Physiotherapy exercises for low back pain: process and clinical outcome

The relationships between spinal amplitude of movement, pain and disability in low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The role of spinal movement alterations in low back pain (LBP) remains unclear. This systematic review and meta-analyses examined the relationships between spinal amplitude of movement, disability and pain intensity in patients with LBP.

DATABASES AND DATA TREATMENT

We searched PubMed, CINAHL, Embase, Pedro and Web of Science for relevant articles until 14th March 2023. Risk of bias was assessed with the Quality in Prognostic Studies Tool. We analysed the relationships between amplitude of movement, disability and pain intensity with standard correlational meta-analyses and meta-analytic structural equation modelling (MASEM) in cross-sectional and longitudinal data.

RESULTS

A total of 106 studies (9001 participants) were included. In cross-sectional data, larger amplitude of movement was associated with lower disability (pooled coefficient: -0.25, 95% confidence interval: [-0.29 to -0.21]; 69/5899 studies/participants) and pain intensity (-0.13, [-0.17 to -0.09]; 74/5806). An increase in amplitude of movement was associated with a decrease in disability (-0.23, [-0.31 to -0.15]; 33/2437) and pain intensity (-0.25, [-0.33 to -0.17]; 38/2172) in longitudinal data. MASEM revealed similar results and, in addition, showed that amplitude of movement had a very small influence on the pain intensity-disability relationship.

CONCLUSIONS

These results showed a significant but small association between amplitude of movement and disability or pain intensity. Moreover, they demonstrated a direct association between an increase in amplitude of movement and a decrease in pain intensity or disability, supporting interventions aiming to reduce protective spinal movements in patients with LBP.

SIGNIFICANCE

The large meta-analyses performed in this work revealed an association between reductions in spinal amplitude of movement and increased levels of disability and pain intensity in people with LBP. Moreover, it highlighted that LBP recovery is associated with a reduction in protective motor behaviour (increased amplitude of movement), supporting the inclusion of spinal movement in the biopsychosocial understanding and management of LBP.

Muscle energy technique for non-specific low-back pain

BACKGROUND

Low-back pain (LBP) is responsible for considerable personal suffering due to pain and reduced function, as well as the societal burden due to costs of health care and lost work productivity. For the vast majority of people with LBP, no specific anatomical cause can be reliably identified. For these people with non-specific LBP there are numerous treatment options, few of which have been shown to be effective in reducing pain and disability. The muscle energy technique (MET) is a treatment technique used predominantly by osteopaths, physiotherapists and chiropractors which involves alternating periods of resisted muscle contractions and assisted stretching. To date it is unclear whether MET is effective in reducing pain and improving function in people with LBP.

OBJECTIVES

To examine the effectiveness of MET in the treatment of people with non-specific LBP compared with control interventions, with particular emphasis on subjective pain and disability outcomes.

SEARCH METHODS

CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers were searched from inception to May and June 2014 together with reference checking and citation searching of relevant systematic reviews.

SELECTION CRITERIA

Randomised controlled trials assessing the effect of MET on pain or disability in patients with non-specific LBP were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias and extracted the data. Meta-analysis was performed where clinical homogeneity was sufficient. The quality of the evidence for each comparison was assessed with the GRADE approach.

