exs therapy for non specific lbp
TRANSCRIPT
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Exercise therapy for treatment of non-specific low back pain
(Review)
Hayden JA, van Tulder MW, Malmivaara A, Koes BW
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2006, Issue 3
http://www.thecochranelibrary.com
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T A B L E O F C O N T E N T S
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .
2SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .
3METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35Table 01. Complete search strategy: MEDLINE, EMBASE . . . . . . . . . . . . . . . . . . . .
36Table 02. Summary of Included Studies . . . . . . . . . . . . . . . . . . . . . . . . . . .
37ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37Comparison 01. Chronic populations . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37Comparison 02. Subacute populations . . . . . . . . . . . . . . . . . . . . . . . . . . .
38Comparison 03. Acute populations . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39Comparison 04. POPULATION SOURCE: Chronic populations (Exploratory analysis) . . . . . . . . . .
39Comparison 05. Methodological Quality of Included Studies . . . . . . . . . . . . . . . . . . . .
39INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41Figure 01. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42Figure 02. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43Analysis 01.01. Comparison 01 Chronic populations, Outcome 01 Function measure (/100): Earliest follow-up . .
44Analysis 01.02. Comparison 01 Chronic populations, Outcome 02 Function measure (/100): Short-term follow-up (6
weeks post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45Analysis 01.03. Comparison 01 Chronic populations, Outcome 03 Function measure (/100): Intermediate follow-up
(6 months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . .
46Analysis 01.04. Comparison 01 Chronic populations, Outcome 04 Function measure (/100): Long-term follow-up (12
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47Analysis 01.05. Comparison 01 Chronic populations, Outcome 05 Pain measure (/100): Earliest follow-up . . . .
48Analysis 01.06. Comparison 01 Chronic populations, Outcome 06 Pain measure (/100): Short-term follow-up (6 weekspost-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49Analysis 01.07. Comparison 01 Chronic populations, Outcome 07 Pain measure (/100): Intermediate follow-up (6
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51Analysis 01.08. Comparison 01 Chronic populations, Outcome 08 Pain measure (/100): Long-term follow-up (12
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52Analysis 02.01. Comparison 02 Subacute populations, Outcome 01 Function measure (/100): Earliest follow-up . .
53Analysis 02.02. Comparison 02 Subacute populations, Outcome 02 Function measure (/100): Short-term follow-up (6
weeks post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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54Analysis 02.03. Comparison 02 Subacute populations, Outcome 03 Function measure (/100): Intermediate follow-up
(6 months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . .
55Analysis 02.04. Comparison 02 Subacute populations, Outcome 04 Function measure (/100): Long-term follow-up (12
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
55Analysis 02.05. Comparison 02 Subacute populations, Outcome 05 Pain measure (/100): Earliest follow-up . . .
56Analysis 02.06. Comparison 02 Subacute populations, Outcome 06 Pain measure (/100): Short-term follow-up (6 weeks post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57Analysis 02.07. Comparison 02 Subacute populations, Outcome 07 Pain measure (/100): Intermediate follow-up (6
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58Analysis 02.08. Comparison 02 Subacute populations, Outcome 08 Pain measure (/100): Long-term follow-up (12
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58 Analysis 03.01. Comparison 03 Acute populations, Outcome 01 Pain measure (/100): Earliest follow-up . . . .
59Analysis 03.02. Comparison 03 Acute populations, Outcome 02 Pain measure (/100): Short-term follow-up (6 weeks
post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
60Analysis 03.03. Comparison 03 Acute populations, Outcome 03 Pain measure (/100): Intermediate follow-up (6
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
61Analysis 03.04. Comparison 03 Acute populations, Outcome 04 Pain measure (/100): Long-term follow-up (12 months
post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62Analysis 03.05. Comparison 03 Acute populations, Outcome 05 Function measure (/100): Earliest follow-up . . .63Analysis 03.06. Comparison 03 Acute populations, Outcome 06 Function measure (/100): Short-term follow-up (6
weeks post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
64Analysis 03.07. Comparison 03 Acute populations, Outcome 07 Function measure (/100): Intermediate follow-up (6
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65Analysis 03.08. Comparison 03 Acute populations, Outcome 08 Function measure (/100): Long-term follow-up (12
months post-randomization) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66Analysis 04.01. Comparison 04 POPULATION SOURCE: Chronic populations (Exploratory analysis), Outcome 01
Function measure (/100); Earliest follow-up: Indirect comparisons . . . . . . . . . . . . . . .
67Analysis 04.02. Comparison 04 POPULATION SOURCE: Chronic populations (Exploratory analysis), Outcome 02
Pain measure (/100); Earliest follow-up: Indirect comparisons . . . . . . . . . . . . . . . . .
68 Analysis 05.01. Comparison 05 Methodological Quality of Included Studies, Outcome 01 criteria met . . . . .
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Exercise therapy for treatment of non-specific low back pain
(Review)
Hayden JA, van Tulder MW, Malmivaara A, Koes BW
Status: Commented
This record should be cited as:
Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database
of Systematic Reviews 2005, Issue 3. Art. No.: CD000335. DOI: 10.1002/14651858.CD000335.pub2.
This version first published online: 20 July 2005 in Issue 3, 2005.
Date of most recent substantive amendment: 30 April 2005
A B S T R A C T
Background
Exercise therapy is widely used as an intervention in low-back pain.
Objectives
To evaluate the effectiveness of exercise therapy in adult non-specific acute, subacute and chronic low-back pain versus no treatment
and other conservative treatments.
Search strategy
The Cochrane Central Register of Controlled Trials (Issue 3, 2004), MEDLINE, EMBASE, PsychInfo, CINAHL databases to October
2004; citation searches and bibliographic reviews of previous systematic reviews.
Selection criteria
Randomized controlled trials evaluating exercise therapy for adult non-specific low-back pain and measuring pain, function, return-to-work/absenteeism, and/or global improvement outcomes.
Data collection and analysis
Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short, intermediate,
and long-term follow-up.
Main results
Sixty-one randomized controlled trials (6390 participants) met inclusion criteria: acute (11), subacute (6) and chronic (43) low-back
pain (1 unclear). Evidence was found of effectiveness in chronic populations relative to comparisons at all follow-up periods; pooled
mean improvement was 7.3 points (95% CI, 3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) at
earliest follow-up. In studies investigating patients (i.e. presenting to healthcare providers) mean improvement was 13.3 points (5.5 to
21.1) for pain, 6.9 (2.2 to 11.7) for function, representing significantly greater improvement over studies where participants included
those recruited from a general population (e.g. with advertisements). There is some evidence of effectiveness of graded-activity exercise
program in subacute low-back pain in occupational settings, though the evidence for other types of exercise therapyin other populationsis inconsistent. There was evidence of equal effectiveness relative to comparisons in acute populations [pain: 0.03 points (95% CI, -1.3
to 1.4)].
Limitations: This review largely reflects limitations of the literature, including low quality studies with heterogeneous outcome measures,
inconsistent and poor reporting, and possibility of publication bias.
Authors conclusions
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain,
particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves
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absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as
either no treatment or other conservative treatments.
P L A I N L A N G U A G E S U M M A R Y
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain,
particularly in populations visiting a healthcare provider. In adults with subacute low-back pain there is some evidence that a graded
activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. For patients with acute low-
back pain, exercise therapy is as effective as either no treatment or other conservative treatments.
B A C K G R O U N D
Low-back pain is one of the leading causes of disability. Exercise
therapy is a management strategy that is widely used in low-back
pain. It encompasses a heterogeneous group of interventions rang-
ing from general physical fitness or aerobic exercise, to muscle
strengthening, various types of flexibility and stretching exercises.
