Acta Scientific Medical Sciences (ASMS)(ISSN: 2582-0931)

Review Article Volume 6 Issue 1

Does Physical Deconditioning in Chronic Low Back Pain Exist? A Systematic Review

Ivan PJ Huijnen1,2*, Bart C Bongers3,4, Bart CA Pepels1, Harriet M Wittink5, Jeanine A Verbunt1,2 and Rob JEM Smeets1,6

1Department of Rehabilitation Medicine, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

2Adelante Center of Expertise in Rehabilitation and Audiology, Adelante Rehabilitation Center, Hoensbroek, The Netherlands

3Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands

4Department of Nutrition and Movement Sciences, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

5Research Group Lifestyle and Health, Utrecht University of Applied Sciences, Utrecht, The Netherlands

6CIR Revalidatie, Eindhoven, The Netherlands

*Corresponding Author: Ivan Huijnen, Department of Rehabilitation Medicine, Maastricht University, The Netherlands.

Received: September 25, 2021; Published: December 20, 2021


The primary aim of this systematic review was to critically appraise the different methodologies used in studies to evaluate aerobic capacity in patients with chronic low back pain (CLBP). The second aim was to evaluate whether aerobic capacity of patients with CLBP differs from aerobic capacity of healthy age- and sex-matched subjects.

PUBMED, EMBASE, Web of Science, PEDro, and Cochrane databases were searched. A critical appraisal was performed on methodological quality of the used protocols using a self-designed assessment list.

A total of 28 studies were included in this review. Eleven studies (39.3%) used maximal exercise testing and seventeen studies (60.7%) used submaximal exercise testing. Large differences exist concerning the used exercise test protocols and methodologies to assess aerobic capacity of patients with CLBP. Similarly, large differences were found in how aerobic capacity of patients with CLBP was compared with age- and sex-matched healthy controls. Based on the results of the included studies, most studies found a lower aerobic capacity in patients with CLBP compared with age- and sex-matched healthy controls.

It can be concluded that it is not clear whether deconditioning is present in patients with CLBP. There are several points that warrant cautiousness before drawing a definitive conclusion.


Keywords: Chronic Low Back Pain; Aerobic Capacity; Physical Fitness; Exercise Testing


