Is exercise therapy effective for the treatment of acute nonspecific low back pain? A Cochrane Review summary with commentary

The aim of this commentary is to discuss the Cochrane Review “Exercise therapy for treatment of acute non-specific low back pain”¹ by IJzelenberg et al., (This summary is based on a Cochrane Review previously published in the Cochrane Database of Systematic Reviews 2023, Issue 8, Art. No.: CD009365. DOI:10.1002/14651858.CD009365.pub2. (see www.cochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review) published by Cochrane Back and Neck Group. This Cochrane Corner is produced in agreement with International Journal of Rheumatic Diseases by Cochrane Rehabilitation with views (The views expressed in the summary with commentary are those of the Cochrane Corner authors (different than the original Cochrane Review authors) and do not represent the Cochrane Library or Wiley) of the review summary authors in the “implications for practice” section.

Low back pain (LBP) is a common condition that affects a significant proportion of the population, leading to considerable pain and disability.² LBP refers to pain, muscle tension, or stiffness situated between the costal margin and the inferior gluteal folds, which may include referred leg pain (sciatica). Acute nonspecific LBP means LBP episodes lasting up to 6 weeks, which were not caused by known underlying conditions, such as infection, cancer, broken bones, or pregnancy.³ Exercise therapy, a widely used conservative treatment, involves active interventions to enhance physical fitness, flexibility, stability, coordination, and muscle strength, but its efficacy in this context remains uncertain.⁴ It may target specific muscles (e.g., transversus abdominus and multifidus) or broader muscle groups (trunk, abdomen, and back). Programs vary in intensity, frequency, duration, and setting. While commonly used, the efficacy of exercise therapy for acute nonspecific LBP remains uncertain.¹ Understanding its impact can guide clinical practice and improve patient outcomes.

Wilhelmina IJzelenberg, Teddy Oosterhuis, Jill A Hayden, Bart W Koes, Maurits W van Tulder, Sidney M Rubinstein, Annemarie de Zoete, 2023.

The implications of this Cochrane Review for rheumatology practice are nuanced due to very uncertain evidence about the effect of exercise therapy in reducing pain or improving functional status compared with placebo, no treatment, or other conservative approaches in people with acute, nonspecific LBP. Given this uncertainty and considering that acute LBP often improves spontaneously without any intervention, the necessity of exercise therapy for this population may be questioned. This contrasts with chronic LBP, where the natural progression differs, and exercise therapy may have a more clearly defined role.

This challenges traditional practices advocating exercise as a primary intervention. For example, a 2023 narrative review of recent international guidelines for Diagnosis and Conservative Treatment of chronic LBP highlights that most international guidelines recommend non-pharmacological treatments, including exercise therapy.⁵ Another review by Cashin et al. suggests that exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, in people with chronic LBP.⁶ It is important to note that most of the other reviews and guidelines, such as those by Cashin et al., focus on chronic LBP, where the condition and its management differ significantly. Therefore, it remains uncertain whether the findings and recommendations for chronic LBP can be directly applied to acute LBP cases. Rheumatologists should consider these findings when recommending treatment options, focusing on personalized approaches that address individual prognostic factors and patient preferences. The evidence emphasizes the importance of patient education, shared decision-making, and considering the natural history of acute LBP. Practitioners should explore alternative evidence-based interventions and consider cost-effectiveness. While exercise therapy may still play a role in multimodal treatment approaches, its limited efficacy highlights the need for regular monitoring and reassessment of treatment plans. Clinical guidelines also align with this differentiation, recommending exercise therapy for chronic LBP but not for acute cases, as highlighted by Oliveira et al. (2018).⁷ Rheumatologists should stay informed about ongoing research and be prepared to adapt their practice as new evidence emerges.

AF: Literature search, writing the first draft, FAR: Conceived the idea, revised the manuscript for important intellectual content, literature search. Both Authors approve the final version of the manuscript and take responsibility for the contents.

The authors declare no conflicts of interest.