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Three Part Question

[In patients with chronic low back pain (more than 3 months duration)] is [exercise therapy better than standard care] at [reducing pain and improving time to return to work and normal activities]

Clinical Scenario

A 35 year old woman presents to the emergency department with a 5 month history of lumbar back pain. The pain developed after a holiday skiing, but there was no specific injury and there is nothing in the history or examination to suggest a serious underlying cause. There are no red flag symptoms or signs. She has been on light duties at work for the last 3 months and is coming under pressure from her employer and family to get back to normal as soon as possible.
She asks if there are any exercises she can do to help and you remember a physiotherapist telling you about an exercise program that can be used by back pain patients. You wonder if it is worth referring her for more advice and information.

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.] and [exercise.mp. or exp EXERCISE THERAPY/ or exp EXERCISE/] and [chronic.af.] Limit to humand english and abstracts.

Search Outcome

328 papers found 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. Chronic back pain was defined as pain of more than 12 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 trials of which 43 examined exercise in chronic back pain. These totalled 3907 participants.	The authors found evidence for publication bias in the results for chronic back pain. As with many reviews the quality of the trials included in the review was not as high as would be desirable.
			Quality of trials found	6/43 were high quality.Lack of observer blinding was the commonest reason for a trial to be deemed low quality. Authors used a 4 point scale to assess quality.
			Effect of exercise	2 high quality and 9 low quality trials showed exercise to be effective. 1 low quality trial showed an adverse effect from exercise. 14 trials showed no difference (4 of which were inadequately powered).
			Pain at first follow up. Pooled analysis of results (meta-analysis)	Improvement with exercise. 10.2 points on 100 point scale (CI 1.31 to 19.09) against no treatment. 5.93 points (CI 2.21 to 9.65) against other conservative treatments.
			Function at first follow up. Pooled analysis of results (meta-analysis)	3 points (CI -0.53 to 6.48 points) when compared against no treatment on 100 points scale. 2.37 (CI 0.74 to 4 points) when compared against other conservative treatments.
			Pain and function at long term follow up	Effects appear to persist in similar effect sizes to those found at initial follow up.
			Subgroup analysis of setting (health, occupational, general, combined)	No significant differences between groups.

Comment(s)

Chronic back pain places an enormous strain on patients who suffer it and on society in general. The costs to the population in the UK has been estimated to be in the billions when sickness payments and lost working are included in the equation. Any treatment that may improve the function and disability in these patients is to be welcomed. This review suggests that there is an effect from exercise therapy in the management of chronic back pain. It appears to better than no other therapy and is probably as effective as other conservative treatments in the short and long term. Such enthusiasm must be tempererd by the relatively small pooled effect size gained by exercise therapy. The difference in pain and fuinction scores are at a level of questionable clinical significance. However, these pooled effect sizes may hide a greater effect size in individual patients and it should be not be completely discounted on the basis of these findings.

Clinical Bottom Line

Exercise therapy has a small benefit in the treatment of chronic back pain against no treatment. It is probably as effective as other conservative therapies.

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