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Advice to athletes with back pain—get active! Seriously?
  1. Kieran O’Sullivan1,2,
  2. Peter B O’Sullivan3,4,
  3. Tim J Gabbett5,6,
  4. Mary O’Keeffe7
  1. 1 Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  2. 2 School of Allied Health, University of Limerick, Limerick, Ireland
  3. 3 School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
  4. 4 Bodylogic Physiotherapy, Perth, Western Australia, Australia
  5. 5 Gabbett Performance Solutions, Brisbane, Queensland, Australia
  6. 6 Institute for Resilient Regions, University of Southern Queensland, Ipswich, Queensland, Australia
  7. 7 School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Kieran O’Sullivan, Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar; kieran.osullivan{at}

Statistics from

The recent Lancet low back pain (LBP) series1–3 recommended exercise and physical activity, particularly for persistent and debilitating pain. Given a dearth of clinical trials for LBP among athletes, is encouraging activity justifiable for athletes with LBP when they are often already highly active? This editorial teases out the role of exercise and activity for LBP among athletes.

Do athletes get LBP because they are too active already?

The evidence that athletes get LBP because they are excessively active is limited. For example, there are data that LBP intensity among rowers is higher during intense training periods,4 and that highly active teenagers develop more future LBP.5 However, these studies either did not always examine how meaningful or disabling the LBP was4 5 or several other factors were also implicated. What is clear is that being consistently active is associated with less pain and injury. In other words, being active might be a good thing to reduce pain, including LBP, as long as the rate of increase in activity is managed appropriately and other relevant factors (eg, sleep, mood, relationships) are also addressed.

What else could contribute to LBP in athletes other than high activity levels?

It is worth remembering that many factors linked with LBP in non-sporting populations (eg, stress, anxiety, mood, self-esteem, impaired sleep, fatigue) also occur in sporting populations.6 Consequently, even among ‘fit and healthy’ athletes it is critical to screen for these markers of ill health, and thereafter assist athletes with these factors. This is particularly relevant when the LBP symptoms do not fit a clear tissue strain/injury model.

Implications for practitioners treating athletes

  1. Do not demonise necessary sporting activities: We need to be very cautious before blaming high activity levels—or one particular form of exercise—for the onset or deterioration of LBP. For example, while a sudden increase in bowling load is associated with increased risk of pain or injury in cricketers, a high chronic bowling load is actually associated with lower risk.7 Therefore, even when a specific activity is linked to the onset of LBP, we need to be mindful not to induce a long-term reluctance among athletes to expose their body appropriately to high loads due to a sense of vulnerability. While specific provocative tasks might be avoided or reduced in the short term, there is evidence that exercising with some pain is at least as effective as painfree rehabilitation.8

  2. Do not ‘sell’ rehabilitation exercises as correcting vulnerability: Certain types of exercise are often pitched as being particularly ‘protective’ for the spine despite evidence that most forms of exercise help LBP to some extent. Whatever exercises are prescribed, there may be little value in selling the exercise to the athlete on the basis that they are particularly vulnerable (eg, through their poor posture, core strength, alignment, etc). Instead, promoting exercises as making them even more robust and resilient may reduce vulnerability and improve physical and psychological readiness.

  3. Keep athletes as active as possible: Closely monitor how LBP behaves as load is changed. For example, reducing activity levels is hard to justify unless it dramatically reduces an athlete’s LBP. Even if certain activities are painful and must be limited, maintaining some form of activity is important. For example, an athlete with bone marrow oedema in the region of the pars interarticularis might be provoked by specific tasks and movements, for example, running and/or spinal extension. Advocating complete rest and/or using bracing in such a situation could increase the risk of an athlete becoming a ‘chronic rehabber’ at risk of poor performance and recurrent pain/injury. In contrast, painfree cross-training (eg, high-intensity static bicycle intervals) is often possible, which can maintain fitness and facilitate earlier return to sport and optimal performance. Specific aspects of skill or conditioning in need of development can also be targeted during these periods.

  4. Do not ignore non-physical factors: Many markers commonly used to monitor training responses (eg, sleep, energy, mood, soreness) offer useful insights into the sensitivity of the athlete’s nervous system and provide opportunities to optimise their health.


Prolonged inactivity for an athlete with LBP can increase their injury risk, which ultimately results in further inactivity and potentially more pain. While ‘keep active’ might seem an odd recommendation for athletes with LBP, emphasising activity as a means to recovering well from LBP, as well as maintaining performance levels, remains an appropriate message. The rationale for any reduction of painful activities, even in the short term, should be communicated clearly and simply to athletes, to avoid them viewing either the activities as dangerous, or their bodies as vulnerable. Since we know how good performances can be when athletes train hard, we need to project and maintain this mindset onto athletes—even in the presence of LBP (figure 1).

Figure 1

How responses to managing low back pain in athletes can influence outcomes.



  • Contributors All authors have made substantial contributions to the conception, design, acquisition, analysis and interpretation of data. All authors have revised it critically for important intellectual content and approved the final version. In doing so, we agree to be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests KO’S, PO’S, MO’K and TJG provide professional development workshops for clinicians and coaches. TJG works as a consultant to several high-performance organisations, including sporting teams, industry, military and higher education institutions. Both KO’S and TJG serve in a voluntary capacity as Senior Associate Editors of BJSM. MO’K is a postdoctoral student of one of the authors involved in the Lancet series.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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