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. 2023 Aug 30;8(8):CD009365.
doi: 10.1002/14651858.CD009365.pub2.

Exercise therapy for treatment of acute non-specific low back pain

Wilhelmina IJzelenberg  1 , Teddy Oosterhuis  2 , Jill A Hayden  3 , Bart W Koes  4   5 , Maurits W van Tulder  1   6 , Sidney M Rubinstein  1 , Annemarie de Zoete  1
Affiliations

Exercise therapy for treatment of acute non-specific low back pain

Wilhelmina IJzelenberg et al. Cochrane Database Syst Rev. .

Abstract

Background: Low back pain (LBP) is the leading cause of disability globally. It generates considerable direct costs (healthcare) and indirect costs (lost productivity). The many available treatments for LBP include exercise therapy, which is practised extensively worldwide.

Objectives: To evaluate the benefits and harms of exercise therapy for acute non-specific low back pain in adults compared to sham/placebo treatment or no treatment at short-term, intermediate-term, and long-term follow-up.

Search methods: This is an update of a Cochrane Review first published in 2005. We conducted an updated search for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We screened the reference lists of all included studies and relevant systematic reviews published since 2004.

Selection criteria: We included RCTs that examined the effects of exercise therapy on non-specific LBP lasting six weeks or less in adults. Major outcomes for this review were pain, functional status, and perceived recovery. Minor outcomes were return to work, health-related quality of life, and adverse events. Our main comparisons were exercise therapy versus sham/placebo treatment and exercise therapy versus no treatment.

Data collection and analysis: We used standard Cochrane methods. We evaluated outcomes at short-term follow-up (time point within three months and closest to six weeks after randomisation; main follow-up), intermediate-term follow-up (between nine months and closest to six months), and long-term follow-up (after nine months and closest to 12 months); and we used GRADE to assess the certainty of the evidence for each outcome.

Main results: We included 23 studies (13 from the previous review, 10 new studies) that involved 2674 participants and provided data for 2637 participants. Three small studies are awaiting classification, and four eligible studies are ongoing. Included studies were conducted in Europe (N = 9), the Asia-Pacific region (N = 9), and North America (N = 5); and most took place in a primary care setting (N = 12), secondary care setting (N = 6), or both (N = 1). In most studies, the population was middle-aged and included men and women. We judged 10 studies (43%) at low risk of bias with regard to sequence generation and allocation concealment. Blinding is not feasible in exercise therapy, introducing performance and detection bias. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on pain scores in the short term (mean difference (MD) -0.80, 95% confidence interval (CI) -5.79 to 4.19; 1 study, 299 participants). The absolute difference was 1% less pain (95% CI 4% more to 6% less), and the relative difference was 4% less pain (95% CI 20% more to 28% less). The mean pain score was 20.1 (standard deviation (SD) 21) for the intervention group and 20.9 (SD 23) for the control group. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on functional status scores in the short term (MD 2.00, 95% CI -2.20 to 6.20; 1 study, 299 participants). The absolute difference was 2% worse functional status (95% CI 2% better to 6% worse), and the relative difference was 15% worse (95% CI 17% better to 47% worse). The mean functional status score was 15.3 (SD 19) for the intervention group and 13.3 (SD 18) for the control group. We downgraded the certainty of the evidence for pain and functional status by one level for risk of bias and by two levels for imprecision (only one study with fewer than 400 participants). There is very low-certainty evidence that exercise therapy compared with no treatment has no clinically relevant effect on pain or functional status in the short term (2 studies, 157 participants). We downgraded the certainty of the evidence by two levels for imprecision and by one level for inconsistency. One study associated exercise with small benefits and the other found no differences. The first study was conducted in an occupational healthcare centre, where participants received one exercise therapy session. The other study was conducted in secondary and tertiary care settings, where participants received treatment three times per week for six weeks. We did not pool data from these studies owing to considerable clinical heterogeneity. In two studies, there were no reported adverse events. One study reported adverse events unrelated to exercise therapy. The remaining studies did not report whether any adverse events had occurred. Owing to insufficient reporting of adverse events, we were unable to reach any conclusions on the safety or harms related to exercise therapy.

Authors' conclusions: Exercise therapy compared to sham/placebo treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Exercise therapy compared to no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. We downgraded the certainty of the evidence to very low for inconsistency, risk of bias concerns, and imprecision (few participants).

PubMed Disclaimer

Conflict of interest statement

WI: none TO: none JAH: none BWK: none MT: MT was formerly Co‐ordinating Editor of Cochrane Back and Neck and is now a member of the Editorial board. Editors are required to conduct at least one Cochrane Review to ensure that they are aware of the processes and commitment needed. This involvement does not seem to be a source of conflict of interest for the group. Any editor who is a review author is excluded from editorial decisions on the review in which they are contributors. SMR: none AZ: none

