A Systematic Review Within the Framework of the Cochrane Collaboration Back Review Group
Maurits van Tulder, PhD,* Antti Malmivaara, MD, PhD† Rosmin Esmail, MSc,‡ and Bart Koes, PhD.
Study Design. A systematic review of randomized controlled trials was performed.
Summary of Background Data. Exercise therapy is a widely used treatment for low back pain.
Objectives. To evaluate the effectiveness of exercise therapy for low back pain with regard to pain intensity, functional status, overall improvement, and return to work.
Methods. The Cochrane Controlled Trials Register, Medline, Embase, PsycLIT, and reference lists of articles were searched. Randomized trials testing all types of exercise therapy for subjects with nonspecific low back pain with or without radiation into the legs were included. Two reviewers independently extracted data and assessed trial quality. Because trials were considered heterogeneous with regard to study populations, interventions, and outcomes, it was decided not to perform a metaanalysis, but to summarize the results using a rating system of four levels of evidence: strong, moderate, limited, or none.
Results. In this review, 39 trials were identified. There is strong evidence that exercise therapy is not more effective for acute low back pain than inactive or other active treatments with which it has been compared. There is conflicting evidence on the effectiveness of exercise therapy compared with inactive treatments for chronic low back pain. Exercise therapy was more effective than usual care by the general practitioner and just as effective as conventional physiotherapy for chronic low back pain.
Conclusions. The evidence summarized in this systematic review does not indicate that specific exercises are effective for the treatment of acute low back pain. Exercises may be helpful for patients with chronic low back pain to increase return to normal daily activities and work.
Low back pain is a major health problem among populations in Western industrialized countries, and a major cause of medical expenses, absenteeism, and disability. Although low back pain usually is a self-limiting and benign disease that tends to improve spontaneously over time, a many varied therapeutic interventions are availablefor the treatment of low back pain. However, the effectiveness associated with most of these interventions has not yet been demonstrated beyond doubt and, consequently, the therapeutic management of low back pain varies widely. One of the major challenges for researchers in the field of low back pain is to provide evidence of which treatment, if any, is of most benefit for subgroups of patients with low back pain. In this systematic review, the results on the effectiveness of exercise therapy are presented. Exercise therapy is a widely used treatment for low back pain. The authors previously conducted a systematic review on the effectiveness of physiotherapy exercises for back pain.27 In this review 16 randomized controlled trials (RCTs) were included, most of which were considered to be of poor methodologic quality. No conclusion could be drawn on whether exercise therapy is more effective than other conservative types of treatment, and little evidence was found in favor of a specific type of exercise (e.g., back or abdominal strengthening, McKenzie, Williams, flexion, extension, or stretching exercises). An update of the evidence on exercise therapy was included in a systematic review of conservative treatment for acute and chronic low back pain.54 Ten trials on acute and 16 trials on chronic low back pain were included, and it was concluded that strong evidence exists showing both that exercise therapy is not effective for acute low back pain and that exercise therapy is effective for chronic low back pain. Because the authors’ previous reviews were based on literature published before 1995, and because several new RCTs have been published since, an update of this review seemed indicated. Furthermore, recent developments in the methodology of systematic reviews have been used. The objective of this systematic Cochrane review was to determine whether exercise therapy is more effective than reference treatments for nonspecific low back pain, and to determine which type of exercise is most effective.