  1. Verbunt JA., et al. “Cause or effect? Deconditioning and chronic low back pain”. Pain3 (2010): 428-430.
  2. Hayden JA., et al. “Exercise therapy for treatment of non-specific low back pain”. Cochrane Database of Systematic Reviews 3 (2005): CD000335.
  3. Wun A., et al. “Why is exercise prescribed for people with chronic low back pain? A review of the mechanisms of benefit proposed by clinical trialists”. Musculoskeletal Science and Practice 51 (2021): 102307.
  4. Vlaeyen JW., et al. “Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance”. Pain3 (1995): 363-372.
  5. Verbunt JA., et al. “Disuse and deconditioning in chronic low back pain: concepts and hypotheses on contributing mechanisms”. European Journal of Pain1 (2003): 9-21.
  6. Smeets RJ., et al. “The association of physical deconditioning and chronic low back pain: a hypothesis-oriented systematic review”. Disability and Rehabilitation11 (2006): 673-693.
  7. Shephard RJ., et al. “The maximum oxygen intake. An international reference standard of cardiorespiratory fitness”. Bulletin of the World Health Organization5 (1968): 757-764.
  8. Wittink H., et al. “Deconditioning in patients with chronic low back pain-Fact or fiction?” Spine17 (2000): 2221-2228.
  9. Smeets RJ., et al. “Is the Fear Avoidance Model Associated with the Reduced Level of Aerobic Fitness in Patients with Chronic Low Back Pain?” Archives of Physical Medicine and Rehabilitation1 (2009): 109-117.
  10. Duque I., et al. “Maximal aerobic power in patients with chronic low back pain: A comparison with healthy subjects”. European Spine Journal1 (2011): 87-93.
  11. Astrand I. “Aerobic work capacity in men and women with special reference to age”. Acta physiologica Scandinavica. Supplementum 169 (1960): 1-92.
  12. Astrand PO., et al. “Evaluation of physical performance based on tests, in Textbook of work physiology”. Human Kinetics: Champaign (2003): 273-297.
  13. Gibbons RJ., et al. “ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing)”. Circulation1 (1997): 345-354.
  14. Higgins JPT and S Green. “Cochrane handbook for systematic reviews of interventions”. John Wiley and Sons Ltd: Chichester (2009): 187-235.
  15. Sanderson S., et al. “Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography”. International Journal of Epidemiology 3 (2007): 666-676.
  16. Arsham H. “Pooling the means, and variances”.
  17. Atalay A., et al. “Deconditioning in chronic low back pain: Might there be a relationship between fitness and magnetic resonance imaging findings?” Rheumatology International1 (2012): 21-25.
  18. Bachynski-Cole., et al. “The cardiovascular fitness of disabled patients attending occupational therapy”. Occupational Therapy Journal of Research4 (1985): 233-242.
  19. Chan CW., et al. “Aerobic exercise training in addition to conventional physiotherapy for chronic low back pain: a randomized controlled trial”. Archives of Physical Medicine and Rehabilitation 92 (2011): 1681-1685.
  20. Doury-Panchout F., et al. “VO2max in patients with chronic pain: Comparative analysis with objective and subjective tests of disability”. Annals of Physical and Rehabilitation Medicine5 (2012): 294-311.
  21. Duque I., et al. “Physical deconditioning in chronic low back pain”. Journal of rehabilitation medicine. Official Journal of the UEMS European Board of Physical and Rehabilitation Medicine 41.4 (2009): 262-266.
  22. Hoch AZ., et al. “Aerobic fitness in women with chronic discogenic non radicular low back pain”. American Journal of Physical Medicine and Rehabilitation 7 (2006): 607-613.
  23. Kell RT and GJG Asmundson. “A comparison of two forms of periodized exercise rehabilitation programs in the management of chronic nonspecific low-back pain”. Journal of Strength and Conditioning Research2 (2009): 513-523.
  24. Koldas Dogan S., et al. “Comparison of three different approaches in the treatment of chronic low back pain”. Clinical Rheumatology7 (2008): 873-881.
  25. Verbrugghe J., et al. “Disability, kinesiophobia, perceived stress, and pain are not associated with trunk muscle strength or aerobic capacity in chronic nonspecific low back pain”. Physical Therapy in Sport 43 (2020): 77-83.
  26. Verbrugghe J., et al. “Exercise Intensity Matters in Chronic Nonspecific Low Back Pain Rehabilitation”. Medicine and Science in Sports and Exercise 12 (2019): 2434-2442.
