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Exercise therapy for treatment of non-specific low back pain

(Review)

Hayden J, van Tulder MW, Malmivaara A, Koes BW

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2011, Issue 2

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Exercise therapy for treatment of non-specific low back pain (Review)

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

9DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Chronic populations, Outcome 1 Function measure (/100): Earliest follow-up. . . . 61Analysis 1.2. Comparison 1 Chronic populations, Outcome 2 Function measure (/100): Short-term follow-up (~6 weeks

post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Analysis 1.3. Comparison 1 Chronic populations, Outcome 3 Function measure (/100): Intermediate follow-up (~6

months post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Analysis 1.4. Comparison 1 Chronic populations, Outcome 4 Function measure (/100): Long-term follow-up (~12 months

post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Analysis 1.5. Comparison 1 Chronic populations, Outcome 5 Pain measure (/100): Earliest follow-up. . . . . . 66Analysis 1.6. Comparison 1 Chronic populations, Outcome 6 Pain measure (/100): Short-term follow-up (~6 weeks post-

randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Analysis 1.7. Comparison 1 Chronic populations, Outcome 7 Pain measure (/100): Intermediate follow-up (~6 months

post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Analysis 1.8. Comparison 1 Chronic populations, Outcome 8 Pain measure (/100): Long-term follow-up (~12 months

post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Analysis 2.1. Comparison 2 Subacute populations, Outcome 1 Function measure (/100): Earliest follow-up. . . . 71Analysis 2.2. Comparison 2 Subacute populations, Outcome 2 Function measure (/100): Short-term follow-up (~6 weeks

post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Analysis 2.3. Comparison 2 Subacute populations, Outcome 3 Function measure (/100): Intermediate follow-up (~6

months post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Analysis 2.4. Comparison 2 Subacute populations, Outcome 4 Function measure (/100): Long-term follow-up (~12

months post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Analysis 2.5. Comparison 2 Subacute populations, Outcome 5 Pain measure (/100): Earliest follow-up. . . . . . 75Analysis 2.6. Comparison 2 Subacute populations, Outcome 6 Pain measure (/100): Short-term follow-up (~6 weeks post-

randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Analysis 2.7. Comparison 2 Subacute populations, Outcome 7 Pain measure (/100): Intermediate follow-up (~6 months

post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Analysis 2.8. Comparison 2 Subacute populations, Outcome 8 Pain measure (/100): Long-term follow-up (~12 months

post-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Analysis 3.1. Comparison 3 Acute populations, Outcome 1 Pain measure (/100): Earliest follow-up. . . . . . . 79Analysis 3.2. Comparison 3 Acute populations, Outcome 2 Pain measure (/100): Short-term follow-up (~6 weeks post-

randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Analysis 3.3. Comparison 3 Acute populations, Outcome 3 Pain measure (/100): Intermediate follow-up (~6 months post-

randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Analysis 3.4. Comparison 3 Acute populations, Outcome 4 Pain measure (/100): Long-term follow-up (~12 months post-

randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Analysis 3.5. Comparison 3 Acute populations, Outcome 5 Function measure (/100): Earliest follow-up. . . . . 83

iExercise therapy for treatment of non-specific low back pain (Review)


Analysis 3.6. Comparison 3 Acute populations, Outcome 6 Function measure (/100): Short-term follow-up (~6 weekspost-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Analysis 3.7. Comparison 3 Acute populations, Outcome 7 Function measure (/100): Intermediate follow-up (~6 monthspost-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Analysis 3.8. Comparison 3 Acute populations, Outcome 8 Function measure (/100): Long-term follow-up (~12 monthspost-randomization). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Analysis 4.1. Comparison 4 POPULATION SOURCE: Chronic populations (Exploratory analysis), Outcome 1 Functionmeasure (/100); Earliest follow-up: Indirect comparisons. . . . . . . . . . . . . . . . . . . . 87

Analysis 4.2. Comparison 4 POPULATION SOURCE: Chronic populations (Exploratory analysis), Outcome 2 Painmeasure (/100); Earliest follow-up: Indirect comparisons. . . . . . . . . . . . . . . . . . . . 88

92ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iiExercise therapy for treatment of non-specific low back pain (Review)


[Intervention Review]


Jill Hayden1, Maurits W van Tulder2, Antti Malmivaara3, Bart W Koes4

1Dept. of Community Health & Epidemiology, Dalhousie University, Halifax, Canada. 2Department of Health Sciences, Facultyof Earth and Life Sciences, VU University, Amsterdam, Netherlands. 3Centre for Health Economics CHESS, National Institute forHealth and Welfare (THL), Helsinki, Finland. 4Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands

Contact address: Jill Hayden, Dept. of Community Health & Epidemiology, Dalhousie University, 5790 University Avenue, Room222, Halifax, NS, B3H 1V7, Canada. [email protected].

Editorial group: Cochrane Back Group.Publication status and date: Edited (no change to conclusions), published in Issue 2, 2011.Review content assessed as up-to-date: 30 September 2004.

Citation: Hayden J, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. CochraneDatabase of Systematic Reviews 2005, Issue 3. Art. No.: CD000335. DOI: 10.1002/14651858.CD000335.pub2.


A B S T R A C T

Background

Exercise therapy is widely used as an intervention in low-back pain.

Objectives

To evaluate the effectiveness of exercise therapy in adult non-specific acute, subacute and chronic low-back pain versus no treatmentand other conservative treatments.

Search methods

The Cochrane Central Register of Controlled Trials (Issue 3, 2004), MEDLINE, EMBASE, PsychInfo, CINAHL databases to October2004; citation searches and bibliographic reviews of previous systematic reviews.

Selection criteria

Randomized controlled trials evaluating exercise therapy for adult non-specific low-back pain and measuring pain, function, return-to-work/absenteeism, and/or global improvement outcomes.

Data collection and analysis

Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short, intermediate,and long-term follow-up.

Main results

Sixty-one randomized controlled trials (6390 participants) met inclusion criteria: acute (11), subacute (6) and chronic (43) low-backpain (1 unclear). Evidence was found of effectiveness in chronic populations relative to comparisons at all follow-up periods; pooledmean improvement was 7.3 points (95% CI, 3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) atearliest follow-up. In studies investigating patients (i.e. presenting to healthcare providers) mean improvement was 13.3 points (5.5 to21.1) for pain, 6.9 (2.2 to 11.7) for function, representing significantly greater improvement over studies where participants includedthose recruited from a general population (e.g. with advertisements). There is some evidence of effectiveness of graded-activity exerciseprogram in subacute low-back pain in occupational settings, though the evidence for other types of exercise therapy in other populations

1Exercise therapy for treatment of non-specific low back pain (Review)


mailto:[email protected]

is inconsistent. There was evidence of equal effectiveness relative to comparisons in acute populations [pain: 0.03 points (95% CI, -1.3 to 1.4)].

Limitations: This review largely reflects limitations of the literature, including low quality studies with heterogeneous outcome measures,inconsistent and poor reporting, and possibility of publication bias.

Authors’ conclusions

Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain,particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improvesabsenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective aseither no treatment or other conservative treatments.

P L A I N L A N G U A G E S U M M A R Y


Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain,particularly in populations visiting a healthcare provider. In adults with subacute low-back pain there is some evidence that a gradedactivity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

B A C K G R O U N D

Low-back pain is one of the leading causes of disability. Exercisetherapy is a management strategy that is widely used in low-backpain. It encompasses a heterogeneous group of interventions rang-ing from general physical fitness or aerobic exercise, to musclestrengthening, various types of flexibility and stretching exercises.

In 2000, van Tulder et al. published a Cochrane review of the lit-erature assessing the effectiveness of exercise therapy for low-backpain for pain intensity, functional status, overall improvement andreturn to work (van Tulder 2000b). It included 39 randomizedcontrolled trials of all types of exercise therapy for individuals withacute and chronic non-specific low-back pain. They synthesizedthe evidence using a levels-of-evidence approach due to the het-erogeneity and insufficiency of the literature, concluding that theevidence did not support effectiveness of exercises for acute low-back pain, but it may be helpful for chronic low-back pain. Sincethe completion of their systematic review, a substantial number ofnew trials have been published. Recent reviews on related topicshave been restricted by population (Hilde 1998, Liddle 2004, Kool2004) or type of exercise therapy (Ernst 2003) and have used onlyqualitative methods of synthesis (Hilde 1998, Liddle 2004, Ernst2003, Abenhaim 2000). Recent clinical guidelines that includedexercise therapy for low-back pain used quantitative methods tosynthesize results of randomized controlled trials, controlled trialsand observational studies (Tugwell 2001), however only 12 studies

overlap with the 61 trials included in this review. There is a needfor an updated review on this topic. Cautious use of quantitativemeta-analysis for direct and indirect comparisons, employed inappropriate subgroups will be informative to synthesize this liter-ature.

O B J E C T I V E S

The primary objective of this systematic review was to assess theeffectiveness of exercise therapy for reducing pain and disability inadults with non-specific acute, subacute and chronic low-back paincompared to no treatment (including placebo and sham treatment)and other conservative treatments.

M E T H O D S

Criteria for considering studies for this review

Types of studies

We included published reports of completed randomized con-trolled trials.



Types of participants

We included studies involving adult participants with acute (lessthan six weeks), subacute (six to 12 weeks), or chronic (longerthan 12 weeks) non-specific low-back pain. We excluded studiesthat involved individuals with low-back pain caused by specificpathologies or conditions.

Types of interventions

Exercise therapy was defined as “a series of specific movements withthe aim of training or developing the body by a routine practice oras physical training to promote good physical health” (Abenhaim2000). We included studies that compared exercise therapy to a)no treatment or placebo treatment, b) other conservative therapy,or c) another exercise group.

Types of outcome measures

Outcomes of interest were self-reported pain intensity, condition-specific physical functioning and global improvement, and returnto work/absenteeism. Outcome assessment data were abstractedfor three time periods: short-term (post-treatment assessment clos-est to six weeks after randomization, not longer than 12 weeks),intermediate (six months), and long-term follow-up (12 monthsor more).

Search methods for identification of studies

We searched the Cochrane Central Register of Controlled Trials(Issue 3, 2004) and these electronic databases: MEDLINE andEMBASE (up to October 2004), PsychInfo and CINAHL (1999to October 2004). We conducted citation searches, screened citedreferences of exercise reviews and contacted content experts foradditional trials. We did not restrict the searches or inclusion cri-teria to any specific language (see Appendix 1; Appendix 2 for fullstrategy).

Data collection and analysis

Study selection and data abstraction

A standard protocol was followed for study selection and data ab-straction (van Tulder 2003). This included two reviewers’ inde-pendent assessment of study eligibility, data extraction, assessmentof trial quality and clinical relevance. Consensus and, if necessary,a third reviewer were used to resolve disagreements. We extractedpopulation characteristics (patient population source or setting,study inclusion criteria, duration of low-back pain episode, andage of patients), intervention characteristics (description and types

of exercise therapy, duration and number of treatment sessions, in-tervention delivery type, and co-interventions) outcome data, andoverall conclusions about the effectiveness of the exercises ontopre-tested standardized forms. Assessment of quality included: ap-propriate randomization, adequate concealment of treatment al-location, adequacy of follow-up, and outcome assessment blind-ing (Jadad 1996). High quality studies were defined as those inwhich all of these key quality criteria were met. Clinical relevanceof each trial was assessed with four items: participants described indetail to assess clinical comparability, interventions and treatmentsettings adequately described to allow repetition, clinically rele-vant outcomes measured and reported, and are likely treatmentbenefits worth potential harms. Reviewers were not blinded to au-thors, institution or journal of publication due to feasibility andbecause they were familiar with most of the literature. Authorsof published trials were contacted to clarify or provide additionalinformation if the study provided insufficient information.

Analysis

We discussed the analyses of study results with clinical contentexperts. We synthesized the earliest outcomes provided for acute,subacute and chronic low-back pain, comparing exercise to notreatment and to other conservative treatment, and overall forshort, intermediate and long-term follow-up periods. Due to im-portant gaps in the reporting of return-to-work/absenteeism andglobal assessment, quantitative analyses were only possible for painand functioning outcomes. In the low-back pain literature, severaloutcome measures are used to assess the constructs of pain intensity(for example, 10 mm or 100 mm visual analogue scales [VAS], or 0to 10 numerical rating scale [NRS]) (see recent review by Von Ko-rff et al (von Korff 2000)) and condition-specific functioning (forexample, the 24-point Roland Morris Disability Questionnaire,or the Oswestry Disability Index scored out of 100) (see recentreview by Kopec (Kopec 2000)). There is moderate to high corre-lation between the different measures of the two constructs. In thisreview, individual trial outcomes for pain and functioning were re-scaled to 0 to 100 points [for example a VAS pain score (standarddeviation) of 5.1 (2.3) out of 10 was re-scaled to 51 (23) out of100], where positive mean effect sizes indicated improvement (i.e.decreased pain, and decreased functional limitations). Re-scalingis common (Kopec 2000) and facilitates comparison and inter-pretability of the syntheses. On the basis of current literature onminimal clinically important differences, we considered that a 20-point (/100) improvement in pain (Salaffi 2004) and a 10-point (/100) improvement in functioning outcomes (Bombardier 2001)were clinically important. Differences were considered statisticallysignificant at the five percent level. The adequacy of sample sizeto detect these differences in each trial was assessed assuming apower of 90%.To be consistent with the previous review and to allow more com-plete use of available data, we used both a qualitative rating sys-



tem and quantitative meta-analyses. The latter were conducted bypooling weighted mean differences with random effects modelsand data from at least three studies (DerSimonian 1986). Exer-cise treatment groups from included trials were included in thesyntheses if they had an independent no treatment or other con-servative treatment comparison group. This requirement appro-priately meant studies with no comparison group (i.e. trials thatcontrast multiple exercise therapy groups only) were not includedand comparison groups were not “double counted” in the meta-analyses. This latter criteria is necessary to avoid correlation in ef-fect sizes resulting from the use of repeated comparison data. Weextracted data on means or median follow-up outcomes for studygroups. To maximize the available data, missing variance scoreswere imputed using the mean variance from studies with similarduration. Sensitivity analyses were conducted to assess the impactof excluding studies reporting median values and excluding stud-ies that did not adequately present variance scores. Statistical het-erogeneity was assessed using I2 statistics and confidence intervals(Higgins 2002). Publication bias was evaluated with Egger’s testand funnel plots (Egger 1997).Qualitative assessment of results was based on primary outcomemeasures and considered the methodological quality and the re-viewers’ overall conclusions for each exercise therapy group. Exer-cise therapy groups were included in the qualitative synthesis if thetrial included a no treatment or other conservative treatment com-parison group. Two reviewers independently rated the findings foreach exercise therapy group. Studies were considered to be pro-viding evidence of effectiveness if statistically significant improve-ment was observed in at least one of the key outcomes in favourof the exercise group and clinically important improvement wasobserved within or between groups. Studies were considered tobe providing evidence that the exercise therapy was ineffective ifthere was statistically significant improvement of the comparisongroup and no clinically important improvement within the exer-cise group. We rated studies neutral if no statistically and clinicallysignificant results were observed and unclear if insufficient datawere presented. A consensus process was used to examine patternsin trial results. Levels of evidence, as recommended by the BackGroup (van Tulder 2003), were used:1. Strong evidence - consistent findings* in multiple high qualitytrials2. Moderate evidence - consistent findings in multiple low qualitytrials and/or one high quality trial3. Limited evidence - one low quality trial4. Conflicting evidence - inconsistent findings in multiple trials.5. No evidence - no randomized trials available.

*Consistent findings were defined as 75% or more trials (66% insensitivity analysis) showing results in the same direction.Further analyses explored heterogeneity due to study-level vari-ables, such as population source and study quality. We character-ized the population sources as healthcare (primary, secondary ortertiary care centres), occupational (patients presenting to occu-pational healthcare facilities or personnel in compensatory situa-tions), or from a general or mixed population (e.g. including in-dividuals recruited by newspaper advertisements) to differentiatethe studies with patients in typical treatment settings (healthcareand occupational) from those including individuals with low-backpain who may not normally present for treatment. Outcomes forsubgroups of studies conducted in these populations were com-pared (Song 2003). The impact of study quality on effect sizes wasassessed using subgroup analysis.SAS for Windows Version 8 (for descriptive), STATA 8 (for pub-lication bias), and Review Manager 4.2 packages were used foranalyses.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excludedstudies.Additional Figure 1 shows details of included and excluded stud-ies. Additional Table 1 contains the descriptive summary and char-acteristics of the 61 studies included (Alexandre 2001; Aure 2003;Buswell 1982; Bendix_a 2000; Bendix_b 1995; Bronfort 1996;Bentsen 1997; Cherkin 1998; Chok 1999; Calmels 2004; Davies1979; Deyo 1990; Delitto 1993; Dalichau 2000; Descarreaux2002; Elnaggar 1991; Farrell 1982; Faas 1993; Frost 1995; Frost2004; Gilbert 1985; Gur 2003; Galantino 2004; Hansen 1993;Hemmila 1997; Hides 1996; Hildebrandt 2000; Johanssen 1995;Jousset 2004; Kendall 1968; Kankaanpaa 1999; Kuukkanen 2000;Lidström 1970; Lindstrom 1992; Ljunggren 1997; Lie 1999;Manniche 1988; Malmivaara 1995; Mannion 1999; Moffett1999; Moseley 2002; Niemisto 2003; Preyde 2000; Petersen 2002;Risch 1993; Rasmussen-Barr 2003; Rittweger 2002; Stankovic1990; Seferlis 1998; Soukup 1999; Storheim 2003; Staal 2004;Turner 1990; Torstensen 1998; Tritilanunt 2001; Underwood1998; Waterworth 1985; Yeung 2003; Yelland 2004; Yozbatiran2004; Zylbergold 1981). A complete description of these studiesis presented in the Table of Included Studies.



Figure 1.



The pain and function outcomes for each trial are presented inAppendix Table 2 (available at www.annals.org). The VAS scale(/100) was the most common outcome measure used to assesspain across studies (22 studies), and 83% of studies reporting painused one of: VAS (/100), VAS (/10), NRS (/100) or NRS (/10).Other pain outcome measures included the McGill pain question-naire (four studies), a five- or nine-point Likert pain scale, theAberdeen pain scale, and the West Haven Yale questionnaire (onestudy each). The most common functional limitation outcomemeasures, employed in 59% of trials, were the Oswestry disabilityindex (15 studies) and the Roland Morris disability questionnaire(12 studies). Other functional measures included: VAS functionscale (four studies), activities of daily living scale (three studies),sickness impact profile (two studies), Quebec disability index (twostudies), Manniche’s low-back rating scale (two studies), and fiveadditional scales that were each used in single trials. The meanfollow-up times (95% confidence interval (95% CI)) for each ofthe short, intermediate, and long-term follow-up periods were 6.3weeks (95% CI: 5.3 to 7.3), 21.0 weeks (95% CI: 18.4 to 23.6),and 53.6 weeks (95% CI: 48.7 to 58.6), respectively.

Risk of bias in included studies

In the original review, which assessed ten quality items, includingthe four key items investigated in the current review, the reviewersdisagreed on 122 of the 351 quality assessment scores (35%).Disagreements were resolved by consensus in most cases, and athird reviewer only had to make a final decision twice. In theupdate, the reviewers disagreed on 19 of the 124 key item scores(15%), resulting in a Kappa score of 0.76 (95% CI: 0.67 to 0.86),indicating high agreement. For the update, disagreements wereresolved by consensus in all cases except two, when a third reviewerwas needed to reach a decision.Only eight studies scored ’positive’ on all the four key valid-ity criteria (Deyo 1990; Frost 1995; Frost 2004; Hansen 1993;Lindstrom 1992; Malmivaara 1995; Manniche 1988; Mannion1999; Torstensen 1998). Based on information in the publishedreport, 37 of the key quality items assessed (15%) were initiallyrated as unclear (the most common item with insufficient descrip-tion was ’adequate concealment of treatment allocation’). Con-tacting the authors of the trials supplemented this information,modifying 14% of the criteria for which responses were received.

