Exercise Interventions for Persistent Non-Specific Low Back Pain – Does Matching Outcomes to Treatment Targets Make a Difference? A Systematic Review and Meta-Analysis

Many randomized trials in a large systematic review were not registered and had evidence of selective outcome reporting: a metaepidemiological study

OBJECTIVES

The primary objectives were to describe characteristics of trial registration in the chronic low back pain (CLBP) field and assess the association of trial registration status (registered vs unregistered, prospectively registered vs retrospectively registered) with risk of bias, sufficient sample size, quality of reporting, and treatment effect estimates. Secondary objectives were to describe trial registration consistency with the final report and assess its association with risk of bias, sufficient sample size, and treatment effect estimates.

STUDY DESIGN AND SETTING

A cross-sectional metaepidemiological study of trials included in a large Cochrane review on exercise treatments for CLBP. We extracted relevant trial and registration information and assessed trials' risk of bias using the Cochrane Risk of Bias 1 tool. We performed descriptive analyses, logistic regressions, and subgroup meta-analyses.

RESULTS

We included 361 trials, of which 23.3% were prospectively registered. Registered trials had lower risk of bias (odds ratio [OR] 0.6; 95% confidence interval [CI] 0.5, 0.7) and higher reporting quality (OR 1.6; 95% CI 1.4, 1.8) than unregistered trials. Prospectively registered trials were more likely to have low risk of reporting bias (OR 2.7; 95% CI 1.2, 6.5) and higher quality of reporting (OR 1.3; 95% CI 1.1, 1.6) than retrospectively registered trials. Trial registration status was not associated with effect estimates. Among prospectively registered trials, 64.3% clearly defined primary outcome(s) in their registration, 58.3% had consistent sample sizes, and 22.6% had no evidence of selective outcome reporting. Trials that clearly defined primary outcome(s) were more likely to report larger effect estimates for pain intensity (mean difference -15.8; 95% CI -22.7, -8.9 vs -6.0; 95% CI -10.6, -1.5; Q = 6.7, P = .01), although the difference was small, the 95% CIs overlapped, and no difference was found for functional limitations.

CONCLUSION

A small proportion of trials in the CLBP field were registered prospectively and many presented registration inconsistencies. Registered trials tend to have lower risk of bias and higher quality of reporting. Policies are needed to improve prospective registration and registration consistency in the field.

PLAIN LANGUAGE SUMMARY

Prospective trial registration is the practice of documenting the planned methods of a randomized controlled trial on a publicly available online platform (ie, website) before enrolling participants. Medical journals require trialists to prospectively register their trials to encourage the conduct of high-quality research and reduce the chance of trialists changing their research plan to report only positive or significant results (known as selective outcome reporting). We investigated whether trialists within the chronic low back pain field were registering their trials, and whether they followed their registered research plan.We used data from a large systematic review of 456 trials that tested the effectiveness of exercise as a treatment for chronic low back pain. We assessed each trials' registration status and whether prospectively registered trials had inconsistencies between their registered research plan and their research conduct (eg, evidence of selective outcome reporting). We also looked at the association among trial registration with trials' quality of reporting (ie, a marker of research transparency), risk of bias (ie, a marker of research quality), and the amount of low back pain improvement reported by the trials (ie, effect estimates).We found that less than 25% of trials were prospectively registered, and many had inconsistencies between their registered research plan and their research conduct. Overall, registered trials had lower risk of bias and higher quality of reporting. However, trial registration status and selective outcome reporting were not associated with effect estimates (the amount of back pain improvement reported by trials). Our findings highlight the need for trialists and journals to better follow trial registration guidelines and policies in the chronic low back pain field. Knowledge users should be cautious when consuming information from unregistered trials as they appear to be more likely to have quality concerns.