In 2000, van Tulder et al. published a Cochrane review of the lit-
erature assessing the effectiveness of exercise therapy for low-back
pain for pain intensity, functional status, overall improvement and
return to work (van Tulder 2000b). It included 39 randomized
controlledtrials of all types of exercise therapy for individuals with
acute and chronic non-specific low-back pain. They synthesized
the evidence using a levels-of-evidence approach due to the het-
erogeneity and insufficiency of the literature, concluding that the
evidence did not support effectiveness of exercises for acute low-
back pain, but it may be helpful for chronic low-back pain. Since
the completion of their systematic review, a substantial number of
new trials have been published. Recent reviews on related topics
have been restrictedby population (Hilde 1998,Liddle 2004,Kool
2004) or type of exercise therapy (Ernst 2003) and have used only
qualitative methods of synthesis (Hilde 1998, Liddle 2004, Ernst
2003, Abenhaim 2000). Recent clinical guidelines that included
exercise therapy for low-back pain used quantitative methods to
synthesize results of randomized controlled trials, controlled trials
and observational studies (Tugwell 2001), however only 12 studies
overlap with the 61 trials included in this review. There is a need
for an updated review on this topic. Cautious use of quantitative
meta-analysis for direct and indirect comparisons, employed in
appropriate subgroups will be informative to synthesize this liter-
ature.
O B J E C T I V E S
The primary objective of this systematic review was to assess the
effectiveness of exercise therapy for reducing pain and disability in
adults with non-specific acute, subacute andchronic low-back pain
compared to no treatment(including placebo andsham treatment)
and other conservative treatments.
C R I T E R I A F O R C O N S I D E R I N G
S T U D I E S F O R T H I S R E V I E W
Types of studies
We included published reports of completed randomized con-
trolled trials.
Types of participants
We included studies involving adult participants with acute (less
than six weeks), subacute (six to 12 weeks), or chronic (longer
than 12 weeks) non-specific low-back pain. We excluded studies
that involved individuals with low-back pain caused by specific
pathologies or conditions.
Types of interventionExercise therapy wasdefined asa seriesof specific movementswith
the aim of training or developing the body by a routine practice or
as physical training to promote good physical health (Abenhaim
2000). We included studies that compared exercise therapy to a)
no treatment or placebo treatment, b) other conservative therapy,
or c) another exercise group.
Types of outcome measures
Outcomes of interest were self-reported pain intensity, condition-
specific physical functioning and global improvement, and return
to work/absenteeism. Outcome assessment data were abstracted
for three timeperiods: short-term (post-treatmentassessmentclos-
est to six weeks after randomization, not longer than 12 weeks),intermediate (six months), and long-term follow-up (12 months
or more).
S E A R C H M E T H O D S F O R
I D E N T I F I C A T I O N O F S T U D I E S
See: Back Group methods used in reviews.
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We searched the Cochrane Central Register of Controlled Trials
(Issue 3, 2004) and these electronic databases: MEDLINE and
EMBASE (up to October 2004), PsychInfo and CINAHL (1999
to October 2004). We conducted citation searches, screened
cited references of exercise reviews and contacted content experts
for additional trials. We did not restrict the searches or inclusioncriteria to any specific language (see Additional Table: Table 01
for full strategy).
M E T H O D S O F T H E R E V I E W
Study selection and data abstraction
A standard protocol was followed for study selection and data
abstraction (van Tulder 2003). This included two reviewers
independent assessment of study eligibility, data extraction,
assessment of trial quality and clinical relevance. Consensus
and, if necessary, a third reviewer were used to resolve
disagreements. We extracted population characteristics (patientpopulation source or setting, study inclusion criteria, duration
of low-back pain episode, and age of patients), intervention
characteristics (description and types of exercise therapy, duration
and number of treatment sessions, intervention delivery type, and
co-interventions) outcome data, and overall conclusions about the
effectiveness of the exercises onto pre-tested standardized forms.
Assessment of quality included: appropriate randomization,
adequate concealment of treatment allocation, adequacy of
follow-up, and outcome assessment blinding (Jadad 1996). High
quality studies were defined as those in which all of these
key quality criteria were met. Clinical relevance of each trial
was assessed with four items: participants described in detail
to assess clinical comparability, interventions and treatmentsettings adequatelydescribed to allowrepetition, clinically relevant
outcomes measured and reported, and are likelytreatment benefits
worth potential harms. Reviewers were not blinded to authors,
institution or journal of publication due to feasibility and because
theywerefamiliar with most of theliterature. Authors of published
trials were contacted to clarify or provide additional information
if the study provided insufficient information.
Analysis
We discussed the analyses of study results with clinical content
experts. We synthesized the earliest outcomes provided for acute,
subacute and chronic low-back pain, comparing exercise to no
treatment and to other conservative treatment, and overall forshort, intermediate and long-term follow-up periods. Due to
important gaps in the reporting of return-to-work/absenteeism
and global assessment, quantitative analyses were only possible for
pain and functioning outcomes. In the low-back pain literature,
several outcome measures are used to assess the constructs of
pain intensity (for example, 10 mm or 100 mm visual analogue
scales [VAS], or 0 to 10 numerical rating scale [NRS]) (see recent
review by Von Korff et al (von Korff 2000)) and condition-
specific functioning (for example, the 24-point Roland Morris
Disability Questionnaire, or the Oswestry Disability Index scored
out of 100) (see recent review by Kopec (Kopec 2000)). There
is moderate to high correlation between the different measures
of the two constructs. In this review, individual trial outcomes
for pain and functioning were re-scaled to 0 to 100 points[for example a VAS pain score (standard deviation) of 5.1 (2.3)
out of 10 was re-scaled to 51 (23) out of 100], where positive
mean effect sizes indicated improvement (i.e. decreased pain,
and decreased functional limitations). Re-scaling is common
(Kopec 2000) and facilitates comparison and interpretability of
the syntheses. On the basis of current literature on minimal
clinically important differences, we considered that a 20-point
(/100) improvement in pain (Salaffi 2004) and a 10-point
(/100) improvement in functioning outcomes (Bombardier 2001)
were clinically important. Differences were considered statistically
significant at the five percent level. The adequacy of sample size
to detect these differences in each trial was assessed assuming a
power of 90%.To be consistent with the previous review and to allow more
complete use of available data, we used both a qualitative rating
system and quantitative meta-analyses. The latter were conducted
by pooling weighted mean differences with random effects
models and data from at least three studies (DerSimonian 1986).
Exercise treatment groups from included trials were included
in the syntheses if they had an independent no treatment or
other conservative treatmentcomparison group. This requirement
appropriately meant studies with no comparison group (i.e. trials
that contrast multiple exercise therapy groups only) were not
included and comparison groupswerenot double counted in the
meta-analyses. This latter criteria is necessary to avoid correlation
in effect sizes resulting from the use of repeated comparison data.
We extracted data on means or median follow-up outcomes for
study groups. To maximize the available data, missing variance
scores were imputed using the mean variance from studies with
similar duration. Sensitivity analyses were conducted to assess the
impact of excludingstudies reportingmedian values and excluding
studies that did not adequately present variance scores. Statistical
heterogeneity was assessed using I2 statistics and confidence
intervals (Higgins 2002). Publication bias was evaluated with
Eggers test and funnel plots (Egger 1997).
Qualitative assessment of results was based on primary outcome
measures and considered the methodological quality and the
reviewers overall conclusions for each exercise therapy group.Exercise therapy groups were included in the qualitative synthesis
if the trial included a no treatmentor other conservative treatment
comparison group. Two reviewersindependentlyrated the findings
for each exercise therapy group. Studies were considered to
be providing evidence of effectiveness if statistically significant
improvement was observed in at least one of the key outcomes in
favour of the exercise group andclinically importantimprovement
was observed within or between groups. Studies were considered
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to be providing evidence that the exercise therapywas ineffective if
there was statistically significant improvement of the comparison
group and no clinically important improvement within the
exercise group. We rated studies neutral if no statistically
and clinically significant results were observed and unclear if
insufficient data were presented. A consensus process was usedto examine patterns in trial results. Levels of evidence, as
recommended by the Back Group (van Tulder 2003), were used:
1. Strong evidence - consistent findings* in multiple high quality
trials
2. Moderate evidence - consistent findings in multiple lowquality
trials and/or one high quality trial
3. Limited evidence - one low quality trial
4. Conflicting evidence - inconsistent findings in multiple trials.
5. No evidence - no randomized trials available.
*Consistent findings were defined as 75% or more trials (66% insensitivity analysis) showing results in the same direction.
