Walking is an accessible, inexpensive activity and, for many people, a feasible form of physical activity. In primary care, it is therefore often recommended as a “safety standard” approach for low back pain and to improve overall fitness. In recent years, the scientific evidence supporting walking for recurrent low back pain has also grown. In this first part, we examine the benefits of walking.

WalkBack: Key Findings 

The WalkBack trial, published in The Lancet in 2024, tested an individualized, progressive walking program with education and coaching in adults who had recently recovered from an episode of nonspecific low back pain. The pragmatic intervention helped participants gradually build up to several walking sessions per week — aiming for about 130 minutes a week, a common target in the literature — and provided self‑management support. The program delivered clinically meaningful benefits: fewer recurrences of disabling low back pain, a longer time to a new episode, and evidence suggesting it was cost‑effective.

Clinically relevant for practice: Although the overall number of adverse events was similar between groups, participants in the walking arm reported more lower-extremity symptoms. This suggests the foot-ankle-knee-hip axis can be stressed in patients with vulnerable biomechanics and should be taken into account when prescribing a walking program.

Why Walking Helps Some Patients 

Walking is very effective for some patients. It is a highly beneficial health intervention with positive effects on cardiovascular, metabolic, immune, and mental health. In addition, walking often takes place outdoors, in nature and during daylight, which offers additional benefits for general health and mood.

Bert Ameloot, a chiropractor and president of the Belgian Chiropractors’ Union, lists several plausible mechanisms:

• Progressive loading and tissue adaptation (muscular endurance, tendons and ligaments, load‑bearing capacity of the paraspinal structures)
• Neuromodulation and stress reduction (rhythmic movement, mindfulness, sleep)
• Behavioral aspect: Walking is easy to incorporate and promotes self‑management

An Australian survey of chiropractors found that a large proportion of respondents recommend physical activity and that walking groups and clubs are viewed as feasible options. At the same time, the survey revealed disparities in knowledge of recommendations and in how advice and screening are systematized — supporting the idea that walking often fits within chiropractic care while underscoring the importance of triaging patients for whom walking is not indicated.

However, walking is not a biomechanically neutral activity; it is a repetitive motion that generates impact, rotation, and often asymmetric loading transmitted along the foot-ankle-knee-hip-pelvis-lumbar spine axis. In some patients, this can make walking suboptimal or even counterproductive. In those cases, cycling — including stationary bikes, which usually involve slight lumbar flexion — or swimming/aquatic therapy may be better‑tolerated alternatives.

A Clinically Useful Decision Framework 

Walking is a first‑line treatment in these cases: 

• Nonspecific low back pain, particularly recurrent episodes
• Good tolerance of the foot and ankle, no neurologic deficit, and no claudication related to spinal stenosis

Cycling (including stationary bikes) is preferred in cases of: 

• Lumbar spinal stenosis or neurogenic claudication (benefit from flexion)
• Hip, knee, foot, or ankle pain being worsened by impact
• Leg‑length discrepancy or asymmetry clearly aggravated by walking
• Marked obesity

Swimming/aquatic therapy is preferred in cases of: 

• Low pain tolerance, osteoarthritis, or overweight
• Concomitant low back pain and peripheral instability or neurologic instability
• Need for an aerobic stimulus without causing pain

As a rule of thumb, start below the irritation threshold, increase activity gradually, and monitor symptoms for 24-48 hours after activity.

This story was translated from MediQuality French, part of the Medscape Professional Network.