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Exercise therapy for chronic nonspecific low-back pain

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Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. During the past 5 years, many additional trials have been published on chronic low back pain. This articles aims to give an overview on the effectiveness of exercise therapy in patients with low back pain.

For this overview, existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria, and the search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. Studies were included if they fulfilled the following criteria: (1) randomised controlled trials,(2) adult (≥18 years) population with chronic (≥12 weeks) nonspecific low back pain and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery or return to work).

Two reviewers independently selected studies and extracted data on study characteristics, risk of bias and outcomes at short-term, intermediate and long-term follow-up. The GRADE approach (GRADE, Grading of Recommendations Assessment, Development and Evaluation) was used to determine the quality of evidence.

In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function.

The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

Section snippets

Exercises for prevention of LBP

Nine reviews have been published that evaluated different types of physical exercise interventions in the prevention of LBP. The reviews are essentially based on the same studies, although the most recent reviews also included some recent trials. Eight reviews concluded that there is some evidence of effect of exercise, but effect sizes were reported to be small to moderate [7], [8], [9], [10], [11], [12], [13], [14]. One review concluded that there was contradictory evidence that various

Acute LBP

The Cochrane review by Hayden et al [16]. included 11 trials (1192 subjects) on exercise therapy for acute LBP. None of the randomised controlled trials (RCTs) found exercise therapy in health-care settings to be effective for acute LBP. The meta-analysis showed no difference in short-term pain relief between exercise therapy and no treatment (three trials), with an effect of−0.59 points on a 100-point scale (95% confidence interval (CI),−12.69–11.51), and between exercise and other

Chronic LBP

Since the publication of the Cochrane review by Hayden et al. in 2005 [16], many additional trials have been published on exercise therapy for chronic LBP. In this section, we describe the results of all randomised trials on exercise therapy for chronic LBP. We included all trials of the Cochrane review and updated the search in MEDLINE, EMBASE, CINAHL, CENTRAL and PEDro up to 22 December 2008. The search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. The following

The effectiveness of the different treatment strategies

No significant treatment effects of exercise therapy compared to no treatment/waiting list controls were found on pain intensity and disability. Compared to usual care, pain intensity and disability were significantly reduced by exercise therapy at short-term follow-up. Adverse events were not reported in any of the included studies.

The Cochrane review, published in 2005, on the effectiveness of exercise for LBP found evidence for the effectiveness on pain and function in chronic patients [16].

Implications for practice

Exercise therapy seems to be effective for the prevention of LBP, but only few recent trials are conducted. This therapy is not effective for acute LBP, whereas it is effective for chronic LBP; however, there is no evidence that any type of exercise is clearly more effective than others. Subgroups of patients with LBP might respond differently to various types of exercise therapy, but it is still unclear which patients benefit most from what type of exercises. Adherence to exercise prescription

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    1

    EMGO-Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, room D518, 1081 BT, Amsterdam, The Netherlands Tel: +31 20 4449813; Fax: +31 20 4446775. [email protected].

    2

    Department of Health Sciences & EMGO Institute for Health and Care Research, VU University Amsterdam, De Boelelaan 1085, U 452, 1081 HV Amsterdam. Tel: +31 20 5986587. [email protected]

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