Graded exercise or walks for recurrent low back pain
As a confirmed exercise-free zone, I am always interested in studies that look at whether specific exercise makes a difference in recovery for people with chronic pain.  My preference is to dance (yes, belly dance is good!), and I enjoy walking and cycling, but gyms? no way!

This study caught my eye because it is a head-to-head comparison of two popular approaches to reactivation for people with recurrent low back pain – graded exercises for eight weeks, or a walking programme for eight weeks.  While I could argue that the small sample size (71 participants), and the lack of double-blinding and a couple of other methodological issues make this study somewhat weak, there are some interesting things to note from it.

The basic study consecutively recruited participants into two groups – one received a graded exercise programme supervised by a physiotherapist in which stabilising exercises (Richardson’s protocol was followed) were prescribed, and ‘the progression of the exercises was based on the patients’ pain level and observed movement control and quality.’ The programme was for 8 weeks.  Specifics of the approach are reasonably well-described in the paper.

The other group was instructed to take one 30-minute or two 15-minute walks each day ‘at the fastest pace that was convenient and did not set off pain. If their pain persisted or increased they should slow down. They should continue with other usual activities. They were also given general home exercises but with no follow-up instructions.’This group was also asked to record their progress over the 8 weeks.

The measures used were the Oswestry, visual analogue scale for pain, and the physical health subscale of the SF-36. A self-efficacy scale was used, and the Fear Avoidance Behaviour Questionnaire.

What happened?

Well, both groups demonstrated a reduction in pain intensity over the 36 months, with the difference between the groups only evident in the exercise group at the first measurement point immediately after the programme.  Both groups also demonstrated improvement in function (reduction in disability) with the exercise group showing slightly more improvement than the walking group.  Physical health and self efficacy also improved for the exercise group but not as much for the walking group.

Neither group showed any changes in fear-avoidance scores.


The authors suggest that their original intention was to identify, in a real clinical setting, whether stabilising exercises made a difference to pain and/or function.  They state ‘it is … not clear that reduced pain and disability after stabilizing exercises is associated with changes in the muscle activity pattern: other underlying explanations are possible.’

What is known, is that in this group of reasonably nondisabled participants, exercises helped them feel slightly more confident about their ability to manage (improved self efficacy).  The authors admit that perhaps the changes were because of what they describe as ‘a behavioural change’, and they cite Wessel, van Tulder et al who reviewed the factors that are known to predict positive outcome in nonsurgical management of low back pain.  So, these two groups may have improved simply because they were both given a structured programme of activity to follow.

There are some real differences between the two groups that weren’t controlled for – one group had 8 weeks of clinical input with a therapist, with a set of special exercises that were monitored.  Their progress was recorded, and undoubtedly they were given praise and felt a sense of achievement when they became competent enough to progress to the next set of exercises.

The comparison group simply recorded their walking over the 8 weeks, and had little or no therapist contact.  Their programme didn’t change or progress, so some of those really exciting positive vibes that come from achievement (and are known to directly influence self efficacy) were missing.  So I’m not surprised they reported a better sense of self efficacy at the follow-up sessions.  I’m a bit surprised there was so little difference between the two groups, actually!

The importance of patient expectations are discussed by the authors of the study. Initially there was no difference in expectation between the two groups, but by the conclusion, the exercise group reported greater satisfaction.  We know that patient satisfaction can strongly influence their adherence to recommendations, and their pain and disability.  This group had a set of ‘special’ exercises they could use whenever they experienced pain, which might have contributed to them feeling as though they had more control, and therefore lower distress when they did have a recurrence.

I’m not surprised there were no changes on FABQ – neither approach directly addressed the specific concerns the participants might have had about pain equalling harm.  It’s interesting that in both groups, participants were specifically told to use pain as their guide and to modify their exercise accordingly.  This is a strategy that can reinforce the sense that experiencing pain is a ‘bad’ thing and movement should be restricted.  I wonder what might have happened if both groups were asked to continue with their programme as normal even during exacerbations of pain.

A final couple of words: one day I hope to see a comparison between something like a graded programme of household tasks and a graded exercise programme.  Or a comparison between dancing and a graded exercise programme.  Then we might see whether it’s movement in general, or specific exercises that are helpful.

Similarly, I’d love to see what would happen if a non-physiotherapist supervised exercises – there could well be a treatment effect simply from having ‘the movement expert tell me I’m safe’.

And I’d love to see what would happen if a cognitive behavioural component was included in both situations – working with the person to see what their thoughts and beliefs are about their problem and their progress.

I do have a hunch that just doing normal activities in a systematic way, with a professional that the person believes in, and some specific work with the person’s thoughts and beliefs while they do their own activities, might do more than all the ‘special’ exercise programmes and gym paraphernalia can do.  Or maybe that’s my exercise-free zone chiming in.

Rasmussen-Barr E, Ang B, Arvidsson I, Nilsson-Wikmar L. (2009). Graded exercise for recurrent low-back pain: a randomized, controlled trial with 6-, 12-, and 36-month follow-ups. Spine, 34 (3), 221-228 DOI: 19179916

Richardson C, Jull G, Hodges P, et al. Therapeutic Exercise for Spinal Segmental
Stabilisation in Low Back Pain. Scientific Basis and Clinical Approach.
1st ed. United Kingdom: Churchill Livingstone; 1999.

Estlander AM, Vanharanta H, Moneta GB, et al. Anthropometric variables,
self-efficacy beliefs and pain and disability ratings on the isokinetic performance
of low back pain patients. Spine 1994;19:941–47.

