Research Review by Dr. Shawn Thistle©

Date:

June 2005

Study Title:

Meta-analysis: Exercise therapy for non-specific low back pain

Authors:

Hayden JA, van Tulder MW, Malmivaara AV, Koes BW

Publication Information:

Annals of Internal Medicine 2005; 142: 765-775.

Summary:

As often discussed in my research reviews, low back pain remains an enigma in modern day health care. It is a common, disabling, and costly condition that we know relatively little about in terms or pathoanatomical causes and effective treatments.

This study was reported in the print and television media, so I felt it important to review here. As always, if you have any questions about this or any of my other reviews, please feel free to contact me.

The goal of this large meta-analysis was to evaluate the effectiveness of exercise therapy in the treatment of low back pain in adults. Exercise therapy was intentionally defined in this study as a heterogeneous group of interventions from general physical fitness interventions to various types of stretching and aerobic exercise protocols. 61 published reports of completed, randomized controlled trials comparing an exercise intervention to placebo, no treatment or other conservative treatments were included in the analysis. Patients suffering acute (< 6 weeks), subacute (6-12 weeks) and chronic (> 12 weeks) low back pain were included in the studies (most of the studies involved chronic patients).

Pertinent Results:

  • there is clear evidence that exercise therapy is at least as effective as other conservative therapies for chronic low back pain, despite conflicting evidence that it is any better
  • for acute low back pain, exercise are not more effective than other conservative therapies (note that exercise therapy is not the same as advice to stay active, which is currently a recommended, evidence-based intervention for low back pain)
  • there is some evidence to support a graded-activity exercise program for subacute low back pain in occupational settings

Conclusions & Practical Application:

This study concludes that evidence from randomized, controlled trials demonstrates that exercise therapy is effective for reducing pain and improving functional outcomes in patients with chronic low back pain. It appears that clinically important improvements are more likely to be seen in healthcare environments, meaning that exercise therapy may work better when supervised by a healthcare provider.

It seems intuitive that exercise would be an appropriate intervention for low back pain, provided that it is administered by qualified professionals in a safe, supervised environment. This seems to be a situation where the literature still needs to catch up to clinical practice.

To this end, I feel more research needs to be directed toward the effectiveness of combining physical and clinical interventions commonly used in practice. I feel the absence of clear data on the treatment of low back pain is due to the lack of "clinical reality" of most randomized trials.

Most manual medicine practitioners combine a number of interventions in addition to exercise to treat these patients. In order to studies to reflect the benefit of such treatment regimens, more large-scale trials need to be performed with this type of design.