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Cited by 10Musculoskeletal pain and rehabilitationPregnancy-related medical researchSpine and Intervertebral Disc Pathology

Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis

Open access
Hernandez-Lucas, Pablo, Leirós-Rodríguez, Raquel, Lopez-Barreiro, Juan, García-Soidán, José L.·2024·Journal of Back and Musculoskeletal Rehabilitation
DOI 10.3233/bmr-230252
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Abstract

BACKGROUND: Clinical practice guidelines stress the importance of prevention and treatment of non-specific back pain through exercise therapy. However, it has not yet been confirmed whether the combination of exercise plus education is more effective than such interventions taken separately. OBJECTIVE: To determine if the combination of exercise plus education is more effective for the prevention of non-specific back pain than exercise or education alone. METHOD: A systematic search of studies whose sample consisted of participants without non-specific back pain (primary prevention) and participants with non-specific back pain (secondary and tertiary prevention) was conducted in the following databases in March 2023: PubMed, Scopus, Web of Science and Medline. RESULTS: A total of 16 articles were selected. Statistically significant results were found in the pain variable with SMD = -2.02 (95% CI = -2.71 to -1.33; p < 0.001), the disability variable with SMD = -1.14 (95% CI = -1.63 to -0.65; p < 0.001), and the kinesiophobia variable with SMD = -1.8 (95% CI = -2.54 to -1.05; p < 0.001). CONCLUSION: Interventions that combine exercise and education seem to have a greater preventive effect on non-specific back pain, disability and kinesiophobia than those that include exercise or education in an isolated manner © 2024 - IOS Press. All rights reserved.

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Crossref · 10.3233/bmr-230252

Cites

58 of 59 references verified0 citation errors · 1 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

33 of 73 cited sources checked · 5 supported · 1 flagged · accuracy not yet measured

  • Premisecitation

    The benefits do not appear to be maintained in the long term.

    “However, these effects do not seem to be maintained in the long term [32,42].”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [32] Cherkin, 2016, Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial, JAMA source

      The Discussion reports that both MBSR and CBT improved back pain and functional limitations relative to usual care at 26 and 52 weeks, and describes MBSR's effectiveness as increasing over that period. The Results say MBSR's significant differences from usual care persisted at 52 weeks. Although CBT was not superior to usual care on the binary primary outcomes at 52 weeks, the paper does not support the general claim that the benefits were not maintained. (LLM, conf=0.91)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [42] Turner, 2016, Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain: similar effects on mindfulness, catastrophizing, self-efficacy, and acceptance in a randomized controlled trial, Pain source

      The Discussion (page not available in our copy) says neither treatment had a long-term effect on mindfulness relative to usual care. But it also reports that both treatments reduced catastrophizing relative to usual care at 52 weeks, so the broader claim that the benefits were not maintained is not supported. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    Prior reviews have confirmed that exercise prevents non-specific back pain in the lumbar and cervical regions.

    “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].”
    Quote in the paperNot a substantial claim4 of 8 sources checked
    • cites [11] Domingues de Freitas, 2020, Effects of the pilates method on kinesiophobia associated with chronic non-specific low back pain: Systematic review and meta-analysis, J Bodyw Mov Ther source
    • cites [12] Frizziero, 2021, Efficacy of Core Stability in Non-Specific Chronic Low Back Pain, J Funct Morphol Kinesiol source

      The Discussion (page not provided) reports that core-stability exercise improves pain and disability in people who already have chronic low back pain. That supports an exercise benefit in the lumbar region, but not the claim that exercise prevents non-specific back pain. This source does not address cervical pain; the citing sentence places separate citations after that part of the claim. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [13] Hayden, 2020, Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials, Br J Sports Med source

      The Introduction reports that exercise therapy decreases pain and improves function in adults with persistent low back pain, and the Pain and functional limitation outcomes section reports benefits over usual care or no treatment. These are treatment findings, not evidence that exercise prevents low back pain. The cervical-region claim has separate citations in the citing sentence and is not attributed to this paper. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [14] source

      The Background (page unavailable) defines this review as assessing exercise treatment in adults who already have chronic non-specific low back pain. The authors’ conclusions (page unavailable) report a probable benefit for pain, supporting the lumbar exercise-benefit portion of the claim, but not prevention of back pain. The cervical portion has separate citations in the citing sentence and is not attributed to this source. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [15] Arimi, 2017, The effect of different exercise programs on size and function of deep cervical flexor muscles in patients with chronic nonspecific neck pain: a systematic review of randomized controlled trials, Am J Phys Med Rehabil source
    • cites [17] source

