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Joint Bone Spine 75 (2008) 533e539

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Review

Exercise and nonspecific low back pain: A literature review

Yves Henchoz a,*, Alexander Kai-Lik So b
a

Institut des sciences du sport et de leducation physique, Universite de Lausanne, Centre administratif de Vidy, 1015 Lausanne, Switzerland
b
Service de Rhumatologie, Departement de medecine, CHUV et Universite de Lausanne, Lausanne, Switzerland
Accepted 11 March 2008
Available online 17 September 2008

Abstract
We reviewed the literature to clarify the effects of exercise in preventing and treating nonspecific low back pain. We evaluated several
characteristics of exercise programs including specificity, individual tailoring, supervision, motivation enhancement, volume, and intensity. The
results show that exercise is effective in the primary and secondary prevention of low back pain. When used for curative treatment, exercise
diminishes disability and pain severity while improving fitness and occupational status in patients who have subacute, recurrent, or chronic low
back pain. Patients with acute low back pain are usually advised to continue their everyday activities to the greatest extent possible rather than to
start an exercise program. Supervision is crucial to the efficacy of exercise programs. Whether general or specific exercises are preferable is
unclear, and neither is there clear evidence that one-on-one sessions are superior to group sessions. Further studies are needed to determine
which patient subsets respond to specific characteristics of exercise programs and which exercise volumes and intensities are optimal.
2008 Elsevier Masson SAS. All rights reserved.
Keywords: Physical activity; Physical training; Exercise; Low back pain; Rehabilitation; Therapy; Review

1. Introduction

2. Methods

Low back pain has been a major public health burden for
many years, generating substantial work disability and
healthcare costs. Among adults in the general population, 70e
85% are believed to experience at least one episode of low
back pain at some time during their lives [1]. Nonspecific low
back pain, defined as pain with no identifiable cause, accounts
for about 85% of cases. Studies of the many treatment
modalities available for low back pain have failed to determine
which strategy is optimal. However, there is convincing
evidence of the harmful effect of bed rest, which was long
recommended for acute low back pain. Patients should
continue their everyday activities to the greatest extent
possible. Exercise is being increasingly used to treat low back
pain, and data on the effect of exercise is accumulating. We
reviewed these data to clarify the role for exercise in the
treatment and prevention of low back pain.

To identify articles on the effect of exercise in low back

pain, we searched the Medline database using the following
keywords: exercise, low back pain, physical training, and
rehabilitation. Further publications were identified by
examining the reference list of each selected article. We
used the widely accepted classification scheme for low back
pain based on symptom duration, which distinguishes acute
pain (<6 weeks), subacute pain (6e12 weeks), and chronic
pain (more than 12 weeks). The level of evidence was
determined using the criteria recommended by the Cochrane
Back Review Group [2], with the necessary adjustments for
reviews that relied on other criteria: strong, consistent
findings among multiple high-quality randomized controlled
trials (RCTs); moderate, consistent findings among multiple
low-quality RCTs and/or clinical controlled trials (CCTs)
and/or one high-quality RCT; limited, one low-quality RCT
and/or CCT; conflicting, inconsistent findings among
multiple trials (RCTs and/or CCTs); and no evidence from
trials, no RCTs or CCTs.

* Corresponding author. Tel.: 41 216 923 296; fax: 41 216 923 293.
E-mail address: yves.henchoz@unil.ch (Y. Henchoz).

1297-319X/$ - see front matter 2008 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jbspin.2008.03.003

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534

3. Results
3.1. Exercise for the prevention and treatment of low
back pain
We identified 20 reviews and meta-analyses of the efficacy
of exercise in preventing and treating low back pain published
between 1997 and 2007 (Table 1). They are discussed below.
3.1.1. Primary prevention of low back pain
Among reviews of data obtained in asymptomatic individuals, four [3e6] produced strong evidence, three [7e9]
moderate evidence, and two [10,11] conflicting evidence that
exercise was effective in preventing low back pain.
3.1.2. Secondary prevention of low back pain
One review each produced strong [3], moderate [12], and
conflicting evidence [7] that exercise prevented recurrences of
low back pain or repeated absence from work.
3.1.3. Treatment of low back pain
3.1.3.1. Acute low back pain. Eight reviews [3,5,6,13e17]
produced strong evidence that exercise was not more effective
in diminishing pain or disability than other conservative
treatments or than placebo treatments. Evidence from another
review [10] was conflicting. A meta-analysis [18] showed that
exercise was as effective as other conservative treatments or no
Table 1
Reviews and meta-analyses on the efficacy of exercise in preventing or treating
low back pain
Authors

