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You Asked For It: Question Authority

Nieman, David C. Dr.PH, FACSM


Examines the relationship between exercise and lower back pain treatment.

David C. Nieman, Dr.PH, FACSM, is Professor and Director of the Human Performance Laboratory, Appalachian State University, in Boone, NC, an active researcher, and author of several textbooks on health and fitness.

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Recent reports about exercise and low back pain treatment have confused me. Can you clear this up?

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I will try, but you have summarized accurately the link between exercise and treatment of low back pain—it is confusing. Before outlining the most recent consensus statements from experts in this field, let me provide some background information on low back pain.

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What Is Low Back Pain?

Low back pain is a common ailment—at some point in their lives, 60-80 of all Americans and Europeans will experience a bout of low back pain ranging from a dull, annoying ache to intense and prolonged pain (1). A nationwide government survey revealed that back pain lasting about one week is reported by one in five working Americans each year. After headaches, low back pain is the second most common ailment in the United States. Additionally, low back pain is topped only by colds and flues in terms of time lost from work, and next to arthritis is the most frequently reported disability.

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Males and females appear to be affected equally, with most cases of low back pain occurring between the ages of 25 and 60, with a peak at about 40 years of age. The first attack often occurs early in life—up to one-third of adolescents report they have experienced at least one bout of low back pain.

Fortunately, most low back pain is self-limiting (1). Without treatment, 60 of back pain sufferers go back to work within a week, and nearly 90 return within six weeks. Pain remains for a long time in 5-10 of patients.

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Risk Factors for Low Back Pain

There are many risk factors for low back pain (2). Most low back pain is due to unusual stresses on the muscles and ligaments that support the spine of people with weak muscles. When the body is in poor shape, weak spinal and abdominal muscles are unable to support the spine properly during certain types of lifting or physical activities.

Even hardy occupation workers and athletes who push beyond their limits are susceptible. Rowers, triathletes, professional golfers, tennis players, wrestlers, and gymnasts, for example, all have high back injury rates (3). Any extreme lifting, bending, and twisting can cause low back pain in the strongest workers and athletes.

Major risk factors for low back pain include:

* Heavy lifting with bending and twisting motions, pushing and pulling, slipping, tripping, or falling.

* Long periods of sitting or driving, especially with vibrations.

* Personal health factors such as obesity, smoking, poor posture, and mental stress.

* Muscular weakness and poor joint flexibility.

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Prevention of Low Back Pain

Education is a common back pain prevention strategy, with emphasis placed on how the back works, preferred lifting techniques, optimal posture, specific exercises, and management of stress. Most attention in low back pain prevention has been placed on teaching people how to improve muscular fitness. The combination of a weak trunk and a back-straining occupation greatly increases the risk of low back pain.

Prevention of low back pain is based on these recommendations:

* Exercise regularly to strengthen back and abdominal muscles.

* Lose weight, if necessary, to lessen strain on the back.

* Avoid smoking (which increases degenerative changes in the spine).

* Lift by bending at your knees, rather than the waist, using leg muscles to do most of the work.

* Receive objects from others or platforms near to the body, and avoid twisting or bending at the waist while handling or transferring it.

* Avoid sitting, standing, or working in any one position for too long.

* Maintain a correct posture (sit with the shoulders back and feet flat on the floor, or on a footstool or chair rung. Stand with head and chest high, neck straight, stomach and buttocks held in, and pelvis forward).

* Use a comfortable, supportive seat while driving.

* Use a firm mattress, and sleep on one side with knees drawn up or on the back with a pillow under bent knees.

* Try to reduce emotional stress that causes muscle tension.

* Be thoroughly warmed-up before engaging in vigorous exercise or sports.

* Undergo a gradual progression when attempting to improve strength or athletic ability.

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Treatment of Low Back Pain: The Exercise Connection

Treatment of low back pain has proven to be complex and frustrating. The optimal management of low back pain is still under debate. Many nonsurgical treatments are available for patients with low back pain, but few have been proven effective or clearly superior to others.

A panel of experts sponsored by the federal Agency for Health Care Policy and Research reviewed nearly 4,000 studies, emphasized findings from the strongest studies, and made multiple recommendations for the treatment of low back pain, including these two related to exercise: (3)

* Engage in low-stress activities such as walking, biking or swimming during the first two weeks after symptoms begin, even if the activities make the symptoms a little worse. The most important goal is to return to normal activities as soon as it is safe.

* Bed rest usually isn’t necessary and shouldn’t last longer than two to four days. More than four days of rest can weaken muscles and delay recovery.

Another group of medical experts recently provided evidence-based clinical guidelines for the conservative (nonsurgical) management of low back pain (4). This group also recommended continued normal activity for most cases of acute low back pain, but added that therapeutic exercise is needed for individuals with long-term low back pain and following back surgery. Most studies, according to these experts, showed no clinically important benefits when individuals with acute low back pain engaged in stretching or strengthening exercises. In contrast, most studies supported the use of therapeutic exercise, including stretching, strengthening, and mobility exercises, with serious cases of low back pain lasting four weeks and longer.

To summarize, low muscular fitness has been linked to a high risk of low back pain, but even strong athletes are at peril when they exceed their limits. For most cases of low back pain lasting less than a month, a return to normal daily activities is recommended. In contrast to what many health and exercise professionals once believed, it is now known that the pace of recovery from acute low back pain is not enhanced with back exercises. If low back pain lasts longer than a month, however, most individuals experience enhanced improvement with a regular regimen of exercises aimed at strengthening and stretching the trunk, hip, and thigh muscles.

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1. Deyo, RA,and JN Weistein. Low back pain. New England Journal of Medicine 344:363-370, 2001.
2. U.S. Department of Health and Human Services. Healthy People 2010. Washington, D.C.: January 2000. (Http://
3. Dreisinger, TE, and B Nelson. Management of back pain in athletes. Sports Medicine 21:313-319, 1996.
4. Harris, GR, and JL Susman. Managing musculoskeletal complaints with rehabilitation therapy: Summary of the Philadelphia Panel evidence-based clinical practice guidelines on musculoskeletal rehabilitation interventions. Journal of Family Practice 51:1042-1046, 2002.
© 2004 American College of Sports Medicine