  27. Brox JI., et al. “Disability, pain, psychological factors and physical performance in healthy controls, patients with sub-acute and chronic low back pain: a case-control study”. Journal of Rehabilitation Medicine 2 (2005): 95-99.
  28. Hodselmans AP., et al. “Exercise capacity in non-specific chronic low back pain patients: A lean body mass-based Astrand bicycle test; reliability, validity and feasibility”. Journal of Occupational Rehabilitation 3 (2008): 282-289.
  29. Hodselmans AP., et al. “Nonspecific chronic low back pain patients are deconditioned and have an increased body fat percentage”. International Journal of Rehabilitation Research 3 (2010): 268-270.
  30. Hodselmans AP., et al. “Short-term outcomes of a back school program for chronic low back pain”. Archives of Physical Medicine and Rehabilitation 8 (2001): 1099-1105.
  31. Hurri H., et al. “Aerobic capacity among chronic low-back-pain patients”. Journal of Spinal Disorders1 (1991): 34-38.
  32. Keller A., et al. “Reliability of the Isokinetic Trunk Extensor Test, Biering-Sorensen Test, and Astrand bicycle test-Assessment of intraclass correlation coefficient and critical difference in patients with chronic low back pain and healthy individuals”. Spine7 (2001): 771-777.
  33. McQuade KJ., et al. “Physical fitness and chronic low back pain. An analysis of the relationships among fitness, functional limitations, and depression”. Clinical Orthopaedics and Related Research 233 (1988): 198-204.
  34. Protas EJ., et al. “Relevance of aerobic capacity measurements in the treatment of chronic work-related spinal disorders”. Spine 19 (2004): 2158-2166.
  35. Rasmussen-Barr E., et al. “Aerobic fitness in patients at work despite recurrent low back pain: a cross-sectional study with healthy age- and gender-matched controls”. Journal of Rehabilitation Medicine5 (2008): 359-365.
  36. Robert JJ., et al. “The effects of a work hardening program on cardiovascular fitness and muscular strength”. Spine10 (1995): 1187-1193.
  37. Storheim K and K Bo. “The effect of intensive group exercise in patients with chronic low back pain”. Advances in Physiotherapy 2 (2000): 113-123.
  38. Velde G and D Mierau “The effect of exercise on percentile rank aerobic capacity, pain, and self-rated disability in patients with chronic low-back pain: a retrospective chart review”. Archives of Physical Medicine and Rehabilitation 81 (2000): 1457-1463.
  39. Verbunt JA., et al. “Fear of injury and physical deconditioning in patients with chronic low back pain”. Archives of Physical Medicine and Rehabilitation8 (2003): 1227-1232.
  40. Wallbom AS., et al. “Concordance between rating of perceived exertion and function in persons with chronic, disabling back pain”. Journal of Occupational Rehabilitation2 (2002): 93-98.
  41. Wormgoor ME., et al. “The impact of aerobic fitness on functioning in chronic back pain”. European Spine Journal 4 (2008): 475-483.
  42. Ramasamy A., et al. “Assessment of Patient-Reported Outcome Instruments to Assess Chronic Low Back Pain”. Pain Medicine 6 (2017): 1098-1110.
  43. Vianin M. “Psychometric properties and clinical usefulness of the Oswestry Disability Index”. Journal of Chiropractic Medicine 4 (2008): 161-163.
  44. ATS and ACCP. “ATS/ACCP statement on cardiopulmonary exercise testing”. American Journal of Respiratory and Critical Care Medicine 2 (2003): 211-277.
  45. “ACSM's guidelines for exercise testing and prescription 8th edition”. A.C.o.S. Medicine. Philadelphia: Lippincott Williams and Wilkins (2009).
  46. Heyward V. “Advanced Fitness Assessment and Exercise Prescription”. Human Kinetics Champain, IL (2014).
  47. Nicholas MK., et al. “What do the numbers mean? Normative data in chronic pain measures”. Pain1-2 (2008): 158-173.
  48. “Physical fitness assessments and norms” (2002): 36-38.
  49. Midgley AW., et al. “Evaluation of true maximal oxygen uptake based on a novel set of standardized criteria”. Applied Physiology, Nutrition, and Metabolism 2 (2009): 115-123.
  50. Roffey DM., et al. “Effect of stage duration on physiological variables commonly used to determine maximum aerobic performance during cycle ergometry”. Journal of Sports Science 12 (2007): 1325-1335.
  51. Balady GJ., et al. “Clinician's Guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association”. Circulation 2 (2010): 191-225.
  52. Pescatello L., et al. “ACSM's guidelines for exercise testing and prescription”. 9th ed. L. Pescatello. Philadelphia: Lippincot Williams and Wilkins (2013): 40-156.
