Exercise therapy for chronic low back pain Hayden, Jill A; Ellis, Jenna; Ogilvie, Rachel ...
Cochrane database of systematic reviews,
09/2021, Volume:
9
Journal Article
Peer reviewed
Open access
Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.
The primary objective of ...this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.
We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.
We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.
Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.
We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias. Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.
We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.
Consecutive case series cohort.
To determine the relative frequencies of the spine, the sacroiliac (SI) joint, and the hip joint being the primary pain generator among patients presenting at a spine ...surgery clinic for low back pain (LBP).
Identification of the primary pain generator in a patient with LBP is difficult. Possible pain sources include the lumbar spine, the SI joint, and the hip joint. Their relative frequencies among patients presenting at a spine surgeon's clinic have not been well established.
Three hundred sixty-eight new patients were seen at a single spine surgeon's clinic during a 10-month period. Of these, 289 (78.5%) complained primarily of LBP with or without leg pain. Seventy-seven had previous surgery. The remaining 200 cases were reviewed for all diagnostic tests performed, as well as the final diagnosis.
One hundred sixty-four (82%) had spine pathology, but only 130 (65%) had spine-only pathology, whereas 35 (17.5%) had a combination of spine plus hip and/or SI joint pathology. An additional 16 (8%) had hip and/or SI joint pathology without spine pathology. Twenty (10%) had an undefined pain source. Overall, 25 (12.5%) had hip pathology, and 29 (14.5%) had SI joint pathology.
For patients presenting to a spine surgeon's clinic for LBP, up to 25% of patients may have significant pain contribution from the hip or SI joints, and an additional 10% will still have an undefined pain source even after diagnostic workup. This underscores the need for clinicians to be aware of nonspinal pain generators and to appropriately pursue alternative diagnoses.
Low back pain (LBP) is common among healthcare workers, whose work is physically strenuous and thus demands certain levels of physical fitness and spinal control. Exercise is the most frequently ...recommended treatment for LBP. However, exercise interventions targeted at sub-acute or recurrent patients are scarce compared to those targeted at chronic LBP patients. Our objective was to examine the effects of 6 months of neuromuscular exercise on pain, lumbar movement control, fitness, and work-related factors at 6- and 12-months' follow-up among female healthcare personnel with sub-acute or recurrent low back pain (LBP) and physically demanding work.
A total of 219 healthcare workers aged 30-55 years with non-specific LBP were originally allocated to four groups (exercise, counselling, combined exercise and counselling, control). The present study is a secondary analysis comparing exercisers (n = 110) vs non-exercisers (n = 109). Exercise was performed twice a week (60 min) in three progressive stages focusing on controlling the neutral spine posture. The primary outcome was intensity of LBP. Secondary outcomes included pain interfering with work, lumbar movement control, fitness components, and work-related measurements. Between-group differences were analysed with a generalised linear mixed model according to the intention-to-treat principle. Per-protocol analysis compared the more exercised to the less exercised and non-exercisers.
The mean exercise attendance was 26.3 (SD 12.2) of targeted 48 sessions over 24 weeks, 53% exercising 1-2 times a week, with 80% (n = 176) and 72% (n = 157) participating in 6- and in 12-month follow-up measurements, respectively. The exercise intervention reduced pain (p = 0.047), and pain interfering with work (p = 0.046); improved lumbar movement control (p = 0.042), abdominal strength (p = 0.033) and physical functioning in heavy nursing duties (p = 0.007); but had no effect on other fitness and work-related measurements when compared to not exercising. High exercise compliance resulted in less pain and better lumbar movement control and walking test results.
Neuromuscular exercise was effective in reducing pain and improving lumbar movement control, abdominal strength, and physical functioning in nursing duties compared to not exercising.
Abstract
BACKGROUND: Due to uncertain evidence, lumbar fusion for degenerative indications is associated with the greatest measured practice variation of any surgical procedure.
OBJECTIVE: To ...summarize the current evidence on the comparative safety and efficacy of lumbar fusion, decompression-alone, or nonoperative care for degenerative indications.
METHODS: A systematic review was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to June 30, 2016). Comparative studies reporting validated measures of safety or efficacy were included. Treatment effects were calculated through DerSimonian and Laird random effects models.
RESULTS: The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk RR 1.17, 95% confidence interval CI 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality.
CONCLUSION: Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153).
The effects of altered neural processing, defined as altering neural networks responsible for perceptions of pain and function, on chronic pain remains unclear.
To estimate the effect of a graded ...sensorimotor retraining intervention (RESOLVE) on pain intensity in people with chronic low back pain.
This parallel, 2-group, randomized clinical trial recruited participants with chronic (>3 months) nonspecific low back pain from primary care and community settings. A total of 276 adults were randomized (in a 1:1 ratio) to the intervention or sham procedure and attention control groups delivered by clinicians at a medical research institute in Sydney, Australia. The first participant was randomized on December 10, 2015, and the last was randomized on July 25, 2019. Follow-up was completed on February 3, 2020.