Further analyses explored heterogeneity due to study-level
variables, such as population source and study quality. We
characterized the population sources as healthcare (primary,
secondary or tertiary care centres), occupational (patients
presenting to occupational healthcare facilities or personnel in
compensatory situations), or from a general or mixed population
(e.g. includingindividuals recruited by newspaper advertisements)
to differentiate the studies with patients in typical treatment
settings (healthcare and occupational) from those including
individuals with low-back pain who may not normally present for
treatment. Outcomes for subgroups of studies conducted in these
populations were compared (Song 2003). The impact of study
quality on effect sizes was assessed using subgroup analysis.
SAS for Windows Version 8 (for descriptive), STATA 8 (for
publication bias), and Review Manager 4.2 packages were used for
analyses.
D E S C R I P T I O N O F S T U D I E S
Additional Figure 01 shows details of included and excluded stud-
ies. Additional Table 02 contains the descriptive summary and
characteristics of the 61 studies included (Alexandre 2001; Aure
2003; Buswell 1982; Bendix_a 2000; Bendix_b 1995; Bronfort1996; Bentsen 1997; Cherkin 1998; Chok 1999; Calmels 2004;
Davies 1979; Deyo 1990; Delitto 1993; Dalichau 2000; Descar-
reaux 2002; Elnaggar 1991; Farrell 1982; Faas 1993; Frost 1995;
Frost 2004; Gilbert 1985; Gur 2003; Galantino 2004; Hansen
1993; Hemmila 1997; Hides 1996; Hildebrandt 2000; Johanssen
1995; Jousset 2004; Kendall 1968; Kankaanpaa 1999; Kuukka-
nen 2000; Lidstrm 1970; Lindstrom 1992; Ljunggren 1997;
Lie 1999; Manniche 1988; Malmivaara 1995; Mannion 1999;
Moffett 1999; Moseley 2002; Niemisto 2003; Preyde 2000; Pe-
tersen 2002; Risch 1993; Rasmussen-Barr 2003; Rittweger 2002;
Stankovic 1990;Seferlis1998; Soukup 1999;Storheim2003; Staal
2004; Turner 1990; Torstensen 1998; Tritilanunt 2001; Under-
wood 1998; Waterworth 1985; Yeung 2003; Yelland 2004; Yoz-
batiran 2004; Zylbergold 1981). A complete description of thesestudies is presented in the Table of Included Studies.
The pain and function outcomes for each trial are presented in
Appendix Table 2 (available at www.annals.org). The VAS scale
(/100) was the most common outcome measure used to assess
pain across studies (22 studies), and 83% of studies reporting pain
used one of: VAS (/100), VAS (/10), NRS (/100) or NRS (/10).
Other pain outcome measures included the McGill pain question-
naire (four studies), a five- or nine-point Likert pain scale, the
Aberdeen pain scale, and the West Haven Yale questionnaire (one
study each). The most common functional limitation outcome
measures, employed in 59% of trials, were the Oswestry disability
index (15 studies) and the Roland Morris disability questionnaire
(12 studies). Other functional measures included: VAS function
scale (four studies), activities of daily living scale (three studies),
sickness impact profile (two studies), Quebecdisability index (two
studies), Manniches low-back rating scale (two studies), and five
additional scales that were each used in single trials. The mean
follow-up times (95% confidence interval (95% CI)) for each of
the short, intermediate, and long-term follow-up periods were 6.3
weeks (95% CI: 5.3 to 7.3), 21.0 weeks (95% CI: 18.4 to 23.6),
and 53.6 weeks (95% CI: 48.7 to 58.6), respectively.
M E T H O D O L O G I C A L Q U A L I T Y
In the original review, which assessed ten quality items, including
the four key items investigated in the current review, the reviewers
disagreed on 122 of the 351 quality assessment scores (35%).
Disagreements were resolved by consensus in most cases, and a
third reviewer only had to make a final decision twice. In the
update, the reviewers disagreed on 19 of the 124 key item scores
(15%), resulting in a Kappa score of 0.76 (95% CI: 0.67 to 0.86),
indicating high agreement. For the update, disagreements were
resolved by consensus in allcases excepttwo, whena third reviewer
was needed to reach a decision.
Only eight studies scored positive on all the four key validity cri-
teria (Deyo 1990; Frost 1995; Frost 2004; Hansen 1993; Lind-
strom 1992; Malmivaara 1995; Manniche 1988; Mannion 1999;
Torstensen 1998). Based on information in the published report,
37 of the key quality items assessed (15%) were initially rated as
unclear (the most common item with insufficient description was
adequate concealment of treatment allocation). Contacting the
authors of the trials supplemented this information, modifying
14% of the criteria for which responses were received.
Clinical relevance of the included studies
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Assessment of clinical relevance found that many of the trial pub-
lications supplied inadequate information. The study population
was adequately described by 90% of the publications, but only
54% adequately described the exercise intervention. There was
adequate reporting of relevant outcomes in 70% of the trials. A
small number of studies reported on the presence or absence ofadverse events (16 studies, 26%). Twelve studies reported mild
negative reactions to the exercise program, such as increased low-
back pain and muscle soreness, in a minority of patients. Due to
limitations of reporting, it was not possible to assess the treatment
benefit to harm ratio.
R E S U L T S
Complete meta-analysis data, Forest plots and results are provided
in the Tables: Comparisons and data section.
Effectiveness
Acute low-back pain populationsTen of 11 trials involving 1192 adults with acute low-back pain
had non-exercise comparisons. These trials provided conflicting
evidence: one high quality trial conducted in an occupational set-
tingfound mobilizing home-exercises to be less effective thanusual
care (Malmivaara 1995) and one low quality trial conducted in a
healthcare setting found a therapist-delivered endurance program
improved short-term functioning more than no treatment (Chok
1999). Of the remaining eight low quality trials, six found no
statistically significant or clinically important differences between
exercise therapy and usual care or no treatment; the results of two
trials were unclear. We rated these trials as low quality most com-
monly because of inadequate assessor blinding. There was inade-
quate power to detect clinically important differences in pain forone trial (Underwood 1998) and for functioning in five trials (Far-
rell 1982; Hides 1996; Seferlis 1998; Underwood 1998; Water-
worth 1985).
The pooled analysis of trials with adequate numeric data failed
to show a difference in short-term pain relief between exercise
therapy and no treatment (three trials), with an effect of -0.59
points/100 (95% CI: -12.69 to 11.51). There was no difference
at earliest follow-up in pain relief when compared to other con-
servative treatments (seven trials): 0.31 points (95% CI: -0.10 to
0.72) [vs. all comparisons (10 trials) 0.03 points (95% CI: -1.34
to 1.40)]. Similarly, there was no significant positive effect of ex-
ercise on functional outcomes. Outcomes show similar trends at
the three follow-up periods in this population, as shown in Figure
02.
Subacute low-back pain populations
In six studies involving 881 individuals with subacute low-back
pain, seven exercise groups had non-exercise comparisons. One
high quality and one low quality trial each found reduced absen-
teeism outcomes with a graded-activity intervention in the work-
place compared to usual care (Lindstrom 1992; Staal 2004). This
provides moderate evidence of effectiveness of a graded-activity
exercise program in subacute low-back pain in occupational set-
tings. One low quality trial foundimproved functioning over usual
care with an exercise program combined with behavioural therapy
(Moffett 1999). Two trials with inadequate assessor blinding were
rated neutral, although they were adequately powered to detectclinically important differences in at least one primary outcome
(Cherkin 1998; Storheim 2003). The results of one trial were un-
clear (Davies 1979). The evidence is conflicting about the effec-
tiveness of other types of exercise therapy in subacute low-back
pain compared to other treatments.
