Exercise therapy for chronic low back pain

Jill A. Hayden*, Jenna Ellis, Rachel Ogilvie, Antti Malmivaara, Maurits W. van Tulder

*Corresponding author for this work

Research output: Contribution to JournalReview articleAcademicpeer-review

Abstract

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

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

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

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

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

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

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

Original languageEnglish
Article numberCD009790
Number of pages553
JournalThe Cochrane database of systematic reviews
Volume2021
Issue number9
DOIs
Publication statusPublished - 28 Sept 2021

Bibliographical note

Funding Information:
We would like to thank Shireen Harbin, Managing Editor of the Cochrane Back and Neck Group, Jordi Pardo Pardo, Managing Editor of the Musculoskeletal Group, Rachel Couban, Trials Search Co-ordinator of the Cochrane Back and Neck Review Group, and Leah Boulos, Evidence Synthesis Coordinator for the Maritime SPOR SUPPORT Unit for their assistance and support conducting literature searches. We would like to thank?Cochrane editors and reviewers, including Bruno T Saragiotto, PhD, Universidade Cidade de S?o Paulo, Brazil and?Timothy Carey MD MPH, Research Professor of Medicine, University of North Carolina at Chapel Hill, NC, USA for their comprehensive peer review. We would also like to thank Kathryn Armitstead for her careful?review as consumer reviewer. We would like to thank Dr. Samuel Stewart, Assistant Professor, Dalhousie University,?for his consultation on our analyses. We would like to acknowledge Jenny Cartwright for her contributions to the development of the protocol, and early study screening and data extraction. We would like to thank Sally Miller, Andrea Smith, and Maria Wilson for their contributions to study screening, data extraction and data preparation, and Selena Glover for study screening, data extraction and assistance making judgements about exercise types. We would like to thank Somayyeh Mohammadi for her assessment of Persian abstracts.

Publisher Copyright:
Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Copyright:
Copyright 2021 Elsevier B.V., All rights reserved.

