Are physiotherapy exercises effective in

reducing chronic low back pain?

Anna Lewis, Meg E. Morris and Clare Walsh
School of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of
Melbourne, Melbourne, Vic. 3010, Australia

The purpose of this systematic review was to evaluate the literature on the effectiveness of
physiotherapy exercises in reducing chronic low back pain (CLBP). A systematic search of the
medical databases was performed, with 64 articles retrieved. After the exclusion criteria were
applied, 15 randomised controlled trials (RCTs) evaluating physiotherapy delivered exercise
programmes to patients with CLBP remained. A methodological quality assessment was
performed, showing the included studies to have medium to high quality. Prescribed
physiotherapy exercises included general fitness and aerobic exercises, flexibility regimes,
stretches, muscle strengthening and spinal stabilising exercises. These interventions were
compared with each other as well as surgical stabilisation, yoga, hydrotherapy, back care
education booklets and placebo groups. Overall, physiotherapy prescribed exercise pro-
grammes were found to be effective in reducing pain in patients with CLBP. However, there was
no consensus on a specific technique or exercise format being consistently superior to other
interventions.
Keywords: exercise, function, low back pain, pain, physiotherapy

Introduction 80–90% showing improvement within 6–8 weeks.4 It

This investigation systematically evaluated the litera- is estimated that 2–3% develop disabling chronic
ture on the effectiveness of physiotherapy exercises in LBP.5 In the first year after an acute episode, 60–86%
reducing pain in patients with chronic low back pain of patients suffer recurrences. Therefore, identifica-
(CLBP). Low back pain (LBP) is a prominent health tion of factors that may relate to this vulnerability to
and socioeconomic problem. The direct and indirect recurrence is important.5 In the absence of a serious
costs of LBP related disability and work absence in underlying pathology, an episode, which has not
the USA has been estimated at more than $50 billion resolved by 12 weeks, is described as chronic in the
per annum and in the UK $11 billion.1 In Australia, Australian Physiotherapy Association (APA) Low
back complaints constitute the second most common Back Pain Position Statement.6
symptom presenting to general practice, following LBP not settled within 8–12 weeks is identified as a
upper respiratory conditions. They are the leading high risk for chronic disabling pain.7 While the
source of musculoskeletal health system expenditure. recovery process for people with CLBP is slow, their
The annual expenditure is estimated to be $9.17 demand on the health care system is large and costly.3
billion, of which $1.2 billion is spent in direct costs It is also associated with major disability and
(general practitioners, physiotherapist and other absenteeism from work.3
allied health professional consultations). The remain- Physiotherapists play a major role in the treatment
ing $8 billion represents lost productivity.2 of CLBP as primary contact practitioners with skills
At some point in their lives, 70–85% of adults have and expertise in musculoskeletal conditions.
an incidence of back pain.3 The prognosis for Although a variety of therapeutic interventions are
recovery in the acute phase is favourable, with available for the treatment of low back pain, the

ß W. S. Maney & Son Ltd 2008

DOI 10.1179/174328808X252000 Physical Therapy Reviews 2008 VOL 13 NO 1 37
Lewis et al. Are physiotherapy exercises effective in reducing chronic low back pain?