Meta-analysis of pain outcomes at the earliest follow-up, including
fivestudies with available data, resulted in a pooled weighted mean
difference in pain score of 1.89 points (95% CI: -1.13 to 4.91)
relative to any comparison. The pooled analysis of four trials pre-
senting data on functional outcomes found a mean difference of
1.07 points (95% CI: -3.18 to 5.32) relative to other comparisons.
There is insufficient evidence to support or refute the effectiveness
of exercise therapy in subacute low-back pain for reducing pain
intensity and improving function. Results for short and interme-
diate follow-up periods in this population are shown in Figure 02.
Chronic low-back pain populations
In 43 trials including3907 individuals with chronic low-back pain,
33 exercise groups had non-exercise comparisons. These trials pro-
vide strong evidence that exercise therapy is at least as effective
as other conservative interventions, and conflicting evidence that
exercise therapyis more effectivethan other treatments forchronic
low-backpain. Two exercise groups in high quality studies andnine
groupsin lowquality studies found that exercise wasmore effective
than comparison treatments. These studies, mostly conducted in
healthcare settings, commonly used exercise programs that wereindividually designed and delivered (as opposed to independent
home exercises) (Bendix_b 1995; Frost 1995; Hildebrandt 2000;
Moseley 2002; Niemisto 2003; Risch 1993). The exercise pro-
grams commonly included strengthening or trunk stabilizing ex-
ercises (Frost 1995; Kankaanpaa 1999; Moseley 2002; Niemisto
2003; Preyde 2000; Risch 1993). Conservative care in addition
to the exercise therapy was often included in these effective in-
terventions, including behavioural and manual therapy, advice to
stay active and education. One low quality trial found a group-
delivered aerobics and strengthening exercise program resulted in
less improvementin pain andfunctionoutcomes than behavioural
therapy (Bendix_b 1995). Of the remaining trials, fourteen (two
high quality and twelve low quality) found no statistically signif-icant or clinically important differences between exercise therapy
and other conservative treatments. Four of these trials were inad-
equately powered to detect clinically important differences on at
least one outcome (Alexandre 2001; Rasmussen-Barr 2003; Yel-
land 2004; Zylbergold 1981). Trials were most commonly rated
as low quality because of inadequate assessor blinding.
Meta-analysis of pain outcomes at the earliest follow-up included
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23 exercise groups with an independent comparison and adequate
data. Synthesis resulted in a pooled weighted mean improvement
of 10.2 points (95% CI: 1.31 to 19.09) for exercise therapy com-
pared to no treatment, and 5.93 points (95% CI: 2.21 to 9.65)
compared to other conservative treatment [compared to all com-
parisons 7.29 points (95% CI: 3.67 to 10.91)]. At the earliest fol-low-up, smaller improvements were seen in functional outcomes
with an observed mean positive effect of 3.00 points (95% CI:
-0.53 to 6.48) compared to no treatment, and 2.37 points (95%
CI: 0.74 to 4.0) compared to other conservative treatment, at the
earliest follow-up [compared to all comparisons 2.50 points (95%
CI: 1.04 to 3.94)]. Results considering different follow-up periods
were similar for pain and functional outcomes (Figure 02). Eg-
gers test suggested there may be publication bias among studies in
chronic populations (p = 0.015); funnel plot analysis showed this
was likely due to three studies that demonstrated highly variable,
large positive effects (Alexandre 2001; Bendix_a 2000; Dalichau
2000).
Sensitivity analyses for qualitative syntheses did not affect the
conclusions. Meta-analyses were conducted excluding the results
of studies that presented data as median scores (Bendix_b 1995;
Chok 1999; Hansen 1993; Rasmussen-Barr 2003), or did not
provide variance scores (Dalichau 2000; Farrell 1982; Hemmila
1997). This did not impact the pooled results for acute and suba-
cute populations. In chronic populations, this sensitivity analysis
resulted in lower, though still significantly improved, pooled effect
sizes. Complete results of all analyses are available on request.
Further Analyses
Analyses were conducted on studies from acute, subacute and
chronic populations to assess the impact of study level variables.Test of statistical heterogeneity of painoutcomes found57% (95%
CI: 12to79), 37% (95%CI: 0 to76) and 81% (95%CI: 72to 87)
for acute, subacute and chronic, respectively, of the heterogeneity
not due to chance; function outcomes showed 80% (95% CI: 63
to 89), 47% (95% CI: 0 to 82) and 52% (95% CI: 19 to 71),
respectively. To account for heterogeneity, random effects models
were used and clinically relevant subgroups of studies investigated.
A complete exploration of intervention heterogeneity is included
in an earlier publication (Hayden 2005b).
Indirect subgroup comparisons using qualitative synthesis and
meta-analysis found trials examining healthcare study populations
observed higher mean improvements in functioning and pain overtheir comparison groups than trials examining occupational or
general populations. In chronic populations, there were mean im-
provements in healthcare settings of 13.3 points (95% CI: 5.5 to
21.1) on pain and 6.9 points (95% CI: 2.2 to 11.7) on function
outcomes. The adjusted differences between studies with differ-
ent source populations found significantly greater improvement
in outcomes in healthcare populations compared to studies from
general population or mixed populations, with a mean of 9.96
points (95% CI: 1.6 to 18.4) more improvement in pain, and5.52
points (95% CI: 0.6 to 10.4) greater improvement in functioning.
Meta-analyses were conducted on the subgroup of high quality
trials. The observed effectiveness of exercise therapy decreased and
only remained significant for pain outcomes in the chronic pop-
ulation.
D I S C U S S I O N
The current review is the most up-to-date assessment of the ef-
fectiveness of exercise therapy in key population subgroups. For
the most part, results were similar using either a qualitative rat-
ing system or meta-analysis. We draw the following conclusions,
which provide useful information for primary care clinicians to
help guide their patient management and referral practices:
1. In acute low-back pain, there is evidence that exercises are not
more effective than other conservative treatments. Meta-analysis
showed no advantage over no treatment for pain and functional
outcomes over the short or long-term.
2. There is moderate evidence of effectiveness of a graded-activity
exercise program in subacute low-back pain in occupational set-
tings. The effectiveness for other types of exercise therapy in other
populations is unclear.
3. In chronic low-back pain, there is strong evidence that exer-
cise is at least as effective as other conservative treatments. Indi-
vidually designed strengthening or stabilizing programs appear to
be effective in healthcare settings. Meta-analysis found functional
outcomes significantly improved, however, the effects were very
small, with less than a three-point (out of 100) difference between
the exercise and comparison groups at earliest follow-up. Pain out-
comes were also significantly improved in groups receiving exer-
cises relative to other comparisons, with a mean of approximately
seven points. Effects were similar over longer follow-up though
confidence intervals increased. Mean improvements in pain and
functioning may be clinically meaningful in studies from health-
care populations in which improvements were significantly greater
than those observed in studies from general or mixed populations.
This study has several strengths and also some limitations. A large
number of randomized controlled trials informed this study and
the data were collected in a systematic waywithin the frameworkof
the Cochrane Collaboration, giving confidence that the synthesis
represents the current state of the literature. However, limitationsin the quality and reporting of the trials are notable. Only a small
number of the studies were rated as high quality and this may have
led to an overestimation of effect. Also, many studies lacked in-
formation to assess quality and clinical relevance. Contacting the
authors of the trials provided missing data, emphasizing the im-
portance and usefulness of this practice. The only outcome mea-
sure used in the majority of studies was pain intensity (in 85%),
limiting the ability to report on other important outcomes. In
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1998, a group of back pain researchers made recommendations for
standardized use of outcome measures in back pain research, sug-
gesting a minimum of pain, functional status and general health
measures (Deyo 1998). It is disappointing to observe the lack of
consistency, and the fact that only three-quarters of the studies
in this review included a measure of functional status and 15% ameasure of general health.Journals in the field of back pain should
adopt reporting guidelines (Begg 1996) and, even more impor-
tant, use them in their review process, to improve the quality of
future reportsof trials in this field. We found potential publication
bias in studies in chronic low-back pain; this may have resulted
in an overestimation of the effectiveness of exercise therapy in this
population. Initiatives in other fields to register randomized con-
trolled trials will also be important in low-back pain research. We
employed both qualitative and quantitative synthesis strategies in
this review, which was informative. Qualitative synthesis methods
facilitate the inclusion of results from trials which inadequately
report outcomes. This is particularly useful when only a small
number of studies are available, for example, in subacute popula-tions in the current review. However, the qualitative synthesis was
more challenging in assessing the evidence in chronic populations,
where a large number of studies were available.