Participants randomized to the intervention group (n = 138) were asked to participate in 12 weekly clinical sessions and home training designed to educate them about and assist them with movement and physical activity while experiencing lower back pain. Participants randomized to the control group (n = 138) were asked to participate in 12 weekly clinical sessions and home training that required similar time as the intervention but did not focus on education, movement, and physical activity. The control group included sham laser and shortwave diathermy applied to the back and sham noninvasive brain stimulation.
The primary outcome was pain intensity at 18 weeks, measured on an 11-point numerical rating scale (range, 0 no pain to 10 worst pain imaginable) for which the between-group minimum clinically important difference is 1.0 point.
Among 276 randomized patients (mean SD age, 46 14.3 years; 138 50% women), 261 (95%) completed follow-up at 18 weeks. The mean pain intensity was 5.6 at baseline and 3.1 at 18 weeks in the intervention group and 5.8 at baseline and 4.0 at 18 weeks in the control group, with an estimated between-group mean difference at 18 weeks of -1.0 point (95% CI, -1.5 to -0.4; P = .001), favoring the intervention group.
In this randomized clinical trial conducted at a single center among patients with chronic low back pain, graded sensorimotor retraining, compared with a sham procedure and attention control, significantly improved pain intensity at 18 weeks. The improvements in pain intensity were small, and further research is needed to understand the generalizability of the findings.
ANZCTR Identifier: ACTRN12615000610538.
Although several studies have found that chronic pain is characterized by increased cross-network connectivity between salience network, sensorimotor network, and default mode network (DMN), a large ...sample-size investigation allowing for a more reliable evaluation of somatotopic specificity and subgroup analyses with linkage to clinical pain intensity has been lacking. We enrolled healthy adults and a large cohort of patients (N = 181) suffering from chronic low back pain (cLBP). To specifically link brain connectivity with clinical pain intensity, patients were scanned at baseline and after performing physical maneuvers that exacerbated pain. Compared with healthy adults, patients with cLBP demonstrated increased connectivity between the functionally localized back representation in the primary somatosensory cortex (S1back) and both salience network and DMN. Pain exacerbation maneuvers increased S1back connectivity to salience network regions, but decreased connectivity to DMN, with greater pain intensity increase associated with greater shifts in these connectivity patterns. Furthermore, only in patients with cLBP reporting high pain catastrophizing, DMN connectivity was increased to a cardinal node of the salience network, anterior insula cortex, which was correlated with increased postmaneuver pain in this cLBP subgroup. Hence, increased information transfer between salience processing regions, particularly anterior insula, and DMN may be strongly influenced by pain catastrophizing. Increased information transfer between the salience network and S1 likely plays an important role in shifting nociceptive afference away from self-referential processing, reallocating attentional focus, and affective coding of nociceptive afference from specific body areas. These results demonstrate S1 somatotopic specificity for cross-network connectivity in encoding clinical back pain and moderating influence of catastrophizing for DMN/insula connectivity.
Study design
Prospective longitudinal study.
Objective
To determine whether systemic cytokines and C-reactive protein (CRP) during an acute episode of low back pain (LBP) differ between individuals ...who did and did not recover by 6 months and to identify sub-groups based on patterns of inflammatory, psychological, and sleep features associated with recovery/non-recovery.
Summary of background data
Systemic inflammation is observed in chronic LBP and may contribute to the transition from acute to persistent LBP. Longitudinal studies are required to determine whether changes present early or develop over time. Psychological and/or sleep-related factors may be related.
Methods
Individuals within 2 weeks of onset of acute LBP (
N
= 109) and pain-free controls (
N
= 55) provided blood for assessment of CRP, tumor necrosis factor (TNF), interleukin-6 (IL-6) and interleukin-1β, and completed questionnaires related to pain, disability, sleep, and psychological status. LBP participants repeated measurements at 6 months. Biomarkers were compared between LBP and control participants at baseline, and in longitudinal (baseline/6 months) analysis, between unrecovered (≥pain and disability), partially recovered (reduced pain and/or disability) and recovered (no pain and disability) participants at 6 months. We assessed baseline patterns of inflammatory, psychological, sleep, and pain data using hierarchical clustering and related the clusters to recovery (% change in pain) at 6 months.
Results
CRP was higher in acute LBP than controls at baseline. In LBP, baseline CRP was higher in the recovered than non-recovered groups. Conversely, TNF was higher at both time-points in the non-recovered than recovered groups. Two sub-groups were identified that associated with more (“inflammatory/poor sleep”) or less (“high TNF/depression”) recovery.