Prevention

Treatment

treatment. Strong evidence supporting advice to stay active or

to avoid bed rest was obtained by seven reviews
[3,5,6,11,13,15,19]. Evidence from two other reviews [20,21]
was less convincing, although the more recent of these two
papers supports a recommendation to stay active, given the
potential harmful effects of prolonged bed rest.
3.1.3.2. Subacute low back pain. Strong evidence that exercise
was effective in the treatment of subacute low back pain was
produced by two reviews [6,13] and moderate evidence by one
review [14]. A meta-analysis [18] yielded moderate evidence
that a graded activity program was associated with less time off
work; the level of evidence was conflicting for other exercise
programs.
3.1.3.3. Chronic low back pain. Evidence that exercise
decreased pain, disability, secondary physical deconditioning,
or time off work in patients with chronic low back pain was
strong in six reviews [6,7,14e16,22], moderate in one review
[5], and conflicting in one review [23]. A meta-analysis [24]
yielded strong evidence that exercise decreased sick-leave
duration over the following year in a population of patients
with nonacute low back pain. Another meta-analysis [18]
showed that exercise produced small but significant decreases
in pain and disability, most notably in healthcare populations.
Two reviews produced moderate evidence [3,13] and two
others conflicting evidence [17,25] that exercise was more
effective than a placebo or no treatment. In two reviews
[3,17], there was strong evidence that exercise was more
effective than usual care by the general practitioner. Strong
evidence was obtained that exercise was not more effective
than physiotherapy [3,17], as well as conflicting evidence
that exercise was less effective than multidisciplinary treatment [3,17].

Primary Secondary Acute Subacute Chronic

1997 Scheer et al. [23]
van Poppel et al. [9]
van Tulder et al. [16]
1998 Casazza et al. [10]
Hilde and Bo [25]
1999 Brox et al. [14]
Maher et al. [6]
2000 Abenhaim et al. [13]
Maher [8]
van Tulder et al. [17]
2001 Linton and
van Tulder [4]
Vuori [5]
Waddell
and Burton [11]
2004 Kool et al. [24]
Liddle et al. [22]
Rainville et al. [7]
Tveito et al. [12]
2005 Hayden et al. [18]
2006 COST B13 [3]
Koes et al. [15]


?













, strong evidence that exercise is effective; , moderate or limited

evidence that exercise is effective; ?, conflicting evidence that exercise is
effective; , moderate or limited evidence that exercise is not effective; ,
strong evidence that exercise is not effective.

3.2. Characteristics of the exercise programs

Although many studies have investigated the link between
exercise and low back pain, few of them provide detailed
descriptions of the exercise programs. Exercise was defined by
the International Paris Task Force [13] as a series of movements specifically designed to condition or develop the body
when performed regularly or to improve fitness as a means of
promoting health. This broad definition covers a wide variety
of exercise programs. Some of the characteristics of exercise
programs are of particular importance in the management of
low back pain.
3.2.1. General versus specific exercises
We identified five studies addressing specific versus
general exercises (Table 2). Physical therapists usually teach
relatively high-intensity exercises that activate the flexors and
extensors of the trunk. Recently, more specific and less
intense exercises that selectively activate the local stabilizing
muscles have been suggested. Beneficial effects on pain and
functional impairment have been reported [26]. In patients
with chronic low back pain, a combination of physician

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535

Table 2
Studies comparing general exercise to specific exercise
Authors

Patients

Interventions

Effects

Ferreira et al. 2007 [28]

