Thread by @PatrickOwenPhD

🚨#Published: #Infographic. What kinds of #exercise are best for chronic low #BackPain? Now available @BJSM_BMJ: dx.doi.org/10.1136/bjspor…

🧵Thread: 1/24 (inspired by @MarinusWinters🙏 #MyFirstThread)

//@DeakinIPAN @MSKAust @AcademicChatter #AcademicTwitter #phdchat #ecrchat

Back pain is the greatest cause of disability and lost productivity world-wide: ncbi.nlm.nih.gov/pmc/articles/P…

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Back pain generates significant financial costs for society in developed countries, such as the United States of America, Japan, Europe and Australia (e.g. US$80 billion per year in direct and indirect costs in the United States of America): pubmed.ncbi.nlm.nih.gov/18164449/

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Chronic low back pain (i.e. ≥12 weeks duration) presents the greatest challenge:

It generates the greatest proportion of economic burden due to back pain: pubmed.ncbi.nlm.nih.gov/11987929/

It affects 20% of the global population: pubmed.ncbi.nlm.nih.gov/22231424/

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Of these, approximately 90% of cases of chronic low back pain are non-specific, meaning that a definitive diagnosis that is agreed upon between clinicians cannot be made: pubmed.ncbi.nlm.nih.gov/27745712/

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Current treatment recommendations for non-specific chronic low back pain include exercise (high quality evidence), manual therapy (low quality evidence) and psychological therapies (moderate quality evidence): pubmed.ncbi.nlm.nih.gov/27745712/, pubmed.ncbi.nlm.nih.gov/29614943/

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There are a number of different modes of exercise training, however prior pairwise meta-analysis concluded that there was no evidence that any particular mode of exercise was more effective than another for non-specific chronic low back pain: pubmed.ncbi.nlm.nih.gov/20227641/

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Network meta-analysis is a method that can overcome limitations of pairwise meta-analysis by incorporating data from studies that do not necessarily have the same kind of comparator groups in a ‘network’ of studies: ncbi.nlm.nih.gov/pmc/articles/P…

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In our recent network meta-analysis, published in the @BJSM_BMJ, we sought to identify the effectiveness of specific exercise training modalities in adults with NSCLBP: dx.doi.org/10.1136/bjspor…

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These modalities were also compared to ‘true control’ (i.e. no intervention) and non-exercise treatments, such as treatment where the therapist provided ‘hands-on’ treatment (e.g. massage, manual therapy) or ‘hands-off’ treatment (e.g. education, GP management).

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Collectively, 89 studies and a total of 5578 patients were included.

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We assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria adapted for network meta-analysis: journals.plos.org/plosone/articl…

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For improving pain, there was low-quality evidence that Pilates, aerobic and stabilisation/motor control exercise training were optimal.

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For improving physical function (reducing disability) there was low quality evidence that stabilisation/motor control and resistance exercise training were the most effective.

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For improving mental health, there was low-quality evidence that resistance and aerobic were best.

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Only seven studies (8%) had low risk of bias.

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Few studies examined trunk muscle strength, trunk muscle endurance and analgesic pharmacotherapy use, making it difficult to compare the effect of different exercise modalities on these outcomes.

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Future studies examining these outcomes are warranted given the importance of considering these variables during the management of non-specific chronic low back pain: pubmed.ncbi.nlm.nih.gov/31610090/

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Stretching and McKenzie exercises did not differ to true control for pain or function.🧐

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In our analysis stabilisation/motor control and Pilates had a clinically significant (>20 point pain reduction on a scale 0-100) greater effect on reducing pain than these exercises modes.

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It is important to consider that exercise does not happen in isolation. Through exercise with an individualised approach, a person with non-specific chronic low back pain can improve confidence in movement and address functional deficits concurrently.

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As we contend in our publication, understanding of the biopsychosocial aspects of (chronic) pain is important for all clinicians managing people with non-specific chronic low back pain.

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CONCLUSION: We expect that there is no one particular kind of exercise that is 'the best' for non-specific chronic low back pain. Rather, we interpret our findings to mean that a range of active exercise therapies are most effective for non-specific chronic low back pain.

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CONCLUSION: Our interpretation is that active exercise, where a patient is progressed through a program guided by an appropriately trained clinician to improve their function, is likely the best form of exercise training for non-specific chronic low back pain.

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//@JeremyLewisPT @KarimKhan_IMHA @PhysioMeScience @AdamMeakins @tomgoom

Toll free link for infographic: bjsm.bmj.com/cgi/content/fu…