Effectiveness of Graded Exercise & Graded Exposure for Chronic Nonspecific Low Back Pain.


Previous literature supports that using a graded exposure (GEXP) approach for managing patients with chronic nonspecific lower back pain (CNSLBP) may have more favourable clinical outcomes than graded activity (GA) and general exercise. However, this evidence is limited and of low quality.

The aim of this research was to rapidly review the current literature to evaluate whether graded exposure or graded activity is more effective than usual physiotherapy care for managing patients with CNSLBP.


The rapid review was performed in line with preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines.

Studies were searched on MEDLINE, PEDro, Cochrane and Google Scholar electronic databases and quality was assessed by one reviewer using the PEDro (Physiotherapy evidence database) scale.

Clinical trials that evaluated the effect of a graded exposure or graded activity approach on outcomes of pain intensity plus or minus disability, psychological determinants or quality of life in patients with CNSLBP were eligible for this review.


Five studies were included in this review which PEDro scores ranged from 6 to 8 (good).

Two studies directly compared GA with usual physiotherapy care showing no significant differences on pain intensity, quality of life and disability.

Three studies comparing GEXP to best practice physiotherapy favoured GEXP intervention with addressing outcomes, which include: disability, kinesphobia and catastrophizing in the short, mid and long term.

However, mixed results were found for pain intensity with two studies finding that GEXP compared to usual Physiotherapy care significantly reduced pain intensity but one study did not find any significant differences.

Current evidence suggests that GEXP is more favourable than usual physiotherapy care for reducing disability, catastrophizing and kinesphobia managing patients with CNSLBP.

However, evidence does not appear to favour one approach over the other (GEXP, GA or usual physiotherapy care) in terms of reducing pain intensity. This is only based on limited evidence so further high quality research is required comparing GA and GEXP with usual physiotherapy care.


Based on the above evidence, it can be concluded that both GA and GEXP are clinically effective interventions to consider for patients with CNSLBP within clinical practice.

Indeed, as GEXP has been shown to address psychological factors that mediate disability, (such as catastrophizing and fear of movement) one consideration is that this approach may be particularly appropriate when managing patients who present with these determinants.

Furthermore, using the GEXP approach may support functional improvements and quality of life with improving the willingness to move despite the pain.

Funding acknowledgements

This work was unfunded.

Additional notes

This work was presented at Physiotherapy UK 2019