Clinical relevance of the included studies

Assessment of clinical relevance found that many of the trial pub-lications supplied inadequate information. The study populationwas adequately described by 90% of the publications, but only

54% adequately described the exercise intervention. There wasadequate reporting of relevant outcomes in 70% of the trials. Asmall number of studies reported on the presence or absence ofadverse events (16 studies, 26%). Twelve studies reported mildnegative reactions to the exercise program, such as increased low-back pain and muscle soreness, in a minority of patients. Due tolimitations of reporting, it was not possible to assess the treatmentbenefit to harm ratio.

Effects of interventions

Complete meta-analysis data, Forest plots and results are providedin the ’Tables: Comparisons and data’ section.

Effectiveness

Acute low-back pain populations

Ten of 11 trials involving 1192 adults with acute low-back painhad non-exercise comparisons. These trials provided conflictingevidence: one high quality trial conducted in an occupational set-ting found mobilizing home-exercises to be less effective than usualcare (Malmivaara 1995) and one low quality trial conducted ina healthcare setting found a therapist-delivered endurance pro-gram improved short-term functioning more than no treatment(Chok 1999). Of the remaining eight low quality trials, six foundno statistically significant or clinically important differences be-tween exercise therapy and usual care or no treatment; the resultsof two trials were unclear. We rated these trials as low quality mostcommonly because of inadequate assessor blinding. There was in-adequate power to detect clinically important differences in painfor one trial (Underwood 1998) and for functioning in five tri-als (Farrell 1982; Hides 1996; Seferlis 1998; Underwood 1998;Waterworth 1985).The pooled analysis of trials with adequate numeric data failed toshow a difference in short-term pain relief between exercise ther-apy and no treatment (three trials), with an effect of -0.59 points/100 (95% CI: -12.69 to 11.51). There was no difference at earli-est follow-up in pain relief when compared to other conservativetreatments (seven trials): 0.31 points (95% CI: -0.10 to 0.72) [vs.all comparisons (10 trials) 0.03 points (95% CI: -1.34 to 1.40)].Similarly, there was no significant positive effect of exercise onfunctional outcomes. Outcomes show similar trends at the threefollow-up periods in this population, as shown in Figure 2.



Figure 2.



Subacute low-back pain populations

In six studies involving 881 individuals with subacute low-backpain, seven exercise groups had non-exercise comparisons. Onehigh quality and one low quality trial each found reduced absen-teeism outcomes with a graded-activity intervention in the work-place compared to usual care (Lindstrom 1992; Staal 2004). Thisprovides moderate evidence of effectiveness of a graded-activityexercise program in subacute low-back pain in occupational set-tings. One low quality trial found improved functioning over usualcare with an exercise program combined with behavioural therapy(Moffett 1999). Two trials with inadequate assessor blinding wererated neutral, although they were adequately powered to detectclinically important differences in at least one primary outcome(Cherkin 1998; Storheim 2003). The results of one trial were un-clear (Davies 1979). The evidence is conflicting about the effec-tiveness of other types of exercise therapy in subacute low-backpain compared to other treatments.Meta-analysis of pain outcomes at the earliest follow-up, includingfive studies with available data, resulted in a pooled weighted meandifference in pain score of 1.89 points (95% CI: -1.13 to 4.91)relative to any comparison. The pooled analysis of four trials pre-senting data on functional outcomes found a mean difference of1.07 points (95% CI: -3.18 to 5.32) relative to other comparisons.There is insufficient evidence to support or refute the effectivenessof exercise therapy in subacute low-back pain for reducing painintensity and improving function. Results for short and interme-diate follow-up periods in this population are shown in Figure 2.

Chronic low-back pain populations

In 43 trials including 3907 individuals with chronic low-back pain,33 exercise groups had non-exercise comparisons. These trials pro-vide strong evidence that exercise therapy is at least as effectiveas other conservative interventions, and conflicting evidence thatexercise therapy is more effective than other treatments for chroniclow-back pain. Two exercise groups in high quality studies and ninegroups in low quality studies found that exercise was more effectivethan comparison treatments. These studies, mostly conducted inhealthcare settings, commonly used exercise programs that wereindividually designed and delivered (as opposed to independenthome exercises) (Bendix˙b 1995; Frost 1995; Hildebrandt 2000;Moseley 2002; Niemisto 2003; Risch 1993). The exercise pro-grams commonly included strengthening or trunk stabilizing ex-ercises (Frost 1995; Kankaanpaa 1999; Moseley 2002; Niemisto2003; Preyde 2000; Risch 1993). Conservative care in additionto the exercise therapy was often included in these effective in-terventions, including behavioural and manual therapy, advice tostay active and education. One low quality trial found a group-

delivered aerobics and strengthening exercise program resulted inless improvement in pain and function outcomes than behaviouraltherapy (Bendix˙b 1995). Of the remaining trials, fourteen (twohigh quality and twelve low quality) found no statistically sig-nificant or clinically important differences between exercise ther-apy and other conservative treatments. Four of these trials wereinadequately powered to detect clinically important differenceson at least one outcome (Alexandre 2001; Rasmussen-Barr 2003;Yelland 2004; Zylbergold 1981). Trials were most commonly ratedas low quality because of inadequate assessor blinding.

Meta-analysis of pain outcomes at the earliest follow-up included23 exercise groups with an independent comparison and adequatedata. Synthesis resulted in a pooled weighted mean improvementof 10.2 points (95% CI: 1.31 to 19.09) for exercise therapy com-pared to no treatment, and 5.93 points (95% CI: 2.21 to 9.65)compared to other conservative treatment [compared to all com-parisons 7.29 points (95% CI: 3.67 to 10.91)]. At the earliest fol-low-up, smaller improvements were seen in functional outcomeswith an observed mean positive effect of 3.00 points (95% CI: -0.53 to 6.48) compared to no treatment, and 2.37 points (95%CI: 0.74 to 4.0) compared to other conservative treatment, at theearliest follow-up [compared to all comparisons 2.50 points (95%CI: 1.04 to 3.94)]. Results considering different follow-up peri-ods were similar for pain and functional outcomes (Figure 2). Eg-ger’s test suggested there may be publication bias among studies inchronic populations (p = 0.015); funnel plot analysis showed thiswas likely due to three studies that demonstrated highly variable,large positive effects (Alexandre 2001; Bendix˙a 2000; Dalichau2000).Sensitivity analyses for qualitative syntheses did not affect the con-clusions. Meta-analyses were conducted excluding the results ofstudies that presented data as median scores (Bendix˙b 1995; Chok1999; Hansen 1993; Rasmussen-Barr 2003), or did not providevariance scores (Dalichau 2000; Farrell 1982; Hemmila 1997).This did not impact the pooled results for acute and subacute pop-ulations. In chronic populations, this sensitivity analysis resultedin lower, though still significantly improved, pooled effect sizes.Complete results of all analyses are available on request.

Further Analyses

Analyses were conducted on studies from acute, subacute andchronic populations to assess the impact of study level variables.Test of statistical heterogeneity of pain outcomes found 57% (95%CI: 12 to 79), 37% (95% CI: 0 to 76) and 81% (95% CI: 72 to 87)for acute, subacute and chronic, respectively, of the heterogeneitynot due to chance; function outcomes showed 80% (95% CI: 63to 89), 47% (95% CI: 0 to 82) and 52% (95% CI: 19 to 71),



respectively. To account for heterogeneity, random effects modelswere used and clinically relevant subgroups of studies investigated.A complete exploration of intervention heterogeneity is includedin an earlier publication (Hayden 2005b).Indirect subgroup comparisons using qualitative synthesis andmeta-analysis found trials examining healthcare study populationsobserved higher mean improvements in functioning and pain overtheir comparison groups than trials examining occupational orgeneral populations. In chronic populations, there were mean im-provements in healthcare settings of 13.3 points (95% CI: 5.5 to21.1) on pain and 6.9 points (95% CI: 2.2 to 11.7) on functionoutcomes. The adjusted differences between studies with differ-ent source populations found significantly greater improvementin outcomes in healthcare populations compared to studies fromgeneral population or mixed populations, with a mean of 9.96points (95% CI: 1.6 to 18.4) more improvement in pain, and 5.52points (95% CI: 0.6 to 10.4) greater improvement in functioning.Meta-analyses were conducted on the subgroup of high qualitytrials. The observed effectiveness of exercise therapy decreased andonly remained significant for pain outcomes in the chronic pop-ulation.

D I S C U S S I O N

The current review is the most up-to-date assessment of the ef-fectiveness of exercise therapy in key population subgroups. Forthe most part, results were similar using either a qualitative rat-ing system or meta-analysis. We draw the following conclusions,which provide useful information for primary care clinicians tohelp guide their patient management and referral practices:

1. In acute low-back pain, there is evidence that exercises are notmore effective than other conservative treatments. Meta-analysisshowed no advantage over no treatment for pain and functionaloutcomes over the short or long-term.

2. There is moderate evidence of effectiveness of a graded-activityexercise program in subacute low-back pain in occupational set-tings. The effectiveness for other types of exercise therapy in otherpopulations is unclear.

3. In chronic low-back pain, there is strong evidence that exer-cise is at least as effective as other conservative treatments. Indi-vidually designed strengthening or stabilizing programs appear tobe effective in healthcare settings. Meta-analysis found functionaloutcomes significantly improved, however, the effects were verysmall, with less than a three-point (out of 100) difference betweenthe exercise and comparison groups at earliest follow-up. Pain out-comes were also significantly improved in groups receiving exer-cises relative to other comparisons, with a mean of approximatelyseven points. Effects were similar over longer follow-up thoughconfidence intervals increased. Mean improvements in pain and

functioning may be clinically meaningful in studies from health-care populations in which improvements were significantly greaterthan those observed in studies from general or mixed populations.

This study has several strengths and also some limitations. A largenumber of randomized controlled trials informed this study andthe data were collected in a systematic way within the framework ofthe Cochrane Collaboration, giving confidence that the synthesisrepresents the current state of the literature. However, limitationsin the quality and reporting of the trials are notable. Only a smallnumber of the studies were rated as high quality and this may haveled to an overestimation of effect. Also, many studies lacked in-formation to assess quality and clinical relevance. Contacting theauthors of the trials provided missing data, emphasizing the im-portance and usefulness of this practice. The only outcome mea-sure used in the majority of studies was pain intensity (in 85%),limiting the ability to report on other important outcomes. In1998, a group of back pain researchers made recommendations forstandardized use of outcome measures in back pain research, sug-gesting a minimum of pain, functional status and general healthmeasures (Deyo 1998). It is disappointing to observe the lack ofconsistency, and the fact that only three-quarters of the studiesin this review included a measure of functional status and 15% ameasure of general health. Journals in the field of back pain shouldadopt reporting guidelines (Begg 1996) and, even more impor-tant, use them in their review process, to improve the quality offuture reports of trials in this field. We found potential publicationbias in studies in chronic low-back pain; this may have resultedin an overestimation of the effectiveness of exercise therapy in thispopulation. Initiatives in other fields to register randomized con-trolled trials will also be important in low-back pain research. Weemployed both qualitative and quantitative synthesis strategies inthis review, which was informative. Qualitative synthesis methodsfacilitate the inclusion of results from trials which inadequatelyreport outcomes. This is particularly useful when only a smallnumber of studies are available, for example, in subacute popula-tions in the current review. However, the qualitative synthesis wasmore challenging in assessing the evidence in chronic populations,where a large number of studies were available.

With meta-analysis, we found no evidence that exercise therapyis more effective than no treatment in improving outcomes inacute low-back pain. This finding is consistent with the originalCochrane review on this topic (van Tulder 2000b) and other sys-tematic reviews (Abenhaim 2000; Hilde 1998; Tugwell 2001).However, it should be stressed that exercise therapy is not the sameas advice to stay active, which is a recommended treatment strat-egy in acute populations (Abenhaim 2000; Waddell 1997). In thesubacute population, which was not considered separately in theoriginal Cochrane review, there were six trials available. In a recentsystematic review of various conservative interventions, Pengel etal. concluded there was an important gap in evidence for theseinterventions in the treatment of subacute low-back pain (Pengel



2002). In our review, two trials looking at a working populationfound reduced absenteeism outcomes with a graded-activity in-tervention compared to usual care (Lindstrom 1992; Staal 2004),though there continues to be uncertainty about other types ofexercises and in populations seeking healthcare. We also recom-mend more clear definitions and further high quality research ofexercise therapy in this population. Finally, our positive findingsin chronic populations reflect the conclusions of earlier reviews(Abenhaim 2000; Hilde 1998; Tugwell 2001). Our quantitativeanalysis provides an estimate of the average treatment effect and itsuncertainty, highlighting an overall small treatment benefit. Ourfinding of greater improvement in trials investigating healthcarepopulations is important. Future intervention studies should beconducted in populations that are seeking care and therefore bestrepresent patients with low-back pain. We do not recommend fur-ther research on the effectiveness of general exercise therapy inter-ventions in chronic low-back pain. Trials should investigate spe-cific exercise intervention strategies in well defined low-back painpatient populations (Hayden 2005b).

A U T H O R S ’ C O N C L U S I O N SImplications for practice

Evidence from randomized controlled trials demonstrates that ex-ercise therapy is effective at reducing pain and functional limi-tations in the treatment of chronic low-back pain, though cau-tious interpretation is required due to limitations in this literature.Overall, mean improvements in outcomes across all research set-tings are small, though significant, over other conservative treat-

ment options. Clinically important improvements are more likelyin healthcare settings. There is some evidence of effectiveness ofa graded-activity exercise program in subacute low-back pain inoccupational settings, though the evidence for other types of ex-ercise therapy in other populations is unclear and further researchis required. This literature suggests exercise therapy is as effectiveas either no treatment or other conservative treatments for acutelow-back pain.

Implications for research

Future RCTs in the area of low-back pain should: 1. include com-plete descriptions of the study populations and exercise interven-tions, 2. include complete reporting of meaningful outcome mea-sures, 3. employ strategies to reduce bias, and 4. include morecomplete tracking (and reporting) of long-term outcomes, includ-ing recurrences.

A C K N O W L E D G E M E N T S

The authors would like to thank Drs Jens Ivar Brox and Jan Lonn,and Mr. Arne Naess for their assistance with the quality assessmentand data extraction from non-English language studies, the Phys-iotherapy ’Educational Influentials’ from the Institute for Work& Health for their guidance with syntheses, Emma Irvin, medicallibrarian at the Institute for Work & Health, for her assistancewith the search strategy, Victoria Pennick for her assistance withediting, and Rosmin Esmail for her contribution to the originalversion of this review.

R E F E R E N C E S

References to studies included in this review

Alexandre 2001 {published data only}

Alexandre NM, de Moraes MA, Correa Filho HR, JorgeSA. Evaluation of a program to reduce back pain in nursingpersonnel. Revista de Saude Publica 2001;35:356–61.

Aure (ex2) {published data only}

Aure 2003 {published data only}

Aure O, Nilsen J, Vasseljen O. Manual therapy andexercise therapy in patients with chronic low back pain. Arandomized, controlled trial with 1-year follow-up. Spine2003;28(6):525–532.

Bendix˙a (ex2) {published data only}

Bendix˙a 2000 {published data only}

Bendix T, Bendix A, Labriola M, Haestrup C, Ebbehoj N.Functional restoration versus outpatient physical training inchronic low back pain: a randomized comparative study.Spine 2000;25:2494–500.

Bendix˙b (ex2) {published data only}

Bendix˙b 1995 {published data only}

Bendix AF, Bendix T, Labriola M, Boekgaard P. Functionalrestoration for chronic low back pain: Two-year follow-upof two randomized clinical trials. Spine 1998;23:717–25.Bendix AF, Bendix T, Lund C, Kirkbak S, Ostenfeld S,Kirking BC. Comparison of three intensive programs forchronic low back pain patients: a prospective, randomized,observer-blinded study with one-year follow-up. Scand J

Rehab Med 1997;29:81–9.∗ Bendix AF, Bendix T, Ostenfeld S, Bush E, Andersen A.Active treatment programs for patients with chronic lowback pain: a prospective randomized, observer-blindedstudy. Eur Spine J 1995;4:148–52.

Bentsen (ex2) {published data only}

Bentsen 1997 {published data only}

Bentsen H, Lindgärde F, Manthorpe R. The effect ofdynamic strength back exercise and/or a home trainingprogram in 57-year old women with chronic low back pain:



results of a prospective randomized study with a 3-yearfollow-up period. Spine 1997;22:1494–500.

Bronfort (ex2) {published data only}

Bronfort 1996 {published data only}

Bronfort G, Goldsmith CH, Nelson C, Boline PD,Anderson AV. Trunk exercise combined with spinalmanipulative or NSAID therapy for chronic low back pain:a randomized, observer-blinded clinical trial. J Manipulative

Physiol Ther 1996;19:570–82.

Buswell (ex2) {published data only}

Buswell 1982 {published data only}

Buswell J. Low back pain: a comparison of two treatmentprogrammes. NZ J Physiotherapy 1982;10:13–7.

Calmels (ex2) {published data only}

Calmels 2004 {published data only}

Calmels P, Jacob JF, Fayolle-Minon I, Charles C, BouchetJP, Rimaud D, Thomas T. [Use of isokinetic techniques vsstandard physiotherapy in patients with chronic low backpain. Preliminary results] [French]. Annales de Readaptation

et de Medecine Physique 2004;47:20–7.

Cherkin 1998 {published data only}

Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. Acomparison of physical therapy, chiropractic manipulation,and provision of an educational booklet for the treatmentof patients with low back pain. N Engl J Med 1998;339:1021–9.

Chok 1999 {published data only}

Chok B, Lee R, Latimer J, Seang BT. Endurance trainingof the trunk extensor muscles in people with subacute lowback pain. Phys Ther 1999;79:1032–42.

Dalichau (ex2) {published data only}

Dalichau 2000 {published data only}

Dalichau S, Scheele K. [Effects of elastic lumbar belts onthe effect of a muscle training program for patients withchronic back pain]. [German]. Zeitschrift fur Orthopadieund Ihre Grenzgebiete 2000;138:8–16.

Davies (ex2) {published data only}

Davies 1979 {published data only}

Davies JR, Gibson T, Tester L. The value of exercises in thetreatment of low back pain. Rheumatol Rehabil 1979;18:243–7.

Delitto (ex2) {published data only}

Delitto 1993 {published data only}

Delitto A, Cibulka MT, Erhard RE, Bowling RW, TenhulaJA. Evidence for use of an extension-mobilization categoryin acute low back syndrome: a prescriptive validation pilotstudy. Phys Ther 1993;73:216–28.

Descarreaux (ex2) {published data only}

Descarreaux 2002 {published data only}

Descarreaux M, Normand MC, Laurencelle L, Dugas C.Evaluation of a specific home exercise program for low backpain.. J Manipulative Physiol Ther 2002;25(8):497–503.

Deyo 1990 {published data only}

Deyo RA, Walsh NE, Martin DC, Schoenfeld LS,Ramamurthy S. A controlled trial of transcutaneouselectrical nerve stimulation (TENS) and exercise for chroniclow back pain. N Engl J Med 1990;322:1627–34.