      The Authors’ Conclusions (Implications for practice; page not provided) report that specific strengthening exercises may reduce pain in people with chronic mechanical neck pain. That supports a benefit in the cervical region, but the review addresses treatment, not prevention of non-specific neck pain. It does not establish the claim about lumbar pain. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [19] O’Riordan, 2014, Chronic Neck Pain and Exercise Interventions: Frequency, Intensity, Time, and Type Principle, Arch Phys Med Rehabil source
    • cites [20] Sihawong, 2011, Exercise Therapy for Office Workers With Nonspecific Neck Pain: A Systematic Review, J Manipulative Physiol Ther source
  • Premisecitation

    Several systematic reviews have examined exercise benefits for low back pain prevention in terms of pain reduction, disability, quality of life, and kinesiophobia.

    “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].”
    Quote in the paperNot a substantial claim3 of 4 sources checked
    • cites [11] Domingues de Freitas, 2020, Effects of the pilates method on kinesiophobia associated with chronic non-specific low back pain: Systematic review and meta-analysis, J Bodyw Mov Ther source
    • cites [12] Frizziero, 2021, Efficacy of Core Stability in Non-Specific Chronic Low Back Pain, J Funct Morphol Kinesiol source

      The Conclusions report that core stability exercises may reduce pain and disability and improve quality of life in people with non-specific chronic low back pain. The Materials and Methods include systematic reviews among the eligible studies. The paper addresses treatment of existing chronic pain, however, not prevention of low back pain, and the cited passages do not support a benefit for kinesiophobia. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [13] Hayden, 2020, Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials, Br J Sports Med source

      The Introduction (page unavailable) describes a Cochrane review and says exercise therapy decreases pain and improves function in adults with persistent low back pain; the References also list other exercise-therapy reviews. The paper addresses treatment of existing pain, not prevention, and the cited review findings do not cover quality of life or kinesiophobia. (LLM, conf=0.89)

      Experimental — accuracy not yet measured
    • cites [14] source

      The Background and Discussion describe this and other systematic reviews of exercise treatment for low back pain, and the review assesses pain and functional limitations in adults with chronic low back pain. It does not assess prevention of low back pain; its stated outcomes are pain and functional limitations, not quality of life or kinesiophobia. The copy mentions kinesiophobia in titles of listed trials, but that does not establish it as an outcome examined by this review. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Findingcitation

    In the meta-analysis, the combination of exercise therapy and health education produced a strong effect on pain compared with exercise therapy alone or health education alone.

    “The combination of exercise therapy and health education has a strong effect on the pain variable compared to exercise therapy alone or health education alone [31,32,33,34,35,36,37,38,39,40,43].”
    Quote in the paperSubstantial claim5 of 10 sources checked
    • cites [31] Bodes Pardo, 2018, pain neurophysiology education and therapeutic exercise for patients with chronic low back pain: A single-blind randomized controlled trial, Arch Phys Med Rehabil source
    • cites [32] Cherkin, 2016, Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial, JAMA source

      The Methods (Interventions) describe a randomized trial comparing mindfulness-based stress reduction, cognitive behavioral therapy, and usual care. The Discussion reports pain outcomes for those groups, but neither section addresses exercise therapy combined with health education versus either intervention alone. Searches for that comparison and for a corresponding meta-analysis found no supporting passage in our copy. (LLM, conf=0.78)

      Experimental — accuracy not yet measured
    • cites [33] Garcia, 2018, McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up, Br J Sports Med source
    • cites [34] Jaromi, 2018, Back School programme for nurses has reduced low back pain levels: A randomised controlled trial, J Clin Nurs source
    • cites [35] Javdaneh, 2020, Scapular exercise combined with cognitive functional therapy is more effective at reducing chronic neck pain and kinesiophobia than scapular exercise alone: a randomized controlled trial, Clin Rehabil source
    • cites [36] Javdaneh, 2021, Pain neuroscience education combined with therapeutic exercises provides added benefit in the treatment of chronic neck pain, Int J Environ Res Public Health source

      The Study Design section (page unavailable) identifies this paper as a three-arm randomized trial, not a meta-analysis; its groups were combined treatment, exercise alone, and a control group, with no education-only group. The Results section (page unavailable) reports better pain-and-disability scores with the combined treatment than with exercise alone in patients with chronic neck pain, but it does not establish the claimed strong effect on pain versus education alone. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [37] Llamas-Ramos, 2023, Effects of a family caregiver care programme in musculoskeletal pain and disability in the shoulder-neck region – A randomised clinical trial, Int J Environ Res Public Health source