With meta-analysis, we found no evidence that exercise therapy
is more effective than no treatment in improving outcomes in
acute low-back pain. This finding is consistent with the original
Cochrane review on this topic (van Tulder 2000b) and other sys-
tematic reviews (Abenhaim 2000; Hilde 1998; Tugwell 2001).
However, it should be stressed that exercise therapy is not the same
as advice to stay active, which is a recommended treatment strat-
egy in acute populations (Abenhaim 2000; Waddell 1997). In the
subacute population, which was not considered separately in theoriginal Cochrane review, there were six trials available. In a recent
systematic review of various conservative interventions, Pengel et
al. concluded there was an important gap in evidence for these
interventions in the treatment of subacute low-back pain (Pengel
2002). In our review, two trials looking at a working population
found reduced absenteeism outcomes with a graded-activity in-
tervention compared to usual care (Lindstrom 1992; Staal 2004),
though there continues to be uncertainty about other types of
exercises and in populations seeking healthcare. We also recom-
mend more clear definitions and further high quality research of
exercise therapy in this population. Finally, our positive findings
in chronic populations reflect the conclusions of earlier reviews
(Abenhaim 2000; Hilde 1998; Tugwell 2001). Our quantitativeanalysis provides an estimate of the average treatment effect and its
uncertainty, highlighting an overall small treatment benefit. Our
finding of greater improvement in trials investigating healthcare
populations is important. Future intervention studies should be
conducted in populations that are seeking care and therefore best
represent patients with low-back pain. We do not recommend fur-
ther research on the effectiveness of general exercise therapy inter-
ventions in chronic low-back pain. Trials should investigate spe-
cific exercise intervention strategies in well defined low-back pain
patient populations (Hayden 2005b).
A U T H O R S C O N C L U S I O N S
Implications for practice
Evidence from randomized controlled trials demonstrates that ex-
ercise therapy is effective at reducing pain and functional limi-
tations in the treatment of chronic low-back pain, though cau-
tious interpretation is required due to limitations in this literature.
Overall, mean improvements in outcomes across all research set-
tings are small, though significant, over other conservative treat-
ment options. Clinically important improvements are more likely
in healthcare settings. There is some evidence of effectiveness of
a graded-activity exercise program in subacute low-back pain in
occupational settings, though the evidence for other types of ex-
ercise therapy in other populations is unclear and further research
is required. This literature suggests exercise therapy is as effective
as either no treatment or other conservative treatments for acute
low-back pain.
Implications for research
Future RCTs in the area of low-back pain should: 1. include com-
plete descriptions of the study populations and exercise interven-
tions, 2. include complete reporting of meaningful outcome mea-
sures, 3. employ strategies to reduce bias, and 4. include more
complete tracking (and reporting) of long-term outcomes, includ-
ing recurrences.
F E E D B A C K
re: 2000 (2) version of review, received Feb 2005
Summary
My concerns with this review stem not from its methodology, but
its objectives. To this point, I refer specifically to the treatment
of exercise therapy as a single form of treatment, rather than a
wide-ranging and multifaceted modality that requires specific pre-
scription. Exercise therapy can mean many things to many peo-
ple, and not just the unqualified. This point is illustrated by the
wide range of interventions your reviewed studies include. Unfor-
tunately, the generalisation of exercise therapy and its efficacy in
the management of low back pain also seems to be reflected in
current guidelines to practitioners such as those published in the
UK by NICE and the RCGP.
In my opinion, reviewing exercise therapy as a single form of
treatment detracts greatly from the interpretation of the results of
this review. The attempt to stratify the data into flexion and/or
extension exercises and strength exercises, although noble, gives
the reader little more information about the nature of the exercises
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undertaken. Although I appreciate the problems with finding suf-
ficient similar trials on specific exercises (which can also be sub-
divided into many forms; McKenzie; transversus abdominus and
multifidus retraining, etc.), I would argue that by design, these
studies maybe too heterogeneous to combine. If the analogy could
be made with drug treatments, general treatment with medica-tion would just not cut it as an objective for a systematic review
of the pharmacological management of any condition.
The area of exercise prescription in the treatment of sub-acute
and chronic low back pain has undergone some major develop-
ments in the last 10 years. Yet unfortunately, growing bodies of
high quality research into specific exercise therapy for LBP, such as
that undertaken initially by a group of physiotherapists from the
University of Queensland in Australia (P Hodges, C Richardson,
G Jull and J Hides, and repeated successfully by other authors -
transversus abdominus and multifidus retraining in the treatment
of low back pain), has been ignored by a large proportion of the
medical community undertaking clinical trials (the UK Beam trial
which recently concluded is a good example of this) and funding
bodies alike. Similar highly specific exercise such as advocated by
these authors requires rigorous assessment by RCTs rather than
the blanket response to exercise therapy most research and cur-
rent good practice guidelines seem to be focusing on. Time after
time, insensitive interventions such as exercise are tested in low
back pain sufferers with understandably conflicting results, serv-
ing only to confuse practitioners and patients and fruitlessly drain
research funds.
I and many of my colleagues would argue strongly that exercise
prescription is as broad a term as drug prescription; and as such
its assessmentin clinical trials requiresexplicit and repeatablemea-
sures such as requiredin drug trials(explicitdescription,type, doseand side-effects etc.). I would argue that until we can assess each
explicit exercise form, we have a general idea what exercise can
do but no more. Considering their ramifications, recommenda-
tions such as those given in your article must be given with great
caution. At the very least they must realise their own limitations
to interpretation and external validity. I would certainly like to see
references to exercise in ALL RCTs on this topic narrowed in
their definitions and I feel large RCTs and subsequent systematic
reviews need to be undertaken to investigate the growing body of
evidence supporting the effectiveness of highly specific exercises
in the management of LBP.
Authors reply
You have identified an argument that rages within the systematic
review field ... when to lump and when to split. All exercises
are again included in the upcoming update of the exercise review.
To this point, the research question has been is exercise of any
benefit to individuals with low back pain ... there has not been
a breakdown of each type of exercise for each duration of symp-
toms, due in part to the lack of data for each comparison, once one
starts breaking it down to this degree, although I think the authors
may have attempted some sub-group analysis. As the literature in-
creases, I suspect it will become more feasible to split into differ-
ent research questions, addressing the efficacy of specific exercises
for specific sub-groups of individuals with low back pain. There
have been some attempts to do this, but the data is still sparseand results must be treated with caution. The authors recognize
that this continues to pose a challenge to clinicians who deliver
exercise therapy. We cannot comment on how the summary of
the scientific literature is used in the development of guidelines,
since guidelines must take more into consideration than just the
available evidence.
I will pass on your comments to the authors of the updated re-
view for their consideration. Please do not hesitate to contact me
should you have any further concerns once the updated review is
published.
Contributors
Michael Noonan, Occupation Physiotherapist/Medical Student
Victoria Pennick, Back Group Coordinator
P O T E N T I A L C O N F L I C T O F
I N T E R E S T
Antti Malmivaara is the first author of one of the trials included in
this review. Methodological quality assessment and data extraction
ofthistrialwasdonebytwootherreviewers(BartKoesandMaurits
van Tulder).