Elnaggar (ex2) {published data only}

Elnaggar 1991 {published data only}

Elnaggar IM, Nordin M, Sheikhzadeh A, ParnianpourM, Kahanovitz N. Effects of spinal flexion and extensionexercises on low-back pain and spinal mobility in chronicmechanical low-back pain patients. Spine 1991;16:967–72.

Faas 1993 {published data only}∗ Faas A, Chavannes AW, van Eijk JThM, Gubbels JW. Arandomized placebo-controlled trial of exercise therapy inpatients with acute low back pain. Spine 1993;18:1388–95.Faas A, van Eijk JThM, Chavannes AW, Gubbels JW. Arandomized trial of exercise therapy in patients with acutelow back pain. Spine 1995;20:941–7.

Farrell 1982 {published data only}

Farrell JP, Twomey LT. Acute low back pain: comparison oftwo conservative treatment approaches. Med J Aus 1982;1:160–4.

Frost 1995 {published data only}∗ Frost H, Klaber Moffett JA, Moser JS, Fairbank JCT.Randomised controlled trial for evaluation of fitnessprogramme for patients with chronic low back pain. Br

Med J 1995;310:151–4.Frost H, Lamb SE, Klaber Moffett JA, Fairbank JCT, MoserJS. A fitness programme for patients with chronic low backpain: 2-year follow-up of a randomised controlled trial.Pain 1998;75:273–9.

Frost 2004 {published data only}∗ Frost H, Lamb SE, Doll HA, Taffe Carver P, Stewart-Brown S. Randomized controlled trial of physiotherapycompared with advice for low back pain. BMJ 2004;329:708–11.

Galantino 2004 {published data only}

Galantino ML, Bzdewka TM, Eissler-Russo JL, HolbrookML, Mogck EP, Geigle P, et al.The impact of modified hathayoga on chronic low back pain: A pilot study. AlternativeTherapies in Health & Medicine 2004;10:56–9.

Gilbert (ex2) {published data only}

Gilbert 1985 {published data only}

Evans C, Gilbert JR, Taylor DW, Hildebrand A. Arandomized controlled trial of flexion exercises, education,and bed rest for patients with acute low back pain.Physiother Can 1987;39:96–101.∗ Gilbert JR, Taylor DW, Hildebrand A, Evans C. Clinicalpractice of common treatments for low-back pain. Br Med J1985;291:789–92.

Gur (ex2) {published data only}

Gur 2003 {published data only}

Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ, Karakoc M.Efficacy of low power laser therapy and exercise on pain and



functions in chronic low back pain. Lasers in Surgery &

Medicine 2003;32:233–8.

Hansen 1993 {published data only}

Hansen FR, Bendix T, Skov P, Jensen CV, Kristensen JH,Krohn L, et al.Intensive, dynamic back-muscle exercises,conventional physiotherapy, or placebo-control treatmentof low back pain. Spine 1993;18:98–107.

Hemmila 1997 {published data only}

Hemmila H, Keinanen-Kiukaanniemi SM, Levoska S,Puska P. Long-term effectiveness of bone-setting, lightexercise therapy, and physiotherapy for prolonged back pain:A randomized controlled trial. J Manip Phys Therapeutics2002;25:99–104.∗ Hemmilä HM, Keinanen-Kiukaanniemi SM, Levoska S,Puska P. Does folk medicine work? A randomized clinicaltrial on patients with prolonged back pain. Arch Phys MedRehabil 1997;78:571–7.

Hides 1996 {published data only}

Hides JA, Jull GA, Richardson CA. Long-term effects ofspecific stabilizing exercises for first-episode low back pain.Spine 2001;26:E243–8.Hides JA, Richardson CA, Jull GA. Multifidus musclerecovery is not automatic after resolution of acute first-episode low back pain. Spine 1996;21:2763–9.

Hildebrandt 2000 {published data only}

Hildebrandt VH, Proper KI, van den Berg R, DouwesM, van den Heuvel SG, van Buuren S. [Cesar therapy istemporarily more effective in patients with chronic low backpain than the standard treatment by family practitioner:randomized, controlled and blinded clinical trial with1 year follow-up]. [Dutch]. Nederlands Tijdschrift voorGeneeskunde 2000;144:2258–64.

Johanssen (ex2) {published data only}

Johanssen 1995 {published data only}

Johanssen F, Remvig L, Kryger P, Beck P, Warming S,Lybeck K, et al.Exercises for chronic low back pain: aclinical trial. J Orthop Sports Phys Ther 1995;22:52–9.

Jousset (ex2) {published data only}

Jousset 2004 {published data only}

Jousset N, Fanello S, Bontoux L, Dubus V, Billabert C,Vielle B, et al.Effects of functional restoration versus 3 hoursper week physical therapy: a randomized controlled study.Spine 2004;29:487–93.

Kankaanpaa 1999 {published data only}

Kankaanpaa M, Taimela S, Airaksinen O, Hanninen O.The efficacy of active rehabilitation in chronic low backpain. Effect on pain intensity, self-experienced disability,and lumbar fatigability. Spine 1999;24:1034–42.

Kendall (ex2) {published data only}

Kendall (ex3) {published data only}

Kendall 1968 {published data only}

Kendall PH, Jenkins JM. Exercises for backache: a double-blind controlled trial. Physiother 1968;54:154–7.

Kuukkanen 2000 {published data only}∗ Kuukkanen TM, Malkia EA. An experimental controlledstudy on postural sway and therapeutic exercise in subjectswith low back pain. Clinical Rehabilitation 2000;14:192–202.

Lidström 1970 {published data only}

Lidström A, Zachrisson M. Physical therapy on low backpain and sciatica. Scand J Rehabil Med 1970;2:37–42.

Lie (ex2) {published data only}

Lie 1999 {published data only}

Lie H, Frey S. [Mobilizing or stabilizing exercisein degenerative disk disease in the lumbar region?].[Norwegian]. Tidsskrift for Den Norske Laegeforening 1999;119:2051–3.

Lindstrom 1992 {published data only}

Lindström I. A successful intervention program for patients

with subacute low back pain. (Academic Thesis). Göteborg:Göteborg University, 1994.∗ Lindström I, Öhlund C, Eek C, Wallin L, Peterson LE,Fordyce WE, et al.The effect of graded activity on patientswith subacute low back pain: a randomized prospectiveclinical study with an operant-conditioning behaviouralapproach. Physical Therapy 1992a;72:279–93.Lindström I, Öhlund C, Eek C, Wallin L, Peterson LE,Nachemson A. Mobility, strength, and fitness after a gradedactivity program for patients with subacute low back pain.A randomized prospective clinical study with a behaviouraltherapy approach. Spine 1992b;17:641–52.

Ljunggren (ex2) {published data only}

Ljunggren 1997 {published data only}

Ljunggren AE, Weber H, Kogstad O, Thom E, KirkesolaG. Effect of exercise on sick leave due to low back pain: arandomized, comparative, long-term study. Spine 1997;22:1610–7.

Malmivaara 1995 {published data only}

Malmivaara A, Häkkinen U, Aro T, Heinrichs ML,Koskenniemi L, Kuosma E, et al.The treatment of acute lowback pain - bed rest, exercises or ordinary activity?. N Engl JMed 1995;332:351–5.

Manniche (ex2) {published data only}

Manniche (ex3) {published data only}

Manniche 1988 {published data only}∗ Manniche C, Hesselsoe G, Bentzen L, Christensen I,Lundberg E. Clinical trial of intensive muscle training forchronic low back pain. Lancet 1988;ii:1473–6.Manniche C, Lundberg E, Christensen I, Bentzen L,Hesselsoe G. Intensive dynamic back exercises for chroniclow back pain: a clinical trial. Pain 1991;47:53–63.

Mannion (ex2) {published data only}

Mannion (ex3) {published data only}



Mannion 1999 {published data only}

Mannion AF, Muntener M, Taimela S, Dvorak J. Arandomized clinical trial of three active therapies for chroniclow back pain. Spine 1999;24:2435–48.Mannion AF, Muntener M, Taimela S, Dvorak J.Comparison of three active therapies for chronic low backpain: results of a randomized clinical trial with one-yearfollow-up. Rheum 2001;40:772–8.Mannion AF, Taimela S, Muntener M, Dvorak J. Activetherapy for chronic low back pain part 1. Effects on backmuscle activation, fatigability, and strength. Spine 2001;26:897–908.

Moffett 1999 {published data only}

Moffett JK, Torgerson D, Bell-Syer S, Jackson D, Llewlyn-Phillips H, Farrin A, et al.Randomised controlled trial ofexercise for low back pain: clinical outcomes, costs, andpreferences. BMJ 1999;319:279–83.

Moseley 2002 {published data only}

Moseley L. Combined physiotherapy and education isefficacious for chronic low back pain. Aust J Physiother

2002;48:297–302.

Niemisto 2003 {published data only}

Niemisto L, Lahtinen-Suopanki T, Rissanen P, LindgrenK-A, Sarna S, Hurri H. A randomized trial of combinedmanipulation, stabilizing exercises, and physicianconsultation compared to physician consultation alone forchronic low back pain. Spine 2003;28:2185–91.

Petersen (ex2) {published data only}

Petersen 2002 {published data only}

Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S.The effect of McKenzie therapy as compared with that ofintensive strengthening training for the treatment of patientswith subacute or chronic low back pain: A randomizedcontrolled trial.. Spine 2002;27:1702–9.

Preyde (ex2) {published data only}

Preyde 2000 {published data only}

Preyde M. Effectiveness of massage therapy for subacutelow-back pain: A randomized controlled trial. Can Med

Assoc J 2000;162:1815–20.

Rasmussen-Barr 2003 {published data only}

Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I.Stabilizing training compared with manual treatment insub-acute and chronic low-back pain. Manual Therapy

2003;8:233–41.

Risch 1993 {published data only}

Risch SV, Norvell NK, Pollock ML, Risch ED, Langer H,Fulton M, et al.Lumbar strengthening in chronic low backpain patients: physiologic and psychological benefits. Spine

1993;18:232–8.

Rittweger (ex2) {published data only}

Rittweger 2002 {published data only}

Rittweger J, Just K, Kautzsch K, Reeg P, Felsenberg D.Treatment of chronic lower back pain with lumbar extensionand whole-body vibration exercise: a randomized controlledtrial. Spine 2002;27:1829–34.

Seferlis 1998 {published data only}

Seferlis T, Nemeth G, Carlsson AM, Gillström P.Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomised study with 12 months’follow-up. Eur Spine J 1998;7(6):461–70.

Soukup (ex2) {published data only}

Soukup 1999 {published data only}

Glomsrod B, Lonn JH, Soukup MG, Bo K, Larsen S.’Active back school’, prophylactic management for low backpain: Three-year follow-up of a randomized, controlledtrial. J Rehab Med 2001;33:26–30.Lonn JH, Glomsrod B, Soukup MG, Bo K, Larsen S. Activeback school: Prophylactic management for low back pain.A randomized controlled, 1-year follow-up study. Spine

1999;24:865–71.Soukup M, Lonn J, Glomsrod B, Bo K, Larsen S. Exercisesand education as secondary prevention for recurrent lowback pain. Phys Res Int 2001;6:27–39.∗ Soukup MG, Glomsrod B, Lonn JH, Bo K, Larsen S,Fordyce WE. The effect of a Mensendieck exercise programas secondary prophylaxis for recurrent low back pain: Arandomized, controlled trial with 12-month follow-up.Spine 1999;24:1585–92.

Staal 2004 {published data only}

Staal JB, Hlobil H, Twisk JW, Smid T, Koke AJ, vanMechelen W. Graded activity for low back pain inoccupational health care: a randomized, controlled trial.[seecomment]. Ann Intern Med 2004;140:77–84.

Stankovic 1990 {published data only}

Stankovic R, Johnell O. Conservative treatment of acutelow-back pain: a 5-year follow-up study of two methods oftreatment. Spine 1995;20:469–72.∗ Stankovic R, Johnell O. Conservative treatment of acutelow back pain: a prospective randomized trial. Spine 1990;15:120–3.

Storheim 2003 {published data only}

Storheim K, Brox JI, Holm I, Koller AK, Bo K. Intensivegroup training versus cognitive intervention in sub-acute low back pain: short-term results of a single-blindrandomized controlled trial. J Rehabil Med 2003;35:132–40.

Torstensen (ex2) {published data only}

Torstensen 1998 {published data only}

Torstensen TA, Ljunggren AE, Meen HD, Odland E,Mowinckel P, Geijerstam S. Efficiency and costs of medicalexercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain: a pragmatic,randomized, single-blinded, controlled trial with 1-yearfollow-up. Spine 1998;23:2616–24.

Tritilanunt (ex2) {published data only}

Tritilanunt 2001 {published data only}

Tritilanunt T, Wajanavisit W. The efficacy of an aerobicexercise and health education program for treatment ofchronic low back pain. J Med Assoc Thailand 2001;84:S528–33.



Turner (ex2) {published data only}

Turner 1990 {published data only}

Turner JA, Clancy S, McQuade KJ, Cardenas DD.Effectiveness of behavioral therapy for chronic low backpain: a component analysis. J Consult Clin Psychol 1990;58:573–9.

Underwood 1998 {published data only}

Underwood MR, Morgan J. The use of a back class teachingextension exercises in the treatment of acute low back painin primary care. Fam Pract 1998;15:9–15.

Waterworth 1985 {published data only}

Waterworth RF, Hunter IA. An open study of diflunisal,conservative and manipulative therapy in the managementof acute mechanical low back pain. N Z Med J 1985;95:372–5.

Yelland 2004 {published data only}

Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernonM. Prolotherapy injections, saline injections, and exercisesfor chronic low-back pain: a randomized trial. Spine 2004;29:9–16.

Yeung (ex2) {published data only}

Yeung 2003 {published data only}

Yeung CK, Leung MC, Chow DH. The use of electro-acupuncture in conjunction with exercise for the treatmentof chronic low-back pain. J Alternative & Complementary

Medicine 2003;9:479–90.

Yozbatiran (ex2) {published data only}

Yozbatiran 2004 {published data only}

Yozbatiran N, Yildirim Y, Parlak B. Effects of fitness andaquafitness exercises on physical fitness in patients withchronic low back pain. The Pain Clinic 2004;16:35–42.

Zylbergold 1981 {published data only}

Zylbergold RS, Piper MC. Lumbar disc disease: comparativeanalysis of physical therapy treatments. Arch Phys Med

Rehabil 1981;62:176–9.

References to studies excluded from this review

Coxhead 1981 {published data only}

Coxhead CE, Inskip H, Meade TW, North WRS, TroupJDG. Multicentre trial of physiotherapy in the managementof sciatic symptoms. Lancet 1981;i:1065–8.

Danielsen 2000 {published data only}

Danielsen JM, Johnsen R, Kibsgaard SK, Hellevik E. Earlyaggressive exercise for postoperative rehabilitation afterdiscectomy. Spine 2000;25:1015–20.

Danneels 2001 {published data only}

Danneels LA, Cools AM, Vanderstraeten GG, CambierDC, Witvrouw EE, Bourgois J, et al.The effects of threedifferent training modalities on the cross-sectional area ofthe paravertebral muscles. Scand J Med Sci Sports 2001;11:335–41.Danneels LA, Vanderstraeten GG, Cambier DC, WitvrouwEE, Bourgois J, Dankaerts W, et al.Effects of three differenttraining modalities on the cross sectional area of the lumbar

multifidus muscle in patients with chronic low back pain.Br J Sports Med 2001;35:186–91.

Friedrich 1998 {published data only}

Friedrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I.Combined exercise and motivation program: Effect on thecompliance and level of disability of patients with chroniclow back pain: A randomized controlled trial. Arch PhysMed Rehab 1998;79:475–87.

Ghoname 1999 {published data only}

Ghoname EA, Craig WF, White PF, Ahmed HE, HamzaMA, Henderson BN, et al.Percutaneous electrical nervestimulation for low back pain: a randomized crossoverstudy. [see comments.] [erratum appears in JAMA 1999May 19;281(19):1795.]. JAMA 1999;281:818–23.

Hagen 2000 {published data only}

Hagen EM, Eriksen HR, Ursin H. Does early interventionwith a light mobilization program reduce long-term sickleave for low back pain?. Spine 2000;25:1973–6.

Helewa 1999 {published data only}

Helewa A, Goldsmith CH, Lee P, Smythe HA, Forwell L.Does strengthening the abdominal muscles prevent lowback pain - A randomized controlled trial. J Rheum 1999;26:1808–15.

Horneij 2001 {published data only}

Horneij E, Hemborg B, Jensen I, Ekdahl C. No significantdifferences between intervention programmes on neck,shoulder and low back pain: a prospective randomizedstudy among home-care personnel. J Rehabil Med 2001;33:170–6.

Lang 2003 {published data only}

Lang E, Liebig K, Kastner S, Neundorfer B, Heuschmann P.Multidisciplinary rehabilitation versus usual care for chroniclow back pain in the community: effects on quality of life.Spine Journal 2003;3(4):270–6.

Little 2001 {published data only}

Little P, Roberts L, Blowers H, Garwood J, Cantrell T,Langridge J, et al.Should we give detailed advice andinformation booklets to patients with back pain? Arandomized controlled factorial trial of a self-managementbooklet and doctor advice to take exercise for back pain.Spine 2001;26:2065–72.

Manniche 1993 {published data only}

Manniche C, Asmussen K, Lauritsen B, Vinterberg H,Karbo H, Abildstrup S, et al.Intensive dynamic backexercises with or without hyperextension in chronic backpain after surgery for lumbar disc protrusion: a clinical trial.Spine 1993;18:560–7.

Martin 1980 {published data only}

Martin PR, Rose MJ, Nichols PJR, Russell PL, HughesJG. Physiotherapy exercises for low back pain: process andclinical outcome. Int Rehabil Med 1980;8:34–8.

Morton 1999 {published data only}

Morton JE. Manipulation in the treatment of acute lowback pain. J Man Manip Ther 1999;7:182–9.



Muller 2001 {published data only}

Muller K, Schwesig R, Leuchte S, Riede D. [Coordinativetreatment and quality of life - A randomised trial of nurseswith back pain] German.. Gesundheitswesen 2001;63:609–18.

Nwuga 1982 {published data only}

Nwuga VCB. Relative therapeutic efficacy of vertebralmanipulation and conventional treatment in back painmanagement. Am J Phys Med 1982;61:273–8.

Nwuga 1985 {published data only}

Nwuga G, Nwuga V. Relative therapeutic efficacy ofthe Williams and McKenzie protocols in back painmanagement. Physiother Pract 1985;1:99–105.

O’Sullivan 1997 {published data only}

O’Sullivan PB, Twomey LT, Allison GT. Evaluation ofspecific stabilising exercise in the treatment of chronic lowback pain with radiologic diagnosis of spondylolysis orspondylolisthesis. Spine 1997;22:2959–67.

Sachs 1994 {published data only}

Sachs BL, Ahmad SS, LaCroix M, Olimpio D, HeathR, David JA, et al.Objective assessment for exercisetreatment on the B-200 isostation as part of work tolerancerehabilitation: a random prospective blind evaluation withcomparison control population. Spine 1994;19:49–52.

Scrimshaw 2001 {published data only}

Scrimshaw SV, Maher CG. Randomized controlled trial ofneural mobilization after spinal surgery. Spine 2001;26:2647–52.

Snook 1998 {published data only}

Snook SH, Webster BS, McGorry RW, Fogleman MT,McCann B. The reduction of chronic nonspecific low backpain through the control of early morning lumbar flexion.A randomized controlled trial. Spine 1998;23:2601–7.

Spratt 1993 {published data only}

Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H.Efficacy of flexion and extension treatments incorporatingbraces for low back pain patients with retrodisplacement,spondylolisthesis, or normal sagittal translation. Spine

1993;18:1839–49.

