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Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis [with consumer summary]
Owen PJ, Miller CT, Mundell NL, Verswijveren SJ, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL
British Journal of Sports Medicine 2019 Oct 30:Epub ahead of print
systematic review

OBJECTIVE: Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP). DESIGN: Network meta-analysis (NMA). DATA SOURCES: Medline, CINAHL, SPORTDiscus, Embase, CENTRAL. ELIGIBILITY CRITERIA: Exercise training randomised controlled/clinical trials in adults with NSCLBP. RESULTS: Among 9,543 records, 89 studies (patients = 5,578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA 100%; pooled standardised mean difference (95% CI) -1.86 (-2.54 to -1.19)), resistance (SUCRA 80%; -1.14 (-1.71 to -0.56)) and stabilisation/motor control (SUCRA 80%; -1.13 (-1.53 to -0.74)) for physical function and resistance (SUCRA = 80%; -1.26 (-2.10 to -0.41)) and aerobic (SUCRA 80%; -1.18 (-2.20 to -0.15)) for mental health. True control was most likely (SUCRA <= 10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA 10%; 0.09 (-0.71 to 0.89)) and physical function (SUCRA 20%; -0.31 (-0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA 20%; -0.31 (-1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p > 0.095; SUCRA < 40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria. SUMMARY/CONCLUSION: There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.
Reproduced with permission from the BMJ Publishing Group.

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