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Unlocking the potential of physical activity for back health
  1. Mary O’Keeffe1,
  2. Chris G Maher2,
  3. Kieran O’Sullivan3
  1. 1 Department of Clinical Therapies, University of Limerick, Limerick, Ireland
  2. 2 Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
  3. 3 Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  1. Correspondence to Mary O’Keeffe, Department of Clinical Therapies, University of Limerick, Health Sciences Building, Castletroy, Limerick 0000, Ireland; Mary.OKeeffe{at}

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Physical activity is central to achieving better back health. Engaging in some forms of physical activity may increase the risk of low back pain (LBP), but in general a physically active lifestyle seems to be protective for LBP.1 The only known effective prevention method is exercise alone or exercise with education.2 Most guidelines for acute LBP focus on advice to increase physical activity. For persistent LBP, most effective treatments have physical activity at their core, either where it is the main component (eg, aerobic exercise) or where there is greater use of psychological principles (eg, graded exposure).

In our view, the potential value of physical activity for back health is not being realised. We address four key issues.

1. Preoccupation with the right physical activity could be holding us back

While many clinicians confidently preach the benefits of physical activity for general health, this confidence seems to be replaced with a pause or panic when advising a patient who has LBP.3 For instance, ‘You need to get moving BUT let pain guide you and avoid running on the road’. Many of us remain guilty of constraining the amount and types of physical activity people with LBP participate in. Encouraging ‘good’ posture or engaging the core during activities like bending still feature in LBP trials, despite a lack of research showing superiority over more simple exercise approaches.4 Pain-contingent pacing also remains popular despite the mixed evidence. We need to be careful not to demonise activities that are not dangerous, as this could instil fear around the spine. Furthermore, the emphasis on the 'right' exercise (usually a complex form only a physiotherapist can deliver) needlessly complicates things. Despite strong evidence showing similar effects across different exercises for LBP4, arguments continue over the best exercise.

We need to stop placing these barriers in the path of people with LBP, which requires abandoning outdated beliefs that the back is only capable of certain amounts and types of activity.

2.  Diluting exercise with adjuncts could be holding us back

It is common for exercise to be combined with adjuncts (eg, manual therapy, back belts) in the treatment of LBP.5 In our quest to be ‘multimodal’ and ‘comprehensive’, could we be guilty of delivering a cocktail of contradictory approaches that could drive muddled thinking about LBP? Adjuncts are often justified as providing a window of opportunity for behavioural change, but could they also close the window of opportunity for exercise to be effective? For example, ‘I always prescribe home exercise BUT the patient needs massage and insoles’. Since dose and supervision of exercise is important to LBP outcome,6 spending time on non-exercise approaches could potentially reduce the priority that people with LBP place on exercise. Asking ourselves why we are delivering adjuncts could be important. If we are delivering education and/or adjuncts with exercise, we need to ensure that they are of real value and the message provided complements the exercise and makes the person feel the spine is capable, not contradict exercise and induce fear and vulnerability.

3. We tend to focus on the ‘bio’ when prescribing exercise for LBP

LBP is best understood from a biopsychosocial perspective yet many revert to a biomedical approach when prescribing exercise. Research has shown that LBP is not just a problem in your back. The condition is associated with a wide range of physical, psychological, lifestyle and social factors, many of which can be helped by physical activity approaches. However, many exercise trials for LBP do not explicitly target this broader range of factors.5

A quick scan of LBP exercise trials illustrates the problem. The types of outcome and process measures usually taken, together with methods of exercise progression, seem to suggest that exercise for LBP is still seen through a biomedical lens. Trialists routinely measure pain outcomes but not sleep or mood, and process measures focus on local lumbar factors like range of motion, muscle activation and strength, despite the lack of evidence linking the effects of exercise in LBP to musculoskeletal system changes.7 Therefore, it seems unclear whether people with LBP are being informed of systemic, health-enhancing effects of exercise.

4. We are not good at getting people physically active: a harsh reality that we need to think about

Despite pleas for a ‘Move for Movement’ and ‘Exercise is Medicine’, our attempts to get people with LBP more active are failing.8 Physical activity is beneficial but it is not being widely adopted in clinical care. We need a better understanding of the barriers and facilitators to getting people physically active. There is a lack of trials implementing goal setting, harnessing intrinsic motivation, enjoyment and exploring a person’s perceptions and experience of activity. These may be helpful avenues to explore. Our current failures need to be addressed. If people do not engage with physical activity, what value is it?


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