A C K N O W L E D G E M E N T S
The authors would like to thank Drs Jens Ivar Brox and Jan Lonn,
and Mr. Arne Naessfor their assistance with the quality assessment
and data extraction from non-English language studies, the Phys-
iotherapy Educational Influentials from the Institute for Work
& Health for their guidance with syntheses, Emma Irvin, medical
librarian at the Institute for Work & Health, for her assistance
with the search strategy, Victoria Pennick for her assistance with
editing, and Rosmin Esmail for her contribution to the original
version of this review.
S O U R C E S O F S U P P O R T
External sources of support
Dutch Health Insurance Board
(Personal funding) Canadian Institutes for Health Research
CANADA
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(Personal funding) Canadian Chiropractic Research Founda-
tion CANADA
Internal sources of support
Institute for Work & Health CANADA
R E F E R E N C E S
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Elnaggar 1991 {published data only}
ElnaggarIM, NordinM, Sheikhzadeh A, ParnianpourM, KahanovitzN. Effects of spinal flexion and extension exercises on low-back painand spinal mobility in chronic mechanical low-back pain patients.Spine1991;16:96772.
Faas 1993 {published data only} Faas A, Chavannes AW, van EijkJThM, Gubbels JW. A randomizedplacebo-controlled trial of exercise therapy in patients with acute lowback pain. Spine1993;18:138895.
Faas A, van Eijk JThM, Chavannes AW, Gubbels JW. A randomizedtrial of exercise therapy in patients with acute low back pain. Spine1995;20:9417.
Farrell 1982 {published data only}Farrell JP, Twomey LT. Acute low back pain: comparison of twoconservative treatment approaches. Med J Aus1982;1:1604.
Frost 1995 {published data only} Frost H, Klaber Moffett JA, Moser JS, Fairbank JCT. Randomisedcontrolled trial for evaluation of fitness programme for patients withchronic low back pain. Br Med J1995;310:1514.
Frost H, Lamb SE, Klaber Moffett JA, Fairbank JCT, Moser JS. Afitness programme for patients with chronic low back pain: 2-yearfollow-up of a randomised controlled trial. Pain 1998;75:2739.
Frost 2004 {published data only} Frost H, Lamb SE, Doll HA, Taffe Carver P, Stewart-Brown S.Randomized controlled trial of physiotherapy compared with advicefor low back pain. BMJ2004;329:70811.
Galantino 2004 {published data only}Galantino ML, Bzdewka TM, Eissler-Russo JL, Holbrook ML,Mogck EP, Geigle P, et al. The impact of modified hatha yoga onchronic low back pain: A pilot study. Alternative Therapies in Health& Medicine2004;10:569.
Gilbert (ex2) {published data only}Gilbert 1985 {published data only}
Evans C, Gilbert JR, Taylor DW, Hildebrand A. A randomized con-trolled trial of flexion exercises, education, and bed rest for patientswith acute low back pain. Physiother Can 1987;39:96101.
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Gur (ex2) {published data only}
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Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ, Karakoc M. Efficacyof low power laser therapy and exercise on pain and functions inchronic low back pain. Lasers in Surgery & Medicine2003;32:2338.
Hansen 1993 {published data only}
Hansen FR, Bendix T, Skov P, Jensen CV, Kristensen JH, Krohn L,et al. Intensive,dynamic back-muscle exercises, conventional physio-therapy, or placebo-control treatment of low back pain. Spine1993;18:98107.
Hemmila 1997 {published data only}
HemmilaH, Keinanen-KiukaanniemiSM, LevoskaS, Puska P. Long-term effectiveness of bone-setting, light exercise therapy, and phys-iotherapy for prolonged back pain: A randomized controlled trial. J
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Hemmil HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P.Does folk medicine work? A randomized clinical trial on patientswith prolonged back pain. Arch Phys Med Rehabil1997;78:5717.
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Hildebrandt 2000 {published data only}
Hildebrandt VH, Proper KI, van den Berg R, Douwes M, van denHeuvel SG, van Buuren S. [Cesar therapy is temporarily more effec-tive in patients with chronic low back pain than the standard treat-ment by family practitioner: randomized, controlled and blindedclinical trial with 1 year follow-up]. [Dutch]. Nederlands Tijdschriftvoor Geneeskunde2000;144:225864.
Johanssen (ex2) {published data only}
Johanssen 1995 {published data only}Johanssen F, Remvig L, Kryger P, Beck P, Warming S, Lybeck K, etal. Exercises for chronic low back pain: a clinical trial.J Orthop SportsPhys Ther1995;22:529.
Jousset (ex2) {published data only}
Jousset 2004 {published data only}
Jousset N, Fanello S, Bontoux L, Dubus V, Billabert C, Vielle B, etal. Effects of functional restoration versus 3 hours per week physicaltherapy: a randomized controlled study. Spine2004;29:48793.
Kankaanpaa 1999 {published data only}
Kankaanpaa M, Taimela S, Airaksinen O, Hanninen O. The efficacyof activerehabilitation in chronic lowback pain.Effecton paininten-sity, self-experienced disability, and lumbar fatigability. Spine1999;24:103442.
Kendall (ex2) {published data only}
Kendall (ex3) {published data only}
Kendall 1968 {published data only}
Kendall PH, Jenkins JM. Exercises for backache: a double-blind con-trolled trial. Physiother1968;54:1547.
Kuukkanen 2000 {published data only} Kuukkanen TM, Malkia EA. An experimental controlled study onpostural sway andtherapeuticexercisein subjects with low back pain.Clinical Rehabilitation 2000;14:192202.
Lidstrm 1970 {published data only}
Lidstrm A, Zachrisson M. Physical therapy on low back pain andsciatica. Scand J Rehabil Med1970;2:3742.
Lie (ex2) {published data only}
Lie 1999 {published data only}
Lie H, Frey S. [Mobilizing or stabilizing exercise in degenerative diskdisease in the lumbar region?]. [Norwegian]. Tidsskrift for Den NorskeLaegeforening1999;119:20513.
Lindstrom 1992 {published data only}
LindstrmI.A succesful intervention program for patients with subacutelow back pain. (Academic Thesis). Gteborg: Gteborg University,1994.
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Lindstrm I, hlund C, Eek C, Wallin L, Peterson LE, FordyceWE, et al. The effect of graded activity on patients with subacute lowback pain: a randomized prospective clinical study with an operant-conditioning behavioural approach. Physical Therapy1992a;72:27993.
Lindstrm I, hlund C, Eek C, Wallin L, Peterson LE, Nachemson A. Mobility, strength, and fitness after a graded activity programfor patients with subacute low back pain. A randomized prospectiveclinical study with a behavioural therapy approach. Spine1992b;17:64152.
Ljunggren (ex2) {published data only}
Ljunggren 1997 {published data only}
Ljunggren AE, Weber H, Kogstad O, Thom E, Kirkesola G. Effectof exercise on sick leave due to low back pain: a randomized, com-parative, long-term study. Spine1997;22:16107.
Malmivaara 1995 {published data only}
Malmivaara A, Hkkinen U, Aro T, Heinrichs ML, Koskenniemi L,Kuosma E, et al. The treatment of acute low back pain - bed rest,exercises or ordinary activity?. N Engl J Med1995;332:3515.
Manniche (ex2) {published data only}
Manniche (ex3) {published data only}
Manniche 1988 {published data only} Manniche C, Hesselsoe G, Bentzen L, Christensen I, Lundberg E.Clinical trial of intensive muscle training for chronic low back pain.Lancet1988;ii:14736.
Manniche C, Lundberg E, Christensen I, Bentzen L, Hesselsoe G.Intensive dynamic back exercises for chronic low back pain: a clinicaltrial. Pain 1991;47:5363.
Mannion (ex2) {published data only}
Mannion (ex3) {published data only}
Mannion 1999 {published data only}
Mannion AF, Muntener M, Taimela S, Dvorak J. A randomizedclinical trial of three active therapies for chronic low back pain.Spine1999;24:243548.
