Most people will experience low back pain at some point in their lives. While this will usually be a short-term condition that passes without complication, some patients can develop chronic pain. People with chronic non-specific low back pain are encouraged to exercise. But should gaming-based exercise (‘exergaming’) be considered exercise for chronic low back pain?
- In the randomised GAMEBACK trial, exergaming reduced chronic low back pain in older people, but improvements were not clinically important.
- Additional evidence showing that exergaming can improve pain and other symptoms in people with chronic low back pain comes from small, short-term studies.
- Key guidelines do not include recommendations on exergaming for low back pain.
- But guidelines do recommend graded exercise that considers a patient's physical activity preferences, beliefs and specific functional impairments.
- If exergaming does not increase risk of harm and allows graded stretching, strengthening or aerobic exercises, then it could probably be considered exercise for chronic low back pain.
Acute non-specific low back pain can become chronic
Around 80% of people will experience low back pain at some point in their lives.1,2
Less than 1% of people with acute low back pain will have a specific spinal pathology and only 5% to 10% will have a radicular syndrome (such as sciatica).3
If alerting clinical features raise suspicion, then health professionals should rule out serious pathologies such as a spinal infection, fracture or cancer.2
Fortunately, around 90% of people will experience non-specific pain without a specific pathoanatomical cause which resolves in 4–6 weeks, without complication and with minimal intervention .2,4-6
Unfortunately, even when there is no serious pathology, some patients with acute non-specific low back pain can experience a subsequent episode or develop chronic pain (lasting more than 12 weeks).2
An integrated biopsychosocial approach is recommended for the management of chronic non-specific low back pain – exercise is particularly beneficial and should be encouraged.2
But what about ‘exergaming’?
Macquarie Dictionary defines ‘gaming’ as ‘the activity of playing computer or video games’.
‘Exergame’ is defined as ‘a video game that requires the gamer to undertake physical exercise, such as one in which the player engages in an interactive virtual bicycle race on screen by pedalling on a bicycle simulator which drives the visualisation’.
Exergaming for low back pain: GAMEBACK
Home-based gaming exercises can reduce chronic low back pain in older people, according to results of the ‘GAMEBACK’ trial.7
However, improvements in pain scores were only significant at some timepoints and not clinically important.7
What was the GAMEBACK trial?
The GAMEBACK trial was led by researchers from the University of Sydney and Westmead Public Hospital. Study results were published in Physical Therapy in September 2018.
In this trial, 60 adults (51.7% female, mean age 67.8 years) were randomised 1:1 to either home-based exercises using a Nintendo Wii U console with the Wii Fit U software (treatment) or continuation of usual activities (control) for 8 weeks.
Participants were included if they had non-specific low back pain for at least 3 months. Those with a serious spinal pathology were excluded.
The treatment group performed in-built Wii Fit flexibility, strengthening and aerobic exercises for 60 minutes, three times per week (with at least 1 day’s rest between sessions).
They also received fortnightly phone calls from a physical therapist (the control group did not).
Primary outcomes were pain self-efficacy – the ability to continue daily activities despite pain – and care-seeking at 3 and 6 months from baseline.
What did GAMEBACK show?
Compared with controls, participants randomised to home-based Wii Fit exercises had statistically significant improvements in:
- pain self-efficacy at 6 months (pain self-efficacy questionnaire; adjusted difference 5.17, 95% confidence interval [CI] 0.52 to 9.82, p = 0.03)
- adherence to flexibility exercises at least once per week at 6 months (self-reported paper diary; adjusted difference 4.36, 95% CI 1.06 to 17.93, p = 0.04)
- pain intensity at 8 weeks/immediately post intervention (numeric rating scale; adjusted difference –1.07, 95% CI –2.11 to –0.03, p = 0.04)
- function at 8 weeks (patient-specific functional scale; adjusted difference 1.21, 95% CI 0.10 to 2.33, p = 0.03).
The study authors compared these improvements with cut-offs previously determined to be a ‘minimal clinically important difference’ in people with chronic musculoskeletal or low back pain.8,9
However, the improvements in pain self-efficacy questionnaire, numeric rating scale and patient-specific functional scale scores did not reach the minimal clinically important differences (of 11, 2 and 2, respectively).
In addition, Wii Fit exercises had no effect on pain self-efficacy at 8 weeks or 3 months, or care-seeking behaviour at 8 weeks, 3 months or 6 months.
There was also no significant effect on engagement in physical activity, disability, fear of movement or re-injury, or concern about falling during daily activities.
Although some participants reported temporary soreness during or after Wii Fit exercises, no injury, fall or other adverse events related to the exercise program were reported.
