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MSK Pain – Reduces frequency of painful episodes

Reduces pain and frequency of painful exacerbations

Evidence summary

There is a large volume of high quality evidence demonstrating that exercise therapy significantly improves pain in those with chronic low back pain. A Cochrane review identified the mean improvement as 10.2 points on a 0-100 VAS scale when compared with no intervention [1]. In addition, trial evidence also suggests that regular exercise is effective at reducing the incidence of back problems in working age populations [2,3]. Lesser quality evidence suggests that exercise therapy is more effective when undertaken alongside an educational programme [4]. Adopting a multidisciplinary biopsychosocial approach is more effective than physical treatments alone at improving pain [5]. A variety of interventions, including walking therapy [6], core stability exercises [7], resistance training [8]and motor control exercises [9], have been shown to be effective.

There is no convincing evidence that exercise interventions are helpful in the management of acute back pain [1]. However, continuing activities during episodes of acute back pain is important in reducing long-term morbidity and should be encouraged [10].

Quality of evidence

High quality

Strength of recommendation



Exercise interventions should be offered to those with chronic lower back pain, with or without educational and psychological interventions depending on the psychosocial contribution to their symptoms. Those with acute low back pain should be encouraged to keep active.


1         Hayden J, van Tulder MW, Malmivaara A, et al.Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst RevPublished Online First: 2005. doi:10.1002/

2         Bigos SJ, Holland J, Holland C, et al.High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J2009;9:147–68. doi:10.1016/j.spinee.2008.11.001

3         Shiri R, Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med2017;51:1410–8. doi:10.1136/bjsports-2016-097352

4         Steffens D, Maher CG, Pereira LSM, et al.Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med2016;176:199–208. doi:10.1001/jamainternmed.2015.7431

5         Kamper SJ, Apeldoorn AT, Chiarotto A, et al.Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj2015;350:h444–h444. doi:10.1136/bmj.h444

6         Lawford BJ, Walters J, Ferrar K. Does walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review. Clin Rehabil2016;30:523–36. doi:10.1177/0269215515590487

7         Wang XQ, Zheng JJ, Yu ZW, et al.A Meta-Analysis of Core Stability Exercise versus General Exercise for Chronic Low Back Pain. PLoS One2012;7:1–7. doi:10.1371/journal.pone.0052082

8         Kristensen J, Franklyn-Miller A. Resistance training in musculoskeletal rehabilitation: a systematic review. Br J Sports Med2012;46:719–26. doi:10.1136/bjsm.2010.079376

9         Macedo LG, Maher CG, Latimer J, et al.Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther2009;89:9–25. doi:10.2522/ptj.20080103

10       NICE. Low back pain and sciatica in over 16s: assessment and management | Guidance and guidelines | NICE. (accessed 14 Jun 2018).