effectiveness of many of these interventions has not were exercise, function, low back pain, pain, therapy
been demonstrated beyond doubt.8 Exercise pro- and physiotherapy. Further searching was performed
grammes, particularly those focussing on core stabi- through reference lists of retrieved articles and
lising exercises, have gained widespread popularity in systematic reviews. From the initial yield, abstracts
treatment regimes for LBP sufferers. At the present were perused and ineligible studies were eliminated if
time, physiotherapists cannot confidently prescribe they did not fulfil the inclusion criteria. Full copies of
the optimal type of exercise for CLBP because the potentially suitable studies were obtained and were
effects of specific exercises have not been system- assessed by two reviewers for inclusion based on the
atically assessed.9 Also, there does not appear to be a eligibility criteria (Table 1). A consensus method was
consensus of opinion on the most effective pro- used to resolve any disparities.
gramme design to maintain exercise benefits.10 Only randomised controlled trials (RCTs) written
In order to determine which physiotherapy exer- in English which studied physiotherapy prescribed
cises are the most effective, a systematic review of the exercises for CLBP were considered for inclusion.
literature was conducted. Studies were assessed for RCTs ‘provide the highest level of evidence for the
quality and outcomes that evaluated physiotherapist effects of an intervention’11 and therefore, studies of a
delivered exercises in a group format. These included narrative, cohort or descriptive nature, controlled
general fitness and aerobic exercises, various types of clinical trials and systematic reviews were excluded.
flexibility and stretching exercises, muscle strengthen- The APA LBP position statement restricts evidence
ing and spinal stabilisation exercises. These were to the two highest levels of evidence defined by the
compared against each other as well as other National Health Medical Research Council, systema-
interventions of surgical stabilisation, yoga, hydro- tic reviews and RCTs.6
therapy, back care education booklets and placebo It was a requirement that patients participating in
groups. The primary aim was to explore which the trials had to be between 18 and 65 years of age
exercises were effective in reducing pain in patients and of either gender. There was no discrimination
suffering with CLBP. The specific research question made based on socioeconomic status or compensa-
was ‘are physiotherapy exercises effective in reducing bility of the patient: all private, public or work cover
CLBP?’. patients were included. The definition of CLBP for
the purpose of this review was pain greater than
Methods 12 weeks duration to exclude cases where a greater
An in-depth literature search was performed electro- chance of natural resolution may occur. Symptoms
nically in the following databases: MEDLINE, identified were located ‘below the level of the scapulas
EMBASE, CINAHL, the Cochrane Collaboration’s and above the cleft of the buttocks, with or without
Register of Clinical Trials, PEDro and the ISI Web of radiation to the lower extremities, including
Science. The database searches were performed up to nerve root pain or sciatica’.8 Patients with spinal
and including May 2006. The key search terms used pathologies of an inflammatory or infectious nature,

Table 1 Criteria used to assess inclusion of articles in this review

Inclusion criteria
Randomised controlled trials (RCTs)
Data driven studies
Subjects aged 18–65 years
Existence of CLBP.12 weeks duration
All levels of socioeconomic status
Compensable, private and public patients included
Otherwise healthy subjects
Exercise/fitness training or rehabilitation in the title
Articles written in English
Physiotherapist prescribed exercise programmes
Exclusion criteria
LBP,12 weeks duration
Current physiotherapy treatment for another condition
Not human subjects
Existence of co-morbidity (CVA/COAD/Ca) or other conditions of an inflammatory or infectious nature
Low back pain related to pregnancy
Depression
Review articles which did not have data
Articles written in a foreign language

38 Physical Therapy Reviews 2008 VOL 13 NO 1

 Lewis et al. Are physiotherapy exercises effective in reducing chronic low back pain?

pregnancy or other concurrent conditions receiving Table 2 Methodology assessment score