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Funnel plot of comparison 4 (Exercise therapy versus other conservative treatments) for the outcome pain. Note: negative values favour exercise therapy.
5
5
Funnel plot of comparison 4 (Exercise therapy versus other conservative treatments) for the outcome functional status.
1.1
1.1. Analysis
Comparison 1: Exercise therapy versus sham/placebo treatment, Outcome 1: Pain
1.2
1.2. Analysis
Comparison 1: Exercise therapy versus sham/placebo treatment, Outcome 2: Functional status
1.3
1.3. Analysis
Comparison 1: Exercise therapy versus sham/placebo treatment, Outcome 3: Return to work
2.1
2.1. Analysis
Comparison 2: Exercise therapy versus no treatment, Outcome 1: Pain
2.2
2.2. Analysis
Comparison 2: Exercise therapy versus no treatment, Outcome 2: Functional status
2.3
2.3. Analysis
Comparison 2: Exercise therapy versus no treatment, Outcome 3: Return to work
4.1
4.1. Analysis
Comparison 4: Exercise therapy versus other conservative treatment (Tx), Outcome 1: Pain
4.2
4.2. Analysis
Comparison 4: Exercise therapy versus other conservative treatment (Tx), Outcome 2: Functional status
4.3
4.3. Analysis
Comparison 4: Exercise therapy versus other conservative treatment (Tx), Outcome 3: Perceived recovery
4.4
4.4. Analysis
Comparison 4: Exercise therapy versus other conservative treatment (Tx), Outcome 4: Return to work
4.5
4.5. Analysis
Comparison 4: Exercise therapy versus other conservative treatment (Tx), Outcome 5: Return to work
4.6
4.6. Analysis
Comparison 4: Exercise therapy versus other conservative treatment (Tx), Outcome 6: Return to work
5.1
5.1. Analysis
Comparison 5: Exercise therapy versus another exercise therapy, Outcome 1: Pain
5.2
5.2. Analysis
Comparison 5: Exercise therapy versus another exercise therapy, Outcome 2: Functional status
5.3
5.3. Analysis
Comparison 5: Exercise therapy versus another exercise therapy, Outcome 3: Return to work
6.1
6.1. Analysis
Comparison 6: Exercise therapy versus the same therapy plus another intervention, Outcome 1: Pain
6.2
6.2. Analysis
Comparison 6: Exercise therapy versus the same therapy plus another intervention, Outcome 2: Functional status
6.3
6.3. Analysis
Comparison 6: Exercise therapy versus the same therapy plus another intervention, Outcome 3: Health‐related quality of life
7.1
7.1. Analysis
Comparison 7: Exercise therapy plus another intervention (ET + other Tx) versus the other intervention alone (other Tx alone), Outcome 1: Pain
7.2
7.2. Analysis
Comparison 7: Exercise therapy plus another intervention (ET + other Tx) versus the other intervention alone (other Tx alone), Outcome 2: Functional status
7.3
7.3. Analysis
Comparison 7: Exercise therapy plus another intervention (ET + other Tx) versus the other intervention alone (other Tx alone), Outcome 3: Perceived recovery
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD009365

References

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References to studies awaiting assessment

Alt 2020 {published data only}
    1. Alt A, Malcherek N, Geisler S, Thietje R. The sustainable effectiveness to avoid chronification in non-specific, non-chronic back pain. Deutsche Zeitschrift für Sportmedizin 2020;71:97-103.
Lohana 2021 {published data only}
    1. Lohana DK, Ahmad U, Sharif F, Ahmad A, Gilani AA, Atta S. Comparison of Mulligan sustained natural apophyseal glides verses Mckenzie extension exercises on disability and functional outcomes in patients with acute nonspecific low back pain. Rawal Medical Journal 2021;46(2):469-72.
Nechvatal 2021 {published data only}
    1. Nechvátal P, Hitrík T, Kendrová LD, Macej M. Comparison of the effect of the Mc Kenzie method and spiral stabilization in patients with low back pain: a prospective, randomized clinical trial. Journal of Back and Musculoskeletal Rehabilitation 2022;35(3):641-647. - PubMed

References to ongoing studies

Côté‐Picard 2020 {published data only}
    1. Côté-Picard C, Tittley J, Mailloux C, Perreault K, Mercier C, Dionne CE, Roy JS, Massé-Alarie H. Effect of thermal therapy and exercises on acute low back pain: a protocol for a randomized controlled trial. BMC Musculoskeletal Disorders 2020;21:814. - PMC - PubMed
Javadov 2018 {published data only}
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NCT03756519 {published data only}
    1. NCT03756519. The effect of exercise on recent onset low back pain in the emergency department. clinicaltrials.gov/ct2/show/NCT03756519 (first received 28 November 2018).
NCT03827486 {published data only}
    1. NCT03827486. Effectiveness of a program of domiciliary exercises against habitual clinical practice in the recurrence of acute low back pain: randomised controlled trial (LUMBAREX). clinicaltrials.gov/ct2/show/NCT03827486 (first received 1 February 2019).

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References to other published versions of this review

Hayden 2005a
    1. Hayden J, Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No: CD000335. [DOI: 10.1002/14651858.CD000335.pub2] - DOI - PMC - PubMed
Hayden 2005b
    1. Hayden JA, Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Annals of Internal Medicine 2005;142(9):756-75. - PubMed
Hayden 2005c
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IJzelenberg 2011
    1. IJzelenberg W, Rubinstein SM, Hayden J, Koes BW, Tulder MW. Exercise therapy for acute non-specific low-back pain. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No: CD009365. [DOI: 10.1002/14651858.CD009365] - DOI - PMC - PubMed
Van Tulder 2000a
    1. Van Tulder MW, Malmivaara A, Esmail R, Koes BW. Exercise therapy for low-back pain. Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No: CD000335. [DOI: 10.1002/14651858.CD000335] - DOI - PubMed
Van Tulder 2000b
    1. Van Tulder MW, Malmivaara A, Esmail R, Koes BW. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000;25(21):2784-96. - PubMed

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