The Importance of Mind-Body in Pilates Method in Patients with Chronic Non-Specific Low Back Pain-A Randomized Controlled Trial

Background/Objectives: Chronic non-specific low back pain (CNSLBP) is a prevalent condition causing significant distress and healthcare costs globally. Despite various treatments, effective management remains challenging. Pilates, recognized for its focus on core strength and postural alignment, has emerged as a promising intervention. This study investigates the impact of mind-body in Pilates for directing participants on CNSLBP outcomes. Methods: A randomized controlled trial was conducted with 67 participants, aged 18 to 65 years, suffering from CNSLBP. They were allocated into two groups: Pilates with mind-body cueing (n = 34) and Pilates without cueing (n = 33). Both groups underwent 60 min sessions twice weekly for 8 weeks. Outcome measures included pain intensity (Visual Analogue Scale), functional disability (Roland Morris Disability Questionnaire), fear of movement (Tampa Scale of Kinesiophobia), and adherence (percentage of sessions attended). Statistical significance was determined through repeated measures ANOVA. Results: Both groups showed significant improvement in pain reduction, functional ability, and kinesiophobia. However, the mind-body group demonstrated a statistically significant reduction in kinesiophobia compared to the non-cueing group (p = 0.048), indicating the potential additional benefit of mind-body cueing in managing movement-related fear in CNSLBP. Conclusions: This study underscores the effectiveness of an 8-week Pilates intervention in managing CNSLBP, highlighting the added value of mind-body cueing in reducing fear of movement. These findings suggest incorporating mind-body cueing in Pilates could enhance the therapeutic benefits, particularly for patients with high levels of movement-related fear, potentially improving long-term adherence to physical activity and rehabilitation outcomes.

Changes in spinal motor behaviour are associated with reduction in disability in chronic low back pain: A longitudinal cohort study with 1-year follow-up

BACKGROUND

The need to improve spinal motor behaviour in chronic low back pain (CLBP) rehabilitation remains unclear. The objective of this study was to test if changes in spinal motor behaviour were associated with changes in disability after an interdisciplinary rehabilitation program (IRP) in patients with CLBP.

METHODS

Seventy-one patients with CLBP participating in an IRP were included. Spinal motor behaviour was assessed with biomechanical (lumbar angular amplitude and velocity, erector spinae muscle activity and duration of the task), cognitive-emotional (task-specific fear [PRF]) and pain-related (movement-evoked pain [MEP]) measures during a lifting task before and after the IRP. Disability was measured before and after the IRP, and at 3-month and 1-year follow-ups.

RESULTS

After adjusting for confounders, changes in disability were significantly associated with MEP changes (β adj. = 0.49, p < 0.001) and PRF changes (β adj. = 0.36, p = 0.008), but not with changes in any of the biomechanical measures. MEP at the end of IRP was also associated with disability at 3 months (β adj. = 0.37, p = 0.001) and 1 year (β adj. = 0.42, p = 0.01). Biomechanical measures at the end of the IRP were not associated with disability, except for the duration of the task that was significantly associated with reduction of disability at 3 months (β non-adj = 0.5, p < 0.001).

CONCLUSIONS

Pain-related and cognitive-emotional measures of spinal motor behaviour were associated with reduction in disability following an IRP. Future research is needed to further investigate causal relationships between spinal motor behaviour and disability.

SIGNIFICANCE STATEMENT

This study supports a multidimensional understanding and analysis of spinal motor behaviour, integrating the cognitive-emotional, pain-related and biomechanical domains. It also supports the consideration of spinal motor behaviour as a potentially important treatment target in chronic low back pain management. Moreover, it suggests that reducing movement-evoked pain and task-specific fear may have more influence on disability than changing lumbar amplitude, lumbar angular velocity or erector muscle activity, which may have important implications for rehabilitation.

An online training resource for clinicians to optimise exercise prescription for persistent low back pain: Design, development and usability testing

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide. A recent realist review identified the behavioural mechanisms of trust, motivation, and confidence as key to optimising exercise prescription for persistent LBP.

OBJECTIVES

Our objectives were to (1) design and develop an online training programme, and (2) gain end-user feedback on the useability, usefulness, informativeness and confidence in using the online training programme using a mixed-methods, pre-post study design.