physiotherapy intervention were excluded (Table 1). Criteria

RCTs in which one of the interventions was a
Study (Ref. no.) 1 2 3 4 5 6 7 8 9 10 11 Total score
programme of physiotherapy prescribed exercises
were included. The types of programmes included 20 3 3 X 3 X X X 3 3 3 3 6
lumbar stabilisation exercises, hydrotherapy, back 13 3 3 X X 3 X X X X 3 3 4
27 3 3 X 3 X X X 3 3 3 3 6
care and functional conditioning programmes as well 15 3 3 X 3 X X 3 X 3 3 3 6
as fitness circuits, which incorporate stretching and 14 3 3 X 3 X X 3 X 3 3 3 6
22 3 3 X 3 3 X 3 X X 3 3 6
aerobic exercises. If there were combinations of
16 3 3 X 3 X X 3 3 3 3 3 7
treatments, the exercise programme had to be able 19 3 3 3 3 X X X 3 X 3 3 6
to be evaluated independently for the effectiveness of 25 3 3 3 3 X X 3 X 3 3 3 7
17 3 3 X 3 X X 3 X 3 3 3 6
the intervention. 26 3 3 X X X X 3 X X 3 3 4
RCTs had to use at least one outcome measure of 21 3 3 X 3 X X X 3 3 3 3 6
24 3 3 3 3 X X 3 3 X 3 3 7
back pain as this was the key variable under review.
18 3 3 X 3 X X X 3 X 3 3 5
van Tulder et al.12 advised that primary outcome 23 3 3 3 3 X X 3 3 3 3 3 8
measures of most relevance in assessing LBP are the Score items: 15eligibility criteria; 25random allocation; 35con-
pain visual analogue scale (VAS), a global measure cealed allocation; 45baseline comparability; 55patient blinding;
(subjective improvement in symptoms), and assess- 65therapist blinding; 75assessor blinding; 85at least 85%
follow-up; 95intention to treat analysis; 105between group
ment of the back pain-specific functional status using statistical analysis; 115point measures and measures of
the Roland disability questionnaire (RDDQ) or the variability. Item 1 is not included on PEDro scale.
Oswestry disability scale (ODS).
Two reviewers independently extracted data using of 6 (Table 2). The Editorial Board of the Cochrane
a customised extraction form to document the study Collaboration Back Review Group12 recommend a
design, randomisation procedures, blinding of per- pilot test of the methodological quality assessment,
sonnel involved, descriptions of interventions and which was conducted before this assessment.
outcome measures used. Any disagreements were
resolved by discussion and for resolution of any Results
uncertainties, a third reviewer was consulted. Three The electronic in-depth literature search initially
authors were contacted for clarification of criteria in identified 64 potentially suitable articles. After
their studies to ascertain the suitability of their trial reading the abstracts and applying the inclusion and
for inclusion. exclusion criteria, 15 studies were identified as
A ten-point checklist based on the physiotherapy suitable for this review (Table 3).
evidence database (PEDro) was used by the two Fifteen RCTs of 1695 patients suffering with CLBP
reviewers to assess the methodological quality of participating in a variety of physiotherapy based
included RCTs. The score items assessed appropriate exercise programmes were reviewed. The study
randomisation, blinding of patients, therapists and characteristics of patients, duration of symptoms,
outcome observer, adequacy of follow-up, between interventions and outcome measures are included in
group baseline comparability and outcome statistical Table 4. Patients were recruited from referrals to
analysis. There is an inherent difficulty in blinding physiotherapy outpatients departments (OPD) in six
physiotherapists delivering exercise programmes; studies,13–18 an occupational health centre,19 referral
therefore, in reality, the highest obtainable score was from general practitioners (GP), specialists, OPD
9. Consideration was given to the presence of any or insurance companies,20 advertisement in local
other intervention which could influence the outcome media,21 self-referral to a spine programme,22
of the treatment and included trials have a mean score mail-out to potentially eligible patients and

Table 3 Yield from database search

Studies initially identified as potentially suitable for inclusion: 64
Studies excluded: 49 Study outcome not specific to topic: 6
Low back pain,12 weeks: 12
Description of proposed RCT: 2
Other type of study: narrative, systematic review, cohort study, non-RCT,
review article, clinical trial: 29
Studies remaining: 15 RCTs involving 1695 patients

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Lewis et al. Are physiotherapy exercises effective in reducing chronic low back pain?