      The Methods (section 2.4; page unavailable) describe a randomised trial in which both groups received a family caregiver care programme, while only the intervention group also received exercise. The Results (section 3.2; page unavailable) report a large effect favouring the combined programme on pain. This was not a meta-analysis, and the trial had no exercise-only group, so it cannot support that comparison. (LLM, conf=0.89)

      Experimental — accuracy not yet measured
    • cites [38] Tunwattanapong, 2016, The effectiveness of a neck and shoulder stretching exercise program among office workers with neck pain: a randomized controlled trial, Clin Rehabil source
    • cites [39] Gorji, 2022, Pain neuroscience education and motor control exercises versus core stability exercises on pain, disability, and balance in women with chronic low back pain, Int J Environ Res Public Health source

      The Abstract and Results report that pain fell more with pain neuroscience education plus motor control exercises than with core stability exercises alone in women with chronic low back pain. The Methods (§2.2) describe a two-group study, not a meta-analysis, and the study did not compare the combination with education alone. It therefore supports only the exercise-only comparison in this specific setting. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [40] Montero-Cuadrado, 2022, Musculoskeletal pain in family caregivers: Does a therapeutic physical program in primary care work? A randomized controlled trial, Int J Environ Res Public Health source

      Methods §2.5 describes a randomized trial in which both groups received caregiver training, but only the intervention group received therapeutic exercise. Results §3.1.1 reports a large reduction in pain relative to the control group. The paper is not a meta-analysis and does not compare the combination with exercise therapy alone. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
  • Findingown data

    In the meta-analysis, the combined intervention showed a strong effect on disability.

    “The disability variable also showed a strong effect in the meta-analysis [28,29,30,31,32,33,36,37,39,40,41,43].”
    Quote in the paperSubstantial claim5 of 10 sources checked
    • cites [28] Aliyu, 2018, Effects of a combined lumbar stabilization exercise and cognitive behavioral therapy on selected variables of individuals with non-specific low back pain: A randomized clinical trial, Fisioterapia source
    • cites [29] Andersen, 2016, Longer term follow-up on effects of Tailored Physical Activity or Chronic Pain Self-Management Programme on return-to-work: A randomized controlled trial, J Rehabil Med source
    • cites [30] Bagheri, 2020, Cognitive behavioral therapy with stabilization exercises affects transverse abdominis muscle thickness in patients with chronic low back pain: A double-blinded randomized trial study, J Manipulative Physiol Ther source
    • cites [31] Bodes Pardo, 2018, pain neurophysiology education and therapeutic exercise for patients with chronic low back pain: A single-blind randomized controlled trial, Arch Phys Med Rehabil source
    • cites [32] Cherkin, 2016, Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial, JAMA source

      The Results (Co-Primary Outcomes; page unavailable) report significantly greater improvement in disability-related functional limitations with mindfulness-based stress reduction than with usual care. However, this paper reports a randomized trial, not the cited meta-analysis’s pooled effect; its Discussion (page unavailable) describes the treatment effects as moderate, not strong. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [33] Garcia, 2018, McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up, Br J Sports Med source
    • cites [36] Javdaneh, 2021, Pain neuroscience education combined with therapeutic exercises provides added benefit in the treatment of chronic neck pain, Int J Environ Res Public Health source

      The Results report that the combined intervention improved pain and disability more than exercise alone (p < 0.001). But the Study Design identifies this paper as a randomized trial, not a meta-analysis; it does not establish the strength of a pooled effect on disability. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [37] Llamas-Ramos, 2023, Effects of a family caregiver care programme in musculoskeletal pain and disability in the shoulder-neck region – A randomised clinical trial, Int J Environ Res Public Health source
    • cites [39] Gorji, 2022, Pain neuroscience education and motor control exercises versus core stability exercises on pain, disability, and balance in women with chronic low back pain, Int J Environ Res Public Health source
    • cites [40] Montero-Cuadrado, 2022, Musculoskeletal pain in family caregivers: Does a therapeutic physical program in primary care work? A randomized controlled trial, Int J Environ Res Public Health source

      The Results (§3.1.1; page unavailable) report large intervention effects on lower-back and cervical disability in this randomized trial. The paper does not report a pooled meta-analytic effect, so it supports the disability finding at the trial level, not the claim about the meta-analysis as a whole. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 27
  • May combine two claims. 24

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

    Premisecitation

    A 2019 meta-analysis concluded that exercise is more cost-effective than usual medical care for subacute and chronic low back pain.

