Evaluation of a specific home exercise program for low back pain. A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain Effect of Motor Control Exercises Versus Graded Activity in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial Spinal segmental stabilisation exercises for chronic low back pain: programme adherence and its influence on clinical outcome Effects of preferred-exercise prescription compared to usual exercise prescription on outcomes for people with non-specific low back pain: a randomized controlled trial [ACTRN12608000524392] A walking programme and a supervised exercise class versus usual physiotherapy for chronic low back pain: a single-blinded randomised controlled trial. (The Supervised Walking In comparison to Fitness Training for Back Pain (SWIFT) Trial) Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Efficacy of the Addition of Modified Pilates Exercises to a Minimal Intervention in Patients With Chronic Low Back Pain: A Randomized Controlled Trial Comparison between massage and routine physical therapy in women with sub acute and chronic nonspeciﬁc low back pain. Multicenter Randomized Controlled Trial to Evaluate the Effect of Home-Based Exercise on Patients With Chronic Low Back Pain: The Japan Low Back Pain Exercise Therapy Study Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial Pilates Exercise or Stationary Cycling for Chronic Nonspecific Low Back Pain: Does it Matter? A Randomized Controlled Trial With 6-Month Follow-up Factors associated with older patients' engagement in exercise after hospital discharge. A randomized clinical trial of three active therapies for chronic low back pain. Physiotherapist-Directed Exercise, Advice, or Both for Subacute Low Back Pain Core Stabilization Exercise Prescription, Part 2 Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group Motor Control Exercises, Sling Exercises, and General Exercises for Patients With Chronic Low Back Pain: A Randomized Controlled Trial With 1-Year Follow-up Adding a physical exercise programme to brief intervention for low back pain patients did not increase return to work Clinical pilates versus general exercise for chronic low back pain: randomized trial. Graded Exercise for Recurrent Low-Back Pain: A Randomized, Controlled Trial With 6-, 12-, and 36-Month Follow-ups Effectiveness of Back School Versus McKenzie Exercises in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial
BACKGROUND The prescription of exercise as a conservative treatment for lumbar pain is frequent and seems effective for the chronic cases of nonspecific low back pain . However , there is no evidence favoring one type of exercise over another . Often , exercise programs are prescribed without adequate evaluation of the individual characteristics like posture , muscular force , and extensibility . Patients with totally different causes of low back pain will often be given the same type of exercises . OBJECTIVE Our objective was to compare the effectiveness of 2 home exercise programs in decreasing disability and pain related to subacute and chronic nonspecific low back pain . To do so we compared a specific ( individualized ) exercise program with a program of commonly prescribed exercises for low back pain . METHOD In a control group study , 20 patients with chronic or subacute nonspecific low back pain participated after giving their informed consent . All subjects were evaluated ( physical evaluation of lumbar and pelvic muscles [ 1 ] force and [ 2 ] extensibility , [ 3 ] trunk range of motion ) and then divided in 2 groups : 10 patients received specific exercises ( experimental group ) based on their evaluation , and 10 patients received a commonly prescribed exercise program for low back pain ( control group ) . Six weeks later a second physical evaluation was conducted . Pain ( visual analog pain scale ) and disability ( modified Oswestry ) question naires were also completed by each subject at both evaluations . DESIGN This was a r and omized experimental study . RESULTS Both groups had similar age , weight , and sex characteristics . The experimental group showed significant improvements for some components targeted by the program . The control group significantly had improvement of some physical characteristics not related to their initial deficits . Even if both groups showed some improvements in muscular force and extensibility , only the members of the group who received specific exercises significantly reduced their level of pain and disability . Both groups showed a similar rate of participation in the program . CONCLUSION The results of this study suggest that applying a specific physical evaluation and exercise prescription is an appropriate treatment for people having subacute or chronic nonspecific pain . Thus clinicians should prescribe exercise programs based on individual muscular deficits rather than most commonly prescribed exercise programs Objective : This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating  chronic low back pain and disability .  Methods : A single blind , r and omized , controlled trial was employed . Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning . In addition , patients received manual therapy or sham manual therapy . Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily . Results : Seventy-two out of 100 patients completed the study . Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction ( P = 0.04 and P = 0.05 , respectively ) , indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received . When controlling for pretreatment scores , patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain . No change in perceived disability was observed , with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment . Discussion : Manual therapy with specific adjuvant exercise appears to be beneficial in treating  chronic low back pain .  Despite changes in pain , perceived function did not improve . It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability . Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population Background Motor control exercises to improve control and coordination of trunk muscles and grade d activity under the principles of cognitive-behavioral therapy are 2 commonly used exercise therapies , yet there is little evidence to support the use of one intervention over the other . Objective The objective of this study was to compare the effectiveness of motor control exercises and grade d activity for patients with chronic nonspecific low back pain . Design This study was a prospect ively registered r and omized controlled trial with outcome assessment and statistical analyses conducted blind to group . Setting The study was conducted in primary care setting s. Patients The participants were 172 patients with chronic ( > 12 weeks ) nonspecific low back pain . Interventions Patients were r and omly assigned to receive either motor control exercises or grade d activity . There was no attempt to subclassify patients to match them to a treatment . Patients in both groups received 14 sessions of individualized , supervised exercise therapy . Measurements Primary outcomes were average pain over the previous week ( numeric rating scale ) and function ( Patient-Specific Functional Scale ) ; secondary outcomes were disability ( 24-item Rol and -Morris Disability Question naire ) , global