Preventing low back pain with exercise

By Ryan Kidd @ 2021-09-28T05:00 (+15)

Disclaimer: I am not a physician or exercise scientist.

Low back pain (LBP) is an extremely common and debilitating symptom worldwide, experienced by people of all ages and socioeconomic circumstance [1]. In 2017, LBP contributed 65 million disability-adjusted life-years and was the primary cause of work absenteeism and disability worldwide [2]. Most LBP cannot be attributed to a specific source and bouts, while typically short, frequently reoccur [1].

Clinical practise guidelines consistently recommend against treating LBP with opioids, foot orthotics, disc replacement and spinal injections [3]. In particular, opioid use is discouraged for LBP due to the potential for opioid-related harms and the recent finding that NSAIDS are equally efficacious for treating acute LBP [3]. Similarly, routine medical imaging for non-specific LBP is associated with harms [3]. Despite the consistency of these guidelines, imaging, surgery and opioids are overused in clinical practise [3].

The most effective preventative treatment for LBP seems to be exercise, with or without accompanying education [4]. Exercise alone reduces the risk of LBP by 33% on average, with a 95% confidence interval of 15-47% risk reduction [5]. Further research into optimal frequency, intensity, type and duration of exercise for the prevention and treatment of low back pain is recommended [4]. As a naive starting point, the Physical Activity Guidelines for Americans recommend that all adults perform resistance exercises of moderate or greater intensity for all major muscle groups at least twice per week, in addition to minimum aerobic activity guidelines [6]; the Physical activity and exercise guidelines for all Australians concur [7].

While no specific form of sufficiently intense full-body resistance exercise is recommended above all others, I have highly enjoyed resistance training with free weights; I find the capacity for consistent and graded progress very rewarding, and there is a wealth of associated high-quality educational resources. I highly recommend Barbell Medicine's free exercise program and their article on understanding and training around pain. Individuals who are unable to perform basic barbell movements through a full range of motion can instead use light dumbbells or even decrease the range of motion if necessary.

Individuals new to resistance training might experience the following barriers:

• Insufficient time or money to engage in gym-based activity. Gyms typically cost $12-15/week in Australia. Resistance training in a gym should not require more than 60-90 minutes per session. Barbell Medicine also provide a free at-home exercise program. Prioritising self-care can be difficult and, ultimately, any training is better than no training.
• A lack of training motivation. Self-monitoring and goal-setting behaviour, such as recording progress and setting achievable targets, can significantly improve exercise motivation [8]. Group exercise, such as with a friend or personal trainer, can also significantly improve motivation and enjoyment [8].
• Fear of injury or preoccupation with perfect form and 'mobility'. There is no evidence that lower back flexion during resistance training is a risk factor for LBP onset or persistence [9]. People with LBP tend to move with a more rigid back than those without pain [10], potentially a learned response to a misplaced narrative about the dangers of spinal flexion. Movement variability is safe and normal, and one should expect lower back flexion during resistance exercise. Improving 'mobility' should not be prioritised over resistance training.