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Exercise and the prevention of back pain disability
  1. Martin R Underwood
  1. Department of General Practice and Primary Care Queen Mary and Westfield College Mile End, London E1 4NS email: m.underwood{at}mds.qmw.ac.uk

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    Back pain is an important health and social problem. Over the last 30 years the amount of time lost from work because of spinal problems has increased across all developed countries. In the United Kingdom, there was a 266% increase in the days of Invalidity Benefit paid for spinal disorders in the 10 years to 1994.1 Since then, Incapacity Benefit has replaced Invalidity Benefit, and the number of days of benefit paid for spinal disorders (for periods of greater than six months) has stabilised at around 90 million a year (DSS figures). Notwithstanding this increase in benefit payments, the prevalence of back pain in the general population appears unchanged.1 This suggests that there may be an epidemic of back pain disability rather than an epidemic of back pain itself. About one in six of the population report having back pain on any one day, one in three sometime in the last month, and 6% will have had long standing or serious disabling low back pain in the previous year.1,2 In 1993, the annual cost to the NHS of treating back pain was estimated at £481 million, and the non-NHS costs of treating back pain was estimated at £197 million.3 Even a small percentage reduction in disability could have a large impact on both NHS costs and the non-NHS costs borne by individuals and their private insurers.

    Many different, general and specific, exercise programmes are advocated for the treatment and prevention of back pain disability. Convincing evidence of a clinically important effect has not been found for any regimens recommending specific spinal exercises for acute back pain.4 There is research evidence that the resumption of normal activities shortens the duration of acute and subacute episodes of back pain, leading to the assumption that chronic disability will also be reduced.5 The evidence review for the United Kingdom national guidelines for the management of acute low back pain considers the diagnosis and treatment of acute back pain in detail.5 The guidelines recommend that patients with back pain who do not have nerve root compression or reasons to suspect a serious underlying condition should be classified as having “simple back pain”. It is thought that encouraging those who develop simple back pain to resume normal activity, including exercise, as soon as possible will reduce the proportion who develop long term disability and is very unlikely to cause significant harm.

    Data on the effect of recreational exercise on the development of back pain disability in symptom free people are sparse. Because few symptom free people progress to back pain disability and because there are significant problems ensuring compliance with an exercise regimen, any community based randomised controlled trial to show an effect of exercise would be unfeasibly large. A number of controlled trials in the workplace have suggested that exercise can reduce the incidence of back disability.6 A 1994 review of observational studies concluded that increased general fitness, or spinal flexibility, may have a slight protective effect against the future development of back pain.7 Most of the studies included were workplace, not community, based. Two long term studies, one Finnish workplace study8 and one Danish population study,9 published too late to be included in the review, also suggested that physical activity protects against the development of back pain. A recent population study based in two general practices in South Manchester followed a cohort of back pain free people for one year. Sporting activity had no effect on the incidence of back pain in men but increased its incidence in women.10 These observational data must be interpreted with caution because the majority were obtained in the workplace, not the general population, and there is the possibility that unknown confounding factors could have affected the results. Most published studies do, however, suggest that regular general exercise has some protective effective.

    In summary, the evidence on the effect of recreational exercise on the development of back pain in the general population is not conclusive. As regular physical activity is thought to reduce the proportion of those with back pain that progress to established disability, it is plausible to hypothesise that regular recreational exercise before the onset of pain would have a similar effect. Controlled trial evidence obtained in workplace settings supports this. Although the evidence for exercise preventing back problems is weak, the other potential benefits of exercise mean that it is reasonable to encourage regular physical activity as part of a strategy to reduce the overall impact of back pain disability, on both the individual and society overall.

    Acknowledgments

    I am funded by an NHS R&D Primary Care Career Scientist Award. The views expressed in this article are my own and do not necessarily represent the views of my employers.

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