impression of change ( Global Perceived Effect Scale ) , and quality of life ( 36-Item Short-Form Health Survey question naire [ SF-36 ] ) . Outcome measures were collected at baseline and at 2 , 6 , and 12 months after intervention . Results A linear mixed models analysis showed that there were no significant differences between treatment groups at any of the time points for any of the outcomes studied . For example , the effect for pain at 2 months was 0.0 ( −0.7 to 0.8 ) . Limitations Clinicians could not be blinded to the interventions . Conclusion The results of this study suggest that motor control exercises and grade d activity have similar effects for patients with chronic nonspecific low back pain Exercise rehabilitation is one of the few evidence -based treatments for chronic non-specific low back pain ( cLBP ) , but individual success is notoriously variable and may depend on the patient ’s adherence to the prescribed exercise regime . This prospect i ve study examined factors associated with adherence and the relationship between adherence and outcome after a programme of physiotherapeutic spine stabilisation exercises .  A total of 32/37 patients with cLBP completed the study ( mean age , 44.0 ( SD = 12.3 ) years ; 11/32 ( 34 % ) male ) . Adherence to the 9-week programme was documented as : percent attendance at therapy , percent adherence to daily home exercises ( patient diary ) and percent commitment to rehabilitation ( Sports Injury Rehabilitation Adherence Scale ( SIRAS ) ) . The average of these three measures formed a multidimensional adherence index ( MAI ) . Psychological disturbance , fear-avoidance beliefs , catastrophising , exercise self-efficacy and health locus of control were measured by question naire ; disability in everyday activities was scored with the Rol and –Morris disability scale and back pain intensity with a 0–10 graphic rating scale . Overall , adherence to therapy was very good ( average MAI score , 85 % ; median ( IQR ) , 89 (15)% ) . The only psychological/beliefs variable showing a unique significant association with MAI was exercise self-efficacy ( Rho = 0.36 , P = 0.045 ) . Pain intensity and self-rated disability decreased significantly after therapy ( each P < 0.01 ) .  Adherence to home exercises  showed a moderate , positive correlation with the reduction in average pain ( Rho = 0.54 , P = 0.003 ) and disability ( Rho = 0.38 , P = 0.036 ) ; higher MAI scores were associated with greater reductions in average pain ( Rho = 0.48 , P = 0.008 ) and a ( n.s . ) tendency for greater reductions in disability ( Rho = 0.32 , P = 0.07 ) Neither attendance at therapy nor SIRAS were significantly related to any of the outcomes . The benefits of rehabilitation depended to a large extent on the patient ’s exercise behaviour outside of the formal physiotherapy sessions . Hence , more effort should be invested in finding ways to improve patients ’ motivation to take responsibility for the success of their own therapy , perhaps by increasing exercise self-efficacy . Whether the “ adherence– outcome ” interaction was mediated by improvements in function related to the specific exercises , or by a more “ global ” effect of the programme , remains to be examined Background Non-specific chronic low back pain ( NSCLBP ) has become a significant problem due to high healthcare utilization , rising costs of care and perceived limitations of effectiveness of many current treatments . Systematic review s have repeatedly concluded that , on average across participants , exercise for NSCLBP appears effective in decreasing pain and improving function . Not all people with NSCLBP benefit from exercise programs and it would assist care-providers and care-seekers if factors that impact on program effectiveness and success were identified . Methods and design The study will be a r and omised controlled trial comparing an exercise rehabilitation program informed by a participant preferences question naire compared to a program without this guideline for patients with chronic low back pain . A sample of 150 patients will be recruited in Melbourne , Australia through community-based healthcare clinics that provide supervised exercise rehabilitation programs for people with non-specific chronic low back pain . Clinicians will be r and omly assigned to exercise preferences question naire or no question naire and participants will be allocated in a concealed manner . A qualitative focus group study of exercise instructor feedback about the exercise preferences instrument will be embedded in the research design . Two qualitative focus group studies will also be conducted for participants in the intervention and the control groups to obtain feedback about participants ' experiences of the two types of exercise programs . The primary outcomes will be functional ability , pain , fear avoidance , exercise adherence . Discussion This trial will evaluate the effectiveness of individualised exercise prescription compared to usual exercise prescription for NSCLP and , using feedback following the trial , refine the exercise preferences question naire Background Chronic low back pain ( CLBP ) is a persistent disabling condition with rising significant healthcare , social and economic costs . Current research supports the use of exercise-based treatment approaches that encourage people with CLBP to assume a physically active role in their recovery . While international clinical guidelines and systematic review s for CLBP support supervised group exercise as an attractive first-line option for treating large numbers of CLBP patients at low cost , barriers to their delivery include space and time restrictions in healthcare setting s and poor patient attendance . The European Clinical Guidelines have identified the need for research in the use of brief/minimal contact self-activation interventions that encourage participation in physical activity for CLBP . Walking may be an ideally suited form of individualized exercise prescription as it is easy to do , requires no special skills or facilities , and is achievable by virtually all ages with little risk of injury , but its effectiveness for LBP is unproven . Methods and design This study will be an assessor-blinded r and omized controlled trial that will investigate the difference in clinical effectiveness and costs of an individualized walking programme and a supervised general exercise programme compared to usual physiotherapy , which will act as the control group , in people with chronic low back pain . A sample of 246 patients will be recruited in Dublin , Irel and through acute general hospital outpatient physiotherapy departments that provide treatment for people with CLBP . Patients will be r and omly allocated to one of the three groups in a concealed manner . The main outcomes will be functional disability , pain , quality of life , fear avoidance , back beliefs , physical activity , satisfaction and costs , which will be evaluated at baseline , and 3 , 6 and 12 months [ follow-up by pre-paid postage ] . Qualitative telephone interviews and focus groups will be embedded in the research design to obtain feedback about participants ' experiences of the interventions and trial participation , and to inform interpretation of the quantitative data . Planned analysis will be by intention to treat ( quantitative data ) and thematic analysis ( qualitative data ) Discussion The trial will evaluate the effectiveness of a walking programme and a supervised general exercise programme compared to usual physiotherapy in people with CLBP.Trial registration Current controlled trial IS RCT BACKGROUND AND PURPOSE The purpose of this r and omized controlled trial was to examine the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with subacute or chronic nonspecific back pain by comparing a specific muscle stabilization-enhanced general exercise approach with a general exercise-only approach . SUBJECTS Fifty-five patients with recurrent , nonspecific back pain ( stabilization-enhanced exercise group : n=29 , general exercise-only group : n=26 ) and no clinical signs suggesting spinal instability were recruited . METHODS Both groups received an 8-week exercise intervention and written advice ( The Back Book ) . Outcome was based on self-reported pain ( Short-Form McGill Pain Question naire ) , disability ( Rol and -Morris Disability Question naire ) , and cognitive status ( Pain Self-Efficacy Question naire , Tampa Scale of Kinesiophobia , Pain Locus of Control Scale ) measured immediately before and after intervention and 3 months after the end of the intervention period . RESULTS Outcome measures for both groups improved . Furthermore , self-reported disability improved more in the general exercise-only group immediately after intervention but not at the 3-month follow-up . There were generally no differences between the 2 exercise approaches for any of the other outcomes . DISCUSSION AND CONCLUSION A general exercise program reduced disability in the short term to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent nonspecific low back pain . Stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic low back pain who have no clinical signs suggesting the presence of spinal instability Background The Pilates method has been used to improve function and reduce pain in patients with chronic nonspecific low back pain , although there is little scientific evidence that describes its efficacy . Objective The purpose of this study was to investigate the effectiveness of the addition of modified Pilates exercises to minimal intervention in patients with chronic low back pain . Design A r and omized controlled trial was conducted . Setting The study was done in an outpatient physical therapy department in Brazil . Patients Eighty-six patients with chronic nonspecific low back pain participated in the study . Intervention All participants received an education booklet containing information about low back pain and were r and omly allocated to receive 12 sessions , over 6 weeks , of exercises based upon Pilates principles ( n=43 ) or of education alone ( n=43 ) . Measurements Primary outcomes were pain intensity and disability measured at 6 weeks and 6 months . Secondary outcomes were patient-specific functional disability , global impression of recovery , and kinesiophobia measured at 6 weeks and 6 months . All outcomes were measured by a blinded assessor in all time points . Results There was no loss to follow-up at any of the time points . Improvements were observed in pain ( mean difference=2.2 points , 95 % confidence interval [CI]=1.1 to 3.2 ) , disability ( mean difference=2.7 points , 95 % CI=1.0 to 4.4 ) , and global impression of recovery ( mean difference=−1.5 points , 95 % CI=−2.6 to −0.4 ) in favor of the Pilates group after intervention , but these differences were no longer statistically significant at 6 months . Limitations Treatment provider and participants could not be blinded to the interventions . Conclusions The addition of modified Pilates exercises to an educational booklet provides small benefits compared with education alone in patients with chronic nonspecific low back pain ; however , these effects were not sustained over time OBJECTIVE The aim of this study was to investigate the comparison of massage therapy and routine physical therapy on patients with sub acute and chronic nonspecific low back pain . METHODS AND MATERIAL S Thirty volunteer female subjects with a sub acute or chronic nonspecific low back pain were r and omly enrolled in two groups , massage therapy and routine physical therapy . After massage application , the hamstring and paravertebral muscles stretching and also stabilizing exercises were prescribed . In the routine physical therapy group , TENS , US and vibrator were used besides exercises . Pain intensity according to Numerical Rating Scale , functional disability level in accordance to Oswestry Disability Index , and modified Schober test , for measurement of flexion range of motion , before and after ten sessions of treatment were used to evaluate the effectiveness of the treatment . RESULTS Pain intensity , Oswestry Disability Index and flexion range of motion had shown significant differences before and after intervention in both groups ( p<0.001 ) . The statistical analysis revealed that the massage therapy had significantly improved the pain intensity and Oswestry Disability Index compared to routine physical therapy ( p=0.015 , p=0.013 respectively ) , but the range of motion changes were not significant between two groups ( p=1.00 ) . CONCLUSION It can be concluded that both massage therapy and routine physical therapy are useful for sub acute and chronic nonspecific low back pain treatment especially if accompanied with exercise . However , massage is more effective than other electrotherapy modalities , and it can be used alone or with electrotherapy for the treatment of patients with low back pain Study Design . Prospect i ve , r and omized , controlled trial . Objective . To investigate the effectiveness of home-based exercise on pain , dysfunction , and quality of life ( QOL ) in Japanese individuals with chronic low back pain ( CLBP ) . Summary of Background Data . Exercise therapy is a widely used treatment for CLBP in many countries . The studies on its effectiveness have been performed only in Western industrialized countries . The existence of cross-cultural differences and heterogeneity of patients in each country may influence the outcome of interventions for CLBP . Data that would enable research ers to compare the effectiveness of interventions between widely different societies is lacking . Methods . A total of 201 patients with nonspecific CLBP were r and omly assigned to either the  control or exercise therapy group : 89 men and 112 women with a mean age of 42.2 years . The control group was treated with nonsteroidal anti-inflammatory drugs ( NSAIDs ) , and the exercise group performed trunk muscle strengthening and stretching exercises . The primary outcome measures were pain intensity ( visual analogue scale ) and dysfunction level ( Japan Low back pain Evaluation Question naire [ JLEQ ] and Rol and -Morris Disability Question naire [ RDQ ] ) over 12 months . The secondary outcome measure was FFD ( Finger-floor distance ) . Statistical analysis was performed using Wilcoxon signed-ranks and Mann-Whitney U tests , and estimation of the median with 95 % CI was calculated . Results . In both groups , significant improvement was found at all points of follow-up assessment . However , JLEQ and RDQ were significantly more improved in the exercise group compared to the control group ( P = 0.021 in JLEQ , P = 0.023 in RDQ ) . The 95 % CI for the difference of medians of the change ratio between exercise and NSAID groups , [ Exercise ] − [ NSAID ] , was −0.25 to −0.02 in JLEQ , −0.33 to 0.00 in RDQ , and −0.20 to 0.06 in visual analogue scale . Conclusion . The home-based exercise prescribed and monitored by board-certified orthopedic surgeons was more effective than NSAIDs for Japanese patients with CLBP Background The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled . Objective The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain . Design This was a r and omized , placebo-controlled trial . Setting The study was conducted in an outpatient physical therapy department in Australia . Patients The participants were 154 patients with chronic low back pain of more than 12 weeks ’ duration . Intervention Twelve sessions of motor control exercise ( ie , exercises design ed to improve function of specific muscles of the low back region and the control of posture and movement ) or placebo ( ie , detuned ultrasound therapy and detuned short-wave therapy ) were conducted over 8 weeks . Measurements Primary outcomes were pain intensity , activity ( measured by the Patient-Specific Functional Scale ) , and patient 's global impression of recovery measured at 2 months . Secondary outcomes were pain ; activity ( measured by the Patient-Specific Functional Scale ) ; patient 's global impression of recovery measured at 6 and 12 months ; activity limitation ( measured by the Rol and -Morris Disability Question naire ) at 2 , 6 , and 12 months ; and risk of persistent or recurrent pain at 12 months . Results The exercise intervention  improved activity and patient 's global impression of recovery but did not clearly reduce pain at 2 months . The mean effect of exercise on activity ( measured by the Patient-Specific Functional Scale ) was 1.1 points ( 95 % confidence interval [CI]=0.3 to 1.8 ) , the mean effect on global impression of recovery was 1.5 points ( 95 % CI=0.4 to 2.5 ) , and the mean effect on pain was 0.9 points ( 95 % CI=−0.01 to 1.8 ) , all measured on 11-point scales . Secondary outcomes also favored motor control exercise . Limitation Clinicians could not be blinded to the intervention they provided . Conclusions Motor control exercise produced short-term improvements in global impression of recovery and activity , but not pain , for people with chronic low back pain . Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups Study Design . R and omized controlled trial . Objective . This is the companion study to a previous publication that presented 8-week pain , disability , and trunk muscle motor control results . The objective of this study was to compare the effect of 8 weeks of specific trunk exercises and stationary cycling on outcomes measures of catastrophizing and fear-avoidance beliefs ( FAB ) in patients with chronic nonspecific low back pain , and provide 6-month outcome data for all self-report measures . Summary of Background Data . It is thought that any form of moderate-to-vigorous physical activity is sufficient to address catastrophizing and FAB , and concomitant levels of pain and disability . Methods . Sixty-four patients with low back pain were r and omly assigned to 8 weeks of specific trunk exercise group ( SEG ) , or stationary cycling group ( CEG ) .  Self-rated pain , disability , catastrophizing and FAB scores were collected before , immediately after ( 8 wk ) , and 6 months after the training program . Clinical ly meaningful improvements were defined as greater than a 30 % reduction from baseline in pain and disability scores . “ Intention-to-treat ” principles were used for missing data . Per- protocol analysis was performed on participants who attended at least two-thirds of the exercise sessions . Results . At 8 weeks , disability was significantly lower in the SEG compared with the CEG ( d = 0.62 , P = 0.018 ) . Pain was reduced from baseline in both the groups after training ( P < 0.05 ) , but was lower for the SEG ( P < 0.05 ) . FAB scores were reduced in the SEG at 8 weeks , and in the CEG at 6 months . No between-group differences in FAB scores were observed . Similar reductions in catastrophizing in each group were observed at each time point . At 6 months , the overall data pattern suggested no long-term difference between groups . Per- protocol analysis of clinical ly meaningful improvements suggests no between-group differences for how many patients are likely to report improvement . Conclusion . Inferential statistics suggest greater improvements at 8 weeks , but not 6 months , for the SEG . Inspection of clinical ly meaningful changes based on a minimum level of adherence suggests no between-group differences . If a patient with low back pain adheres to either specific trunk exercises or stationary cycling , it is reasonable to think that similar improvements will be achieved . Level of Evidence : OBJECTIVES To identify factors that are associated with older patients ' engagement in exercise in the 6 months after hospital discharge . DESIGN A prospect i ve observational study using qualitative and quantitative evaluation . SETTING Follow-up of hospital patients in their home setting after discharge from a metropolitan general hospital . PARTICIPANTS Participants ( N=343 ) were older patients ( mean age ± SD , 79.4 ± 8.5y ) discharged from medical , surgical , and rehabilitation wards and followed up for 6 months after discharge . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Self-perceived awareness and risk of falls measured at discharge with a survey that addressed elements of the Health Belief Model . Engagement and self-reported barriers to engagement in exercise  measured at 6 months after discharge using a telephone survey . RESULTS Six months after discharge , 305 participants remained in the study , of whom 109 ( 35.7 % ) were engaging in a structured exercise program . Multivariable logistic regression analysis demonstrated participants were more likely to be engaging in exercise  if they perceived they were at risk of serious injury from a fall ( odds ratio [ OR ] = .61 ; 95 % confidence interval [ CI ] , .48-.78 ; P<.001 ) , if exercise was recommended by the hospital physiotherapist ( OR=1.93 ; 95 % CI , 1.03 - 3.59 ; P=.04 ) , and if they lived with a partner ( OR=1.97 ; 95 % CI , 1.18 - 3.28 ; P=.009 ) . Barriers to exercise identified by 168 participants ( 55 % ) included low self-efficacy , low motivation , medical problems such as pain , and impediments to program delivery . CONCLUSIONS Older patients have low levels of engagement in exercise after hospital discharge . Research ers should design exercise programs that address identified barriers and facilitators , and provide education to enhance motivation and self-efficacy to exercise in this population STUDY DESIGN A r and omized clinical trial . OBJECTIVES To examine the relative efficacy of three active therapies for chronic low back pain . SUMMARY OF BACKGROUND DATA There is much evidence documenting the efficacy of exercise in the conservative management of chronic low back pain , but many questions remain regarding its exact prescription and method of application . The most successful method must be identified to enable refinement of future rehabilitation programs to target the specific needs of the