Background
Methods
Protocol and registration
Eligibility criteria
Criteria | Description |
---|---|
Study design | Systematic review of RCTs. A review was considered systematic if the review authors had identified it as such. |
Population | Adult (18–65 years) patients with non-specific acute LBP (onset to 6 weeks). If the systematic review contained primary studies on other populations, e.g., adolescents, at least 70% of the included studies had to be on adult populations. Findings for populations with acute LBP had to be separable from other populations. |
Interventions | Interventions classified as exercise therapy (earlier defined in the background) used by physiotherapists. |
Comparisons | Placebo, sham, waiting list, no treatment, usual care, minimal intervention, non-steroid anti-inflammatory drugs (NSAIDs), analgesics, or other physiotherapeutic interventions. |
Outcomes | Pain intensity (hereafter referred to as pain), disability, recurrence, adverse effects. |
Length of follow-up | Post-treatment, short-term (closest to three months), intermediate-term (closest to 6 months), and long-term (closest to 12 months) follow-up. |
Minimal important difference (MID)a | 15 mm on the Visual Analogue Scale (VAS) (0–100), 5 on the Roland Morris Disability Questionnaire (RMDQ) (0–24), and 10 for the Oswestry Disability Index (ODI) (0–100) [37]. |
Clinical relevance for pooled effect sizes | Small mean difference (MD) < 10%; medium MD 10–20%; large MD > 20% of the scale (e.g., < 10 mm on a 100 mm VAS). For relative risk: small standardized mean difference (SMD) < 0.4; medium SMD 0.41 to 0.7; large SMD > 0.7 [38]. |
Settings | Primary care physiotherapy or other settings in which the intervention could be practiced, such as home or gym. |
Search methods
Search strategy
Electronic searches
Other sources
Selection of systematic reviews
Overlap
Assessment of methodological quality of included reviews
Data extraction
Data synthesis
Assessment of certainty of evidence
Results
Search results
Description of included reviews
First author and year in chrono-logical order | Aim of SR | Databases and search periods | No. of RCTs (of which aLBP) | Publications on RCTs (aLBP); first author, year, (no. of participants), country | Population defined in PICO of SR and described in RCT | Interventions defined in PICO of SR and described in RCT | Comparisons defined in PICO of SR and described in RCT | Outcomes defined in PICO of SR and described in RCT |
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Koes 1991 [49] | To determine the quality of RCTs of ET for back pain. | MEDLINE 1966–1990 | 16 (4) | |||||
Faas 1996 [57] | To determine from recently published trials the efficacy of exercises in patients with acute, subacute, or chronic back pain. | MEDLINE 1991 to first quarter 1995. | 11 (4) | |||||
van Tulder 1997 [63] | To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic LBP. | MEDLINE 1966-, EMBASE 1908- and PsycLIT 1984- Sep 1995. | 150 (7) | |||||
van Tulder 2000 [64] | To determine whether ET is more effective than reference treatments for nonspecific LBP, and to determine which type of exercise is most effective. | MEDLINE 1966- Apr 1999. EMBASE 1988- Sep 1998.PsycLIT 1984–Apr 1999.Cochrane Library Issue 1 1999. | 39 (10) | Adults 18 to 65 years, non-specific LBP = pain located below the scapulas and above the cleft of the buttocks, ± radiation to the legs, including nerve root pain or sciatica. See above [53, 63, 64, 67‐70]. LBP severe neurological sign and sciatica excluded. Age 20–64. Female 48% [71]. LBP ± sciatica requiring sick leave. Age: 19–64. Female: 47 [60]. LBP ± referred pain. Age: 16–70. Female: 40% [72]. | Specific back exercises as well as abdominal, flexion, extension, static, dynamic, strengthening, stretching or aerobic exercises, if they were prescribed or performed in the treatment of LBP. Additional physicaltreatment methods were allowed. See above [51, 52, 54‐56, 61, 62]. McK [71]. Intensive training program [60]. McK + advice [72]. | Pain, global measure, back pain-specific functional status, return to work, ROM, generic functional status, medication use and side effects.See above [51, 52, 54‐56, 61, 62]. Global improvement, disability, cost of care, patient satisfaction, recurrence, use of care [71]. Pain, disability, ROM recurrence, patient satisfaction, days of work [60]. Pain, disability, recurrence [72]. | ||
