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Exercise Interventions for Persistent Non-Specific Low Back Pain – Does Matching Outcomes to Treatment Targets Make a Difference? A Systematic Review and Meta-Analysis

  • Lianne Wood
    Correspondence
    Address reprint requests to Lianne Wood, Primary Care Centre Versus Arthritis, School for Primary, Community and Social Sciences, Faculty of Medicine and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK.
    Affiliations
    Primary Care Centre Versus Arthritis, School for Primary, Community and Social Sciences, Faculty of Medicine and Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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  • Nadine E Foster
    Affiliations
    Primary Care Centre Versus Arthritis, School for Primary, Community and Social Sciences, Faculty of Medicine and Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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  • Martyn Lewis
    Affiliations
    Primary Care Centre Versus Arthritis, School for Primary, Community and Social Sciences, Faculty of Medicine and Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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  • Annette Bishop
    Affiliations
    Primary Care Centre Versus Arthritis, School for Primary, Community and Social Sciences, Faculty of Medicine and Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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      Highlights

      • Twenty seven trials compared exercise to no-exercise with a sample sufficient to detect a moderate difference.
      • Randomised controlled trials (RCTs) had a variety of treatment targets, despite sometimes using the same exercise approach.
      • Most RCTs did not match their primary outcome to their stated exercise treatment targets.
      • Matched RCTs were more likely to conclude statistically significant results in favor of exercise.

      Abstract

      Exercise is a core treatment for persistent non-specific low back pain (NSLBP), but results from randomised controlled trials (RCTs) of exercise typically show only small to moderate standardised mean differences (SMDs) compared to nonexercise controls. The choice of primary outcome, and relationship to the specific targets of exercise may influence this. This systematic review aimed to explore whether primary outcomes match the exercise treatment targets used in NSLBP RCTs and the potential impact of matching on SMDs. Included RCTs were conducted with patients with persistent NSLBP, compared exercise to no exercise, with sample sizes >60 per arm. Screening, data extraction and risk of bias assessment were independently undertaken by paired reviewers. Of 19272 initial titles, 27 RCTs were included with 31 treatment targets and 6 primary outcome domains identified. Only 25% of included RCTs had primary outcomes that matched the treatment targets. SMDs of exercise versus comparison arms were observed to be larger in the matched (SMD .54 (95% Confidence Interval .23 to.85), P =.0006) compared to the unmatched category (SMD 0.22 (95% Confidence Interval .01, .44) P = .04) but this difference was not statistically significant (P = .10). These exploratory findings may have implications for future teams developing RCTs of exercise for NSLBP and warrant further investigation in larger datasets.

      Perspective

      This review was an exploratory study that investigated the primary outcome and treatment targets used in RCTs of exercise for NSLBP. The SMDs of the matched group were descriptively larger than those of the unmatched group, but further analysis with larger sample sizes is required to have confidence in these results.

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