The Most Effective Exercises for Low Back Pain: A Literature Review
Trevor Shaw DC, DACRB, CSCS 1, Adam Sergent DC, DACBSP1
1 Associate Professor of Clinic Affairs at Palmer College of Chiropractic, Port Orange, FL
Published: August 2020
Journal of the International Academy of Neuromusculoskeletal Medicine
August 2020, Volume 17, Issue 1
The original article copyright belongs to the original publisher. This review is available from: http://ianmmedicine.org ©2020 Shaw/Sergent and the International Academy of Neuromusculoskeletal Medicine. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
To perform a literature review of the most effective exercises to be performed which increase core stability
A need for this review was prompted when reviewing core stability exercises, although they are known to be effective, it is unclear which exercises or technique should be specifically utilized in a clinical setting to improve patient outcomes.
Peer reviewed articles were accessed from PubMed from years 2014-2019 using the search terms Core Stability AND Low back pain. A total of 51 articles with those search terms were returned. Following our initial results, inclusion criteria allowed for a review of 13 articles.
For providers who wish to implement a core strengthening routine for their patients choosing the most effective exercise is of utmost importance. The ability for the average doctor to know which exercises most patients will benefit from with the least amount of adverse reaction is not a well-known fact. The evidenced based chiropractic physician must know the most current exercises to effectively treat their patients.
The results of the literature review demonstrated that the prescription of generalized exercise positively benefits patient outcomes regardless of the particular type. Providers should prescribe exercise based on patient preference and clinician knowledge.
Core Stability, Core Strength, Performance, Specific Exercises, and Guidelines
Estimates suggest as high as 70-80% of the general population will experience some generalized low back pain at some point in their life1. This is not only a burden on the individual but has a further impact on family, financial status, and the healthcare system as a whole2. It is well known that the addition of a core strengthening routine to the management of low back pain is an effective tool and can aid in the prevention of future injuries3. Unfortunately, initial treatment often depends on the type of provider that is seen first and not necessarily accepted best practices. Current evidence suggests that the most effective treatment for generalized back pain be, patient education, advice to remain as active as the pain allows, and exercise4. The European guidelines for Management of Chronic Non-specific Low Back Pain, recommend supervised exercise therapy as the initial treatment of generalized low back pain2. The advantage of continued supervised exercise is that the provider can not only ensure proper technique but also make any session modifications as needed.
There are several known techniques recommended for patients with low back pain, such as McKenzie method, pilates, yoga, back school, and general core exercises have demonstrated varying levels of improvement in overall pain levels of the patient1. Of the known techniques and exercises it is unclear which one is the most effective in the management of back pain. There are copious amounts of information stating that core strengthening exercises are effective but little information on which ones seem to be the most effective.
The main muscles that are active in lumbar stabilization are erector spinae, psoas, multifidus, internal and external obliques, rectus abdominis, and transversus abdominis. Many exercises activate these muscles that can be easily performed by most patients at the initiation of care with little to no additional cost to the patient 5. The difficulty lies with the exercise selection itself.
Current guidelines suggest the addition of a core strengthening program is effective in decreasing pain and improving function.2 The literature however does not make clear recommendations as to which exercises would be most effective in this task of adding core strength. Due to inconsistent use of the terms core strength and core stability, we must define the meaning and purpose of each first.
Historically core-specific exercise was considered more effective than general exercise for the management of low back pain. These exercises were thought to decrease pain while increasing back-specific functional status in patients6 more effectively than other forms of exercise. However, many recent papers have suggested that generalized exercise is as effective as specific exercise for the management of back pain 2,3,6,7. These findings suggest the goal of core strengthening exercises is to target the entire core musculature in place of focusing on specific muscles.
The purpose of this literature review is to determine the most effective core strengthening exercises that engage the core muscles.
A literature search was performed using the terms “Core Strength AND Specific Exercises AND Guidelines AND Low back pain” using Pubmed returning a total of 5 articles. We then revised our original search criteria to include core stability AND low back pain AND guidelines. Our criteria returned a total of 4 articles. Of these articles only two met the inclusion criteria due to the date range. With such a limited scope our search was again revised, eliminating the search term guidelines. Our final review of terms only included Core Stability Exercises AND Low back pain, returning a total of 51 publications.
Of these abstracts reviewed for inclusion, 13 were included in the review. The inclusion criteria consisted of articles in the date range of 2014-2019 and be specific to core stability and low back pain with no other treatments, and discussed exercise performed.
The question remains, what is the most effective exercise when dealing with low back pain? Many exercises have demonstrated the capacity to reduce pain, but which one does so consistently? Which exercises produce the highest outcomes while being the most cost-effective for clinical use? These are a few of the questions many practitioners have when selecting exercises to help treat low back pain. Historically many practitioners have believed it necessary to isolate and target specific core muscles to generate spine stability. This practice has left many practitioners confused and even frustrated as attempts to isolate and control internal reflexive muscle is both difficult to coach and learn.
Furthermore, is the time required to teach and learn these techniques even necessary, is there a benefit in isolation over-generalized exercise? Another concern brought on by overly specific complex exercises is the patient’s ability to perform them outside of the office. As requirements for home exercise prescriptions continue to grow, the practitioners should feel confident the assigned exercises can and will be done.
When comparing techniques, Halliday et al., (2019)8 discovered that McKenzie exercises caused participants to report higher pain reduction values when compared to their counterparts who received motor control exercises. This is significant as McKenzie exercises are global spinal movement exercises while the motor control exercises were isolation exercises for the transverse abdominus, multifidi and pelvic floor.
Smith, Littlewood and May, (2014)9 conducted a 29-study review which concluded there was no evidence that stabilization exercises were more effective than other forms of exercise for low back pain. Stuber et al., (2014)10 in their 5 study 151 participant review concluded that specific exercise was not more effective than general exercise.
Adding to the evidence that generalized exercise provides quality outcomes for individuals with low back pain are the papers published by Joyce and Kotler (2017)11 and Zou et al. (2019)12 who concluded that Pilates and tai chi both serves as quality tools in the treatment of low back pain respectively. These papers continue to support the effectiveness of generalized spinal exercise over specific isolation exercises.
Anderson and Bliven’s (2017)13 contribution demonstrated that non-specific exercises such and breathing could influence back pain and quality of life in their respective cohort.
However, there is also contradicting research performed by Coulombe et al., (2017)6 who concluded that core stabilization exercises were more effective than generalized exercise for the management of low back pain.
In conclusion, generalized exercise serves an important role in the management of low back pain. However, when compared to other forms of exercise the information is conflicting as to which is more effective. The lack of consistency should serve as empowering information for the general practitioner as the evidence seems to suggest that general exercise prescriptions are acceptable for the management of low back pain while overly specific isolation exercise programs seem unnecessary. Practitioners and patients are then free to choose the most cost-effective, time-efficient patient preferred exercise for the management of low back pain.
Limitations of this study include a limited search. Searching additional databases and additional phrasing may have revealed more results. Author bias towards specific exercise was present and though attempts were made to remove bias, it cannot be eliminated.
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