Wessel T, van Tulder M, Sigl T, et al. What predicts outcome in nonoperative
treatments of chronic low back pain? A systematic review. Eur
Spin J 2006;15:1633–44.


  1. What’s up Bron? Have we fallen out or something? You’ve already acknowledged some of the weaknesses of the study, so I won’t go back over that, but would like to raise a few additional points.

    1. There is plenty of research out there that would suggest that activity per se is helpful with CLBP rather than a specific intervention. So your hunch already has an academic basis to it.
    2. Both exercise regimes offered in this study remain pain contingent. Hardly fitting with a biopsychosocial framework – what are the researchers worried about, they might cause more damage? It’s of little surprise the FABQ was consistent – the message they received was consistent.
    3. Don’t we know that at long term follow ups the majority of chronic pain patients are failing to apply their taught strategies – and this goes across the board. So the initial gains of a ‘dynamic stability’ programme would hopefully be reflected in the patients function (just like the walking) rather than some ‘abs of steel’ outcome.

    I agree that it isn’t the physio’s exclusive role to encourage movement, just as it isn’t the psychologists exclusive role to use a CBT approach, but if you move away from an IDT and look at a clinicians core skill set, then it’s the physio we are all going to look to get the person up and moving.

    Surely the most important influence on the nature of the acitivity used with someone with chronic pain is the patient? Self management would imply some self-motivation, and looking at what they want to do, and having exercises or activity to reflect that, or that lead to its reintroduction.


    1. Hi Mary
      No falling out intended!!
      Simply to suggest that it doesn’t have to be a physiotherapist – but could be anyone the person trusts and believes in. Which could mean that the ‘essential’ requirement of ACC (and from some physiotherapists) to have physiotherapy ‘direct’ activity rather than exercise could be challenged. I’m going to temporarily put my occupational therapy hat on and stomp around a bit – why on earth are occupational therapists not putting their clinical skills to the fore to help people put together a daily activity programme rather than leaving it to physiotherapists and psychologists to do this? At least when I trained (waaaaaay back) occupational therapists had a good deal of training on exercise principles, anatomy, physiology (bugger all on pain, but I don’t think anyone did!), and use this to apply to graded reactivation of daily activities. What is the difference between applying this to walking or doing the vacuuming?! So I challenge your statement that ‘it’s the physio we are all going to look to get the person up and moving’ – other professions have a similar skill set – look at the walking component of the Mick Sullivan programme (not that I would suggest this is a programme to necessarily emulate, but at least it uses walking rather than specific exercises! and it is delivered by any allied health professional. Sadly he thinks that non-psychologists can’t identify mood and anxiety problems, nor use psychometrics adequately, so that aspect remains psychology exclusive).

      Back to self management – I recall years ago being told that ‘it doesn’t matter what exercise you do, provided you do it, you’ll benefit’ – the problem is finding something that people want to do. Which is why I belly dance and don’t go to the gym! I don’t think this is explored nearly enough in subacute or chronic pain management – the funding structures don’t allow it under ACC. If physiotherapists, occupational therapists, psychologists, nurses, social workers, GP’s and others could ask the person what they do for activity (not simply exercise), building on this would be the way to go. Does it have sufficient face validity to a patient? I don’t know – there is a whole industry that is built upon having ‘the right exercises’ to do to ‘correct’ back pain – along with the belief that when you have a cold, you need to walk away from the GP’s surgery with a prescription! so I’m guessing the patient expectancy is a large part of this.
      ’nuff said, I’m going off to practice my hip drops and shimmies!

  2. We are on the same here Bron. My ‘who do you look to?’ point shares your frustration – each clinical area is pigeon holed and needs clinicians to highlight (and use) their broader skill base.

    As a physio, I can help schedule activity, discuss a patients anxieties around their activities, and explain the potential risks of avoiding these activities (not sure if I could sing a song about it, or weave it into a bag, but we all have our weaknesses too).

    One of the liberating things about working wtih chronic pain patients is their experience of health professionals so far. There’s no point going down the same route as was tried before (it didn’t work or they would still be presenting) so already you are needing to work outside the usual ‘box’.

    Right, I’m off to find an article on how OT’s aren’t the only people who can clean baths – and see how YOU like it!

  3. I’d be delighted! I do know that 15 year olds seem to be completely UNABLE to do so… suggestions?!
    You could try tie-dying I’m sure, it might start a new modality for physiotherapists – but you’d have to watch out or the psychologists would want to analyse them instead of ink blots!

  4. Ever since my highschool days of kickboxing, football, and weightlifting I have had lower back pains. The thing I have seen help me the most are daily stretches, some yoga helps allot and what you sleep in. Walks and biking by far are my favorite excersizes. Hiking can be a little tough in the begining as the muscles begin to warm up. I push through the uncomfort and next thing you know after 30 minutes I can’t stop walking or hiking. The best thing I ever slept on was a memory foam mattress. Stretching is also a good daily practice and I’ve also noticed acupuncture does wonders for long periods of time.

  5. I myself am active. I bike play tennis play other sports. Yet my back pains come and go. Ever since my highschool days of kickboxing, football, and weightlifting I have had lower back pains. The thing I have seen help me the most are daily stretches, some yoga helps allot and what you sleep in. The best thing I ever slept on was a memory foam mattress. Stretching is also a good daily practice and I’ve also noticed acupuncture does wonders for long periods of time.

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