advertisement,23 physiotherapy private practice, The interventions reported in the trials were
medical and pain management clinics,24 hospital commonly used physiotherapeutic treatments for
orthopaedic clinic and GP practices,25 GP and LBP. Some studies examined more than one treat-
physiotherapist referrals,26 referral to a multicentre ment protocol and therefore, it may be included in
(15 hospital) orthopaedic and rehab centres.27 more than one intervention category. The interven-
Trial sizes ranged from 41–349 patients with a tions under review have been allocated into three
median of 80 patients with ages ranging from 18– broad-based categories: (1) functional restoration/
65 years. All patients had greater than 12 weeks back care or rehabilitation programmes; (2) lumbar
duration of symptoms of low back pain. The stabilisation exercise programmes; (3) other exercise
treatments were physiotherapist delivered exercises programmes, including yoga, hydrotherapy, aerobic
in one or more of the groups and often there was a and fitness circuits, strengthening exercises and back
comparison between two physiotherapy treatment school.
modalities. Six studies investigated functional restoration or
All selected RCTs included in this review fulfilled back rehabilitation programmes. These were com-
the inclusion criteria of age, gender, definition of low pared to interventions of manual therapy, surgical
back pain, the absence of concurrent pathology spinal fusion and various control groups, which
requiring other physiotherapy treatment and comprised of static abdominal exercises, thermal
described in detail the interventions received. They therapy and massage and fitness sessions involving
all investigated the effect of physiotherapy exercises aerobics and strengthening exercises utilising
on CLBP with pain as one of the outcome variables machines.
assessed. Two studies20,27 conducted full time functional
Quantitative data were collected in all studies to restoration programmes. In one,20 the programme
assess pain (among other variables), as one of the was run over a 3 week period and included group
primary outcome variables. Outcome measures multidisciplinary treatment of patients, with intensive
included the Oswestry disability questionnaire (seven physical and ergonomic training, psychological pain
studies), the short form McGill questionnaire (five management, back school and work related issues.
studies), the pain locus of control questionnaire The outcome of back pain for this intervention
(three studies), the 11 point back/leg pain scale (three demonstrated a systematic reduction over time.20
studies), the Quebec back pain disability scale (two A similar intensive rehabilitation programme
studies), the VAS (six studies), the pain rating index incorporated daily education and physiotherapy run
(PRI) (two studies), the numerical rating scale (NRS) exercise sessions. These sessions included stretching,
(one study), the Roland–Morris disability question- spinal flexibility, muscle strengthening, spinal stabi-
naire (four studies), the pain self-efficacy question- lisation exercises, aerobic exercises and daily hydro-
naire (one study) and the fear avoidance beliefs therapy sessions.27 These sessions were individually
questionnaire (FABQ) (one study). Other outcome designed and delivered by physiotherapists based on
measures included active lumbar spine movements principles of cognitive behaviour therapy. This
(five studies), straight leg raise (SLR), lower limb programme was compared to surgical lumbar spinal
strength, sensation and reflexes (one study), abdom- fusion and at the 12 month follow-up, the Oswestry
inal muscle recruitment patterns (one study), scores improved slightly more in favour of surgery.
Manniches rating scale (ADL) (one study), general No other difference between groups reached statis-
well-being (one study), shuttle walking test (three tical significance.
studies), SF-36 (three studies), Nottingham health Four investigations reviewed patients participating
profile (one study), surface EMG of muscle fatigue in part-time active rehabilitation programmes with
ability (two studies), Tampa scale of Kinesophobia interventions based on functional capacity. Patients
(one study), modified somatic perception question- attended structured functional programme sessions
naire (MSPQ) (one study) and Zung questionnaire 1–2 times per week for 1–2 hours duration. These
(one study). Outcome measures of pain were based programmes addressed strengthening, coordination
on questionnaires completed by the patients at and aerobic exercises, ergonomic advice and home
pre-trial, post-trial and various follow-up points exercises,21 exercises specifically designed to treat
of 3, 6, 12 or 24 months. All included trials musculoskeletal dysfunctions and home exercises,22
had at least one report of pain as an outcome educational components comprising demonstrations,
variable. lectures, video and specific exercise programme,13

40 Physical Therapy Reviews 2008 VOL 13 NO 1

 Lewis et al. Are physiotherapy exercises effective in reducing chronic low back pain?