Ferreira 2003 [73] | To assess the efficacy of manual therapy techniques in the treatment of nonspecific LBP of less than 3 months duration. | MEDLINE 1966-, EMBASE 1974-, CINAHL 1982- Mar 2001.PEDro- Jul 2002. | 27 (4) | |||||
Clare 2004 [70] | To investigate the efficacy of the McK method of management of non- specific spinal pain. Specific questions: What is the comparative efficacy of McK therapy in relation to inactive treatment (placebo or sham) or no treatment? What is the comparative efficacy of McK treatment in relation to other standard therapies? | MEDLINE, EMBASE, DARE, CINAHL, PEDro, CENTRAL, CDSR to Sep 2003. | 6 (3) | |||||
Hayden 2005c [69] | To assess the effectiveness of ET for reducing pain and disability in adults with non-specific acute, subacute and chronic LBP compared to no treatment, placebo, or other conservative treatments. | CENTRAL Issue 3 2004, MEDLINE, EMBASE to Oct 2004, PsychInfo, CINAHL 1999–Oct 2004. | 61 (9) | |||||
Ferreira 2006 [68] | To conduct a SR of the effects of specific SE for spinal or pelvic pain when this intervention was compared with placebo, no treatment, another active treatment, or when specific SE was added as a supplement to other interventions. | MEDLINE 1966-, EMBASE 1974-, CINAHL 1982- and PEDro- March 2004. | 12 (1) | Hides 1996/2001 [72] | Adults with symptoms in the cervical, thoracic, low back, or pelvic area. Symptoms could be referred distal. See above [53]. | One group received specific SE or exercise aimed at activating, training, or restoring the stabilization function of specific muscles of the spine and pelvis in isolation or in conjunction with other therapies. See above [53]. | Not defined in PICO of SR. See above [53]. | Disability, pain, return to work, no. of episodes, global perceived effect, or health-related quality of life. See above [53] + Recurrence. |
Machado 2006 [76] | To evaluate whether the McK method is more effective than other reference treatments for acute or chronic nonspecific LBP. | MEDLINE, EMBASE, PEDro, and LILACS to Aug 2003. | 11 (5) | |||||
Rackwitz 2006 [28] | To evaluate the effectiveness of segmental SE for acute, subacute and chronic LBP with regard to pain, recurrence of pain, disability and return to work. | MEDLINE 1988- and EMBASE 1989- Dec 2004. | 7 (1) | Hides 1996/2001 [72]. | Adults > 18 years and take part in a program treating acute, subacute or chronic LBP ± sciatica. See above [53]. | The intervention group has to have received segmental SE at least as part of the treatment. See above [53]. | Not defined in PICO of SR. See above [53]. | Pain, recurrence, disability, and return to work. See above [53]. |
Hauggaard 2007 [78] | To evaluate the effects of specific spinal SE in patients with LBP, and to assess the methodological quality and level of evidence of the studies. | PubMed 1985- Oct 2005.PEDro 1985- Dec 2006. | 10 (1) | Hides 1996/2001 [72]. | Acute, sub-acute, or chronic LBP. See above [53]. | Intervention containing specific spinal SE including co-contraction of multifidus muscles and transversus abdominis muscles. See above [53]. | Not defined in PICO of SR. See above [53]. | Specific functional questionnaires and/or generic questionnaires and/or pain rating. See above [53]. |
Keller 2007 [62] | To synthesize the results of RCTs for common LBP treatments comparing the interventions to placebo/ sham or no-treatment, to estimate a pooled effect size for each treatment, and compare them with each other. | CENTRAL issue 2 2005.MEDLINE, EMBASE, CINAHL, AMED from the last search in each Cochrane review to Dec 2005. | 47 (4) | |||||
Liddle 2007 [80] | To examine the evidence for the use of advice in management of LBP. Secondary objectives included assessment of the effectiveness of interventions in relation to LBP phase. | MEDLINE, AMED, CINAHL, PsycInfo, DARE, andCENTRAL 1985 to Sept 2004. | 39 (7) | |||||
