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How do you tailor exercise for chronic low back pain?

How do you tailor exercise for low back pain? This is an important consideration for all physios. One approach is to use graded activity (GA), which can be defined as “a biopsychosocial intervention that consists of combined exercises with a gradual increase in intensity based on quotas that are based on the actual functional capacity of the patient and the ability to meet the goals set in the patient-therapist collaboration.” This differs from graded exposure, which focuses more on the fear-inducing task and less on exercise intensity. Each approach is beneficial in clinical practice, depending on a patient’s presentation and goals. This study (PMID: 36348309) sought to compare GA with supervised exercise therapy (SET) for patients with chronic nonspecific low back pain (CNLBP).

The GA group (n=59) received cognitive-behavioral therapy, group-based supervised exercise, and education. The SET group (n=63) received combined supervised group-based exercise and education. The control group (n=58) received written and pictorial presentations of recommended exercises and optimal posture in some activities. Each intervention group completed eight 60-minute sessions over four weeks. Each group received combined exercises, but the intensity and progression differed.

The GA exercises were individually tailored to each participant depending on functional capacity, functional goals, and “quotas” (a form of pacing). The GA exercises were time-contingent while SET was pain-contingent, only allowing pain-free exercise. The SET intervention was group tailored while the GA intervention was individually-tailored. The exercise intensity was low. The exercises are mostly performed in the supine, prone, and four-legged positions and on a gymnastic ball. Dumbbells maxed out at 1kg and no intensity standard was used (such as RPE).

At the end of the study, both intervention groups had clinically significant improvements in pain compared to the control. The GA group also demonstrated clinically significant improvements in function and fear, while SET only reached statistical significance.

There are two interesting findings that suggest GA was the superior intervention though. Effect sizes differed but overall, GA had statistically significantly greater improvements in pain, disability, fear‐avoidance beliefs, spinal extensor endurance, range of extension, and quality of life compared to the SET and the control group. At 3- and 6-month follow-ups, improvements in function and fear were clinically greater from GA than SET. Also, the GA group continued to improve across the board as time progressed while the SET group either stayed the same or the results deteriorated.

The results of this study suggest a personalized, graded activity approach to treating chronic pain may be a superior strategy for improving function and reducing fear with activity.


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