Table 3

Level and grade of evidence for physical activity recommendations for patients with low back pain

RECOMMENDATIONLEVEL*GRADE
Those with nonspecific chronic low back pain, without serious underlying conditions, can safely perform a variety of exercises that are progressive in nature. However, they should initially avoid high-impact physical activity, heavy resistance training, or extreme trunk flexion, extension, or rotation in a direction that induces painIIB
Those with acute (duration between 2 d and 4 wk) low back pain, without serious underlying conditions, can safely perform direction-preference–based physical activities.§ These include low back extension and flexion exercises or a combination of these movements. Pain relief and functional ability is enhanced if these are combined with heat-wrap treatmentIIB
Those with subacute low back pain, without serious underlying conditions, can safely perform physical activity consisting of walking, cycling, stretching, and trunk and limb strengthening, including progressive strength and postural training of the back and abdominal musclesIIB
Those with spondylolisthesis or spondylolysis can safely perform progressive strength and postural training of the back and abdominal muscles. (Athletes should cease strenuous sport participation for at least 3 mo)II (III)A (A)
Those who had surgery for disk herniation more than 1 y ago can safely perform isometric abdominal and back exercise and progressive physical activity involving aquatic exercises and dynamic back or hip extension and abdominal exercisesIIB
  • * Level I evidence includes randomized controlled trials; level II evidence includes randomized controlled trials with important limitations or observational trials with overwhelming evidence; level III evidence includes observational trials; and level IV evidence includes anecdotal evidence or expert opinion.

  • Grade A recommendations are strong; grade B recommendations are intermediate; and grade C recommendations are weak.

  • Previous back surgery, spondylolysis, spondylolisthesis, neurologic symptoms, inflammatory and infectious conditions, or spinal fractures.

  • § Movement in the direction that does not induce pain.