Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Of the 75 titles assessed, 10 were protocols only and 54 were excluded (10 protocols and 44 full reviews).

“Ultimately, of the 75 titles requiring further assessment, 10 were reviews at protocol stage only (five of which have potential to be included once published as a full review, one which was unclear, and four that were excluded based on information within the protocol).Hence, we excluded 54 titles (10 protocols and 44 full reviews; Figure 1), reasons for which are listed in Table 2.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims. The quote only partly states this claim.

The 21 included reviews came from five different Cochrane Review groups: 11 from Musculoskeletal, four from Neck and Back, two from Peripheral Vascular Diseases, one from Menstrual Disorders and Subfertility, one from Injuries, one from Neuromuscular, and one from Bone, Joint and Muscle Trauma.

“The 21 included reviews were published by five different Cochrane Review groups: 11 from the Cochrane Musculoskeletal Group (Bartels 2007;Bidonde 2014;Busch 2007;Busch 2013;Cramp 2013;Fransen 2014;Fransen 2015;Han 2004; Hurkmans 2009; Regnaux 2015; Silva 2010); four from the Cochrane Neck and Back Group previously the Cochrane Back Group) (Gross 2015a; Hayden 2005; Saragiotto 2016; Yamato 2015);”

• Also stated in: § Specificity of chronic pain condition of included reviews · plain

  “two from the Cochrane Peripheral Vascular Diseases Group (Lane 2014; Lauret 2014); one from the Cochrane Menstrual Disorders and Subfertility Group (Brown 2010); one from the Cochrane Injuries Group (Boldt 2014); one from the Cochrane Neuromuscular Group (Koopman 2015); and one from the Cochrane Bone, Joint and Muscle Trauma”

May combine two claims.

Of the included studies, 264 studies with 19,642 participants compared exercise with no exercise or minimal intervention in adults with chronic pain and were used in the qualitative analysis.

“Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain (the focus of this overview) and so were used in the qualitative analysis.”

May combine two claims. The quote only partly states this claim.

The included reviews assessed land-based exercise or physical activity of various styles, pool-based or aquatic therapy, or any exercise therapy.

“Interventions assessed included: any specified style of land-based exercise or physical activity such as one designed to improve strength, range of movement, aerobic capacity, or a combination of these”

May combine two claims.

The frequency of exercise or physical activity interventions varied from once weekly to twice daily, with some short two-minute exercise series performed every 15 minutes during the day.

“There was large variation in the exercise or physical activity intervention being implemented, ranging from just once a week (Bidonde 2014;Busch 2007;Fransen 2014;Fransen 2015;Han 2004;Saragiotto 2016), to twice a day (Boldt 2014), and some performing a short series of exercises (two-minute duration) every 15 minutes during the day (Gross 2015a).”

May combine two claims.

Baseline intensity was often accepted as low or moderate, with progression aims of 70% to 85% HRmax or heart rate reserve for aerobic interventions, and 70% to 80% 1-RM or 50% to 70% maximum voluntary contraction for strength or resistance training.

“Baseline intensity was often accepted as low/moderate, with the aim to progress over the intervention period to 70% to 85% of HRmax or heart rate reserve (HRR) for aerobic interventions (Brown 2010;Cramp 2013;Hurkmans 2009), 70% to 80% of an individual's 1-RM, or 50% to 70% maximum voluntary contraction (Koopman 2015) in strength/resistance training programmes (Busch 2013;Hurkmans 2009).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The search found 475 potentially relevant titles, of which 75 were assessed as full papers.

“The search strategy was performed in the Cochrane Library only, and revealed 475 potentially relevant titles, of which 75 were assessed as full papers.”

May combine two claims.

21 reviews met inclusion criteria, covering rheumatoid arthritis (4), osteoarthritis (4), fibromyalgia (3), low back pain (3), intermittent claudication (2), dysmenorrhoea (1), mechanical neck disorder (1), spinal cord injury (1), postpolio syndrome (1), and patellofemoral pain (1).

“Following abstract and full paper assessment, 21 reviews fulfilled the inclusion criteria: four in rheumatoid arthritis (Cramp 2013;Han 2004;Hurkmans 2009;Silva 2010), four in osteoarthritis (Bartels 2007;Fransen 2014;Fransen 2015;Regnaux 2015), three in fibromyalgia (Bidonde 2014;Busch 2007;Busch 2013), three in low back pain (Hayden 2005;Saragiotto 2016;Yamato 2015)”

• Also stated in: § Specificity of chronic pain condition of included reviews · plain

  “two in intermittent claudication (Lane 2014;Lauret 2014), one in dysmenorrhoea (Brown 2010), one in mechanical neck disorder (Gross 2015a), one in spinal cord injury (Boldt 2014), one in postpolio syndrome (Koopman 2015), and one in patellofemoral pain (van der Heijden 2015).”

May combine two claims.

The overview included 21 Cochrane Reviews with 381 studies and 37,143 participants.

“We included 21 reviews with 381 included studies, totalling 37,143 participants.”

May combine two claims.

Physical function/disability was the most commonly reported outcome measure and was the primary measure in eight of the 21 reviews.

“physical function/disability was the most commonly reported outcome measure, and was the primary measure in eight out of the 21 reviews.”

May combine two claims.

Without the two reviews that labelled lack of blinding as low risk, only 7.8% (18/229) of included studies would have scored low risk of performance bias; including them raised the overall proportion to about 20% (53/264).

