Patients often ask me “What can I do to avoid my back pain coming back?” An excellent question that probably sounds like easy to answer, and you would expect me or any other health professionals answer it easily. The trouble is, there is no definite answer or I should say there was no definite answer. There has been a debate for decades about whether we should stretch or strengthen bad backs. There were lots of different opinions but no clear evidence on which might be better. A very big study (1) was very recently published in one of the leading back research journals. They assessed whether strengthening or stretching was more effective for patients with recurrent episodes of low-back pain. To do this, they followed 600 hundred patients over 10 years. They were divided in four groups:
- 150 patients performed strengthening exercises,
- 150 patients performed stretching/flexibility exercises,
- 150 patients performed strengthening exercises and used abdominal bracing* (this refers to contracting muscles – not to wearing a lumbar support! See at the end of the article for more information on bracing) in daily activities/exercises,
- 150 patients performed flexibility exercises and used abdominal bracing in daily activities/exercises.
To compare the effects of these exercises, they assessed the 600 patients over 10 years on 6 outcomes:
- frequency, intensity, and duration of pain,
- frequency, intensity, and duration of exercises.
And their results were….. drum roll….
- No differences between the strengthening and stretching groups
- The bracing groups improved more than the non-bracing groups on: pain intensity (almost 2 times lower), pain frequency (more than 1.5 times lower) and pain duration (more than 1.5 times shorter)
- Interestingly, the bracing groups did their exercises more frequently than the non-bracing groups. The intensity and duration were similar.
In other words, the activity performed by people who have recurrent low back pain may not be that relevant to pain outcomes but more how often the activity is performed! Of course the activity still needs to either strengthen or stretch (any kind of sport or classes including Pilates or Yoga, etc).
Abdominal bracing may be helpful, but in this study it may have played a role in reminding patients to perform their exercises regularly rather than having a mechanical effect. This study can’t tell us how abdominal bracing may have affected the outcomes.
Low back pain is affected by many factors other than purely mechanical ones (more information here). Tackling these factors alongside doing some physical activity would of course be more beneficial!
(1) Aleksiev, A. R. Ten-Year Follow-up of Strengthening Versus Flexibility Exercises With or Without Abdominal Bracing in Recurrent Low Back Pain. SPINE 2014;39(13):997 – 1003
* The authors define bracing as such: “The abdominal bracing groups received additional training to incorporate bracing in daily living activities and exercises without interrupting the breathing “brace and breathe.” The most important requirement was to initiate abdominal bracing immediately before any whole-body movement/exercise, shifting the body center of gravity away from the bearing surface. Bracing intensity and duration was dependent on the individual judgment and the situation—the higher/longer the physical demand the higher/longer the bracing intensity. Every patient received instructions to self-perform the learned bracing and/or exercise as frequently as possible throughout the day with self-judged duration and intensity.”
I have back pain – should I have an X-ray?