patient with chronic low back pain and the budget of the healthcare provider . METHODS One hundred forty-eight patients with chronic low back pain were r and omized to one of the following treatments , which they attended twice a week for 3 months : 1 ) modern active physiotherapy , 2 ) muscle reconditioning on training devices , or 3 ) low-impact aerobics . Pretherapy and posttherapy , objective measurements of lumbar mobility were performed , and question naires were administered inquiring about self-rated pain and disability , and psychosocial factors . Similar question naires were administered 6 months after therapy . The data were analyzed using the intention-to-treat principle . RESULTS Of the 148 patients , 16 ( 10.8 % ) dropped out of the therapy . One hundred thirty-seven question naires ( 93 % ) were available for analysis at all three time points . After therapy , significant reductions were observed in pain intensity , frequency , and disability ; Fear-Avoidance Beliefs about physical activity ( FABQactivity ) ; and " praying/hoping , " " catastrophizing , " and " pain behavior " coping strategies -- each with no group differences in the extent of the response . These effects were maintained over the subsequent 6 months , with the exception of disability and FABQactivity for the physiotherapy group . There were small but significant posttherapy increases in lumbar mobility , with aerobics and devices showing a greater response than physiotherapy . CONCLUSION The general lack of treatment specificity suggests that the main effects of the therapies were educed not through the reversal of physical weaknesses targeted by the corresponding exercise modality , but rather through some " central " effect , perhaps involving an adjustment of perception in relation to pain and disability . The direct costs associated with administering physiotherapy were three times as great , and devices four times as great , as those for aerobics . Administration of aerobics as an efficacious therapy for chronic low back pain has the potential to relieve some of the huge financial burden associated with the condition Context Exercise and advice are common treatments for patients with subacute low back pain  , but their effectiveness is unclear . Contribution In this trial , 259 adults with subacute low back pain received 12 real or sham physiotherapist-directed exercise sessions and 3 real or sham advice sessions over 6 weeks . Compared with sham exercise and sham advice , patients who received real exercise and real advice had the most benefit at 6 weeks . However , only a small benefit on patient-reported function persisted at 12 months . Implication Compared with no exercise or advice , a combination of physiotherapist-directed exercise and advice seems to improve pain and function in the short term for patients with subacute low back pain . The Editors Back pain is 1 of the most frequent reasons for consultation with a general practitioner ( 1 , 2 ) . Most treatment guidelines provide advice for patients on managing acute or recent-onset low back pain but not chronic pain ( 3 ) . This reflects the view that acute low back pain is typically self-limited and that only a small proportion of persons develop chronic pain . However , a recent systematic review of the prognosis of acute low back pain ( 4 ) showed that this view is inaccurate : Pain and disability are typically ongoing , and recurrences are common . Thus , effective treatments for patients whose pain and disability persist beyond the acute phase are needed . We are interested in the subacute phase , which is the transition period from acute ( duration < 6 weeks ) to chronic ( duration > 3 months ) low back pain . All treatment guidelines ( 3 ) endorse advice as a treatment for subacute low back pain , and advice is the most frequently administered treatment in general practice ( 1 ) . Exercise is the most common treatment for low back pain ( 2 , 5 , 6 ) , and some guidelines recommend it for subacute low back pain ( 3 ) . However , a systematic review of treatment for subacute low back pain ( 7 ) concluded that no high- quality evidence exists for the efficacy of any intervention . To address this knowledge gap , we conducted a factorial r and omized , placebo-controlled trial of the effect of exercise , advice , or both on pain , function , and global perceived effect . Methods Setting The trial was conducted at 7 physiotherapy clinics in Australia and New Zeal and , of which 6 were in university teaching hospitals and 1 was in a primary care clinic . There were 16 physiotherapists . Each clinic had 1 to 5 therapists providing treatment . We enrolled participants from January 2001 to June 2003 . The study protocol was approved by the institutional review boards of the University of Sydney , Sydney , Australia , and of each clinic . Participants We sought persons between 18 and 80 years of age with nonspecific low back pain lasting for at least 6 weeks but no longer than 12 weeks . Participants were recruited by direct referral to the trial by a health care professional ( n= 1 ) , invitations to patients on hospital waiting lists for physiotherapy treatment of low back pain ( n= 73 ) , and advertisements in newspapers ( n= 185 ) . Exclusion criteria were spinal surgery in the past 12 months , pregnancy , nerve root compromise , confirmed or suspected serious spinal abnormality ( for example , infection , fracture , or the cauda equina syndrome ) , contraindications to exercise , and poor comprehension of the English language . We did not exclude participants who were receiving low back pain treatment other than spinal surgery . Potential participants who reported osteoarthritis ; spondylitis ; spondylolysis ; spondylolisthesis ; disc protrusion , herniation , or prolapse ; or spinal stenosis were eligible . We asked participants not to take other treatments for low back pain during the 6-week treatment phase . Written informed consent was obtained from all participants before they enrolled in the trial . R and omization and Interventions After completing the baseline assessment , we r and omly allocated participants to 1 of 4 intervention groups : exercise and advice , exercise and sham advice , sham exercise and advice , or sham exercise and sham advice . The allocation schedule was generated by using the r and om-number function in Microsoft Excel ( Microsoft , Inc. , Redmond , Washington ) , and the allocation codes were placed in sequentially numbered , sealed , opaque envelopes . At each site , the trial coordinator or the physiotherapist allocated participants to groups by opening the next numbered envelope . This process ensured that allocation was concealed from participants , referring medical practitioners , trial staff who determined eligibility , and the assessor of outcomes . The 12 exercise or sham exercise sessions were delivered over 6 weeks : 3 sessions per week in weeks 1 and 2 , 2 sessions per week in weeks 3 and 4 , and 1 session per week in weeks 5 and 6 . In weeks 1 , 2 , and 4 , participants also received advice or sham advice . Sham treatments were design ed to provide similar contact time with the treating clinician . The clinicians who provided the sham treatments were the same ones who provided the real treatments . Registered physiotherapists who received training from an