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1. Exercise for Nonspecific LBP

   • Steven J Kamper
   • Christopher G Maher, Kathryn M Refshauge and James H McAuley

   School of Physiotherapy, University of Sydney

   To the Editor,

   The application of meta-regression analyses to a meta-analysis of RCTs investigating exercise for chronic low back pain presents a practical and constructive approach to synthesis of the literature. We commend Hayden et al2 for the breadth of their study and attempts to deal with the complexities inherent in the topic. The depth of analysis is impressive and the blend of quantitative and qualitative methods provides a distinctive insight into the relevant issues.

   There are however, some methodological issues of concern. The authors excluded studies on the basis of ‘low back pain caused by specific pathologies or conditions’. We assume that these ‘specific pathologies or conditions’ include radiologic diagnoses of degenerative disc disease and spondylolisthesis because some studies that specifically investigated these diagnoses were not included, such as the studies by Ghoname1 and O’Sullivan4. As there is a poor correlation between such radiologic findings and LBP symptoms5, there is some question as to whether these exclusions are supportable. Moreover given the prevalence of these radiologic findings, it is probable that other included studies enrolled patients with these radiologic findings.

   There also appears to be some inconsistency with which the criterion of LBP duration was applied during assessment of studies for inclusion in the analysis of chronic LBP. A significant number of studies that included patients with LBP of less than 3 months duration were not recognized by the authors as ‘mixed populations’ (in Appendix Table 12 incl. refs: 26, 31, 32, 34, 40, 43, 48, 49) and therefore presumably were not included in the sensitivity analysis. This point is particularly pertinent in light of the contention that duration of LBP influences the efficacy of exercise.

   A potential solution to this problem may be available within the meta -regression model employed in the companion paper3. By including a category describing ‘chronicity’ as a variable within the model, quantitative data could be generated regarding the apparent correlation between exercise efficacy and duration of LBP while controlling for the effects of the other selected factors.

   The methodological rigour and application of innovative statistical techniques demonstrated by the authors of this review are deserving of commendation. However some apparent flaws in the data collection process make interpretation of the results as presented somewhat difficult.

   Sincerely,

   Steven Kamper, Christopher Maher, Kathryn Refshauge, James McAuley.

   1. Ghoname EA, Craig, WF, White PF, Ahmed HE, Hamza MA, Henderson BN et al. Percutaneous electrical nerve stimulation for low back pain. JAMA. 1999;281:818-23

   2. Hayden JA, van Tulder MW, Malmivaara AV, Koes, BW. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142:765-75

   3. 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;142:775-85

   4. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:2959-67

   5. van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM. Spinal radiographic findings and non-specific low back pain: a systematic review of observational studies. Spine. 1997;22:427-34

   Conflict of Interest:

   None declared

   Submit response
   Published May 31, 2005
2. EXERCISE AND LOW BACK PAIN

   • MARK H. HYMAN, MD

   UCLA

   May 9, 2005

   To the Editor Annals of Internal Medicine 190 N. Independence Mall West Philadelphia, PA 19106-1572

   To the Editor,

   The articles by Hayden et. al.1-2, review treating back pain of varying duration with exercise. The authors indicated in their discussion that there is more specific data available regarding the studies examined. As recommending exercise is a cornerstone for medical practice in general and is often cited as being recommended in back pain patients, I am curious if they could provide information on the duration of follow up in their studies evaluating the exercise intervention. A short term follow up may underestimate long term gain when a patient institutes a physically active lifestyle. The literature continues to identify exercise as increasing productivity and decreasing disability3.

   Mark Hyman

   1Hayden JA, van Tulder MW, Malmivaara AV, et. al. Meta- analysis:Exercise for nonspecific low back pain. Ann Intern Med.2005;142:765-775.

   2Hayden JA, van Tulder MW and Tomlinson G. Systematic review:Strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med.2005;142:776-785.

   3Burton WN, McCalister KT, Chen C, et. al. The association of health status, worksite fitness center participation, and two measures of productivity. J Occup Environ Med. 2005;47:343-351.

   Conflict of Interest:

   None declared

   Submit response
   Published May 13, 2005