The Effect of Exercising on the Decrease Back Pain: A Systematic Review

The aim of this study was to determine the impact of exercising on the back pain. Tools used for the literature review are electronic databases: Google Scholar, PubMed, Medline, Mendeley, for the time period from 2010 to 2019. After the selection of papers regarding the criteria, 20 studies that suit the needs of this systematic review were selected. Therapeutic training for relieving back pain is very heterogeneous, a total of 12 different therapeutic exercise programs were conducted. The most used programs are pilates and conventional (traditional) program for relieving back pain, followed by stabilization exercises, as well as other methods, such as: sling method, motor control exercises, stretching exercises, segment stabilization, as well as combined programs. Based on the analysis of the research conducted so far, it has been determined that exercising has positive impact in decreasing pain intensity and the level of disability, on the increase of the maximum strength, durability and trunk flexibility, as well as on the improvement of the overall health related functionality of patients with back pain. It has been concluded that program of exercises has a multiple positive impact on the health of patients with the chronical back pain and that exercising to these patients is, therefore, recommended.


Introduction
Technological and organizational changes in the industry during the last couple of decades have significantly increased a number of jobs conducted in monotonous and body postures with limited movements (Amit, Manish, & Taruna, 2013). Moreover, looking at the daily activities of the contemporary human, it can be noticed that almost all activities, from having breakfast, to working in the office, to watching television in the evening, humans conduct in the sitting position. This indicates that the sedentary lifestyle is one of the leading causes of the back pain occurrence (Sarabon, Palma, Vengust, & Strojnik, 2011). Back pain develops in over 80% of population at some point in their lives and it is considered to be the main health issue in the developed countries and to be responsible for major treatment, work absence and invalidity related expenses (Sarabon et al., 2011). Back pain syndrome is one of the most common causes of disability and is increasing faster than any other (Amit et al., 2013;Sarabon et al., 2011). Pain is the consequence of the pres-sure of abdomen on the thoracic and lumbar-sacral part of the spine in sedentary position. Long-term irregular sitting position puts large load on the back muscles and on the inter-vertebral discs. Due to the additional pressure on the soft tissues (muscles, tendons and joints), work in sedentary position highly increases the back pain (Pranjic & Males-Bilic, 2015). Biomechanical risk factors for the lower back pain include: extended static posture (McGill, 2007), work in sitting position, frequent folding with rotations, lifting, pulling, pushing and vibrations, as well as the muscle weakness, especially in the sedentary position (Sarabon et al., 2011). Norris & Matthews (2008) stipulate that the causes of the back pain are multiple, but that the basis is the muscle dis-balance of the lumbar and abdominal region. Pranjic & Males-Bilic (2015) are warning us that the main cause of weakness of back and stomach muscles is insufficient physical activity (hypokinesis). The more and more prevalent sedentary lifestyle, incorrect sitting posture and hypokinesis are the factors that contribute to the decrease of the endurance of lumbar extensors THE EFFECT OF EXERCISING ON THE BACK PAIN | B. KATANIC ET AL. and, therefore, to the appearance of the lumbar syndrome (Mc-Gill, 2007). Deep abdominal muscles, primarily m. transversus abdominis and m. multifidus, are responsible for maintaining spine stability and, therefore, their stability impacts the reduction of the lower back pain (Amit et al., 2013). Physiotherapists are using therapeutic exercises to reduce the pain, reduce the level of disability and to return some muscle functions (Brumitt, Matheson, & Meira, 2013). Sarabon et al. (2011) noticed that therapeutic training nowadays, in order to reduce the pain, is very heterogenic and varies significantly in type, intensity, frequency and training duration. The main purpose of the training is the improvement of the body posture, release of contracted muscles, improvement of strength, intensity and endurance of the abdominal muscles, as well as the improvement of the overall aerobic physical condition (Quittan, 2002).
The aim of this research was to determine the impact of exercising on the back pain. Gathering of the adequate data has been conducted from the previous experimental researches in the time period from 2010 to 2019, under the assumption that implementation of the exercising program decreases the back pain.

Data sourcing and strategy
For the literature review, following electronic databases were used: Google Scholar, PubMed, Medline, Mendeley in the period between 2010 and 2019. Key words used in the research were: back pain, training program, exercise. Research strategy was cus-tomized for each electronic database, wherever it was possible, in order to increase sensitivity. All titles and abstracts were examined for potential papers that will be included in the systematic review. Also, reference lists from previous systematic reviews and original researches were examined. Relevant studies were systematized after detailed examination, based on fulfilling the criteria to be included.

Inclusion criteria
Criteria for being included from the study: experimental research determining the impact of exercising on the back pain, research in English language, research published between 2010 and 2019, research published as a full paper.

