PROSPERO

International prospective register of systematic reviews

Systematic review and meta-analysis of exercise interventions for the treatment of chronic back pain

Citation

Daniel Belavy, Clint Miller, Helena Brisby, Simone Verswijveren, Niamh Mundell, Patrick Owen, Scott Tagliaferri,
Steve Bowe. Systematic review and meta-analysis of exercise interventions for the treatment of chronic back pain.
PROSPERO 2017 CRD42017068668 Available from:
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017068668

Review question
1) Are exercise interventions more effective than non-exercise interventions for decreasing pain, improving strength,
endurance and function, improving psychological status and reducing medication use in patients with chronic low back
pain?
2) Are there specific physical activities or exercise interventions that are more effective than others for decreasing pain,
improving strength, endurance and function, improving psychological status and reducing medication use in patients with
chronic low back pain?

Searches
Databases:
MEDLINE (Filters: All Adult: 19+ years; Randomized Controlled Trial; Human)
SPORTDiscus (Filters: Academic Journal)
CINAHL (Filters: Exclude MEDLINE records; Human, Randomized Controlled Trials; Journal Article; All Adult)
EBSOHOST (MEDLINE, SPORTDiscus, CINAHL; Filters: Journals)
EMBASE (Filters: RCT; Not Medline; Adult; Article)
Cochrane Central Register of Controlled Trials (CENTRAL) (Filters: Trials)
Exercise search terms (applicable to all above):
(((((((((((((((((((("exercise") OR "physical activity") OR "aerobic") OR "resistance") OR "strength") OR "endurance")
OR "yoga") OR "pilates") OR "tai chi") OR "physiotherapy") OR "physical therapy") OR "kinesiology") OR
"feldenkrais") OR "core stab*") OR "motor control") OR "hydrotherapy") OR "training") OR "core stability") OR
"motor control"))
Pain search terms (applicable to all above):
(((((((((((((((((((("exercise") OR "physical activity") OR "aerobic") OR "resistance") OR "strength") OR "endurance")
OR "yoga") OR "pilates") OR "tai chi") OR "physiotherapy") OR "physical therapy") OR "kinesiology") OR
"feldenkrais") OR "core stab*") OR "motor control") OR "hydrotherapy") OR "training") OR "core stability") OR
"motor control"))
Additional searches (previously published systematic reviews):
The Cochrane database of systematic reviews – search terms = chronic back pain exercise; limiters = none
GoogleScholar – search terms = systematic review chronic back pain exercise; limiter = previous 10 years

Types of study to be included

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RCT only
• Minimum of 4 weeks intervention duration
• Exercise compared to (a) non-active intervention control (e.g. no intervention, 'education', usual care, manual therapy)
or (b) specific exercise forms run up against one another
• Two or more groups (comparisons)
• n>20 (n>50 may limit some functional outcomes that are less likely to be feasible with large samples)
• Language: no restrictions
• Include only journal publications (no grey literature)
• Cluster RCTs will be included.

Condition or domain being studied

Non-specific chronic back pain and exercise.

Participants/population
Age: 'Adult' ('19+') .

Sex: Males and females

Race: Any

Definition of chronic non-specific lower back pain:

Chronic, = is defined as existing for a minimum of 12 weeks pain (Koes et al 2010). If unclear from manuscript, based
on duration listed in inclusion/exclusion criteria
Non-specific low back pain, defined as low back pain not attributable to specific pathology (infection, tumour,
osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome). If
any studies include those conditions, then they are excluded. If not clear then include. "Low back pain is defined as pain
and discomfort, localised below the costal margin and above the inferior gluteal folds, with or without leg pain" (van
Tulder M, Becker A, Bekkering T, et al. Chapter 3 European guidelines for the management of acute nonspecific low
back pain in primary care. Eur Spine J 2006; 15(Suppl 2): s169-s91). If have studies with this as an inclusion, then the
study is excluded.
Further exclusion criteria: pregnancy related pain - study includes people who have cervical or thoracic pain (but not
lumbar pain)
Rehabilitation post surgery is excluded.

Excluded if on a waiting list for surgery.

Intervention(s), exposure(s)
The intervention to be reviewed is: I. Exercise based intervention and II. Types of exercise intervention in multi-
treatment comparison, including
1) Resistance exercise (based on ACSM definition, Garber (2011) Med Sci Sports Exerc 43: 1334-1335);
2) Stabilisation/motor control (includes trunk stabilisation, lumbar stabilisation, core stabilisation, core strengthening
(excluding high load));
3) Pilates;

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4) Yoga;
5) McKenzie;
6) Flexion exercise;
7) Aerobic exercise (walking, cycling, jogging in any land-based mode);
8) Water based exercise;
9) Stretching;
10) Other exercise;
11) Physical therapy with exercise;
12) Multi-modal exercise (i.e. any combination of exercise types 1-9).

Comparator(s)/control
The comparator group will be non-exercise based interventions, including:
• no intervention at all, therapist hands-on treatment (e.g. manual therapy only, chiropractic only, passive physiotherapy,
osteopathic, acupuncture),
• therapist hands-off treatment (e.g. GP management, education, psychological interventions, pain education).
These will be combined to compare exercise based interventions with non-exercise based interventions and considered
separately as:
1) no intervention;
2) therapist hands-on;
3) therapist hands-off in multiple treatment comparison.

Context
All settings (e.g. community, primary care, specialty, inpatients) will be considered.

Main outcome(s)
Physical function (e.g. Oswestry, Roland Morris, physical function subcomponent of SF-36)

Strength (i.e. all objective measurements of back extension strength).

