Karlsson M1, Bergenheim A1,2, Larsson MEH1,3, Nordeman L1,4, van Tulder M5, Bernhardsson S1,3
1University of Gothenburg, Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Section of Physiotherapy, Gothenburg, Sweden, 2Region Vastra Gotaland, Research and Development Center Fyrbodal, Närhälsan Research and Development Primary Health Care, Vänersborg, Sweden, 3Region Vastra Gotaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden, 4Region Vastra Gotaland, Research and Development Center Södra Älvsborg, Närhälsan Research and Development Primary Health Care, Borås, Sweden, 5Vrije Universiteit Amsterdam, Dept. Health Sciences, Faculty of Science, Amsterdam Movement Sciences, Amsterdam, Netherlands
Background: Acute, non-specific, low back pain (LBP) leads to disability for the affected individual but symptoms often resolve within a few weeks, regardless of intervention or no intervention at all. Physiotherapists use different types of exercise therapy as treatment, which is concordant with many published guidelines despite conflicting evidence. The effect of exercise therapy remains questionable.
Purpose: To assess the overall certainty of evidence for the effect of exercise therapy in comparison with other interventions on pain, disability, recurrence, patient satisfaction, global improvement, and adverse effects in adult patients with acute LBP.
Methods: MEDLINE, Cochrane library, PEDro, CINAHL, Open Grey, Web of Science and PROSPERO were searched, from inception to March 2017, for systematic reviews of randomised controlled trials. Records were screened in duplicate and reference lists of included studies were scrutinized for additional studies. Methodological quality was assessed independently by two authors using AMSTAR. Data for the outcomes pain, disability, recurrence (primary outcomes), patient satisfaction, global improvement or perceived recovery, and adverse effects (secondary outcomes) were extracted, tabulated and synthesized. When data permitted, meta-analyses were performed. Certainty of evidence was assessed using the GRADE approach. A review protocol was registered in PROSPERO.
Results: The searches retrieved 2602 records, of which 134 publications were selected for full text screening according to a predefined PICO. Twenty-four systematic reviews (6 Cochrane reviews and 18 other reviews) were finally included, including a total of 572 RCTs. Of these RCTs, 22 reported data for populations with acute LBP (2547 participants). Overlap was high, 77%. Methodological quality ranged from 2 to 11 assessed with AMSTAR.
Meta-analyses or syntheses showed no clinically important difference between exercise therapy and placebo, usual care or no treatment at any of the time points examined, for any of the primary outcomes. No type of exercise seemed to be superior to any other type. Certainty in the evidence for the lack of clinically important effects of the different types of exercise and outcomes varied from very low to moderate.
Conclusion(s): The findings of this systematic review of systematic reviews suggest that exercise therapy of any type may make little or no difference with regard to pain or disability in patients with acute LBP, and it is uncertain whether stabilization exercise in the acute phase reduces the risk of recurrence.
Implications: In view of the low certainty in the research-based evidence for exercise intervention in the acute phase of LBP, the other components of evidence-based practice will play a larger role in clinical decision making. Physiotherapists must use their clinical expertise and elicit their patients' preferences and goals when choosing the most appropriate interventions.
Keywords: Low back pain, exercise, systematic review
Funding acknowledgements: The first author received partial funding from the Local Research and Development Council Fyrbodal.
Purpose: To assess the overall certainty of evidence for the effect of exercise therapy in comparison with other interventions on pain, disability, recurrence, patient satisfaction, global improvement, and adverse effects in adult patients with acute LBP.
Methods: MEDLINE, Cochrane library, PEDro, CINAHL, Open Grey, Web of Science and PROSPERO were searched, from inception to March 2017, for systematic reviews of randomised controlled trials. Records were screened in duplicate and reference lists of included studies were scrutinized for additional studies. Methodological quality was assessed independently by two authors using AMSTAR. Data for the outcomes pain, disability, recurrence (primary outcomes), patient satisfaction, global improvement or perceived recovery, and adverse effects (secondary outcomes) were extracted, tabulated and synthesized. When data permitted, meta-analyses were performed. Certainty of evidence was assessed using the GRADE approach. A review protocol was registered in PROSPERO.
Results: The searches retrieved 2602 records, of which 134 publications were selected for full text screening according to a predefined PICO. Twenty-four systematic reviews (6 Cochrane reviews and 18 other reviews) were finally included, including a total of 572 RCTs. Of these RCTs, 22 reported data for populations with acute LBP (2547 participants). Overlap was high, 77%. Methodological quality ranged from 2 to 11 assessed with AMSTAR.
Meta-analyses or syntheses showed no clinically important difference between exercise therapy and placebo, usual care or no treatment at any of the time points examined, for any of the primary outcomes. No type of exercise seemed to be superior to any other type. Certainty in the evidence for the lack of clinically important effects of the different types of exercise and outcomes varied from very low to moderate.
Conclusion(s): The findings of this systematic review of systematic reviews suggest that exercise therapy of any type may make little or no difference with regard to pain or disability in patients with acute LBP, and it is uncertain whether stabilization exercise in the acute phase reduces the risk of recurrence.
Implications: In view of the low certainty in the research-based evidence for exercise intervention in the acute phase of LBP, the other components of evidence-based practice will play a larger role in clinical decision making. Physiotherapists must use their clinical expertise and elicit their patients' preferences and goals when choosing the most appropriate interventions.
Keywords: Low back pain, exercise, systematic review
Funding acknowledgements: The first author received partial funding from the Local Research and Development Council Fyrbodal.
Topic: Musculoskeletal: spine; Research methodology & knowledge translation
Ethics approval required: No
Institution: N/A, systematic review
Ethics committee: N/A, systematic review
Reason not required: Systematic review, not applicable
All authors, affiliations and abstracts have been published as submitted.