Conclusions
This is the first evidence of a relationship between an “acute-phase” systemic inflammatory response and recovery at 6 months. High inflammation (CRP/IL-6) was associated with good recovery, but specific elevation of TNF, along with depressive symptoms, was associated with bad recovery. Depression and TNF may have a two-way relationship.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Low back pain (LBP) is a common and costly problem that many interpret within a biopsychosocial model. There is renewed concern that core-sets of outcome measures do not capture what is important. To ...inform debate about the coverage of back pain outcome measure core-sets, and to suggest areas worthy of exploration within healthcare consultations, we have synthesised the qualitative literature on the impact of low back pain on people's lives.
Two reviewers searched CINAHL, Embase, PsycINFO, PEDro, and Medline, identifying qualitative studies of people's experiences of non-specific LBP. Abstracted data were thematic coded and synthesised using a meta-ethnographic, and a meta-narrative approach.
We included 49 papers describing 42 studies. Patients are concerned with engagement in meaningful activities; but they also want to be believed and have their experiences and identity, as someone 'doing battle' with pain, validated. Patients seek diagnosis, treatment, and cure, but also reassurance of the absence of pathology. Some struggle to meet social expectations and obligations. When these are achieved, the credibility of their pain/disability claims can be jeopardised. Others withdraw, fearful of disapproval, or unable or unwilling to accommodate social demands. Patients generally seek to regain their pre-pain levels of health, and physical and emotional stability. After time, this can be perceived to become unrealistic and some adjust their expectations accordingly.
The social component of the biopsychosocial model is not well represented in current core-sets of outcome measures. Clinicians should appreciate that the broader impact of low back pain includes social factors; this may be crucial to improving patients' experiences of health care. Researchers should consider social factors to help develop a portfolio of more relevant outcome measures.
Low back pain (LBP) is an increasingly common condition worldwide with significant costs associated with its management. Identification of musculoskeletal risk factors that can be treated clinically ...before the development of LBP could reduce costs and improve the quality of life of individuals. Therefore the aim was to systematically review prospective cohort studies investigating lower back and / or lower limb musculoskeletal risk factors in the development of LBP.
MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus, and the Cochrane Library were searched from inception to February 2016. No age, gender or occupational restrictions of participants were applied. Articles had to be published in English and have a 12 month follow-up period. Musculoskeletal risk factors were defined as any osseous, ligamentous, or muscular structure that was quantifiably measured at baseline. Studies were excluded if participants were pregnant, diagnosed with cancer, or had previous low back surgery. Two authors independently reviewed and selected relevant articles. Methodological quality was evaluated independently by two reviewers using a generic tool for observational studies.
Twelve articles which evaluated musculoskeletal risk factors for the development of low back pain in 5459 participants were included. Individual meta-analyses were conducted based on risk factors common between studies. Meta-analysis revealed that reduced lateral flexion range of motion (OR = 0.41, 95% CI 0.24-0.73, p = 0.002), limited lumbar lordosis (OR = 0.73, 95% CI 0.55-0.98, p = 0.034), and restricted hamstring range of motion (OR = 0.96, 95% CI 0.94-0.98, p = 0.001) were significantly associated with the development of low back pain. Meta-analyses on lumbar extension range of motion, quadriceps flexibility, fingertip to floor distance, lumbar flexion range of motion, back muscle strength, back muscle endurance, abdominal strength, erector spinae cross sectional area, and quadratus lumborum cross sectional area showed non-significant results.
In summary, we found that a restriction in lateral flexion and hamstring range of motion as well as limited lumbar lordosis were associated with an increased risk of developing LBP. Future research should aim to measure additional lower limb musculoskeletal risk factors, have follow up periods of 6-12 months, adopt a standardised definition of LBP, and only include participants who have no history of LBP.
To standardize outcome reporting in clinical trials of patients with nonspecific low back pain, an international multidisciplinary panel recommended physical functioning, pain intensity, and ...health-related quality of life (HRQoL) as core outcome domains. Given the lack of a consensus on measurement instruments for these 3 domains in patients with low back pain, this study aimed to generate such consensus. The measurement properties of 17 patient-reported outcome measures for physical functioning, 3 for pain intensity, and 5 for HRQoL were appraised in 3 systematic reviews following the COSMIN methodology. Researchers, clinicians, and patients (n = 207) were invited in a 2-round Delphi survey to generate consensus (≥67% agreement among participants) on which instruments to endorse. Response rates were 44% and 41%, respectively. In round 1, consensus was achieved on the Oswestry Disability Index version 2.1a for physical functioning (78% agreement) and the Numeric Rating Scale (NRS) for pain intensity (75% agreement). No consensus was achieved on any HRQoL instrument, although the Short Form 12 (SF12) approached the consensus threshold (64% agreement). In round 2, a consensus was reached on an NRS version with a 1-week recall period (96% agreement). Various participants requested 1 free-to-use instrument per domain. Considering all issues together, recommendations on core instruments were formulated: Oswestry Disability Index version 2.1a or 24-item Roland-Morris Disability Questionnaire for physical functioning, NRS for pain intensity, and SF12 or 10-item PROMIS Global Health form for HRQoL. Further studies need to fill the evidence gaps on the measurement properties of these and other instruments.
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