Funding

Conflicts of interest: None to declare Funding source: Science and Technology Development Fund of Shanghai Pudong (PKJ2008-Y39); Program of Shanghai Pudong Subject Chief Scientist (PWRd2010-06); Science and Technology Development Fund of Shanghai Pudong (PKJ2011-Y05) Other: None Jill Hayden has received peer-reviewed funding from the Nova Scotia Health Research Foundation (now Research Nova Scotia), the Canadian Institutes of Health Research, Cochrane Strategic Methods Fund and Cochrane Methods Innovation Fund, the QEII Foundation, and the Nova Scotia Health Authority. She previously held a Canadian Chiropractic Research Foundation/Dalhousie University Research Professorship in Epidemiology. Core outcomes reported: Pain (Numerical Rating Scale); function (Roland-Morris Disability Questionnaire) Follow-up time periods available for syntheses: 13 weeks (short); 26 weeks (moderate); 52 weeks (long) Conflicts of interest: The care provider who treated patients in the MDT group has completed first level McKenzie training, however has no involvement with the McKenzie Institute. This trial did not receive either funding from McKenzie Institute or any assistance in writing/analysing the results of this trial. Authors do not have any involvement with the McKenzie Institute. MJH, LOPC and ANG receive funding from International Mechanical Diagnosis and Therapy Research Foundation for the following studies on MDT: (1) Hancock MJ, Maher CG, Mota da Silva T, Clare H, Steffens D (2016). Secondary prevention of a recurrence of low back pain. (2) Hancock MJ, Garcia AN, Costa LdCM, Costa LOP (2014). Identifying patients with back pain who respond best to MDT. MJH was keynote speaker at the 2017 McKenzie conference and his travel costs were paid. Funding source: São Paulo Research Foundation; Coordination for the Improvement of Higher Education Personnel Other: Information modified for author contact We would like to thank Shireen Harbin, Managing Editor of the Cochrane Back and Neck Group, Jordi Pardo Pardo, Managing Editor of the Musculoskeletal Group, Rachel Couban, Trials Search Co-ordinator of the Cochrane Back and Neck Review Group, and Leah Boulos, Evidence Synthesis Coordinator for the Maritime SPOR SUPPORT Unit for their assistance and support conducting literature searches. We would like to thank Cochrane editors and reviewers, including Bruno T Saragiotto, PhD, Universidade Cidade de São Paulo, Brazil and Timothy Carey MD MPH, Research Professor of Medicine, University of North Carolina at Chapel Hill, NC, USA for their comprehensive peer review. We would also like to thank Kathryn Armitstead for her careful review as consumer reviewer. We would like to thank Dr. Samuel Stewart, Assistant Professor, Dalhousie University, for his consultation on our analyses. We would like to acknowledge Jenny Cartwright for her contributions to the development of the protocol, and early study screening and data extraction. We would like to thank Sally Miller, Andrea Smith, and Maria Wilson for their contributions to study screening, data extraction and data preparation, and Selena Glover for study screening, data extraction and assistance making judgements about exercise types. We would like to thank Somayyeh Mohammadi for her assessment of Persian abstracts. Conflicts of interest: Not reported Funding source: Cleveland State University; Korea University and the Basic Science Research Program, National Research Foundation of Korea, Ministry of Education, Science and Technology (2010-0003015) Other: None Conflicts of interest: None to declare Funding source: Swiss National Science Foundation (SNSF) (Project no. 127240) Other: Information modified for author contact Conflicts of interest: None to declare Funding source: Department of the Scientific Research Projects of Uludag University (Project Number = HDP(T)-2014/4) Other: SDs imputed Jenna Ellis: Research funded by grant from the Canadian Institute of Health Research Nova Scotia Health Research Foundation (presently Research NovaScotia). Conflicts of interest: Not reported Funding source: National Science Foundation for Distinguished Young Scholars (Grant: 81101391); Science and Technology Foundation Program of Shanghai University of Sport (Grant: YJSCX201120); Shanghai Natural Science Foundation of Chine (Grant: 11ZR1434900) Other: None Conflicts of interest: None to declare Funding source: National Institutes of Health’s National Center for Complementary and Alternative Medicine grant (no.1 R21 AT001679-01A2) Other: Information modified for author contact; SDs imputed Core outcomes reported: Pain (McGill Pain Score); function (Roland-Morris Disability Questionnaire); HRQoL (36-Item Short Form Survey); Global Perceived Health or Recovery (Global Perceived Health or Recovery (global change in condition (5-point)) Follow-up time periods available for syntheses: 6 weeks (short); 26 weeks (moderate) Conflicts of interest: Dr. Perera received funding from Eli Lily & Co. to do observational research Funding source: National Center for Complementary and Alternative Medicine (Grant R01 AT000985); National Institute on Aging, National Institutes of Health; Pittsburgh Claude D. Pepper Older Americans Independence Center (NIA P30 AG-024827) Other: None Conflicts of interest: Not reported Funding source: National Agenda Project, Korea Research Council of Fundamental Science & Technology (P-09-JC-LU63-C01); Korea University; Basic Science Research Program through the National Research Foundation of Korea, Ministry of Education, Science and Technology (2010-0003015) Other: Sufficient data not available for inclusion in meta-analyses

FundersFunder number
Canadian Institute of Health Research Nova Scotia Health Research Foundation
Cochrane Methods Innovation Fund
International Mechanical Diagnosis and Therapy Research Foundation
National Agenda Project
Nova Scotia Health Authority
Pittsburgh Claude D. Pepper Older Americans Independence Center
Science and Technology Foundation Program of Shanghai University of SportYJSCX201120
Shireen Harbin
National Institutes of Health
National Institute on AgingP30 AG-024827
National Center for Complementary and Alternative Medicine1 R21 AT001679-01A2, R01 AT000985
Cleveland State University
Natural Science Foundation of Shanghai11ZR1434900
QEII Foundation
Shanghai Science and Technology Development FoundationPKJ2008-Y39
Bursa Uludağ Üniversitesi= HDP(T)-2014/4
Nova Scotia Health Research Foundation
Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung127240
National Natural Science Foundation of China81101391
Korea University
Korea Research Council of Fundamental Science and TechnologyP-09-JC-LU63-C01
National Research Foundation of Korea
Ministry of Education, Science and Technology2010-0003015
Program of Shanghai Subject Chief ScientistPKJ2011-Y05, PWRd2010-06

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