It probably won’t surprise you that research generally supports the idea that exercising and being fit can help prevent lower back problems.
But what might surprise you are the reasons why it seems to help.
It’s not what you think!
Yes, exercise prevents back problems.
In 2009, an article was published in The Spine Journal that reviewed research on the prevention of back problems 1. After a comprehensive review, only 20 out of 185 articles fulfilled their criteria as relevant, high-quality research. So what did they find?
- The only thing that consistently prevented low back problems was exercise.
- Effect sizes huh? were moderate, which is actually pretty good.
- What wasn’t effective? Some very popular ideas:
- Education alone.
- Lumbar (back) supports.
- Shoe orthoses (inserts).
- Reduce lifting loads.
Of course, there are limitations to this research. For instance: what do they mean by education? We’ve seen before that learning how pain works can actually prevent and reduce low back pain in some people. Typically, education for preventing back pain involves “how to avoid hurting your back” videos and classes – but not pain science education. Maybe it’s all about what type of education people receive!
Types might be important? Then what about exercise?
That actually brings to the most important point:
Does it matter what type of exercise people do to prevent back problems?
Apparently not – the research studies on exercise used very different protocols. Some included everything from strengthening + endurance + flexibility + education, while one study simply consisted of “passive extension”. No matter what type of exercise was performed, it generally helped prevent back problems.
The authors of the 2009 review conclude in the final line of their abstract:
“The varied successful exercise approaches suggest possible benefits beyond their intended physiologic goals.”
That’s a powerful statement. The “physiologic goals” of exercise (to improve strength, endurance, flexibility, and even coordination) are probably not the same reasons it has an effect on pain – it’s probably due to other benefits!
Exercise isn’t good for preventing or reducing pain because it “strengthens / conditions your core”, or “improves spinal mobility / flexibility / stability”, or even “improves motor control”.
Core stability experts – don’t get mad at me – check the research: when these highly specialized approaches are formally studied, they are never shown to be any better than “general exercise”. 2, 3, 4, 5
These “physiologic goals” might be important for health, physical function, and athletic performance, but they do not ‘prevent’ or ‘treat’ pain.
Then why does exercise help with pain?
You might be asking yourself: so why does exercise help with pain?
Science to the rescue!
A 2012 article has been published in the journal Pain that reviewed pain perception in athletes 6. They looked at how athletes differ from normally active people when it comes to their pain threshold and pain tolerance. So what did they find?
- Athletes tend to have higher pain tolerance than normally active people.
- However, their pain threshold didn’t appear to be any better.
So it wasn’t that athletes feel less pain – it’s just that they deal with it better. And this was true for a variety of different types of exercise.
It should be noted that we’re not talking about improved pain tolerance during or immediately after exercise (often attributed to increases in adrenaline, endorphins, or endocannabinoids). We’re talking about pain tolerance in general.
So why do athletes tolerate pain better?
There are a lot of potential reasons – and the authors of the study mention the fact that pain tolerance is strongly influenced by “psycho-social factors”. For example, pain acceptance and coping may be improved through exercise. Exercise may also reduce ‘kinesiophobia’ – a fear of movement, perhaps through graded exposure, and teaching people that it’s okay to move when they have pain.
Of course, it’s probably quite a bit more complicated than that, and there are likely many reasons why exercise is good for pain besides just improved tolerance.
Either way, it seems clear that exercise is good for pain because of its complex effects on biochemistry, neurophysiology, and psychology.
Not because it puts you back together like humpty dumpty.
Exercise of any sort probably has its effect on pain through psychology, neurophysiology and biochemistry – but not strength, flexibility, alignment, or stability.
This is important to understand so that we keep asking the right questions, keep doing good research, and ultimately help people with their pain.
1. Bigos SJ, Holland J, Holland C, Webster JS, Battie M, Malmgren JA. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J. 2009 Feb;9(2):147-68. Review. PubMed PMID: 19185272.
2. van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):193-204. Review. PubMed PMID: 20227641.
3. Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J. 2012 Apr;21(4):575-98. Epub 2011 Nov 10. PubMed PMID: 22072093; PubMed Central PMCID: PMC3326132.
4. Mannion AF, Caporaso F, Pulkovski N, Sprott H. Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. Eur Spine J. 2012 Jan 24. [Epub ahead of print] PubMed PMID: 22270245.
5. Mannion AF, Dvorak J, Taimela S, Müntener M. [Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance]. Schmerz. 2001 Dec;15(6):468-73. German. PubMed PMID: 11793153.
6. Tesarz J, Schuster AK, Hartmann M, Gerhardt A, & Eich W (2012). Pain perception in athletes compared to normally active controls: A systematic review with meta-analysis. Pain, 153 (6), 1253-62 PMID: 22607985