MAIN RESULTS

There were 12 randomised controlled trials with 14 comparisons included in the review, with a total sample of 500 participants across all comparisons. Included studies were typically very small (n = 20 to 72), all except one were assessed as being at high risk of bias, and all reported short-term outcomes. For the purposes of pooling, studies were divided into seven clinically homogenous comparisons according to the patient population (acute or chronic LBP) and the nature of the control intervention. Most of the comparisons (five out of seven) included only one study, one comparison had two studies, and one comparison included seven studies.The meta-analyses provided low-quality evidence that MET provided no additional benefit when added to other therapies on the outcomes of chronic pain and disability in the short-term (weighted mean difference (WMD) for pain 0.00, 95% CI -2.97 to 2.98 on a 100-point scale; standardised mean difference (SMD) for disability -0.18, 95% CI -0.43 to 0.08, 7 studies, 232 participants). There was low-quality evidence that MET produced no clinically relevant differences in pain compared to sham MET (mean difference (MD) 14.20, 95% CI -10.14 to 38.54, 1 study, 20 participants). For the comparison of MET to other conservative therapies for acute non-specific LBP, there was very low-quality evidence of no clinically relevant difference for the outcomes of pain (MD -10.72, 95% CI -32.57 to 11.13, 2 studies, 88 participants) and functional status (MD 0.87, 95% CI -6.31 to 8.05, 1 study, 60 participants). For the comparison of MET to other conservative therapies for chronic non-specific LBP, there was low-quality evidence of no clinically relevant difference for the outcomes of pain (MD -9.70, 95% CI -20.20 to 0.80, 1 study, 30 participants) and functional status (MD -4.10, 95% CI -9.53 to 1.33, 1 study, 30 participants). There was low-quality evidence of no clinically relevant difference for the addition of MET to other interventions for acute non-specific LBP for the outcome of pain (MD -3, 95% CI -11.37 to 5.37, 1 study, 40 participants) and low-quality evidence of an effect in favour of MET for functional status (MD -17.6, 95% CI -27.05 to -8.15, 1 study, 40 participants). For chronic non-specific LBP, there was low-quality evidence of an effect in favour of MET for the addition of MET to other interventions for the outcomes of pain (MD -34.1, 95% CI -38.43 to -29.77, 1 study, 30 participants) and functional status (MD -22, 95% CI -27.41 to -16.59, 1 study, 30 participants). Lastly, there was low-quality evidence of no difference for the addition of MET to another manual intervention compared to the same intervention with other conservative therapies for the outcomes of pain (MD 5.20, 95% CI -3.03 to 13.43, 1 study, 20 participants) and functional status (MD 6.0, 95% CI -0.49 to 12.49, 1 study, 20 participants).No study reported on our other primary outcome of general well-being. Seven studies reported that no adverse events were observed, whereas the other five studies did not report any information on adverse events.

AUTHORS' CONCLUSIONS

The quality of research related to testing the effectiveness of MET is poor. Studies are generally small and at high risk of bias due to methodological deficiencies. Studies conducted to date generally provide low-quality evidence that MET is not effective for patients with LBP. There is not sufficient evidence to reliably determine whether MET is likely to be effective in practice. Large, methodologically-sound studies are necessary to investigate this question.

Sling exercise for chronic low back pain: a systematic review and meta-analysis

Background

Trials on sling exercise (SE), commonly performed to manage chronic low back pain (LBP), yield conflicting results. This study aimed to review the effects of SE on chronic LBP.

Methods

The randomized controlled trials comparing SE with other treatments or no treatment, published up to August 2013, were identified by electronic searches. Primary outcomes were pain, function, and return to work. The weighted mean difference (WMD) and 95% confidence interval (CI) were calculated, using a random-effects model.

Results

Risk of bias was rated as high in 9 included trials, where some important quality components such as blinding were absent and sample sizes were generally small. We found no clinically relevant differences in pain or function between SE and other forms of exercise, traditional Chinese medical therapy, or in addition to acupuncture. Based on two trials, SE was more effective than thermomagnetic therapy at reducing pain (short-term: WMD –13.90, 95% CI –22.19 to –5.62; long-term: WMD –26.20, 95% CI –31.32 to –21.08) and improving function (short-term: WMD –10.54, 95% CI –14.32 to –6.75; long-term: WMD –25.75, 95% CI –30.79 to –20.71). In one trial we found statistically significant differences between SE and physical agents combined with drug therapy (meloxicam combined with eperisone hydrochloride) but of borderline clinical relevance for pain (short-term: WMD –15.00, 95% CI –19.64 to −10.36) and function (short-term: WMD −10.00; 95% CI −13.70 to −6.30). There was substantial heterogeneity among the two trials comparing SE and thermomagnetic therapy; both these trials and the trial comparing SE with physical agents combined with drug therapy had serious methodological limitations.