240 patients with LBP

A: General exercise, 12 sessions over

8 weeks
B: Specific exercise, 12 sessions over
8 weeks
C: Manipulations

At treatment completion: function (PSFS) and

perceived global effect (11-point scale): A > B and
C. Pain (VAS) and disability (RolandeMorris): no
significant difference between A, B, and C. After 6
and 12 months: no significant difference between A,
B, and C
Hurwitz et al. 2005 [30]
681 patients with acute, subacute, A: Chiropractic with physical modalities Recreational physical activity inversely associated
or chronic LBP
B: Chiropractic without physical
with pain, disability, and depression; specific back
modalities
exercises positively associated with pain and
C: Medical care with physical modalities disability
D: Medical care without physical
modalities
Koumantakis et al. 2005 [29] 55 patients with subacute or
A: General exercise specific exercise At treatment completion: pain (McGill): A z B.
chronic LBP
twice weekly for 8 weeks
Disability (RolandeMorris): A > B. After
B: General exercise twice weekly for
3 months: no significant difference between
8 weeks
A and B
Niemisto et al. 2005 [27]
204 patients with chronic LBP
A: Usual care 4 sessions of specific
After 5 and 12 months: pain (VAS) and disability
exercise and manipulations
(Oswestry): B > A. After 2 years: no significant
B: Usual care
difference between A and B
OSullivan et al. 1997 [26]
44 patients with chronic LBP
A: Specific exercise 10e15 min per day At treatment completion and after 30 months: pain
for 10 weeks
(McGill) and disability (Oswestry): B > A
B: Treatment as directed by the usual
physician
>, significantly better than; LBP, low back pain; VAS, visual analog scale; PSFS, patient-specific functional scale.

consultation, manipulation, and stabilizing exercises

produced greater decreases in pain and disability after 1 year
than physician consultation alone [27]. After 2 years,
however, pain severity was slightly less in the intervention
group but disability and health-related quality of life were
not significantly different, and physician consultation alone
was more cost-effective. Compared to general exercise,
retraining specific trunk muscles using ultrasound feedback
was significantly better in terms of short-term function and
perception of effect but failed to significantly improve shortterm disability or any of the 6 or 12 month outcomes of
patients with chronic low back pain [28]. A combination of
trunk muscle stabilization training and general exercise was
associated with smaller short-term reductions in disability
than general exercise alone in a population of patients with
recurrent low back pain, and the two exercise programs had
similar effects on pain [29]. After 3 months, the effects of
both programs were sustained, with no significant differences
between the two groups. In a randomized trial of chiropractic
or medical care, recreational physical activities were
inversely associated with low back pain, whereas back
exercises were positively associated with low back pain [30].
Thus, available data on the relative advantages of general
exercise and specific exercise are conflicting, indicating
a need for further studies.
3.2.2. Group versus one-on-one exercise programs
Seven studies compared individualized to standardized
exercise programs (Table 3). Because the cause of low back
pain is usually unknown, choosing a specific exercise
modality may be difficult. However, the volume and intensity
of exercise can be tailored individually based on the results

of a baseline evaluation. In a group of 20 patients with

subacute or chronic nonspecific low back pain, exercises
whose type, volume and intensity were individualized
produced significantly greater decreases in pain and
disability and a significantly greater increase in strength than
a standard exercise program [31]. Similarly, a meta-analysis
showed that individually designed exercise programs were
more effective than standard programs [32]. With group
sessions, the characteristics of the exercise program are more
difficult to delineate than with one-on-one sessions. Nevertheless, benefits have been reported with group exercises
alone [33] or combined with other treatments [34]. No
significant differences were found between a group exercise
program and individual physiotherapy for patients with
subacute or chronic low back pain residing in a severely
deprived area of the UK [35]. A trend toward better outcomes
with group exercises was noted among the patients from the
least deprived areas [35]. Two other randomized controlled
trials [36,37] found no differences between one-on-one and
group reconditioning sessions. No significant differences
were noted after individual physiotherapy sessions, muscle
reconditioning using training machines in groups of two or
three patients, or low-impact aerobics classes with up to 12
patients per class [38]. After 6 months, disability was
significantly more severe in the individual physiotherapy
group than in the other two groups.
Group exercise programs may be better than one-on-one
programs in some patients. The desire to support one another
within the group may improve motivation. Further studies are
needed to identify the patient characteristics that are associated with greater benefits from group sessions than from oneon-one sessions.