Strand 2001 {published data only}

Strand LI, Ljunggren AE, Haldorsen EMH, Esphehaug B.The impact of physical function and pain on work status at1-year follow-up in patients with back pain. Spine 2001;26:800–8.

White 1966 {published data only}

White AWM. Low back pain in men receiving workmen’scompensation. Can Med Assoc J 1966;95:50–56.

References to studies awaiting assessment

Erhard 1994 {published data only}

Erhard RE, Delitto A, Cibulka MT. Relative effectivenessof an extension program and a combined program ofmanipulation and flexion and extension exercises in patientswith acute low back syndrome. Phys Ther 1994;74(12):1093–100.

Gillan 1998 {published data only}

Gillan MG, Ross JC, McLean IP, Porter RW. The naturalhistory of trunk list, its associated disability and theinfluence of McKenzie management. Eur Spine J 1998;7:480–3.

Kladny 2003 {published data only}

Kladny B, Fischer FC, Haase I. [Evaluation of specificstablizing exercise in the treatment of low back pain andlumbar disk disease in outpatient rehabilitation][German].Zeitschrift fur Orthopadie und Ihre Grenzgbiete 2003;141:401–5.

Additional references

Abenhaim 2000

Abenheim L, Rossignol M, Valat J, Nordin M, AvouacB, Blotman F, et al.The role of activity in the therapeuticmanagement of back pain: Report of the International ParisTask Force on back pain. Spine 2000;25:1S–33S.

Begg 1996

Begg C, Cho M, Eastwood S. Improving the quality ofreporting of randomized controlled trials: the CONSORTstatement. JAMA 1996;276:637–9.

Bombardier 2001

Bombardier C, Hayden JA, Beaton DE. Minimally clinicallyimportant difference: Low back pain outcome measures. J

Rheumatol 2001;28:431–8.

DerSimonian 1986

DerSimonian R, Laird N. Meta-analysis in clinical trials.Controlled Clinical Trials 1986;7:177–88.

Deyo 1998

Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P,Koes B, et al.Outcome measures for low back pain research:A proposal for standardized use. Spine 1998;23:2003–13.

Egger 1997

Egger M, Zellweger-Zähner T, Schneider M, JunkerC, Lengeler C, Antes G. Language bias in randomisedcontrolled trials published in English and German. Lancet

1997;350:326–9.

Ernst 2003

Ernst E, Canter PH. The Alexander technique: asystematic review of controlled clinical trials. Forschende

Komplementarmedizin und Klassische Naturheilkunde 2003;10:325–9.

Higgins 2002

Higgins JP, Thompson SG. Quantifying heterogeneity in ameta-analysis. Statistics in Medicine 2002;21(11):1539–58.

Hilde 1998

Hilde G, Bo K. Effect of exercise in the treatment of chroniclow back pain: a systematic review emphasizing type anddose of exercise. Physical Therapy Reviews 1998;3:107–17.

Jadad 1996

Jadad AR, Moore A, Carroll D, Jenkinson C, ReynoldsJM, Gavaghan DJ, et al.Assessing the quality of reports ofrandomized clinical trials: Is blinding necessary?. Controlled

Clinical Trials 1996;17(1):1–12.



Kool 2004

Kool J, de Bie R, Oesch P, Knusel O, van den Brandt P,Bachmann S. Exercise reduces sick leave in patients withnon-acute non-specific low back pain: a meta-analysis.Journal of Rehabilitation Medicine 2004;36:49–62.

Kopec 2000

Kopec JA. Measuring functional outcomes in persons withback pain: A review of back-specific questionnaires. Spine

2000;25:3110–4.

Liddle 2004

Liddle SD, Baxter GD, Gracey JH. Exercise and chroniclow back pain: what works?. Pain 2004;107:176–90.

Pengel 2002

Pengel HM, Maher CG, Refshauge KM. Systematic reviewof conservative interventions for subacute low back pain.Clin Rehabil 2002;16:811–20.

Salaffi 2004

Salaffi F, Stancati A, Silvestri CA, Ciapetti A, GrassiW. Minimally clinically important changes in chronicmusculoskeletal pain intensity measured on a numericalrating scale. European Journal of Pain 2004;8:283–91.

Song 2003

Song F, Altman DG, Glenny AM, Deeks JJ. Validity ofindirect comparison for estimating efficacy of competinginterventions: empirical evidence from published meta-analyses. BMJ 2003;326:472.

Tugwell 2001

Tugwell P. Philadelphia panel evidence-based clinicalpractice guidelines on selected rehabilitation interventionsfor low back pain. Physical Therapy 2001;81:1641–74.

van Tulder 2003

van Tulder MW, Furlan A, Bombardier C, Bouter L, theEditorial Board of the Cochrane Collaboration Back Review

Group. Updated method guidelines for systematic reviewsin the Cochrane Collaboration Back Review Group. Spine2003;28:1290–9.

von Korff 2000

von Korff M, Jensen MP, Karoly P. Assessing global painseverity by self-report in clinical health services research.Spine 2000;25:3140–51.

Waddell 1997

Waddell G, Feder G, Lewis M. Systematic reviews of bedrest and advice to stay active for acute low back pain. Br J

Gen Pract 1997;47:647–52.

References to other published versions of this review

Hayden 2005a

Hayden JA, van Tulder MW, Malmivaara AV, Koes BW.Meta-analysis: Exercise Therapy for Nonspecific Low BackPain. Annals of Internal Medicine 2005;142:765–75.

Hayden 2005b

Hayden JA, van Tulder MW, Tomlinson G. SystematicReview: Strategies for Using Exercise Therapy to ImproveOutcomes in Chronic Low Back Pain. Annals of Internal

Medicine 2005;142:776–85.

van Tulder 2000a

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]

van Tulder 2000b

van Tulder MW, Malmivaara A, Esmail R, Koes BW.Exercise therapy for low back pain: A systematic reviewwithin the framework of the Cochrane Collaboration BackReview Group. Spine 2000;25(21):2784–96.

∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Alexandre 2001

Methods See Comparisons and Data Table 05: Methodological Quality of Included Studies for detailed information

Participants Chronic population; Occupational; N=33

Interventions ‡E1. Multiple components: exercise, plus home exercises; Time :24; Deliv:Group; Other:Advice to stayactive/ education; C1. No treatment

Outcomes §Pain (VAS/10)

Notes See footnote for explanation of symbols, terms and abbreviations

Risk of bias

Bias Authors’ judgement Support for judgement

Allocation concealment? Unclear risk B - Unclear

Aure (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias


Allocation concealment? Unclear risk D - Not used

Aure 2003

Methods See Comparisons and Data Table 05:




Aure 2003 (Continued)

Interventions E1. Stretching exercises (2/3); passive manipulation (1/3); Time:10; Deliv:Individual; independent; Other:Manual therapy; analgesics/NSAIDS; E2. Individually designed: strengthening, stretching, mobilizing,coordination, stabilizing exercises for abdominal, back, pelvic, lower limb; equipment; Time:10; Deliv:Individual; independent; Other:Analgesics/NSAIDS;

Outcomes Pain (VAS), function (Osw), RTW

Notes

Risk of bias


Allocation concealment? Low risk A - Adequate

Bendix˙a (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Bendix˙a 2000



Interventions E1. Aerobics and strengthening (machines); Time:36; Deliv:Group; Other:None; E2. Functional restora-tion; comprehensive multidisciplinary approach including aerobics, strengthening, stretching; Time:36;Deliv:Group; Other:Behavioural therapy; backschool;

Outcomes Pain (NRS), function (MRS), RTW, global

Notes



Bendix˙a 2000 (Continued)

Risk of bias



Bendix˙b (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Bendix˙b 1995


Participants Chronic population; Secondary or tertiary care (referred); N=106

Interventions E1. Functional restoration; comprehensive multidisciplinary approach including aerobics, strengthening,stretching; Time:24; Deliv:Group; Other:Behavioural therapy; backschool; E2. Aerobics and strengthen-ing ; Time:24; Deliv:Group; Other:Backschool; C1. Other conservative

Outcomes Pain (VAS/10), function (ADL/30), RTW

Notes

Risk of bias





Bentsen (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Bentsen 1997


Participants Chronic† population; General population; N=74

Interventions E1. Dynamic strength back exercises: at gym and home; Time:21.8; Deliv:Individual; independent; Other:None; E2. Home exercises; Time:21.8; Deliv:Independent only; Other:None;

Outcomes Function (Million), RTW

Notes

Risk of bias



Bronfort (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Bronfort (ex2) (Continued)



Bronfort 1996


Participants Chronic population; General population; N=103

Interventions E1. Dynamic trunk (Manniche) and abdominal strengthening; Time:20; Deliv:Individual; Other:Manualtherapy; E2. Same exercise plus NSAIDS; Time:20; Deliv:Individual; Other:Analgesics/NSAIDS; C1.Other conservative

Outcomes Pain (VAS/10), function (RMDQ)

Notes

Risk of bias



Buswell (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias





Buswell 1982


Participants Chronic† population; Primary care; N=50

Interventions E1. Extension exercise program (cites McKenzie); Time:11; Deliv:Individual; Other:Manual therapy;advice to stay active/ education; E2. Flexion program (mobilizing exercises plus posture); Time:11; Deliv:Individual; Other:Manual therapy; advice to stay active/ education;

Outcomes Pain (unknown measure)

Notes

Risk of bias



Calmels (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Calmels 2004



Interventions E1. Isokinetic strengthening exercises (Cybex machines); Time:4.5; Deliv:Individual; Other:Manual ther-apy; E2. Physiotherapy exercises: series of three groups of exercises (whole body); Time:4.5; Deliv:Indi-vidual; Other:None;

Outcomes Pain (VAS), function (QDI)



Calmels 2004 (Continued)

Notes

Risk of bias



Cherkin 1998


Participants Subacute population; Secondary or tertiary care (referred); N=321

Interventions E1. McKenzie exercise program (trained physiotherapists, centralize symptoms); Time:7.3; Deliv:Indi-vidual; Other:Advice to stay active/ education; C1. No treatment; C2. Other conservative

Outcomes Pain (VAS/10), function (RMDQ /23), RTW

Notes

Risk of bias



Chok 1999


Participants Acute population; Secondary or tertiary care (referred); N=54

Interventions E1. Extensor endurance program: aerobics, stretching, strengthening; Time:13.5; Deliv:Individual; Other:Advice to stay active/ education; passive modality; C1. No treatment

Outcomes Pain (VAS), function (RMDQ)

Notes

Risk of bias





Dalichau (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Dalichau 2000



Interventions E1. Strengthening: warm up aerobic exercises, 60 min equipment training (total body); Time:12; Deliv:Individual; Other:Lumbar support; E2. Same as above with no lumbar support during exercises; Time:12; Deliv:Individual; Other:None; C1. No treatment

Outcomes Pain (VAS/10), function (Osw)

Notes

Risk of bias



Davies (ex2)

Methods

Participants

Interventions

Outcomes

Notes



Davies (ex2) (Continued)

Risk of bias



Davies 1979


Participants Subacute population; Primary care; N=43

Interventions E1. Extension exercises (‘prone, raising trunk’ - described as back muscle strengthening); Time:9.6; Deliv:Individual; Other:Passive modality; E2. Flexion exercises (described as ‘mobilizing’) ; Time:9.6; Deliv:Individual; Other:Passive modality; C1. Other conservative

Outcomes Pain (VAS), RTW, global

Notes

Risk of bias



Delitto (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias





Delitto 1993



Interventions E1. Williams flexion exercise regimen with home exercises; Time:7.3; Deliv:Individual; Other:Manualtherapy; E2. McKenzie regimen plus long-lever manipulation; Time:7.3; Deliv:Individual; Other:Manualtherapy;

Outcomes Function (Osw)

Notes

Risk of bias



Descarreaux (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Descarreaux 2002


Participants Chronic† population; General population; N=20

Interventions E1. Standard stretching/ strengthening program; Time:18.3; Deliv:Independent; Other:None; E2. Force,extensibility exercises of trunk and hip muscles based on initial evaluation; targeted increased ; Time:18.3; Deliv:Independent with FU; Other:None;

Outcomes Pain (VAS), function (Osw)



Descarreaux 2002 (Continued)

Notes

Risk of bias


Allocation concealment? High risk C - Inadequate

Deyo 1990



Interventions E1. 12 sequential relaxation and stretching exercises (improve flexibility) (home exercises with repeatedinstruction); exercises plus TENS; Time:10.6; Deliv:Independent with FU; Other:Advice to stay active/education; passive modality; C1. Other conservative

Outcomes Pain (VAS), function (SIP), global

Notes

Risk of bias



Elnaggar (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias





Elnaggar 1991



Interventions E1. Extension exercises (‘prone, raising trunk’ - described as back muscle strengthening); Time:7; Deliv:Independent with FU; Other:None; E2. Flexion exercises (described as ‘mobilizing’); Time:7; Deliv:Independent with FU; Other:None;

Outcomes Pain (MPQ)

Notes

Risk of bias



Faas 1993


Participants Acute population; Primary care; N=473

Interventions E1. Eight exercises: ‘resting position’, side bending, stretching, isometric abdominal strengthening; Time:3.3; Deliv:Individual; Other:Advice to stay active/ education; analgesics/NSAIDS; C1. Sham treatment;C2. Usual GP care

Outcomes Pain (VAS/85), function (LOM), RTW

Notes

Risk of bias



Farrell 1982


Participants Acute population; Unclear; N=48

Interventions E1. Isometric abdominal exercises, ergonomic advice, home abdominal exercises; Time:2.7; Deliv:Indi-vidual; independent; Other:Advice to stay active/ education; passive modality; C1. Other conservative



Farrell 1982 (Continued)

Outcomes Pain (VAS/10), function (BU), global

Notes

Risk of bias



Frost 1995


Participants Chronic population; Primary care; N=71

Interventions E1. Warm-up, stretching, progressive exercises, light aerobic and advice, plus backschool; Time:8; Deliv:Group; Other:Advice to stay active/ education; backschool; C1. Other conservative


Notes

Risk of bias



Frost 2004


Participants Chronic† population; Secondary or tertiary care (referred); N=286

Interventions E1. Standard physiotherapy: 94% received exercises (stretching, strengthening, mobility exercises); Time:3.5; Deliv:Individual; Other:Manual therapy; advice to stay active/ education; C1. Other conservative

Outcomes Function (Osw), global

Notes

Risk of bias




Frost 2004 (Continued)


Galantino 2004


Participants Chronic population; Mixed; N=22

Interventions E1. Hatha yoga: sequence of postures that leads to a state of relaxation (strength, flexibility, balance);Time:19.5; Deliv:Group; independent; Other:None; C1. No treatment

Outcomes Function (Osw)

Notes

Risk of bias



Gilbert (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Gilbert 1985





Gilbert 1985 (Continued)

Interventions E1. Adapted Kendall’s flexion routine (home program), education plus analgesics; Time:4.8; Deliv:Inde-pendent; Other:Advice to stay active/ education; analgesics/NSAIDS; E2. Exercise, education plus bedrest four days; Time:4.8; Deliv:Independent; Other:Education; bed rest; C1. Usual GP care; C2. Otherconservative

Outcomes Pain (MPQ), function (ADS)

Notes

Risk of bias



Gur (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Gur 2003



Interventions E1. Stretching and strengthening exercises of lumbar and extremity muscle groups; Time:5; Deliv:Inde-pendent; Other:None; E2. Same exercises as above with additional intervention; Time:5; Deliv:Indepen-dent; Other:Low power laser therapy; C1. Other conservative


Notes



Gur 2003 (Continued)

Risk of bias



Hansen 1993


Participants Chronic† population; Mixed; N=180

Interventions E1. Intensive dynamic back-muscle training: extension strengthening; Time:8; Deliv:Individual; Other:None; C1. Other conservative; C2. Other conservative

Outcomes Pain (VAS/9), global

Notes

Risk of bias



Hemmila 1997



Interventions E1. Bending, rotation exercises; “auto-stretching when appropriate”; Time:13.8; Deliv:Independent;Other:None; C1. Other conservative; C2. Other conservative

Outcomes Pain (VAS)

Notes

Risk of bias





Hides 1996



Interventions E1. Multifidus isometric retraining; Time:N/A; Deliv:N/A; Other:Advice to stay active/ education; anal-gesics/NSAIDS; C1. Usual GP care

Outcomes Pain (VAS), function (RMDQ)

Notes

Risk of bias



Hildebrandt 2000



Interventions E1. Postural exercises (Cesar therapy); Time:10.5; Deliv:Individual; Other:None; C1. Usual GP care

Outcomes Global

Notes

Risk of bias



Johanssen (ex2)

Methods

Participants

Interventions

Outcomes

Notes



Johanssen (ex2) (Continued)

Risk of bias



Johanssen 1995



Interventions E1. Aerobics, exercises emphasizing coordination, balance, stability, stretching; Time:24; Deliv:Group;Other:None; E2. Aerobics, dynamic exercises emphasizing muscle endurance: abdominal, shoulder, hipmuscles stretching; Time:24; Deliv:Group; Other:None;

Outcomes Pain (Likert/9), function (ADL/12), RTW

Notes

Risk of bias



Jousset (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias





Jousset 2004



Interventions E1. Functional restoration; Time:150; Deliv:Group; Other:None; E2. Active individual therapy (strength-ening, stretching, aerobics recommended); Time:19; Deliv:Individual; independent; Other:Advice to stayactive/ education;

Outcomes Pain (VAS/10), function (QDI), RTW

Notes

Risk of bias



Kankaanpaa 1999



Interventions E1. Strengthening (machines) with stretching, coordination; David Beck Clinic program (functionalrestoration); Time:36; Deliv:Group; Other:Behavioural therapy; advice to stay active/ education; C1.Other conservative

Outcomes Pain (VAS), function (PDI)

Notes

Risk of bias



Kendall (ex2)

Methods

Participants

Interventions

Outcomes



Kendall (ex2) (Continued)

Notes

Risk of bias



Kendall (ex3)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Kendall 1968



Interventions E1. Mobilizing, strengthening, posture; Time:7.9; Deliv:Independent; Other:Advice to stay active/ edu-cation; E2. Isometric flexion exercises: strengthening abdominal and trunk muscles (2 exercises); Time:7.9; Deliv:Independent; Other:Advice to stay active/ education; E3. Strengthening extension muscles,posture, lifting; Time:7.9; Deliv:Independent; Other:Advice to stay active/ education;

Outcomes Global

Notes

Risk of bias





Kuukkanen 2000


Participants Chronic† population; Occupational; N=57

Interventions E1. Strengthening, endurance, balance and coordination; Time:21; Deliv:Independent only; Other:None;C1. No treatment


Notes

Risk of bias



Lidström 1970


Participants Chronic† population; Secondary or tertiary care (referred); N=62

Interventions E1. Mobilizing (kneeling, and supine) and strengthening (isotonic abdom and back) exercises and homeexercises; Time:4.8; Deliv:Individual; independent; Other:Passive modality; C1. Other conservative; C2.Other conservative

Outcomes Global

Notes

Risk of bias



Lie (ex2)

Methods

Participants

Interventions

Outcomes

Notes



Lie (ex2) (Continued)

Risk of bias



Lie 1999



Interventions E1. Mobilizing and stretching, walking in ’flexible way’; Time:15; Deliv:Group; independent; Other:None;

Outcomes Global (COS), includes pain and function

Notes

Risk of bias



Lindstrom 1992


Participants Subacute† population; Occupational; N=103

Interventions E1. Individually graded activity program (quota based): endurance, strengthening, aerobics; Time:133;Deliv:Individual; independent; Other:Advice to stay active/ education; backschool; C1. Usual GP care