PARTICIPANTS AND INTERVENTION

The online training programme was designed and developed using the results from a realist review, and input from a multi-disciplinary stakeholder group. A five-module online training programme was piloted by the first 10 respondents who provided feedback on the course. Further modifications were made prior to additional piloting. The satisfaction, usefulness, ease of use, and confidence of clinicians in applying the learned principles were assessed on completion.

RESULTS

The online programme was advertised to clinicians using social media. Forty-four respondents expressed initial interest, of which 22 enrolled and 18 completed the course. Of the participants, most were physiotherapists (n = 16/18, 88.9%), aged between 30 and 49 (n = 11/18, 61.1%). All participants were satisfied with the course content, rated the course platform as easy to use and useful, and reported that they were very confident to apply the learning. Most (n = 10/14, 71.4%) reported that their manner of prescribing exercise had changed after completion of the course.

CONCLUSIONS

An online training programme to optimise exercise prescription for persistent LBP appears to be easy to use, informative and improves confidence to apply the learning.

Hip biomechanics in patients with low back pain, what do we know? A systematic review

BACKGROUND

Biomechanical alterations in patients with low back pain (LBP), as reduced range of motion or strength, do not appear to be exclusively related to the trunk. Thus, studies have investigated biomechanical changes in the hip, due to the proximity of this joint to the low back region. However, the relationship between hip biomechanical changes in patients with LBP is still controversial and needs to be summarized. Therefore, the aim of this study was to systematically review observational studies that used biomechanical assessments in patients with non-specific LBP.

METHODS

The search for observational studies that evaluated hip biomechanical variables (i.e., range of motion, kinematic, strength, and electromyography) in adults with non-specific acute, subacute, and chronic LBP was performed in the PubMed, Embase, Cinahl and Sportdiscus databases on February 22nd, 2024. Four blocks of descriptors were used: 1) type of study, 2) LBP, 3) hip and 4) biomechanical assessment. Two independent assessors selected eligible studies and extracted the following data: author, year of publication, country, study objective, participant characteristics, outcomes, and results. The methodological quality of the studies was assessed using the Epidemiological Appraisal Instrument and classified as low, moderate, and high. Due to the heterogeneity of the biomechanical assessment and, consequently, of the results among eligible studies, a descriptive analysis was performed.

RESULTS

The search strategy returned 338 articles of which 54 were included: nine articles evaluating range of motion, 16 evaluating kinematic, four strength, seven electromyography and 18 evaluating more than one outcome. The studies presented moderate and high methodological quality. Patients with LBP, regardless of symptoms, showed a significant reduction in hip range of motion, especially hip internal rotation, reduction in the time to perform functional activities such as sit-to-stance-to-sit, sit-to-stand or walking, greater activation of the hamstrings and gluteus maximus muscles and weakness of the hip abductor and extensor muscles during specific tests and functional activities compared to healthy individuals.

CONCLUSION

Patients with LBP present changes in range of motion, task execution, activation, and hip muscle strength when compared to healthy individuals. Therefore, clinicians must pay greater attention to the assessment and management of the hip during the treatment of these patients.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020213599).

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Understanding how therapeutic exercise prescription changes outcomes important to patients with persistent non-specific low back pain: a realist review protocol

INTRODUCTION

Persistent low back pain (LBP) is the leading cause of disability worldwide, and therapeutic exercise is recommended as a first-line treatment in international guidelines. The effects of exercise on clinical outcomes of pain and physical function are small to moderate, despite broader impacts on cardiovascular systems, biological health, mood, and emotional well-being. Therapeutic exercise prescription is defined as exercise that is prescribed by a clinician for a health-related treatment. It is unknown how therapeutic exercise prescription creates effects on outcomes of importance. Realist reviews explore how underlying mechanisms (M) may be active in the context (C) of certain situations, settings, or populations to create an intended or unintended outcome (O). Our objective is to explore and understand the mechanisms by which therapeutic exercise prescription changes outcomes for people with persistent LBP.

METHODS

We will develop initial programme theories based on preliminary data from a previous systematic review and consensus workshop. These theories will be modified with input from a steering group (experts), a stakeholder group (people with lived experience of exercise for persistent LBP and clinicians), and a scoping search of the published literature. An information specialist will design and undertake an iterative search strategy. These will be used to create CMO configurations, which will be refined and tested using the literature. The realist review will be reported following RAMESES guidance.