Mannion AF, Muntener M, Taimela S, Dvorak J. Comparison ofthree active therapies for chronic low back pain: results of a random-ized clinical trial with one-year follow-up. Rheum 2001;40:7728.
Mannion AF, Taimela S, Muntener M, Dvorak J. Active therapy forchronic low back pain part 1. Effects on back muscle activation,fatigability, and strength. Spine2001;26:897908.
Moffett 1999 {published data only}
Moffett JK, Torgerson D, Bell-Syer S, Jackson D, Llewlyn-PhillipsH, Farrin A, et al. Randomised controlled trial of exercise for lowback pain: clinical outcomes, costs, and preferences.BMJ1999;319:
27983.Moseley 2002 {published data only}
Moseley L. Combined physiotherapy and education is efficacious forchronic low back pain. Aust J Physiother2002;48:297302.
Niemisto 2003 {published data only}
Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren K-A, SarnaS, Hurri H. A randomized trial of combined manipulation, stabiliz-ing exercises, and physician consultation compared to physician con-sultation alone for chronic low back pain. Spine2003;28:218591.
Petersen (ex2) {published data only}
Petersen 2002 {published data only}Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S. The effect ofMcKenzie therapy as compared with that of intensive strengtheningtraining for the treatment of patients with subacute or chronic low
back pain: A randomized controlled trial. Spine2002;27:17029.Preyde (ex2) {published data only}
Preyde 2000 {published data only}
Preyde M. Effectiveness of massage therapy for subacute low-backpain: A randomized controlled trial. Can Med Assoc J 2000;162:181520.
Rasmussen-Barr 2003 {published data only}Rasmussen-BarrE, Nilsson-Wikmar L, Arvidsson I. Stabilizingtrain-ing compared with manual treatment in sub-acute and chronic low-back pain. Manual Therapy2003;8:23341.
Risch 1993 {published data only}
Risch SV, Norvell NK, Pollock ML, Risch ED, Langer H, FultonM, et al. Lumbar strengthening in chronic low back pain patients:physiologic and psychological benefits. Spine1993;18:2328.
Rittweger (ex2) {published data only}
Rittweger 2002 {published data only}
Rittweger J, Just K, Kautzsch K, Reeg P, Felsenberg D. Treatment ofchronic lower back pain with lumbar extension and whole-body vi-bration exercise: a randomized controlled trial. Spine2002;27:182934.
Seferlis 1998 {published data only}
Seferlis T, Nemeth G, Carlsson AM, Gillstrm P. Conservative treat-ment in patients sick-listed for acute low-back pain: a prospectiverandomised study with 12 months follow-up. Eur Spine J1998;7(6):46170.
Soukup (ex2) {published data only}
Soukup 1999 {published data only}
Glomsrod B, Lonn JH, Soukup MG, Bo K, Larsen S. Active backschool, prophylactic management for low back pain: Three-year fol-low-up of a randomized, controlled trial. J Rehab Med2001;33:2630.
Lonn JH, Glomsrod B, Soukup MG, Bo K, Larsen S. Active backschool: Prophylactic management for low back pain. A randomizedcontrolled, 1-year follow-up study. Spine1999;24:86571.
Soukup M, Lonn J, Glomsrod B, Bo K, Larsen S. Exercises andeducation as secondary prevention for recurrent low back pain. PhysRes Int2001;6:2739.
Soukup MG, Glomsrod B, Lonn JH, Bo K, Larsen S, FordyceWE. The effect of a Mensendieck exercise program as secondaryprophylaxis for recurrent low back pain: A randomized, controlledtrial with 12-month follow-up. Spine1999;24:158592.
Staal 2004 {published data only}
Staal JB, Hlobil H, Twisk JW, Smid T, Koke AJ, van Mechelen W.Graded activity for low back pain in occupational health care: a ran-domized, controlled trial.[see comment]. Ann Intern Med2004;140:7784.
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Stankovic 1990 {published data only}
Stankovic R, Johnell O. Conservative treatment of acute low-backpain: a 5-year follow-up study of two methods of treatment. Spine1995;20:46972.
Stankovic R, Johnell O. Conservative treatment of acute low back
pain: a prospective randomized trial. Spine1990;15:1203.Storheim 2003 {published data only}
Storheim K, Brox JI, Holm I, Koller AK, Bo K. Intensive grouptraining versus cognitive intervention in sub-acute low back pain:short-term results of a single-blind randomized controlled trial. JRehabil Med2003;35:13240.
Torstensen (ex2) {published data only}
Torstensen 1998 {published data only}Torstensen TA, Ljunggren AE, Meen HD, Odland E, MowinckelP, Geijerstam S. Efficiency and costs of medical exercise therapy,conventional physiotherapy, and self-exercisein patientswith chroniclow back pain: a pragmatic, randomized, single-blinded, controlledtrial with 1-year follow-up. Spine1998;23:261624.
Tritilanunt (ex2) {published data only}
Tritilanunt 2001 {published data only}
Tritilanunt T, Wajanavisit W. The efficacy of an aerobic exercise andhealth education program for treatment of chronic low back pain. J
Med Assoc Thailand2001;84:S52833.
Turner (ex2) {published data only}
Turner 1990 {published data only}
Turner JA, Clancy S, McQuade KJ, Cardenas DD. Effectiveness ofbehavioral therapy for chronic low back pain: a component analysis.
J Consult Clin Psychol1990;58:5739.
Underwood 1998 {published data only}
Underwood MR,MorganJ. Theuseof a backclassteachingextensionexercises in the treatment of acute low back pain in primary care.Fam Pract1998;15:915.
Waterworth 1985 {published data only}
Waterworth RF, Hunter IA. An open studyof diflunisal, conservativeand manipulative therapy in the management of acute mechanicallow back pain. N Z Med J1985;95:3725.
Yelland 2004 {published data only} Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon M.Prolotherapy injections, saline injections, and exercises for chroniclow-back pain: a randomized trial. Spine2004;29:916.
Yeung (ex2) {published data only}
Yeung 2003 {published data only}
Yeung CK, Leung MC, Chow DH. The use of electro-acupuncturein conjunction with exercise for the treatment of chronic low-backpain. J Alternative & Complementary Medicine2003;9:47990.
Yozbatiran (ex2) {published data only}
Yozbatiran 2004 {published data only}
Yozbatiran N, Yildirim Y, Parlak B. Effects of fitness and aquafitnessexercises on physical fitness in patients with chronic low back pain.The Pain Clinic2004;16:3542.
Zylbergold 1981 {published data only}
Zylbergold RS, Piper MC. Lumbar disc disease: comparative analysisof physical therapy treatments. Arch Phys Med Rehabil1981;62:1769.
References to studies excluded from this review
Coxhead 1981
Coxhead CE, Inskip H, Meade TW, North WRS, Troup JDG. Mul-ticentre trial of physiotherapy in the management of sciatic symp-toms. Lancet1981;i:10658.
Danielsen 2000Danielsen JM, Johnsen R, KibsgaardSK, Hellevik E. Early aggressiveexercise for postoperative rehabilitation after discectomy. Spine2000;25:101520.
Danneels 2001
Danneels LA, Cools AM, Vanderstraeten GG, Cambier DC,Witvrouw EE, Bourgois J, et al. The effects of three different trainingmodalities on the cross-sectional area of the paravertebral muscles.Scand J Med Sci Sports2001;11:33541.
Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw EE,Bourgois J, Dankaerts W, et al. Effects of three different trainingmodalities on the cross sectional area of the lumbar multifidus mus-cle in patients with chronic low back pain. Br J Sports Med2001;35:18691.
Friedrich 1998
Friedrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I. Com-bined exercise and motivation program: Effect on the complianceand level of disability of patients with chronic low back pain: A ran-domized controlled trial. Arch Phys Med Rehab 1998;79:47587.
Ghoname 1999
Ghoname EA, Craig WF, White PF, Ahmed HE, Hamza MA, Hen-derson BN, et al. Percutaneous electrical nerve stimulation for lowback pain: a randomized crossover study. [see comments.] [erratumappears in JAMA 1999 May 19;281(19):1795.]. JAMA 1999;281:81823.
