Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review
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The effect size for exercise therapy in the treatment of chronic non-specific low back pain (cLBP) is only modest. This review aims to analyse the specificity of the effect by examining the relationship between the changes in clinical outcome (pain, disability) and the changes in the targeted aspects of physical function (muscle strength, mobility, muscular endurance) after exercise therapy.
We searched for exercise therapy trials for cLBP published up to 15 April 2010 in Medline, Embase, Cochrane Library, Cinahl, and PEDro. Two independent reviewers selected studies according to the inclusion criteria. Data extraction: one author extracted the data of the articles.
Data synthesis: 16 studies with a total of 1,476 participants met the inclusion criteria. There was little evidence supporting a relationship between the changes in pain or physical function and the changes in performance for the following measures: mobility (no correlation in 9 studies, weak correlation in 1 study), trunk extension strength (7 and 2, respectively), trunk flexion strength (4 and 1, respectively) and back muscle endurance (7 and 0, respectively). Changes in disability showed no correlation with changes in mobility in three studies and a weak correlation in two; for strength, the numbers were four (no correlation) and two (weak correlation), respectively.
The findings do not support the notion that the treatment effects of exercise therapy in cLBP are directly attributable to changes in the musculoskeletal system. Future research aimed at increasing the effectiveness of exercise therapy in cLBP should explore the coincidental factors influencing symptom improvement.
KeywordsChronic non-specific low back pain Correlation Clinical outcome Physical performance Exercise therapy
We acknowledge the financial support of the Institute of Human Movement Sciences and Sport, Swiss Federal Institute of Technology, Zürich, Switzerland. We would like to thank the librarians of the Swiss Federal Institute of Technology Library, Zürich, for their assistance with the literature search.
Conflict of interest
- 2.Howard PD, Hudicka K, Keating C, Neidig N, Quiros S (2010) The effect of trunk strengthening on chronic low back pain: a systematic review of the literature. Orthop Phys Ther Pract 22(1):19–22Google Scholar
- 8.Siddall PJ, Stanwell P, Woodhouse A, Somorjai RL, Dolenko B, Nikulin A, Bourne R, Himmelreich U, Lean C, Cousins MJ, Mountford CE (2006) Magnetic resonance spectroscopy detects biochemical changes in the brain associated with chronic low back pain: a preliminary report. Anesth Analg 102(4):1164–1168. doi: 10.1213/01.ane.0000198333.22687.a6 PubMedCrossRefGoogle Scholar
- 9.Giesecke T, Gracely RH, Clauw DJ, Nachemson A, Duck MH, Sabatowski R, Gerbershagen HJ, Williams DA, Petzke F (2006) Central pain processing in chronic low back pain. Evidence for reduced pain inhibition. Schmerz 20(5):411–414, 416–417. doi: 10.1007/s00482-006-0473-8
- 11.Baliki MN, Chialvo DR, Geha PY, Levy RM, Harden RN, Parrish TB, Apkarian AV (2006) Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. J Neurosci 26(47):12165–12173. doi: 10.1523/JNEUROSCI.3576-06.2006 PubMedCrossRefGoogle Scholar
- 13.Schmidt-Wilcke T, Leinisch E, Ganssbauer S, Draganski B, Bogdahn U, Altmeppen J, May A (2006) Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients. Pain 125(1–2):89–97. doi: 10.1016/j.pain.2006.05.004 PubMedCrossRefGoogle Scholar
- 16.Mannion AF, Dvorak J, Taimela S, Muntener M (2001) Kraftzuwachs nach aktiver therapie bei patienten mit chronischen ruckenschmerzen (LBP): muskulare adaptationen und klinische relevanz (Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance) [German]. Der Schmerz 15(6):468–473PubMedCrossRefGoogle Scholar
- 18.Keller A, Brox JI, Reikerås O (2008) Predictors of change in trunk muscle strength for patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Pain Med (Malden, Mass) (6):680–687Google Scholar
- 31.Ferguson SA, Marras WS, Burr DL, Davis KG, Gupta P (2004) Differences in motor recruitment and resulting kinematics between low back pain patients and asymptomatic participants during lifting exertions. Clin Biomech (Bristol, Avon) 19(10):992–999. doi: 10.1016/j.clinbiomech.2004.08.007 CrossRefGoogle Scholar