Adherence based on total exercise time and total number of sessions over the study period (irrespective of duration) was high, at 70.8% and 85.1% of that recommended, respectively.
However, minutes of exercise time, number of exercise sessions and number of sessions ≥ 60 minutes long decreased over the study period.
Adherence to sessions ≥ 60 minutes long was only 33.3% of that recommended and the number of weeks participants adhered to the exercise program was only 25% of that recommended.
The details are provided in Table 1.
Table 1: Adherence to exergaming in the GAMEBACK trial
|What was the adherence outcome?||What would maximum adherence have been?||What was the adherence level?|
|Mean exercise time||
(60 minutes per session × 3 times per week × 8 weeks)
|1019.1 minutes = 70.8%|
|Median number of weeks exercising ≥ 180 minutes/week||8 weeks||2 weeks = 25%|
|Median number of exercise sessions ≥ 60 minutes||24 sessions||8 sessions = 33.3%|
|Mean number of exercise sessions, irrespective of duration||24 sessions||
20.4 sessions = 85.1%
Exergaming for low back pain: other small studies
A small number of studies have shown that gaming-based exercise can improve pain, disability, function, strength, flexibility, aerobic capacity and wellbeing in people with low back pain.10-16
However, results of the studies are limited by the small number of included participants and investigation of short-term exercise programs or short-term effects.
In addition, the studies investigated different ‘exergaming’ methods and did not always investigate gaming as the sole exercise intervention.
You can read a short summary of these studies below.
Wii Fit yoga for 4 weeks10
Participants: 30 women (mean age 44–50 years) with low back pain lasting more than 2 months.
Intervention: A 4-week exercise program consisting of physical therapy or Nintendo Wii Fit yoga.
Program: The Wii Fit yoga exercise program consisted of 12 sessions, with each session lasting 30 minutes. Activities included deep breathing and a variety of poses (half-moon, warrior, tree, chest to knee, chair, palm tree).
Control exercises consisted of 30 minutes each of trunk stabilisation and conventional physical therapy.
Findings: There were significant improvements in pain (p < 0.05), disability (p < 0.05) and fear avoidance (p < 0.01) scores with Wii Fit yoga versus physical therapy exercises, although improvements were seen in both groups.10
Wii Fit Plus for 8 weeks11
Participants: 30 women (mean age 68 years) with chronic low back pain.
Intervention: An 8-week exercise program consisting of strength exercises and core training alone or in addition to exercises using Nintendo Wii Fit Plus.
Program: Exercise sessions lasted 90 minutes each and were performed three-times per week.
Findings: Pain scores significantly improved in both groups (p = 0.0001) but balance did not improve in either group.
Capacity to sit improved only in women who exercised using Nintendo Wii Fit in addition to undertaking strength and core training (p = 0.04), although the effect size was small.11
Multicomponent exercise for 6 weeks12
Participants: Six participants (four females, mean age 50 years) with non-specific low back pain (lasting more than 3 months).
Intervention: A 6-week multicomponent activity program. There was no control group and the study did not investigate exercise as the sole intervention.
Program: Participants could self-select exercise activities at Week 5, with exergaming included as one of the potential activities.
Findings: Following the 6-week program, there were significant improvements in back strength scores (23%), aerobic capacity (23%), negative wellbeing scores (32%) and disability scores (16%).
ValedoMotion for nine sessions13
Participants: 20 participants (eight female) with non-specific low back pain lasting longer than 4 weeks. They were described as having at least moderate disability (Oswestry disability index > 8%) .
Intervention: Nine sessions of home-based conventional physiotherapy exercise or exercise with real-time augmented feedback on performance using a system consisting of a laptop and two sensors attached to the spine (ValedoMotion). Games were controlled by lower back movements.
Program: The home-based exercise program consisted of 3–5 exercises that required 10–20 minutes to complete each day.
Findings: The physiotherapy group exercised for a median of 4 minutes and 19 seconds while the augmented feedback group exercised for 9 minutes and 4 seconds (recorded in a self-reported exercise diary).
However, there was no significant difference in self-reported exercise duration between groups (p = 0.315), and the clinical importance of the small difference in exercise time between groups is unknown.
In addition, both exercise groups had similar improvements in self-perceived disability or lumbar movement control.
Virtual dodgeball over 3 days
In other studies, postural feedback using the ValedoMotion system helped perform home-based exercises correctly (18-week study, 10 participants),14 playing virtual dodgeball increased lumbar flexion over 3 days (26 participants in the treatment group),15 and virtual walking with physiotherapy reduced pain and fear of movement, and improved function immediately after treatment (22 participants in the treatment group).16
Is gaming recommended for low back pain management?
