Meta-analysis Finds Exercise and Education Best for Back Pain

By John Henry Dreyfuss, staff.

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  • Meta-analysis includes 23 randomized controlled trials and more than 30,000 patients.
  • Surgery provides no clear benefit for most patients with back pain
  • Anti-inflammatory drugs plus exercise and education are most effective.
  • Rest found to exacerbate back pain.
  • Opioid analgesics should be avoided in the vast majority of cases.
  • Education alone, back belts, and shoe insoles offer no benefit.

A meta-analysis of 23 randomized, controlled trials including 30,850 patients finds exercise plus education to be the most effective treatments for patients with low back pain (LBP). Opioids, surgery, education alone, back belts, and shoe insoles, do not appear to prevent LBP.

Figure 1. Lumbar anatomy.

A majority of your patients will suffer from LBP. Many physicians will suggest surgery or opioids, as well as back belts, rest, or shoe insoles to treat this sometimes debilitating pain. This new study, published recently in JAMA Internal Medicine, finds that those therapies will offer no benefit to your patients. Some of these may in fact exacerbate the condition.

This new report offers refreshing clarification regarding treatments for LBP. Physicians can now prescribe exercise and education with confidence to help suffering patients. These therapies are clinically effective and cost effective for LBP.


Figure 2. Yoga has been found to be effective for low back pain.

The Study

This multicenter meta-analysis of randomized, controlled studies include more than 30,000 patients provides solid evidence that exercise and education are the best treatments for LBP. The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP.

The literature search identified 6133 potentially eligible studies; of these, 23 published reports met the inclusion criteria. Results were presented as relative risks ( RRs/ 95% confidence intervals [Cis]). The reviewers found that there was moderate-quality evidence showing that exercise combined with education reduces the risk of an episode of LBP (RR 0.55 [0.41-0.74]). They found low-quality evidence of no effect on sick leave (RR 0.74 [0.44-1.26]).

The researchers found low- to very low–quality evidence that exercise alone may reduce the risk of both an LBP episode (RR 0.65 [0.50-0.86]) and an episode of sick leave from work (RR 0.22 [0.06-0.76]). For education alone, there was moderate- to very low–quality evidence of no effect on LBP (RR 1.03 [0.83-1.27]) or sick leave (RR 0.87 [0.47-1.60]).

There was low- to very low–quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71-1.44]) or sick leave (0.87 [0.47-1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74-1.40]), according to the study.

“The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low,” the authors concluded.

“For exercise to remain protective against future LBP, it is likely that ongoing exercise is required. Prevention programs focusing on long-term behavior change in exercise habits seem to be important,” the reviewer added.


Figure 3. Wall-sit exercises are effective for treatment of low back pain.

What Helps, What Hurts?

A Cochrane meta-analysis has identified specific exercises that are beneficial for patients with LBP. This study included 13 articles reporting on 9 studies with 9 interventions. Four studies with 407 participants evaluated post-treatment programs and 5 studies with 1113 participants evaluated exercise as a treatment modality.

“We found moderate quality evidence that post-treatment exercises were more effective than no intervention for reducing the rate of recurrences at one year (Rate Ratio 0.50; 95% Confidence Interval 0.34 to 0.73). There was moderate quality evidence that the number of recurrences was significantly reduced in two studies (Mean Difference -0.35; 95% CI -0.60 to -0.10) at one-half to two years’ follow-up,” the Cochrane reviewers noted.

Excises that have been shown to be effective include:

  • Aerobic exercises such as walking, swimming, and cycling
  • Bridging
  • Coordination/stabilization
  • Hamstring stretches
  • Knee-to-chest pulls
  • Partial crunches
  • Pelvic tilts
  • Pilates
  • Press up back extensions
  • Strength/resistance
  • The “bird dog” pose
  • Wall sits
  • Weight lifting
  • Yoga

Exercises to be avoided include:

Figure 4. The partial crunch is effective in preventing or treating low back pain.
Advise Your Patients

These data provide the physician with clear guidance for patients with LBP. Patients will ask for strong analgesics but the evidence shows that this is a bad choice. Others, seeming at wits end will inquire about surgery. There is no good evidence that surgery will benefit these patients. In many cases it will exacerbate the patient’s condition.

Non-steroidal anti-inflammatory drugs plus exercise and education will be much more effective in most cases. See our list of effective exercises above. An education program will include instruction on proper body posture, proper strategies for lifting heavy objects, exercises to avoid, and advice that rest and shoe inserts will also be ineffective or may also exacerbate the painful condition.


Figure 5. Pilates exercises can treat low back pain effectively.

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