DISCUSSION

Realist reviews are uncommon in LBP research to date, yet those offer an opportunity to contrast with traditional methods of randomised controlled trials and systematic reviews and provide additional information regarding the contexts and mechanisms that may trigger certain outcomes. This can aid our understanding of the contextual features that may influence exercise prescription, such as for whom they are most effective, in what setting, how they are implemented and why. This realist synthesis will enhance our understanding of therapeutic exercise prescription to improve adherence and engagement and ultimately will provide clinically relevant recommendations regarding exercise prescription for those with persistent LBP.

SYSTEMATIC REVIEW REGISTRATION

The review has been registered with PROSPERO (CRD42017072023).

The relationships between spinal amplitude of movement, pain and disability in low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The role of spinal movement alterations in low back pain (LBP) remains unclear. This systematic review and meta-analyses examined the relationships between spinal amplitude of movement, disability and pain intensity in patients with LBP.

DATABASES AND DATA TREATMENT

We searched PubMed, CINAHL, Embase, Pedro and Web of Science for relevant articles until 14th March 2023. Risk of bias was assessed with the Quality in Prognostic Studies Tool. We analysed the relationships between amplitude of movement, disability and pain intensity with standard correlational meta-analyses and meta-analytic structural equation modelling (MASEM) in cross-sectional and longitudinal data.

RESULTS

A total of 106 studies (9001 participants) were included. In cross-sectional data, larger amplitude of movement was associated with lower disability (pooled coefficient: -0.25, 95% confidence interval: [-0.29 to -0.21]; 69/5899 studies/participants) and pain intensity (-0.13, [-0.17 to -0.09]; 74/5806). An increase in amplitude of movement was associated with a decrease in disability (-0.23, [-0.31 to -0.15]; 33/2437) and pain intensity (-0.25, [-0.33 to -0.17]; 38/2172) in longitudinal data. MASEM revealed similar results and, in addition, showed that amplitude of movement had a very small influence on the pain intensity-disability relationship.

CONCLUSIONS

These results showed a significant but small association between amplitude of movement and disability or pain intensity. Moreover, they demonstrated a direct association between an increase in amplitude of movement and a decrease in pain intensity or disability, supporting interventions aiming to reduce protective spinal movements in patients with LBP.

SIGNIFICANCE

The large meta-analyses performed in this work revealed an association between reductions in spinal amplitude of movement and increased levels of disability and pain intensity in people with LBP. Moreover, it highlighted that LBP recovery is associated with a reduction in protective motor behaviour (increased amplitude of movement), supporting the inclusion of spinal movement in the biopsychosocial understanding and management of LBP.

What do we mean by 'self-management' for chronic low back pain? A narrative review

BACKGROUND

Chronic low back pain (CLBP) is a highly prevalent musculoskeletal condition affecting 60-80% of the general population within their lifetime. Given the large numbers of people affected, self-management approaches have been introduced as a way to manage this condition with endorsement by the national institute for health and care excellence. Interventions are often termed self-management without defining either content or goals. Our study sought to determine the content, characteristics, and evidence for self-management of CLBP.

METHODS

This narrative review was conducted using a systematic approach to search journal articles in English that focused on CLBP self-management. MEDLINE, EMBASE, CINAHL, and PsycINFO databases were used to identify publications with terms relating to back pain and self-management from January 2016 until January 2022.

RESULTS

In total, 15 studies were found suitable for inclusion in the review. Core components of self-management strategies include exercise, education, and psychological interventions, but there was a lack of consistency with respect to content. Intervention characteristics were either under-reported or varied. Furthermore, outcome measures used to assess these self-management programmes were diverse, mainly focusing on functional disability and pain intensity.

CONCLUSIONS

Inconsistencies in the content of self-management interventions, intervention characteristics, and outcome measures used for assessing self-management programmes were found across the literature. Current self-management approaches do not consider the complex biopsychosocial nature of CLBP. A consensus on the key components of self-management interventions, and how they should be evaluated, will pave the way for research to determine whether self-management can effectively manage CLBP.