Interpretation

Based on limited evidence from 2 trials, SE was more effective for LBP than thermomagnetic therapy. Clinically relevant differences in effects between SE and other forms of exercise, physical agents combined with drug therapy, traditional Chinese medical therapy, or in addition to acupuncture could not be found. More high-quality randomized trials on the topic are warranted.

Effects of abdominal hollowing during stair climbing on the activations of local trunk stabilizing muscles: a cross-sectional study

Objective

To examine using surface electromyography whether stair climbing with abdominal hollowing (AH) is better at facilitating local trunk muscle activity than stair climbing without AH.

Methods

Twenty healthy men with no history of low back pain participated in the study. Surface electrodes were attached to the multifidus (MF), lumbar erector spinae, thoracic erector spinae, transverse abdominus - internal oblique abdominals (TrA-IO), external oblique abdominals (EO), and the rectus abdominis. Amplitudes of electromyographic signals were measured during stair climbing. Study participants performed maximal voluntary contractions (MVC) for each muscle in various positions to normalize the surface electromyography data.

Results

AH during stair climbing resulted in significant increases in normalized MVCs in both MFs and TrA-IOs (p<0.05). Local trunk muscle/global trunk muscle ratios were higher during stair climbing with AH as compared with stair climbing without AH. Especially, right TrA-IO/EO and left TrA-IO/EO were significantly increased (p<0.05).

Conclusion

Stair climbing with AH activates local trunk stabilizing muscles better than stair climbing without AH. The findings suggest that AH during stair climbing contributes to trunk muscle activation and trunk stabilization.

Effect of lumbar stabilization and dynamic lumbar strengthening exercises in patients with chronic low back pain

Objective

To compare the effects of lumbar stabilization exercises and lumbar dynamic strengthening exercises on the maximal isometric strength of the lumbar extensors, pain severity and functional disability in patients with chronic low back pain (LBP).

Methods

Patients suffering nonspecific LBP for more than 3 months were included prospectively and randomized into lumbar stabilization exercise group (n=11) or lumbar dynamic strengthening exercise group (n=10). Exercises were performed for 1 hour, twice weekly, for 8 weeks. The strength of the lumbar extensors was measured at various angles ranging from 0° to 72° at intervals of 12°, using a MedX. The visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ) were used to measure the severity of LBP and functional disability before and after the exercise.

Results

Compared with the baseline, lumbar extension strength at all angles improved significantly in both groups after 8 weeks. The improvements were significantly greater in the lumbar stabilization exercise group at 0° and 12° of lumbar flexion. VAS decreased significantly after treatment; however, the changes were not significantly different between the groups. ODQ scores improved significantly in the stabilization exercise group only.

Conclusion

Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP. However, the lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP.

Comparison of a biopsychosocial therapy (BT) with a conventional biomedical therapy (MT) of subacute low back pain in the first episode of sick leave: a randomized controlled trial

This randomized controlled clinical trial compares the effectiveness of a biopsychosocial treatment with a solely conventional biomedical therapy in patients with subacute low back pain using parameters for pain intensity, functional status, depressive dysfunction and work performance. Sixty-four patients with a first-time sick leave between 3 and 12 weeks due to low back pain were randomly assigned to either a conventional biomedical therapy (MT; n=33) group, or a biopsychosocial therapy (BT; n=31) group including a psychotherapeutic module; both in accordance with a standardized 3 weeks inpatient treatment. Pain intensity, functional back capacity, clinical parameters and depressive dysfunction revealed significant improvement in both treatment groups at end of 3 weeks therapy (T1). However, at 6 months (T2), analysis revealed significant better results for nearly all parameters in the BT group that showed further improvement from T1 to T2, whereas the values in the MT group deteriorated from T1 back to the baseline values. During the 2-year period after therapy, 10% in MT and 59% in BT required no further sick leave due to low back pain. The results of the study indicate that a psychotherapeutic element in the treatment of low back pain appears to positively influence pain, functional status and work performance when conducted at an early stage of chronification and helps in the achievement of a better outcome.

