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How Exercise “Really” Prevents Low Back Pain (Probably)

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.

Pretty interesting!

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.


CONCLUSIONS:

Exercise of any sort probably has its effect on pain through psychology, neurophysiology and biochemistry – but not strength, flexibility, alignment, or stability.

Those things may still be important. But pain is complex. It’s not ’caused’ by damage, and it must be treated with many factors in mind. See the ‘Pain Education‘ section of this site.

This is important to understand so that we keep asking the right questions, keep doing good research, and ultimately help people with their pain.


References:

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.

ResearchBlogging.org6. 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

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    15 Responses to How Exercise “Really” Prevents Low Back Pain (Probably)

    1. Kenny says:

      Tony,

      Just wanted to say, as a current DPT student, I love reading your blog posts. They are always very informative, carefully researched and well written.

      I had just read an article today comparing Graded Activity and Motor Control interventions in people with chronic LBP. It was found that both were effective in decreasing pain and disability, but neither one was found to be “superior” to the other. Intriguing results, especially in the context of your blog post.

      It is interesting to see more and more literature suggesting that no one exercise approach is superior to another in chronic LBP. Makes you wonder what is most important in creating good clinical outcomes with that population? Could patient expectations (do they buy into the treatment? do they trust the clinicians expertise and ability to treat their pain?) and pain science/education be more important than whether you focus on the motor control of TrA and multifidus or a graded exposure to eliminate kinesiophobia?

      • Tony Ingram says:

        Hi Kenny,

        Thanks so much! Really appreciate the feedback.

        I’ve been thinking about the same things lately. I wonder if we need to stop fancying ourselves as ‘mechanics’ for human bodies – fixing stuff. Instead, we need to work on being good ‘therapists’ – being empathetic, reassuringly informative, and truly understanding the patient and their problem.

        We still need a thorough understanding of exercise science, anatomy, physiology, biomechanics, pathology, pain science – you name it. But not because we are to have specific answers and prescriptions, but to guide clients through their recovery effectively.

        Sometimes I feel disillusioned by all the research showing things to be no better than whatever, but then I realize that I’m becoming more effective because now I know what NOT to do! Plus I don’t waste money on silly expensive courses in hopes of simply expanding my ‘bag of tricks’.

        Tony

        • Kenny says:

          I agree. I think Joel Bialosky is doing a lot of interesting stuff in regards to the mechanisms of manual therapy. Is it restoring mobility to a hypomobile segment, or is it more of a neurophysiological response? It certainly feels like a lot of physical therapy ideas are being turned upside down

          • Tony Ingram says:

            I like Bialosky’s work too. Totally agree about ideas being turned upside down, but in the end, it’s a good thing.

            Therapists just need to get over the cognitive dissonance! Stay humble and don’t be certain of anything. Personally, I enjoy continuing to learn. I try my best to admit when I’m wrong!

        • Jay says:

          “Instead, we need to work on being good ‘therapists’ – being empathetic, reassuringly informative, and truly understanding the patient and their problem.”

          I love this! Since reading and following people like yourself online I feel more confident with what I don’t know, but not letting that effect my enthusiasm.

          My results have been much improved despite utilising more time during subjective assessments and less on hands on treatment.

          Listening to the patients story is crucial, especially in an empathetic manner and reassuring them what they feel is normal, and educating them in pain neuroscience. Checking their stressors and anxiety.

          Way too much to say, bit off topic of this post…but thank you!

          -Jay

    2. Hi Tony,

      Great article. The study on athletes is very interesting but I’m not convinced that elevated pain tolerance is the primary thing that exercise improves in regard to pain.

      Question: in the other studies you reference, do they show that exercise increases pain tolerance or lowers pain? Or do they distinguish? My personal experience and that of many of my clients is that exercise takes pain away, not just that it makes it easier to bear.

      By the way I have noticed that some of my clients who suffer the most pain also seem to have the highest pain tolerance. I had one client who hurt all over. I pressed at one point and said I’m sorry does that hurt? She was proud of being tough and said you can’t hurt me. I said no you are incredibly easy to hurt. You just won’t tell me to stop when you do.

      • Tony Ingram says:

        Hi Todd,

        Thanks for the comment. I agree, pain tolerance probably isn’t the only thing. Still, the point I guess I’m trying to make is that ‘psycho-social’ factors are more pertinent than structural ones. But again, this article is mainly about prevention rather than treatment. I should bone up on my statistics, but I think it’s easier to get impressive looking differences in prevention studies. The articles I reference in the middle were intervention studies, and they reported lowered pain, not just improved tolerance (but effect sizes were low). Check those studies out, they are gems!

