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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

    1Exercise therapy for treatment of non-specific low back pain (Review)

    Copyright 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

    http://www.thecochranelibrary.com/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 . . . . .

    iiExercise therapy for treatment of non-specific low back pain (Review)

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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

    References to studies included in this reviewAlexandre 2001 {published data only}

    Alexandre NM, de Moraes MA, Correa Filho HR, Jorge SA. Evalu-ation of a program to reduce back pain in nursing personnel. Revistade Saude Publica 2001;35:35661.

    Aure (ex2) {published data only}

    Aure 2003 {published data only}Aure O, Nilsen J, Vasseljen O. Manual therapy and exercise therapyin patients with chronic low back pain. A randomized, controlled

    trial with 1-year follow-up. Spine2003;28(6):525532.Bendix_a (ex2) {published data only}

    Bendix_a 2000 {published data only}Bendix T, Bendix A, LabriolaM, Haestrup C, EbbehojN. Functionalrestoration versus outpatient physical training in chronic low backpain: a randomized comparative study. Spine2000;25:2494500.

    Bendix_b (ex2) {published data only}

    Bendix_b 1995 {published data only}Bendix AF, Bendix T, Labriola M, Boekgaard P. Functional restora-tion for chronic low back pain: Two-year follow-up of two random-ized clinical trials. Spine1998;23:71725.

    Bendix AF, Bendix T, Lund C, Kirkbak S, Ostenfeld S, Kirking BC.Comparisonof three intensiveprogramsfor chronic lowback painpa-tients: a prospective, randomized, observer-blinded study with one-year follow-up. Scand J Rehab Med1997;29:819.

    Bendix AF, Bendix T, Ostenfeld S, BushE, Andersen A. Active treat-ment programs for patientswith chronic low backpain: a prospectiverandomized, observer-blinded study. Eur Spine J1995;4:14852.

    Bentsen (ex2) {published data only}

    Bentsen 1997 {published data only}Bentsen H, Lindgrde F, Manthorpe R. The effect of dynamicstrength backexercise and/or a home training program in 57-year oldwomen with chronic low back pain: results of a prospective random-ized study with a 3-year follow-up period. Spine1997;22:1494500.

    Bronfort (ex2) {published data only}

    Bronfort 1996 {published data only}Bronfort G, Goldsmith CH, Nelson C, Boline PD, Anderson AV.TrunkexercisecombinedwithspinalmanipulativeorNSAIDtherapyfor chronic low back pain: a randomized, observer-blinded clinicaltrial. J Manipulative Physiol Ther1996;19:57082.

    Buswell (ex2) {published data only}

    Buswell 1982 {published data only}Buswell J. Low back pain: a comparison of two treatment pro-grammes. NZ J Physiotherapy1982;10:137.

    Calmels (ex2) {published data only}

    Calmels 2004 {published data only}

    Calmels P, Jacob JF, Fayolle-Minon I, Charles C, Bouchet JP, Ri-maud D, Thomas T. [Use of isokinetic techniques vs standard phys-iotherapy in patients withchronic low back pain. Preliminary results][French]. Annales de Readaptation et de Medecine Physique2004;47:207.

    Cherkin 1998 {published data only}

    Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison

    of physical therapy, chiropractic manipulation, and provision of aneducational booklet for the treatment of patients with low back pain.N Engl J Med1998;339:10219.

    Chok 1999 {published data only}

    Chok B, LeeR, Latimer J, Seang BT. Endurancetrainingof thetrunkextensor muscles in people with subacute low back pain. Phys Ther1999;79:103242.

    Dalichau (ex2) {published data only}

    Dalichau 2000 {published data only}

    Dalichau S, Scheele K. [Effects of elastic lumbar belts on the effectof a muscle training program for patients with chronic back pain].[German].Zeitschrift fur Orthopadieund IhreGrenzgebiete 2000;138:816.

    Davies (ex2) {published data only}

    Davies 1979 {published data only}

    DaviesJR, Gibson T, Tester L. Thevalueof exercisesin the treatmentof low back pain. Rheumatol Rehabil1979;18:2437.

    Delitto (ex2) {published data only}

    Delitto 1993 {published data only}Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA. Evi-dence for use of an extension-mobilization category in acutelow backsyndrome: a prescriptive validation pilot study. Phys Ther1993;73:21628.

    Descarreaux (ex2) {published data only}

    Descarreaux 2002 {published data only}

    Descarreaux M, Normand MC, Laurencelle L, Dugas C. Evaluationof a specific home exercise program for low back pain.J ManipulativePhysiol Ther2002;25(8):497503.

    Deyo 1990 {published data only}Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S. Acontrolled trial oftranscutaneous electricalnerve stimulation(TENS)and exercise for chronic low back pain. N Engl J Med 1990;322:162734.

    Elnaggar (ex2) {published data only}

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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.

    Gilbert JR, Taylor DW, HildebrandA, Evans C. Clinical practice ofcommon treatments for low-back pain. Br Med J1985;291:78992.

    Gur (ex2) {published data only}

    Gur 2003 {published data only}

    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

    Manip Phys Therapeutics2002;25:99104.

    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.

    Hides 1996 {published data only}

    Hides JA, Jull GA, Richardson CA. Long-term effects of specificstabilizing exercises for first-episode low back pain. Spine2001;26:E2438.

    Hides JA, Richardson CA,Jull GA.Multifidus muscle recovery is notautomatic after resolution of acute first-episode low back pain. Spine1996;21:27639.

    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.

    10Exercise therapy for treatment of non-specific low back pain (Review)

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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.

    Song 2003Song F, Altman DG, Glenny AM, Deeks JJ. Validity of indirect com-parison for estimating efficacy of competing interventions: empiricalevidence from published meta-analyses. BMJ2003;326:472.

    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.

    Method guidelines for systematic reviews in the Cochrane Collab-oration Back Review Group for Spinal Disorders. Spine 1997;22:232330.

    van Tulder 2003

    van Tulder MW, Furlan A, Bombardier C, Bouter L, the EditorialBoard of the Cochrane Collaboration Back Review Group. Updatedmethod guidelines for systematic reviews in the Cochrane Collabo-ration Back Review Group. Spine2003;28:12909.

    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