“Without these two reviews, only a small percentage (7.8% or 18/229) of the included studies would have scored low risk of performance bias (blinding of participants and personnel), but by including them (all 35 studies from those two reviews assessed as low risk of bias) the overall proportion of studies assessed as having low risk of bias was closer to 20% (53/264).”

May combine two claims.

Overall, results were inconsistent across interventions and follow-up, as exercise did not consistently change self-reported pain scores at any single point.

“Overall, results were inconsistent across interventions and followup (see Table 9), as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point.”

May combine two claims.

Second tier evidence was also lacking; three reviews found at least 30% pain reduction from baseline, one of which also had long enough exercise programmes but totalled only 81 participants across two studies, and the other two did not fulfil study duration or size criteria.

“Second tier evidence (at least 30% pain reduction from baseline, study duration between four and eight weeks, and more than 200 participants in total or 100 participants per arm) was also lacking in these reviews; three reviews found at least 30% reduction in pain from baseline (Busch 2007;Busch 2013;van der Heijden 2015)”

May combine two claims.

Reporting bias was classed as low risk in only 46% of included studies; the remainder were mostly unclear rather than high risk because trial protocols were not always published or accessible.

“Reporting bias was classed as low risk in only 46% of included studies.However, it is important to note this was not due to the remainder having high risk of bias, but instead 'unclear', as trial protocols were not always published or accessible to the review authors to accurately assess/interpret.”

The quote only partly states this claim.

The remaining 14 reviews showed that intervention produced a statistically significant benefit over control in physical function at a minimum of one reported time point (129 studies, n greater than 9559).

“The remaining 14 reviews showed that the intervention produced a statistically significant benefit over the control at a minimum of one reported time point”

Probably not a substantial claim: may not pass S3 (load-bearing).

In other reviews, intensity was described loosely as variable, low intensity to maximum effort, low intensity, or moderate or moderate-to-high.

“In other reviews, intensity was described more loosely as “variable” or “low intensity (very light) to maximum effort (vigorous)” ( Bidonde 2014; Fransen 2014; Lane 2014; Regnaux 2015), “low intensity” (Fransen 2014;Gross 2015a;Han 2004;Silva 2010), or “moderate or moderate-to-high” (Cramp 2013;Fransen 2015).”

May combine two claims.

Selection bias had the largest proportion of included studies with low risk of bias, with 63% adequately undertaking and 42% adequately reporting the methods used.

“Selection bias had the largest proportion of included studies with low risk of bias (63% and 42% of studies adequately undertaking and reporting the methods used).”

May combine two claims.

Only 26 out of 264 included studies (10%) across the 21 reviews reported over 100 participants in total or 50 per arm, and a further 6% (15/264) included over 200 participants per arm.

“Only 26 out of 264 included studies (10%) across the 21 reviews reported over 100 participants in total (or 50 per arm), a further 6% (15/264) included over 200 participants per arm.”

May combine two claims.

Results were inconsistent across interventions and follow-up, and the intervention did not consistently produce a change in self-reported pain scores at any single time point.

“However, results were inconsistent across interventions and followup, as the intervention did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point.”

May combine two claims.

There were no negative effects on psychological function or quality of life.

“There were no negative effects.”

May combine two claims.

Of seven reviews claiming long-term follow-up, one defined long-term as longer than six weeks, and the remaining six defined it as over 12 months post-intervention.

“Of the seven reviews claiming to report “long term” follow-up, one classed long-term as longer than six weeks (intermediate term as one to six weeks' follow-up) (Boldt 2014).The remaining six reviews defined long-term follow up as over 12 months (one year) post-intervention (Gross 2015a;Hayden 2005;Hurkmans 2009;Regnaux 2015;Saragiotto 2016;van der Heijden 2015).”

May combine two claims.

Review authors assessed risk of bias in different ways for blinding, which may cause confusion; the majority declared lack of possible blinding as high or unclear risk, while two reviews labelled such cases as low risk to avoid excluding studies.

“Due to the difficulty of blinding participants to their group allocation, review authors assessed the risk of bias in different ways, which may cause confusion: whereas the majority declared this lack of possible blinding to be high risk of bias or unclear, two reviews labelled such cases as low risk of bias in order not to exclude these studies unnecessarily from their analysis (Lane 2014;Lauret”

• AssumptionRests on an assumption: Blinding participants and personnel to exercise or physical activity allocation is very difficult.

May combine two claims.

The lowest AMSTAR score was 6/11 for one review, though five categories were not applicable because it had no included studies.

“The lowest score was 6/11 ( Silva 2010) though five categories were not applicable (n/a) due to there being no included studies.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Five reviews did not report post-intervention results but reported at short-term, mid or intermediate-term, and long-term post-randomisation.

“Five reviews did not report “post-intervention” but at short-term, mid/intermediate-term, and long-term postrandomisation (short, mid, and long term: Boldt 2014; short and intermediate term: Koopman 2015; Yamato 2015; short and long-term: Hurkmans 2009; van der Heijden 2015).”

May combine two claims.

None of the included reviews reported results as number of participants achieving 50% or 30% pain reduction, so reported absolute and relative change values were used instead.

“Our assessment criteria stated that we would accept the information as graded evidence when reported as the number of participants achieving a 50% (first tier evidence) or 30% (second tier evidence) reduction in pain, but none of the included reviews reported results in this way, and so instead we used the reported absolute and relative change values.”

May combine two claims.

Of the remaining reviews that reported studies examining intervention versus control, two did not report pain as an absolute or relative severity, intensity, or change score, and one assessed pain-free time and distance during exercise rather than mean or usual pain.

“Of the remaining reviews that did report studies examining intervention versus control (no physical activity or exercise, or minimal intervention), two did not report pain as an absolute or relative score of severity, intensity, or change as a result of the intervention (Brown 2010;Han 2004), and one review assessed pain-free time and distance during exercise (they did not assess pain using a mean”

May combine two claims.

Three reviews needed further comment because the strength of their conclusions was not appropriate based on available data, or their interpretation could not be agreed with due to difficulty extracting data.

“and three reviews needed further comment as the strength of the conclusions were not appropriate based on the available data (Brown 2010;Fransen 2014), or we were unable to agree with their interpretation due to difficulty in extracting the data (van der Heijden 2015).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A version of quality of life assessment was reported in nine reviews; six were termed quality of life or health-related quality of life, and other reviews assessed global perceived effect, global wellbeing, global assessment, global impression of recovery, health assessment questionnaire, multi-dimensional function, and work status.

“A version of quality of life assessment was reported in nine reviews.Six were termed quality of life or health-related quality of life (HRQoL) (Bartels 2007;Boldt 2014;Fransen 2014;Fransen 2015;Gross 2015a;Lauret 2014).”

• Also stated in: § Quality of life · plain

  “Other reviews assessed global perceived effect (Gross 2015a), global wellbeing (Busch 2007), global assessment (Hayden 2005), global impression of recovery (Saragiotto 2016;Yamato 2015), health assessment questionnaire (Silva 2010), multi-dimensional function (Bidonde 2014;Busch 2013), and work status (Hayden 2005).”

May combine two claims.

Five reviews assessed withdrawals or dropouts, one reported all-cause attrition, and another reported the discontinuation rate.

“However, five reviews assessed withdrawals or dropouts (Bidonde 2014;Fransen 2014;Han 2004;Regnaux 2015;Saragiotto 2016), one reported all-cause attrition (Busch 2013), and another reported the discontinuation rate (Silva 2010).”

May combine two claims.

Three reviews reported change data, and control group baseline and earliest control group scores were used as assumed or approximate baseline measures for intervention groups in nine reviews.

“Three reviews reported change data (Bartels 2007;Busch 2007;Busch 2013), but we were able to use control group baseline and earliest control group scores as assumed or approximate baseline measures for the intervention groups in nine reviews ( Bartels 2007; Busch 2007; Fransen 2014; Fransen 2015; Gross 2015a; Koopman 2015; Saragiotto 2016; van der Heijden 2015; Yamato 2015).”

May combine two claims.

Results for psychological function and quality of life were variable: either favourable to exercise (two reviews with significantly large effect sizes for quality of life) or showing no difference between groups.

“there were variable results for psychological function and quality of life: results were either favourable to exercise (two reviews reporting significantly large effect sizes for quality of life), or showed no difference between groups.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Individual session duration varied from two minutes to 90 or 120 minutes, but was mostly around 45 to 60 minutes.

“Individual sessions varied in length from two minutes (Gross 2015a), to 90 minutes (Busch 2013;Cramp 2013;Han 2004) or 120 minutes (Boldt 2014), but mostly situated around 45 to 60 minutes.”

May combine two claims.

There were significant effects in favour of intervention for mental health and depression scores, and variable effect for depression.

“There were significant effects in favour of the intervention for mental health (Bartels 2007) and depression (Busch 2013) scores, and “variable effect” for depression (Cramp 2013).”

May combine two claims.

In the remaining reviews, a cursory statement was commonly made about review authors' conflicts of interest, but AMSTAR also requires a statement about conflicts of interest for included studies.

“In the remaining reviews, a cursory statement was commonly made regarding the review authors' conflicts of interests, however, fulfilling the AMSTAR criteria also requires a statement to be made regarding any conflict of interest for any of the included studies.”

May combine two claims.

There was also no effect or no difference between control and intervention groups for mental health, anxiety, and depression in some reviews.

“However, there was also no effect or no differences between control and intervention groups reported for mental health (Bidonde 2014;Busch 2013), anxiety (Cramp 2013), and depression (Boldt 2014).”

May combine two claims. The quote only partly states this claim.

Seven reviews reported clinically significant pain results as a result of exercise intervention, with specific improvements ranging from 1.3/10 to 14.9/100.

“Additionally, seven reviews reported clinically significant results (minimally important difference: reduction in pain from baseline of at least 10 points on a 0 to 100 scale or an absolute improvement of at least 10% to 20%, Dworkin 2008) as a result of the exercise intervention”

• cites Dworkin 2008 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Physical function was statistically significantly improved as a result of the intervention in 14 reviews, though effect sizes were small-to-moderate in all but one review.

“Physical function was significantly (statistically) improved as a result of the intervention in 14 reviews, though even these statistically significant results had only smallto-moderate effect sizes in all but one review.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some earlier reviews did not assess bias using the same format because the reporting bias format changed; others reported additional criteria as other bias including similarity of baseline characteristics and timing points.

“The format for reporting bias has changed, and therefore some earlier reviews (that are yet to be updated) did not assess bias using the same format.Others reported additional criteria as 'other bias' including the similarity of baseline characteristics, and similarity of timing points.”

May combine two claims.

AMSTAR criteria that scored badly were characteristics of included studies, reporting of publication bias, and conflict of interest declarations.

“Criteria which scored badly using the AMSTAR tool were characteristics of included studies (question six of Table 1), reporting of publication bias (question 10 of Table 1), and conflict of interest declarations (question 11 of Table 1).”

May combine two claims.

Assessment of publication bias was omitted entirely in five reviews, and when assessed it was reported only with a simple statement without test values, analyses, or diagrams in two reviews.

“Assessment of publication bias was omitted entirely in five reviews (Bartels 2007;Fransen 2014;Fransen 2015;Han 2004;Hurkmans 2009), and when it was assessed, it was reported using only a simple statement (with no test values, analyses used, or diagrams to demonstrate the result; Busch 2007;Koopman 2015).”

Classified as probably not a substantial claim.

The remaining 15 reviews reported a mean or usual pain score for exercise and no-exercise groups.

“The remaining 15 reviews reported a mean or usual pain score for exercise (intervention) and no-exercise (control) groups ( Bartels 2007; Bidonde 2014; Boldt 2014; Busch 2007; Busch 2013; Cramp 2013; Fransen 2014; Fransen 2015; Gross 2015a; Hayden 2005; Hurkmans 2009; Koopman 2015; Saragiotto 2016; van der Heijden 2015; Yamato 2015).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Relevant data could not be extracted from one review because it compared two exercise interventions and a control but did not report data compared to control.

“We could not extract relevant data for one review as they compared two different exercise interventions and a control but did not report the data compared to the control (Regnaux 2015).”

May combine two claims.

No included review achieved a perfect AMSTAR score of 11/11; five achieved 10/11 and eight scored 9/11.

“No review achieved a perfect score of 11/11, though five achieved 10/11 (Boldt 2014 Busch 2013; Hayden 2005; Koopman 2015; Regnaux 2015) and eight scored 9/11 (Cramp 2013; Gross 2015a; Hurkmans 2009; Lane 2014; Lauret 2014; Saragiotto 2016; van der Heijden 2015; Yamato 2015).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Reviews also analysed outcome measures immediately post-intervention and at one or more follow-up points.

“Reviews also analysed outcome measures immediately post-intervention and at one or more follow-up points.”

Probably not a substantial claim: may not pass S3 (load-bearing).

One review assessed participants in an ongoing fashion over three menstrual cycles.

“One review assessed participants in an ongoing fashion “over three menstrual cycles” (Brown 2010).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Four of the 19 reviews that reported data reported results at a single post-intervention time point only.

“Four of the 19 reviews that reported data, reported results at a single time point only ('post-intervention': Bidonde 2014;Busch 2007;Cramp 2013;Han 2004).”

May combine two claims.

Two reviews had appropriate conclusions but only limited discussion of quality or did not adequately consider evidence quality in interpreting results.

“two reviews had appropriate conclusions but had only limited discussion of quality or did not adequately consider the quality of the evidence in the interpretation of the results (Hurkmans 2009;Lane 2014);”

May combine two claims.

Results from relevant reviews were pooled as all tier three quality, and should be interpreted with caution due to low quality evidence.

“Consequently results from relevant reviews have been pooled (all tier three quality) where appropriate, though results should be interpreted with caution due to the low quality evidence.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two reviews that reported physical function had no data to extract, and for one review relevant data could not be extracted.

“Two reviews which reported physical function had no data to extract (Lauret 2014;Silva 2010), and for one review we were unable to extract the relevant data (Regnaux 2015).”

May combine two claims.

Included study characteristics were limited, often reporting inclusion criteria instead of actual participant characteristics and excluding age, gender split, ethnicity, and disease status.

“Included study characteristics were limited, often reporting the “inclusion criteria” used to recruit participants in the study instead of the characteristics of actual included participants, and excluding information such as participants' age, gender split, ethnicity, and disease status.”

May combine two claims.

The remaining 223 studies (84%) had fewer than 50 participants per arm or did not report sample size, often not reaching 50 in total.

“The remaining 223 studies (84%) had fewer than 50 participants per arm (or sample size was not reported), often not reaching 50 in total.”

May combine two claims.

Based on five studies, death had a risk ratio of 0.71 (95% CI 0.28 to 1.78) in favour of exercise as protective, though this was not statistically significant (P = 0.47).

“Based on five studies within the review, death had an RR of 0.71 (95% CI 0.28 to 1.78) in favour of exercise as being protective, though was not statistically significant (P = 0.47).”

May combine two claims. The quote only partly states this claim.

Two reviews assessed only a specific adverse event, one observed safety regarding pain and radiological damage, and another referred to any side-effects.

“Two reviews only assessed a specific adverse event (”

Probably not a substantial claim: may not pass S3 (load-bearing).

One protocol that had potential to be included was published in 2006 with no full review available yet.

“One protocol that had potential to be included was published in 2006 with no full review available yet (Craane 2006).”

• cites Craane 2006 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Risk of withdrawal or dropout was slightly higher in the exercising group (82.8 per 1000 versus 81 per 1000), though the group difference was not significant.

“However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was not significant.”

May combine two claims.

Physical function was the primary outcome in eight of 21 reviews and a reported non-primary outcome in nine more; only two reviews did not list physical function, disability, or activity limitation as a potential outcome.

“Measures of physical function were the primary outcome measure in eight out of 21 reviews (Busch 2013;Han 2004;Hayden 2005;Hurkmans 2009;Koopman 2015;Lane 2014;Lauret 2014;Silva 2010), and a reported (non-primary) outcome measure in nine more reviews”

• Also stated in: § Secondary outcomes · plain

  “Only Boldt 2014 and Brown 2010 did not list physical function (or disability, or activity limitation) as a potential outcome measure.”

May combine two claims.

Two reviews mentioned publication bias in methods as planned analyses but did not mention it again, and a third mentioned it in methods but appeared to use it interchangeably with reporting bias.

“Two reviews mentioned in the methods as planned analyses, though was not mentioned again (Brown 2010;van der Heijden 2015), and a third review mentioned it in the methods, but appeared to use it interchangeably with reporting bias causing great confusion (Bidonde 2014).”

May combine two claims.

Only one review calculated a risk ratio for adverse events, showing a reduced risk of amputation in the intervention group (RR 0.20, 95% CI 0.01 to 4.15, based on one study).

“one review calculated an RR for the adverse events, showing a reduced risk for amputation in the intervention group (two amputations in the usual care/control group: RR 0.20, 95% CI 0.01 to 4.15, based on one study in one review, Lane 2014).”

• cites Lane 2014 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Shorter sessions were often performed more regularly than longer sessions.

“However, it is important to note that the shorter sessions were often performed more regularly than longer sessions.”

May combine two claims.

Adverse events were largely reported as a total number per trial, though one review separately reported results for the intervention group versus the control group, and two others reported adverse events for the intervention group only.

“Adverse events were largely reported as a total number per trial, though one review separately reported results for the intervention group versus the control group (Saragiotto 2016), and two others reported adverse events for the intervention group only (Boldt 2014;Regnaux 2015).”

Classified as probably not a substantial claim.

The included reviews did not discuss the possible impact of this non-reporting by the original trials.

“The included reviews did not discuss the possible impact of this non-reporting by the original trials”

May combine two claims.

The labelling of participants as having mild-to-moderate pain was cautious because of the lack of specific baseline data; only three reviews included baseline pain scores in the intervention group and two further reviews provided control group baseline scores.

“the labelling of participants as having mild-moderate pain was a cautious one within this overview due to the lack of specific data available at baseline assessment; only three reviews included baseline pain scores in the intervention group, and two further reviews provided control group baseline scores.”

• AssumptionThe authors state this as an assumption: The majority of the included population had mild-to-moderate pain severity, assumed because of the lack of exact baseline group data.

May combine two claims.

A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.

“A number of studies within the reviews had adequately long interventions, but planned follow-up was limited to less than one year (12 months) in all but six reviews.”

May combine two claims.

Apart from blinding, the trials did not consistently and adequately report potential attrition and reporting biases, with less than half of studies at low risk of bias.

“Other than issues surrounding blinding (which are problematic in exercise intervention studies due to the nature of the intervention), the trials did not consistently and adequately report potential attrition and reporting biases, with less than half of studies within these reviews at low risk of bias.”

May combine two claims.

For people with hip or knee osteoarthritis, the overview authors report that the Bartels 2007 review found a statistically significant reduction in pain immediately after exercise intervention, but the effect was not clinically significant.

“Statistically significant post-intervention in hip + knee OA group, but not clinically significant”

• cites Bartels 2007 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The most commonly reported adverse events were increased soreness or muscle pain, which subsided after several weeks of the intervention.

“The most commonly reported adverse events were increased soreness or muscle pain, which subsided after several weeks of the intervention.”

May combine two claims.

All 21 included reviews scored well across the AMSTAR assessment, likely because of the stringent reporting guidelines implemented by Cochrane before publication.

“All 21 included reviews scored well across the AMSTAR assessment, though this is likely due to the stringent reporting guidelines implemented by Cochrane prior to publication.”

May combine two claims.

The quality of the evidence was low (third tier); no tier one or tier two evidence was found.

“In summary, the quality of the evidence was low (third tier): within this overview we found no tier one or tier two evidence.”

May combine two claims.

Of the 21 included reviews, 12 used a pain measure as their primary outcome and the remaining nine included it as a secondary outcome only.

“Of the 21 included reviews, 12 used a pain measure as their primary outcome (Bartels 2007 Boldt 2014; Brown 2010; Busch 2007; Fransen 2014; Fransen 2015; Gross 2015a; Hayden 2005; Regnaux 2015; Saragiotto 2016; van der Heijden 2015; Yamato 2015), and the remaining nine reviews included the measure as a secondary outcome only.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Occasionally results were not discussed with regard to the quality of the evidence or risk of bias.

“Occasionally results were not discussed with regards to the quality of the evidence or risk of bias”

May combine two claims.

Not all exercise sessions were supervised or baseline fitness/physical ability was assessed subjectively, so it was not reported whether the intervention was fulfilled as described or whether the dose was enough to elicit a physiological response.

“Additionally, not all exercise sessions were supervised or baseline fitness/physical ability was assessed subjectively, and consequently it was not reported whether the intervention was fulfilled as described, or whether the dose was enough to elicit a physiological response.”

Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

In the Fransen 2015 review of land-based therapeutic exercise for knee osteoarthritis, only 54% of the included studies adequately described the exercise intervention.

“only 54% adequately described the exercise intervention”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For the Bartels 2007 review, the overview authors report that adverse events were recorded but none occurred.

“Adverse events were recorded (and reported), but none occurred”

• cites Bartels 2007 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

None of the included reviews examined generalised or widespread chronic pain as a global condition; each examined specific conditions in which chronic pain is a symptom or result.

“None of the included reviews examined generalised or widespread chronic pain as a global condition, each instead examined specific conditions that included chronic pain as a symptom or result of the ongoing condition”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The authors are not aware of any overviews or reviews summarising non-Cochrane reviews.

“This is a summary overview of current Cochrane Reviews, we are not aware of any overviews or reviews summarising non-Cochrane reviews.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Bartels 2007 review did not mention quality or risk of bias in its conclusions, even though the review was found to be of high quality in its results section.

“No mention of quality/risk of bias in conclusions, though found to be high quality in results section”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

Interpretation of the available data and the conclusions drawn by the review authors were appropriate, although the conclusions were sometimes stronger than warranted by the available data.

“Interpretation of the available data, and conclusions drawn by the review authors, were appropriate, although the conclusions were sometimes stronger than warranted by the available data.”

May combine two claims.

In the Bidonde 2014 review of aquatic exercise for fibromyalgia, none of the included studies met the ACSM exercise guidelines for aerobic or strength training, and only one study met the ACSM guidelines for flexibility training.

“None of the studies met the ACSM exercise guidelines specified for aerobic or strength training.Only 1 study met the ACSM guidelines for flexibility training”

May combine two claims.

Intervention length ranged from a single session to regular sessions over 30 months, with the majority between eight and 12 weeks.

“Intervention length ranged from a single session to regular sessions over a period of 30 months, though the majority were between eight and 12 weeks.”

May combine two claims.

For people with hip or knee osteoarthritis, the overview authors report that the Bartels 2007 review found a statistically significant improvement in function immediately after exercise intervention only, and the effect size was small.

“Function was significantly improved in people with hip + knee OA immediately post-intervention only -small effect size only”

• cites Bartels 2007 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The overview authors' pooled analysis of 30 studies with 2256 participants found no significant difference in withdrawal rates between exercise and control groups, with a risk ratio of 1.02 (95% CI 0.94 to 1.12) and an odds ratio of 1.05 (95% CI 0.88 to 1.25).

“Total 30 studies, n = 2256 82.8/1000 81/1000 Calculated RR 1.02 (95% CI 0.94 to 1.12) Calculated OR 1.05 (95% CI 0.88 to 1.25)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Exercise matters greatly for cardiovascular and bone health.

“exercise is of great importance for cardiovascular (Vigorito 2014) and bone health (Sakuma 2012).”

• cites Vigorito 2014 sourceNot checked yet

  Not checked in the free run.

• cites Sakuma 2012Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Data extraction and quality assessment used the latest published version of each full review.

“All extracted data and methodological quality assessment were taken from the most recent published version of the full review.”

May combine two claims.

Due to limited data, the overview could not directly compare and analyse interventions and instead reported evidence qualitatively.

“However due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively only.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Aerobic training has a strong association with weight loss.

“Aerobic exercise is also strongly linked to weight loss (Messier 2013)”

• cites Messier 2013 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Exercise might lessen chronic pain severity and could enhance general physical and mental health and physical function in adults with chronic pain.

“Exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning”

• Also stated in: § How the intervention might work · hedged

  “Exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning of people with chronic pain”

Classified as probably not a substantial claim.

Methodological quality of each included review was assessed independently by two authors using the AMSTAR tool.

“Two overview authors (LG, CC) independently assessed each included review to see if it satisfied the criteria specified in the 'assessment of multiple systematic reviews' (AMSTAR) measurement tool (Shea 2007), for rigorous methodological quality.”

• cites Shea 2007 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Data were not entered into Cochrane's statistical software for analysis because relevant and comparable data were lacking.

“Data were not entered for analysis into Cochrane's statistical software due to the lack of relevant and comparable data (RevMan 2014).”

• cites RevMan 2014Not checked yet

  Not checked in the free run.

May combine two claims.

The overview did not consider mean changes in pain scores as high quality because responses to pain interventions are not Gaussian and few people have the mean response.

“We did not consider the use of mean changes in pain scores as high quality because responses to pain interventions are not Gaussian, and few people have the mean response.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In chronic low back pain, repeated resistance exercise through the full range of motion at the lumbar spine might influence disc metabolism, possibly improving metabolic exchange in the discs and helping repair.

“Resistance training through repetitive full range-of-motion exercise around the lumbar spine (in chronic low back pain) may affect disc metabolism itself, with the possibility that the exercise programme could improve metabolic exchange in the lumbar discs and aid in repair (Mooney 2006).”

• cites Mooney 2006Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The overview planned to compare only like with like, such as study duration, because insufficient length can be an additional source of bias.

“We planned to compare only like with like (where possible); for example in study duration, which can be an additional source of bias if insufficient in length (Moore 2010).”

• cites Moore 2010 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Balance and flexibility training reduces the risk of falls and the potential for further pain or injury.

“Training to improve balance and flexibility also has benefits as it reduces the risk of falls, and the potential for further pain or injury (Harvard 2013).”

• cites Harvard 2013Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two overview authors independently searched and selected reviews for inclusion, with disagreements resolved by discussion and arbitration by a third author.

“Two overview authors (LG, CC) independently carried out searches and selected reviews for inclusion.Disagreements were resolved through discussion, and a third overview author (RAM) acted as arbitrator where necessary.”

May combine two claims.

Resistance exercise or other strength training can improve a person's ability to support bone and cartilage through better musculature around a joint, potentially relieving stiffness and producing some pain relief.

“resistance exercise, or other forms of strength training, can improve the person's capacity to support bone and cartilage through improved musculature supporting movement around a joint, with potential to relieve stiffness (Mayer 2008) and bringing about some pain relief.”

• cites Mayer 2008 sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

A Summary of findings table could not be included as planned because of data limitations.

“For this reason we have also been unable to include a 'Summary of findings' table as planned and stated in the protocol.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two overview authors independently assessed methodological quality and extracted data, with disagreements resolved by discussion or a third author.

“Two overview authors (independently carried out assessment of methodological quality (LG, CC), and extracted data (LG, RAM).Any disagreements were resolved through discussion, or involving a third overview author if necessary (DM).”

Classified as probably not a substantial claim.

When exercise and activity programmes safely and effectively lower pain intensity or frequency, they are likely to be preferred as an alternative or add-on to drug or surgical treatment for chronic pain.

“If physical activity and exercise interventions are shown to effectively and safely reduce pain intensity or frequency (or both), they are likely to be a preferable alternative or adjunct therapy to pharmacological/surgical treatments for chronic pain.”

• AssumptionRests on an assumption: Exercise is likely to have minimal adverse effects compared with pharmaceutical and surgical interventions in adults with chronic pain.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two overview authors independently extracted data using a standardised form and checked agreement before entering it into Excel.

“Two overview authors (LG, RAM) independently extracted data from the included review using a standardised data extraction form and checked for agreement prior to entry into Microsoft Excel for Windows.”

May combine two claims.

Exercise caused no actual harm, with most adverse events being increased soreness or muscle pain that reportedly subsided after several weeks of the intervention.

“importantly, exercise caused no actual harm, with most adverse events being increased soreness or muscle pain, which reportedly subsided after several weeks of the intervention.”

May combine two claims.

Mild-to-moderate pain is often the desired post-intervention outcome of many drug therapies for pain, so it may be difficult to show a clinically significant improvement in these people.

“This is often the desired outcome (post-intervention) of many drug therapies for pain, and it may therefore be difficult to show a clinically significant improvement in these people.”

• AssumptionThe authors state this as an assumption: The majority of the included population had mild-to-moderate pain severity, assumed because of the lack of exact baseline group data.

May combine two claims.

The majority of participants reviewed had mild-to-moderate pain at commencement, with only one review reporting a mean of severe pain (aquatic exercise for fibromyalgia), though this labelling should be interpreted with caution due to lack of specific data.

“This suggests the majority of participants reviewed had mild-tomoderate pain (only one review reported a mean of severe pain (aquatic exercise for fibromyalgia, Bidonde 2014) at the commencement of each intervention (less than 30/100 mild pain, 30/ 100 to 60/100 moderate pain, more than 60/100 severe pain; Collins 1997), though labelling the majority as having only mildto-moderate pain should be”

• cites Collins 1997 sourceNot checked yet

  Not checked in the free run.

• AssumptionThe authors state this as an assumption: Control group baseline and earliest control group scores can serve as approximate baseline measures for intervention groups.

Classified as probably not a substantial claim. May combine two claims.

The original review authors of that review highlighted low to very low quality of evidence because many studies had high or unclear risk of bias across multiple domains.

“However, the original review authors highlighted the low to very low quality of the evidence as many studies had high or unclear risk of bias across multiple domains (van der Heijden 2015).”

May combine two claims.

The broad spectrum of physical activity and exercise interventions assessed are potentially beneficial, though the evidence for benefit is of low quality and inconsistent.

“The evidence in this overview suggests that the broad spectrum of physical activity and exercise interventions assessed here (aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi) are potentially beneficial, though the evidence for benefit is low quality and inconsistent.”

May combine two claims.

The evidence showed variable results, though in some reviews there was a clinical and statistical benefit in pain relief and physical function, based on low quality evidence.

“The evidence showed variable results, though in some reviews there was a clinical and statistical benefit in pain relief and physical function (based on low quality evidence).”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Non-subjective physical assessment should be performed where possible.

“it was concluded that nonsubjective physical assessment should be performed where possible (Perruchoud 2014)”

• cites Perruchoud 2014 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The overview authors judged the conclusions of the Boldt 2014 review to be appropriate given the available data.

“Appropriate conclusions based on available data.”

May combine two claims.

There is a delay in muscular hypertrophy as a result of exercise, and initial gains within the first few weeks of a training programme are due to neural factors.

“It is widely accepted that there is a delay in muscular hypertrophy as a result of exercise, and initial gains within the first few weeks of any training programme will be as a result of neural factors (Enoka 1997)”

• cites Enoka 1997 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

Cochrane Reviews may be the most reliable source of evidence because of their higher quality grading.

“previous publications have referred to the higher quality grading (high AMSTAR score) in Cochrane Reviews due to the basic criteria necessary for publication at any stage (protocol or full review) suggesting they may be the most reliable source of evidence (O'Connell 2013).”

• cites O'Connell 2013 sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

Each review team will have included studies that did not use their chosen outcome measures as the primary measure, and that were therefore powered according to a different primary outcome.

“Likewise, each review team will have included studies that did not use their chosen outcome measures as the primary measure, and that were therefore powered according to a different primary outcome.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

People with higher pain scores are more likely to be assigned medical or surgical interventions than physical activity and exercise alone, may be less able to engage in exercise, and may be more difficult to recruit into exercise-only studies.

“However, it can be argued that those people are more likely to be assigned medical or surgical interventions than physical activity and exercise alone (where available), and as a group they may be less able to engage in exercise, and may therefore be more difficult to recruit into exercise-only studies.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The overview authors assert that a review's comment on the absence of adverse events was inappropriate because the included study did not report adverse events, and that this contravened Cochrane guidance.

“Review authors should not have commented on lack of adverse events as this was not reported in the included study.The comment on lack of adverse events contravened present Cochrane guidance”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The AMSTAR tool is useful for assessing the reporting of a systematic review, though it does not inform about the actual undertaking or conduct of the review process.

“The AMSTAR tool is useful in assessing the reporting of a systematic review, though it does not inform us of the actual undertaking or conduct of the review process.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The overview authors state that they used only one of the six studies included in the Regnaux 2015 review because that study alone had a control group, and they could not extract data because the review authors did not use the control comparison in their analysis.

“This overview has only used one study of the six included as it alone included a control group, for which we could not extract data as the control comparison was not used in the analysis by the review authors”

• cites Regnaux 2015 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Studies often rely on participants' self-report of the actual physical activity undertaken, which can lead to greater risk of bias and reduced study quality.

“Studies often rely on the self-report of participants as to the actual physical activity and exercise being undertaken, which can lead to a greater risk of bias, and reduced study quality”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The overview authors report that the Yamato 2015 review did not perform subgroup analysis by pain duration, which made it difficult to extract appropriate data, and that the review presented results altogether as chronic pain.

“There was no subgroup analysis to differentiate between acute, subacute, and chronic pain made it difficult to extract appropriate data for this review (one included study had subacute back pain (> 6 weeks), all others were chronic back pain (> 12 weeks)) but results are presented altogether as chronic pain”

• cites Yamato 2015 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The overview authors state that the Cramp 2013 review's conclusion omitted any mention of study quality or risk of bias even though the results and discussion sections reported low or unclear quality scores.

“However, no mention of quality/risk of bias of studies in conclusion despite low/unclear quality score in results and discussion sections”

• cites Cramp 2013 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The overview authors report that the van der Heijden 2015 review did not perform subgroup analysis by pain duration (acute, subacute, chronic), which made it difficult for the overview to extract appropriate data.

“No subgroup analysis to differentiate between acute, subacute, and chronic pain made it difficult to extract appropriate data for this review”

• cites van der Heijden 2015 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The overview authors note that the Cramp 2013 review drew no conclusions about the effect on pain because data were insufficient.

“No conclusions about effect on pain (insufficient data).”

• cites Cramp 2013 sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

For 20% to 25% of participants undertaking an exercise programme there is little to no favourable response, while 5% to 10% have adverse events.

“It has been previously suggested that for 20% to 25% of participants undertaking an exercise programme there is little to no favourable response (Timmons 2014), while a small percentage (5% to 10%) have adverse events (Bouchard 2012).”

• cites Timmons 2014Not checked yet

  Not checked in the free run.

• cites Bouchard 2012 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

There is some evidence of improved physical function and a variable effect on both psychological function and quality of life.

“There is some evidence of improved physical function and a variable effect on both psychological function and quality of life.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The overview authors judged the conclusions of the Bidonde 2014 review to be appropriate given the available data.

“Appropriate conclusions based on available data.”

Classified as probably not a substantial claim. May combine two claims.

The overview employed the AMSTAR tool to examine the reviews, extracted risk-of-bias data to examine the primary evidence, and evaluated the review authors' conclusions for appropriateness.

“In assessing the quality of the evidence, we employed the AM-STAR tool to examine the reviews, extracted data on risk of bias to examine the available primary evidence, and evaluated the au-thors' conclusions to ensure that they were appropriate based on the available data.”

May combine two claims.

Physical activity and exercise may improve pain severity as well as physical function and quality of life.

“Physical activity and exercise may improve pain severity as well as physical function and quality of life.”

May combine two claims.

The evidence suggests that physical activity or exercise is an acceptable intervention in people with chronic pain, with minimal negative adverse effects.

“The evidence suggests that physical activity or exercise is an acceptable intervention in people with chronic pain, with minimal negative adverse effects.”

May combine two claims.

Results are inconsistent and the evidence is of low quality (tier three).

“However, results are inconsistent and the evidence is low quality (tier three).”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

The pain in the included conditions can occur secondary to other symptoms such as fatigue, muscle stiffness, difficulty sleeping and depression, all of which could separately and more effectively be influenced by the intervention.

“The pain in these cases can occur secondary to other symptoms such as fatigue, muscle stiffness, difficulty sleeping, and depression, all of which could separately (and more effectively) be influenced by the intervention.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The overview authors judged the conclusions of the Bartels 2007 review to be appropriate given the available data.

“Appropriate conclusions based on available data.”

May combine two claims.

The non-reporting of adverse events by the original trials may lead to underestimating possible adverse events or overestimating the safety of the intervention.

“this may lead to underestimating possible adverse events from an intervention, or overestimating its safety.”