Outcomes Pain (VAS), RTW

Notes

Risk of bias





Ljunggren (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Ljunggren 1997


Participants Unclear population; Primary care; N=126

Interventions E1. Terapi-Master device for general exercise: strengthening, stretching; Time:39; Deliv:Independent withFU; Other:None; E2. Conventional PT exercises: low-tech strengthening, stretching; Time:39; Deliv:Independent with FU; Other:None;

Outcomes RTW

Notes

Risk of bias



Malmivaara 1995


Participants Acute population; Occupational; N=186

Interventions E1. Flexibility/mobilizing exercises: back extension, lateral bending movements; Time:10; Deliv:Inde-pendent; Other:Advice to stay active/ education; analgesics/ NSAIDS; C1. No treatment; C2. Otherconservative

Outcomes Pain (VAS/10), function (Osw), RTW



Malmivaara 1995 (Continued)

Notes

Risk of bias



Manniche (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Manniche (ex3)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias





Manniche 1988



Interventions E1. Intensive strengthening: trunk, back strengthening routine; Time:45; Deliv:Individual; Other:None;E2. Back strengthening routine; similar to intensive less dose; Time:45; Deliv:Individual; Other:None;E3. Isometric exercises for L/S ; Time:45; Deliv:Individual; Other:Manual therapy; passive modality;

Outcomes Pain (VAS/30), function (ADL/15)

Notes

Risk of bias



Mannion (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Mannion (ex3)

Methods

Participants

Interventions

Outcomes

Notes



Mannion (ex3) (Continued)

Risk of bias



Mannion 1999



Interventions E1. Aerobics, stretching; Time:24; Deliv:Group; Other:None; E2. Controlled progressive exercises withmachines; David Beck Clinic program (functional restoration); Time:24; Deliv:Group; Other:None; E3.Physiotherapy including exercises using Therabands and general strength training; Time:17.6; Deliv:Individual; Other:Ergonomic advice; passive modality;


Notes

Risk of bias



Moffett 1999


Participants Subacute† population; Primary care; N=187

Interventions E1. Aerobics, strengthening, stretching; Time:8; Deliv:Group; Other:Behavioural therapy; advice to stayactive / education; C1. Usual GP care

Outcomes Pain (APS), function (RMDQ), RTW

Notes

Risk of bias





Moseley 2002



Interventions E1. Specific trunk muscle training: individualized with home exercise program (Richardson&Jull); Time:12; Deliv:Individual; independent; Other:Manual therapy; advice to stay active/ education; C1. UsualGP care

Outcomes Pain (NRS), function (RMDQ /18)

Notes

Risk of bias



Niemisto 2003



Interventions E1. Stablizing exercises aiming to correct lumbopelvic rhythm’; Time:4; Deliv:Individual; independent;Other:Manual therapy; advice to stay active/ education; C1. Usual GP care


Notes

Risk of bias



Petersen (ex2)

Methods

Participants

Interventions

Outcomes

Notes



Petersen (ex2) (Continued)

Risk of bias



Petersen 2002



Interventions E1. Strengthening training: stationary bike, intensive dynamic back strengthening in flexion and extension;Time:6.9; Deliv:Group; Other:None; E2. McKenzie therapy; Time:6.9; Deliv:Individual; Other:None;

Outcomes Pain (VAS/60), function (MRS), RTW, global

Notes

Risk of bias



Preyde (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias





Preyde 2000



Interventions E1. Stretching, flexion/extension, ’general strengthening or mobility’; Time:2; Deliv:Individual; Other:Manual therapy; E2. Comprehensive massage (massage + exercises); Time:2; Deliv:Individual; Other:Advice to stay active/ education; C1. Sham treatment; C2. Other conservative

Outcomes Pain (PPI), function (RMDQ)

Notes

Risk of bias



Rasmussen-Barr 2003



Interventions E1. Stablizing exercises: activation and control deep abdominal, multifidus muscles; Time:7; Deliv:Indi-vidual; independent with follow-up; Other:Advice to stay active/ education; C1. Other conservative


Notes

Risk of bias



Risch 1993



Interventions E1. Dynamic extension strengthening program (machine); Time:11.4; Deliv:Individual; Other:None;C1. No treatment

Outcomes Pain (WHY), function (SIP)



Risch 1993 (Continued)

Notes

Risk of bias



Rittweger (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Rittweger 2002



Interventions E1. Lumbar extension, repetitive contraction cycles, constant speed, load gradually increased; resistanceexercise of the abdominal and thigh muscles ; Time:3; Deliv:Individual; Other:None; E2. Specific exercise:“platform that oscillates around a resting axis between the subjects feet ... during exercise units, the subjectperformed slow movements of the hip and waist, with bending in the sagittal and frontal planes androtation in the horizontal plane”; Time:3; Deliv:Individual; Other:None;

Outcomes Pain (VAS), function (VAS /70)

Notes

Risk of bias




Rittweger 2002 (Continued)


Seferlis 1998


Participants Acute population; Occupational; N=180

Interventions E1. Intensive training program: information, muscle training and general conditioning; Time:130.5;Deliv:Group; Other:Advice to stay active/ education; C1. Other conservative; C2. Usual GP care

Outcomes Pain (VAS/10), function (Osw), RTW

Notes

Risk of bias



Soukup (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Soukup 1999





Soukup 1999 (Continued)

Interventions E1. Mensendiek exercise: aerobic, stretching, strength, coordination and ergonomic education; Time:20; Deliv:Group; Other:None; E2. Active Back School 30 min exercise session; Time:20; Deliv:Group;Other:Backschool; C1. No treatment

Outcomes Pain (VAS), function (VAS)

Notes

Risk of bias



Staal 2004


Participants Subacute population; Occupational; N=134

Interventions E1. Graded activity program; Time:13; Deliv:Individual; Other:Advice to stay active/ education; C1.Usual GP care

Outcomes Pain (NRS/10), function (RMDQ), RTW

Notes

Risk of bias



Stankovic 1990


Participants Acute population; Unclear; N=100

Interventions E1. McKenzie analysis and exercises; Time:2; Deliv:Individual; independent; Other:Advice to stay active/education; C1. No treatment

Outcomes Pain (VAS), RTW

Notes

Risk of bias



Stankovic 1990 (Continued)



Storheim 2003


Participants Subacute population; Occupational; N=93

Interventions E1. Intensive training program: aerobic, strength, flexibility; Time:31; Deliv:Group; Other:None; C1.Other conservative; C2. Usual GP care

Outcomes Pain (VAS), function (RMDQ), RTW

Notes

Risk of bias



Torstensen (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias





Torstensen 1998



Interventions E1. Ordinary activity level: walking exercise program; Time:36; Deliv:Independent; Other:None; E2.MET (medical exercise therapy): mobilizing and strengthening with special equipment; aerobic exercisewarm-up; Time:36; Deliv:Group; Other:None; C1. Other conservative


Notes

Risk of bias



Tritilanunt (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Tritilanunt 2001



Interventions E1. Aerobic exercises; Time:N/A; Deliv:N/A; Other:Advice to stay active/ education; E2. Flexion exercises,posture and behavioural; Time:N/A; Deliv:N/A; Other:Advice to stay active/ education;

Outcomes Pain (VAS)

Notes



Tritilanunt 2001 (Continued)

Risk of bias



Turner (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Turner 1990



Interventions E1. Increasing aerobic fitness (fast walking, slow jogging); warm-up, cool-down stretching; Time:16;Deliv:Group; Other:None; E2. Behavioural/ exercise: same as exercise plus behavioral therapy (withspousal participation); Time:16; Deliv:Group; Other:Behavioural therapy; C1. No treatment; C2. Otherconservative

Outcomes Pain (MPQ), function (SIP)

Notes

Risk of bias





Underwood 1998



Interventions E1. Education regarding McKenzie principles, teaching extension exercises plus general advice; Time:1.8; Deliv:Group; Other:Advice to stay active/ education; analgesics/ NSAIDS; C1. Usual GP care

Outcomes Pain (VAS), function (Osw), RTW, global

Notes

Risk of bias



Waterworth 1985



Interventions E1. Conservative physiotherapy including active flexion and extension exercises; Time:6.3; Deliv:Indi-vidual; Other:Advice to stay active/ education; C1. Other conservative; C2. Other conservative

Outcomes Pain (Likert/4), global

Notes

Risk of bias



Yelland 2004



Interventions E1. Sagittal loading flexibility/ mobilizing exercises; Time:12; Deliv:Independent; Other:Passive modality;C1. Other conservative

Outcomes Pain (VAS), function (RMDQ/23)



Yelland 2004 (Continued)

Notes

Risk of bias



Yeung (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Yeung 2003



Interventions E1. Stretching, mobilizing, strengthening exercises; Time:7.5; Deliv:Group; independent; Other:Adviceto stay active/ education; E2. Stretching, mobilizing, strengthening exercises plus electro-acupuncture;Time:7.5; Deliv:Group; independent; Other:Passive modality; advice to stay active/ education;

Outcomes Pain (NRS/10), function (VAS)

Notes

Risk of bias





Yozbatiran (ex2)

Methods

Participants

Interventions

Outcomes

Notes

Risk of bias



Yozbatiran 2004



Interventions E1. Warm-up, stretching, progressive exercises, light aerobics on land; Time:8; Deliv:Group; Other:None;E2. Warm-up, stretching, progressive exercises, light aerobics in water; Time:8; Deliv:Group; Other:None;


Notes

Risk of bias



Zylbergold 1981



Interventions E1. Flexion exercises; Time:3.5; Deliv:Individual; Other:Passive modality; C1. No treatment; C2. Otherconservative

Outcomes Pain (Likert/5), function (Likert/5)

Notes



Zylbergold 1981 (Continued)

Risk of bias



‡ E=exercise group(s); C=comparison group(s); description of the exercise programs: Time is intervention time (in hours), calculatedas ’best estimate’ when a home exercise program was employed and study compliance information was not available (see text); Delivdescribes the format in which the program was delivered; Other describes any interventions included in the treatment program inaddition to exercise.

§ VAS=Visual analogue scale (unless otherwise noted, /100); RMDQ=Roland Morris Disability Questionnaire (unless otherwise noted/24); Osw=Oswestry Disability Questionnaire (/100); LOM=Loss of Mobility Dimension (/100); BU= Berquist-Ullman functionallimitations; MPQ=McGill Pain Questionnaire (/78); ADS=Activity Discomfort Scale; APS=Aberdeen Pain Scale (/100); NRS=Numer-ical Rating Scale (11 point); MRS= Manniche’s low back pain rating scale (/100); ADL=Activities of Daily Living scale; SIP=SicknessImpact Factor - physical (/100); COS=Clinical Overall Score (/1000); PPI=PPI of McGill Pain Questionnaire (/5); WHY=West HavenYale questionnaire; OEP-VAS=Mean VAS of 13 pain-related questions.† Sensitivity analysis as ’Mixed’ population

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Coxhead 1981 Patient population not meeting our inclusion criteria - specific cause of LBP, neurological symptoms

Danielsen 2000 Post-surgical patients

Danneels 2001 No primary outcome measures

Friedrich 1998 No clear contrast for exercise

Ghoname 1999 No clear contrast for exercise

Hagen 2000 Not true exercise therapy

Helewa 1999 Prevention study, no treatment information

Horneij 2001 Prevention study, no treatment information

Lang 2003 Not randomized

Little 2001 No true exercise therapy

Manniche 1993 Subjects with or without radiation after surgery for lumbar disc protrusion



(Continued)

Martin 1980 “Pseudorandom” allocation

Morton 1999 No clear contrast for exercise

Muller 2001 Prevention study; no treatment data available

Nwuga 1982 Acute LBP due to prolapsed intervertebral disc

Nwuga 1985 Acute LBP due to prolapsed intervertebral disc

O’Sullivan 1997 Chronic LBP with or without radiation, with radiologically confirmed spondylolysis or spondylolisthesis

Sachs 1994 Range of motion reported

Scrimshaw 2001 Post-surgical patients

Snook 1998 Not randomized: initial coin flip, followed by alternate assignments to treatment and control groups

Spratt 1993 There is no clear contrast for exercise in this study. The flexion treatment group received a flexion jacket andinstructions for flexion exercises. The extension treatment group received a hyperextension brace and instructionsfor McKenzie-type extension exercises. The control group received a placebo brace

Strand 2001 Not true exercise therapy

White 1966 Patient populations not meeting our inclusion criteria - specific cause for LBP including neurological symptoms,spondylolisthesis and spondylolysis



D A T A A N D A N A L Y S E S

Comparison 1. Chronic populations

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Function measure (/100):Earliest follow-up

20 1710 Mean Difference (IV, Random, 95% CI) -2.49 [-3.94, -1.04]

1.1 Exercise vs. Notreatment/sham/placebo

7 337 Mean Difference (IV, Random, 95% CI) -2.98 [-6.48, 0.53]

1.2 Exercise vs. Otherconservative treatment


2 Function measure (/100):Short-term follow-up (~6weeks post-randomization)






3 Function measure (/100):Intermediate follow-up (~6months post-randomization)






4 Function measure (/100):Long-term follow-up (~12months post-randomization)






5 Pain measure (/100): Earliestfollow-up






6 Pain measure (/100): Short-termfollow-up (~6 weekspost-randomization)








7 Pain measure (/100):Intermediate follow-up (~6months post-randomization)






8 Pain measure (/100): Long-termfollow-up (~12 monthspost-randomization)






Comparison 2. Subacute populations


studies

No. of













2 321 Mean Difference (IV, Random, 95% CI) 1.26 [-1.87, 4.38]







































Comparison 3. Acute populations


studies

No. of




















































Comparison 4. POPULATION SOURCE: Chronic populations (Exploratory analysis)


studies

No. of


1 Function measure (/100);Earliest follow-up: Indirectcomparisons

21 Mean Difference (IV, Random, 95% CI) Subtotals only

1.1 Health care population 8 645 Mean Difference (IV, Random, 95% CI) -6.94 [-11.67, -2.22]1.2 Occupational population 3 249 Mean Difference (IV, Random, 95% CI) -0.98 [-3.72, 1.75]

1.3 General population ormixed population source




2 Pain measure (/100);Earliest follow-up: Indirectcomparisons

23 Mean Difference (IV, Random, 95% CI) Subtotals only

2.1 Health care population(primary or secondary care)


2.2 Occupational population 4 282 Mean Difference (IV, Random, 95% CI) -9.21 [-22.93, 4.52]

2.3 General population ormixed population source


Comparison 5. Methodological Quality of Included Studies


studies

No. of


1 criteria met Other data No numeric data

Analysis 1.1. Comparison 1 Chronic populations, Outcome 1 Function measure (/100): Earliest follow-up.

Review: Exercise therapy for treatment of non-specific low back pain

Comparison: 1 Chronic populations

Outcome: 1 Function measure (/100): Earliest follow-up

Study or subgroup Exercise Other interventionMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise vs. No treatment/sham/placebo

Dalichau 2000 21 40 (12.89) 21 49 (12.89) 2.8 % -9.00 [ -16.80, -1.20 ]

Kuukkanen 2000 29 10 (7.6) 28 11 (7.8) 6.8 % -1.00 [ -5.00, 3.00 ]

Preyde 2000 22 28.44 (23.35) 26 28.56 (14.6) 1.5 % -0.12 [ -11.38, 11.14 ]

Risch 1993 31 7.7 (9.4) 23 19.3 (15.6) 3.1 % -11.60 [ -18.78, -4.42 ]

Soukup 1999 34 40 (17.8) 35 39 (21.1) 2.1 % 1.00 [ -8.20, 10.20 ]

Turner 1990 24 5.49 (6.79) 23 5.37 (5.93) 7.4 % 0.12 [ -3.52, 3.76 ]

Zylbergold 1981 10 16.28 (4.38) 10 18 (13.46) 2.3 % -1.72 [ -10.49, 7.05 ]

Subtotal (95% CI) 171 166 26.0 % -2.98 [ -6.48, 0.53 ]

Heterogeneity: Tau?? = 10.09; Chi?? = 12.01, df = 6 (P = 0.06); I?? =50%

Test for overall effect: Z = 1.66 (P = 0.096)

2 Exercise vs. Other conservative treatment

-50 -25 0 25 50

Favours Exercise Favours Other tx

(Continued . . . )



(. . . Continued)



Difference


Bendix˙b (ex2) 40 28.31 (31.64) 35 53.61 (24.98) 1.2 % -25.30 [ -38.13, -12.47 ]

Bronfort 1996 71 19.1 (19.3) 51 20.8 (17.3) 3.6 % -1.70 [ -8.23, 4.83 ]

Deyo 1990 63 3.2 (3.1) 62 3.2 (3.1) 12.9 % 0.0 [ -1.09, 1.09 ]

Frost 1995 36 16.3 (10.3) 35 21.2 (14.2) 4.3 % -4.90 [ -10.68, 0.88 ]

Frost 2004 144 18.47 (9.34) 142 20.27 (9.29) 10.7 % -1.80 [ -3.96, 0.36 ]

Gur 2003 25 26.27 (14.6) 25 27.52 (12.09) 3.0 % -1.25 [ -8.68, 6.18 ]

Kankaanpaa 1999 30 14.87 (17.02) 24 16.59 (15.59) 2.3 % -1.72 [ -10.44, 7.00 ]

Niemisto 2003 96 14.7 (11.6) 100 18.6 (11) 8.4 % -3.90 [ -7.07, -0.73 ]

Preyde (ex2) 25 9.84 (11.68) 25 14.34 (11.68) 3.7 % -4.50 [ -10.97, 1.97 ]

Rasmussen-Barr 2003 24 9 (10.29) 23 12 (5.88) 5.6 % -3.00 [ -7.77, 1.77 ]

Torstensen 1998 71 46.2 (13.1) 67 46.9 (13.1) 6.1 % -0.70 [ -5.07, 3.67 ]

Turner (ex2) 24 3.63 (2.98) 25 4.72 (4.12) 11.0 % -1.09 [ -3.10, 0.92 ]

Yelland 2004 55 36.98 (33.06) 55 47.85 (33.06) 1.3 % -10.87 [ -23.23, 1.49 ]

Subtotal (95% CI) 704 669 74.0 % -2.37 [ -4.00, -0.74 ]



Total (95% CI) 875 835 100.0 % -2.49 [ -3.94, -1.04 ]



-50 -25 0 25 50




Analysis 1.2. Comparison 1 Chronic populations, Outcome 2 Function measure (/100): Short-term follow-

up (~6 weeks post-randomization).