- 36.Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Maher C, Refshauge K (2009) Relationship between spinal stiffness and outcome in patients with chronic low back pain. Man Ther (1):61–67Google Scholar
- 42.Fregni F, Gimenes R, Valle AC, Ferreira MJ, Rocha RR, Natalle L, Bravo R, Rigonatti SP, Freedman SD, Nitsche MA, Pascual-Leone A, Boggio PS (2006) A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia. Arthritis Rheum 54(12):3988–3998. doi: 10.1002/art.22195 PubMedCrossRefGoogle Scholar
- 43.Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G, Pain CBWGoGfCLB (2006) Chapter 4 European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15 Suppl 2:S192–S300Google Scholar
- 44.Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Bouter LM, Knipschild PG (1998) The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 51(12):1235–1241 pii:S0895435698001310PubMedCrossRefGoogle Scholar
- 47.Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700PubMedCrossRefGoogle Scholar
- 49.Elnaggar IM, Nordin M, Sheikhzadeh A, Parnianpour M, Kahanovitz N (1991) Effects of spinal flexion and extension exercises on low-back pain and spinal mobility in chronic mechanical low-back pain patients. Spine (8):967–972Google Scholar
- 50.Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshauge KM (2007) Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain (1–2):31–37Google Scholar
- 52.Reilly K, Lovejoy B, Willams R, Roth H (1989) Differences between a supervised and independent strength and conditioning program with chronic low back syndromes. J Occup Med (6):547–550Google Scholar
- 53.Johannsen F, Remvig L, Kryger P, Beck P, Warming S, Lybeck K, Dreyer V, Larsen LH (1995) Exercises for chronic low back pain: a clinical trial. J Orthop Sports Phys Ther (2):52–59Google Scholar
- 55.Khalil TM, Asfour SS, Martinez LM, Waly SM, Rosomoff RS, Rosomoff HL (1992) Stretching in the rehabilitation of low-back pain patients. Spine (3):311–317Google Scholar
- 58.Mannion AF, Müntener M, Taimela S, Dvorak J (1999) A randomized clinical trial of three active therapies for chronic low back pain. Spine (23):2435–2448Google Scholar
- 61.Mannion AF, Dvorak J, Taimela S, Müntener M (2001) [Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance]. Schmerz (Berlin, Germany) (6):468–473Google Scholar
- 62.Kankaanpää M, Taimela S, Airaksinen O, Hänninen O (1999) The efficacy of active rehabilitation in chronic low back pain. Effect on pain intensity, self-experienced disability, and lumbar fatigability. Spine (10):1034–1042Google Scholar
- 63.Roche G, Ponthieux A, Parot-Shinkel E, Jousset N, Bontoux L, Dubus V, Penneau-Fontbonne D, Roquelaure Y, Legrand E, Colin D, Richard I, Fanello S (2007) Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil (10):1229–1235Google Scholar
- 65.Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikerås O (2004) Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine (1):3–8Google Scholar
- 70.Lewis A, Morris M, Walsh C (2008) Are physiotherapy exercises effective in reducing chronic low back pain? Phys Ther Rev 13(1)Google Scholar
- 75.Southwick SM, White AA (1983) The use of psychological tests in the evaluation of low-back pain. J Bone Jt Surg Am 65(4):560–565Google Scholar
- 76.Sertpoyraz F, Eyigor S, Karapolat H, Capaci K, Kirazli Y (2009) Comparison of isokinetic exercise versus standard exercise training in patients with chronic low back pain: a randomized controlled study. Clinical Rehabilitation (3):238–247Google Scholar
- 79.Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J (2001) Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy. Spine (8):920–929Google Scholar
- 80.Lindstrom I, Ohlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL (1992) The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Phys Ther 72(4):279–290 (discussion 291–293)PubMedGoogle Scholar
- 91.Karimi N, Ebrahimi I, Ezzati K, Kahrizi S, Torkaman G, Arab AM (2009) The effects of consecutive supervised stability training on postural balance in patients with chronic low back pain. Pakistan J Med Sci 25(2):177–181Google Scholar