Graded exercise for chronic low back pain
Mathew Forman, Physiotherapist
Chronic low back pain is a leading cause of pain and disability. It is estimated that chronic low back pain affects up to 1 in 6 Australians at any given time (Australian Institute of Health and Welfare, 2016) and pain can often limit the ability to engage in daily activities, having a significant impact on quality of life. Pain symptoms can result in many people living with chronic low back pain being relatively under-active, and over time this can lead to reduced physical fitness and further make it difficult to return to meaningful activity and worsen pain.
Exercise rehabilitation is well-established as a safe and effective treatment for chronic low back pain. A recent Cochrane systematic review that included 249 randomised controlled trials and a total of 24,486 participants demonstrated that exercise is effective for meaningfully improving pain and function in chronic low back pain (Hayden et al., 2021). A feature of many of the studies included in this review, was that the exercise programs were graded or progressed over time. In the context of chronic low back pain, graded exercise programs involve starting exercise at a level that is within the individual’s physical capacity and does not significantly increase pain levels. As the exercise program is completed, the body and muscles supporting the spine will begin to strengthen and the program can be gradually progressed in intensity and duration. Over time this leads to increased strength, confidence, and ability to engage in activities that are meaningful, and the achievement of individualised goals. As the exercise program is progressed pain will often start to improve, and many people also report improvements in their mental wellbeing and quality of life.
A well-designed graded exercise and activity program demonstrating gradual progression of the exercise program leading to decreased pain and the achievement of meaningful goals.
While the review from Hayden et al., (2021) demonstrated that many different types of exercise can be effective, our research and clinical experience indicates that taking an individualised approach, specific to the type of back pain and individual, appears to be more effective. In 2016, our team published a randomised controlled trial including 300 participants that compared individualised physiotherapy to guideline-based advice (Ford et al., 2016). The results demonstrated that individualised physiotherapy, including an exercise program tailored to the person, was more effective at reducing pain and disability than a ‘one size fits all approach’.
It can be challenging for people living with chronic back pain to know where to start with a graded exercise program. Particularly when symptoms are more severe, knowing the amount and type of exercise to complete without significantly aggravating symptoms can be difficult. For many people with chronic low back pain, walking at a duration and speed that is within your physical capacity is a great first step towards starting a graded exercise program. The program can then be further developed and progressed depending on your individual circumstances and functional goals.
If you are having difficulty starting or progressing your exercise program, physiotherapists are well-placed to help you design and implement safe and effective exercise to promote recovery. Over time, this can significantly improve pain, function, and quality of life, and help you return to the things you find meaningful.
References
Australian Institute of Health and Welfare (2016) Impacts of chronic back problems, AIHW, Australian Government, accessed 26 February 2023.
Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021. DOI: 10.1002/14651858.CD009790.pub2.
Ford JJ, Hahne AJ, Surkitt LD, et alIndividualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial. British Journal of Sports Medicine 2016;50:237-245.
Mathew practices from Advance Healthcare Hoppers Crossing and Geelong. He has experience treating whiplash associated disorder and has completed post graduate studies in musculoskeletal physiotherapy. He has worked in private practice in Melbourne treating a variety of musculoskeletal and sports injury conditions since then.