experienced clinical psychologist delivered treatment . Treatment consistency was promoted at the initial staff meeting and at regular trial treatment meetings , and by providing a treatment manual to all treatment providers . To assess treatment validity , an investigator recorded and assessed sample treatment sessions . In addition , 1 investigator regularly visited each treatment site to monitor delivery of treatment . The comprehensive treatment manual is in the Appendix . Appendix . Treatment Manual Exercise The exercise program was based on the program described by Lindstrm and colleagues ( 8) . It included an individualized , progressive , submaximal program design ed to improve the abilities of participants to complete functional activities that they specified as being difficult to perform because of low back pain . Each participant undertook aerobic exercise ( for example , a walking or cycling program ) ; stretches ; functional activities ; activities to build speed , endurance , and coordination ; and trunk- and limb-strengthening exercises . Physiotherapists used principles of cognitive-behavioral therapy , including setting goals of progressively increasing difficulty , encouraging self-monitoring of progress , and promoting self-reinforcement ( 9 ) . Physiotherapists provided individualized home exercise programs , which they regularly review ed , and they encouraged continuation of the home program after the intervention finished . Sham Exercise The control for the exercise intervention consisted of sham pulsed ultrasonography ( 5 minutes ) and sham pulsed short-wave diathermy ( 20 minutes ) . The sham units were identical to active units ( for example , the on and off lights illuminated and the output dial moved ) except that they did not provide output . To optimize treatment credibility , physiotherapists followed the usual clinical routine for delivering these treatments . The active forms of these treatments delivered in pulsed mode do not produce heat ; thus , previous experience with the treatments would not unblind participants . Participants allocated to exercise did not receive the active forms of these treatments . Advice Advice sessions were based on the program by Indahl and colleagues ( 10 ) and aim ed to encourage a grade d return to normal activities . The physiotherapist explained the benign nature of low back pain , addressed any unhelpful beliefs about back pain , and emphasized that being overly careful and avoiding light activity would delay recovery . Sham Advice During sham advice sessions , participants were given the opportunity to talk about their low back pain and any other problems . The physiotherapist responded in a warm and empathic manner , displaying genuine interest in the participant , but did not give advice about the low back pain ( 11 ) . Participants were told that the trial included active and placebo physiotherapy treatments and that they would receive 2 treatments , but they were not told whether the interventions they received were active or sham . Outcomes and Measurements We determined participants ' perceptions of the effectiveness of treatment at the beginning of the trial and at 12 months . We assessed treatment adherence by the number of  appointments attended  ,  session  duration , and amount of time the physiotherapist spent with each participant . Participants were asked not to seek other treatments during the 6-week treatment period . Participants who discontinued treatment were encouraged to return for follow-up . Immediately before r and omization , we obtained baseline measurements . We collected additional data on work status , medication use , side effects , adverse events , and number and type of co- interventions  at 6 weeks , 3 months , and 12 months after r and omization . We chose primary and secondary outcomes a priori . The primary outcomes were pain , global perceived effect , and functional ability at 6 weeks and 12 months . Secondary outcomes were pain , global perceived effect , and functional ability at 3 months ; number of health care contacts during the past 6 weeks ( determined at 12 months ) ; and disability and depression at 6 weeks , 3 months , and 12 months . We rated pain as average pain over the past week on a scale of 0 ( no pain ) to 10 ( worst pain possible ) ( 12 ) . We measured functional ability by using the Patient-Specific Functional Scale ( score range , 0 [ can not perform activity ] to 10 [ can perform activity at preinjury level ] ) ( 13 ) . We measured global perceived effect of treatment on an 11-point scale , ranging from 5 ( vastly worse ) to 5 ( completely recovered ) , with 0 being no change . We measured disability with the Rol and Morris Disability Question naire ( score range , 0 to 24 ) ( 14 ) . We measured depression , anxiety , and stress by using the 21-item Depression Anxiety Stress Scales ( DASS-21 ) ( score range for each subscale , 0 to 42 ) ( 15 ) . These measures have acceptable psychometric properties and are widely used in Context Therapeutic exercises are frequently prescribed to patients with low back pain . Numerous exercise programs for patients with low back pain have been described . Many of these treatment programs are based on 1 of 2 popular rehabilitation strategies : a motor control exercise approach or a general exercise approach . Data Sources PubMed clinical queries from 1966 to March 2013 for keyword combinations including motor control exercise , core stability exercise , therapeutic exercise , general exercise , global exercise , local exercise , transversus abdominis , segmental stabilization , and low back pain . Study Selection R and omized controlled trials that assessed the effects of a motor control exercise approach , a general exercise approach , or both for patients with low back pain that were published in scientific peer- review ed journals . Data Extraction Included studies underwent appraisal for exercise intervention and outcomes . Results Fifteen studies were identified ( 8 , motor control exercise approach without general exercise comparison ; 7 , general exercise approach with or without motor control exercise approach comparison ) . Current evidence suggests that exercise interventions may be effective at reducing pain or disability in patients with low back pain . Conclusion : Stabilization exercises for patients with low back pain may help to decrease pain and disability . It may not be necessary to prescribe exercises purported to restore motor control of specific muscles Description The American College of Physicians ( ACP ) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain . Methods Using the ACP grading system , the committee based these recommendations on a systematic review of r and omized , controlled trials and systematic review s published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain . Up date d search es were performed through November 2016 . Clinical outcomes evaluated included reduction or elimination of low back pain , improvement in back-specific and overall function , improvement in health-related quality of life , reduction in work disability and return to work , global improvement , number of back pain episodes or time between episodes , patient satisfaction , and adverse effects . Target Audience and Patient Population The target audience for this guideline