People are increasingly advised to be physically active and engage in exercise given its benefits for many aspects of physical and mental health. For example, it is now known that being physically inactive is worse for your health than smoking, diabetes and obesity combined! However, for a lot of people who experience low back pain, there is often a hesitation to exercise. This frequently means that exercise is overlooked in managing low back pain, often in the favour of treatments like medications and surgery. Many think the experience of low back pain is always a sign of damage and fear that exercise may cause them more problems. However this is not the case!
Movement is key to recovery from back pain
There is scientific evidence that prolonged rest and avoidance of activity for people with low back pain actually leads to people in pain becoming even more disabled. For example, prolonged bed rest is unhelpful, and is linked with higher levels of pain, greater disability, poorer recovery and longer absence from work. In fact, it appears that the longer a person stays inactive because of back pain, the worse the pain becomes.
In the first few days of a new episode of low back pain, avoiding aggravating activities may help to relieve pain, similarly to pain in any other part of the body, such as a sprained ankle. However, there is evidence that staying as active as possible and returning to all usual activities gradually, including work, hobbies and exercise, is important in aiding recovery from back pain. People often move differently and more slowly in the first few days of having back pain. This is normal, like limping after an ankle sprain. However, many people continue to move differently and slowly for too long after the onset of low back pain. This altered movement can be unhealthy in the long term and can actually result in people feeling more stiff and tense.
Should people with low back pain avoid certain movements?
When people have low back pain, they are often told that activities involving lifting, bending, twisting and high impact (e.g. jogging, running) are dangerous and should be avoided. This is based upon a misunderstanding of the research in this area. For example, there is some research suggesting that a person can get back pain (sometimes) if they lift something awkwardly or lift something that is heavier than they would usually lift. Similarly, if a person has low back pain, activities like lifting and running might be more sore than usual. This, however, does not mean that the activity is dangerous or should be avoided. While lifting, bending or twisting awkwardly could initially give a person back pain, bending and lifting is normal and should actually be practised to help strengthen the back, similar to returning to running and sport after spraining an ankle. Overall, using your back normally (to twist, bend, run, etc.) will make it stronger, more flexible and healthier in the long run.
Benefits of exercise for low back pain and general health
Scientific evidence is now showing that exercise can significantly prevent the recurrence of an episode of low back pain. It also helps reduce low back pain and disability levels, when people start gradually and stick with it in the long-term. Furthermore, the average results for exercise are on par (or better) than treatments like drugs or surgery; with fewer side effects and lower costs. Regular exercise has the following benefits for pain as well as general health:
- Reduces muscle tension and nervous system sensitivity, by activating our own body’s natural pain killers (e.g. endorphins)
- Improves mood
- Increases muscle strength and flexibility
- Improves sleep quality
- Reduces fatigue, tiredness and increases energy levels
- Prevent and reduce stress and anxiety
- Reduces the risk and progression of major life threatening conditions such as heart disease, chest and lung problems, type 2 diabetes, and neurological conditions (e.g. multiple sclerosis)
- Helps with weight control when supplemented with a healthy diet
Scientific research is now showing that low back pain can be driven by many related factors such as lack of exercise, sleep, mood, stress, improving these factors by increasing your levels of exercise could significantly help your pain.
Which type of exercise is best for back pain and how much should I do?
Contrary to popular belief, most types of exercise are of some benefit, with no single type clearly being the best at reducing pain or improving function for people with a low back problem. That is good news because you do not need to sign up for the latest (and normally expensive) exercise fad to see results. People should feel comfortable choose simple options like walking, running, cycling, swimming, yoga, and pilates; knowing that all seem to be safe and equally effective for low back pain.
The amount of exercise you do is probably more important than the type of exercise. The greatest gains are got when an inactive person starts doing any exercise, but getting more than 150 minutes a week has the greatest health benefits. Doing the exercises in a relaxed manner (e.g. moving normally, not guarding and not breath-holding) and progressing them gradually may also be important.
Most importantly, people should do an exercise or activity that they enjoy, that is affordable and easy to access (e.g. not too far or difficult to fit in to your daily routine). This will increase the chances of sticking with the exercise in the long-term.
Is exercise always the answer for low back pain?
Each person’s low back pain is different and some may benefit from more emphasis on other aspects of their health and lifestyle. These may include things like diet, sleep and stress management. However, even in these cases, exercise can be helpful and should be encouraged.
Is exercise safe and how to get started?
When you are in pain, starting exercise can be very hard. Underused muscles get sore more quickly than healthy muscles. Feeling stiff and sore after exercise does not indicate harm or damage to your body – it simply reflects your body not being used to the activity. You can start by doing some gentle activity and then increase your levels when you feel confident to do so. Exercise is very safe, and often of greatest benefit in people with poor health. If you are in doubt about whether you should exercise due to ill health or any other concerns, speak to your doctor/GP or other health professional (e.g. a physiotherapist) and they can check if exercise is safe for you. If you feel you need supervision during exercise to increase your confidence, a health professional (e.g. a physiotherapist, personal trainer or strength and conditioning coach) can help you form an exercise plan, which will involve increasing your activity levels gradually and when you are happy to do so.
Overall, exercise is medicine! No drug or tablet delivers the diverse range of benefits as exercise. Unfortunately, it is often overlooked or not given as part of the management of low back pain. There are a range of exercises available, and all low back pain is not the same. So if you have tried in the past and it has not helped you may need some help from a physiotherapist or other health care professional to set you up on a specific program to meet your needs.
3 Top Tips for picking the right kind of exercise
- Pick an exercise that you enjoy (Exercise that’s fun, gets done!)
- Pick an exercise or activity that is cheap enough that you can afford to maintain it in the long term.
- Pick an exercise or activity that you can easily access (eg. not too far away or difficult to fit in with your daily schedule)
Authors: Dr Mary O’Keeffe and Dr Kieran O’Sullivan (University of Limerick, Ireland), Professor Chris Maher (The George Institute for Global Health, Sydney Medical School, University of Sydney, Australia)
About Dr Mary O’Keeffe
Mary is a physiotherapist and low back pain researcher who has just received her PhD in the University of Limerick, Ireland. Her PhD research examined the effectiveness of a patient-centred multidimensional treatment for persistent low back pain. She also works in clinical practice in Midwest Physiotherapy Clinic, Castletroy, Co. Limerick.
About Dr. Kieran O’Sullivan
Dr Kieran O’Sullivan is a lecturer and low back pain researcher at the University of Limerick, Ireland. In addition to his teaching and research at the University of Limerick, he works in clinical practice as a Specialist Musculoskeletal Physiotherapist in Limerick, Ireland. He promotes evidence-based assessment and management of persistent pain through www.pain-ed.com.
About Professor Chris Maher
Chris is a Professor of Physiotherapy in Sydney Medical School, The University of Sydney and Director of the Musculoskeletal Division at The George Institute for Global Health. He has been awarded 124 grants and fellowships totalling ~ $AUD39 million. He leads a research division focusing on the management of musculoskeletal conditions in primary care and community settings. His main research evaluates the primary care management of low back pain.