and exercise sessions utilising specific equipment, significance when all time points were analysed with
stretching and relaxation exercises.19 ANCOVA.25
Pain was significantly reduced in all groups The results for the stabilisation groups showed
immediately after therapy and retained at month significant improvement (p,0.05) in mean treatment
12, with no significant difference amongst the three group scores compared for ODQ and RMDQ
groups.21 The standardised residual change scores on following the intervention period, while the control
the VAS and MPQ in the specific exercise and muscle group scores either stayed the same or were
energy group displayed a significant decrease on both significantly worse.18 In contrast,17 no consensus
pain measures.22 The back rehabilitation group (eight was found in their study regarding the efficacy of
sessions) showed a statistically significant reduction one form of treatment over the other and at the
in pain (VAS score) compared to the control group. 6 month follow-up, and there was no significant
There was no difference in pain reduction between a difference between groups in particular with the
longer rehabilitation programme of eight sessions MPQ. Both forms of interventions produced similar
and a shorter programme of four sessions.13 Back clinically important reductions in symptoms.
pain intensity and functional disability decreased Four studies investigated the interventions of
significantly more in the active rehabilitation group fitness programmes compared to a back education
compared to the passive control treatment group in a programme, yoga, a self-care book and hydrotherapy
1 year follow-up (p,0.05). There were decreased versus a control group (delayed treatment). One
values on both scores during the 12 weeks of active programme’s objective was to evaluate the interven-
rehabilitation.19 tion of a fitness programme against a back school.15
Five studies examined the effect of a lumbar spine Results showed significant differences between the
stabilisation programme. These included physiother- groups’ post-intervention in scores on the ODQ
apy exercises for transversus abdominis, multifidus, (p,0.005), pain reports (sensory p,0.05 and affective
pelvic floor and diaphragm muscles. Training for p,0.05) and self-efficacy reports (p,0.05 and walk-
these exercises commenced in low loaded positions ing distance p,0.005). A 2 year follow-up on the
and were progressed as appropriate. All five trials ran above trial14 showed that 62 (78%) of initial trial
their programme over an 8–10 week period and participants demonstrated a statistically significant
comparisons made against interventions of manual difference in disability scores in a between group
therapy, education with active participation in a back comparison.
school programme, general exercise programmes An investigation was conducted to evaluate the
incorporating swimming, walking and gym work effectiveness of yoga exercises in comparison to
and no intervention. conventional therapeutic exercises and a self-care
One investigation that compared stabilisation book.23 The results of this trial suggested that yoga is
exercises against manual therapy and education an effective treatment for LBP as it consistently
groups showed reduction in pain in all groups at reported superior outcomes compared to the exercise
the 3 month stage (NRS, pain diagram and ODQ group. However, none of these differences were both
scores) and a statistically significant group benefit in statistically and clinically significant.23
the spinal stabilisation group at the 6 month stage in In the group of hydrotherapy study, the findings
the case of self-reported back pain. A within group showed a statistically significant greater number of
analysis showed a statistically significant improve- subjects in the experimental group improved in their
ment at each data collection stage, in favour of the function in comparison to those in the control group
spinal stabilisation group in back and leg pain who deteriorated.26 Outcome measures used a range
intensity and the site of pain.16 of tests for pain and functional disability measures
Another trial analysed differences within each (ODQ, PRI and pain intensity scale) with a known
group after the intervention period which showed reliability and acceptability to both the therapists and
significant differences in the stabilisation group with patients.26 However, outcome measures for pain,
a decrease in pain intensity (MPQ, p,0.0001) and light touch, reflexes, strength and active movements
pain descriptor scores.24 The control group did not of the lumbar spine, were not significant between the
report any significant difference on these pain scores. experimental and control groups. What is left to
In a third trial, both groups achieved similar change question regarding the outcomes is the adequacy of
over time on pain and pain belief scales and the sample size or the type of outcome measure used
the RMDQ data just failed to reach statistical in the study.26 In view of the brevity of treatment time

Physical Therapy Reviews 2008 VOL 13 NO 1 41

Lewis et al. Are physiotherapy exercises effective in reducing chronic low back pain?