        I’ve noticed similar things about people in pain too. I wonder if they have much of a choice – do having pain build your “tolerance”? After all, the authors of the article on athletes and pain suggested that athletes build their tolerance due to enduring the rigors of intense training.

        Again thanks for reading!

        Tony

        • Anthony @ Back Pain Relief Hawaii says:

          Pain Tolerance I think is more harmful, as it convinces your mind that there is no pain, but the muscles have to take all the wrath, and when it goes beyond the tolerance, the condition is beyond control. So thats why Todd is right in saying that people with high pain tolerance suffers more.

          • Tony Ingram says:

            I’m not sure that’s what Todd meant. Pain tolerance does not convince your mind that there is no pain. The results of the study above reported higher pain tolerance, not higher thresholds. People with higher pain tolerance still feel the pain, they just deal with it better.

            Also, we cannot assume pain always equals harm. Check out this article: Damage does not ’cause’ pain.

    3. Hi Tony,

      I see your point.

      In my own experience, when I have even a small amount of pain I find it completely distracting and I want to put all my attention into fixing it. That’s how I got interested in this stuff in the first place, I was a lawyer with moderate back pain and it was ruining my life. So I put everything into fixing it. I’ve met many other people in much more pain who could seem to care less about investing even a small amount of effort into fixing it. Obviously they have a much higher tolerance, or an ability to put it in the background or something. I find that amazing and it shows that different people are very different in how they deal with pain.

      I have also noticed that my own pain tolerance is very different in different parts of the body. For example, I can have a lot of pain in a knee or foot but it is easy to tolerate, but even a slight disturbance in the neck or upper back drives me nuts. Luckily for me I now have very few pains and can rid of them in pretty short order if I just get moving in the right way.

    4. Lior says:

      Hi tony
      Great post.
      Can you elaborate on the term LBP?
      Are we talking about the acute phase? the chronic? With radiation to the leg or without? etc
      In my opinion, the main problem is the definition of low back pain regarding the literature.
      Lior.

      • Tony Ingram says:

        Hi Lior, good question.

        The articles I cited: the Tesarz 2012 article on athletes studied pain tolerance, not low back pain specifically. The Bigos 2009 study on exercise preventing low back ‘problems’ did their review by using search terms of back pain, back injuries or sciatica, and excluded any studies that looked at people with “serious underlying spinal pathology (spinal fracture, dislocation, tumor or infection, or cauda equina syndrome), inflammatory arthropathies, systemic disease, pregnancy or other nonspinal causes of referred back pain…”

        What I meant: again, I tend to simplify things as much as possible on this blog – without creating any more confusion or committing any logical fallacies. But to be more specific, I’m referring to acute or chronic episodes of low back pain that do not include clear cut red flags of serious conditions that may require surgery and such. Similar to the Bigos 2009 study.

        I made a jump in reasoning that the positive effects of exercise on low back pain may be attributed to psycho-social factors, rather than structural factors. Even though it’s a jump, I think I provided reasonable evidence.

        I hope that answers your question!

        Tony

    5. Anoop says:

      H Tony,

      Great post!

      But this such a complex topic, that I can guarantee that most people who liked it on facebook or said ‘great post’, will go back to their structural tendencies and explanations.

      This is a post I wrote about pain. Not sure if you read it. But it says the same: http://bretcontreras.com/2011/03/a-revolution-in-the-understanding-of-pain-and-treatment-of-chronic-pain/

      • Tony Ingram says:

        Hi Anoop,

        Thanks, and yes, I’ve read your article and it’s excellent! And I think you’re right, people will go back to their previous explanations because that is what they learned first… and cognitive dissonance – it’s a killer!

        Pain (especially chronic) is super complex, and I think some structural explanations have their place, especially in extreme cases – for example, the exclusion criteria of the Bigos 2009 article sums up a lot of ‘structural’ causes: “serious underlying spinal pathology (spinal fracture, dislocation, tumor or infection, or cauda equina syndrome), inflammatory arthropathies, systemic disease, pregnancy or other nonspinal causes of referred back pain…”. But in almost all other cases of back pain, it is far better explained with modern pain science.

        I went to physiotherapy school after having already completed a degree in neuroscience. I am so thankful for that background, as it always caused me to think critically when learning these structural theories – they just seemed wrong. Luckily I also found somasimple, and learned so much about why things hurt.

        Anyway, thanks again for the comment!

        Tony

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