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536

Table 3
Studies of individualized versus group exercise
Authors

Patients

Interventions

Effects

Carr et al. 2005 [35]

237 patients with subacute or

chronic LBP

A: Group exercises twice a week for 4 weeks

B: Individual physiotherapy

After 3 and 12 months: disability (Rolande

Morris), no significant difference between A
and B
At treatment completion, significant
improvements in pain (VAS) and disability
(Oswestry) with A but not with B
At treatment completion, pain (VAS) and
function (FFbH-R): no significant difference
between A and B

Descarreaux et al. 2002 [31] 20 patients with subacute or

chronic LBP

A: Individualized exercises twice a day for

6 weeks
B: Standard exercises twice a day for 6 weeks
A: Individualized exercises acupuncture/
Swedish massage
B: Group exercises acupuncture/Swedish
massage
A: Specific exercises at home twice a day for
6 weeks group exercises twice a week for
4 weeks
B: Specific exercises at home twice a day for
6 weeks
A: Exercise in groups of 2e3 patients
B: Exercise in groups of up to 12 patients
C: Individual physiotherapy

Franke et al. 2000 [37]

109 patients with chronic LBP

Frost et al. 1998 [34]

81 patients with chronic LBP

Mannion et al. 2001 [38]

148 patients with chronic LBP

Moffett et al. 1999 [33]

187 patients with subacute or

chronic LBP

A: Group exercises twice a week for 4 weeks

B: Usual care

Rose et al. 1997 [36]

42 patients with chronic LBP

A: Multidisciplinary program (including group

exercises)
B: Multidisciplinary program (including
individualized exercises)

After 6 and 24 months: disability (Oswestry),

A>B

At treatment completion: pain (VAS) and

disability (RolandeMorris): no significant
difference between A, B, and C. After 6 and
12 months: pain, no significant difference
between A, B, and C. Disability: C > A and B
At treatment completion and after 1 year,
disability (RolandeMorris) and clinical status
(Aberdeen back pain scale): A > B. Patient
preference for A or B did not influence the
treatment response
At treatment completion and after 6 months,
pain (VAS) and disability (RolandeMorris):
no significant difference between A and B

LBP, low back pain; >, significantly better than; VAS, visual analog scale; FFbH-R, Funktionsfragebogens Hannover in seiner Ruckenschmerzversion.

3.2.3. Supervised versus home exercise

Five studies compared supervised exercises to home exercises (Table 4). In the vast majority of studies of exercise
programs for low back pain, the exercises were supervised by
skilled healthcare professionals [22]. Disability after 6 and
24 months was significantly less with a combination of
supervised exercises and home exercises than with home
exercises alone [34]. Similarly, substantial benefits from
supervision were found in other studies [39e41] and in
a review [22]. In another study, however, home exercises were
as effective as supervised exercises in improving disability,
time off work, and healthcare service utilization after 3 and
12 months, although adherence was significantly better with
supervision [42]. In a meta-analysis, outcomes were significantly better when at least some supervision was provided, for
instance by having the patients perform exercises at home in
the intervals between regular sessions with a healthcare
professional [32]. Strong evidence is available that supervision
significantly improves the effect of exercise programs.
3.2.4. Patient motivation and preferences
Three studies investigated the impact of motivation and
patient preferences (Table 5). Exercise combined with a motivational program was significantly better than exercise alone
in improving pain and disability after 1 and 5 years [43].
Patient preferences for group exercise classes or usual care had
no influence on the response to treatment [33]. Directional

preference can be defined as the direction (flexion, extension,

or sideglide/rotation) of exercise associated with marked and
lasting pain relief at the baseline evaluation [44]. Directional
exercises that matched the directional preference of each
individual patient were more effective than exercises in the
opposite direction or nondirectional exercises [44]. Finally,
motivation and preference should be taken into account when
designing and implementing exercise programs. Other studies
of these important factors are needed.
3.2.5. Training volume and intensity
Exercise programs for patients with low back pain usually
include muscle strengthening exercises, aerobic exercises, and
range-of-motion exercises. Independently from the type of
exercise, the volume and intensity of training vary widely
across programs. Exercising daily for short periods has been
recommended [26,45], chiefly for patients with acute low back
pain. Two to three weekly sessions each lasting 60e90 min are
often advocated for patients with subacute, recurrent, or
chronic low back pain [33,34,46e49]. In one study, patients
performed Pilates-based exercises three times a week for 1 h at
the clinic and six times a week for 15 min at home [50].
During a 1-year study, the number of weekly sessions
completed by the patients decreased over time [39]. However,
the frequency of the sessions may have a limited impact. In
asymptomatic individuals, one, two, and three weekly sessions
of lumbar extensor strengthening exercises produced similar

