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MSK Pain – Reduces frequency of painful episodes

Evidence Summary (Updated 2022)
There is a large volume of high-quality evidence demonstrating that exercise therapy significantly improves pain in those with chronic low back pain (4). A Cochrane review previously identified the mean improvement as 10.2 points on a 0-100 VAS scale when compared with no intervention (1). These findings were corroborated in the most recent update which found a pooled mean difference of -15.2 (95%CI, -18.3 to -12.2, I2=75%)(3). Based on GRADE the Cochrane review thought the data was of moderate quality due to the risk of inconsistency (3).

In addition, trial evidence also suggests that regular exercise is effective at reducing the incidence of back problems in working age populations (13,14). Review studies found that pain was improved in the elderly with back pain when treated with an exercise intervention (5).

Lesser quality evidence suggests that exercise therapy is more effective when undertaken alongside an educational programme (15). Adopting a multidisciplinary biopsychosocial approach is more effective than physical treatments alone at improving pain (9).

Either isolated or multi-modal physical activity interventions can significantly reduce pain (16). A variety of interventions, including walking therapy (17), core stability exercises (18), resistance training (19), motor control exercises (20), Pilates, water-based interventions, yoga(7) and other mindful exercises(8) have been shown to be effective (16). In a review by Denham-Jones et al, not only did the study find improvement in pain with Pilates interventions but 3 included studies found that the frequency of painful episodes was also reduced (21).

There is no convincing evidence that exercise interventions are helpful in the management of acute back pain (1). However, continuing activities during episodes of acute back pain is important in reducing long-term morbidity and should be encouraged (22).

Quality of Evidence
Grade B – moderate quality

Strength of recommendation
Grade 1 – strong recommendation

Exercise interventions should be offered to those with chronic lower back pain, with or without educational and psychological interventions depending on the psychosocial contribution to their symptoms. Those with acute low back pain should be encouraged to keep active.


  1. Hayden J, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane database Syst Rev [Internet]. 2005 Jul 20 [cited 2022 Aug 18];(3). Available from:
  2. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: An overview of Cochrane Reviews. Cochrane Database Syst Rev [Internet]. 2017 Apr 24 [cited 2022 Aug 18];2017(4). Available from:
  3. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Vol. 2021, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2021.
  4. Hayden JA, Wilson MN, Stewart S, Cartwright JL, Smith AO, Riley RD, et al. Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials. Br J Sports Med [Internet]. 2020 Nov 1 [cited 2022 Aug 18];54(21):1277–8. Available from:
  5. Vadalà G, Russo F, De Salvatore S, Cortina G, Albo E, Papalia R, et al. Physical Activity for the Treatment of Chronic Low Back Pain in Elderly Patients: A Systematic Review. J Clin Med [Internet]. 2020 Apr 1 [cited 2022 Jul 6];9(4). Available from:
  6. Clael S, Campos LF, Correia KL, de Lucena JMS, Gentil P, Durigan JL, et al. Exercise interventions can improve muscle strength, endurance, and electrical activity of lumbar extensors in individuals with non-specific low back pain: a systematic review with meta-analysis. Sci Rep [Internet]. 2021 Dec 1 [cited 2022 Jul 7];11(1). Available from:
  7. Zhu F, Zhang M, Wang D, Hong Q, Zeng C, Chen W. Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS One [Internet]. 2020 Sep 1 [cited 2022 Jul 6];15(9). Available from:
  8. Zou L, Zhang Y, Yang L, Loprinzi PD, Yeung AS, Kong J, et al. Are Mindful Exercises Safe and Beneficial for Treating Chronic Lower Back Pain? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med [Internet]. 2019 May 1 [cited 2022 Jul 7];8(5). Available from:
  9. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJEM, Ostelo RWJG, Guzman J, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane database Syst Rev [Internet]. 2014 Sep 2 [cited 2022 Aug 18];2014(9). Available from:
  10. Parreira P, Heymans MW, van Tulder MW, Esmail R, Koes BW, Poquet N, et al. Back Schools for chronic non-specific low back pain. Cochrane database Syst Rev [Internet]. 2017 Aug 3 [cited 2022 Aug 18];8(8). Available from:
  11. Poquet N, Lin CWC, Heymans MW, van Tulder MW, Esmail R, Koes BW, et al. Back schools for acute and subacute non-specific low-back pain. Cochrane database Syst Rev [Internet]. 2016 Apr 26 [cited 2022 Aug 18];4(4). Available from:
  12. De Campos TF, Maher CG, Fuller JT, Steffens D, Attwell S, Hancock MJ. Prevention strategies to reduce future impact of low back pain: a systematic review and meta-analysis. Br J Sports Med [Internet]. 2021 May 1 [cited 2022 Jul 7];55(9):468–76. Available from:
  13. Bigos SJ, Holland J, Holland C, Webster JS, Battie M, Malmgren JA. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. 2009 Feb 1 [cited 2022 Aug 18];9(2):147–68. Available from:
  14. Shiri R, Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med [Internet]. 2017 Oct 1 [cited 2022 Aug 18];51(19):1410–8. Available from:
  15. Steffens D, Maher CG, Pereira LSM, Stevens ML, Oliveira VC, Chapple M, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med [Internet]. 2016 Feb 1 [cited 2022 Aug 18];176(2):199–208. Available from:
  16. Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, et al. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. 2020 Nov 1 [cited 2022 Mar 7];54(21):1279–87. Available from:
  17. Lawford BJ, Walters J, Ferrar K. Does walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review. Clin Rehabil [Internet]. 2016 Jun 1 [cited 2022 Aug 18];30(6):523–36. Available from:
  18. Wang XQ, Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, et al. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One [Internet]. 2012 Dec 17 [cited 2022 Aug 18];7(12). Available from:
  19. Kristensen J, Franklyn-Miller A. Resistance training in musculoskeletal rehabilitation: a systematic review. Br J Sports Med [Internet]. 2012 Aug [cited 2022 Aug 18];46(10):719–26. Available from:
  20. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther [Internet]. 2009 Jan [cited 2022 Aug 18];89(1):9–25. Available from:
  21. Denham-Jones L, Gaskell L, Spence N, Pigott T. A systematic review of the effectiveness of Pilates on pain, disability, physical function, and quality of life in older adults with chronic musculoskeletal conditions. Musculoskeletal Care [Internet]. 2021 May 24 [cited 2022 Jan 5]; Available from:
  22. National Institute for Health and Care Excellence. Low Back Pain and Sciatica in Over 16s: Assessment and Management. 2016 [cited 2022 Aug 18];(November):0–816. Available from:
  23. Schaafsma FG, Whelan K, van der Beek AJ, van der Es-Lambeek LC, Ojajärvi A, Verbeek JH. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane database Syst Rev [Internet]. 2013 Aug 30 [cited 2022 Aug 18];2013(8). Available from:
  24. Oesch P, Kool J, Hagen KB, Bachmann S. Effectiveness of exercise on work disability in patients with non-acute non-specific low back pain: Systematic review and meta-analysis of randomised controlled trials. J Rehabil Med [Internet]. 2010 Mar [cited 2022 Aug 18];42(3):193–205. Available from: