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Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials.

  • Author(s): Hayden, Jill A
  • Wilson, Maria N
  • Stewart, Samuel
  • Cartwright, Jennifer L
  • Smith, Andrea O
  • Riley, Richard D
  • van Tulder, Maurits
  • Bendix, Tom
  • Cecchi, Francesca
  • Costa, Leonardo OP
  • Dufour, Ninna
  • Ferreira, Manuela L
  • Foster, Nadine E
  • Gudavalli, Maruti R
  • Hartvigsen, Jan
  • Helmhout, Pieter
  • Kool, Jan
  • Koumantakis, George A
  • Kovacs, Francisco M
  • Kuukkanen, Tiina
  • Long, Audrey
  • Macedo, Luciana G
  • Machado, Luciana AC
  • Maher, Chris G
  • Mehling, Wolf
  • Morone, Giovanni
  • Peterson, Tom
  • Rasmussen-Barr, Eva
  • Ryan, Cormac G
  • Sjögren, Tuulikki
  • Smeets, Rob
  • Staal, J Bart
  • Unsgaard-Tøndel, Monica
  • Wajswelner, Henry
  • Yeung, Ella W
  • Chronic Low Back Pain IPD Meta-Analysis Group
  • et al.
Abstract

BACKGROUND:Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise. METHODS:In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers. RESULTS:We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics. CONCLUSIONS:This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

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