Endurance (i.e. all objective measurements of back extension endurance, e.g. hold times, number of repetitions until
fatigue)

Medication use (analgesic)

Psychological status (any quantifying mental health, depression or anxiety).

Measures of effect
Timing: The specified end point of the trial will be used as the end-point in the assessment.
Effect measure: Standardised mean difference at the end of the study

Additional outcome(s)

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None.
Measures of effect

Data extraction (selection and coding)

All search results will be exported into EndNote and duplicates will be removed. Titles and abstracts from the initial
literature search will be independently assessed by two reviewers (P.O. and S.V). Full texts for articles deemed eligible
for inclusion from the title and abstract search by either reviewer, in addition to those where no decision could be
reached by the reviewers from this initial screen, will be screened independently by two researchers (P.O. and S.V.). Any
discrepancies will be resolved by discussion with all researchers in the review team. Two reviewers (P.O. and S.T.) will
independently extract data from the final inclusion list of articles into a standardised data extraction spreadsheet in Excel.
This form will include publication details (author, title, year, journal), study design details (e.g. two-arm or multi-arm
trial, number of assessment time points), the number of participants at the beginning and subsequent time points of the
study (total and by treatment arm), recruitment process, participant characteristics (e.g. gender, average age, average
weeks of pain), interventions considered, the primary measure used to assess each of the outcomes of interest, mean and
standard deviation of each outcome measure at post-intervention for all treatment groups and study conclusions relating
to the intervention effect. The extraction form will be piloted on 3 included papers and amended if necessary.

Risk of bias (quality) assessment

Risk of bias will be assessed using the Cochrane Collaboration Risk of Bias Tool. Potential selection bias, performance
bias, detection bias, attrition bias, reporting bias will all be examined. For each source of bias, studies will be classified
as low risk, high risk or unclear risk (if reporting not sufficient to assess a particular domain). For example, studies that
used a random approach to treatment allocation (e.g. random number generator) would be classified as low risk for this
component of selection bias assessment while those that did not use a random approach (e.g. date of birth assignment)
would be classified as high. As this study involved exercise interventions, it would not have been possible to blind
participants to treatment allocation. Therefore, participant blinding will not be considered in the risk of bias assessment. .
Following risk of bias assessment, an overall risk of bias for each study was determined (low, unclear or high) based on
Cochrane guidelines.

Strategy for data synthesis

Aggregated data will be used and a narrative synthesis will be presented. In addition, a quantitative synthesis is planned.
A pairwise meta-analysis is planned to compare exercise-based interventions to non-exercise based interventions (Part I).
Random effects meta-analysis will be used as it is anticipated that there will be heterogeneity in the populations
considered in the included studies. Heterogeneity will be assessed using the χ² test and I² statistic. Forest plots will be
used to graphically depict the individual and pooled effect sizes and funnel plots will be used to assess potential
publication bias. Network meta-analysis is planned for the multiple treatment comparison (Part II). Heterogeneity will be
assessed, in addition to consistency which will be examined by fitting consistency and inconsistency models. This will
determine if the treatment effect for a pair of treatments estimated from an indirect comparison is consistent with the
treatment effect estimated from a direct comparison.

Analysis of subgroups or subsets

Potential sub-group analyses pending I² statistic (heterogeneity) and number of studies available: e.g. comorbidities
(mental and physical), medication use, severity of pain, duration of pain, severity of disability, age and gender. In
addition, a sensitivity analysis will be conducted which will exclude studies deemed to be high risk of bias.

Contact details for further information

Niamh Mundell
niamh.mundell@deakin.edu.au

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Organisational affiliation of the review

Deakin University
http://www.deakin.edu.au

Review team members and their organisational affiliations [1 change]

Assistant/Associate Professor Daniel Belavy. Deakin University, Geelong, Australia

Dr Clint Miller. Deakin University, Geelong, Australia
Professor Helena Brisby. Institute of Clinical Sciences, University of Gothenburg, Sweden
Ms Simone Verswijveren. Deakin University, Geelong, Australia
Ms Niamh Mundell. Deakin University, Geelong, Australia
Dr Patrick Owen. Deakin University, Geelong, Australia
Mr Scott Tagliaferri. Deakin University, Geelong, Australia
Dr Steve Bowe. Deakin University, Geelong, Australia

Type and method of review

Meta-analysis, Narrative synthesis, Systematic review

Anticipated or actual start date

30 April 2018

Anticipated completion date [1 change]

29 March 2019

Funding sources/sponsors
MOVE muscle, bone & joint health provided the funding for this project.

Conflicts of interest
None known

Language
English

Country
Australia, Sweden

Stage of review [1 change]

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Review Completed not published

Subject index terms status

Subject indexing assigned by CRD

Subject index terms

Back Pain; Exercise Therapy; Health Services; Humans; Network Meta-Analysis

Date of registration in PROSPERO

14 June 2017

Date of first submission

15 August 2018

Stage of review at time of this submission [1 change]

Stage Started Completed

Preliminary searches Yes Yes

Piloting of the study selection process Yes Yes

Formal screening of search results against eligibility criteria Yes Yes

Data extraction Yes Yes

Risk of bias (quality) assessment Yes Yes

Data analysis Yes Yes

The record owner confirms that the information they have supplied for this submission is accurate and complete and they
understand that deliberate provision of inaccurate information or omission of data may be construed as scientific
misconduct.

The record owner confirms that they will update the status of the review when it is completed and will add publication
details in due course.

Versions
14 June 2017
01 November 2017
06 September 2018
01 May 2019

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