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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
Open accessAbstract
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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“Different reviews have confirmed the benefits of exercise on the prevention of NBP in the lumbar [11,12,13,14] and cervical regions [15,17,19,20].”
From Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis (2024) · cites this paper as [13]
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“In fact, there are several systematic reviews that have examined the benefits of exercise for the prevention of low back pain with regard to pain reduction, improvement of disability, quality of life and kinesiophobia [11,12,13,14].”
From Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis (2024) · cites this paper as [13]
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Self-citationWhat low back pain is and why we need to pay attention
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Self-citationUpdated Method Guidelines for Systematic Reviews in the Cochrane Collaboration Back Review Group
van Tulder, M., Furlan, A., Bombardier, C., & Bouter, L. (2003) · Spine · doi:10.1097/01.brs.0000065484.95996.af · Cited by 2,180
The epidemiology of low back pain
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Meta-analysis of individual participant data: rationale, conduct, and reporting
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Self-citationThe Rising Prevalence of Chronic Low Back Pain
Freburger, J. K., Holmes, G. M., Agans, R. P., Jackman, A. M., Darter, J. D., Wallace, A. S., Castel, L. D., Kalsbeek, W. D., & Carey, T. S. (2009) · Archives of Internal Medicine · doi:10.1001/archinternmed.2008.543 · Cited by 1,507
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Exercise therapy for chronic low back pain
Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd009790.pub2 · Cited by 589
Self-citationChiarotto, A., & Koes, B. W. (2022) · New England Journal of Medicine · doi:10.1056/nejmcp2032396 · Cited by 298
Zhu, F., Zhang, M., Wang, D., Hong, Q., Zeng, C. C., & Chen, W. (2020) · PLoS ONE · doi:10.1371/journal.pone.0238544 · Cited by 139
Grooten, W. J. A., Boström, C., Dedering, Å., Halvorsen, M., Kuster, R. P., Nilsson-Wikmar, L. B., Olsson, C., Rovner, G., Tseli, E., & Rasmussen-Barr, E. (2022) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-022-05722-x · Cited by 105
Self-citationMarshall, A., Joyce, C. T., Tseng, B., Gerlovin, H., Yeh, G. Y., Sherman, K. J., Saper, R. B., & Roseen, E. J. (2021) · Pain Medicine · doi:10.1093/pm/pnab318 · Cited by 77
Metadata
- Authors
- Hayden, J. A., Wilson, M. N., Stewart, S., Cartwright, J. L., Smith, A. O., Riley, R. D., van Tulder, M., Bendix, T., Cecchi, F., Costa, L. O. P., Dufour, N., Ferreira, M. L., Foster, N. E., Gudavalli, M. R., Hartvigsen, J., Helmhout, P., Kool, J., Koumantakis, G. A., Kovacs, F. M., Kuukkanen, T., Long, A., Macedo, L. G., Machado, L. A. C., Maher, C. G., Mehling, W., Morone, G., Peterson, T., Rasmussen-Barr, E., Ryan, C. G., Sjögren, T., Smeets, R., Staal, J. B., Unsgaard-Tøndel, M., Wajswelner, H., & Yeung, E. W.
- Affiliations
- Dalhousie University (CA)
- Keele University (GB)
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
- University of Copenhagen (DK)
- Don Carlo Gnocchi Foundation (IT)
- Universidade Cidade de São Paulo (BR)
- Department of Rheumatology, A2 Rheumatology and Sports Medicine, Hillerød, Denmark
- The University of Sydney (AU)
- Arthritis UK (GB)
- Keiser University (US)
- University of Southern Denmark (DK)
- Department of Training Medicine and Training Physiology, Personnel Command, Royal Netherlands Army, Utrecht, The Netherlands
- Valens Clinics (CH)
- Centre for Rehabilitation Science, University of Manchester, Manchester Royal Infirmary, Manchester, UK
- Unidad de la Espalda Kovacs, Hospital Universitario HLA-Moncloa, Red Española de Investigadores en Dolencias de la Espalda, Madrid, Spain
- JAMK University of Applied Sciences (FI)
- Bonavista Physical Therapy, Calgary, Alberta, Canada
- McMaster University (CA)
- Universidade Federal de Minas Gerais (BR)
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- University of California, San Francisco (US)
- Fondazione Santa Lucia (IT)
- Back Center Copenhagen, Copenhagen, Denmark
- Karolinska Institutet (SE)
- Teesside University (GB)
- University of Jyväskylä (FI)
- Maastricht University (NL)
- Radboud University Medical Center (NL)
- Department of Neuromedicine and Movement Science, and Department of Public Health and Nursing, NTNU, Trondheim, Norway
- La Trobe University (AU)
- Hong Kong Polytechnic University (HK)
- Corresponding author
- Hayden, Jill A
- ORCID
- Hayden, Jill A
- Wilson, Maria N
- Stewart, Samuel
- Riley, Richard D
- Cecchi, Francesca
- Costa, Leonardo O P
- Ferreira, Manuela L
- Foster, Nadine E
- Gudavalli, Maruti R
- Hartvigsen, Jan
- Helmhout, Pieter
- Kool, Jan
- Koumantakis, George A
- Kovacs, Francisco M
- Macedo, Luciana G
- Machado, Luciana A C
- Maher, Chris G
- Mehling, Wolf
- Morone, Giovanni
- Rasmussen-Barr, Eva
- Ryan, Cormac G
- Sjögren, Tuulikki
- Smeets, Rob
- Staal, J Bart
- Wajswelner, Henry
- Yeung, Ella W
- Venue
- British Journal of Sports Medicine
- Publisher
- BMJ
- Published
- 2019-11-28
- Volume
- 54
- Issue
- 21
- Pages
- 1277-1278
- ISSN
- 0306-3674 (ISSN-L)
- 1473-0480
- OpenAlex
- W2991244705
- Cited by
- 146
- References
- 70
- Citations by year
- 2026: 11 · 2025: 20 · 2024: 28 · 2023: 16 · 2022: 46 · 2021: 16 · 2020: 8 · 2019: 1
- FWCI
- 2.27
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- British Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- Teesside University Research Portal (Teesside University) (publishedVersion, cc-by-nc-nd)
- University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion, cc-by-nc)
- Jyväskylä University Digital Archive (University of Jyväskylä) (submittedVersion, cc-by-nc)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Keele Research Repository (Keele University) (submittedVersion, cc-by)
- eScholarship (California Digital Library) (submittedVersion)
- Florence Research (University of Florence) (submittedVersion)
- TeesRep (Teesside University) (submittedVersion, cc-by-nc-nd)
- NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
- HighWire Press Open Archive (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- VU Research Portal (submittedVersion, other-oa)
- Archivio Istituzionale della Ricerca - Università degli Studi dell Aquila (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Funders
- Nova Scotia Health Research Foundation (PSO2011-7506)
- Topics
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy-related medical research
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Spine and Intervertebral Disc Pathology
- Keywords
- chronic low back pain, exercise therapy, treatment effect modifiers, non-specific low back pain, analgesia, functional limitations, medication use, body mass index, subgroup analysis, individual patient data
- MeSH terms
- Exercise Therapy, Humans, Body Mass Index, Randomized Controlled Trials as Topic, Low Back Pain
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