Lifestyle Medicine, Exercise and Nutrition for Managing Chronic Low Back Pain

Original Editor - Stacy Schiurring based on the course by Ziya Altug
Top Contributors - Stacy Schiurring, Jess Bell, Ewa Jaraczewska, Kim Jackson and Lucinda hampton


Introduction[edit | edit source]

The management of chronic low back pain (LBP) often requires a lifestyle change for long-lasting effect. Research shows that altering diet and increasing activity level through exercise can help improve subjective complaints of chronic LBP.[1][2] The biopsychosocial model considers the importance of behavioural modifications in the management of chronic LBP, introducing the concept of positive[3] or whole-person health[4] as a prevention strategy against long-term disability from chronic LBP.  

“Whole person health refers to helping individuals improve and restore their health in multiple interconnected domains—biological, behavioral, social, environmental—rather than just treating disease. Research on whole person health includes expanding the understanding of the connections between these various aspects of health, including connections between organs and body systems.”[4]

Lifestyle Medicine Components

Lifestyle Medicine combines the modern western practice of medicine with evidence-based lifestyle therapeutic approaches to prevent and reverse lifestyle-related chronic illness.  Examples of lifestyle practices include:

  • Nutritional: Whole-food and plant-based diet, dietary supplements, probiotics
  • Physical: Regular physical activity, acupuncture, massage, adequate sleep
  • Psychological: meditation, hypnosis, music therapy, relaxation techniques
  • Combination of the above: yoga, tai chi, dance therapy, art therapy.

[4]

This article will discuss the use of exercise and nutrition to manage chronic LBP within the framework of Lifestyle Medicine.  This approach takes a holistic look at medicine and pain management and attempts to identify the root cause of pain rather than just treat its symptoms.  It is recommended to consult a healthcare provider before starting a new exercise routine.  Physiotherapists can create a unique individualised exercise routine appropriate for each client’s needs.  In addition a dietician-nutritionist can assist to create individualised diet plans.

Conventional Exercises[edit | edit source]

Conventional exercises are common treatment prescriptions for physiotherapists.  The use of these relatively inexpensive exercises as part of physiotherapy treatment have been found to reduce subjective LBP, disability, and overall quality of life.

Conventional Exercise Categories
  1. Aerobic training provides cardiovascular conditioning.  Examples include: outdoor or treadmill walking, stationary cycling, stairclimber, elliptical walking, swimming, hiking, or sport activities.
    • A 2005 study by Hoffman found people with chronic LBP and minimal to moderate levels of disability experienced exercise-induced analgesia for greater than 30 minutes following aerobic exercise.[5]
    • A 2019 study by Vanti suggests a walking program alone can provide similar pain relief and improvements to disability, movement avoidance, and quality of life with a walking program combined with exercise, and an exercise program alone.[6]
  2. Resistance Training is any exercise that causes the muscles to contract against an external resistance with the expectation of increases in strength, power, hypertrophy, and/or endurance.
    • A 2021 study by Tataryn found that resistive exercises targeting the extensor muscles of the thoracic and lumbar spine and hip can have a positive effect on preserved pain and level of disability.[7]
    • A 2016 study by Michaelson found no significant difference in the effectiveness of high load lifting and low load motor control intervention on improving LBP and disability.[8]
  3. Flexibility Training is any exercise that increases the motion in a joint or group of joints, or the ability to move joints effectively through a complete range of motion.


Due to the complexities of LBP etiology, it is important to fully assess and evaluate a client prior to creating a physiotherapy plan of care.  Often it is a combination of the above conventional exercises which will give an individual client their best results.  It is also important to take a client’s needs and beliefs into consideration when creating a plan of care.[9][10][11]

Integrative Exercises[edit | edit source]

Integrative Exercises Categories

An alternative to conventional exercises is integrative exercises.  This type of exercise is unique because they combine both physical and mental exercises and are part of a greater lifestyle change goal for sustainable wellness and health condition management.  Integrative exercises indirectly address pain by improving physical conditioning, teaching pain-coping mechanisms, and addressing kinesiophobia by improving body awareness.  In general they:

  • are easy to access
  • require little to no equipment
  • are adaptable to a client’s needs and ability level.[12]

Many of these exercises involve moving through various postures, with the spine moving between flexion, extension, rotation, and sidebending, with postural strengthening. Read more about the benefits of movement and avoiding prolonged static postures on LBP here. Many of these exercises, most significantly yoga, tai chi, and qigong involve mediation and can address psychological and emotional needs for the person with chronic LBP.[13] More research is needed to strengthen the evidence for the use of these exercises in the treatment of chronic LBP.

