Physical activity and low back pain

Low back pain is pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). About 85% of low back pain cases are non-specific, not attributable to recognizable pathology. The poorly defined pathophysiology and mechanism of pain explain to a large degree the difficulties of prevention and treatment of low back pain.

Low back pain is a common disorder, the lifetime incidence being around 60-80%. Most cases are resolved within 2-4 weeks and 90% recover by 12 weeks [48]. However, in a follow-up study nearly one-third of cases had not recovered completely in 1 year [49,50], and recurrence of low back pain is very frequent with rates of up to 50% in the year following the initial episode.

The origin and mechanisms of low back pain are not exactly known, but it seems that the symptoms originate from tissue injury or inflammation and from the resulting irritation, nociception [51]. This in turn causes increased muscular tension in order to decrease movements that cause pain. Thus, trunk muscles are an important element related to low back pain syndrome, and these muscles have a decisive role in protecting back structures from excessive mechanical loading.

Physical activity might relate to the development of low back pain as a provoking or preventing factor. Heavy physical work, frequent bending, twisting, lifting, pulling and pushing, repetitive work and static postures as well as reduced muscle strength in back, abdominal and thigh muscles, reduced endurance in back muscles, hypermobility in the lumbar column and hypomobility of hip joints are commonly listed, activity-related risk factors for low back pain [52]. The theoretical rationale for the role of physical activity (PA) in the causation or prevention of low back pain includes the following ideas: (i) PA can induce acute and repetitive subclinical or more severe injuries in the back structures; (ii) higher strength of the muscles of the back and trunk could protect the back from injury or minimize the effects of injurious events; (iii) higher endurance of the trunk muscles helps to maintain motor control due to less fatigue in various tasks thus decreasing the risk of high loading of spine structures or occurrence of malfunctions and consequently development of injury; (iv) better flexibility may decrease the risk of injury especially during lifting and bending activities; (v) good motor skills decrease the risk of injury in various tasks; and (vi) good general or aerobic endurance helps to counteract fatigue and development of injury [53]. Additional suggested mechanisms include improved circulation to the back structures and improved mood that would influence favorably sensitivity to pain [51]. In addition, PA may influence the development or the course of low back pain episodes in indirect, unspecific ways, e.g. through influences on body mass, mood, perceptions and motivation, and by decreasing or abolishing the effects of physiologic deconditioning due to inactivity or hypoactivity.

Current scientific evidence on the role of physical activity in provoking or preventing low back pain can be summarized as follows. Prolonged, repetitive, heavy physical activity at work or in sports can cause low back pain in susceptible individuals, but the ultimate contributory role of injury is not known. The most commonly practised leisure-time physical activities have not been found to increase the risk of low back pain. Strong evidence indicates that physical activity can have a preventive effect on low back pain and is currently the only effective tested modality for this purpose [51,54]. However, all studies do not show physical activity to be effective for prevention of low back pain. Further, the characteristics of an effective exercise program have not been defined. It is worth noting, however, that trunk muscle endurance in some cross-sectional studies and endurance training of these muscles in controlled trials has been associated with positive preventative findings [55].

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