includes all clinicians , and the target patient population includes adults with acute , subacute , or chronic low back pain . Recommendation 1 Given that most patients with acute or subacute low back pain improve over time regardless of treatment , clinicians and patients should select nonpharmacologic treatment with superficial heat ( moderate- quality evidence ) , massage , acupuncture , or spinal manipulation ( low- quality evidence ) . If pharmacologic treatment is desired , clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants ( moderate- quality evidence ) . ( Grade : strong recommendation ) . Recommendation 2 For patients with chronic low back pain , clinicians and patients should initially select nonpharmacologic treatment with exercise , multidisciplinary rehabilitation , acupuncture , mindfulness-based stress reduction ( moderate- quality evidence ) , tai chi , yoga , motor control exercise , progressive relaxation , electromyography biofeedback , low-level laser therapy , operant therapy , cognitive behavioral therapy , or spinal manipulation ( low- quality evidence ) . ( Grade : strong recommendation ) . Recommendation 3 In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy  , clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy , or tramadol or duloxetine as second-line therapy . Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients . ( Grade : weak recommendation , moderate- quality evidence ) Study Design . Systematic Review . Objectives . To assess the effects of massage therapy for nonspecific low back pain . Summary of Background Data . Low back pain is one of the most common and costly musculoskeletal problems in modern society . Proponents of massage therapy cl aim it can minimize pain and disability , and speed return to normal function . Methods . We search ed MEDLINE , EMBASE , CINAHL from their beginning to May 2008 . We also search ed the Cochrane Central Register of Controlled Trials ( The Cochrane Library 2006 , issue 3 ) , HealthSTAR and Dissertation abstract s up to 2006 . There were no language restrictions . References in the included studies and in review s of the literature were screened . The studies had to be r and omized or quasi-r and omized trials investigating the use of any type of massage ( using the h and s or a mechanical device ) as a treatment for nonspecific low back pain . Two review authors selected the studies , assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group , and extracted the data using st and ardized forms . Both qualitative and meta-analyses were performed . Results . Thirteen r and omized trials were included . Eight had a high risk and 5 had a low risk of bias . One study was published in German and the rest in English . Massage was compared to an inert therapy ( sham treatment ) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups . In 8 studies , massage was compared to other active treatments . They showed that massage was similar to exercises , and massage was superior to joint mobilization , relaxation therapy , physical therapy , acupuncture , and self-care education . One study showed that reflexology on the feet had no effect on pain and functioning . The beneficial effects of massage in patients with chronic low back pain  lasted at least 1 year after the end of the treatment . Two studies compared 2 different techniques of massage . One concluded that acupuncture massage produces better results than classic ( Swedish ) massage and another concluded that Thai massage produces similar results to classic ( Swedish ) massage . Conclusion . Massage might be beneficial for patients with subacute and chronic nonspecific low back pain , especially when combined with exercises and education . The evidence suggests that acupuncture massage is more effective than classic massage , but this need confirmation . More studies are needed to confirm these conclusions , to assess the impact of massage on return-to-work , and to determine cost-effectiveness of massage  as an intervention for low back pain Background Exercise benefits patients with chronic nonspecific low back pain ; however , the most effective type of exercise remains unknown . Objective This study compared outcomes after motor control exercises , sling exercises , and general exercises for low back pain . Design This was a r and omized controlled trial with a 1-year follow-up . Setting The study was conducted in a primary care setting in Norway . Patients The participants were patients with chronic nonspecific low back pain ( n=109 ) . Interventions The interventions in this study were low-load motor control exercises , high-load sling exercises , or general exercises , all delivered by experienced physical therapists , once a week for 8 weeks . Measurements The primary outcome measure was pain reported on the Numeric Pain Rating Scale after treatment and at a 1-year follow-up . Secondary outcome measures were self-reported activity limitation ( assessed with the Oswestry Disability Index ) , clinical ly examined function ( assessed with the Fingertip-to-Floor Test ) , and fear-avoidance beliefs after intervention . Results The postintervention assessment showed no significant differences among groups with respect to pain ( overall group difference ) or any of the outcome measures . Mean ( 95 % confidence interval ) group differences for pain reduction after treatment and after 1 year were 0.3 ( −0.7 to 1.3 ) and 0.4 ( −0.7 to 1.4 ) for motor control exercises versus sling exercises , 0.7 ( −0.6 to 2.0 ) and 0.3 ( −0.8 to 1.4 ) for sling exercises versus general exercises , and 1.0 ( −0.1 to 2.0 ) and 0.7 ( −0.3 to 1.7 ) for motor control exercises versus general exercises . Limitations The nature of the interventions made blinding impossible . Conclusions This study gave no evidence that 8 treatments with individually instructed motor control exercises or sling exercises were superior to general exercises for chronic low back pain Aims : To investigate if a st and ardised physical exercise programme given in addition to a brief intervention at a spine clinic had an effect on return to work . Methods : A total of 246 patients sick-listed 8—12 weeks for non-specific low back pain were offered a brief intervention programme at the spine clinic with examination , information , reassurance , and encouragement to engage in physical activity as normal as possible , before they were r and omised into an intervention group ( n = 124 ) and a control group ( n = 122 ) . Patients in the intervention group participated in a physical exercise programme at the spine clinic . Results : During the 2-year follow-up , there were no significant differences between the groups on sick leave , pain , use of analgesics , psychological distress , coping strategies , fear-avoidance beliefs , self-reported disability , or walking distances . However , both groups increased return to work , reported less pain and better function , and reduced fear-avoidance beliefs for physical activity during the follow-up period . Fear-avoidance beliefs for work were not changed . Conclusions : A physical exercise programme for low back pain patients given after a brief intervention at a spine clinic did not have any additional effect on sick leave or fear-avoidance beliefs . Both groups reported less pain , better physical function , and