Examples of integrative exercises include:

Yoga[edit | edit source]

Yoga: began as a spiritual practice but has branched into a way of promoting physical and mental well-being. Yoga as practiced in the western countries typically emphasizes physical postures, breathing techniques, and meditation.[13] A 2020 meta-analysis found that yoga may decrease chronic LBP for the short to intermediate term and improve disability status from short to long term. This study also found that yoga had the same effect on pain and disability as conventional exercises and physiotherapy. [14]

Please view the following video to learn about the origins of yoga, and how this practice is linked to both mediation and cognitive therapy.

[15]

Pilates[edit | edit source]

Pilates: began as a treatment for dancers. Pilates techniques focus on abdominal and low back muscle coactivation, flowing movement patterns that are precise, and a steady and controlled breathing. Pilates routines can be performed on specially-designed apparatuses, called a reformer, or on the floor using a mat.[16] A 2016 systematic review of nine random clinical trials found pilates provided short term pain reduction for persons with chronic LBP.[17]

Qigong and Tai Chi[edit | edit source]

Qigong: can be described as a mind-body-spirit practice that improves mental and physical health by integrating posture, mindful movements, breathing technique, self-massage, and sound.[18] A 2019 systematic review and meta-analysis of nine randomized controlled trials found that Baduanjin, a type of Qigong, is effective for LBP. [19]

Tai Chi: is a a series of slow mindfully produced movements pattern with stretching and deep breathing. Movements are continuous and flows from one posture to another.[20] A 2019 systematic review and meta-analysis of randomized controlled trials found that Tai Chi alone or when used with conventional exercises and physiotherapy may decrease pain and improve disability for persons with LBP. [21]

The following video discusses the origins and relationship between Quigong and Tai Chi. It also compares and constrasts how they are practiced.

[22]

Next, please view the following two videos. The first is a demonstration of the Eight Strands of Brocade Qigong. The second is a demonstration of Tai Chi for Rehabilitation. How are the movements similar and how to they differ?

Mindfulness[edit | edit source]

Mindful walking: a mediative practice of focusing on the five senses, breathing, sensations in your body, conscious mindful movements of your body, and the changing environmental around you while walking.[25] A 2021 RCT found that persons with chronic LBP identified therapeutic procedures and change in subjective pain ratings after completing proper training and education on cognitive and mindfulness-based interventions for chronic LBP. [26]

Alternative Exercise Therapies[edit | edit source]

Alexander Technique: A type of exercise therapy which attempts to improve movement pattern efficiency, ease and comfort of range of motion, balance, and coordination through mindfulness of movement.[27] A 2008 study found that private Alexander Technique lessons from registered teachers have long term benefits on chronic LBP. The effectiveness of the lessons were increased when combined with conventional exercises.[28]

Feldenkrais Method: A type of exercise therapy which attempts to stimulate neuroplasticity by improving awareness of body awareness, flexibility, balance, and coordination.[29] A 2020 study found that the Feldenkrais method improved quality of life and decreased measured disability as compared to core stability exercises for non-specific chronic LBP.[30]

Please view the following two videos. The first is a discussion of the Alexander Technique, the second a discussion on the Feldenkrais Method and how it can address chronic pain.

Nutrition[edit | edit source]

“Let food be thy medicine and medicine be thy food.”  -Hippocrates

Like medicine, the food we eat can fight pain and disease. A proper diet can enhance our body's ability to heal, prevention is better than intervention. It is strongly recommended to work with a nutritionist-dietician for optimal nutritional results and to strengthen interprofessional referrals and collaborations.[11] Please read this articles on nutrition for a good overview on the topic and the role of physiotherapy in giving nutritional or dietary advise.