    “A meta-analysis published in 2019 concluded that exercise is more cost-effective compared to usual medical care for subacute and chronic low back pain [10].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [10] Miyamoto, 2019, Cost-effectiveness of exercise therapy in the treatment of non-specific neck pain and low back pain: a systematic review with meta-analysis, Br J Sports Med source

      The Abstract says exercise therapy may be cost-effective compared with usual care for subacute and chronic low back pain, but calls the cost-utility estimates uncertain. The ‘Subacute and chronic low back pain’ section reports mixed cost-utility results, including one finding that exercise was not cost-effective. The citing sentence overstates this qualified conclusion as a definitive one. Page numbers are unavailable in our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    Clinical practice guidelines emphasize preventing and treating non-specific back pain with exercise therapy and health education.

    “Clinical practice guidelines stress the importance of NBP prevention and treatment through exercise therapy (i.e., yoga, stretching, Pilates and strength training) and health education (i.e., selfmanagement techniques, pacing strategies, back protection techniques and pain neuroscience education) [3,7,8,9].”
    Quote in the paperSubstantial claim2 of 4 sources checked
    • cites [3] Dagenais, 2008, A systematic review of low back pain cost of illness studies in the United States and internationally, Spine J source
    • cites [7] Corp, 2021, Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines, Eur J Pain source

      The Results section (Consistency of CPG recommendations for low back pain; page unavailable) reports guideline support for exercise interventions and patient advice and education. It does not establish prevention as a guideline goal or recommend the specific exercise and education techniques listed in the citing sentence; the Discussion notes that guidelines often lacked detail on exercise delivery and education components. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [8] George, 2021, Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association, J Orthop Sports Phys Ther source

      The 2021 Recommendations under Patient Education endorse active education for acute low back pain and active treatments such as yoga, stretching, Pilates, and strength training for chronic low back pain. They recommend pain neuroscience education alongside other interventions for chronic low back pain, not education as a stand-alone treatment. The cited guideline addresses management of patients with low back pain; these passages do not establish the broader claim about preventing non-specific back pain. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [9] Hurwitz, 2018, The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies, Eur Spine J source

  • May combine two claims.

    Premisecitation

    Education yields short-term improvements in non-specific back pain and disability, but as a sole treatment its effects are small and may be insufficient.

    “Furthermore, in terms of education, it provides short-term improvements in pain and disability related to NBP, but, as a sole treatment for patients with spinal pain, the effects are small and may be insufficient [21].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [21] Jones, 2021, Advice and education provide small short-term improvements in pain and disability in people with non-specific spinal pain: a systematic review, J Physiother source

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

    Premisecitation

    The biopsychosocial model is currently the most recommended paradigm for treating and preventing non-specific back pain.

    “Currently, the biopsychosocial model is the most recommended paradigm for the treatment and prevention of NBP [54].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [54] Knezevic, 2021, Low back pain, The Lancet source

      The Conclusions (page not specified) describe widespread acceptance of the biopsychosocial model, and the Abstract says it should be considered in interdisciplinary treatment plans. The Prevention section discusses psychosocial risk factors and multidimensional interventions, but the paper does not call the model the *most recommended* paradigm for treating and preventing non-specific back pain. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

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

    Premisecitation

    Pain is not only a physical sensation but also an emotional experience influenced by emotions such as anxiety or fear.

    “The International Association for the Study of Pain also establishes a relationship between fear-painknowledge, as they state that pain not only represents the sensation of physical harm, but also an emotional experience that can be influenced by other emotions, such as anxiety or fear of the unknown [53].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [53] Raja, 2020, The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises, Pain source

      The section on the initial recommendation to the IASP Council (page unavailable) defines pain as a sensory and emotional experience and says psychological factors can influence it. That supports the central point, but the cited passages do not specifically identify anxiety, fear, or fear of the unknown as influences on pain. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

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

    Premisecitation

    The latest non-specific back pain clinical intervention guideline (2021) recommends exercise and education as key elements.

    “Therefore, the latest NBP clinical intervention guideline published in 2021 recommends exercise and education as key elements in NBP clinical interventions [7].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [7] Corp, 2021, Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines, Eur J Pain source

      The Results section on low back pain reports that the reviewed guidelines support advice and education, including exercise advice, and exercise interventions. But the cited 2021 paper is a systematic review of European guidelines, not itself the latest clinical intervention guideline; its Conclusion says it identified seventeen guidelines. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

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

    Premisecitation

    Prior studies have identified perceived improvements from exercise in the lumbar and cervical regions.

