Meta-Analysis: Exercise Therapy for Nonspecific Low Back Pain

3 May 2005 | Volume 142 Issue 9 | Pages 765-775

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.

Editors' Notes Context Many experts recommend exercise therapy for nonspecific low back pain. Contribution This meta-analysis summarizes data from 61 randomized, controlled trials that compared exercise therapy with placebo, no treatment, conservative management, or another exercise group. Exercise therapy decreased pain and improved physical function by modest amounts in adults with chronic low back pain. In adults with acute low back pain, exercise therapy, conservative management, and no treatment had similar effects on pain. Cautions Trials used various measures to assess pain and function, and many were small and of low quality. –The Editors

 

Author and Article 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{at}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.

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