(4 weeks), these findings should be viewed as specific alteration of function of the local stabilising
indicative of a possible beneficial role of hydrother- system and the imbalance with the global muscle
apy for subjects with CLBP of long duration.26 system.16 Of the trials reported upon in this review,
conflicting evidence emerged from moderate to high
Discussion quality trials regarding the efficacy of this interven-
The main finding to emerge from this systematic tion. This may prompt physiotherapists to be more
review was that many physiotherapy exercises were selective in delivering these programmes in the
effective in reducing pain in people with CLBP. Other presence of clinical instability25 or in acute, first
systematic reviews on the efficacy of exercises in episode LBP patients.5
CLBP have reached a similar conclusion.10,28 Most The long term follow-up results of the implementa-
studies reviewed here concluded that active exercises tion of lumbar stabilisation exercises in the acute
were a valuable therapeutic approach, despite the phase of LBP are positive, with reduced recurrence of
lack of consensus on the optimal techniques, intensity episodes at the 1 year follow-up, 30% recurrence rate
or active intervention.29 No single exercise based compared to 84% recurrence rate in a medical control
treatment was consistently shown to be superior to group.5 Only one study included pathologies identi-
other interventions. fied with instability as part of the inclusion criteria.24
Functional restoration programmes focused The varying results across the trials involving core
strongly on self-responsibility, activity and a multi- stabilisation exercises highlight the need for continu-
disciplinary approach.20 A more structured back ing clinical research in this area.
rehabilitation class appeared to generate additional General fitness programmes were shown to be
benefits to a general fitness or aerobics class20 and beneficial although the strength of their continued
might provide a more realistic replication of a typical success lies with a motivated and compliant patient to
work day situation as well as enabling people to continue once discharged from the care of the
regain confidence to return to pre-injury activities. physiotherapist.15 Encouragingly, people who
The objective assessment of the load on the lumbar embraced the self-management strategy and incorpo-
paraspinal muscles followed by exercises using rated exercise and increased activity levels into their
specific equipment has helped to contribute to daily routine were shown to have more successful
improved back muscle endurance.19 Lumbar muscle outcomes in the longer term.14
fatigue leads to abnormal spinal movements due to Exercising in groups appears to enhance compli-
the loss of precise muscle coordination and proprio- ance and motivation in patients which may lead to
ception.19 This finding endorses the idea of incorpor- behavioural changes towards increased activity
ating lumbar muscle endurance training as well as levels.21 Fitness programmes delivered in a group
general cardiovascular exercises to enable patients to format tend to improve confidence to eliminate
rediscover more normal movement patterns.19 aberrant movement patterns often adopted in
There was some evidence that using a group patients with CLBP. A yoga group intervention23
approach was effective for people who received reported some superior outcomes compared to
lumbar muscle endurance training that incorporated the fitness group. The practice of yoga places
relaxation and stretching exercises.19 Most of the equal emphasis on mental focus and physical move-
back care or functional restoration programmes used ment23, therefore increasing body awareness of
a cognitive behavioural approach and the rationale is movement patterns,23 relaxing tense muscles and
to normalise behaviour patterns and give people the inherently providing some stabilising components to
confidence to overcome fear of movement. There was the programme.
strong evidence to support the idea that ‘multi- For patients with CLBP, the challenge for phy-
disciplinary interventions appear to have the greatest siotherapists is to provide a treatment rationale
efficacy in treating chronic pain’,22 as they address which is effective and directs patients towards self-
the multifactorial components of CLBP. Reducing management.13 Therapists need to be cognisant of the
pain does not necessarily lead to a change in function complexity of CLBP and the need for a multi-
due to pain-related fear, depression and dysfunc- factorial approach.22 Exercise therapy targeting
tional movement patterns.22 CLBP can be delivered in many formats as seen in
Lumbar stabilising exercises have increased in the analysis of these studies. Confidence needs to be
popularity in the past decade for treatment of low instilled into patients to regain normal movement
back pain. This treatment approach addresses the patterns21 and overcome fear avoidance behaviours.

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 Lewis et al. Are physiotherapy exercises effective in reducing chronic low back pain?

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ANNA LEWIS
Bldg 921, Wylde Street, Potts Point, NSW 2011, Australia
Tel: z61 2 9359 3375; Fax: z61 2 9359 2503
Email: Anna.Lewis@defence.gov.au

44 Physical Therapy Reviews 2008 VOL 13 NO 1