Engers 2008c [81] | To determine whether individual patient education is effective for pain, global improvement, functioning and return-to-work in the treatment of non-specific LBP, and to determine which type of education is most effective. | MEDLINE 1966-, EMBASE 1988-, CINAHL 1982- and PsycINFO 1984 to July 2006. CENTRAL 2006 Issue 2. | 24 (2) | |||||
May 2008 [82] | To evaluate the effectiveness of SE in the treatment of pain and dysfunction from LBP. | MEDLINE 1966-, CINAHL 1982-, AMED 1985- and PEDro to Oct 2006. CENTRAL 2006 Issue 1. | 18 (2) | |||||
Ferreira 2009 [84] | To investigate the efficacy of motor control exercises for low-back and pelvic pain. | Cochrane, MEDLINE, PEDro to 2009. | 8 (1) | Hides 1996/2001 [72]. | Studies examining MCE in isolation or with other treatment. See above [53]. | MCE according to Richardson et Jull. See above [53]. | Not defined in SR. See above [53]. | Pain and disability. See above [53]. |
Choi 2010c [85] | To investigate the effectiveness of exercises for preventing new episodes of LBP or LBP-associated disability. | CENTRAL- 2009, issue 3, MEDLINE, EMBASE, CINAHL to July 2009. | 9 (4) | Exercise aimed at the prevention of recurrences of LBP, divided into post-treatment and treatment. Post-treatment = exercise provided after regular treatment for an episode of back pain had been finished with the explicit aim to prevent new occurrences of back pain. Treatment = exercise for a current episode of back pain with the aim to also prevent new episodes of back pain. See above [53, 56, 62, 71]. | ||||
Dahm 2010c [86] | To determine the effects of advice to rest in bed or stay active for patients with LBP or sciatica. | Cochrane Back Review Register to May 2009. CENTRAL 2009 issue 2. MEDLINE, EMBASE, SPORT and SCISEARCH 1998- May 2009. | 10 (2) | One group of subjects was advised to rest in bed (instructions to stay in bed for at least two days) and at least one group was not. Or at least one group of subjects was advised to stay active (instructions to stay as active as possible and continue normal daily activities) and at least one group was not. See above [51, 52]. | ||||
Kriese 2010 [71] | To evaluate the effectiveness of Segmental SE for acute, subacute, chronic and recurrent LBP. | PubMed Nov 2008–March 2009 | 17 (1) | Hides 1996/2001 [72]. | Acute, subacute, chronic or recurrent LBP. SR in German with abstract in English. See above [53]. | Segmental SE. See above [53]. | Other forms of therapy. See above [53]. | Not defined in PICO of SR. See above [53]. |
Dunsford 2011 [87] | To summarize current research evidence for DP exercises, as applied under the McK method, in the treatment of mechanical LBP. | CINAHL, AMED, MEDLINE, PubMed, EMBASE, Cochrane Library, Google Scholar, PEDro, 1995- Feb 2010. | 4 (3) | |||||
Rubinstein 2012c [23] | To examine the effectiveness of SMT for aLBP on primary and secondary outcomes as compared to inert interventions, sham, and all other treatments. | CENTRAL, MEDLINE, EMBASE,CINAHL, PEDro, and Index Chiropractic 2000 to July 2012. | 20 (4) | |||||
Surkitt 2012 [88] | To determine the efficacy of treatment using the principles of DP Management for people with LBP and a DP. | MEDLINE 1950-, EMBASE 1980-, CENTRAL, CINAHL 1982- and PEDro to Jan 2010. | 6 (2) | |||||
Macedo 2016c [17] | To evaluate the effectiveness of motor control exercise for patients with acute non- specific LBP. | MEDLINE, EMBASE, CENTRAL, AMED to March 2015.MEDLINE In-Process and Non-Indexed Citations, CINAHL, SportDiscus, PEDro, LILACS, PubMed to April 2015. | 3 (3) | Adults, mean age 36 (31–38). Trials with a mixed population in relation to type and duration of back pain only if separate data were provided for each group, or if the acute/subacute population corresponded to the majority of included participants (> 75%). See above [53, 74]. LBP. Age: mean 36 (SD 9.4). Female: 85% [65]. | ||||