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537

Table 4
Studies of supervised exercise versus unsupervised home exercise
Authors

Patients

Bentsen et al. 1997 [42]

74 women with chronic LBP

Interventions

Effects

A: Supervised exercises twice a week for

12 weeks home exercises daily for
12 months
B: Home exercises daily for 12 months
Frost et al. 1998 [34]
81 patients with chronic LBP A: Specific exercises at home twice a day for
6 weeks group exercises twice a week for
4 weeks
B: Specific exercises at home twice a day for
6 weeks
Ljunggren et al. 1997 [40] 153 patients with chronic LBP A: Physiotherapist-designed training program, 3
times a week for 12 months, with supervision
during 8 sessions
B: Training using the TerapiMaster apparatus, 3
times a week for 12 months, with supervision
during 8 sessions
Manniche et al. 1991 [39] 105 patients with chronic LBP A: Intensive training program with supervised
group exercises
B: One-fifth of the intensive training program
C: Thermotherapy, massage, and mild exercise
Torstensen et al. 1998 [41] 208 patients with chronic LBP A: Supervised group exercises (up to 5 patients/
group), three times a week for 12 weeks
B: Conventional physiotherapy, three times a
week for 12 weeks
C: Unsupervised 1-hour walk three times a
week for 12 weeks

Significant improvement in function (Million

scale) after 3 and 12 months with A but only
after 3 months with B
Disability (Oswestry) after 6 and 24 months:
A>B

At treatment completion and after 1 year,

significant decreases in time off work, with no
significant difference between A and B

At treatment completion and after 3 months:

disability and pain, A > B > C

At treatment completion and after 1 year: pain

(VAS) and disability (Oswestry): C > A and B

LBP, low back pain; >, significantly better than; VAS, visual analog scale.

results [51] and in patients with chronic low back pain no

significant differences were found between two and three
training sessions per week [52].
3.2.5.1. Muscle strengthening. Series of eight to 12 dynamic
contractions are usually performed [39,40,53,54], although 15e
20 [46,49,54] or 20e30 [41] repetitions have been used also.
Isometric contractions are usually reserved for specific trunk
muscle strengthening and stabilization. Gradually increasing the
duration of each isometric contraction up to 10 s per contraction
with 10 contractions in all has been suggested [26]. Often, neither
the duration nor the number of isometric contractions is specified

[50], and physicians may need to rely on their clinical judgment to

determine these parameters [55]. Contraction intensity is rarely
specified, although an increase over time in the number of repeats
or load is sometimes mentioned [26,33,34,48]. In two studies,
exercise intensity was a set percentage of the one-repetition [46]
or 10-repetition [54] maximum estimated from the number of
repetitions performed at predefined amplitude and speed values,
without compensatory movements. Intensity can also be defined
based on maximal isometric strength [56] or the Borg perceived
exertion scale [46,57].
No single muscle contraction modality or training regimen
has been found capable of specifically relieving low back pain.

Table 5
Studies evaluating the influence of patient motivation and preferences on the response of patients with low back pain to exercise
Authors

Patients

Interventions

Effects

Friedrich et al. 2005 [43]

93 patients with recurrent or

chronic LBP

After 4 months, 1 year, and 5 years: disability

(low back outcome scale questionnaire) and pain
(101-point numerical rating scale): B > A

Long et al. 2004 [44]

230 patients with acute,

subacute, or chronic LBP

Moffett et al. 1999 [33]

187 patients with subacute or

chronic LBP

A: 10 exercise sessions, 25 min each, 2e3 times

a week 5 motivation-enhancing measures
B: 10 exercise sessions, 25 min each, 2e3 times
a week
A: 3e6 exercise sessions (McKenzie) for
2 weeks matching the patients directional
preference
B: 3e6 exercise sessions (McKenzie) for
2 weeks opposite the patients directional
preference
C: 3e6 nondirectional exercise sessions
(McKenzie)
A: Group exercises twice a week for 4 weeks
B: Usual care