Purpose of Food:

  1. Energy and survival
  2. Health and healing
  3. Maintain a healthy immune system
  4. Social interaction

[33][34][35][36][11]

Enhance our healthful eating experiences:

  1. Choose a variety of colourful and predominantly plant-based foods
  2. Learn how to cook. Cooking can enhance health, save money, and be used as a socialization activity.
  3. Mindful eating

[11]

The following video provides information on mindful eating and step-by-step instructions on how to perform this meditation.

[37]

Food as Medicine[edit | edit source]

A 2020 article states that the low inflammatory foods everyday or LIFE diet, or a regular American diet supplemented with the LIFE smoothie may quickly reduce systemic inflammation and the risk of many chronic diseases.[38] The 32oz LIFE smoothie as outlined in the American College of Lifestyle Medicine journal, contained the following ingredients:

  1. Spinach, baby bok choy, or baby kale
  2. Blueberries
  3. Banana
  4. Unsweetened cocoa powder
  5. Ground flaxseed
  6. Soy milk or almond milk
  7. Water

[38]

The same study provides a small sample of foods that may be used for pain relief:[38]

  1. Magnesium – from a fresh salad
  2. Turmeric root – that may be added in soups
  3. Strawberries – used in a desert bowl

[11]

Please view this Physiopedia page for additional information on culinary medicine for health and disease management.

Resources[edit | edit source]

  • For more information on Tai Chi for Rehabilitation, please view this video by Dr Paul Lam.

[39]

References[edit | edit source]

  1. Kirsch Micheletti J, Bláfoss R, Sundstrup E, Bay H, Pastre CM, Andersen LL. Association between lifestyle and musculoskeletal pain: cross-sectional study among 10,000 adults from the general working population. BMC musculoskeletal disorders. 2019 Dec;20(1):1-8.
  2. Wasser JG, Vasilopoulos T, Zdziarski LA, Vincent HK. Exercise benefits for chronic low back pain in overweight and obese individuals. PM&R. 2017 Feb 1;9(2):181-92.
  3. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P, Hartvigsen J, Cherkin D, Foster NE, Maher CG. Low back pain: a call for action. The Lancet. 2018 Jun 9;391(10137):2384-8.
  4. 4.0 4.1 4.2 National Institute of Health. Complementary, Alternative, or Integrative Health: What’s In a Name? Available from: https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name (accessed 01/01/2022).
  5. Hoffman MD, Shepanski MA, Mackenzie SP, Clifford PS. Experimentally induced pain perception is acutely reduced by aerobic exercise in people with chronic low back pain. J Rehabil Res Dev. 2005;42(2):183-190
  6. Vanti C, Andreatta S, Borghi S, Guccione AA, Pillastrini P, Bertozzi L. The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials. Disabil Rehabil. 2019;41(6):622-632.
  7. Tataryn N, Simas V, Catterall T, Furness J, Keogh JWL. Posterior-chain resistance training compared to general exercise and walking programmes for the treatment of chronic low back pain in the general population: a systematic review and meta-analysis. Sports Med Open. 2021;7(1):17.
  8. Michaelson P, Holmberg D, Aasa B, Aasa U. High load lifting exercise and low load motor control exercises as interventions for patients with mechanical low back pain: A randomized controlled trial with 24-month follow-up. J Rehabil Med. 2016;48(5):456-463.
  9. Sherman KJ, Cherkin DC, Wellman RD, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171(22):2019-2026.
  10. Wewege MA, Booth J, Parmenter BJ. Aerobic vs. resistance exercise for chronic non-specific low back pain: A systematic review and meta-analysis. J Back Musculoskelet Rehabil. 2018;31(5):889-899.
  11. 11.0 11.1 11.2 11.3 11.4 Altug, Z. Exercise and Nutrition for Managing Chronic Low Back Pain. Managing Chronic Low Back Pain with Integrative Lifestyle Medicine. Physioplus. 2022.
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  14. Zhu F, Zhang M, Wang D, Hong Q, Zeng C, Chen W. Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PloS one. 2020 Sep 1;15(9):e0238544.
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