Welcome back to Spine IQ’s BackBlog! We are finishing off Women’s History Month by focusing on a study led by Jill Hayden, DC, PhD and her team (3/5 woman co-authors) titled, “Exercise for chronic low back pain.”1 This Cochrane review is an update of Dr. Hayden’s 2005 Cochrane review on the same subject2 and took 10 years to develop as a result of how quickly new studies were being published. It is one of the largest conducted in any health condition, with 13,087 articles screened. Ultimately, 249 studies were analyzed and summarized in this clinically relevant study, which is important for anyone treating, experiencing, or researching chronic low back pain. Feeling overwhelmed by the thought of reading 249 studies that can help you take better care of patients? At Spine IQ we know that while that sheer volume of research conducted for chronic low back pain is exciting, it can also be overwhelming for the busy clinician. That is why we are ‘bringing the research to you” by summarizing Hayden’s Cochrane review (results, benefits, and risks) below.

Objective and Methods

Exercise is recommended as first-line care for chronic low back pain by numerous clinical practice guidelines.3,4 Our previous blogs have discussed how to incorporate exercise in your clinic. However, an updated synthesis of all the exercise for chronic low back pain research had not been done since 2005. The gap in the literature on this topic is well known to anyone attempting to keep up with the exercise for chronic low back pain evidence, made more difficult by the fact that it seems as if a new study is published on this topic every week. As a result, Hayden’s study, published in the prestigious Cochrane library, is one of the most comprehensive reviews every conducted.


After screening more than 13,000 individual studies, 249 unique randomized controlled trials were synthesized. Overall, 107/249 studies compared exercise vs other exercise, while 142/249 compared exercise vs non-exercise. Dr. Hayden and her team found that there is moderate-certainty level of evidence that exercise improves pain and disability. The scales for pain and disability were both on a 0 to 100 point, that means that any change can be interpreted as % change. For example, 1 point change is 1% better improvement than the comparison group. There seems to be a clinically meaningful 15% difference (-15.2 in a scale of 0-100) on pain in favor of exercise compared to no treatment, usual care, or placebo for chronic low back pain. In addition, they found a 9% difference on pain in favor of exercise compared to other conservative treatment (e.g., education, manual therapy, electrotherapy, and psychological). The effects on disability were lower with just under a 7% difference in favor of exercise compared to no treatment, usual care, or placebo and a 4% difference in favor of exercise compared to other conservative treatments (e.g., education, manual therapy, electrotherapy, and psychological). Adverse events were rare, mostly minor (e.g., muscle soreness), and almost as likely to be found in the non-exercise comparison group (29%) in a study compared to the exercise group (33%).


This large, well-conducted systematic review confirms that exercise can be a beneficial treatment with low risk for chronic low back pain and should continue to be incorporated into treatment plans by conservative spine clinicians. While the overall effect may seem to be small, it is important to remember that this effect is in addition to the positive effect of time, regression to the mean, natural history, therapeutic alliance, and other contextual factors. Thus it is likely a difference that is meaningful to patients. Low back pain tends to have an overall good prognosis regardless of the intervention, with most people recovering within 6 weeks.5,6 There is a possibility that delivering exercise may lead to a quicker or overall better (lower pain and better function) recovery when the effect is added on top of the effect of time, other conservative treatments and contextual factors. Take home message? Exercise therapy is an evidence-based treatment for chronic low back pain and is one of the most researched treatments for any condition.

  1. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, Tulder MW van. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;(9). doi:10.1002/14651858.CD009790.pub2
  2. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335. doi:10.1002/14651858.CD000335.pub2
  3. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  4. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  5. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171. doi:10.1136/bmj.a171
  6. Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatol Oxf Engl. 2010;49(12):2346-2356. doi:10.1093/rheumatology/keq245