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Chronic Nonspecific Low Back Pain and Exercise

Ronai, Peter MS, RCEP, CSCS*D, NSCA-CPT*D1; Sorace, Paul MS, RCEP, CSCS*D2

Section Editor(s): Ronai, Peter MS, RCEP, CSCS*D, NSCA-CPT

Strength & Conditioning Journal: February 2013 - Volume 35 - Issue 1 - p 29–32
doi: 10.1519/SSC.0b013e3182822bb1
Special Populations


1Exercise Science Department, Sacred Heart University, Fairfield, Connecticut

2Hackensack University Medical Center, Hackensack, New Jersey



The Special Populations Column provides personal trainers who work with apparently healthy or medically cleared special populations with scientifically supported background information.


Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding.

Peter Ronai is an associate clinical professor in the exercise science department at Sacred Heart University.

Paul Sorace is a clinical exercise physiologist for The Cardiac Prevention and Rehabilitation Program and the program coordinator for The Bariatric Rehabilitation Program at Hackensack University Medical Center in Hackensack, New Jersey.

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Low back pain (LBP) is a common musculoskeletal disorder affecting 70–85% of people in the United States at one or more times in their lives (4). Chronic nonspecific low back pain (CNSLBP) is the second leading cause of physician's visits, the leading cause of lost time at work, the second leading cause of disability, and most common cause of physical activity (PA) limitations in persons younger than 45 years (3). The annual estimated medical cost of back pain in the United States is approximately $50 billion (4). Back pain is typically classified by the etiology, location, and duration of symptoms (14).

Some evidence indicates that persons with CNSLBP experience PA intolerance, lower levels of physical fitness and function, and PA avoidance and thus engage in a more sedentary lifestyle than age- and gender-matched persons without CNSLBP (5–8,19,21,23,24).

This column will discuss the epidemiology, pathophysiology, benefits of exercise, and exercise program goals for persons with CNSLBP, whereas the accompanying One-on-One column will discuss specific exercise program recommendations. This article is not intended to help exercise professionals diagnose, treat, or rehabilitate clients with LBP of any type (specific, nonspecific, acute, subacute, or chronic). Information within this column pertains to clients who have been discharged from rehabilitation and medically screened and cleared to engage in a comprehensive fitness/exercise program. Clients with new or worsening symptoms of LBP should be referred to their physician or health care provider.

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Evidence indicates that lower PA levels (21,23), physical functioning (5), and physical fitness (6,7,19) exist in persons with CNSLBP. The reported lifetime prevalence of LBP in westernized countries ranges between 49 and 70% and 70 and 85% in the United States (3,14). LBP is generally classified by its cause, location, severity, and duration (14). Typically, LBP is classified as follows:

  • Specific pain caused by unique or unusual pathophysiologic mechanisms (disc herniation, tumor, osteoporosis, arthritis, diseases, trauma, mechanical disorders or spinal pathology)
  • Nonspecific pain not caused by a specific disease or spine pathology
  • Acute pain lasting less than 6 weeks
  • Subacute pain lasting 6–12 weeks
  • Chronic pain lasting longer than 12 weeks (14).

Table 1 lists a number of “red flags” (identified by qualified health care providers) as conditions often accompanying specific LBP that can indicate possible underlying spinal pathology, nerve root problems, and a need to consult the client's physician or health care provider.

Table 1

Table 1

CNSLBP is generally diagnosed or “ruled in” when red flags, magnetic resonance imaging, and x-ray results are found to be negative for spine or nerve pathology, respectively (14). CNSLBP is generally defined as pain, muscle tension, or stiffness localized below the costal margins (ribs) and above the inferior gluteal folds with or without leg pain (sciatica) (14). Persons with CNSLBP are typically treated with nonsteroidal anti-inflammatory drugs and acetaminophen and are advised to stay active and avoid bed rest (14). Occasionally, muscle relaxants and narcotic analgesics, which can cause drowsiness, increased reaction time, and impaired judgment, are prescribed for severe pain.

CNSLBP can contribute to the following:

  • Recurring pain and increased severity
  • Lost work time
  • Decreased health-related quality of life (HRQOL)
  • Decreased neuromuscular function
  • Decreased physical fitness, strength, and function
  • Decreased PA levels
  • Fear/avoidance of PA secondary to pain anticipation (4,6–8,10,11–13,15,18,19,24).
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Although many persons with CNSLBP are less physically active and physically fit than apparently healthy aged-matched cohorts, CNSLBP does not exert specific effects on the exercise response (18). Exercise response limitations are typically affected by the following:

  • Individual pain severity and location
  • Physical fitness and strength
  • Body positions required during exercise testing and training. Prolonged standing, sitting, and frequent bending (trunk flexion) can exacerbate CNSLBP symptoms and prevent clients from obtaining their best exercise and/or testing efforts (18).
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Exercise has been shown to be effective in increasing PA tolerance, physical fitness, strength, HRQOL, pain tolerance, and overall PA participation levels in persons with CNSLBP (4,11–13,15). Although home-based exercise programs have been found to be beneficial, significantly greater physical benefits and compliance rates have been observed in persons engaging in supervised individualized exercise programs (4,15). Both aerobic training (AT) and resistance training (RT) programs have produced increased PA tolerance, physical fitness, and HRQOL in persons with CNSLBP (4,9,11–13,15). Periodized progressive RT programs have been well tolerated and proven effective for increasing strength and PA participation levels and in reducing disability levels in sedentary and athletic populations with CNSLBP (11–13).

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Exercise program and PA goals for medically cleared persons with CNSLBP are similar to those previously established for apparently healthy populations with appropriate adjustments (1,2,16,18,20). Current PA guidelines encourage persons with diseases/disabilities to maintain an active lifestyle, avoid being sedentary as much as possible, and strive to meet the same PA guidelines set for apparently healthy individuals (1,2,20).

Common exercise program goals for clients with CNSLBP are to increase the following:

  • Health and well-being
  • Exercise tolerance
  • Physical function/functional capacity
  • HRQOL (15,18).

Components of a comprehensive exercise/fitness program include RT, AT, flexibility training, and neuromotor (1,2,16,18).

Because of the potential physical deconditioning and pain/discomfort, a slower rate of exercise program progression, volume, and intensity might be warranted in some individuals. Exercise program goals should be individualized, and exercise selections should be determined by client tolerance (4,9,15). Clients with CNSLBP should monitor their ratings of perceived exertion with both the Borg’s scale (1) and the OMNI perceived exertion scale for resistance training (OMNI-RES) (17) (Table 2) and report any new or increasing symptoms of LBP to the exercise professional immediately.

Table 2

Table 2

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CNSLBP is a potentially debilitating condition that can decrease physical fitness, PA participation and tolerance, and HRQOL. Individualized exercise programs that follow current American College of Sports Medicine’s guidelines and employ periodized RT have been well tolerated and proven effective in increasing PA tolerance, performance, and HRQOL in persons with CNSLBP.

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