  53. McArdle WD., et al. “Exercise physiology: energy, nutrition, and human performance”. (8th edition). Philadelphia: Wolters Kluwer Health | Lippincott Williams and Wilkins (2015).
  54. Akalan C., et al. “Prediction of VO2max from an individualized submaximal cycle ergometer protocol”. Journal of Exercise Physiology 11.2 (2008): 1-17.
  55. Stuiver MM., et al. “Validation and Refinement of Prediction Models to Estimate Exercise Capacity in Cancer Survivors Using the Steep Ramp Test”. Archives of Physical Medicine and Rehabilitation 11 (2017): 2167-2173.
  56. Ansuategui Echeita J., et al. “Maximal cardiopulmonary exercise test in patients with chronic low back pain: feasibility, tolerance and relation with central sensitization. An observational study”. Disability and Rehabilitation (2021): 1-8.
  57. Baba R., et al. “Oxygen uptake efficiency slope: a new index of cardiorespiratory functional reserve derived from the relation between oxygen uptake and minute ventilation during incremental exercise”. Journal of the American College of Cardiology 6 (1996): 1567-1572.
  58. Bongers BC., et al. “An evaluation of the validity of the pre-operative oxygen uptake efficiency slope as an indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery”. Anaesthesia10 (2017): 1206-1216.
  59. Pogliaghi S., et al. “Calculation of oxygen uptake efficiency slope based on heart rate reserve end-points in healthy elderly subjects”. European Journal of Applied Physiology 6 (2007): 691-696.
  60. Huijnen IP., et al. “Physical performance measurement in chronic low back pain: measuring physical capacity or pain-related behaviour?” European Journal of Physics (2013): 103-110.
  61. Smeets RJ., et al. “Do patients with chronic low back pain have a lower level of aerobic fitness than healthy controls? are pain, disability, fear of injury, working status, or level of leisure time activity associated with the difference in aerobic fitness level?” Spine (Phila Pa 1976) 31.1 (2006): 90-97.
  62. , et al. “Blood pressure responses to bicycleexercise testing in apparently healthy middle-aged men”. Cardiology 66 (1980): 56-63.
  63. Shvartz E and RC Reibold. “Aerobic fitness norms for males and females aged 6 to 75 years: a review”. Aviation, Space, and Environmental Medicine 61 (1990): 3-11.
  64. Astrand PO. “Quantification of exercise capability and evaluation of physical capacity in man”. Progress in Cardiovascular Diseases 1 (1976): 51-67.
  65. Vos JA. “Ergometry and exercise accompaniment”. Amersfoort: Nederland’s Paramedisch Instituut (2004).
  66. Seliger V and Z Bartunek. “Mean Values of Indices of Physical Fitness in the Investigation of Czechoslovak Population Aged 12-55 Years”. Prague, Czechoslovakia: Czechoslovak Association of Physical Culture (1976).
  67. Research CIFA. “The fitness specialist certification manual” (2005).
  68. Heyward V. “Advanced Fitness Assessment and Exercise Prescription”. Human Kinetics. Champain, IL (1991).
  69. Government of Canada, M.O.S., Fitness and Amateur Sport. “Canadian Standardized Test of Fitness (CSTF) operations manual”. Government of Canada: Ottawa (1987).
  70. Fletcher GF., et al. “Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association”. Circulation 4 (1996): 857-862.
  71. Fletcher GF., et al. “Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association”. Circulation 14 (2001): 1694-740.


Citation: Ivan PJ Huijnen., et al. “Does Physical Deconditioning in Chronic Low Back Pain Exist? A Systematic Review". Acta Scientific Medical Sciences 6.1 (2022): 191-216.


Copyright: © 2022 Ivan PJ Huijnen., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Acceptance rate30%
Acceptance to publication20-30 days
Impact Factor1.403

Indexed In

News and Events

  • Certification for Review
    Acta Scientific certifies the Editors/reviewers for their review done towards the assigned articles of the respective journals.
  • Submission Timeline for Upcoming Issue
    The last date for submission of articles for regular Issues is April 30th, 2024.
  • Publication Certificate
    Authors will be issued a "Publication Certificate" as a mark of appreciation for publishing their work.
  • Best Article of the Issue
    The Editors will elect one Best Article after each issue release. The authors of this article will be provided with a certificate of "Best Article of the Issue"
  • Welcoming Article Submission
    Acta Scientific delightfully welcomes active researchers for submission of articles towards the upcoming issue of respective journals.

Contact US