Matching the Outcomes to Treatment Targets of Exercise for Low Back Pain: Does it Make a Difference? Results of Secondary Analyses From Individual Patient Data of Randomised Controlled Trials and Pooling of Results Across Trials in Comparative Meta-analysis

OBJECTIVE

To explore whether using a single matched or composite outcome might affect the results of previous randomized controlled trials (RCTs) testing exercise for non-specific low back pain (NSLBP). The first objective was to explore whether a single matched outcome generated greater standardized mean differences (SMDs) when compared with the original unmatched primary outcome SMD. The second objective was to explore whether a composite measure, composed of matched outcomes, generated a greater SMD when compared with the original primary outcome SMD.

DESIGN

We conducted exploratory secondary analyses of data.

SETTING

Seven RCTs were included, of which 2 were based in the USA (University research clinic, Veterans Affairs medical center) and the UK (primary care clinics, nonmedical centers). One each were based in Norway (clinics), Brazil (primary care), and Japan (outpatient clinics).

PARTICIPANTS

The first analysis comprised 1) 5 RCTs (n=1033) that used an unmatched primary outcome but included (some) matched outcomes as secondary outcomes, and the second analysis comprised 2) 4 RCTs (n=864) that included multiple matched outcomes by developing composite outcomes (N=1897).

INTERVENTION

Exercise compared with no exercise.

MAIN OUTCOME MEASURES

The composite consisted of standardized averaged matched outcomes. All analyses replicated the RCTs' primary outcome analyses.

RESULTS

Of 5 RCTs, 3 had greater SMDs with matched outcomes (pooled effect SMD 0.30 [95% confidence interval {CI} 0.04, 0.56], P=.02) compared with an unmatched primary outcome (pooled effect SMD 0.19 [95% CI -0.03, 0.40] P=.09). Of 4 composite outcome analyses, 3 RCTs had greater SMDs in the composite outcome (pooled effect SMD 0.28 [95% CI 0.05, 0.51] P=.02) compared with the primary outcome (pooled effect SMD 0.24 [95% CI -0.04, 0.53] P=.10).

CONCLUSIONS

These exploratory analyses suggest that using an outcome matched to exercise treatment targets in NSLBP RCTs may produce greater SMDs than an unmatched primary outcome. Composite outcomes could offer a meaningful way of investigating superiority of exercise than single domain outcomes.

Do rehabilitation patients with chronic low back pain meet World Health Organisation's recommended physical activity levels?

PURPOSE

Primary: to analyse the time that patients with chronic low back pain (CLBP) admitted to pain rehabilitation spent on moderate to vigorous physical activity (MVPA) and compare this to the WHO recommendations. Secondary: to explore factors that might differentiate between those who do and do not meet the recommendations.

MATERIALS AND METHODS

A Cross-sectional study embedded in secondary interdisciplinary rehabilitation of adults with CLBP. PA was measured with a tri-axial accelerometer for 1 week during admission phase. Time spent in each PA level was calculated. MVPA was also analysed in ≥10 min bouts.

RESULTS

Complete datasets of 4-6 days recorded accelerometery of n = 46 patients were analysed. Time spent in MVPA was on average 6.0% per day. MVPA per day in ≥10-min bouts occurred on average 0.8 times per day (sd = 0.9; min-max 0-4). Percentage of patients meeting the recommended level of MVPA was 21.7% (10/46) and 84.8% (39/46) for the 2010 and 2020 recommendations, respectively. Most demographic and clinical variables did not seem to differentiate between those who met the WHO recommendations, and those who did not.

CONCLUSION

The minority of the patients (22%) met the WHO recommended MVPA level of 2010. The more lenient recommendation of 2020 was met by 85%.

"You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise." A scoping review of the possible mechanisms underpinning exercise therapy

BACKGROUND

Exercise is considered to be both essential and at the forefront of the management of rotator cuff-related shoulder pain (RCRSP). Despite this, many fail to substantially improve with exercise-based treatment. Hence, expanding the current knowledge about the possible mechanisms of exercise for RCRSP is critical.