Hagen 2000
Hagen EM, Eriksen HR, Ursin H. Does early intervention with alight mobilization program reduce long-term sick leave for low backpain?. Spine2000;25:19736.
Helewa 1999
Helewa A, Goldsmith CH, Lee P, Smythe HA, Forwell L. Doesstrengthening the abdominal muscles prevent low back pain - A ran-domized controlled trial. J Rheum 1999;26:180815.
Horneij 2001
HorneijE, Hemborg B, Jensen I, Ekdahl C. Nosignificant differencesbetween intervention programmes on neck, shoulder and low backpain: a prospective randomized study among home-care personnel.
J Rehabil Med2001;33:1706.
Lang 2003
Lang E, Liebig K, Kastner S, Neundorfer B, Heuschmann P. Multi-disciplinary rehabilitation versususual care for chronic low back painin the community: effects on quality of life. Spine Journal2003;3(4):2706.
Little 2001
Little P, Roberts L, Blowers H, Garwood J, Cantrell T, LangridgeJ, et al. Should we give detailed advice and information booklets topatients with back pain? A randomized controlled factorial trial of aself-management booklet and doctor advice to take exercise for backpain. Spine2001;26:206572.
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Jadad 1996
Jadad AR, MooreA, Carroll D, Jenkinson C, ReynoldsJM, GavaghanDJ, et al. Assessing the quality of reports of randomized clinical trials:Is blinding necessary?. Controlled Clinical Trials1996;17(1):112.
Koes 1991
Koes BW, Bouter LM,Beckerman H, vander Heijden GJMG, Knip-schild PG. Physiotherapy exercises and back pain: a blinded review.Br Med J1991;302:15726.
Kool 2004
Kool J, de Bie R, Oesch P, Knusel O, van den Brandt P, BachmannS. Exercise reduces sick leave in patients with non-acute non-specificlow back pain: a meta-analysis. Journal of Rehabilitation Medicine2004;36:4962.
Kopec 2000
Kopec JA. Measuringfunctional outcomes in persons withback pain:A review of back-specific questionnaires. Spine2000;25:31104.
Liddle 2004
Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low backpain: what works?. Pain 2004;107:17690.
Nutter 1987
Nutter P. Aerobic exercise in the treatment and prevention of lowback pain. In: DeyoRA editor(s). Spine: State of the Art Reviews. Vol.2, Philadelphia: Hanley and Belfus, Inc., 1987:13745.
Pengel 2002
Pengel HM, Maher CG, RefshaugeKM. Systematic review of conser-vative interventions for subacute low back pain. Clin Rehabil2002;16:81120.
Salaffi 2004
Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimallyclinically important changes in chronic musculoskeletal pain inten-sity measured on a numerical rating scale. European Journal of Pain2004;8:28391.
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Tugwell 2001
Tugwell P. Philadelphia panel evidence-based clinical practice guide-lines on selected rehabilitation interventions for low back pain. Phys-ical Therapy2001;81:164174.
van Tulder 1997a
van Tulder MW, Koes BW, Bouter LM. Conservative treatment ofacute and chronic nonspecific low back pain: a systematic review
of randomized controlled trials of the most common interventions.Spine1997;22:212856.
van Tulder 1997b
van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM, and theEditorial Board of the Cochrane Collaboration Back Review Group.
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van Tulder 2003
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von Korff 2000
von Korff M, Jensen MP, Karoly P. Assessing global pain severity byself-report in clinical health services research. Spine2000;25:314051.
Waddell 1997
Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and
advice to stay active for acute low back pain. Br J Gen Pract1997;47:64752.
References to other published versions of this review
Hayden 2005a
Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-anal-ysis: Exercise Therapy for Nonspecific Low Back Pain. Annals of In-ternal Medicine2005;142:76575.
Hayden 2005b
Hayden JA, van Tulder MW, Tomlinson G. Systematic Review:Strategies for Using Exercise Therapy to Improve Outcomes inChronic Low Back Pain. Annals of Internal Medicine2005;142:77685.
van Tulder 2000avan Tulder MW, Malmivaara A, Esmail R, KoesBW. Exercise therapyfor low-back pain. In: The Cochrane Database of Systematic Reviews,2, 2000.
van Tulder 2000b
van Tulder MW, Malmivaara A, Esmail R, KoesBW. Exercise therapyfor low back pain: A systematic review within the framework of theCochrane Collaboration Back Review Group. Spine 2000;25(21):278496.
Indicates the major publication for the study
T A B L E S
Characteristics of included studies
Study Alexandre 2001
Methods See Comparisons and Data Table 05: Methodological Quality of Included Studies for detailed information.
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Characteristics of included studies (Continued)
Participants Chronic population; Occupational; N=33
Interventions E1. Multiple components: exercise, plus home exercises; Time :24; Deliv:Group; Other:Advice to stay
active/ education; C1. No treatment
Outcomes Pain (VAS/10)
Notes See footnote for explanation of symbols, terms and abbreviations Allocation concealment B Unclear
Study Aure (ex2)
Methods
Participants
Interventions
Outcomes
Notes
Allocation concealment D Not used
Study Aure 2003
Methods See Comparisons and Data Table 05:
Participants Chronic population; Occupational; N=49
Interventions E1. Stretching exercises (2/3); passive manipulation (1/3); Time:10; Deliv:Individual; independent;
Other:Manual therapy; analgesics/NSAIDS; E2. Individually designed: strengthening, stretching, mobiliz-
ing, coordination, stabilizing exercises for abdominal, back, pelvic, lower limb; equipment; Time:10; De-
liv:Individual; independent; Other:Analgesics/NSAIDS;
Outcomes Pain (VAS), function (Osw), RTW
Notes
Allocation concealment A Adequate
Study Bendix_a (ex2)
Methods
Participants
Interventions
Outcomes
Notes
Allocation concealment D Not used
Study Bendix_a 2000
Methods See Comparisons and Data Table 05:
Participants Chronic population; Occupational; N=138
Interventions E1. Aerobics and strengthening (machines); Time:36; Deliv:Group; Other:None; E2. Functional restora-
tion; comprehensive multidisciplinary approach including aerobics, strengthening, stretching; Time:36; De-
liv:Group; Other:Behavioural therapy; backschool;
Outcomes Pain (NRS), function (MRS), RTW, global
Notes
Allocation concealment B Unclear
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Characteristics of included studies (Continued)
Study Bendix_b (ex2)
Methods
Participants
Interventions
Outcomes
Notes
Allocation concealment D Not used
Study Bendix_b 1995
Methods See Comparisons and Data Table 05:
Participants Chronic population; Secondary or tertiary care (referred); N=106
Interventions E1. Functional restoration; comprehensive multidisciplinary approach including aerobics, strengthening,
stretching; Time:24; Deliv:Group; Other:Behavioural therapy; backschool; E2. Aerobics and strengthening
; Time:24; Deliv:Group; Other:Backschool; C1. Other conservative
Outcomes Pain (VAS/10), function (ADL/30), RTW
Notes
Allocation concealment B Unclear
Study Bentsen (ex2)
Methods
Participants
Interventions
Outcomes
Notes
Allocation concealment D Not used
Study Bentsen 1997
Methods See Comparisons and Data Table 05:
Participants Chronic population; General population; N=74
Interventions E1. Dynamic strength back exercises: at gym and home; Time:21.8; Deliv:Individual; independent;
Other:None; E2. Home exercises; Time:21.8; Deliv:Independent only; Other:None;
Outcomes Function (Million), RTW
Notes
Allocation concealment A Adequate
Study Bronfort (ex2)
Methods
Participants
Interventions
Outcomes
Notes
Allocation concealment D Not used
Study Bronfort 1996
Methods See Comparisons and Data Table 05:
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Characteristics of included studies (Continued)
Participants Chronic population; General popul