MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

This study aimed to investigate the clinical effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention to prevent the recurrence of low back pain.

WalkBack was a two-armed, randomised clinical trial, which recruited adults (aged 18 years or older) from across Australia who had recently recovered from an episode of non-specific low back pain that was not attributed to a specific diagnosis, and which lasted for at least 24 h. Participants were randomly assigned to an individualised, progressive walking and education intervention facilitated by six sessions with a physiotherapist across 6 months or to a no treatment control group (1:1). The randomisation schedule comprised randomly permuted blocks of 4, 6, and 8 and was stratified by history of more than two previous episodes of low back pain and referral method. Physiotherapists and participants were not masked to allocation. Participants were followed for a minimum of 12 months and a maximum of 36 months, depending on the date of enrolment. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected in the intention-to-treat population via monthly self-report. Cost-effectiveness was evaluated from the societal perspective and expressed as incremental cost per quality-adjusted life-year (QALY) gained. The trial was prospectively registered (ACTRN12619001134112)

Between Sept 23, 2019, and June 10, 2022, 3206 potential participants were screened for eligibility, 2505 (78%) were excluded, and 701 were randomly assigned (351 to the intervention group and 350 to the no treatment control group). Most participants were female (565 [81%] of 701) and the mean age of participants was 54 years (SD 12). The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio 0·72 [95% CI 0·60–0·85], p=0·0002). The median days to a recurrence was 208 days (95% CI 149–295) in the intervention group and 112 days (89–140) in the control group. The incremental cost per QALY gained was AU$7802, giving a 94% probability that the intervention was cost-effective at a willingness-to-pay threshold of $28 000. Although the total number of participants experiencing at least one adverse event over 12 months was similar between the intervention and control groups (183 [52%] of 351 and 190 [54%] of 350, respectively, p=0·60), there was a greater number of adverse events related to the lower extremities in the intervention group than in the control group (100 in the intervention group and 54 in the control group).

The authors concluded that an individualised, progressive walking and education intervention significantly reduced low back pain recurrence. This accessible, scalable, and safe intervention could affect how low back pain is managed.

Rigorous clinical trials of excercise therapy are difficult to conceive and conduct because of a range of methodological issues. For instance, there is no obvious placebo and thus it is hardly possible to control for placebo effects. Nonetheless, the benefits of exercise therapy for back pain is undoubted. As previously discussed on this blog, a recent systematic review concluded that “the relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance.”

I have always been convinced of the health benefits of excercise. In fact, 40 years ago, when I did my inaugural lecture at the University of Munich (LMU), excercise was its topic and I concluded that, if exercise were a pharmaceutical product, it would out-sell any drug. The new study only confirms my view. It adds to our knowledge by suggesting that exercise also reduces the risk of recurrences.

Forget about spinal manipulation, acupuncture, etc., despite the undeniable weaknesses in the evidence, exercise is by far the most promissing treatment for back pain

9 Responses to Exercise for back pain prevention: forget about chiropractic, osteopathy, acupuncture, etc., exercise is by far the most promising treatment

  • Thanks for sharing solid justification for something I learned about myself. My lower back has always been my exercise meter–if it’s beginning to hurt I get up and get moving. Regular exercise, for me, has also kept lower back pain issues at bay. Pretty sure the couple of times I did see a chiropractor for it, the condition would’ve healed at the same rate without any such intervention.

    • @Norman
      Pain-guided exercise/activity has been the standard of care for uncomplicated lower back pain for some 40 years now. Before that, bed rest and painkillers were prescribed – and yes, I’m old enough to have experienced that as well. Let’s just say I’ll take the moderate exercise option any day.

      And no, I never felt the urge to pay chiropractors or other medically uneducated practitioners for ‘treating’ my back problems, especially after evidence-based interventions such as the above got quite effective, thank you very much.

      So to all those people who experience lower back problems at some time in their life: don’t waste your money on dumb quacks like chiropractors.

      Just check with your (real) doctor that there’s nothing more serious going on than our evolutionary drawback of walking upright, and take the advice of this doctor or a physiotherapist: just keep moving, and take it easier if the pain gets worse. Some mobility exercises for the pelvis may help a little bit, but the main thing is to keep active as much as possible.

  • Interesting the intervention group didn’t stop going to a chiropractor when compared to the control group.

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