Exercise therapy for chronic low back pain

Hayden et al. (Cochrane Review, 2021)

Aim

To evaluate the effectiveness of exercise therapy in adults with chronic non-specific low back pain, and to compare its effects with no treatment, usual care, and other conservative interventions.

Methods

This Cochrane review included 249 randomised controlled trials, representing more than 24,000 participants with chronic low back pain (>12 weeks).

Exercise therapy was compared to:

• no treatment / usual care / placebo
• other conservative interventions (e.g. education, manual therapy, electrotherapy)

The main outcomes were pain intensity and functional limitations.

Importantly, the authors predefined thresholds for clinical importance:

• 15/100 for pain
• 10/100 for function

This allows interpretation beyond statistical significance, focusing on what may be meaningful for patients.

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Results

When compared to no treatment or usual care, exercise therapy reduced pain by around 15/100 and improved function by around 7/100. This suggests a moderate effect on pain, while improvements in function are more modest.

When compared to other conservative treatments, differences were smaller, with reductions of around 9/100 for pain and 4/100 for function. In practice, this indicates that exercise performs well, but its advantage over other commonly used interventions is limited.

Exercise appeared more effective than education alone or electrotherapy, and showed similar effects to manual therapy. Adverse events were rare and mostly minor, typically involving temporary soreness.

Taken together, these results suggest that exercise is an effective intervention, although the magnitude of its effects remains moderate across outcomes.

Limitations

This review has several strengths, including the large number of trials, rigorous methodology, and the use of predefined thresholds for clinical importance.

However, some limitations should be considered. The term “exercise” covered a wide range of interventions, including strengthening, aerobic exercise, motor control training, and mixed programmes. There was also substantial variability in delivery, with differences in supervision, dosage, and co-interventions.

Risk of bias was present in several studies, particularly due to the difficulty of blinding participants and therapists. In addition, most outcomes were measured in the short to medium term, providing limited insight into long-term effects.

These limitations reflect both the heterogeneity of the research and the complexity of clinical practice.

In practice

This review supports the role of exercise as a central component in the management of chronic low back pain. It is safe, adaptable, and provides meaningful improvements in pain for many patients.

At the same time, the relatively modest effect sizes and small differences between interventions highlight an important point. Chronic low back pain is a multifactorial condition, influenced not only by physical factors but also by beliefs, behaviours, psychological distress, lifestyle, and social context.

From this perspective, it is perhaps not surprising that exercise alone produces moderate average effects when applied across large and diverse populations. While it can support movement confidence, physical capacity, and re-engagement with activity, it does not address all potential drivers of persistent pain.

This suggests that exercise is best understood not as a stand-alone solution, but as one component of a broader, person-centred approach. Supporting engagement, addressing beliefs and behaviours around movement, and integrating care within the patient’s context are likely to be key elements of effective management.

Reference

Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790.
DOI: 10.1002/14651858.CD009790.pub2.