Low back pain is the most common musculoskeletal condition we see, and there is plenty of conflicting advice
This month, we are unpacking a study from 2022, by the Journal of orthopaedic and Sports Physical Therapy on exercise for lower back pain.
Rubén Fernández-Rodríguez et al. (2022) Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain: Pilates, Strength, Core-Based, and Mind-Body. A Network Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. . Vol 52, Issue 8 – 505-521. link: https://www.jospt.org/doi/10.2519/jospt.2022.10671
Background: Why is it worth looking at?
- Lower back pain is the most common cause of chronic/persistent pain
- Chronic lower back pain is the most common Musculoskeletal condition.
- Essentially as therapists, it is the most common thing we see!
- For the vast majority, conservative management (non-surgical) is best, and for chronic pain, medication is rarely the answer, but there is contention on what the best treatment for back pain is.
- You will hear one person say, ‘do this stretch, it sorted my back out’ and the next person say ‘I was just told to stretch it and that just made it worse!’, so there is a need to establish what exercise we should be using to help people suffering with back pain.
What did the study do?
- This study is a ‘Network-Meta-Analysis’: a systematic review of 118 studies looking at the effect of different types of exercise as treatment for chronic lower back pain (defined in this case as more than 12 weeks of symptoms)
- It compares the different exercise types against a control (no exercise), and against each-other (eg. stretching vs strengthening exercise).
- By using multiple studies looking at similar things, they can combine results to give a better consensus on what all the research is telling us. They set some criteria to balance getting a good amount of data, whilst filtering out studies of poor quality that may not be as trustworthy.
- They assessed changes in self-reported outcomes, meaning the measures were people’s own assessment of their pain levels, and how much their back pain disabled them (usually a score based on multiple questions around physical function and/or confidence). Different studies used the same or similar outcome measures, that were then combined where this was possible, to assess an overall effect across all studies.
What did the study find?
- All exercise types studied improved disability and/or pain measures (most on both), compared to a control.
- All of the above improvements were statistically significant, meaning there is high confidence that the results are not down to chance.
- Pilates came out number one for both measures, followed by ‘mind-body’ then ‘core’ for pain, and ‘strength’ then ‘combined’ for disability.
- The study’s own conclusion: Exercise was effective for reducing pain and disability in patients with chronic LBP […] The most beneficial programs were those that included (1) at least 1 to 2 sessions per week of Pilates or strength exercises; (2) sessions of less than 60 minutes of core-based, strength, or mind-body exercises; and (3) training programs from 3 to 9 weeks of Pilates and core-based exercises.
What are the studies strengths and limitations
- Strengths
- It includes 118 studies and over 9,000 participants across these a very reasonable sample size to strengthen the data found.
- Studies cover mean ages of 18-61 years, meaning findings are potentially applicable to a lot of the population.
- It covers a lot of different exercise types, making for a good comparison of a lot of options in terms of exercise-treatments.
- Limitations:
- A reasonable proportion of the included studies have a moderate or high risk of bias (which unfortunately is common within a lot of MSK and therapy research), largely as blinding is not feasible for clinicians or participants when it comes to exercise intervention to remove placebo.
- Moderate to high heterogeneity within a large proportion of study samples (lots of different demographics of people studied in the same group), though the review itself argues this makes results more generalisable to more of the population.
- The use of SMD (standardised mean difference) is disputed by some researchers as it can risk inflating a result that is found.
- They were not able to remove other things that may influence results, such as use of medications or individual barriers to engaging in treatment, as these variables were not reported in most articles.
- The authors rated the certainty of evidence for most comparisons as low to very low, so the finding that pilates outperformed other exercise modalities. Or any type being clearly better or worse than the next, should be interpreted with caution.
What is my opinion?
This study paints an overall very positive picture of the benefits of exercise intervention for back pain.
Quite a lot of the time studies into interventions for musculoskeletal problems may not show meaningful changes from treatments. This can arguably be down to challenges in achieving large enough participant numbers, and quality and/or quantity of intervention, but my professional opinion is that so often this trend in the research is a reflection of the reality that all individuals are exactly that: Individual, unique, different from the next person.
There used to be a principle in understanding back pain in two types (how reductionist!): control impairment, and movement impairment type back pain. The former was someone who has mobility of their spine, but lack the ability or awareness to control it. For this person, improving control, awareness, strength of muscles would help, stretching or manipulation would not, and may even hinder. The latter lacked mobility, either a stiffness, or a fear and avoidance of certain movements, muscle guarding, bracing, etc. This person would benefit from stretching, graded exposure to the things they struggled with. Although this idea is too simplistic, there is some truth in features of back pain in different people and within this the simple idea that different things work for different people.
So how do we interpret this study in the context of that reality?
Firstly, commonly used adage is ‘the best exercise is the one that gets done’, and this study is incredibly affirming of this. Yes, Pilates came out on top, but if you prefer strengthening, or core based exercise, or mind-body, these will also make a difference! The often subtle differences in overall benefit would easily be outweighed by engaging more consistently in a type of exercise you like more, or is just more convenient for you to access.
Second, the truth is that even though pilates is number one here, I am confident both in theory and experience that pilates will not work for some people and something else will. The opposite is also true, I am sure. There will also be times that for a period, regardless of exercise preference, a certain type of exercise like pilates, or ‘mind-body’, will bridge the gap from where you are now, to where you want to be, and the exercise you might rather be doing. Essentially sometimes we can’t do the exercise we want due to pain, but other types of exercise are beneficial, and can tide us over, or help us get back to what we love doing.
So why Pilates? We have pilates trained clinicians in our team, so I feel like a fraud declaring my own less educated opinions, though I certainly adopt pilates exercises and some of its principles within my own practice. Pilates is many things. It can be a gentle introduction to movement that is less likely to irritate, it can feel safe when movement is scary, it makes you think about what your body is doing (what is engaging, where you are in space, and likely less on what hurts and how much), it aims to train stabilising muscles that improve joint stability. For some these things are exactly what is needed. For others it is the start, and building that early stability and control of movement is what allows progression back to other things, be it aerobic exercise like walking or running, or back to conventional strength training. For some an ongoing combination of pilates and strength provides the joint stability and the capacity for more strenuous day-to-day tasks.
So what would this look like at Southampton Physio?
Here’s how we would approach this evidence in our practice. Let’s say you come in with a flare of lower back pain, that has been on and off for some time, so it is chronic. If we have assessed to rule out anything else concerning, we may see if there is a need to settle symptoms first, advice, education, hands on treatment where this is helpful to calm things down. If we identify a need to start with small manageable movement, lower intensity, or a need to build deeper stability, we may refer your to Andy or Seana in the team, our pilates trained physios. They set you on a program, possibly with guidance in the gym here. After this perhaps you engage well with pilates exercise, and continue for further sessions here for that extra support, or find your own local class to continue longer term. Maybe assessment finds a need and benefit to get the rest of you stronger, and you do some strength training with Jake or Ewan our sports therapists, to build on the control you got from pilates, to establish lasting strength. Or maybe you wanted to get back to a specific exercise you were doing before. You see Ian to return to climbing, you see me to help you run again. The journey is about what you need, and what your goals are.