Healthy lifestyle care vs guideline-based care for low back pain: a randomized clinical trial

Key Points

1. Healthy lifestyle management with guideline-based care for chronic low back pain was superior to guideline-based care alone for disability, weight, and quality of life.
2. The benefits were substantially larger among participants who complied with the lifestyle management program.

BACKGROUND & OBJECTIVE

Research has linked chronic low back pain (LBP) to lifestyle factors like being overweight, smoking, physical inactivity and poor diet. But there is uncertainty about whether interventions directed at lifestyle factors are effective treatments for LBP.

This trial aimed to assess whether adding lifestyle-focused support to guideline-based care would improve disability outcomes compared to guideline-based care alone.

Chronic low back pain (LBP) has been linked to lifestyle factors like being overweight, smoking, physical inactivity and poor diet.

The findings suggest clinicians should consider addressing lifestyle factors as part of a comprehensive approach to managing chronic low back pain.

METHODS

• 346 participants with chronic LBP and at least one lifestyle risk factor (overweight, poor diet, physical inactivity, or smoking) were randomized to receive either:

  • (1) The Healthy Lifestyle Program (HeLP), which combined guideline-based physiotherapy with lifestyle education, dietitian consultation, educational resources, and telephone health coaching over 6 months (see Figure 1), or
  • (2) guideline-based physiotherapy care.

• The primary outcome was disability at 26 weeks measured by the Roland Morris Disability Questionnaire.

• Secondary outcomes included pain intensity, weight, quality of life, and smoking status.

RESULTS

• At 26 weeks, the HeLP group showed greater improvement in:

  • Disability (1.3 points better on a 24-point scale)
  • Weight loss (1.6 kg more weight lost)
  • Physical function

• Among participants who complied with the program, the benefits were substantially larger (more than 5 points improvement in disability.)

• There were no differences between groups in pain intensity or smoking rates. Both programs had similar safety profiles.

LIMITATIONS

• The patients and clinicians were not blinded as to treatment group.

• About one-quarter of participants discontinued treatment over the six-month period.

• The sample had a very long duration of back pain (7.5-10 years median) which may limit generalizability to those with more recent onset.

• The differences between groups, while statistically significant, were relatively small for most outcomes except among participants who completed the program.

CLINICAL IMPLICATIONS

LBP is a major contributor to disability (1). Research has identified several lifestyle factors, including being overweight, smoking, physical inactivity, and poor diet as risk factors for developing and maintaining LBP (2). At the same time, having back pain can lead to unhealthy lifestyle behaviors, creating a cycle that increases risk for other chronic diseases (3).

Although clinical practice guidelines recommend exercise as a core treatment for LBP, evidence for other lifestyle interventions is limited (4). For example, the World Health Organization does not currently recommend weight loss programs for back pain management due to the very low quality of existing research.

This study provides evidence that integrating lifestyle management into back pain care can safely produce small additional benefits beyond standard physiotherapy, with larger improvements for those who adhere to the program.

The findings suggest clinicians should consider addressing lifestyle factors as part of a comprehensive approach to managing chronic low back pain, while recognizing that patient engagement and adherence will likely impact outcomes.

+STUDY REFERENCE

Mudd E, Davidson S, Kamper S, et al. (2025) Healthy Lifestyle Care vs Guideline-Based Care for Low Back Pain: A Randomized Clinical Trial. JAMA Network Open, 8(1).

SUPPORTING REFERENCE

1. Chen S ,Chen M , Wu X, et al. Global, regional and national burden of low back pain 1990-2019: a systematic analysis of the Global Burden of Disease study 2019. J Orthop Translat. 2021;32:49-58.
2. Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol. 2010;171(2):135-154.
3. Williams A, Kamper SJ, Wiggers JH, et al. Musculoskeletal conditions may increase the risk of chronic disease: a systematic review and meta-analysis of cohort studies. BMC Med. 2018;16(1):167.
4. Huijbers JCJ, Coenen P, Burchell GLB, et al. The (cost-)effectiveness of combined lifestyle interventions for people with persistent low-back pain who are overweight or obese: a systematic review. Musculoskelet Sci Pract. 2023;65:102770.