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Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain

Jill A. Hayden, DC; Maurits W. van Tulder, PhD; and George Tomlinson, PhD
[+] Article, Author, and Disclosure Information

From Institute for Work & Health and University of Toronto, Toronto, Ontario, Canada, and Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, the Netherlands.

Acknowledgments: The authors thank Drs. Bart Koes and Antti Malmivaara for their contribution to the data collection and participation in the summative analysis of this review; the Physiotherapy “Educational Influentials” from the Institute for Work & Health for their guidance with syntheses; and Victoria Pennick for her assistance with editing.

Grant Support: No external 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, mailto:jhayden@iwh.on.ca.

Current Author Addresses: Dr. Hayden: Institute for Work & Health, 481 University Avenue, Suite 800, 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. Tomlinson: Division of Clinical Decision Making & Health Care Research, Toronto General Research Institute, TGH, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.

Ann Intern Med. 2005;142(9):776-785. doi:10.7326/0003-4819-142-9-200505030-00014
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Background: Exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain.

Purpose: To identify particular exercise intervention characteristics that decrease pain and improve function in adults with nonspecific chronic low back pain.

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

Study Selection: Randomized, controlled trials evaluating exercise therapy in populations with chronic (>12 weeks duration) low back pain.

Data Extraction: Two reviewers independently extracted data on exercise intervention characteristics: program design (individually designed or standard program), delivery type (independent home exercises, group, or individual supervision), dose or intensity (hours of intervention time), and inclusion of additional conservative interventions.

Data Synthesis: 43 trials of 72 exercise treatment and 31 comparison groups were included. Bayesian multivariable random-effects meta-regression found improved pain scores for individually designed programs (5.4 points [95% credible interval (CrI), 1.3 to 9.5 points]), supervised home exercise (6.1 points [CrI, −0.2 to 12.4 points]), group (4.8 points [CrI, 0.2 to 9.4 points]), and individually supervised programs (5.9 points [CrI, 2.1 to 9.8 points]) compared with home exercises only. High-dose exercise programs fared better than low-dose exercise programs (1.8 points [CrI, −2.1 to 5.5 points]). Interventions that included additional conservative care were better (5.1 points [CrI, 1.8 to 8.4 points]). A model including these most effective intervention characteristics would be expected to demonstrate important improvement in pain (18.1 points [CrI, 11.1 to 25.0 points] compared with no treatment and 13.0 points [CrI, 6.0 to 19.9 points] compared with other conservative treatment) and small improvement in function (5.5 points [CrI, 0.5 to 10.5 points] compared with no treatment and 2.7 points [CrI, −1.7 to 7.1 points] compared with other conservative treatment). Stretching and strengthening demonstrated the largest improvement over comparisons.

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

Conclusions: Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain. Strategies should be used to encourage adherence. Future studies should test this multivariable model and further assess specific patient-level characteristics and exercise types.


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Figure 1.
Breakdown of design of 43 included trials.

Numbers of exercise therapy and comparison groups are indicated. For example, 13 trials included 1 exercise group and 1 comparison group, and 15 trials compared 2 types of exercise groups.

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Figure 2.
Pain (left) and function (right) outcomes for study groups within each trial.

Exercise, conservative comparison, and no-treatment comparison groups are noted. Results for each group represent mean outcome scores at earliest follow-up period on a 100-point scale.

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Figure 3.
Probability functions based on data from systematic review.

Meta-analysis includes all relevant studies of exercise therapy. Results represent mean improvement scores in pain outcome (top) and function outcome (bottom) at earliest follow-up on a 100-point scale. The area to the right of the vertical line indicates clinically important improvement. *Meta-regression modeling of best levels of intervention characteristics includes individually designed exercise treatment program, supervised home exercises with follow-up, high-intensity or high-dose intervention, and additional conservative intervention (see text for detailed description).

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Figure 4.
Mean rank of included exercise types on the basis of association with improved pain (top) and function (bottom) outcomes at earliest follow-up compared with no treatment or other conservative treatment.

Lines indicate 95% credible intervals for exercise type ranks.

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Submit a Comment/Letter
Response to Systematic Review on Exercise and Chronic LBP
Posted on June 14, 2005
Sarah D Liddle
Research Associate
Conflict of Interest: None Declared

14th June 2005

Dear Sir / Madam,

Hayden and colleagues have raised some interesting points in their recent systematic review of the use of exercise for the management of chronic low back pain (1). Whilst the task of analysing exercise type and quality is fraught with difficulties, typically stemming from the lack of methodological detail provided on the specific type(s) and dose of exercise being prescribed within randomised controlled trials (2), the findings from their comprehensive analysis have important implications for the clinical management of this particular patient group. They have clearly indicated that both the content and method of exercise programme delivery have an important influence on clinically relevant treatment outcomes. In particular, their analysis of the degree of supervision provided within trials, supports the recent findings of other authors (3, 4), that supervision does result in pain and functional improvements. The importance of encouraging exercise adherence in order to achieve the appropriate exercise dose is also highlighted by the authors as a key factor mediating the success of exercise programmes, and one, no doubt, that many clinicians would agree is a key limitation to the success of exercise-based rehabilitation.

Whilst recognising the value of Hayden and colleagues' findings, we would like to draw your readers' attention our previous review in this area: we also investigated similar aspects of exercise programme delivery, and came to strikingly similar conclusions (2) which in our view should have been acknowledged within this paper. Although our findings were not the result of a meta-regression analysis, we did conduct the review in accordance with the QUOROM, and Cochrane Methodological Quality Guidelines (5, 6), used similar methods of trial identification and data extraction, and reported similar limitations in the literature as that reported by Hayden et al.

Yours faithfully,

S. Dianne Liddle G. David Baxter Jacqueline H. Gracey

Health and Rehabilitation Sciences Research Institute University of Ulster Shore Road, Newtownabbey Co. Antrim BT37 OQB Northern Ireland

1. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal Medicine 2005; 142: 776-785.

2. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain 2004; 107: 176-190.

3. Airakinsinen O, Brox JL, Cedraschi C, Hildebrandt J, Klaber- Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G. European guidelines for the management of chronic non-specific low back pain. COST B13 Working Group 2004, www.backpaineurope.org.

4. Maul I, Laubli T, Oliveri M, Krueger H. Long-term effects of supervised physical training in secondary prevention of low back pain. European Spine Journal 2005; epublished ahead of print.

5. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: The QUOROM Statement. The Lancet 1999; 354: 1896-1900.

6. Van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM and the Editorial Board of the Cochrane Collaboration Back Review Group. Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders. Spine 1997; 22: 2323-2330.

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Best Types of Exercise for Low Back Pain

The summary below is from the full report titled “Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain.” It is in the 3 May 2005 issue of Annals of Internal Medicine (volume 142, pages 776-785). The authors are J.A. Hayden, M.W. van Tulder, and G. Tomlinson.


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