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Three Part Question

[In adult patients with simple acute lumbar back pain (not sciatica)] is [exercise therapy better that standard care] at [reducing pain and improving time to return to normal activities]

Clinical Scenario

A 32 year old man presents to the emergency department. He has a 5 day history of back pain that came on after a long bike ride. He has no red flag symptoms and there are no neurological signs on clinical examination. You advise him to take analgesia and stay active. He is keen to cycling as soon as possible and wonders if there are any specific exercises or program of exercises that he can do to get him back to cycling quicker.

Search Strategy

Medline 1966-May 2005. OVID interface via ATHENS.
back pain.mp. or exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp. or exp Back Pain/ and exercise.mp. or exp EXERCISE THERAPY/ or exp EXERCISE/[ and [acute.af.] limit to humans and english language and abstracts

Search Outcome

Medline: 118 citations of which 1 recent high quality meta-analysis was found. No further relevant citations were found after the time of the meta-analysis search strategy.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hayden JA 2005 Canada	Randomised controlled trials evaluating exercise therapy for adult non-specific low back pain and measuring pain, function, return to work or absenteeism, and global improvement outcomes. Acute back pain was defined as less than 6 weeks duration.	Systematic review with meta-analysis of findings. The authors conducted an extensive search strategy and are linked to the cochrane back pain group.	Number of trials found	61 studies were used in the review of which 11 were specific to acute low back pain.	High quality was defined as meeting all of 4 criteria specified by the authors.
			Quality of trials found	1/11 high quality trial. 9 low quality. 1 did not have a non-exercise comparison (low quality). Lack of assessor blinding was a common feature of most trials. 6 trials were underpowered to show a clinically important difference.
			Effect of exercise in acute back pain	1 high quality trial found exercise to be less effective than usual care. One low quality showed an improvement in short term treatment against placebo. Of the remaining trials6 found no difference and 2 were unclear.
			Short term pain relief. Pooled analysis of results (meta-analysis)	No difference. -0.59 (CI -12.69 - 11.51) out of 100 points.
			Earliest follow up (7 trials). Pooled analysis of results (meta-analysis)	No difference. 0.31 (CI -0.10 to 0.72) out of 100 points
			Mean improvement in functional impairement	No difference (specific figures not given, but graphs show minimal effect size and confidence intervals passing through 0).

Comment(s)

The management of low back pain is controversial. On the one hand there is a relatively nihilistic approach that suggests that little can be done to speed recovery or progression to chronicity. On the other there are a range of medical and para-medical therapies advocated to improve pain and function. Exercise therapy is interesting as it has been advocated by both medical and paramedical groups in the past. This review suggests that in the acute setting there is little evidence to suggest that specific exercises or exercise programs affect the recovery from acute back pain. It is important to re-iterate the authors comments that exercise therapy is not the same as "advice to stay active", which is still advocated as effective.

Clinical Bottom Line

Exercise therapy had not been shown to improve pain or function for acute back pain.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Hayden JA, van Tulder W, Malmivaara AV, Koes BW. Meta-analysis: Exercise therapy for non-specific low back pain. Annals of Internal Medicine 2005;142:765-775