An individualised swimming and education program delivered by physiotherapists improved disability in people with chronic low back pain after eight weeks, although the benefits waned over time as adherence declined.
Swimming could become a more evidence-based prescription for chronic low back pain after Australian researchers demonstrated that an individualised swimming program combined with education produced clinically meaningful improvements in disability.
However, the benefits diminished once people stopped swimming regularly.
“This study suggests that a swimming program is appropriate for people with chronic low back pain, but clinicians should be mindful of the potential longer-term adherence challenges,” the researchers wrote.
“The reductions in adherence over time suggest that there may be barriers to maintaining long-term swimming.
“Before prescribing swimming, clinicians should consider a patient’s exercise preference, including their experience and ability to access a pool.
“Clinicians should also consider how they can support longer-term adherence. For some people, swimming may be a good option for initial exposure to exercise and movement, to build confidence, self-efficacy and overcome barriers to initiating exercise.”
The EduSwim randomised controlled trial, published in the British Journal of Sports Medicine, is the first study to directly evaluate swimming as the primary intervention for chronic low back pain, addressing a long-recognised evidence gap despite swimming being commonly recommended by clinicians.
Researchers from Macquarie University recruited 76 adults with chronic non-specific low back pain lasting longer than 12 weeks.
Participants had moderate pain and disability at baseline, reported average pain scores of 4.4 out of 10, and disability scores of 11.5 out of 24 on the Roland Morris Disability Questionnaire. Participants also needed to be capable of swimming at least 25 metres and be confident in the water.
Participants were randomly allocated to either an eight-week swimming and education program or an education-only control group.
The intervention extended well beyond simply telling patients to swim. Participants received free pool access for eight weeks and attended four telehealth consultations with a physiotherapist, who developed an individualised swimming program based on each person’s fitness, swimming ability and goals. The target was to progressively build towards three swimming sessions of 30 to 45 minutes each week.
The physiotherapist also incorporated health coaching techniques including motivational interviewing, goal setting, identifying barriers to exercise and strategies to improve self-efficacy, while delivering education based on Australian Clinical Care Standards for low back pain and the GLA:D Back program.
Patients were encouraged to understand that pain was an alarm signal rather than evidence of ongoing damage, that the back was designed to move and that flare-ups were common but usually manageable through continued activity.
The control group received the same educational messages through one or two telehealth consultations but no structured swimming program.
After eight weeks, disability improved significantly more in the swimming group, with an adjusted mean difference of -2.48 points on the Roland Morris Disability Questionnaire compared with education alone (95% CI -4.50 to -0.46).
The researchers said the estimated treatment effect exceeded commonly accepted thresholds for clinical importance, although the confidence interval suggested the true benefit could range from modest to substantial.
Benefits were also seen across several secondary outcomes. Pain intensity fell by an additional 0.71 points on a 10-point scale compared with controls, although the confidence interval included no effect and the magnitude was unlikely to be clinically meaningful.
Participants in the swimming group also reported greater improvements in self-efficacy, global recovery, and patient-specific function during the early follow-up period.
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Satisfaction with treatment was particularly striking, with 95% of participants in the swimming arm reporting they were satisfied or very satisfied compared with just 46% of those receiving education alone.
The improvements gradually diminished over time, however. Although disability scores continued to favour swimming at 13 weeks, the differences between the groups were no longer statistically significant at 26 or 52 weeks.
The researchers attributed much of this decline to falling adherence after supervised support ended.
While participants averaged around 1.5 swimming sessions each week during the intervention and progressively increased both swimming time and distance, participation fell substantially after free pool access and physiotherapy coaching ceased.
By six months, participants expressed only neutral intentions to continue swimming regularly.
The researchers noted that swimming’s buoyancy may allow people with chronic low back pain to move more comfortably while improving strength, cardiovascular fitness, and confidence with movement. They also suggested combining swimming with pain education may reinforce positive beliefs about movement and reduce fear avoidance, explaining the favourable improvements seen in self-efficacy and global recovery.
The intervention was not without drawbacks. Fifty-six per cent of participants in the swimming group experienced at least one adverse event compared with 30% in the education-only group. Most were non-serious musculoskeletal complaints affecting the back, neck or limbs and reflected the expected risks associated with starting a new exercise program.
Only one serious adverse event occurred during the trial, a cardiovascular event, which the researchers considered unlikely to be related to the intervention because it did not occur while swimming.
The researchers said clinicians should consider swimming as another evidence-based exercise option for appropriately selected patients, particularly those who are comfortable in the water and have ready access to a pool.
However, they cautioned that long-term success is likely to depend on strategies that support ongoing adherence, such as extended coaching or booster sessions after the initial supervised program ends.
“This study demonstrated that swimming, in addition to education, is an effective exercise option for people with chronic low back pain, with clinically important effects on the primary outcome of disability at eight weeks,” the researchers concluded.
“There was a trend of more adverse events in the swimming and education group; however, these were largely non-serious.
“These findings equip clinicians to better discuss the potential benefits and risks of swimming with people with chronic low back pain.”
