THE IMPACT OF EXERCISE PRESCRIPTION VARIABLES ON INTERVENTION OUTCOMES IN MUSCULOSKELETAL PAIN: UMBRELLA REVIEW OF SYSTEMATIC REVIEWS

N.K. Arora^1,2, L. Donath², P. Owen³, C. Miller³, T. Saueressig⁴, F. Winter¹, M. Hambloch¹, C. Neason¹, V. Karner¹, D. Belavy¹

¹Hochschule für Gesundheit Bochum, Bochum, Germany, ²German Sport University, Cologne, Germany, ³Deakin University, Victoria, Australia, ⁴Physio Meets Science GmbH, Baden-Württemberg, Germany

Background: Musculoskeletal pain conditions are the largest contributors to disability and healthcare burden globally. Exercise interventions improve physical function and quality of life in individuals with musculoskeletal pain, yet the optimal exercise prescription variables (e.g. duration, frequency, intensity) are unclear.

Purpose: We conducted this prospectively registered (CRD42021287440) umbrella review to examine evidence gaps, methodological quality and exercise prescription recommendations. Identifying the optimal exercise prescription variables is vital for the management of musculoskeletal pain and subsequently integral for reducing global burden.

Methods: PubMed, SPORTDiscus, Cochrane Database of Systematic Reviews, EMBASE, and CINAHL were searched from inception to October 2021 for peer-reviewed systematic reviews published in English. Backward citation tracking was also performed. We included systematic reviews and meta-analyses of randomized controlled trials and controlled clinical trials comparing exercise training to conservative treatment, no treatment or other exercise interventions in adults with musculoskeletal pain. Outcome measures included pain intensity, disability, mental health, adverse events and treatment adherence. AMSTAR-2 was used to assess the methodological quality of the included reviews and overlap analysis was conducted to assess the degree of primary study overlap.

Results: From 5,480 records, 209 systematic reviews were included. The included reviews examined low back pain (n=54), knee pain (n=50), shoulder pain (n=16), neck pain (n=17), rheumatoid arthritis (n=6), hip pain (n=7), ankle and foot pain (n=4), chronic widespread pain (n=14), hand pain (n=3), and elbow pain (n=2). Collectively, 12% of reviews did not report any exercise prescription data and only 11% (n=23) of reviews quantitatively analysed the relationship between prescription variables and the outcome(s). Of the 17 studies assessing exercise dose for alteration of pain intensity, 14 (82.35%) examined exercise duration and 10 (58.8%) examined exercise frequency. Of the 12 studies quantitatively assessing the role of exercise dose on physical function, 11 (91.67%) examined duration and 7 (58.33%) examined the frequency of training sessions. All the included reviews used one of the following types of exercise training: a) aerobic (n=10), b) mind-body (n=31), c) resistance (n=36), d) stabilization (n=18), e) stretching (n=2), f) other and water-based (n=13) and g) a combination of two or more exercise types (n=99). The overall methodological quality was critically low in 84.7% of reviews. Overlap analysis revealed a corrected covered area of 1.27% indicating a slight degree of overlap of primary studies in the included reviews.

Conclusions: High methodological quality evidence is lacking for optimal exercise training prescription variables in individuals with musculoskeletal pain. It is vital that future research:
(1) identify optimum exercise prescription variables, for example via dose-response (network) meta-analysis,
(2) perform high-quality reviews per AMSTAR-2 criteria, and
(3) include outcomes of mental health, adverse events and exercise adherence.

Implications: Over-prescription of exercise can contribute to an increased risk of injury, while under-prescription may fail to provide adequate stimulus to attain clinically meaningful improvements. Identifying optimal exercise dose can help improve the efficacy of exercise programs in individuals with musculoskeletal disorders. Improvements in reporting of exercise prescription variables will increase reproducibility and improve the translation of research evidence to clinical practice.

Funding acknowledgements: No specific grant was received from any funding agency in the public, commercial or not-for-profit sectors.

Keywords:
Exercise training
Musculoskeletal pain
Training load

Topics:
Musculoskeletal
Pain & pain management
Health promotion & wellbeing/healthy ageing/physical activity

Did this work require ethics approval? No

Reason: Umbrella reviews involve the synthesis of information from systematic reviews without the involvement of human participants in the research process. Hence, ethical approval was not needed for this review.