Exercise therapy for treatment of non-specific low back pain

BACKGROUND

Exercise therapy is widely used as an intervention in low-back pain.

OBJECTIVES

To evaluate the effectiveness of exercise therapy in adult non-specific acute, subacute and chronic low-back pain versus no treatment and other conservative treatments.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (Issue 3, 2004), MEDLINE, EMBASE, PsychInfo, CINAHL databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews.

SELECTION CRITERIA

Randomized controlled trials evaluating exercise therapy for adult non-specific low-back pain and measuring pain, function, return-to-work/absenteeism, and/or global improvement outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short, intermediate, and long-term follow-up.

MAIN RESULTS

Sixty-one randomized controlled trials (6390 participants) met inclusion criteria: acute (11), subacute (6) and chronic (43) low-back pain (1 unclear). Evidence was found of effectiveness in chronic populations relative to comparisons at all follow-up periods; pooled mean improvement was 7.3 points (95% CI, 3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) at earliest follow-up. In studies investigating patients (i.e. presenting to healthcare providers) mean improvement was 13.3 points (5.5 to 21.1) for pain, 6.9 (2.2 to 11.7) for function, representing significantly greater improvement over studies where participants included those recruited from a general population (e.g. with advertisements). There is some evidence of effectiveness of graded-activity exercise program in subacute low-back pain in occupational settings, though the evidence for other types of exercise therapy in other populations is inconsistent. There was evidence of equal effectiveness relative to comparisons in acute populations [pain: 0.03 points (95% CI, -1.3 to 1.4)].

LIMITATIONS

This review largely reflects limitations of the literature, including low quality studies with heterogeneous outcome measures, inconsistent and poor reporting, and possibility of publication bias.

AUTHORS' CONCLUSIONS

Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

A systematic review of physiotherapy for spondylolysis and spondylolisthesis

The purpose of this systematic review was to assess the evidence concerning the effectiveness of physiotherapy intervention in the treatment of low back pain related to spondylolysis and spondylolisthesis. A literature search of published and unpublished articles resulted in the retrieval of 71 potential studies on the subject area. Fifty-two of the 71 articles were studies, and these studies were reviewed using preset relevance criteria. Given the inclusion and exclusion criteria chosen for this systematic review, there were very few acceptable studies and only two studies met the relevance criteria for the critical appraisal. Both studies provide evidence to suggest that specific exercise interventions, alone or in combination with other treatments, have a positive effect on low-back pain due to spondylolysis and spondylolisthesis; however, the type of exercise used was different in the two studies. In this review, very few prospective studies were found that examined the efficacy of physiotherapy on the topic area; therefore, few conclusions can be made, and further research is warranted.

Adherence to rehabilitation in patients with low back pain

This study investigated adherence to low back pain rehabilitation in the clinical setting. Adherence was assessed in 105 (71 male and 34 female) patients attending private physiotherapy clinics for rehabilitation of low back pain. Three aspects of adherence were measured over the 4-week study period: attendance at clinic-based rehabilitation sessions, adherence to a home exercise component of rehabilitation, and adherence to activities and advice during clinic-based rehabilitation. Rehabilitation outcome was measured using the Patients' Measure of Perceived Rehabilitation (McDonald & Hardy 1990) and the Physiotherapists' Measure of Perceived Rehabilitation (McDonald & Hardy 1990). It was found that patients attended 87.7% of their scheduled physiotherapy rehabilitation appointments and reported completing 71.6% of their prescribed home exercises. In relation to adherence to clinic-based rehabilitation activities (as measured by the Sport Injury Rehabilitation Adherence Scale, Brewer et al. 2000), patients scored an average of 11.6/15. Although no gender differences were found, compensable patients adhered significantly less to clinic-based rehabilitation activities than did their non-compensable counterparts. Further, it was found that higher levels of adherence to clinic-based activities significantly predicted both the patients' and physiotherapists' perception of degree of rehabilitation at the end of the 4-week rehabilitation period. These findings are discussed in relation to rehabilitation strategies for physiotherapists.

