Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials

Jill A Hayden¹, Maria N Wilson², Samuel Stewart², Jennifer L Cartwright², Andrea O Smith², Richard D Riley³, Maurits van Tulder⁴, Tom Bendix⁵, Francesca Cecchi⁶, Leonardo O P Costa⁷, Ninna Dufour⁸, Manuela L Ferreira⁹, Nadine E Foster¹⁰, Maruti R Gudavalli¹¹, Jan Hartvigsen¹², Pieter Helmhout¹³, Jan Kool¹⁴, George A Koumantakis¹⁵, Francisco M Kovacs¹⁶, Tiina Kuukkanen¹⁷, Audrey Long¹⁸, Luciana G Macedo¹⁹, Luciana A C Machado²⁰, Chris G Maher²¹, Wolf Mehling²², Giovanni Morone²³, Tom Peterson²⁴, Eva Rasmussen-Barr²⁵, Cormac G Ryan²⁶, Tuulikki Sjögren²⁷, Rob Smeets²⁸, J Bart Staal²⁹, Monica Unsgaard-Tøndel³⁰, Henry Wajswelner³¹, Ella W Yeung³²; Chronic Low Back Pain IPD Meta-Analysis Group

Affiliations

¹ Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada jhayden@dal.ca.
² Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
³ Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
⁴ Department of Health Sciences, VU University, Amsterdam, The Netherlands.
⁵ Center for Rheumatology and Spine Diseases, Rigshospitalet, and University of Copenhagen, Copenhagen, Denmark.
⁶ Fondazione Don Carlo Gnocchi, Scientific Institute, Florence, Italy.
⁷ Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil.
⁸ Department of Rheumatology, A2 Rheumatology and Sports Medicine, Hillerød, Denmark.
⁹ Institute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia.
¹⁰ Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, UK.
¹¹ College of Chiropractic Medicine, Keiser University, West Palm Beach, Florida, USA.
¹² Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.
¹³ Department of Training Medicine and Training Physiology, Personnel Command, Royal Netherlands Army, Utrecht, The Netherlands.
¹⁴ Research Department and Department of Rheumatology, Rehabilitation Centre Valens, Valens, Switzerland.
¹⁵ Centre for Rehabilitation Science, University of Manchester, Manchester Royal Infirmary, Manchester, UK.
¹⁶ Unidad de la Espalda Kovacs, Hospital Universitario HLA-Moncloa, Red Española de Investigadores en Dolencias de la Espalda, Madrid, Spain.
¹⁷ School of Health and Social Studies, JAMK University of Applied Sciences, Jyväskylä, Finland.
¹⁸ Bonavista Physical Therapy, Calgary, Alberta, Canada.
¹⁹ School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.
²⁰ University Hospital, UFMG-Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
²¹ Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
²² Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA.
²³ Clinical Laboratory of Experimental Neurorehabilitation, Santa Lucia Foundation, Rome, Italy.
²⁴ Back Center Copenhagen, Copenhagen, Denmark.
²⁵ Department of Neurobiology Care Sciences, and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden.
²⁶ School of Health and Life Sciences, Teesside University, Middlesbrough, UK.
²⁷ Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland.
²⁸ Department of Rehabilitation Medicine, Research School of CAPHRI, Maastricht University, Maastricht, The Netherlands.
²⁹ Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
³⁰ Department of Neuromedicine and Movement Science, and Department of Public Health and Nursing, NTNU, Trondheim, Norway.
³¹ Discipline of Physiotherapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.
³² Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Kowloon, Hong Kong.

PMID: 31780447
DOI: 10.1136/bjsports-2019-101205

Free article

Review

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials

Jill A Hayden et al. Br J Sports Med. 2020 Nov.

Free article

. 2020 Nov;54(21):1277-1278.

doi: 10.1136/bjsports-2019-101205. Epub 2019 Nov 28.

Authors

Affiliations

¹ Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada jhayden@dal.ca.
² Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
³ Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
⁴ Department of Health Sciences, VU University, Amsterdam, The Netherlands.
⁵ Center for Rheumatology and Spine Diseases, Rigshospitalet, and University of Copenhagen, Copenhagen, Denmark.
⁶ Fondazione Don Carlo Gnocchi, Scientific Institute, Florence, Italy.
⁷ Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil.
⁸ Department of Rheumatology, A2 Rheumatology and Sports Medicine, Hillerød, Denmark.
⁹ Institute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia.
¹⁰ Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, UK.
¹¹ College of Chiropractic Medicine, Keiser University, West Palm Beach, Florida, USA.
¹² Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.
¹³ Department of Training Medicine and Training Physiology, Personnel Command, Royal Netherlands Army, Utrecht, The Netherlands.
¹⁴ Research Department and Department of Rheumatology, Rehabilitation Centre Valens, Valens, Switzerland.
¹⁵ Centre for Rehabilitation Science, University of Manchester, Manchester Royal Infirmary, Manchester, UK.
¹⁶ Unidad de la Espalda Kovacs, Hospital Universitario HLA-Moncloa, Red Española de Investigadores en Dolencias de la Espalda, Madrid, Spain.
¹⁷ School of Health and Social Studies, JAMK University of Applied Sciences, Jyväskylä, Finland.
¹⁸ Bonavista Physical Therapy, Calgary, Alberta, Canada.
¹⁹ School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.
²⁰ University Hospital, UFMG-Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
²¹ Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
²² Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA.
²³ Clinical Laboratory of Experimental Neurorehabilitation, Santa Lucia Foundation, Rome, Italy.
²⁴ Back Center Copenhagen, Copenhagen, Denmark.
²⁵ Department of Neurobiology Care Sciences, and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden.
²⁶ School of Health and Life Sciences, Teesside University, Middlesbrough, UK.
²⁷ Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland.
²⁸ Department of Rehabilitation Medicine, Research School of CAPHRI, Maastricht University, Maastricht, The Netherlands.
²⁹ Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
³⁰ Department of Neuromedicine and Movement Science, and Department of Public Health and Nursing, NTNU, Trondheim, Norway.
³¹ Discipline of Physiotherapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.
³² Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Kowloon, Hong Kong.

PMID: 31780447
DOI: 10.1136/bjsports-2019-101205

Abstract

Background: Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise.

Methods: In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers.

Results: We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics.

Conclusions: This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

Keywords: exercise rehabilitation; intervention effectiveness; lower back; meta-analysis.

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Conflict of interest statement

Competing interests: MvT and the members of the Chronic LBP IPD Meta-analysis Group are investigators of the individual trials included in the IPD data set.

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Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials

Affiliations

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials

Authors

Affiliations

Abstract

Conflict of interest statement

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical