Chronic low back pain.
A new Saudi guideline.
No exercise dose.
Saudi Arabia published its national low back pain guideline in 2026. It stratifies risk and restricts imaging, but it does not say how much exercise to prescribe. This page brings together what is known, what international guidelines say about dose, and where the gaps are.
Annual prevalence
Lifetime prevalence
High prevalence, a new guideline, uneven practice.
Low back pain is the leading cause of disability in Saudi Arabia, according to the national guideline itself. The 2026 guideline structures assessment and management, but leaves exercise prescription open.
The lumbar region at a glance
Guidelines talk about strengthening the trunk, activating specific muscles and limiting imaging. This diagram shows the structures they refer to.
Tap an item in the list to highlight it in the drawing and read what it does.
Vertebrae L1 to L5 and sacrum. The five lumbar vertebrae are the largest in the mobile spine; their bodies carry most of the axial load. The sacrum joins them to the pelvis.
Intervertebral discs. They spread load between vertebral bodies and allow movement. Disc changes on imaging are common in people without pain too, which is why the Saudi guideline reserves imaging for red flags or for when the result would change management.
Multifidus. Short, deep fascicles beside the spinous processes that stiffen each segment. A usual target of the specific trunk-muscle activation recommended by JOSPT 2021, and active in the bird dog.
Erector spinae. Long extensor group on both sides of the spine; it extends the trunk and controls flexion. Involved in the trunk strengthening and endurance recommended by JOSPT 2021.
Psoas major. It arises from the lumbar vertebral bodies and transverse processes and reaches the femur: the main hip flexor, and it compresses the spine when it contracts.
Transversus abdominis. The deepest layer of the abdominal wall; it wraps the trunk like a corset and raises intra-abdominal pressure. It appears in motor control programmes.
Illustrative lateral view (back on the left, abdomen on the right), not to scale.
Saudi clinical practice guideline for low back pain and sciatica in adults
Aldera M, … Alshehri MA. J Clin Med 2026;15(2):528. Developed by a multidisciplinary task force with the NCEBM of the Saudi Health Council using GRADE ADOLOPMENT, with NICE NG59 as the primary source. It answers 11 clinical questions: ten adapted from NG59 and one added on pain neuroscience education.
| Topic | Strength | Content |
|---|---|---|
| Validated risk tools | Strong | Stratify with tools such as STarT Back (very low certainty). |
| Stratified management | Strong | Match treatment intensity to risk (moderate certainty). |
| Imaging | Conditional | Only with red flags or if the result would change management. |
| Other recommendations | Conditional | Drugs for sciatica, psychological interventions, multidisciplinary return to work, epidural injections, decompression, radiofrequency denervation and pain neuroscience education (very low to low certainty). |
| Exercise dose | Not addressed | None of the 11 questions covers exercise frequency, volume, intensity or progression. |
Meta-analysis of 124 Saudi studies totalling 146,552 participants: annual prevalence 52.3% (100 studies) and lifetime prevalence 64.0% (28 studies). Heterogeneity between studies is very high (I² 97.5 to 99.7%).
doi.org/10.2147/jpr.s607375How it is practised: three surveys
Of 72 primary care physicians working in Saudi Arabia, only 35% reported using clinical practice guidelines for low back pain. Orientation was mostly biomedical.
PMC8728917133 physiotherapists answered 6 clinical vignettes. Guideline adherence ranged from 5.3% to 57.4%: highest with red flags, lowest in acute pain with mobility deficit.
PubMed 32838639304 physiotherapists. Most used treatments: home exercise 87.1%, education 82.0%, specific back exercises 80.6% and electrotherapy 61.9%. Passive treatments not recommended by guidelines remain common.
BMJ Open e037159 · PMC7311013Attribution: the adherence range of 5.3% to 57.4% comes from Moslem et al. 2022 (physiotherapists), not from Alhowimel et al. 2021 (primary care physicians). The BMJ Open link returns 403 to automated checkers; the PMC copy is added.
Iqbal, King Saud University
90 men aged 30 to 39 with chronic low back pain, an 8 week trial with two groups of 45: stabilisation exercises and kinesio taping, with or without EMG biofeedback. VAS and modified Oswestry at weeks 0, 2, 4, 6 and 8. CC BY 4.0. No dose variables.
zenodo.org/records/23498061STarT Back and ODI validated
Arabic STarT Back: Elsabbagh et al., J Orthop Sci 2019, cross-cultural adaptation and validation in Saudi Arabia (n = 59). doi
Arabic ODI: Algarni et al., Ann Phys Rehabil Med 2014, 100 patients with chronic low back pain, intra-observer reliability ICC 0.99. abstract only PubMed
All recommend exercise. Almost none say how much.
Eight guidelines reviewed. Only the Dutch KNGF 2021 and the Danish draft give figures for frequency, duration or intensity; WHO sets a minimum of total hours.
| Guideline | What it says about exercise | Dose |
|---|---|---|
| NICE NG59 2016, updated 29 Jul 2026 | Consider a group exercise programme (biomechanical, aerobic, mind and body or combined) according to needs, preferences and capabilities. Manual therapy only within a package that includes exercise. | No dose |
| ACP 2017 Qaseem et al., Ann Intern Med abstract only | Strong recommendation to start with non-drug treatment, including exercise. Individually designed, supervised home and group programmes with stretching and strengthening were the most effective. | No dose |
| WHO 2023 ISBN 978-92-4-008178-9 | Conditional recommendation, low certainty: a structured exercise programme as part of care. Better when personalised, supervised and adherence-focused. No modality is superior. | ≥ 20 h total programme |
| JOSPT 2021 George et al. | Recommends trunk strengthening and endurance, multimodal exercise, specific activation, aerobic, aquatic and general exercise. Notes that duration, dosing and intensity were highly variable and calls for RCTs on dose. | No dose |
| KCE 287 Belgium, 2017 | No clear evidence that any type, programme, duration or intensity is better. Exercise is the only compulsory element of the multimodal approach. | No dose |
| Alberta TOP Canada, 3rd ed. 2015, rev. 2017 | Start gentle exercise and increase it gradually within pain tolerance. Inconclusive evidence on frequency or intensity for preventing recurrence. | No dose |
| KNGF 2021 Netherlands | Exercise for moderate or high risk profiles, graded and time contingent, guided by pain; return to the previous level in 6 to 12 weeks. | Full FITT table |
| Denmark Draft 14 Dec 2016 | Physical training 2 to 3 times per week, 30 to 90 minutes, for at least 6 to 12 weeks, at moderate to high intensity where possible. | Yes (final 2017 version not verified) |
The most specific guideline: KNGF 2021
| Component | Frequency and duration | Intensity and volume |
|---|---|---|
| Strength | 2 to 3 days per week per muscle group, 48 h recovery after intensive training | 60 to 70% of 1RM, 2 to 4 sets of 8 to 12 reps, 30 to 60 s rest |
| Aerobic | ≥ 5 days per week moderate or ≥ 3 days vigorous; ≥ 30 min per day in bouts of ≥ 10 min | Moderate 40 to 60% HRmax, vigorous 60 to 90% HRmax, gradual increase |
| Flexibility | Daily, at least 2 to 3 days per week, after 8 to 10 min of activity | 2 to 4 repetitions of 10 to 30 s |
| Neuromotor control | Insufficient knowledge on optimal dose; prioritise movement quality without pain increase. | |
Response rule: tolerable pain or fatigue lasting at most 24 h and then decreasing is acceptable; night pain, or fatigue or loss of function that increases after 24 h, is undesirable.
KNGF (PDF, Dutch)The McGill approach
Stuart McGill, a spine biomechanist (Spine Biomechanics Laboratory, University of Waterloo), is a highly influential author in practice. His approach is an author's proposal, not a guideline recommendation.
Verifiable example: McGill and Karpowicz 2009 used surface EMG and 3D analysis to quantify variants of the curl up, side bridge and bird dog in 8 healthy men, to guide starting level, progression, dosage and corrective technique. These are the three exercises popularly called the “Big 3”. It is basic science, not a patient trial.
Pictograms of the three exercises analysed by McGill and Karpowicz (2009); colour marks the region that works most, following the usual description of each exercise.
McGill SM, Karpowicz A. Arch Phys Med Rehabil 2009;90(1):118-26Dose response: flat, U shaped and low certainty.
The best analyses predict useful ranges, but none shows a single optimal dose. Individualisation, supervision and adherence matter as much as volume.
239 RCTs, dose-response network meta-analysis
Predicted optimal doses in the short term:
Credible intervals overlap, there is little additional benefit with higher exposure, 84% of trials are at high risk of bias and certainty is low or very low. The authors conclude that a single optimal dose is not supported.
PubMed 42785965Pain improvement versus unsupervised home exercise
Points out of 100, Bayesian meta-regression of 43 RCTs.
High versus low dose: 1.8 points, credible interval minus 2.1 to 5.5, not conclusive. Supervised home: interval minus 0.2 to 12.4. The definition of high dose (≥ 20 h) comes from the WHO text.
PubMed 1586741082 RCTs, n = 5,033. Nonlinear U shaped relationship; maximum effect at 920 MET·min and minimal clinically important difference from 520 MET·min per week. Very low to moderate certainty.
PubMed 3845713450 RCTs of stabilisation exercise. Largest effect with 20 to 30 min sessions and 3 to 5 sessions per week (moderate and low quality).
PMC7547082Secondary analysis, n = 20. Lower pain associated with higher session RPE, more time under tension and shorter sessions. Data available from the corresponding author on reasonable request.
PMC10773405n = 206 (CFT 106, group exercise 100). Includes sessions completed, number of treatments, total minutes and weeks, with NRS and ODI up to 12 months. The best open dataset close to dose.
zenodo.org/records/6760585What still needs measuring in Riyadh.
The proposals in this section are working ideas, not results.
The 2026 Saudi guideline does not address exercise dose, and the international evidence on dose is low certainty.
There is no open chronic low back pain dataset with session-level load (RPE, time under tension, progression). The closest are CFT (sessions and minutes) and Neason (on request).
There are no data on adherence to the 2026 guideline. The available Saudi surveys date from 2020 to 2022, before the guideline.
Proposed study: adherence to the 2026 Saudi guideline PROPOSAL
A cross-sectional vignette survey of physiotherapists and primary care physicians in Riyadh, following the designs of Moslem et al. 2022 and Alhowimel et al. 2021.
Vignettes on STarT Back stratification, imaging decisions and exercise prescription.
Share of answers concordant with the 2026 guideline and what exercise dose is prescribed in practice.
Identify training needs and contribute local data to the dose gap.
Rule-based dosing protocol
A rule set derived from guidelines and meta-analyses for a rule engine like the Achilles module. It has not been tested in patients and does not replace clinical judgement.
- 2 to 4 sessions per week.Arora 2026; Denmark (draft); KNGF
- 25 to 45 minutes per session.Arora 2026 (25 to 30 min); Mueller 2020 (20 to 30 min); Denmark allows up to 90 min
- 8 to 13 weeks, with at least 20 h of total programme time.Arora 2026; WHO 2023
- Strength per the KNGF table: 60 to 70% of 1RM, 2 to 4 sets of 8 to 12.KNGF 2021
- Time contingent progression, not pain contingent, with the 24 h response rule.KNGF 2021
- Alert if frequency falls below about 1.5 sessions per week.Association with recurrence in a small cohort (Krause 2021, abstract only); exploratory threshold
- Record session RPE, attendance and NRS every 2 weeks.Variables used by Neason 2024 and Iqbal
Personalise, supervise and support adherence (WHO 2023, Hayden 2005).
Sources and link status
Links checked on 25 October 2026. “abstract only” means the figure was taken from the abstract, not the full text.
- Al Amer HS. Prevalence of Low Back Pain in Saudi Arabia: A Systematic Review and Meta-Analysis of 124 Studies. J Pain Res. 2026. https://doi.org/10.2147/jpr.s607375
- Aldera M, Alturkistany A, Al Rayes H, et al., Alshehri MA. Saudi Clinical Practice Guideline for the Assessment and Management of Low Back Pain and Sciatica in Adults. J Clin Med. 2026;15(2):528. https://pmc.ncbi.nlm.nih.gov/articles/PMC12842004/
- NICE. Low back pain and sciatica in over 16s: assessment and management (NG59). 2016, last updated 29 July 2026. Recommendations · Update information
- Alhowimel AS, Alotaibi MA, Alamam DM, Alodaibi FA, Fritz JM. Attitudes and Beliefs of Primary Care Physicians Working in Saudi Arabia Regarding the Management of Low Back Pain. Int J Gen Med. 2021;14:10225-10233. https://pmc.ncbi.nlm.nih.gov/articles/PMC8728917/
- Moslem WM, Alrwaily M, Almarwani MM. Adherence to low back pain clinical practice guidelines by Saudi physical therapists: a cross-sectional study. Physiother Theory Pract. 2022;38(7):938-951. https://pubmed.ncbi.nlm.nih.gov/32838639/ [abstract only]
- Alshehri MA, Alzahrani H, Alotaibi M, Alhowimel A, Khoja O. Physiotherapists' pain attitudes and beliefs towards chronic low back pain and their association with treatment selection. BMJ Open. 2020;10(6):e037159. https://bmjopen.bmj.com/content/10/6/e037159 [403 to automated checkers; the page exists] · PMC7311013
- Iqbal A. Longitudinal Rehabilitation Trial Dataset of Disability, Pain, and Abdominal Task Performance in Men With Chronic Low Back Pain. Zenodo, 2026, CC BY 4.0. https://zenodo.org/records/23498061 [the Zenodo website returns 403 to automated checkers; the record exists per its API]
- Elsabbagh L, Al-Atwi T, Aldossary D, Alshami AM, Hill JC, et al. Cross-cultural adaptation and validation of the STarT Back Tool for Arabic speaking adults with low back pain in Saudi Arabia. J Orthop Sci. 2019;24:200-206. https://doi.org/10.1016/j.jos.2018.09.007
- Algarni AS, Ghorbel S, Jones JG, Guermazi M. Validation of an Arabic version of the Oswestry index in Saudi Arabia. Ann Phys Rehabil Med. 2014;57(9-10):653-63. https://pubmed.ncbi.nlm.nih.gov/25262247/ [abstract only]
- Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:514-530. https://www.acpjournals.org/doi/10.7326/M16-2367 [403 to automated checkers; the page exists] · PubMed 28192789
- World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. 2023. ISBN 978-92-4-008178-9. IRIS PDF
- George SZ, Fritz JM, Silfies SP, et al. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60. https://pmc.ncbi.nlm.nih.gov/articles/PMC10508241/
- KCE Report 287. Low back pain and radicular pain: assessment and management. Belgian Health Care Knowledge Centre, 2017. Summary PDF
- Toward Optimized Practice. Evidence-informed primary care management of low back pain. Alberta, 3rd ed. 2015, minor revision 2017. PDF
- KNGF/VvOCM. KNGF-richtlijn Lage rugpijn en lumbosacraal radiculair syndroom. October 2021. PDF
- Sundhedsstyrelsen. Anbefalinger for tværsektorielle forløb for mennesker med kroniske lænderygsmerter. Hearing draft, 14 Dec 2016: PDF. Final 2017 version: sst.dk [429 rate limit; final version not verified]
- McGill SM, Karpowicz A. Exercises for spine stabilization: motion/motor patterns, stability progressions, and clinical technique. Arch Phys Med Rehabil. 2009;90(1):118-26. https://doi.org/10.1016/j.apmr.2008.06.026
- Arora NK, Saueressig T, Schleimer T, et al., Belavý DL. Optimal exercise dose in adults with chronic low back pain disorders: systematic review with dose-response network meta-analysis. Br J Sports Med. 2026 (online ahead of print). https://pubmed.ncbi.nlm.nih.gov/42785965/ [abstract only]
- Liang Z, Tian S, Wang C, et al. The Best Exercise Modality and Dose for Reducing Pain in Adults With Low Back Pain: A Systematic Review With Model-Based Bayesian Network Meta-analysis. J Orthop Sports Phys Ther. 2024;54:315-327. https://pubmed.ncbi.nlm.nih.gov/38457134/ [abstract only]
- Mueller J, Niederer D. Dose-response-relationship of stabilisation exercises in patients with chronic non-specific low back pain: a systematic review with meta-regression. Sci Rep. 2020;10:16921. https://pmc.ncbi.nlm.nih.gov/articles/PMC7547082/ [abstract only]
- Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:776-785. https://pubmed.ncbi.nlm.nih.gov/15867410/ [abstract only]
- Neason C, Miller CT, Tagliaferri SD, Belavý DL, et al. Exercise prescription variables predict reductions in pain intensity in adults with chronic low back pain: secondary analysis of a randomised controlled trial. BMJ Open Sport Exerc Med. 2024;10:e001744. https://pmc.ncbi.nlm.nih.gov/articles/PMC10773405/
- O'Keeffe M. CFT trial dataset (cognitive functional therapy vs group exercise, participant level). Zenodo, 2022, CC BY 4.0. https://zenodo.org/records/6760585 [the Zenodo website returns 403 to automated checkers; the record exists per its API]
- Tsiarleston G, Gil-Gutiérrez YM, Donoso B, Villegas-Fuente A, et al. The BACKFIT project dataset (NCT05443880). Zenodo, 2023, CC BY 4.0. https://zenodo.org/records/7798024 [the Zenodo website returns 403 to automated checkers; the record exists per its API]