Chronic Lower Back Pain

58% to 70% of people are likely to suffer from Low Back Pain (LBP) in their lifetime and between 15% and 37% will suffer from this condition each year1,2. In 2000, the annual cost of all types of low back pain was said to be between £265m and £383m2 whilst in 2005, it was suggested that 500m working days are lost each year as a result of this condition2.  It should be noted that acute (short term) and chronic (long term) low back pain are different conditions and need to be addressed as such.
In the CLBP client there is often a strong relationship with psychosocial factors including fear of re-injury, incomplete or confusing diagnosis or work-related aspects2. If an individual believes that movement will increase their pain then avoidance of leisure activities is likely3.
Effects on the exercise response
LBP itself does not have an effect on the exercise repsonse, although the ability to exercise may be limited by physical factors (pain or fatigue), psychological factors (fear), or sociological factors (poor advice)1. People with LBP should be encouraged to exercise in a variety of modes of exercise in order to find the best method that works for them. 
Effects of exercise training
The period of inactivity that results from LBP should be limited by time and not pain1. It is appropriate to motivate clients to be active and undertake a balanced exercise regime, as for chronic nonspecific LBP, exercise and activity are strongly recommended1. Practitioners should address fears about exercise or activity as a cause of further pain and reinjury1.
Management and medication
NSAID's and non-narcotic analgesics are commonly taken but these should have no effect on the individual's exercise capacity1. There may however, be medications for other conditions that should be taken into consideration.
Exercise testing
Individuals with LBP should be able to perform all exercise tests recommended for uninjured, sedentary participants1. Of particular interest are isometric assessments of core stability (trunk extension, flexion)1.
Exercise Programming
Whilst a number of studies have shown that exercise is preferable to rest for LBP, there is little evidence to suggest that any particular exercise regime is preferable1. Programmes have focussed on aerobic capacity, core strength, flexibility or a combination of these. Whilst there is little evidence to support the use of aerobic exercise as a sole therapy, it can be used to maintain and enhance the ability to perform activities of daily living (ADLs)2. Aerobic activity can be carried out for as little as 2 minutes up to 20-30 minutes and ideally at an intensity of RPE 11-14 although postural control should be stressed at all times2.
It has been suggested that spinal stabilization exercises (core stability) are beneficial for individuals with back pain. They should be introduced initially in stable positions where the skill of isolating and contracting can be learnt and practised. This should then proceed on to progressively more challenging functional activities such as walking or stair climbing prior to their use in more vigorous activities2. Particular attention should be paid to the use of graded progressions and the use of stability balls is questionable and should be limited and supervised.
It is also appropriate to incorporate a whole body approach to resistance training along the lines of the relevant ACSM guidelines. This may provide the general benefits that a resistance training programme can provide but a well designed programme can both assist in training core stability in many different movements and also boost confidence and address any issues of fear of re-injury.
It seems likely that a combination of all these types of training should be incorporated in any graded exercise programmes.  

Key Reading
Asghar Norasteh, A. (2012) Low Back Pain. InTech Available from:

Lecture Notes
Click here for a Prezi

1.    American College of Sports Medicine (2009) ACSM's exercise management for persons with
        chronic diseases and disabilities (3rd Ed) Champaign, IL: Human Kinetics. (Ch35, p256-266-269) 
2.    Buckley, J. (Ed) (2008) Exercise Physiology in Special Populations. Oxford; Elsevier. (Ch5, p 139-160)
3.    Picavet, H.S.J., Vlaeyen, J.W.S., Schouten, J.S. (2002) Pain catastrophizing and kinesiophobia: predictors of
        chronic low back pain. American Journal of Epidemiology 156(11): 1028-1034
Key Reading
McGill, S.M. (2007) Low Back Disorders:Evidence based prevention and rehabilitation (2nd Ed) Champaign, IL: Human Kinetics [google books][]

Adams, M. A., Burton, A. K., Dolan, P., & Bogduk, N. (2012). The biomechanics of back pain (3rd Ed). Churchill Livingstone. [companion website]

Norasteh, A. (2012) Low Back Pain. InTech [full text]

Further Reading
Click here for more references
Suggested Resources
Revised Oswestry Back Pain Disability Questionnaire -click here
Acute Low Back Pain Questionnaire (Linton & Hallden, 1996) - Click here

Fear-Avoidance Beliefs Questionnaire (FABQ) for Patients with Back Pain (Waddell, Newton et al, 1993) – click here

Roland-Morris Disability Questionnaire - website - pdf

New Zealand Acute Low Back Pain Guide (2004) – Click here

Patient UK.
The American Academy of Spine Physicians.
The American Association of Neurological Surgeons.
The North American Spine Society.
Core Stability on

HSE Better backs campaign – Click here for more

Keele STarT Back Musculoskeletal Screening Tool – click here for more

Anatomy of the Spine

YouTube Video