Lam 2018 [89] | To determine the effectiveness of MDT provided by trained therapists compared to that of different types of comparator interventions for improving pain and disability in patients with acute and chronic LBP separately. | MEDLINE, EMBASE, CINAHL, CDSR PsycINFO, and PEDro. Three searches: Nov, 2015, May 2016 and Sep 2017. | 17 (4) | Patients with LBP. Only trials in which therapists were MDT trained. See above [66, 71]. aLBP, pain between the 12th rib and buttock crease, ± leg pain, < 6 weeks in duration, preceded by at least 4 weeks without LBP in which the patient did not consult a health care practitioner, 18–80 years of age. Female 50% [59]. LBP, at least 3 of 5 selection criteria from clinical prediction rules, ≥ 18 years of age mean symptom duration, 15 days. Female 61% [75]. | Studies in which an MDT classification was not completed prior to the treatment were excluded, as a priori classification is essential for the MDT approach. See above [66, 71]. MDT: first-line care, DP exercises, postural correction and education, Treat Your Own Back book, lumbar roll, home exercise program [59]. MDT: DP exercises, home exercise program [75]. | |||
24 SRs published from 1991 to 2018. | Sub-categories in aim: Exercise therapy in 5 SRs, conservative or common treatment in 2 SRs, comparison in 5 SRs, McK in 5 SRs and SE in 7 SRs. | 19 databases/registers/Indexes included. Search range from 1908 to Sep 2017. | 572 RCTs (88)a | 25 publications based on 21 RCTs, n = 2685. Published from 1982 to 2013. | All RCTs include aLBP with or without referred pain in legs. Female: 47%. | Types of exercise therapy: general exercise therapy, stabilization exercise and McKenzie therapy. | 34 different definitions of comparisons | 22 different definitions of outcomes |
Exercise therapy
Comparisons
Treatment duration and frequency
Outcomes
Outcome measures
Time points
Methodological quality of included reviews
AMSTAR questions | ||||||||||||
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1. Was an 'a priori' design provided? | ||||||||||||
2. Was there duplicate study selection and data extraction? | ||||||||||||
3. Was a comprehensive literature search performed? | ||||||||||||
4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? | ||||||||||||
5. Was a list of studies (included and excluded) provided? | ||||||||||||
6. Were the characteristics of the included studies provided? | ||||||||||||
7. Was the scientific quality of the included studies assessed and documented? | ||||||||||||
8. Was the scientific quality of the included studies used appropriately in formulating conclusions? | ||||||||||||
9. Were the methods used to combine the findings of studies appropriate? | ||||||||||||
10. Was the likelihood of publication bias assessed? | ||||||||||||
11. Was the conflict of interest included? | ||||||||||||
Review/Question | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | Sum |
Koes 1991 | – | – | – | – | Y | – | Y | Y | Y | – | – | 4/11 |
Faas 1996 | – | – | – | – | Y | – | Y | Y | – | – | – | 3/11 |
vanTulder 1997 | – | – | – | – | – | Y | Y | Y | Y | – | – | 4/11 |
vanTulder 2000 | Y | Y | Y | – | Y | Y | Y | Y | Y | – | – | 8/11 |
Ferreira 2003 | – | – | Y | – | Y | – | Y | Y | Y | – | – | 5/11 |
Clare 2004 | – | Y | Y | Y | Y | – | – | Y | Y | – | – | 6/11 |
Hayden 2005 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | – | 10/11 |
Ferreira 2006 | – | – | Y | Y | – | – | – | Y | Y | – | – | 4/11 |
Machado 2006 | – | Y | Y | – | Y | Y | Y | Y | Y | – | – | 7/11 |
Rackwitz 2006 | – | Y | Y | – | Y | Y | Y | Y | Y | – | – | 7/11 |
Hauggaard 2007 | – | – | Y | – | – | Y | Y | Y | – | – | – | 4/11 |
Keller 2007 | – | – | – | – | Y | – | Y | Y | Y | – | – | 4/11 |
Liddle 2007 | – | Y | Y | Y | Y | Y | Y | Y | Y | – | – | 8/11 |
Engers 2008 | Y | Y | Y | - | Y | Y | Y | Y | Y | – | – | 8/11 |
May 2008 | – | – | Y | – | – | Y | – | Y | Y | – | – | 4/11 |
Ferreira 2009 | – | – | – | – | – | Y | Y | Y | – | – | – | 3/11 |
Choi 2010 | Y | Y | Y | - | Y | Y | Y | Y | Y | Y | – | 9/11 |
Dahm 2010 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | – | 10/11 |
Kriese 2010 | – | – | – | – | – | Y | – | Y | – | – | – | 2/11 |
Dunsford 2011 | – | – | – | – | – | Y | Y | Y | Y | – | – | 4/11 |
Rubinstein 2012 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 11/11 |
Surkitt 2012 | Y | Y | Y | Y | – | Y | Y | Y | Y | – | – | 8/11 |
Macedo 2016 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 11/11 |
Lam 2018 | – | Y | Y | Y | – | Y | Y | Y | Y | – | – | 7/11 |