Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2024 Oct 23;22(1):484.
doi: 10.1186/s12916-024-03679-3.

The impact of contextual effects in exercise therapy for low back pain: a systematic review and meta-analysis

Aaltje de Roode  1 , Martijn W Heymans  2 , Wim van Lankveld  3 , J Bart Staal  4   5
Affiliations
Meta-Analysis

The impact of contextual effects in exercise therapy for low back pain: a systematic review and meta-analysis

Aaltje de Roode et al. BMC Med. .

Abstract

Background: Low back pain is the leading cause of global disability for which exercise therapy is a widely recommended treatment. Research indicates that contextual factors may also influence treatment outcomes in low back pain. Examples include the patient-therapist relationship and other treatment-related circumstances that affect patient expectations. By focusing on the specific treatment effect, clinical trials often ignore the effect of contextual factors, thereby contributing to the so-called efficacy paradox. This means that treatment effects observed in clinical practice are often greater than those reported in clinical trials. This systematic review aims to investigate the proportion of improvement in pain and disability that can be attributed to contextual effects in the outcome of exercise therapy for patients with low back pain.

Methods: A meta-analysis was conducted. PubMed, Embase, and the Cochrane database were searched for eligible articles reporting randomized controlled trials that compared exercise therapy to placebo interventions. Risk of bias was assessed with the Revised Cochrane Risk of Bias Tool. Outcomes of interest were pain and disability. Meta-analysis was carried out to calculate the proportion attributable to contextual effects for both pain and disability. The body of evidence was assessed using the GRADE methodology.

Results: Eight studies met the inclusion criteria and were included in the meta-analysis. Five studies were rated as having a moderate risk of bias and two studies had a low risk of bias. Proportion attributable to contextual effects was 0.60 (95% CI 0.40-0.89) for pain and 0.69 (95% CI 0.48-1.00) for disability. Certainty of the evidence as assessed with the GRADE methodology was low.

Conclusions: A large extent of pain and disability improvement after exercise therapy in low back pain is attributable to contextual effects although this conclusion is based on low certainty evidence.

Keywords: Contextual factors; Exercise; Low back pain; Placebo.

PubMed Disclaimer

Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Flowscheme of included studies. PRISMA 2020 flow diagram
Fig. 2
Fig. 2
Risk of bias as assessed with the revised Cochrane Risk of Bias tool
Fig. 3
Fig. 3
A Proportion attributable to the contextual effect for pain. B Proportion attributable to the contextual effect for disability
See this image and copyright information in PMC

References

    1. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(6):968–74. - DOI - PubMed
    1. Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust. 2017;206(6):268–73. - DOI - PubMed
    1. Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin C-WC, Chenot J-F, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur spine J. 2018;27(11):2791–803. - PubMed
    1. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane database Syst Rev. 2021;9(9):CD009790. - PMC - PubMed
    1. Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142(9):765–75. - DOI - PubMed

LinkOut - more resources