    “Accordingly, Frizziero et al. also identified perceived improvements through exercise in the lumbar region and [19] observed them in the cervical region.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [12] Frizziero, 2021, Efficacy of Core Stability in Non-Specific Chronic Low Back Pain, J Funct Morphol Kinesiol source
    • cites [19] O’Riordan, 2014, Chronic Neck Pain and Exercise Interventions: Frequency, Intensity, Time, and Type Principle, Arch Phys Med Rehabil source

  • May combine two claims.

    Findingown data

    In regional subgroup analyses, both lumbar and cervical regions showed statistically significant improvements in disability, with SMD -1.18 (95% CI -1.70 to -0.65; p<0.001; I2=93.05%).

    “disability (SMD = -1.18(95% CI = -1.70 to -0.65; p < 0.001; I 2 = 93.05%)),”
    Quote in the paperSubstantial claim

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

    Findingown data

    The mean age was 49 years, and 74.9% of participants were women.

    “The average age was 49 years and 74.9% of the participants were women (Table 3).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Fourteen studies analyzed the pain variable.

    “Out of the analyzed studies, 14 of them [28,29,31,32,33,34,35,36,37,38,39,40,41,43] analyzed the pain variable.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    On the Jadad scale, 11 articles scored at least four points, four scored three points, and one scored two points.

    “In the analysis of methodological quality using the Jadad scale, 11 articles obtained four or more points [28,29,30,31,32,33,34,35,36,37,38], four articles obtained three points [39,40,41,42], and only one obtained two points [43].”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Two articles analyzed back pain in all regions, ten in the lumbar region, four in the cervical region, and none in the thoracic region.

    “Two articles [29,40] analyzed back pain in all regions, ten studies analyzed [28,30,31,32,33,34,39,41,42,43] it specifically in the lumbar region, four papers [35,36,37,38] analyzed it specifically in the cervical region and none of them analyzed it specifically in the thoracic region.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Overall risk of bias was low in eight articles, some concerns in four, and high in four.

    “The overall risk of bias was low in eight articles [29,31,33,35,36,37,40,41], in four articles was some concerns [30,34,38,39] and in four articles was high [28,32,42,43] (Fig. 2).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Eight articles analyzed the kinesiophobia variable.

    “Out of the analyzed studies, eight articles [28,29,30,31,33,35,36,41] analyzed the kinesiophobia variable.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Twelve articles analyzed the disability variable.

    “Out of the analyzed studies, 12 articles [28,29,30,31,32,33,36,37,39,40,41,43] analyzed the disability variable.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    GRADE assessment indicated moderate certainty, meaning further research could importantly affect confidence in the effect estimate and may change it.

    “The degree of certainty assessed by the GRADE system shows a moderate degree of certainty which means that additional research is likely to have an important impact on our confidence in the estimate of the effect and may change the estimate [45] (Table 2).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    All 16 full-text articles assessed for eligibility were included in the synthesis.

    “Out of the 16 full-text articles assessed for eligibility, all of them were finally included in the synthesis (Fig. 1).”
    Quote in the paperNot a substantial claim

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

    Findingcitation

    Adverse effects occurred in only one case and were minor.

    “Participants only experienced adverse effects in one case and these were minor adverse events [32].”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In regional subgroup analyses, both lumbar and cervical regions showed statistically significant improvements in pain, with SMD -2.14 (95% CI -2.99 to -1.28; p<0.001; I2=96.75%).

    “Statistically significant improvements were found in both regions in the variables pain (SMD = -2.14(95% CI = -2.99 to -1.28; p < 0.001; I 2 = 96.75%)),”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    All studies scored at least five on the PEDro scale, and the mean and nine items scored at least seven.

    “At the same time, all studies were five or more points on the PEDro scale and the mean and nine items have seven or more points in the scala PEDro [29,30,32,33,34,35,36,37,38].”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    No included study examined effects in participants without non-specific back pain, so primary prevention results were not included.

    “No studies were found that examined effects in participants without NBP; therefore, results relating to primary prevention were not included.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    The mean PEDro score across articles was 6.9, indicating good methodological quality.

    “The average score of all articles on the PEDro scale was 6.9 points, which is considered a good methodological quality [44] (Table 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    No articles analyzed dorsal back pain, and only six articles analyzed neck pain.

