Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis

Patrick J Owen, Clint T Miller, Niamh L Mundell, Simone J J M Verswijveren, Scott D Tagliaferri, Helena Brisby, Steven J Bowe, Daniel L Belavy, Patrick J Owen, Clint T Miller, Niamh L Mundell, Simone J J M Verswijveren, Scott D Tagliaferri, Helena Brisby, Steven J Bowe, Daniel L Belavy

Abstract

Objective: Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP).

Design: Network meta-analysis (NMA).

Data sources: MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL.

Eligibility criteria: Exercise training randomised controlled/clinical trials in adults with NSCLBP.

Results: Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): -1.86 (-2.54 to -1.19)), resistance (SUCRA=80%; -1.14 (-1.71 to -0.56)) and stabilisation/motor control (SUCRA=80%; -1.13 (-1.53 to -0.74)) for physical function and resistance (SUCRA=80%; -1.26 (-2.10 to -0.41)) and aerobic (SUCRA=80%; -1.18 (-2.20 to -0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (-0.71 to 0.89)) and physical function (SUCRA=20%; -0.31 (-0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; -0.31 (-1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria.

Summary/conclusion: There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.

Keywords: analgesics; behavioural symptoms; catastrophization; physical activity; physical therapy modalities; rehabilitation; spine.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
PRISMA flow diagram of the search process for studies examining the efficacy of exercise training in patients with non-specific chronic low back pain. LBP, low back pain; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis; RCT, randomised controlled trial.
Figure 2
Figure 2
Percentage of studies examining the efficacy of exercise training in patients with non-specific chronic low back pain with low, unclear and high risk of bias for each feature of the Cochrane Risk of Bias Tool. It is not possible to truly blind patients to treatment allocation in exercise training trials; thus, this was not included in the overall risk of bias assessment of each study.
Figure 3
Figure 3
Network meta-analysis maps of studies examining the efficacy of exercise training in patients with non-specific chronic low back pain on pain, physical function, mental health and muscle strength. CON: non-exercise control, INT: exercise training intervention. The size of the nodes relates to the number of participants in that intervention type and the thickness of lines between interventions relates to the number of studies for that comparison.

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