Dose-response of physical activity and low back pain, osteoarthritis, and osteoporosis

PURPOSE

The purpose of this study was to examine the evidence for causal relationships between physical activity (PA) and low back pain (LBP), osteoarthritis (OA), and osteoporosis (OP), and for dose-response relations involved.

METHODS

Computer database searches and personal retrieval systems were used to locate relevant literature.

RESULTS

PA can be effective in preventing LBP (Category A) but prolonged, heavy loading can lead to LBP (Category C). Specific exercises have not been found effective in treatment of acute LBP (Category A), but PA can be effective in chronic LBP (Category B), especially for diminishing the effects of deconditioning. No evidence indicates that PA directly prevents OA. Large amounts of intensive PA involving high impacts or torsional loadings or causing injuries increases risk of OA (Category C). Light or moderate PA does not increase the risk of OA (Category C). PA can be effective in the treatment and rehabilitation of OA (Category B). High-intensity loading is osteogenic and possibly useful in prevention of OP (Category A) at the loaded site, but low to moderate loading is not osteogenic (Category D). Static efforts and slow movements are ineffective or less effective than fast application of force (Category B). The types of PA to attain the effects mentioned above are known except in the case of prevention of LBP, but dose-response relationships are poorly known; at best, semiquantitatively on the basis of just a few studies.

CONCLUSION

Given the shown primary and/or secondary preventative effectiveness of PA regarding LBP, OA, and OP, research to elucidate the inadequately known dose-response relations should be given high priority.

[Critical analysis of a systematic review of the literature and a meta-analysis on exercise therapy and chronic low back pain]

OBJECTIVES

To determine wether the type of quality assessment scale used for evaluating the role of the physical training in chronic low back pain affects the conclusions of meta-analytic studies.

DESIGN AND SETTING

Analysis of 20 trials assessing exercise therapy in chronic low back pain using 16 different scales to identify high-quality trials. Correlations between the scale scores were assessed using the Spearmans rank correlation coefficient. Inter-reader reliability was assessed with the intraclass correlation coefficient (ICC) and with the Bland and Altman technique. For the quality assessment scales allowing the classification in high quality or low quality trials, the degree of agreement between the two readers was calculated using the kappa coefficient.

RESULTS

The range of the Spearman rank correlation coefficients between the different quality scales was wide (from 0.94 to 0.49). The quality scales inter-reader reliability were heterogeneous, ICC ranging from 0.86 to 0.39. The Bland and Altman analysis showed that with two scales the differences were not centered and that with 3 scales there was a systematic effect (r=0.32, 0.41, and 0.50). Finally, inter-reader agreement was low most of the time, the K coefficient being less than or equal to 0.60 for 8 of the 12 quality scales tested.

CONCLUSIONS

Our data suggest that the use of summary scores to identify trials of high quality is problematic. Relevant methodological aspects should be assessed more specifically based on treatment strategies than on the own disease. A large reflexion on the elaboration and validation of specific quality scales is needed.

Effects of a three-month therapeutic exercise programme on flexibility in subjects with low back pain

BACKGROUND AND PURPOSE

Spinal and muscle flexibility have been studied intensively and used clinically as outcome measurements in the rehabilitation of subjects with low back pain. The results of previous studies are contradictory and there is a lack of longitudinal data on the effects of long term therapeutic exercise on flexibility.

METHOD

A controlled experimental study was conducted to determine the effects of progressive therapeutic exercise on spinal and muscle flexibility. Eighty-six chronic low back pain subjects fulfilled the inclusion criteria and were divided into three study groups: (1) intensive training group, (2) home exercise group and (3) control group. The intervention period lasted three months and measurements were performed at both the beginning of the study and immediately after intervention. Follow-up measurements were carried out six and 12 months after baseline. Spinal flexibility was measured with lumbar flexion, extension, spinal lateral flexion and rotation, and muscle flexibility was measured with measurements of erector spinae, hamstring and iliopsoas muscles. Also self-reported outcomes of the Oswestry Index and Borg Scale--Back Pain Intensity were used. Associations between change (pre- to post-treatment) were determined for the dependent variables.

