Article

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

Institute for Work & Health and University of Toronto, Toronto, Ontario, Canada.
Annals of internal medicine (Impact Factor: 16.1). 05/2005; 142(9):776-85. DOI: 10.7326/0003-4819-142-9-200505030-00014
Source: PubMed

ABSTRACT Exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain.
To identify particular exercise intervention characteristics that decrease pain and improve function in adults with nonspecific chronic low back pain.
MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004 and citation searches and bibliographic reviews of previous systematic reviews.
Randomized, controlled trials evaluating exercise therapy in populations with chronic (>12 weeks duration) low back pain.
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.
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 of the literature, including low-quality studies with heterogeneous outcome measures and inconsistent and poor reporting; publication bias.
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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    • "Stretching, spine stabilization, and proprioception exercise are generally recommended with or without manual therapy or massage. According to a recent Cochrane review [8], exercise therapy has evidence of being effective in the treatment of chronic nonspecific low back pain in the short and long term, especially individual exercise programs carried out "
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    ABSTRACT: Objective. Comparing global postural reeducation (GPR) to a standard physiotherapy treatment (PT) based on active exercises, stretching, and massaging for improving pain and function in chronic low back pain (CLBP) patients. Design. Prospective controlled study. Setting. Outpatient rehabilitation facility. Participants. Adult patients with diagnosis of nonspecific, chronic (>6 months) low back pain. Interventions. Both treatments consisted of 15 sessions of one hour each, twice a week including patient education. Measures. Roland Morris Disability Questionnaire to evaluate disability, and Numeric Analog Scale for pain. A score change >30% was considered clinically significant. Past treatments, use of medications, smoking habits, height, weight, profession, and physical activity were also recorded on baseline, on discharge, and 1 year after discharge (resp., T0, T1, and T2). Results. At T0 103 patients with cLBP (51 cases and 52 controls) were recruited. The treatment (T1) has been completed by 79 (T1) of which 60 then carried out the 1-year follow-up (T2). Both GPR and PT at T1 were associated with a significant statistical and clinical improvement in pain and function, compared to T0. At T2, only pain in GPR still registered a statistically significant improvement.
    The Scientific World Journal 08/2014; 2015. DOI:10.1155/2015/271436 · 1.73 Impact Factor
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    • "The current evidence for management of non-specific chronic low back pain (NSCLBP) reveals that interventions such as manual therapy, exercise, acupuncture , spinal injections and cognitive behavioural therapy are not superior to each other and have a limited long-term impact on the disorder (Assendelft et al., 2004; Furlan et al., 2005; Hayden et al., 2005; Ostelo et al., 2005; Staal et al., 2008). Possible reasons for the failure of current clinical practice to effectively manage NSCLBP are proposed to lie in two main domains: (1) The failure to adequately deal with NSCLBP within a multidimensional biopsychosocial framework (Borkan et al., 2002). "
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    ABSTRACT: Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another. Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59). Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points. Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
    European journal of pain (London, England) 07/2013; 17(6). DOI:10.1002/j.1532-2149.2012.00252.x · 3.22 Impact Factor
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    • "The current evidence for management of non-specific chronic low back pain (NSCLBP) reveals that interventions such as manual therapy, exercise, acupuncture , spinal injections and cognitive behavioural therapy are not superior to each other and have a limited long-term impact on the disorder (Assendelft et al., 2004; Furlan et al., 2005; Hayden et al., 2005; Ostelo et al., 2005; Staal et al., 2008). Possible reasons for the failure of current clinical practice to effectively manage NSCLBP are proposed to lie in two main domains: (1) The failure to adequately deal with NSCLBP within a multidimensional biopsychosocial framework (Borkan et al., 2002). "
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