusion criteria, and a third researcher was consulted in cases of disagreement.

Eligible trials needed to fit the following inclusion criteria:

• they included people without lower back pain at the start of the study or without at least one of the outcomes the study was interested in – for example, some participants might have mild lower back pain, but still be able to work if the study was looking at work absence
• they aimed at preventing future episodes of lower back pain
• they had an intervention group that was compared with no intervention, placebo (an ineffective “dummy” intervention) or minimal intervention
• they followed participants up to identify any new episode of lower back pain or time off work for lower back pain

The relevant trials were assessed for quality using standard assessment systems. Trials measuring similar interventions were pooled together in the meta-analyses using appropriate statistical techniques.

Results from the studies were grouped into short-term results (findings up to a year) and long-term results (findings after a year). 

What were the basic results?

The review included 21 RCTs involving 30,850 people. Several studies were performed in the armed services. Others included airline employees, postal workers, nurses and office workers.

The main results for each intervention were as follows.

Exercise plus education:

• moderate-quality evidence this reduces the risk of lower back pain by 45% in the short term (relative risk [RR] 0.55, 95% confidence interval [CI] 0.41 to 0.74) and low-quality evidence it does in the long term (RR 0.73, 95% CI 0.55 to 0.96)
• low-quality evidence it has no effect on preventing sick leave as a result of lower back pain in the short term (RR 0.74, 95% CI 0.44 to 1.26) or long term

Exercise alone:

• low-quality evidence this reduces the risk of lower back pain by 35% in the short term (RR 0.65, 95% CI 0.50 to 0.86) but very low-quality evidence it does not in the long term (RR 1.04, 95% CI 0.73 to 1.49)
• low to very low-quality evidence this reduces risk of sick leave as a result of lower back pain by 78% in the long term (RR 0.22, 95% CI 0.06 to 0.76)

Education alone:

• moderate-quality evidence this has no effect on reducing the risk of lower back pain in the short term (RR 1.03, 95% CI 0.83 to 1.27) or long term
• very low-quality evidence this has no effect on risk of sick leave as a result of lower back pain in the short term (RR 0.87, 95% CI 0.47 to 1.60)

Back belt:

• very low-quality evidence this has no effect on reducing the risk of lower back pain in the short term (RR 1.01, 95% CI 0.71 to 1.44) or long term
• low-quality evidence this has no effect on risk of sick leave as a result of lower back pain in the short term (RR 1.44, 95% CI 0.73 to 2.86)

Shoe insoles:

• low-quality evidence this has no effect on risk of lower back pain in the short term (RR 1.01, 95% CI 0.74 to 1.40)  

How did the researchers interpret the results?

The researchers concluded that, “Exercise in combination with education is likely to reduce the risk of LBP [lower back pain] and that exercise alone may reduce the risk of an episode of LBP and sick leave due to LBP, at least for the short-term.”

They said that, “The available evidence suggests that education alone, back belts, shoe insoles, and ergonomics do not prevent LBP”, and it is “uncertain whether education, training, or ergonomic adjustments prevent sick leave due to LBP because the quality of evidence is very low”.

Conclusion

This systematic review and meta-analysis found exercise reduces the risk of lower back pain and sick leave as a result of lower back pain.

The types of exercise studied included improving core strength (abdominals and lumbar region), leg and back muscle strengthening, stretching and cardiovascular workouts.

Although the researchers concluded that, “education alone, back belts, shoe insoles, and ergonomics do not prevent LBP”, this is based on limited low-quality evidence.

However, these interventions might prove effective for individuals in situations that have not been studied, or if tested in better-quality trials. For example, the shoe insoles were only studied on army recruits, so the results may not be generalisable to the general population.

The review also purely focused on people who have not already experienced anything other than mild lower back pain, so it does not tell us whether these interventions are effective strategies for managing the condition.

For people with non-specific lower back pain, giving education advice and advising people to stay physically active and exercise are part of the early management currently recommended by the UK’s National Institute for Health and Care Excellence (NICE).

The evidence for the effect of each intervention on the risk of sick leave for lower back pain was based on between one and three small trials, which limits the reliability of the results.

These limitations aside, the study adds to the weight of evidence that one of the many benefits of exercise may be preventing back pain. Additionally, there is expert consensus it can also be effective at relieving the symptoms of back pain in most people – though, as mentioned, the study did not look at this issue.

Get more exercises recommended for back pain.

Links To The Headlines

The best cure for back pain revealed – but you’re not going to like it. Daily Mirror, January 11 2016

Daily walk could help alleviate crippling back pain, new study claims. Daily Express, January 12 2016

The best way to banish back pain? Regular exercise: Working out is ‘far more effective than any other treatments’. Mail Online, January 12 2016

Links To Science

Steffens D, Maher CG, Pereira LSM, et al. Prevention of Low Back Pain – A Systematic Review and Meta-analysis. JAMA Internal Medicine. Published online January 11 2016