RESULTS

The results showed no correlation between flexibility, the Oswestry Index or back pain intensity. After the first three-month period lumbar flexion, extension and spinal rotation decreased among all subjects. Spinal rotation and erector spinae muscle flexibility improved significantly with intensive training. At the nine-month follow-up, erector spine flexibility was still greater than at baseline. Hamstring flexibility increased among the intensive training and home exercise groups from pre- to post-intervention. However, the degree of hamstring flexibility gained during training was subsequently lost following the period without programmed exercise in both training groups. Self-reported outcome variables showed positive changes among the three study groups after the completion of intervention period, but these changes were only able to be maintained during subsequent follow-ups for the intensive training and home exercise groups.

CONCLUSIONS

The findings suggest that flexibility does not play an important role in coping with chronic low back pain for subjects whose functional limitations are not severe. Also, it appears that the achieved gains in spinal and muscle flexibility may not be able to be maintained without continued exercise.

Exercise therapy for low back pain

BACKGROUND

Exercise therapy is a widely used treatment for low back pain.

OBJECTIVES

The objective of this review was to assess the effectiveness of exercise therapy for low back pain with regard to pain intensity, functional status, overall improvement and return to work.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (1999, issue 1), MEDLINE (1966 - April 1999), EMBASE (1988 - September 1998), PsycLIT (from 1984 to April 1999) and reference lists of articles.

SELECTION CRITERIA

Randomised trials of all types of exercise therapy for subjects with non-specific low back pain with or without radiation into the legs.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. Because trials were considered heterogeneous with regard to study populations, interventions and outcomes, we decided not to perform a meta-analysis but to summarise the results using a rating system of four levels of evidence (strong, moderate, limited or no evidence).

MAIN RESULTS

39 RCTs were identified. There is strong evidence that exercise therapy is not more effective than inactive or other active treatments it has been compared with for acute low back pain. There is conflicting evidence on the effectiveness of exercise therapy compared with inactive treatments for chronic low back pain. Exercise therapy was more effective than usual care by the general practitioner and equally effective as conventional physiotherapy for chronic low back pain.

REVIEWER'S CONCLUSIONS

The evidence summarised in this systematic review does not indicate that specific exercises are effective for the treatment of acute low back pain. Exercises may be helpful for chronic low back pain patients to increase return to normal daily activities and work.

Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions

STUDY DESIGN

A systematic review of randomized controlled trials.

OBJECTIVES

To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy.

METHODS

A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results.

RESULTS

The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti-inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term effects.

CONCLUSIONS

The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.

Effect of exercise on sick leave due to low back pain. A randomized, comparative, long-term study

STUDY DESIGN

The study was carried out as an open, randomized, multicenter, parallel-group study with an observation period of 12 months. Four norwegian physiotherapy institutes took part. Patients were subsequently followed for 12 months of home exercise on their own, without for 12 months of home exercise on their own, without the supervision of a physiotherapist.

OBJECTIVES

1) To investigate and compare the effects of two different exercise programs on low back problems in patients after a 1-year training program under the supervision of a physiotherapist. 2) To investigate the effect supervision by, and motivation from, physiotherapists has on training compliance and efficacy.

SUMMARY OF BACKGROUND DATA

After ordinary physiotherapy treatment for low back problems, patients were randomly allocated either to a conventional training program designed by physiotherapists or to a training program using a new Norwegian-developed training apparatus called the TerapiMaster. The study included 153 patients with low back problems, all of whom had been referred to physiotherapy by their general practitioners. One hundred twenty-six patients were followed for an additional 12 months when performing home exercise programs on their own.

METHODS

Monitoring patient satisfaction with the training program, compliance with the program, and absenteeism from work during the training period.