Exclusion criteria
Criteria for being excluded from the study: research written in any language other than English, research published before 2010, research not published as a full paper (abstracts), systematic research, research that did not show systematical approach to obtaining results, duplicates.

Data extraction and selection
Experimental research which met the set criteria was then analyzed and presented based on the following parameters: references (the first author and year of publication), the sample of participants, research duration, type of treatment, measurement instruments, results and conclusion.

Results
This systematic review included 20 studies that examined the impact of exercising on the back pain. Studies jointly included 1174 participants who suffered from back pain, at least 10 and at most 296 participants per study. The most frequently used measurement instruments were: VAS (Visual Analogue Scale) with emphasis on the following muscles: musculus multifidus, musculus quadratum lumborum, musculus erector spinae, 18 out of 20 papers, followed by ODI (Osvestri Disability Index) used in 11 studies and RMQ (Roland-Morris's Questionnaire) used in 6 studies. Several studies examined the muscle activation after the back pain relief treatment, and musculus transversus abdominis, therefore, the deep muscles that are, according to Amit et al. (2013) responsible for spine stability. In these 20 studies a total of 35 interventions was implemented, which were a part of 12 different programs of therapeutic exercises, in line with claims by Sarabonа et al. (2011), who stipulate that contemporary therapeutic training for back pain relief are very heterogenous, but that the basis for all the programs is strengthening of the abdominal deep muscles. Duration of programs was from 4 to 16 weeks, out of which the most frequent duration was 8 weeks (in 8 papers), and the treatments included were from 1 to 3 times per week.

CG: No significant changes
After 12-weeks exercising program for lumbar muscle stabilization, multi-fundus muscles and abdomen muscles stabilization, rotation was improved, while the level of disability and of the chronic back pain was decreased.
Note The most frequent therapeutic programs were: pilates and conventional (traditional) program for back pain relief (8 programs), followed by the stabilization exercises (6 programs), as well as other methods, such as: sling method, motoric control exercises, stretching exercises, segmental stabilization, as well as combined programs, in which participants were succumbed to different treatments simultaneously (such as back exercises and walking in the aerobic zone etc.). The main purpose of all therapeutic exercising programs is the posture improvement, relief from muscle cramps, improvement of the intensity, strength and abdominal muscle durability, as well as the increase of the overall aerobic physical condition (Quittan, 2002).