LBP, low back pain; >, significantly better than; VAS, visual analog scale

After 2 weeks: pain (VAS) and disability

(RolandeMorris): B and C > A

At treatment completion and after 1 year,

disability (RolandeMorris) and clinical status
(Aberdeen back pain scale): A > B. Patient
preference for A or B did not influence the
treatment response

538

Y. Henchoz, A. Kai-Lik So / Joint Bone Spine 75 (2008) 533e539

This fact may explain the considerable variability of muscle

strengthening methods described in the literature. The American College of Sports Medicine recommends that patients
with low back pain follow the exercise plan suggested for the
general population, with appropriate adjustments such as
decreased exercising during bouts of acute pain. Muscle
strengthening exercises should be performed at least twice
a week, with 8e12 repetitions in patients younger than
50 years of age and 10e15 repetitions in older patients, in
whom muscle endurance should receive special attention [58].
It has been suggested that emphasis should be put on endurance rather than on maximum force in patients with low back
pain, regardless of age [55].
3.2.5.2. Cardiovascular endurance. The duration and intensity of aerobic exercise varies widely across published studies.
Exercising for 5e20 min at 60% of the maximum heart rate
(HRmax) has been recommended [49]. The same intensity was
used for 20 min during the first week, 30 min during the
second week, and 45 min during the next 8 weeks in a trial of
aerobic exercise for treating low back pain [59]. In other
studies, patients exercised at 60e70% of HRmax for 10e
20 min [45], 65e80% of HR max for 20 min [46], or 70e85%
of HRmax for 30 min [47].
High-intensity aerobic exercise may increase the risk of
cardiovascular events (by more than 70% for some cardiovascular conditions). This fact may explain the variations in
exercise intensity across studies, although none of the reports
mentions concerns about the cardiovascular risk. However,
provided the exercise program is properly planned and the
patients are investigated for cardiovascular disease, the risk of
cardiovascular events does not seem higher in patients with
low back pain than in healthy individuals. The ACSM
recommends that patients with low back pain improve their
aerobic performance via functional exercises such as brisk
walking for 5 min three to five times a week and repeatedly
sitting and standing in and from a chair for 1 min two to three
times a week, without supplying further details on exercise
intensity. The ACSM advises against high-impact aerobic
exercise such as running [58].
3.2.5.3. Stretching. Details on stretching exercises are rarely
supplied. The isometric technique seems to be the most widely
used method. The Back to Fitness program includes exercises to
stretch the muscles in the legs, thighs, hips, and trunk twice
a week, with each stretch being held for 20 s; the number of
repetitions is not specified [57]. Another program includes oncea-week stretching exercises that focus on the legs, hips, and
trunk; each stretch is held for 30 s, but the number of repetitions
is not indicated [60]. A group exercise program involves
stretching exercises that focus on the hip muscles, with four 15-s
repetitions and two exercise sessions per week [47].
The ACSM cautions against performing stretching exercises that exacerbate the pain, most notably when working on
the flexors and extensors of the trunk and hips. Stretching
exercises should be performed two to three times a week, and
each session should include three repetitions for each muscle

group. Static stretches can be performed, holding each stretch

for 10 s, or proprioceptive or ballistic neuromuscular facilitation can be used [58].
4. Conclusion
Exercise is effective for the primary and secondary prevention of low back pain. Exercise is more effective in decreasing
pain and disability from low back pain than control treatments or
physician consultation. The results are less consistent in
subacute low back pain, and the usefulness of exercise in acute
low back pain remains controversial. The volume and intensity
of exercises and the methods used for muscle strengthening,
aerobic training, and stretching are not described in sufficient
detail. Moreover, the methods used for muscle strengthening
and aerobic training rarely complied with ACSM recommendations. There is no firm evidence supporting general versus
specific exercise, individualized versus group programs, or
supervised versus home exercise. However, no single exercise
program is optimal in all patients with low back pain. The
physiological, psychological, and social effects of exercise vary
across patients. Studies are needed to identify patient subsets
that are likely to benefit from specific exercise programs.
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