RESULTS

Patient satisfaction with both training programs was high, with about 83% of participating patients completing the study in accordance with the protocol. Mean absenteeism (SD) during the preceding year totaled 82.5 days (19.8) in the conventional training group and 61.6 days (14.7) in the TerapiMaster group. Significant reductions to 17.2 days (6.0) and 16.4 days (5.3) in the two groups, respectively, were recorded during the training period, corresponding to a 75% to 80% reduction compared with the preceding 1-year period. Mean absenteeism showed a further significant decline during the 12-month period without supervised training. The average values were 9.9 days (3.2) for conventional training and 9.3 days (3.1) for the TerapiMaster, respectively.

CONCLUSIONS

Both exercise programs reduced absenteeism significantly (75-80%). No difference in the effects of the two different programs was discernible. Regular follow-up through encouragement and variation in the training programs appear to be important factors for motivating patients to adhere to regular exercise programs for low back problems. This thesis was corroborated by the 12-month study of unsupervised exercise.

Exercises for chronic low back pain: a clinical trial

Different training models are effective for the treatment of chronic low back pain, but no consensus has been found. Earlier studies have emphasized training of spinal mobility and back strength. To evaluate if other physiological parameters, such as coordination, are of equal importance, we performed a randomized trial on 40 consecutive patients with chronic low back pain. Two training models were compared: 1) intensive training of muscle endurance and 2) muscle training, including coordination. In both groups, training was performed 1 hour twice a week for 3 months. Pain score, disability score, and spinal mobility improved in both training groups without differences between the two groups. Only intensive training of muscle endurance improved isokinetic back muscle strength. At study entry, we found a significant correlation between spinal mobility and dysfunction, but after the training, no correlation was found between improvement of spinal mobility or isokinetic back extension strength and improvement of function or pain level. We conclude that coordination training for patients with chronic low back pain is as equally effective as endurance training.

Characteristics of low back pain patients who do not complete physiotherapeutic treatment

Patients' problems in following recommendations of health professionals is an issue of great concern. The purpose of the present study was to investigate whether patients with low back pain (n = 46) who dropped out of a treatment programme differed in characteristics measured prior to treatment from a matched comparison group (n = 46) who completed the programme. Data collected on work disability and sick leave, frequency, duration and intensity of pain, physical function, and personality characteristics were compared. The results indicated that the groups differed significantly on 3 of 16 variables. The non-completers had been on sick leave for a longer time period prior to treatment, experienced more intense pain and performed at a lower level on the test of physical function than those who completed the treatment programme.

Physiotherapy exercises and back pain: a blinded review

OBJECTIVE

To determine the quality of randomised controlled trials of exercise therapy for back pain.

DESIGN

Computer aided search of published papers and blinded assessment of the methods of studies.

SUBJECTS

23 randomised controlled trials, of which 16 studied exercise therapy given by physiotherapists to individual patients with back pain. Other conservative treatments could be included.

MAIN OUTCOME MEASURES

Score for quality of methods (based on four main categories: study population, interventions, measurement of effect, and data presentation and analysis) and main conclusion of author(s) with regard to exercise therapy.

RESULTS

Only four studies scored more than 50 points (maximum 100), indicating that most were of poor quality. Six studies found that exercise was better than reference treatments and 10 reported it to be no better or worse than the reference treatment. Those reporting positive results tended to have higher methods scores (4/6 positive v 4/10 negative scored greater than or equal to 42).

CONCLUSIONS

No conclusion can be drawn about whether exercise therapy is better than other conservative treatments for back pain or whether a specific type of exercise is more effective. Further trials are needed in which greater attention is paid to methods of study.

Clinical trial of intensive muscle training for chronic low back pain

105 patients who had chronic low back pain without clinical signs of lumbar nerve root compression or radiological evidence of spondylolysis or osteomalacia were randomised to three treatments: 30 sessions of intensive dynamic back extensor exercises over three months; a similar programme at one-fifth the exercise intensity; or one month of thermotherapy, massage, and mild exercises. The results consistently favoured intensive exercise, which had no adverse effects. Since these exercises can be conducted in groups, the intensive programme is no more costly than conventional strategies that require individual attention.