increased return to work during follow-up . The treatment at the spine clinic did not contain a vocational rehabilitation programme directed towards individual work-related problems , which might explain no change in fear-avoidance beliefs for work PURPOSE This single-assessor-blinded r and omized controlled trial aim ed to compare the efficacy of physiotherapy-delivered clinical Pilates and general exercise for chronic low back pain  . METHODS Eighty-seven community volunteers with low back pain for ≥3 months and age 18 - 70 were r and omized to either the Pilates ( n = 44 ) or general exercise ( n = 43 ) group . The primary outcome was pain/disability measured with the Quebec scale . Secondary outcomes included pain on a numeric rating scale , Patient-Specific Functional Scale , Pain Self-efficacy Question naire , quality of life , and global perceived effect of treatment . All participants attended 60-min exercise sessions twice weekly for 6 wk supervised by a physiotherapist and performed daily home exercises that were continued during the follow-up . Participants from the clinical Pilates group received an individualized direction-specific exercise program prescribed by the physiotherapist after a clinical examination . The general exercise group received a generic set of exercises that were multidirectional and nonspecific . Outcomes were assessed after 6 wk ( primary time point ) and at 12 and 24 wk . Differences in mean change were compared between groups using ANCOVA adjusted for baseline values of the outcome . RESULTS Eighty-three participants ( 96 % ) completed the 6-wk intervention and 60 ( 69 % ) completed the 24-wk follow-up . At 6 wk , no difference was found between groups for change in the Quebec scale ( 3.5 , 95 % confidence interval = -7.3 to 0.3 , P = 0.07 ) ; both groups showed significant improvements . Similar results were found at the 12- and 24-wk follow-up and for the secondary outcome measures . CONCLUSIONS An individualized clinical Pilates program produced similar beneficial effects on self-reported disability , pain , function and health-related quality of life  as a general exercise program in community volunteers with chronic low back pain Study Design . The study was a r and omized controlled trial . Treatment was for 8 weeks , with follow-up posttreatment and at 6- , 12- , and 36- months . Objective . The purpose was to evaluate the effect of a grade d exercise intervention emphasizing stabilizing exercises in patients with nonspecific , recurrent low back pain ( LBP ) . Summary of Background Data . Exercise therapy is recommended and widely used as treatment for LBP . Although stabilizing exercises are reportedly effective in the management of certain subgroups of LBP , such intervention protocol s have not yet been evaluated in relation to a more general exercise regimen in patients with recurrent LBP , all at work . Methods . Seventy-one patients recruited consecutively ( 36 men , 35 women ) with recurrent nonspecific LBP seeking care at an outpatient physiotherapy clinic were r and omized into 2 treatment groups ; grade d exercise intervention or daily walks . The primary outcome was perceived disability and pain at 12-month follow-up . Secondary outcomes included physical health , fear-avoidance , and self-efficacy beliefs . Results . Of the participants , 83 % provided data at the 12-month follow-up and 79 % at 36 months . At 12 months , between-group comparison showed a reduction in perceived disability in favor of the exercise group , whereas such an effect for pain emerged only immediately postintervention . Ratings of physical health and self-efficacy beliefs also improved in the exercise group over the long term , though no changes were observed for fear-avoidance beliefs . Conclusion . A grade d exercise intervention , emphasizing stabilizing exercises , for patients with recurrent LBP still at work seems more effective in improving disability and health parameters than daily walks do . However , no such positive results emerged for improvement regarding pain over a longer term , or for fear-avoidance beliefs Background Back School and McKenzie methods are popular active treatment approaches that include both exercises and information for patients with chronic nonspecific low back pain . Objective The purpose of this study was to compare the effectiveness of Back School and McKenzie methods in patients with chronic nonspecific low back pain . Design The study was a prospect ively registered , 2-arm r and omized controlled trial with a blinded assessor . Setting The study was conducted in the outpatient physical therapy clinic in São Paulo , Brazil . Patients The study participants were 148 patients with chronic nonspecific low back pain . Interventions The 4-week treatment program ( one session/week ) was based on the Back School ( delivered to the group ) or McKenzie ( delivered individually ) principles . The participants also were instructed to perform a daily set of home exercises . Measurements Clinical outcomes were assessed at follow-up appointments at 1 , 3 , and 6 months after r and omization . Primary outcome measures were pain intensity ( measured by the 0–10 pain numerical rating scale ) and disability ( measured by the 24-item Rol and -Morris Disability Question naire ) 1 month after r and omization . Secondary outcome measures were pain intensity and disability at 3 and 6 months after r and omization , quality of life ( measured by the World Health Organization Quality of Life – BREF instrument ) at 1 , 3 , and 6 months after r and omization , and trunk flexion range of motion measured by an inclinometer at 1 month after r and omization . The data were collected by a blinded assessor . Results Participants allocated to the McKenzie group had greater improvements in disability at 1 month ( mean effect=2.37 points , 95 % confidence interval=0.76 to 3.99 ) but not for pain ( mean effect=0.66 points , 95 % confidence interval=−0.29 to 1.62 ) . No between-group differences were observed for all secondary outcome measures . Limitations It was not possible to monitor the home exercise program . Therapists and participants were not blinded . Conclusions The McKenzie method ( a more re source -intensive intervention ) was slightly more effective than the Back School method for disability , but not for pain intensity immediately after treatment in participants with chronic low back pain
Participants believed that there were distinctions between general activity , real/fitness exercise , and medical exercise .
People participating in exercise classes and group work may be more comfortable when matched for abilities and experience .
When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement , people make a reasoned decision to discontinue .
DISCUSSION People are likely to prefer and participate in exercise or training programs and activities that are design ed with consideration of their preferences , circumstances , fitness levels , and exercise experiences
OBJECTIVES The global burden of low back pain is the highest ranked condition contributing to years of living with disability .
Exercise is moderately effective , and adherence to exercise may improve if participants are engaged .
Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions .
The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain .