Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain

3 May 2005 | Volume 142 Issue 9 | Pages 776-785

Background: Exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain.

Purpose: To identify particular exercise intervention characteristics that decrease pain and improve function in adults with nonspecific chronic low back pain.

Data Sources: MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004 and citation searches and bibliographic reviews of previous systematic reviews.

Study Selection: Randomized, controlled trials evaluating exercise therapy in populations with chronic (>12 weeks duration) low back pain.

Data Extraction: Two reviewers independently extracted data on exercise intervention characteristics: program design (individually designed or standard program), delivery type (independent home exercises, group, or individual supervision), dose or intensity (hours of intervention time), and inclusion of additional conservative interventions.

Data Synthesis: 43 trials of 72 exercise treatment and 31 comparison groups were included. Bayesian multivariable random-effects meta-regression found improved pain scores for individually designed programs (5.4 points [95% credible interval (CrI), 1.3 to 9.5 points]), supervised home exercise (6.1 points [CrI, –0.2 to 12.4 points]), group (4.8 points [CrI, 0.2 to 9.4 points]), and individually supervised programs (5.9 points [CrI, 2.1 to 9.8 points]) compared with home exercises only. High-dose exercise programs fared better than low-dose exercise programs (1.8 points [CrI, –2.1 to 5.5 points]). Interventions that included additional conservative care were better (5.1 points [CrI, 1.8 to 8.4 points]). A model including these most effective intervention characteristics would be expected to demonstrate important improvement in pain (18.1 points [CrI, 11.1 to 25.0 points] compared with no treatment and 13.0 points [CrI, 6.0 to 19.9 points] compared with other conservative treatment) and small improvement in function (5.5 points [CrI, 0.5 to 10.5 points] compared with no treatment and 2.7 points [CrI, –1.7 to 7.1 points] compared with other conservative treatment). Stretching and strengthening demonstrated the largest improvement over comparisons.

Limitations: Limitations of the literature, including low-quality studies with heterogeneous outcome measures and inconsistent and poor reporting; publication bias.

Conclusions: Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain. Strategies should be used to encourage adherence. Future studies should test this multivariable model and further assess specific patient-level characteristics and exercise types.

Editors' Notes Context Which types of exercise therapy are most beneficial to patients with nonspecific chronic low back pain? Contribution This Bayesian meta-regression of 43 trials suggests that the most effective exercises for improving pain and function in adults with chronic low back pain are stretching and strengthening, respectively. Exercise performed over longer periods of time seemed more effective than exercise performed less than 20 hours total. Supervised programs that were individually tailored seemed to be more effective than other delivery modes. Cautions Trials used various measures to assess pain and function, and many were small and of low quality. –The Editors

 

Author and Article Information

From Institute for Work & Health and University of Toronto, Toronto, Ontario, Canada, and Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, the Netherlands.

Acknowledgments: The authors thank Drs. Bart Koes and Antti Malmivaara for their contribution to the data collection and participation in the summative analysis of this review; the Physiotherapy "Educational Influentials" from the Institute for Work & Health for their guidance with syntheses; and Victoria Pennick for her assistance with editing.

Grant Support: No external funding was obtained for this study. Dr. Hayden is funded by a postdoctoral fellowship award from the Canadian Institutes of Health Research and Canadian Chiropractic Research Foundation.

Potential Financial Conflicts of Interest: None disclosed.

Corresponding Author: Jill A. Hayden, DC, Institute for Work & Health, 481 University Avenue, Suite 800, 8th Floor, Toronto, Ontario M5G 2E9, Canada; e-mail, mailto:jhayden{at}iwh.on.ca.

Current Author Addresses: Dr. Hayden: Institute for Work & Health, 481 University Avenue, Suite 800, Toronto, Ontario M5G 2E9, Canada.

Dr. van Tulder: Institute for Research in Extramural Medicine, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.

Dr. Tomlinson: Division of Clinical Decision Making & Health Care Research, Toronto General Research Institute, TGH, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.

Read all Rapid Responses

Response to Systematic Review on Exercise and Chronic LBP

Sarah D Liddle, et al.

Annals Online, 15 Jun 2005 [Full text]