Dave and I will often comment on how different our approach to many common injuries is now versus when we first started practice 16 years ago (yes we are getting old).

 

One that stands out is common lower back pain.

 

Our evolution to treatment has changed, however the backbone has always been rehab, rehab, and rehab.

 

Over and over the research shows that exercise is the most important facet to resolving most if not all forms of low back pain.

 

How into exercise as a means of care are we?

 

Somewhere in one of our clinic hard drives are a series of 10 interviews Dave and I did about 6 or 7 years ago.  We planned on publishing a free e-book on low back pain management when we were young, before having kids and had more time and energy!

 

We sought out who we thought were the 10 most informed and important people in the world on low back pain and did zoom interviews with them.  Essentially our ‘low back pain heros’.

 

Thinking back about their designation likely tells you a lot about how we have always viewed low back pain.  Here is a selection of some of the folks we interviewed:

• Eric Cressey (Renowned strength and conditioning coach and head strength coach for the New York Yankees)
• Dan John (one of the most respected Olympic strength coaches in history)
• Mike Boyle (Elite Boston strength coach who has had stints at Boston University, The Boston Red Sox, and the US Women’s Ice Hockey Team)
• Kelly Starrett (Physiotherapist, strength coach and one of the first Crossfit gym owners who has published 2 extremely popular books on mobility).
• Dr. Stuart McGill (PhD biomechanist from the University of Waterloo and the most published low back researcher of all time. He was recently on the Huberman Lab podcast and Peter Attia the drive to show you how well he is thought of)
• Ryan Flaherty (Senior Director of Performance at Nike – essentially trains all of Nike’s best athletes).

 

Looking at that list I can’t help but think we should resurrect our little project……what a group of experts!

 

Our evolution of exercises has changed quite a bit over time (which is a good thing!)

 

Fast forward to today and in addition to other exercises, if you walk into our clinic with low back pain, you will 100% be receiving one exercise as part of your home exercise rehab routine.

 

WALKING.

 

Yes walking.

 

So simple but so effective.

 

It’s slowly becoming evident that walking may be considered THE MOST important exercise intervention for many types of lower back pain.

 

Last year in The Lancet, one of the most important papers ever on low back rehab was published.

 

It was important because it was a prospective randomized controlled trial which is the highest quality type of research to judge the effectiveness of an intervention (and also EXTREMELY difficult to perform on those with low back pain because it is SO HARD to get enough people with similar types of back pain).

 

The reason I love this article is it looked at people that already HAD low back pain and looked at how to PREVENT recurrences.

 

How often do people that have low back pain get a recurrence?  A shocking 70% of people with common low back pain will experience a recurrence within 12 months after recovery.

 

The current recommendations are for exercise and education however the exercise component is group based, largely without guidelines, and under clinical supervision.

 

This was a 2 armed trial that used 25 private physiotherapy clinics in Australia.  They looked at adults who had recovered from an episode of ‘non specific low back  pain’ within the past 6 months.  This meant people with low back pain not attributed to a specific disease like cancer or a fracture, with pain lasting at least 24 hours, above a 2/10 in intensity and interfered with day to day activities.  Essentially the most common type of low back pain that essentially all of you reading this have had.

 

They randomly assigned individuals to group A which was the walking program as well as education on low back pain, or group B which was a control group so had no intervention at all.

 

The walking group received 6 sessions with a physiotherapist who acted as a ‘health coach’ for the walking program.  The first 5 were within the first 12 weeks and then a final booster session at 6 moonths.  The entire program was structured to try and individualize the walking program to promote long term adherence with the guiding target of getting people to walk 5 times weekly for at least 30 minutes by the 6 month mark.

 

The education session was given to help people understand modern pain sciences and reduce the fear associated with low back pain as well as strategies to self-manage minor recurrences.

 

One interesting variable was that participants were free to seek any type of care they desired for their low back pain.  If they typically went to a massage therapist, or a chiropractor when they had a recurrence they could continue to do so.

 

The tough part about a trial like this is who to include.  To ensure a high quality paper you want the participants to be as similar as possible.  Because of this there were a lot of exclusion criteria including people that were already walking 3 times weekly and those that met the 150 minimum threshold of moderate to vigorous intensity exercise weekly established by guidelines.  When it was all said and done they excluded nearly 80% of people that entered the trial and honed in on 701 people in each arm.

 

So what were the outcomes that were interesting?

 

• Low back pain in these people were EXTREMELY common with the average participant experiencing 33 prior low back pain episodes!
• The walking group did a great job increasing their tolerance. In the first week the average was 80 minutes of walking but by week 12 it was 130 minutes weekly.
• Walking REDUCED THE RISK OF ACTIVITY LIMITING RECURRENCES OF LOW BACK PAIN! The median days to recurrence was 208 in the intervention group versus 112 in the control group.
• Walking also reduced the risk of care seeking for low back pain where less than half of people in the walking group seeking an intervention. And when they did, it averaged 295 days since starting the trial versus just 116 for the control group.
• Aside from the walking intervention there was no difference between the groups in any other physical activity measure, meaning the walking group didn’t start working out more……the changes were just from walking. Of interest the walking group averaged over 600 steps more per day than the control group and 51 minutes more weekly.

 

Who would have thought walking was so darn important!

 

The one caveat when reading this paper is that it was done on folks that were not previously engaging in regular physical activity.  At our clinic we tend to see fairly active folks (which we love!)  I’m guessing there will be a follow up study on people that are a bit more active.

 

Walking is easy, cost effective, takes no equipment, and provides some agency or feeling of control to people suffering from low back pain.

 

All wins in my book.

 

So the next time you come to clinic with low back pain don’t be surprised when you leave with a recommendation for brisk walking to tolerance!