Outcome: 2 Function measure (/100): Short-term follow-up (˜6 weeks post-randomization)

Study or subgroup Exercise therapy Other interventionMean


Difference



Dalichau 2000 21 40 (11.5) 21 49 (12.1) 2.5 % -9.00 [ -16.14, -1.86 ]

Kuukkanen 2000 29 10 (7.6) 28 11 (7.8) 6.5 % -1.00 [ -5.00, 3.00 ]

Preyde 2000 22 28.44 (11.44) 26 28.56 (7.15) 3.9 % -0.12 [ -5.63, 5.39 ]

Risch 1993 31 7.7 (9.4) 23 19.3 (15.6) 2.5 % -11.60 [ -18.78, -4.42 ]

Turner 1990 24 5.49 (6.79) 23 5.37 (5.93) 7.4 % 0.12 [ -3.52, 3.76 ]

Zylbergold 1981 10 16.28 (2.48) 10 18 (7.61) 4.6 % -1.72 [ -6.68, 3.24 ]

Subtotal (95% CI) 137 131 27.3 % -3.03 [ -6.35, 0.28 ]




Bronfort 1996 71 19.1 (19.3) 51 20.8 (17.3) 2.9 % -1.70 [ -8.23, 4.83 ]

Deyo 1990 63 3.2 (3.1) 62 3.2 (3.1) 20.0 % 0.0 [ -1.09, 1.09 ]

Frost 1995 36 16.3 (10.3) 35 21.2 (14.2) 3.6 % -4.90 [ -10.68, 0.88 ]

Frost 2004 144 18.47 (9.34) 142 20.27 (9.29) 13.4 % -1.80 [ -3.96, 0.36 ]

Gur 2003 25 26.27 (14.6) 25 27.52 (12.09) 2.3 % -1.25 [ -8.68, 6.18 ]

Kankaanpaa 1999 30 14.87 (17.02) 24 16.59 (15.59) 1.7 % -1.72 [ -10.44, 7.00 ]

Preyde (ex2) 25 9.84 (11.68) 25 14.34 (11.68) 3.0 % -4.50 [ -10.97, 1.97 ]

Rasmussen-Barr 2003 24 9 (10.29) 23 12 (5.88) 4.9 % -3.00 [ -7.77, 1.77 ]

Torstensen 1998 71 46.2 (13.1) 67 46.9 (13.1) 5.7 % -0.70 [ -5.07, 3.67 ]

Turner (ex2) 24 3.63 (2.98) 25 4.72 (4.12) 14.3 % -1.09 [ -3.10, 0.92 ]

Yelland 2004 55 36.98 (33.06) 55 47.85 (33.06) 0.9 % -10.87 [ -23.23, 1.49 ]

Subtotal (95% CI) 568 534 72.7 % -0.81 [ -1.62, 0.00 ]

Heterogeneity: Tau?? = 0.0; Chi?? = 9.67, df = 10 (P = 0.47); I?? =0.0%


Total (95% CI) 705 665 100.0 % -1.75 [ -2.94, -0.56 ]



-50 -25 0 25 50

Favours Exercise Favours Other



Analysis 1.3. Comparison 1 Chronic populations, Outcome 3 Function measure (/100): Intermediate follow-

up (~6 months post-randomization).



Outcome: 3 Function measure (/100): Intermediate follow-up (˜6 months post-randomization)



Difference



Dalichau 2000 21 45 (12.89) 21 52 (12.89) 5.2 % -7.00 [ -14.80, 0.80 ]

Kuukkanen 2000 29 8 (6.6) 28 12 (9) 8.7 % -4.00 [ -8.11, 0.11 ]

Preyde 2000 22 23.8 (20.02) 26 27.1 (17.5) 3.4 % -3.30 [ -14.03, 7.43 ]

Soukup 1999 34 40 (17.8) 35 39 (21.1) 4.2 % 1.00 [ -8.20, 10.20 ]

Subtotal (95% CI) 106 110 21.6 % -3.84 [ -7.06, -0.61 ]




Bendix˙b (ex2) 40 28.3 (31.63) 35 53.6 (24.97) 2.6 % -25.30 [ -38.13, -12.47 ]

Bronfort 1996 71 15.1 (17.4) 51 18.4 (17.1) 6.5 % -3.30 [ -9.50, 2.90 ]

Deyo 1990 63 3.5 (4) 62 2.5 (4) 11.4 % 1.00 [ -0.40, 2.40 ]

Frost 1995 36 15.1 (8.3) 35 23.4 (15.2) 7.0 % -8.30 [ -14.02, -2.58 ]

Frost 2004 144 18.23 (11.59) 142 19.8 (10.61) 10.4 % -1.57 [ -4.14, 1.00 ]

Kankaanpaa 1999 30 8.7 (8.3) 24 19.02 (15.44) 5.9 % -10.32 [ -17.17, -3.47 ]

Niemisto 2003 96 14.7 (11.6) 100 18.6 (11) 9.8 % -3.90 [ -7.07, -0.73 ]

Preyde (ex2) 25 6.42 (8.34) 25 11.93 (12.93) 6.7 % -5.51 [ -11.54, 0.52 ]

Rasmussen-Barr 2003 24 6 (5.88) 23 13 (14.71) 6.3 % -7.00 [ -13.46, -0.54 ]

Turner (ex2) 24 4.51 (4.68) 25 7.6 (9.86) 8.5 % -3.09 [ -7.38, 1.20 ]

Yelland 2004 55 32.63 (28.71) 55 41.33 (33.06) 3.1 % -8.70 [ -20.27, 2.87 ]

Subtotal (95% CI) 608 577 78.4 % -5.07 [ -7.91, -2.23 ]

Heterogeneity: Tau?? = 14.63; Chi?? = 46.25, df = 10 (P<0.00001); I?? =78%


Total (95% CI) 714 687 100.0 % -4.64 [ -7.00, -2.27 ]



-50 -25 0 25 50




Analysis 1.4. Comparison 1 Chronic populations, Outcome 4 Function measure (/100): Long-term follow-up

(~12 months post-randomization).



Outcome: 4 Function measure (/100): Long-term follow-up (˜12 months post-randomization)



Difference



Kuukkanen 2000 29 6 (5.2) 28 10 (9.5) 11.0 % -4.00 [ -8.00, 0.00 ]

Soukup 1999 34 42 (23.8) 35 48 (24.1) 4.8 % -6.00 [ -17.30, 5.30 ]

Subtotal (95% CI) 63 63 15.8 % -4.22 [ -7.99, -0.46 ]




Bendix˙b (ex2) 40 29.6 (19.98) 35 54.61 (12.65) 7.6 % -25.01 [ -32.49, -17.53 ]

Frost 1995 36 15.4 (11.3) 35 22.5 (15.4) 8.7 % -7.10 [ -13.40, -0.80 ]

Frost 2004 144 17.85 (10.99) 142 19.4 (11.47) 12.3 % -1.55 [ -4.15, 1.05 ]

Kankaanpaa 1999 30 7.58 (11.58) 24 14.01 (12.87) 8.4 % -6.43 [ -13.04, 0.18 ]

Niemisto 2003 96 13.7 (11.6) 100 16.5 (11.6) 11.7 % -2.80 [ -6.05, 0.45 ]

Rasmussen-Barr 2003 24 8 (8.82) 23 8 (16.18) 7.5 % 0.0 [ -7.50, 7.50 ]

Torstensen 1998 71 44.1 (13.79) 67 43 (12.9) 10.5 % 1.10 [ -3.35, 5.55 ]

Turner (ex2) 24 4.75 (3.4) 25 5.25 (6.72) 12.0 % -0.50 [ -3.46, 2.46 ]

Yelland 2004 55 20.88 (29.01) 55 22.19 (25.8) 5.4 % -1.31 [ -11.57, 8.95 ]

Subtotal (95% CI) 520 506 84.2 % -4.34 [ -8.00, -0.69 ]



Total (95% CI) 583 569 100.0 % -4.31 [ -7.41, -1.20 ]



-50 -25 0 25 50




Analysis 1.5. Comparison 1 Chronic populations, Outcome 5 Pain measure (/100): Earliest follow-up.



Outcome: 5 Pain measure (/100): Earliest follow-up



Difference



Alexandre 2001 14 6 (17.18) 19 37 (17.18) 3.6 % -31.00 [ -42.86, -19.14 ]

Dalichau 2000 21 21 (17.18) 21 55 (17.18) 4.0 % -34.00 [ -44.39, -23.61 ]

Kuukkanen 2000 29 11.82 (10.91) 28 10 (11.82) 5.1 % 1.82 [ -4.09, 7.73 ]

Preyde 2000 22 32.8 (16) 26 33 (16) 4.3 % -0.20 [ -9.28, 8.88 ]

Risch 1993 31 29 (17) 23 41 (15) 4.5 % -12.00 [ -20.57, -3.43 ]

Soukup 1999 34 23 (16) 35 24 (17) 4.7 % -1.00 [ -8.79, 6.79 ]

Turner 1990 24 22.43 (13.06) 23 26.82 (13.6) 4.7 % -4.39 [ -12.02, 3.24 ]

Zylbergold 1981 10 26 (17) 10 30 (16.4) 3.0 % -4.00 [ -18.64, 10.64 ]

Subtotal (95% CI) 185 185 33.9 % -10.20 [ -19.09, -1.31 ]




Bendix˙b (ex2) 40 27 (23) 35 56 (29) 3.6 % -29.00 [ -40.96, -17.04 ]

Bronfort 1996 71 34 (19) 51 39 (21) 4.8 % -5.00 [ -12.26, 2.26 ]

Deyo 1990 63 19.8 (20.4) 62 25.9 (20.4) 4.8 % -6.10 [ -13.25, 1.05 ]

Frost 1995 36 12.1 (9.9) 35 22.1 (20.1) 4.8 % -10.00 [ -17.40, -2.60 ]

Gur 2003 25 18 (12) 25 19 (14) 4.8 % -1.00 [ -8.23, 6.23 ]

Hansen 1993 56 33.33 (7.78) 59 33.33 (4.44) 5.8 % 0.0 [ -2.33, 2.33 ]

Hemmila 1997 35 30 (17.18) 34 25 (17.18) 4.6 % 5.00 [ -3.11, 13.11 ]

Kankaanpaa 1999 30 36.8 (28.8) 24 44.9 (26.7) 3.0 % -8.10 [ -22.94, 6.74 ]

Moseley 2002 29 19 (15) 28 31 (15) 4.7 % -12.00 [ -19.79, -4.21 ]

Niemisto 2003 96 25 (23) 100 36.1 (23.3) 5.0 % -11.10 [ -17.58, -4.62 ]

Preyde (ex2) 25 8.8 (12) 26 20.8 (14) 4.8 % -12.00 [ -19.15, -4.85 ]

Rasmussen-Barr 2003 24 20 (17.65) 23 24 (33.82) 2.8 % -4.00 [ -19.52, 11.52 ]

Torstensen 1998 71 37.2 (25.3) 67 39 (28) 4.4 % -1.80 [ -10.72, 7.12 ]

-50 -25 0 25 50


(Continued . . . )



(. . . Continued)



Difference


Turner (ex2) 24 18.92 (14.6) 23 22.67 (15.5) 4.4 % -3.75 [ -12.37, 4.87 ]

Yelland 2004 55 42 (20.8) 55 37 (37.8) 3.7 % 5.00 [ -6.40, 16.40 ]

Subtotal (95% CI) 680 647 66.1 % -5.93 [ -9.65, -2.21 ]



Total (95% CI) 865 832 100.0 % -7.29 [ -10.91, -3.67 ]



-50 -25 0 25 50


Analysis 1.6. Comparison 1 Chronic populations, Outcome 6 Pain measure (/100): Short-term follow-up (~6

weeks post-randomization).



Outcome: 6 Pain measure (/100): Short-term follow-up (˜6 weeks post-randomization)



Difference



Dalichau 2000 21 21 (17.18) 21 55 (17.18) 4.6 % -34.00 [ -44.39, -23.61 ]

Kuukkanen 2000 29 11.82 (10.91) 28 10 (11.82) 6.5 % 1.82 [ -4.09, 7.73 ]

Preyde 2000 22 32.8 (16) 26 33 (16) 5.1 % -0.20 [ -9.28, 8.88 ]

Risch 1993 31 29 (17) 23 41 (15) 5.3 % -12.00 [ -20.57, -3.43 ]

Turner 1990 24 22.43 (13.06) 23 26.82 (13.6) 5.8 % -4.39 [ -12.02, 3.24 ]

Zylbergold 1981 10 26 (17) 10 30 (16.4) 3.2 % -4.00 [ -18.64, 10.64 ]

Subtotal (95% CI) 137 131 30.6 % -8.58 [ -18.46, 1.29 ]




-50 -25 0 25 50


(Continued . . . )



(. . . Continued)



Difference


Bronfort 1996 71 34 (19) 51 39 (21) 5.9 % -5.00 [ -12.26, 2.26 ]

Deyo 1990 63 19.8 (20.4) 62 25.9 (20.4) 6.0 % -6.10 [ -13.25, 1.05 ]

Frost 1995 36 12.1 (9.9) 35 22.1 (20.1) 5.9 % -10.00 [ -17.40, -2.60 ]

Gur 2003 25 18 (12) 25 19 (14) 5.9 % -1.00 [ -8.23, 6.23 ]

Hansen 1993 56 33.33 (7.77) 59 33.33 (8.89) 7.6 % 0.0 [ -3.05, 3.05 ]

Hemmila 1997 35 30 (17.18) 34 30 (17.18) 5.5 % 0.0 [ -8.11, 8.11 ]

Kankaanpaa 1999 30 36.8 (28.8) 24 44.9 (26.7) 3.2 % -8.10 [ -22.94, 6.74 ]

Moseley 2002 29 19 (15) 28 31 (15) 5.7 % -12.00 [ -19.79, -4.21 ]

Preyde (ex2) 25 8.8 (12) 26 20.8 (14) 6.0 % -12.00 [ -19.15, -4.85 ]

Rasmussen-Barr 2003 24 20 (17.65) 23 24 (33.82) 3.0 % -4.00 [ -19.52, 11.52 ]

Torstensen 1998 71 37.2 (25.3) 67 39 (28) 5.2 % -1.80 [ -10.72, 7.12 ]

Turner (ex2) 24 18.92 (14.6) 23 22.67 (15.46) 5.3 % -3.75 [ -12.35, 4.85 ]

Yelland 2004 55 42 (20.8) 55 37 (37.8) 4.2 % 5.00 [ -6.40, 16.40 ]

Subtotal (95% CI) 544 512 69.4 % -4.47 [ -7.41, -1.53 ]



Total (95% CI) 681 643 100.0 % -5.64 [ -9.02, -2.26 ]



-50 -25 0 25 50




Analysis 1.7. Comparison 1 Chronic populations, Outcome 7 Pain measure (/100): Intermediate follow-up




Outcome: 7 Pain measure (/100): Intermediate follow-up (˜6 months post-randomization)



Difference



Alexandre 2001 14 6 (17.18) 19 37 (17.18) 5.4 % -31.00 [ -42.86, -19.14 ]

Dalichau 2000 21 33 (17.18) 21 56 (17.18) 5.9 % -23.00 [ -33.39, -12.61 ]

Kuukkanen 2000 29 9.09 (11.82) 28 11.8 (14.5) 7.2 % -2.71 [ -9.59, 4.17 ]

Preyde 2000 22 26.6 (16) 26 35 (12) 6.7 % -8.40 [ -16.52, -0.28 ]

Soukup 1999 34 23 (16) 35 24 (17) 6.9 % -1.00 [ -8.79, 6.79 ]

Subtotal (95% CI) 120 129 32.1 % -12.48 [ -22.69, -2.27 ]




Bendix˙b (ex2) 40 27 (23) 35 56 (29) 5.4 % -29.00 [ -40.96, -17.04 ]

Bronfort 1996 71 27 (20) 51 33 (23) 6.8 % -6.00 [ -13.84, 1.84 ]

Deyo 1990 63 26.5 (24.6) 62 25.6 (24.6) 6.6 % 0.90 [ -7.73, 9.53 ]

Hansen 1993 56 44.4 (13.3) 59 44.4 (8.88) 8.0 % 0.0 [ -4.16, 4.16 ]

Hemmila 1997 35 29 (17.18) 34 25 (17.18) 6.7 % 4.00 [ -4.11, 12.11 ]

Kankaanpaa 1999 30 35.9 (27.4) 24 46 (20.5) 5.1 % -10.10 [ -22.88, 2.68 ]

Niemisto 2003 96 25 (23) 100 36.1 (23.3) 7.3 % -11.10 [ -17.58, -4.62 ]

Preyde (ex2) 25 8.4 (12) 25 23.6 (30) 5.2 % -15.20 [ -27.87, -2.53 ]

Rasmussen-Barr 2003 24 14 (16.18) 23 22 (33.82) 4.4 % -8.00 [ -23.26, 7.26 ]

Turner (ex2) 24 17 (11.7) 25 24.96 (20.12) 6.4 % -7.96 [ -17.13, 1.21 ]

Yelland 2004 55 33 (24.6) 55 32 (28.4) 6.1 % 1.00 [ -8.93, 10.93 ]

Subtotal (95% CI) 519 493 67.9 % -6.55 [ -11.52, -1.57 ]



Total (95% CI) 639 622 100.0 % -8.42 [ -12.98, -3.86 ]



-50 -25 0 25 50




Analysis 1.8. Comparison 1 Chronic populations, Outcome 8 Pain measure (/100): Long-term follow-up




Outcome: 8 Pain measure (/100): Long-term follow-up (˜12 months post-randomization)



Difference



Kuukkanen 2000 29 9.09 (11.82) 28 11.87 (16.36) 9.9 % -2.78 [ -10.21, 4.65 ]

Soukup 1999 34 26 (19) 35 32 (23) 8.8 % -6.00 [ -15.94, 3.94 ]

Subtotal (95% CI) 63 63 18.7 % -3.93 [ -9.89, 2.02 ]




Bendix˙b (ex2) 40 33 (34) 35 65 (25) 7.2 % -32.00 [ -45.40, -18.60 ]

Bronfort 1996 71 29 (18.4) 51 28.5 (20.6) 10.1 % 0.50 [ -6.59, 7.59 ]

Hansen 1993 56 27.8 (8.9) 59 44.4 (11.1) 11.4 % -16.60 [ -20.27, -12.93 ]

Kankaanpaa 1999 30 28 (18.6) 24 44.4 (22.5) 8.2 % -16.40 [ -27.60, -5.20 ]

Niemisto 2003 96 26 (23) 100 32.2 (23.3) 10.4 % -6.20 [ -12.68, 0.28 ]

Rasmussen-Barr 2003 24 13 (14.71) 23 18 (29.41) 7.2 % -5.00 [ -18.38, 8.38 ]

Torstensen 1998 71 40.5 (24.4) 67 42.9 (29.5) 9.2 % -2.40 [ -11.46, 6.66 ]

Turner (ex2) 24 23.3 (17.04) 25 21 (17.45) 8.9 % 2.30 [ -7.36, 11.96 ]

Yelland 2004 55 20.5 (28.2) 55 16.5 (26) 8.7 % 4.00 [ -6.14, 14.14 ]

Subtotal (95% CI) 467 439 81.3 % -7.62 [ -14.45, -0.79 ]



Total (95% CI) 530 502 100.0 % -6.97 [ -12.69, -1.24 ]



-50 -25 0 25 50




Analysis 2.1. Comparison 2 Subacute populations, Outcome 1 Function measure (/100): Earliest follow-up.


Comparison: 2 Subacute populations




Difference



Cherkin 1998 129 17.84 (20.01) 65 21.32 (18.7) 27.5 % -3.48 [ -9.19, 2.23 ]

Subtotal (95% CI) 129 65 27.5 % -3.48 [ -9.19, 2.23 ]

Heterogeneity: not applicable



Moffett 1999 89 15.8 (13.34) 98 15.1 (13.34) 37.8 % 0.70 [ -3.13, 4.53 ]

Staal 2004 67 26.27 (27.94) 67 20.43 (25.85) 15.5 % 5.84 [ -3.27, 14.95 ]

Storheim 2003 30 25.44 (15.85) 34 32.11 (15.85) 19.3 % -6.67 [ -14.45, 1.11 ]

Subtotal (95% CI) 186 199 72.5 % -0.18 [ -5.99, 5.63 ]



Total (95% CI) 315 264 100.0 % -1.07 [ -5.32, 3.18 ]



-20 -10 0 10 20




Analysis 2.2. Comparison 2 Subacute populations, Outcome 2 Function measure (/100): Short-term follow-

up (~6 weeks post-randomization).