Currently , there is no recommendation on the use of exergaming for low back pain in key guidelines.2,17-19
In addition, as discussed above, there is currently limited evidence to form a recommendation.
However, exercise is recommended as part of a biopsychological approach that also includes patient education and reassurance, and the identification and management of psychological factors.2
Therapeutic Guidelines for low back pain explain that, owing to the range of potentially appropriate exercise modes and dosages, it is difficult to conclude which exercise program is best.2
However, the exercise programs may include stretching, strengthening and aerobic exercises.2
Exercise should be graded according to a patient’s preferences, level of fitness and function to find the balance between underdoing and overdoing exercise.2,20
Overall, a specific exercise program should consider a patient's physical activity preferences, beliefs and specific functional impairments.2
So, until further evidence emerges, if exergaming encourages a patient to exercise and aligns with the above recommendations, then exergaming could probably be considered an exercise option to help manage low back pain.
Consider the following practice points from the Therapeutic Guidelines when recommending exercise – of any type – for your patients with non-specific low back pain.2
- Emphasise that it is safe and helpful to move. Consider using phrases like ‘hurt does not mean harm’ and ‘sore but safe’.
- Consider physical activity preferences, beliefs and specific functional impairments and consider functionally-oriented stretching, strengthening and aerobic exercises.
- Start with gentle movements that might encourage the spine to move in its normal planes (for example, water- or land-based walking, gentle swimming and floor stretches).
- Grade exercise by exercise duration rather than pain level.
- Progress exercise type, frequency and/or intensity as tolerance to activity increases.
- Gradually introduce functional exercises (such as squats, lunges or step-ups) and other exercises that are enjoyed (for example, yoga or Pilates).
- Reserve more dynamic and higher-load exercises for later stages of rehabilitation.
- Australian Institute of Health and Welfare. Back problems snapshot. Canberra, ACT: Australian Institute of Health and Welfare, 2018 (accessed 14 November 2018).
- Rheumatology Expert Group. Therapeutic Guidelines: Rheumatology. Version 3. West Mebourne, VIC: Therapeutic Guidelines Ltd, 2017 (accessed 14 November 2018).
- Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust 2017;206:268-73.
- Machado GC, Ferreira PH, Maher CG, et al. Transient physical and psychosocial activities increase the risk of nonpersistent and persistent low back pain: a case-crossover study with 12 months follow-up. Spine J 2016;16:1445-52.
- Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014;384:1586-96.
- Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet 2017;389:736-47.
- Zadro JR, Shirley D, Simic M, et al. Video game-based exercises for older people with chronic low back pain: a randomized controlled trial (GAMEBACK). Phys Ther 2018.
- Maughan EF, Lewis JS. Outcome measures in chronic low back pain. Eur Spine J 2010;19:1484-94.
- Salaffi F, Stancati A, Silvestri CA, et al. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain 2004;8:283-91.
- Kim SS, Min WK, Kim JH, et al. The effects of VR-based Wii Fit yoga on physical function in middle-aged female LBP patients. J Phys Ther Sci 2014;26:549-52.
- Monteiro-Junior RS, de Souza CP, Lattari E, et al. Wii-workouts on chronic pain, physical capabilities and mood of older women: a randomized controlled double blind trial. CNS Neurol Disord Drug Targets 2015;14:1157-64.
- Bloxham S, Barter P, Scragg S, et al. Person-centered, physical activity for patients with low back pain: piloting service delivery. Healthcare (Basel) 2016;4.
- Hugli AS, Ernst MJ, Kool J, et al. Adherence to home exercises in non-specific low back pain. A randomised controlled pilot trial. J Bodyw Mov Ther 2015;19:177-85.
- Matheve T, Claes G, Olivieri E, et al. Serious gaming to support exercise therapy for patients with chronic nonspecific low back pain: a feasibility study. Games Health J 2018;7:262-70.
- Thomas JS, France CR, Applegate ME, et al. Feasibility and safety of a virtual reality dodgeball intervention for chronic low back pain: a randomized clinical trial. J Pain 2016;17:1302-17.
- Yilmaz Yelvar GD, Cirak Y, Dalkilinc M, et al. Is physiotherapy integrated virtual walking effective on pain, function, and kinesiophobia in patients with non-specific low-back pain? Randomised controlled trial. Eur Spine J 2017;26:538-45.
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-91.
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. Belmore, UK: NICE, 2016
- NSW Agency for Clinical Innovation. Management of people with acute low back pain: model of care. Chatswood: NSW Health, 2016 (accessed 1 March 2018).
- NSW Agency for Clinical Innovation. Pain and pacing. Sydney: NSW Agency for Clinical Innovation, 2018 (accessed 2 May 2018).