The full content of Annals is available to subscribers

Subscribe/Learn More  >
Reviews |

Meta-Analysis: Exercise Therapy for Nonspecific Low Back Pain

Jill A. Hayden, DC; Maurits W. van Tulder, PhD; Antti V. Malmivaara, MD, PhD; and Bart W. Koes, PhD
[+] Article, Author, and Disclosure Information

From Institute for Work & Health and University of Toronto, Toronto, Ontario, Canada; Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, the Netherlands; Finnish Office for Health Care Technology Assessment, National Research and Development Centre for Welfare and Health, Helsinki, Finland; and Erasmus University Medical Center, Rotterdam, the Netherlands.

Acknowledgments: The authors thank Drs. Jens Ivar Brox and Jan Lonn and Mr. Arne Naess for their assistance with the quality assessment and data extraction from non-English-language studies; the Physiotherapy “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.

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

Potential Financial Conflicts of Interest: None disclosed.

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

Current Author Addresses: Dr. Hayden: Institute for Work & Health, 481 University Avenue, Suite 800, 8th Floor, Toronto, Ontario M5G 2E9, Canada.

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

Dr. Malmivaara: Finnish Office for Health Care Technology Assessment, PO Box 220, FIN-00531 Helsinki, Finland.

Dr. Koes: Department of General Practice, Erasmus University Medical Center, PO Box 1738, 3000 DR Rotterdam, the Netherlands.

Ann Intern Med. 2005;142(9):765-775. doi:10.7326/0003-4819-142-9-200505030-00013
Text Size: A A A

Background: Exercise therapy is widely used as an intervention in low back pain.

Objective: To evaluate the effectiveness of exercise therapy in adult nonspecific acute, subacute, and chronic low back pain versus no treatment and other conservative treatments.

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

Study Selection: Randomized, controlled trials evaluating exercise therapy for adult nonspecific low back pain and measuring pain, function, return to work or absenteeism, and global improvement outcomes.

Data Extraction: Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short-, intermediate-, and long-term follow-up.

Data Synthesis: 61 randomized, controlled trials (6390 participants) met inclusion criteria: acute (11 trials), subacute (6 trials), and chronic (43 trials) low back pain (1 trial was unclear). Evidence suggests that exercise therapy is effective in chronic back pain relative to comparisons at all follow-up periods. Pooled mean improvement (of 100 points) was 7.3 points (95% CI, 3.7 to 10.9 points) for pain and 2.5 points (CI, 1.0 to 3.9 points) for function at earliest follow-up. In studies investigating patients (people seeking care for back pain), mean improvement was 13.3 points (CI, 5.5 to 21.1 points) for pain and 6.9 points (CI, 2.2 to 11.7 points) for function, compared with studies where some participants had been recruited from a general population (for example, with advertisements). Some evidence suggests effectiveness of a graded-activity exercise program in subacute low back pain in occupational settings, although the evidence for other types of exercise therapy in other populations is inconsistent. In acute low back pain, exercise therapy and other programs were equally effective (pain, 0.03 point [CI, −1.3 to 1.4 points]).

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

Conclusions: Exercise therapy seems to be slightly effective at decreasing pain and improving function in adults with chronic low back pain, particularly in health care populations. In subacute low back pain populations, some evidence suggests that a graded-activity program improves absenteeism outcomes, although evidence for other types of exercise is unclear. In acute low back pain populations, exercise therapy is as effective as either no treatment or other conservative treatments.


Grahic Jump Location
Figure 1.
Flow diagram of systematic review inclusion or exclusion.
Grahic Jump Location
Grahic Jump Location
Figure 2.
Results of meta-analyses of exercise versus any comparison for acute (top), subacute (middle), and chronic low back pain populations (bottom) and pain and function outcomes at short-, intermediate-, and long-term follow-ups.

Results shown are mean change on a 100-point scale (lines are 95% CIs). Clinically important improvement is considered to be 20 of 100 points for pain intensity and 10 of 100 points for functional impairment.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Meta-analyses for population source subgroups in chronic low back pain populations: health care, occupational, and general or mixed populations at earliest follow-up.

Results shown are mean change on a 100-point scale (lines are 95% CIs). Clinically important improvement is considered to be 20 of 100 points for pain intensity and 10 of 100 points for functional impairment.

Grahic Jump Location




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Posted on May 10, 2005
Conflict of Interest: None Declared

May 9, 2005

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

To the Editor,

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

Mark Hyman

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

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

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

Conflict of Interest:

None declared

Exercise for Nonspecific LBP
Posted on May 30, 2005
Steven J Kamper
School of Physiotherapy, University of Sydney
Conflict of Interest: None Declared

To the Editor,

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

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

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

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

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


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

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

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

3. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:775-85

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

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

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Exercise for Low Back Pain

The summary below is from the full report titled “Meta-Analysis: Exercise Therapy for Nonspecific Low Back Pain.” It is in the 3 May 2005 issue of Annals of Internal Medicine (volume 142, pages 765-775). The authors are J.A. Hayden, M.W. van Tulder, A.V. Malmivaara, and B.W. Koes.


Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.