Discussion
Exercising program has proven to be efficient in decreasing the level of disability (Valenza et al., 2017) and lumbar pain intensity (Cruz-Díaz, Romeu, Velasco-González, Martínez-Amat, & Hita-Contreras, 2018; Kliziene et al., 2017;Yoo & Lee, 2012). Also, positive impact on flexibility and balance has been stipulated (Valenza et al., 2017), as well as on the maximum extensors and abdominal flexors strength (Kliziene et al., 2017;Yoo & Lee, 2012), on the isometric abdominal muscle durability (Kliziene et al., 2017), as well as on the Tamp kinesiophobia scale (Cruz-Díaz et al., 2018). No significant differences were found between pilates groups, even though it has been determined that group who exercised pilates three times per week has shown better results (Miyamoto et al., 2018).
Stabilization exercises have proven to be efficient in decreasing pain intensity (Javadian, Behtash, Akbari, Taghipour-Darzi, & Zekavat, 2012) and the level of disability (Shamsi, Sarrafzadeh, & Jamshidi, 2015;Sipaviciene, Kliziene, Pozeriene, & Zaicenkoviene, 2018;Sung, 2013;Sarabon et al., 2011). Significant improvement of the maximum flexor strength and lateral abdominal flexor strength, as well as of the passive flexibility of extensors and flexors of the hip joint has been established (Shamsi et al., 2015;Sarabon et al., 2011). Program had positive impact on increasing the level of lumbar muscles and deep muscles activation (Javadian et al., 2012;Sipaviciene et al., 2018). When it comes to the impact on the muscle tiredness, Sung (2013) did not find any significant difference, compared to Javadian et al. (2012) who determined that pilates impacted the decrease of local muscles tiredness.
The rest of the studies were less represented in the review, even though a certain effectiveness of programs has been established. For example, a method of segmental stabilization has proven to be extremely efficient in pain relief and in decreasing the level of disability compared to the pre-test range of 90-98% for all variables, except on the PBU test, where an improvement of 48% has been detected (Franca, Burke, Caffaro, Ramos, & Marques, 2012;Fran-ca, Burke, Hanada, & Marques, 2010). Sling method had significant impact on decreasing the pain intensity (Unsgaard-Tondel et al., 2010;Yoo & Lee, 2012), level of invalidity, on the improvement of the trunk flexion and on the results of the questionnaire on the fear of physical activity (Unsgaard-Tondel et al., 2010), as well as on the improvement of the patient's lumbar strength (Yoo & Lee, 2012). Strength exercises have proven to be efficient in pain relief (Cho, Kim, & Kim, 2014;Cuesta-Vargas et al., 2011;Franca et al., 2010), in decreasing the level of disability (Cuesta-Vargas et al., 2011;Franca et al., 2010), in increasing the lumbar area range of movements (Cho et al., 2014), as well as on the overall health condition of the patient and muscle durability (Cuesta-Vargas et al., 2011). Stretching method has proven to have positive impact on the pain relief (Masharawi & Nadaf, 2013;Sung, 2013), on decreasing the level of invalidity in the range 37-56% (Sung, 2013), and in improving lumbar area flexibility (Masharawi & Nadaf, 2013). It had statistically insignificant impact on the lumbar area muscle activation of 6.6% (Sung, 2013). Only one study considered motor control, but has proven a significant impact of this method on decreasing the level of disability and pain intensity, on increasing the abdominal flexion and on the results of the questionnaire on avoiding physical activity. (Unsgaard-Tondel et al., 2010). Additionally, one paper examined the impact of the exercises of dorsiflexion of the ankle with straps in combination with exercises for stretching of the trunk. A significant decrease of 32.5% on the pain questionnaire and of 23.2% on the disability index has been established (You, Kim, Oh, & Chon, 2014). Besides the exercising systems, impact of aerobic walking training and walking has been examined and it was determined that it has positive effects on: decreasing the level of disability and pain intensity, increasing the level of flexibility, abdominal flexor muscles durability, as well as on the results on the walking test and questionnaire on avoiding physical activity (Shnayderman & Katz-Leurer, 2013).
Therefore, it has been established that all therapeutic exercising programs have significant impact on decreasing the level of disability and back pain intensity. Also, exercising has positive impact on the maximum strength, muscle durability and trunk flexibility. Positive effects have been achieved in the level of muscle activation, functionality, balance, health status and the results on the kinesiophobia scale.
Certain authors compared two and more therapeutic programs, in order to determine differences between them. Therefore, it has been concluded that there are no significant differences between conventional therapeutic program and pilates, except the fact that conventional program has proven to be somewhat more successful than pilates in improvement of functionality and flexibility (Mostagi et al., 2015). When comparing sling and pilates, pilates has proven to be somewhat more successful (Yoo & Lee, 2012). Also, no significant differences between stabilization and conventional program were found. No significant differences between groups of motor control, conventional and sling method were found, even though the group who was undertaking motor exercises achieved somewhat better results than the conventional group (Unsgaard-Tondel et al., 2010). Certain authors have in their papers stipulated segmental stability as a significantly superior program compared to strength and stretching exercises (Franca et al., 2010, Franca et al., 2012. Walking on the treadmill program and abdomen strengthening exercises program have proven to be more efficient than aerobic activities (Shnayderman & Katz-Leurer, 2013), while the additional aerobic training has not been proven to have any impact on the back pain (Cuesta-Vargas et al., 2011).
In general, exercising positively impacts the decrease of the level of disability and lumbar pain intensity, as well as on other factors. Nevertheless, there are certain limitations when it comes to comparing different programs and their results. One of the main limitations is the large number of various exercising programs reviewed, a total of 12. Other limitations are related to the fact that many programs include similar or same elements, so it was not easy to determine a border between them. Also, there are other differences to be considered, such as the duration of the program, number of training sessions per week, the duration of the single training session, differences related to sex, age, level of disability and so on. On the other hand, mentioned parameters are pointing us towards the topics for future research.

Conclusion
Systematic review included 20 studies and analyzed the impact of a total of 35 exercising programs. The most frequently used therapeutic programs were as follows: pilates, conventional (traditional) program for back pain relief, stabilization exercises, as well as sling, motor control exercises, stretching, segmental stabilization, combined programs and so on. Mostly, the impact examined was the one that particular exercising program can have on the level of disability, pain intensity, motoric capabilities, muscle activation level and so on.
Based on the results obtained, it has been established that the exercising program has multiple positive impacts on the patients with the back pain, as follow: decreasing the level of disability, decreasing the lumbar area pain intensity, development of the maximum flexor strength, strength of the lateral flexors and abdomen extensors, increase of extensors and hip joint flexors, improvement of stability and balance, isometric durability of muscle flexors and abdomen extensors, increasing of the level of lumbar and abdomen muscles activation, improvement of the overall health condition and functionality of the patient, better results at the questionnaire on avoiding physical activity.
Finally, it can be concluded that exercising has multiple positive effects on the back pain patients. For these reason, exercising is being recommended to all patients with back pain.