Difference



Cherkin 1998 129 17.84 (9.59) 65 21.32 (8.97) 40.8 % -3.48 [ -6.22, -0.74 ]

Subtotal (95% CI) 129 65 40.8 % -3.48 [ -6.22, -0.74 ]




Moffett 1999 89 15.8 (6.53) 98 15.1 (6.53) 45.7 % 0.70 [ -1.17, 2.57 ]

Staal 2004 67 26.27 (27.94) 67 20.43 (25.85) 13.5 % 5.84 [ -3.27, 14.95 ]

Subtotal (95% CI) 156 165 59.2 % 1.26 [ -1.87, 4.38 ]



Total (95% CI) 285 230 100.0 % -0.31 [ -4.22, 3.60 ]



-20 -10 0 10 20




Analysis 2.3. Comparison 2 Subacute populations, Outcome 3 Function measure (/100): Intermediate

follow-up (~6 months post-randomization).




Study or subgroup Exercise therapy OtherMean


Difference



Cherkin 1998 129 17.84 (21.75) 65 18.7 (21.32) 26.3 % -0.86 [ -7.26, 5.54 ]

Subtotal (95% CI) 129 65 26.3 % -0.86 [ -7.26, 5.54 ]




Moffett 1999 89 15.26 (16.26) 98 16.35 (16.26) 39.5 % -1.09 [ -5.76, 3.58 ]

Staal 2004 67 32.53 (27.52) 67 26.69 (27.52) 14.6 % 5.84 [ -3.48, 15.16 ]

Storheim 2003 30 25.44 (15.85) 34 32.11 (15.85) 19.6 % -6.67 [ -14.45, 1.11 ]

Subtotal (95% CI) 186 199 73.7 % -1.08 [ -6.90, 4.74 ]



Total (95% CI) 315 264 100.0 % -1.11 [ -5.00, 2.78 ]



-20 -10 0 10 20




Analysis 2.4. Comparison 2 Subacute populations, Outcome 4 Function measure (/100): Long-term follow-







Difference



Cherkin 1998 129 11.31 (19) 65 19.58 (18.8) 46.7 % -8.27 [ -13.89, -2.65 ]

Subtotal (95% CI) 129 65 46.7 % -8.27 [ -13.89, -2.65 ]




Moffett 1999 89 14.42 (15.43) 98 15.8 (15.43) 53.3 % -1.38 [ -5.81, 3.05 ]

Subtotal (95% CI) 89 98 53.3 % -1.38 [ -5.81, 3.05 ]



Total (95% CI) 218 163 100.0 % -4.60 [ -11.34, 2.14 ]



-20 -10 0 10 20




Analysis 2.5. Comparison 2 Subacute populations, Outcome 5 Pain measure (/100): Earliest follow-up.






Difference



Cherkin 1998 129 23 (29) 65 31 (32) 9.0 % -8.00 [ -17.25, 1.25 ]

Subtotal (95% CI) 129 65 9.0 % -8.00 [ -17.25, 1.25 ]




Davies 1979 14 1.8 (3.6) 15 3.7 (5.4) 34.7 % -1.90 [ -5.22, 1.42 ]

Moffett 1999 89 16.35 (9.9) 98 16.53 (9.9) 39.1 % -0.18 [ -3.02, 2.66 ]

Staal 2004 67 28 (24) 67 25 (28) 9.8 % 3.00 [ -5.83, 11.83 ]

Storheim 2003 30 38.3 (22.4) 34 48.3 (19.9) 7.3 % -10.00 [ -20.44, 0.44 ]

Subtotal (95% CI) 200 214 91.0 % -1.21 [ -4.01, 1.59 ]



Total (95% CI) 329 279 100.0 % -1.89 [ -4.91, 1.13 ]



-50 -25 0 25 50




Analysis 2.6. Comparison 2 Subacute populations, Outcome 6 Pain measure (/100): Short-term follow-up

(~6 weeks post-randomization).






Difference



Cherkin 1998 129 23 (9.17) 65 31 (10.12) 28.8 % -8.00 [ -10.93, -5.07 ]

Subtotal (95% CI) 129 65 28.8 % -8.00 [ -10.93, -5.07 ]


Test for overall effect: Z = 5.36 (P < 0.00001)


Davies 1979 14 1.8 (3.6) 15 3.7 (5.4) 27.8 % -1.90 [ -5.22, 1.42 ]

Moffett 1999 89 16.35 (9.9) 98 16.53 (9.9) 29.0 % -0.18 [ -3.02, 2.66 ]

Staal 2004 67 28 (24) 67 25 (28) 14.3 % 3.00 [ -5.83, 11.83 ]

Subtotal (95% CI) 170 180 71.2 % -0.69 [ -2.78, 1.41 ]



Total (95% CI) 299 245 100.0 % -2.46 [ -6.91, 1.99 ]



-20 -10 0 10 20




Analysis 2.7. Comparison 2 Subacute populations, Outcome 7 Pain measure (/100): Intermediate follow-up







Difference



Cherkin 1998 129 27 (28) 65 32 (32) 18.2 % -5.00 [ -14.16, 4.16 ]

Subtotal (95% CI) 129 65 18.2 % -5.00 [ -14.16, 4.16 ]




Moffett 1999 89 17.67 (12) 98 17.41 (12) 50.9 % 0.26 [ -3.18, 3.70 ]

Staal 2004 67 29 (31) 67 27 (28) 15.9 % 2.00 [ -8.00, 12.00 ]

Storheim 2003 30 38.3 (22.4) 34 48.3 (19.9) 14.9 % -10.00 [ -20.44, 0.44 ]

Subtotal (95% CI) 186 199 81.8 % -1.54 [ -7.36, 4.27 ]



Total (95% CI) 315 264 100.0 % -1.95 [ -6.48, 2.57 ]



-50 -25 0 25 50




Analysis 2.8. Comparison 2 Subacute populations, Outcome 8 Pain measure (/100): Long-term follow-up







Difference



Cherkin 1998 129 20 (20) 65 28 (22) 39.0 % -8.00 [ -14.37, -1.63 ]

Subtotal (95% CI) 129 65 39.0 % -8.00 [ -14.37, -1.63 ]




Moffett 1999 89 15.01 (11.2) 98 17.04 (11.2) 61.0 % -2.03 [ -5.24, 1.18 ]

Subtotal (95% CI) 89 98 61.0 % -2.03 [ -5.24, 1.18 ]



Total (95% CI) 218 163 100.0 % -4.36 [ -10.06, 1.35 ]



-20 -10 0 10 20




Analysis 3.1. Comparison 3 Acute populations, Outcome 1 Pain measure (/100): Earliest follow-up.


Comparison: 3 Acute populations




Difference



Chok 1999 30 10.2 (29.9) 24 22.8 (18.5) 1.1 % -12.60 [ -25.61, 0.41 ]

Faas 1993 156 20.18 (24.78) 162 21 (27.14) 5.1 % -0.82 [ -6.53, 4.89 ]

Malmivaara 1995 52 31 (17.21) 67 19 (17.21) 4.4 % 12.00 [ 5.77, 18.23 ]

Subtotal (95% CI) 238 253 10.5 % 0.59 [ -11.51, 12.69 ]




Farrell 1982 24 3 (17.21) 24 3 (17.21) 1.9 % 0.0 [ -9.74, 9.74 ]

Gilbert (ex2) 65 10.7 (1.13) 65 11.01 (1.68) 40.5 % -0.31 [ -0.80, 0.18 ]

Gilbert 1985 62 9.55 (1.54) 60 9.83 (2.55) 37.9 % -0.28 [ -1.03, 0.47 ]

Hides 1996 21 0 (25.7) 20 11 (25.7) 0.7 % -11.00 [ -26.74, 4.74 ]

Seferlis 1998 60 46 (17) 60 46 (17) 4.5 % 0.0 [ -6.08, 6.08 ]

Underwood 1998 35 18 (28.4) 40 23.4 (28.4) 1.1 % -5.40 [ -18.28, 7.48 ]

Waterworth 1985 34 11 (17.1) 36 11 (17.1) 2.7 % 0.0 [ -8.01, 8.01 ]

Subtotal (95% CI) 301 305 89.5 % -0.31 [ -0.72, 0.10 ]



Total (95% CI) 539 558 100.0 % -0.03 [ -1.40, 1.34 ]



-50 -25 0 25 50




Analysis 3.2. Comparison 3 Acute populations, Outcome 2 Pain measure (/100): Short-term follow-up (~6

weeks post-randomization).






Difference



Chok 1999 30 10.2 (29.9) 24 22.8 (18.5) 1.1 % -12.60 [ -25.61, 0.41 ]

Faas 1993 156 20.18 (24.78) 162 21 (27.14) 5.1 % -0.82 [ -6.53, 4.89 ]

Malmivaara 1995 52 31 (17.21) 67 19 (17.21) 4.4 % 12.00 [ 5.77, 18.23 ]

Subtotal (95% CI) 238 253 10.5 % 0.59 [ -11.51, 12.69 ]




Farrell 1982 24 3 (17.21) 24 3 (17.21) 1.9 % 0.0 [ -9.74, 9.74 ]

Gilbert (ex2) 65 10.7 (1.13) 65 11.01 (1.68) 40.5 % -0.31 [ -0.80, 0.18 ]

Gilbert 1985 62 9.55 (1.54) 60 9.83 (2.55) 37.9 % -0.28 [ -1.03, 0.47 ]

Hides 1996 21 0 (25.7) 20 11 (25.7) 0.7 % -11.00 [ -26.74, 4.74 ]

Seferlis 1998 60 46 (17) 60 46 (17) 4.6 % 0.0 [ -6.08, 6.08 ]

Underwood 1998 35 18 (28.4) 40 23.4 (28.4) 1.1 % -5.40 [ -18.28, 7.48 ]

Waterworth 1985 34 11 (17.21) 36 11 (17.21) 2.7 % 0.0 [ -8.07, 8.07 ]

Subtotal (95% CI) 301 305 89.5 % -0.31 [ -0.72, 0.10 ]



Total (95% CI) 539 558 100.0 % -0.03 [ -1.40, 1.34 ]



-50 -25 0 25 50




Analysis 3.3. Comparison 3 Acute populations, Outcome 3 Pain measure (/100): Intermediate follow-up (~6

months post-randomization).






Difference



Chok 1999 30 8.1 (34.7) 24 20.1 (24.4) 7.9 % -12.00 [ -27.79, 3.79 ]

Faas 1993 156 14.28 (28.32) 162 17.46 (33.04) 29.9 % -3.18 [ -9.94, 3.58 ]

Malmivaara 1995 52 18 (18) 67 13 (18) 31.2 % 5.00 [ -1.52, 11.52 ]

Subtotal (95% CI) 238 253 69.0 % -1.39 [ -9.54, 6.76 ]




Seferlis 1998 60 35 (26) 60 35 (26) 19.2 % 0.0 [ -9.30, 9.30 ]

Underwood 1998 35 11.1 (27.6) 40 12 (27.6) 11.8 % -0.90 [ -13.42, 11.62 ]

Subtotal (95% CI) 95 100 31.0 % -0.32 [ -7.79, 7.15 ]



Total (95% CI) 333 353 100.0 % -0.44 [ -5.11, 4.23 ]



-50 -25 0 25 50




Analysis 3.4. Comparison 3 Acute populations, Outcome 4 Pain measure (/100): Long-term follow-up (~12

months post-randomization).






Difference



Faas 1993 156 11.92 (27.14) 162 12.74 (30.68) 43.7 % -0.82 [ -7.18, 5.54 ]

Subtotal (95% CI) 156 162 43.7 % -0.82 [ -7.18, 5.54 ]




Seferlis 1998 60 25 (17) 60 25 (17) 47.8 % 0.0 [ -6.08, 6.08 ]

Underwood 1998 35 8.6 (31.8) 40 13.7 (31.8) 8.5 % -5.10 [ -19.53, 9.33 ]

Subtotal (95% CI) 95 100 56.3 % -0.77 [ -6.38, 4.84 ]



Total (95% CI) 251 262 100.0 % -0.79 [ -5.00, 3.41 ]



-20 -10 0 10 20




Analysis 3.5. Comparison 3 Acute populations, Outcome 5 Function measure (/100): Earliest follow-up.






Difference



Chok 1999 30 16.68 (26.67) 24 39.62 (16.68) 7.1 % -22.94 [ -34.59, -11.29 ]

Faas 1993 156 15.3 (19) 162 13.3 (18) 13.6 % 2.00 [ -2.07, 6.07 ]

Malmivaara 1995 52 18.6 (16.4) 67 10 (16.4) 11.9 % 8.60 [ 2.66, 14.54 ]

Subtotal (95% CI) 238 253 32.5 % -2.82 [ -15.35, 9.71 ]




Farrell 1982 24 40 (14.88) 24 36.66 (14.88) 9.6 % 3.34 [ -5.08, 11.76 ]

Gilbert (ex2) 65 24.35 (8.75) 65 20.9 (8.46) 14.5 % 3.45 [ 0.49, 6.41 ]

Gilbert 1985 62 21.34 (9.22) 60 24.34 (10.04) 14.1 % -3.00 [ -6.42, 0.42 ]

Hides 1996 20 0 (14.88) 19 12.51 (14.88) 8.8 % -12.51 [ -21.85, -3.17 ]

Seferlis 1998 60 20 (18) 60 20 (18) 11.4 % 0.0 [ -6.44, 6.44 ]

Underwood 1998 35 7.6 (19.6) 40 11.5 (19.6) 9.1 % -3.90 [ -12.79, 4.99 ]

Subtotal (95% CI) 266 268 67.5 % -1.34 [ -5.50, 2.81 ]



Total (95% CI) 504 521 100.0 % -1.38 [ -5.56, 2.79 ]



-50 -25 0 25 50




Analysis 3.6. Comparison 3 Acute populations, Outcome 6 Function measure (/100): Short-term follow-up

(~6 weeks post-randomization).






Difference



Chok 1999 30 16.68 (26.67) 24 39.62 (16.68) 7.1 % -22.94 [ -34.59, -11.29 ]

Faas 1993 156 15.3 (19) 162 13.3 (18) 13.6 % 2.00 [ -2.07, 6.07 ]

Malmivaara 1995 52 18.6 (16.4) 67 10 (16.4) 11.9 % 8.60 [ 2.66, 14.54 ]

Subtotal (95% CI) 238 253 32.5 % -2.82 [ -15.35, 9.71 ]




Farrell 1982 24 40 (14.88) 24 36.66 (14.88) 9.6 % 3.34 [ -5.08, 11.76 ]

Gilbert (ex2) 65 24.35 (8.75) 65 20.9 (8.46) 14.5 % 3.45 [ 0.49, 6.41 ]

Gilbert 1985 62 21.34 (9.22) 60 24.34 (10.04) 14.1 % -3.00 [ -6.42, 0.42 ]

Hides 1996 20 0 (14.88) 19 12.51 (14.88) 8.8 % -12.51 [ -21.85, -3.17 ]

Seferlis 1998 60 20 (18) 60 20 (18) 11.4 % 0.0 [ -6.44, 6.44 ]

Underwood 1998 35 7.6 (19.6) 40 11.5 (19.6) 9.1 % -3.90 [ -12.79, 4.99 ]

Subtotal (95% CI) 266 268 67.5 % -1.34 [ -5.50, 2.81 ]



Total (95% CI) 504 521 100.0 % -1.38 [ -5.56, 2.79 ]



-50 -25 0 25 50




Analysis 3.7. Comparison 3 Acute populations, Outcome 7 Function measure (/100): Intermediate follow-







Difference



Chok 1999 30 12.51 (24.19) 24 16.68 (22.52) 3.2 % -4.17 [ -16.66, 8.32 ]

Faas 1993 154 12.3 (20) 162 10.3 (19) 27.0 % 2.00 [ -2.31, 6.31 ]

Malmivaara 1995 52 10.8 (10.2) 67 7.4 (10.2) 36.7 % 3.40 [ -0.29, 7.09 ]

Subtotal (95% CI) 236 253 67.0 % 2.47 [ -0.26, 5.21 ]




Seferlis 1998 60 11.7 (12) 60 11.7 (12) 27.2 % 0.0 [ -4.29, 4.29 ]

Underwood 1998 35 4.7 (20.4) 40 7 (20.4) 5.9 % -2.30 [ -11.55, 6.95 ]

Subtotal (95% CI) 95 100 33.0 % -0.41 [ -4.30, 3.49 ]



Total (95% CI) 331 353 100.0 % 1.52 [ -0.72, 3.76 ]



-20 -10 0 10 20




Analysis 3.8. Comparison 3 Acute populations, Outcome 8 Function measure (/100): Long-term follow-up







Difference



Faas 1993 154 10.3 (19) 162 8.3 (19) 42.8 % 2.00 [ -2.19, 6.19 ]

Subtotal (95% CI) 154 162 42.8 % 2.00 [ -2.19, 6.19 ]




Seferlis 1998 60 9.8 (11) 60 9.8 (11) 48.5 % 0.0 [ -3.94, 3.94 ]

Underwood 1998 35 4.7 (20.4) 40 8 (20.4) 8.8 % -3.30 [ -12.55, 5.95 ]

Subtotal (95% CI) 95 100 57.2 % -0.51 [ -4.13, 3.12 ]



Total (95% CI) 249 262 100.0 % 0.57 [ -2.17, 3.31 ]



-20 -10 0 10 20




Analysis 4.1. Comparison 4 POPULATION SOURCE: Chronic populations (Exploratory analysis),

Outcome 1 Function measure (/100); Earliest follow-up: Indirect comparisons.


Comparison: 4 POPULATION SOURCE: Chronic populations (Exploratory analysis)

Outcome: 1 Function measure (/100); Earliest follow-up: Indirect comparisons



Difference


1 Health care population

Bendix˙b (ex2) 40 28.31 (17.34) 35 53.61 (13.69) 9.8 % -25.30 [ -32.33, -18.27 ]

Dalichau 2000 21 40 (11.5) 21 49 (12.1) 9.6 % -9.00 [ -16.14, -1.86 ]

Frost 1995 36 16.3 (10.3) 35 21.2 (14.2) 12.1 % -4.90 [ -10.68, 0.88 ]

Frost 2004 144 18.47 (9.34) 142 20.27 (9.29) 21.2 % -1.80 [ -3.96, 0.36 ]

Gur 2003 25 26.27 (14.6) 25 27.52 (12.09) 9.2 % -1.25 [ -8.68, 6.18 ]

Rasmussen-Barr 2003 24 9 (10.29) 23 12 (5.88) 14.5 % -3.00 [ -7.77, 1.77 ]

Risch 1993 31 7.7 (9.4) 23 19.3 (15.6) 9.6 % -11.60 [ -18.78, -4.42 ]

Zylbergold 1981 10 16.28 (2.48) 10 18 (7.61) 14.0 % -1.72 [ -6.68, 3.24 ]

Subtotal (95% CI) 331 314 100.0 % -6.94 [ -11.67, -2.22 ]



2 Occupational population

Kankaanpaa 1999 30 14.87 (14.23) 24 16.59 (13.03) 22.8 % -1.72 [ -9.01, 5.57 ]

Kuukkanen 2000 29 10 (7.6) 28 11 (7.8) 39.8 % -1.00 [ -5.00, 3.00 ]

Torstensen 1998 71 46.2 (13.1) 67 46.9 (13.1) 37.4 % -0.70 [ -5.07, 3.67 ]

Subtotal (95% CI) 130 119 100.0 % -0.98 [ -3.72, 1.75 ]



3 General population or mixed population source

Bronfort 1996 71 19.1 (19.3) 51 20.8 (17.3) 7.1 % -1.70 [ -8.23, 4.83 ]

Deyo 1990 63 3.2 (3.1) 62 3.2 (3.1) 15.5 % 0.0 [ -1.09, 1.09 ]

Mannion 1999 49 27.94 (10.21) 49 28.36 (10.01) 10.9 % -0.42 [ -4.42, 3.58 ]

Niemisto 2003 96 14.7 (11.6) 100 18.6 (11) 12.4 % -3.90 [ -7.07, -0.73 ]

Preyde (ex2) 25 9.84 (5.72) 25 14.34 (5.72) 12.4 % -4.50 [ -7.67, -1.33 ]

Preyde 2000 22 28.44 (11.44) 26 28.56 (7.15) 8.4 % -0.12 [ -5.63, 5.39 ]

Soukup 1999 34 40 (17.8) 35 39 (21.1) 4.6 % 1.00 [ -8.20, 10.20 ]

-50 -25 0 25 50


(Continued . . . )



(. . . Continued)



Difference


Turner (ex2) 24 3.63 (2.98) 25 4.72 (4.12) 14.3 % -1.09 [ -3.10, 0.92 ]

Turner 1990 24 5.49 (6.79) 23 5.37 (5.93) 11.5 % 0.12 [ -3.52, 3.76 ]

Yelland 2004 55 36.98 (33.06) 55 47.85 (33.06) 2.9 % -10.87 [ -23.23, 1.49 ]

Subtotal (95% CI) 463 451 100.0 % -1.39 [ -2.73, -0.05 ]



-50 -25 0 25 50


Analysis 4.2. Comparison 4 POPULATION SOURCE: Chronic populations (Exploratory analysis),

Outcome 2 Pain measure (/100); Earliest follow-up: Indirect comparisons.


