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, Kim Jackson, Jess Bell, Ewa Jaraczewska and Lucinda hampton

Introduction[edit | edit source]

The management of chronic low back pain (LBP) often requires lifestyle changes for long-lasting effect. Research shows that altering diet and increasing activity levels 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:


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 dietitian-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 et al.[5] found people with chronic LBP and minimal to moderate levels of disability experienced exercise-induced analgesia for greater than 30 minutes following aerobic exercise.
    • A 2019 study by Vanti et al.[6] suggests a walking programme alone can provide similar pain relief and improvements to disability, movement avoidance, and quality of life with a walking programme combined with exercise, and an exercise programme alone.
  2. Resistance training is any exercise that causes muscles to contract against an external resistance with the expectation of increases in strength, power, hypertrophy, and/or endurance.
    • A 2021 study by Tataryn et al.[7] 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.
    • A 2016 study by Michaelson et al.[8] found no significant difference in the effectiveness of high load lifting and low load motor control interventions on improving LBP and disability.
  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 aetiology, 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

Integrative exercises are an alternative to conventional exercises. This type of exercise is unique because it combines both physical and mental exercises and is 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 side-bending, 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 meditation 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 become a way of promoting physical and mental well-being. Yoga, as practised in Western countries, typically emphasises physical postures, breathing techniques, and meditation.[13] A 2020 meta-analysis[14] 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 has 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 meditation and cognitive therapy.


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 steady and controlled breathing. Pilates routines can be performed on specially-designed apparatuses, such as a reformer, or on the floor using a mat.[16] A 2016 systematic review of nine randomised 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 randomised controlled trials found that Baduanjin, a type of Qigong, is effective for LBP.[19]

Tai Chi: A series of slow mindfully produced movement patterns with stretching and deep breathing. Movements are continuous and flow from one posture to another.[20] Tai Chi practice has origins in martial arts. A 2019 systematic review and meta-analysis of randomised 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 contrasts how they are practised.


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 do 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 environment around you while walking.[25] A 2021 randomised controlled trial found that persons with chronic LBP identified therapeutic procedures and experienced changes in their 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 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, and prevention is better than intervention. It is strongly recommended to work with a nutritionist-dietitian for optimal nutritional results and to strengthen interprofessional referrals and collaborations.[11] Please read this article on nutrition for a good overview of the topic and the role of physiotherapy in giving nutritional or dietary advice.

Purpose of Food:

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


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 socialisation activity
  3. Mindful eating


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


Food as Medicine[edit | edit source]

A 2020 article states that the Low Inflammatory Foods Everyday or LIFE diet, or a regular healthy 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


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


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.


Recommended websites:

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: (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. Plus. 2022.
  12. American Academy of Physical Medicine and Rehabilitation. Integrative Approaches to Therapeutic Exercise. Available from: (accessed 01/01/2022).
  13. 13.0 13.1 National Institute of Health. Yoga: What You Need To Know. Available from: (accessed 02/01/2022).
  14. 14.0 14.1 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.
  15. YouTube. Zen Stories | The Science of Yoga Part I. Available from: [last accessed 03/01/2022]
  16. Cleveland Clinic. Everything you want to know about pilates. Available from: (accessed 03/01/2022).
  17. Kamioka H, Tsutani K, Katsumata Y, Yoshizaki T, Okuizumi H, Okada S, Park SJ, Kitayuguchi J, Abe T, Mutoh Y. Effectiveness of Pilates exercise: A quality evaluation and summary of systematic reviews based on randomized controlled trials. Complementary Therapies in Medicine. 2016 Apr 1;25:1-9.
  18. National Qigong Association. What is Qigong? Available from: (accessed 02/01/2022).
  19. Li H, Ge D, Liu S, et al. Baduanjin exercise for low back pain: A systematic review and meta-analysis. Complement Ther Med. 2019;43:109-116.
  20. The Mayo Clinic. Tai chi: A gentle way to fight stress. Available from: (accessed 02/01/2022).
  21. Qin J, Zhang Y, Wu L, He Z, Huang J, Tao J, Chen L. Effect of Tai Chi alone or as additional therapy on low back pain: Systematic review and meta-analysis of randomized controlled trials. Medicine. 2019 Sep;98(37).
  22. YouTube. Holden QiGong|Tai Chi vs Qi Gong: What’s the Difference Between Tai Chi and Qi Gong? Available from: [last accessed 03/01/2022]
  23. YouTube. Yoga Lily| Eight Brocades Qigong Practice with English instruction. Available from: [last accessed 03/01/2022]
  24. YouTube. Flowing Mobility Tai Chi | Tai Chi for Rehabilitation. Available from: [last accessed 03/01/2022]
  25. Heart Foundation. The Mindful Walk. Available from: (accessed 03/01/2022).
  26. Cattanach BK, Thorn BE, Ehde DM, Jensen MP, Day MA. A qualitative comparison of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain. Rehabilitation psychology. 2021 Aug;66(3):317.
  27. Alexander Technique. What is the Alexander Technique? Available from: (accessed 02/01/2022).
  28. Little P, Lewith G, Webley F, Evans M, Beattie A, Middleton K, Barnett J, Ballard K, Oxford F, Smith P, Yardley L. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. Bmj. 2008 Aug 19;337.
  29. Feldenkrais Mathod. Frequently asked questions. Available from: (accessed 02/01/2022).
  30. Ahmadi H, Adib H, Selk-Ghaffari M, et al. Comparison of the effects of the Feldenkrais method versus core stability exercise in the management of chronic low back pain: a randomised control trial. Clin Rehabil. 2020;34(12):1449-1457.
  31. JYouTube. TedxTalks| Change Your Life with the Alexander Technique | August Berger. Available from: [last accessed 03/01/2022]
  32. YouTube. Future Life Now | Feldenkrais Method and Chronic Pain: How does it work? Available from: [last accessed 03/01/2022]
  33. Zick SM, Murphy SL, Colacino J. Association of chronic spinal pain with diet quality. Pain reports. 2020 Sep;5(5).
  34. Martinez-Rodriguez A, Leyva-Vela B, Martinez-Garcia A, Nadal-Nicolas Y. Effects of lacto-vegetarian diet and stabilization core exercises on body composition and pain in women with fibromyalgia: randomized controlled trial. Nutricion hospitalaria. 2018 Mar 1;35(2):392-9.
  35. Elma Ö, Yilmaz ST, Deliens T, Coppieters I, Clarys P, Nijs J, Malfliet A. Do nutritional factors interact with chronic musculoskeletal pain? A systematic review. Journal of clinical medicine. 2020 Mar;9(3):702.
  36. Hashem LE, Roffey DM, Alfasi AM, Papineau GD, Wai DC, Phan P, Kingwell SP, Wai EK. Exploration of the inter-relationships between obesity, physical inactivity, inflammation, and low back pain. Spine. 2018 Sep 1;43(17):1218-24.
  37. YouTube. Food Insight | 6 Tips for Mindful Eating. Available from: [last accessed 03/01/2022]
  38. 38.0 38.1 38.2 Perzia B, Ying GS, Dunaief JL, Dunaief DM. Once-Daily Low Inflammatory Foods Everyday (LIFE) Smoothie or the Full LIFE Diet Lowers C-Reactive Protein and Raises Plasma Beta-Carotene in 7 Days. American Journal of Lifestyle Medicine. 2020 Oct 5:1559827620962458.
  39. YouTube. Lesson 1 Tai Chi for Rehabilitation | Dr Paul Lam | Free Lesson and Introduction. Available from: [last accessed 03/01/2022]