OBJECTIVE

To synthesise the range of mechanisms proposed for exercise in people with RCRSP.

DESIGN

Scoping review METHODS: A systematic search of the Physiotherapy Evidence Database (PEDro) was conducted from inception to July 3, 2022. Two reviewers conducted the search and screening process and one reviewer extracted the data from each study. Randomised clinical trials using exercise for the management of RCRSP of any duration were included. The PEDro search terms used were "fitness training", "strength training", "stretching, mobilisation, manipulation, massage", "upper arm, shoulder, or shoulder girdle", "pain", and "musculoskeletal". Data were analysed using quantitative and qualitative approaches.

RESULTS

626 studies were identified and 110 were included in the review. Thirty-two unique mechanisms of exercise were suggested by clinical trialists, from which 4 themes emerged: 1) neuromuscular 2) tissue factors 3) neuro-endocrine-immune 4) psychological. Neuromuscular mechanisms were proposed most often (n = 156, 77%). Overall, biomedical mechanisms of exercise were proposed in 95% of cases.

CONCLUSIONS

The causal explanation for the beneficial effect of exercise for RCRSP in clinical research is dominated by biomedical mechanisms, despite a lack of supporting evidence. Future research should consider testing the mechanisms identified in this review using mediation analysis to progress knowledge on how exercise might work for RCRSP.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Comparative Analysis of Pain, Muscle Strength, Disability, and Quality of Life in Middle-Aged and Older Adults After Web Video Lower Back Exercise

This study analyzed the effect of lower back exercise using Web for each age group to use it as nursing intervention. We conducted a randomized experiment with 54 patients with low back pain, composed of 26 middle-aged and 28 older adult people with low back pain who visited a joint center. The participants were instructed to perform the exercise at least twice a day, four times a week. Pain, muscle strength, disability, and quality of life were measured before the exercise intervention, and data were collected again 8 weeks after. The data were analyzed using independent t tests, χ2test, Fisher's exact tests, repeated measures analysis of variance, and paired t tests. The middle-aged and older groups showed differences in pain, muscle strength, disability, and quality of life before and after exercise. In particular, the older group showed statistically significantly larger differences in quality of life compared with the middle-aged group. The results indicated that the effects of the lower back exercises, performed using the Web-based videos, were the same for both the middle-aged and older groups, whereas quality of life showed better improvement in the latter than in the former group. For elderly patients, exercise intervention is an appropriate nursing care to improve the quality of life.

Treatment targets of exercise for persistent non-specific low back pain: a consensus study

OBJECTIVES

Despite several hundred previous randomised controlled trials (RCTs), the key treatment targets of exercise for persistent non-specific low back pain (NSLBP) remain unclear. This study aimed to generate consensus about the key treatment targets of exercise interventions for patients with NSLBP.

DESIGN

Consensus was generated using modified nominal group technique in two, sequential, workshops. The results of a previous systematic review informed the first, national, workshop idea generation and the results of this workshop informed the second, international, workshop. The authors generated a starting list of 30 treatment targets from the systematic review. A pre-specified consensus threshold of 75% was used in the voting stage.

PARTICIPANTS

Workshop participants included people with experience of using exercise to manage their persistent NSLBP, clinicians who prescribe exercise for persistent NSLBP, and researchers who design and evaluate exercise interventions in RCTs. All participants generated, voted and ranked the treatment targets in each workshop using an online platform.

RESULTS

A total of 39 participants contributed to the consensus (15 in the national workshop and 24 in the international workshop), comprising two people with NSLBP, six clinicians and 31 researchers/clinicians. A total of 40 exercise treatment targets were generated, and 25 were retained after voting and ranking. The prioritised targets of exercise for persistent NSLBP were: improving function, improving quality of life, reducing pain, meeting patient-specific goals and reducing fear of movement.

CONCLUSIONS

Future RCTs of exercise should specify the targets of their exercise intervention and consider assessing these treatment targets as well as including mediation analyses.