Comparison: 4 POPULATION SOURCE: Chronic populations (Exploratory analysis)

Outcome: 2 Pain measure (/100); Earliest follow-up: Indirect comparisons



Difference


1 Health care population (primary or secondary care)

Bendix˙b (ex2) 40 27 (23) 35 56 (29) 11.3 % -29.00 [ -40.96, -17.04 ]

Dalichau 2000 21 21 (17.18) 21 55 (17.18) 12.5 % -34.00 [ -44.39, -23.61 ]

Frost 1995 36 12.1 (9.9) 35 22.1 (20.1) 14.9 % -10.00 [ -17.40, -2.60 ]

Gur 2003 25 18 (12) 25 19 (14) 15.0 % -1.00 [ -8.23, 6.23 ]

Moseley 2002 29 19 (15) 28 31 (15) 14.6 % -12.00 [ -19.79, -4.21 ]

Rasmussen-Barr 2003 24 20 (17.65) 23 24 (33.82) 8.9 % -4.00 [ -19.52, 11.52 ]

Risch 1993 31 29 (17) 23 41 (15) 13.9 % -12.00 [ -20.57, -3.43 ]

Zylbergold 1981 10 26 (17) 10 30 (18) 9.0 % -4.00 [ -19.35, 11.35 ]

Subtotal (95% CI) 216 200 100.0 % -13.33 [ -21.13, -5.53 ]


-50 -25 0 25 50


(Continued . . . )



(. . . Continued)



Difference



2 Occupational population

Alexandre 2001 14 6 (17.18) 19 37 (17.18) 22.5 % -31.00 [ -42.86, -19.14 ]

Kankaanpaa 1999 30 36.8 (28.8) 24 44.9 (26.7) 18.5 % -8.10 [ -22.94, 6.74 ]

Kuukkanen 2000 29 11.82 (10.91) 28 10 (11.82) 31.9 % 1.82 [ -4.09, 7.73 ]

Torstensen 1998 71 37.2 (25.3) 67 39 (28) 27.1 % -1.80 [ -10.72, 7.12 ]

Subtotal (95% CI) 144 138 100.0 % -9.21 [ -22.93, 4.52 ]



3 General population or mixed population source

Bronfort 1996 71 34 (19) 51 39 (21) 9.3 % -5.00 [ -12.26, 2.26 ]

Deyo 1990 63 19.8 (20.4) 62 25.9 (20.4) 9.3 % -6.10 [ -13.25, 1.05 ]

Hansen 1993 56 33.33 (7.78) 59 33.33 (4.44) 11.2 % 0.0 [ -2.33, 2.33 ]

Hemmila 1997 35 30 (17.18) 34 25 (17.18) 8.9 % 5.00 [ -3.11, 13.11 ]

Niemisto 2003 96 25 (23) 100 36.1 (23.3) 9.7 % -11.10 [ -17.58, -4.62 ]

Preyde (ex2) 25 8.8 (12) 26 20.8 (14) 9.3 % -12.00 [ -19.15, -4.85 ]

Preyde 2000 22 32.8 (16) 26 33 (16) 8.4 % -0.20 [ -9.28, 8.88 ]

Soukup 1999 34 23 (16) 35 24 (17) 9.0 % -1.00 [ -8.79, 6.79 ]

Turner (ex2) 24 18.92 (14.6) 23 22.67 (15.5) 8.6 % -3.75 [ -12.37, 4.87 ]

Turner 1990 24 22.43 (13.06) 23 26.82 (13.6) 9.1 % -4.39 [ -12.02, 3.24 ]

Yelland 2004 55 42 (20.8) 55 37 (37.8) 7.2 % 5.00 [ -6.40, 16.40 ]

Subtotal (95% CI) 505 494 100.0 % -3.37 [ -6.61, -0.13 ]



-50 -25 0 25 50


Analysis 5.1. Comparison 5 Methodological Quality of Included Studies, Outcome 1 criteria met.

criteria met

Study randomization OK allocation concealed adequate follow-up outcome assess blind

Alexandre 2001 unclear unclear yes unclear

Aure 2003 yes yes yes no

Bendix a 2000 unclear unclear no no



criteria met (Continued)

Bendix b 1995 yes unclear no no

Bentsen 1997 yes yes yes no

Bronfort 1996 yes yes no yes

Buswell 1982 no unclear no no

Calmels 2004 unclear unclear yes no

Cherkin 1998 yes yes yes no

Chok 1999 yes unclear yes no

Dalichau 2000 unclear unclear yes no

Davies 1979 no unclear yes yes

Delitto 1993 no unclear unclear no

Descarreaux 2002 yes no yes no

Deyo 1990 yes yes yes yes

Elnaggar 1991 yes yes no yes

Faas 1993 no unclear yes yes

Farrell 1982 no unclear yes yes

Frost 1995 yes yes yes yes

Frost 2004 yes yes no no

Galantino 2004 yes unclear no no

Gilbert 1985 no unclear yes no

Gur 2003 unclear unclear yes no

Hansen 1993 yes yes yes yes

Hemmila 1997 no yes yes yes

Hides 1996 yes yes yes no

Hildebrandt 2000 yes yes no no




Johanssen 1995 no unclear no no

Jousset 2004 yes unclear yes no

Kankaanpaa 1999 yes yes yes no

Kendall 1968 no unclear yes no

Kuukkanen 2000 unclear unclear yes no

Lidström 1970 no unclear yes unclear

Lie 1999 yes unclear no yes

Lindstrom 1992 yes yes yes yes

Ljunggren 1997 yes yes yes no

Malmivaara 1995 yes yes yes yes

Manniche 1988 yes yes yes yes

Mannion 1999 yes yes yes yes

Moffett 1999 yes yes yes no

Moseley 2002 yes yes no no

Niemisto 2003 yes yes yes no

Petersen 2002 yes yes no yes

Preyde 2000 yes no yes yes

Rasmussen-Barr 2003 unclear unclear no no

Risch 1993 no no yes no

Rittweger 2002 yes yes yes no

Seferlis 1998 no unclear no yes

Soukup 1999 yes yes yes no

Staal 2004 yes yes yes no

Stankovic 1990 yes yes yes unclear




Storheim 2003 yes yes no no

Torstensen 1998 yes yes yes yes

Tritilanunt 2001 yes unclear yes no

Turner 1990 yes yes no no

Underwood 1998 yes yes yes yes

Waterworth 1985 no no yes no

Yelland 2004 yes yes yes no

Yeung 2003 unclear yes yes no

Yozbatiran 2004 unclear unclear yes no

Zylbergold 1981 no unclear yes no

A D D I T I O N A L T A B L E S

Table 1. Summary of Included Studies

Characteristic All Studies (n=61) Acute (n=11) Subacute (n=6) Chronic (n=43)

Population source:

- Healthcare 33 (54) 7 (78) 3 (50) 22 (51)

- Occupational 12 (20) 2 (22) 3 (50) 7 (16)

- General Population 7 (11) 0 0 7 (16)

- Mixed 7 (11) 0 0 7 (16)

Age of study population:Mean years (95% CI)

41 (39 to 42) 38 (35 to 40) 38 (32 to 44) 42 (40 to 44)

% Male of study popula-tion

0.49 (0.45, 0.55) 0.56 (0.46, 0.66) 0.63 (0.42, 0.84) 0.46 (0.39, 0.52)

Observed duration oflow back pain: Mean(95% CI)

4.5 years(2.6 to 6.3)

8 days(5 to 11)

12 weeks (n/a) 5.6 years(3.4 to 7.8)



Table 1. Summary of Included Studies (Continued)

Observed severity ofpain at baseline: Mean /100 (95% CI)

47 (43, 51) 45 (36, 53) 56 (33, 78) 46 (41, 50)

Outcome measures as-sessed:

- Pain 52 (85) 10 (91) 6 (100) 36 (84)

- Functional abilities 46 (75) 9 (82) 4 (67) 33 (77)

- Work status 21 (34) 5 (45) 6 (100) 9 (21)

- Global assessment 13 (21) 3 (27) 1 (17) 7 (16)

Cost evaluation infor-mation presented

8 (13) 2 (18) 2 (33) 4 (9)

Adverse effects assessed:

Any reported 14 (23) 2 (18) 2 (33) 10 (23)

Negative reported 10 (16) 2 (18) 1 (17) 7 (16)

Study quality: Studiessatisfying key items

All 4 8 (13) 1 (9) 1 (17) 6 (14)

Any 3 18 (30) 4 (36) 3 (50) 10 (23)

Any 2 15 (25) 2 (18) 2 (33) 11 (26)

Any 1 15 (25) 3 (27) 0 12 (28)

None 5 (8) 1 (9) 0 4 (9)

* Study populations wereclassified according tomost appropriate cate-gory based on inclusioncriteria and reported du-ration. Thirteen studiesincluded subjects withmixed duration of lowback pain



A P P E N D I C E S

Appendix 1. MEDLINE search strategy

1. exp Exercise Movement Techniques/2. Exercise Therapy/3. Physical Fitness/4. exp EXERTION/5. RECREATION/6. exercis$.mp.7. McKenzie$.mp.8. Alexander.mp.9. William$.mp.10. Feldendrais.mp.11. or/1-1012. limit 11 to randomized controlled trial13. Randomized Controlled Trials/14. double blind method/ or single-blind method/15. Random Allocation/16. PLACEBOS/17. Research Design/18. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$)).mp.19. placebo$.mp.20. random$.mp.21. volunteer$.mp.22. or/13-2123. exp Back Pain/ or back pain.mp.24. backache.mp.25. (lumbar adj pain).mp.26. (lumbar adj trauma).mp.27. lumbosacral.mp.28. dorsalgia.mp.29. sciatica.mp.30. or/23-2931. 11 and 2232. 12 or 3133. 32 and 3034. limit 33 to (human)

Appendix 2. EMBASE search strategy

1. clinical article/2. clinical study/3. clinical trial/4. controlled study/5. randomized controlled trial/6. major clinical study/7. double blind procedure/8. multicenter study/9. single blind procedure/10. placebo/11. or/1-1012. allocat$.mp.



13. assign$.mp.14. blind$.mp.15. (clinic$ adj25 (study or trial)).mp.16. compar$.mp.17. control$.mp.18. cross?over.mp.19. factorial$.mp.20. follow?up.mp.21. placebo$.mp.22. random$.mp.23. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$)).mp.24. trial$.mp.25. (versus or vs).mp.26. or/12-2527. low back pain/28. backache/29. back pain.mp.30. backache.mp.31. or/27-3032. kinesiotherapy/33. exp Physical Activity/34. exp EXERCISE/35. REHABILITATION/36. exercise$.mp.37. McKenzie$.mp.38. Alexander.mp.39. William$.mp.40. Feldendrais.mp.41. yoga.mp.42. or/32-4143. 11 or 2644. 31 and 42 and 4345. limit 44 to (human and yr=1999-2002)46. limit 45 to yr=199947. limit 45 to yr=200048. limit 45 to yr=200149. from 48 keep 1-14450. 45 not (46 or 47 or 48)51. from 50 keep 1-5852. 4453. limit 52 to (human)

F E E D B A C K



re: 2000 (2) version of review, received Feb 2005

Summary

My concerns with this review stem not from its methodology, but its objectives. To this point, I refer specifically to the treatment of’exercise therapy’ as a single form of treatment, rather than a wide-ranging and multifaceted modality that requires specific prescription.’Exercise therapy’ can mean many things to many people, and not just the unqualified. This point is illustrated by the wide range ofinterventions your reviewed studies include. Unfortunately, the generalisation of ’exercise therapy’ and its efficacy in the managementof low back pain also seems to be reflected in current guidelines to practitioners such as those published in the UK by NICE and theRCGP.In my opinion, reviewing ’exercise therapy’ as a single form of treatment detracts greatly from the interpretation of the results ofthis review. The attempt to stratify the data into ’flexion and/or extension exercises’ and ’strength exercises’, although noble, gives thereader little more information about the nature of the exercises undertaken. Although I appreciate the problems with finding sufficientsimilar trials on ’specific exercises’ (which can also be sub-divided into many forms; McKenzie; transversus abdominus and multifidusretraining, etc.), I would argue that by design, these studies may be too heterogeneous to combine. If the analogy could be made withdrug treatments, ’general treatment with medication’ would just not cut it as an objective for a systematic review of the pharmacologicalmanagement of any condition.The area of exercise prescription in the treatment of sub-acute and chronic low back pain has undergone some major developments inthe last 10 years. Yet unfortunately, growing bodies of high quality research into specific exercise therapy for LBP, such as that undertakeninitially by a group of physiotherapists from the University of Queensland in Australia (P Hodges, C Richardson, G Jull and J Hides,and repeated successfully by other authors - transversus abdominus and multifidus retraining in the treatment of low back pain), hasbeen ignored by a large proportion of the medical community undertaking clinical trials (the UK Beam trial which recently concludedis a good example of this) and funding bodies alike. Similar highly specific exercise such as advocated by these authors requires rigorousassessment by RCT’s rather than the ’blanket response’ to exercise therapy most research and current ’good practice guidelines’ seem tobe focusing on. Time after time, insensitive interventions such as ’exercise’ are tested in low back pain sufferers with understandablyconflicting results, serving only to confuse practitioners and patients and fruitlessly drain research funds.I and many of my colleagues would argue strongly that ’exercise prescription’ is as broad a term as ’drug prescription’; and as such it’sassessment in clinical trials requires explicit and repeatable measures such as required in drug trials (explicit description, type, dose andside-effects etc.). I would argue that until we can assess each explicit exercise form, we have a ’general idea’ what exercise can do butno more. Considering their ramifications, recommendations such as those given in your article must be given with great caution. Atthe very least they must realise their own limitations to interpretation and external validity. I would certainly like to see references to’exercise’ in ALL RCT’s on this topic narrowed in their definitions and I feel large RCT’s and subsequent systematic reviews need tobe undertaken to investigate the growing body of evidence supporting the effectiveness of highly specific exercises in the managementof LBP.

Reply

You have identified an argument that rages within the systematic review field ... when to ’lump’ and when to ’split’. All exercises areagain included in the upcoming update of the exercise review. To this point, the research question has been ’is exercise of any benefitto individuals with low back pain’ ... there has not been a breakdown of each type of exercise for each duration of symptoms, due inpart to the lack of data for each comparison, once one starts breaking it down to this degree, although I think the authors may haveattempted some sub-group analysis. As the literature increases, I suspect it will become more feasible to split into different researchquestions, addressing the efficacy of specific exercises for specific sub-groups of individuals with low back pain. There have been someattempts to do this, but the data is still sparse and results must be treated with caution. The authors recognize that this continues topose a challenge to clinicians who deliver exercise therapy. We cannot comment on how the summary of the scientific literature is usedin the development of guidelines, since guidelines must take more into consideration than just the available evidence.I will pass on your comments to the authors of the updated review for their consideration. Please do not hesitate to contact me shouldyou have any further concerns once the updated review is published.

Contributors

Michael Noonan, Occupation Physiotherapist/Medical StudentVictoria Pennick, Back Group Coordinator



W H A T ’ S N E W

Last assessed as up-to-date: 30 September 2004.

Date Event Description

19 January 2011 Amended Contact details updated.

H I S T O R Y

Protocol first published: Issue 2, 1997

Review first published: Issue 2, 2000

Date Event Description

23 November 2009 Amended Contact details updated.

8 September 2008 Amended Contact details updated

17 June 2008 Amended Converted to new review format.

30 April 2005 New search has been performed Compared to the previous version of this review, sev-eral changes have been made:1. Search of CINAHL electronic database was in-cluded.2. Trials were excluded if they investigated individualswith low back pain caused by specific pathologies andconditions; pseudo-randomized trials were excluded.3. Subgroup analysis of study populations includedacute (<6 weeks), subacute (6 to 12 weeks), andchronic (>12 weeks) nonspecific low back pain.4. Assessment of methodological quality included ap-propriate randomization, adequate concealment oftreatment allocation, adequacy of follow-up, and out-come assessment blinding. We defined high-qualitystudies as those that met all of these key quality crite-ria.5. Clinical relevance was assessed.6. Analysis included both a qualitative rating systemand quantitative meta-analyses. Further analyses ex-plored heterogeneity due to study-level variables, suchas population source and study quality and an accom-panying paper explored intervention heterogeneity us-ing Bayesian meta-regression analysis



(Continued)

30 April 2005 New citation required but conclusions have notchanged

Thirty-two new trials (3021 participants) were in-cluded in this update (10 previously included studieswere excluded). Overall, the conclusions remain un-changed regarding the effectiveness of exercise therapyin adults with chronic low back pain, though meta-analysis shows that these effects are modest. More im-provement was found in trials investigating health-care populations. There is some evidence suggestinga graded-activity program improves absenteeism out-comes in subacute low back pain, although evidencefor other types of exercise is unclear. In acute low backpain populations, conclusions - that exercise therapyhas similar effects as other conservative managementand no treatment - remain unchanged

C O N T R I B U T I O N S O F A U T H O R S

Jill Hayden, Bart Koes and Maurits van Tulder identified and selected studies.

Jill Hayden, Antti Malmivaara, Bart Koes and Maurits van Tulder assessed the methodological quality of studies.

Jill Hayden, Antti Malmivaara, Bart Koes and Maurits van Tulder performed the data extraction.

Jill Hayden and Maurits van Tulder conducted the data analyses.

All authors were involved in writing of the review protocol and writing of the final review.

D E C L A R A T I O N S O F I N T E R E S T

Antti Malmivaara is the first author of one of the trials included in this review. Methodological quality assessment and data extractionof this trial was done by two other reviewers (Bart Koes and Maurits van Tulder).

S O U R C E S O F S U P P O R T

Internal sources

• Institute for Work & Health, Canada.



External sources

• Dutch Health Insurance Board, Not specified.• (Personal funding) Canadian Institutes for Health Research, Canada.• (Personal funding) Canadian Chiropractic Research Foundation, Canada.

I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Exercise Therapy; Acute Disease; Low Back Pain [∗therapy]; Randomized Controlled Trials as Topic

MeSH check words

Humans



cochrane database of systematic reviews (reviews) || exercise therapy for treatment of non-specific...

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