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Disclaimer: I am not a physician or exercise scientist.

Low back pain (LBP) is an extremely common and debilitating symptom worldwide, experienced by people of all ages and socioeconomic circumstance [1]. In 2017, LBP contributed 65 million disability-adjusted life-years and was the primary cause of work absenteeism and disability worldwide [2]. Most LBP cannot be attributed to a specific source and bouts, while typically short, frequently reoccur [1].

Clinical practise guidelines consistently recommend against treating LBP with opioids, foot orthotics, disc replacement and spinal injections [3]. In particular, opioid use is discouraged for LBP due to the potential for opioid-related harms and the recent finding that NSAIDS are equally efficacious for treating acute LBP [3]. Similarly, routine medical imaging for non-specific LBP is associated with harms [3]. Despite the consistency of these guidelines, imaging, surgery and opioids are overused in clinical practise [3].

The most effective preventative treatment for LBP seems to be exercise, with or without accompanying education [4]. Exercise alone reduces the risk of LBP by 33% on average, with a 95% confidence interval of 15-47% risk reduction [5]. Further research into optimal frequency, intensity, type and duration of exercise for the prevention and treatment of low back pain is recommended [4]. As a naive starting point, the Physical Activity Guidelines for Americans recommend that all adults perform resistance exercises of moderate or greater intensity for all major muscle groups at least twice per week, in addition to minimum aerobic activity guidelines [6]; the Physical activity and exercise guidelines for all Australians concur [7].

While no specific form of sufficiently intense full-body resistance exercise is recommended above all others, I have highly enjoyed resistance training with free weights; I find the capacity for consistent and graded progress very rewarding, and there is a wealth of associated high-quality educational resources. I highly recommend Barbell Medicine's free exercise program and their article on understanding and training around pain. Individuals who are unable to perform basic barbell movements through a full range of motion can instead use light dumbbells or even decrease the range of motion if necessary.

Individuals new to resistance training might experience the following barriers:

  • Insufficient time or money to engage in gym-based activity. Gyms typically cost $12-15/week in Australia. Resistance training in a gym should not require more than 60-90 minutes per session. Barbell Medicine also provide a free at-home exercise program. Prioritising self-care can be difficult and, ultimately, any training is better than no training.
  • A lack of training motivation. Self-monitoring and goal-setting behaviour, such as recording progress and setting achievable targets, can significantly improve exercise motivation [8]. Group exercise, such as with a friend or personal trainer, can also significantly improve motivation and enjoyment [8].
  • Fear of injury or preoccupation with perfect form and 'mobility'. There is no evidence that lower back flexion during resistance training is a risk factor for LBP onset or persistence [9]. People with LBP tend to move with a more rigid back than those without pain [10], potentially a learned response to a misplaced narrative about the dangers of spinal flexion. Movement variability is safe and normal, and one should expect lower back flexion during resistance exercise. Improving 'mobility' should not be prioritised over resistance training.
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Are you aware of any organizations trying to combat lower back pain by encouraging exercise in the developing world? This post seems like half personal advice, half the implication that this might be a solid cause area for global health, and I'm wondering whether anyone is doing anything in the latter space.

Also, anyone who found this post interesting might also want to read this post on lower back pain.

Regarding Magnus' post, which you linked, I partly wrote this article as a response. The evidence base for preventing low back pain with exercise seems much greater than that for adjusting posture, stretching and using ergonomic furniture, which his post also recommends. I wanted to emphasise the importance of exercise as the primary intervention.

The evidence base for preventing low back pain with exercise seems much greater than that for adjusting posture, stretching and using ergonomic furniture, which his post also recommends. I wanted to emphasise the importance of exercise as the primary intervention.

It's not clear to me that Huang et al. compared exercise to the best alternative interventions, so it seems safer to say that it's best among those included in that review, and perhaps among the interventions that have been studied the most. But that's a considerably weaker claim than "low back pain is best prevented by exercise".

[ETA: Also, are you sure that stretching wasn't in many cases part of the exercise studies included in the review? It's not clear to me from reading the paper, and if it was included, the review might actually support stretching, too, as opposed to supporting exercise over stretching. In any case, it's not clear to me that the claim about exercise being more important than stretching is in fact supported by the review in question.]

FWIW, the data I've seen on the effects of getting a better bed, both in terms of small-scale studies and anecdotal evidence, suggests that it could well be more significant, and at least that it's more significant for a considerable number of people (probably especially among those who are already quite physically active). (Note also that it might be expensive and difficult to find appropriate beds for a large number of people in a study, which could be a hurdle to proper studies of this intervention.) I also wouldn't be surprised if curcumin supplementation did significantly better than the best exercise interventions if compared head-to-head (it's probably the single most effective thing I've tried, and I'd strongly encourage people with LBP to try it).

Regarding global health, the Happier Lives Institute produced a report on pain in 2020 that identified low back pain as a focus area, but missed my references [3-5]. In particular, my reference [4] seems to supersede their reference (Steffens et al., 2017) and my reference [3] seems broader and more recent than their reference (NICE, 2016). I think their recommendations might reasonably update with respect to these references. https://forum.effectivealtruism.org/posts/3MiMJYwYrhPmNcNBM/problem-area-report-pain-1

Hi Aaron,

World Spine Care is a non-profit focused on decreasing the burden of disability caused by low back pain. While the primary projects are direct care through clinics and research, they did trial a Yoga Project which trained patients and other local people in Botswana to teach yoga classes with movements modified for people experiencing chronic pain. They were also teaching a simple movement practice called Straighten-Up to patient groups and school-aged children.

I've wondered whether there would be any benefit to a media campaign similar to Development Media International.

Has anyone ever done a proper trial (with independent funding!)  of the methods proposed by James Pennebaker,  John Sarno, Howard Schubiner, Alan Gordon or (my personal favourite- it worked for me) David Hanscom?

I saw that Scott asked for volunteers for a trial here : https://slatestarcodex.com/2016/06/26/book-review-unlearn-your-pain/ 

"Part of me is tempted to recommend Unlearn Your Pain to my patients on the same principle. And if any readers of this blog have chronic pain and want to try  the month-long self-help therapy course in this book, I would be very interested in hearing back from you (please tell me before you start, so that there aren’t response biases).  "

But I don't know if anyone ever took him up on the offer. The actual treatment costs are virtually zero, so if these methods work (partially?) they could potentially save a large number of those 65 million disability years. It's the ultimate effective altruism project. Surely someone who reads this has the authority and cash to get a proper trial done?

To build on this, I want to emphasise on the role of education in the treatment of LBP. I recommend this article discussing the body of evidence on how pain-related beliefs can promote the transition of acute pain to chronic pain and disability. Interventions to reduce pain-related fear (and thus catastrophising, fear-avoidance and kinesiophobia), and their efficacy in reducing pain severity and disability are also discussed.

A bit of time spent familiarising yourself with these ideas seems to be a decent low-cost investment in your wellbeing and resillience. Alan Thrall has a few short accessible videos on back tweaks and, I agree, Barbell Medicine's article on pain self-management is an excellent guide.

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