    “There are also no articles that analyze dorsal back pain and only six articles analyze neck pain.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Study design and conductnone given

    Because heterogeneity was observed, the meta-analysis used a random-effects model.

    “Due to the observed heterogeneity, the meta-analysis was performed using the random-effects model.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The review was prospectively registered on PROSPERO under CRD42021290875.

    “This study was prospectively registered on PROS-PERO (code: CRD42021290875)”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation

    The review followed PRISMA, PERSIST, and Cochrane Collaboration recommendations.

    “followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [22] reporting guidelines for Exercise, Rehabilitation, Sport Medicine and Sports (PERSIST) [23], and the recommendations from the Cochrane Collaboration [24].”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Inter-rater agreement between reviewers 1 and 2 was a Kappa score of 0.85, almost perfect.

    “After the first reading of all the prospective full texts, the Kappa score for reviewers 1 and 2 was 0.85, which was almost perfect [27].”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Two reviewers independently screened articles for eligibility after duplicate removal, with a third reviewer resolving disagreements.

    “After removing duplicates, two reviewers independently screened articles for eligibility.In case of disagreement, a third reviewer made the final decision as to whether the study should be included or not.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Two reviewers independently extracted data using a customized Excel table, resolving disagreements through discussion.

    “The two reviewers mentioned independently extracted data from the included studies using a customized data extraction table on Microsoft Excel.In case of disagreement, both reviewers debated the issue until an agreement was reached.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Jadad and PEDro scales assessed study quality, RoB2 assessed risk of bias, and GRADE assessed overall certainty.

    “The Jadad and PEDro scales were used to assess the quality of these studies.The risk of bias was assessed using the Cochrane Collaboration Toolkit RoB2.Finally, the GRADE system was used to evaluate the overall assessment of certainty.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Two reviewers applied the Jadad, PEDro, RoB2 and GRADE scales, with a third author resolving disagreements.

    “Two reviewers (P.H-L; J.L-B) applied the Jadad, Pedro, RoB2 and GRADE scales.In case of disagreement, a third author (R-L-R) also participated in the process to reach an agreement.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Social factors such as false beliefs about non-specific back pain or work-related factors are risk factors for non-specific back pain.

    “or we can even mention social factors, such as false beliefs about NBP or work-related factors [49,50]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [49] Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Prim Care. 12.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [50] Shiri, 2019, Risk factors for low back pain: A population-based longitudinal study, Arthritis Care Res source

  • May combine two claims.

    Study design and conductown data

    Due to high heterogeneity among the analyzed studies, it was not possible to determine which exercise and education interventions are most effective or the most appropriate frequency and duration of sessions.

    “However, it is worth mentioning that, due to the high heterogeneity in the analyzed studies, it has not been possible to establish which exercise and education interventions are the most effective, as well as the most appropriate frequency and duration of sessions.”
    Quote in the paperSubstantial claim

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

    Study design and conductreasoning

    The review included various exercise and health education programmes, which might reduce the specificity of the results.

    “Different types of exercise and health education programmes have been included in this review which could affect the specificity of the results.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Disability is strongly related to pain.

    “This finding is congruent because disability is strongly related to pain [51].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [51] Arnstein, 1999, Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients, Pain source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The certainty of the evidence was assessed using GRADE.

    “Table 2 Certainty of the evidence (GRADE)”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Some authors conclude that the type of exercise does not matter, as long as exercise is performed.

    “Although, different authors conclude that the important aspect is to exercise regardless of the type of exercise [55,56]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [55] Van Middelkoop, 2010, Exercise therapy for chronic nonspecific low-back pain, Best Pract Res Clin Rheumatol source
    • cites [56] Hayden, 2005, Meta-analysis: exercise therapy for nonspecific low back pain, Ann Intern Med source

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

    Study design and conductown data

    The risk of bias of included studies was assessed using the PEDro scale.

    “Table 1 Risk of bias assessment using the physiotherapy evidence database (PEDro) scale”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    The review did not perform analyses differentiated by gender and age subgroups, nor did it include studies comparing the combination with usual medical care or passive physiotherapy.

    “Among the limitations of the present research, the authors must acknowledge that they have not taken into account analyses differentiated by gender and age subgroups, nor have they included studies comparing the combination of exercise and education with the usual medical care or with passive physiotherapy interventions.”
    Quote in the paperNot a substantial claim
39 of 39

  • The paper relies on this without support.

    No recent systematic reviews have compared whether combined exercise plus education is more effective for preventing non-specific back pain than exercise or education alone.

    “However, there are no recent systematic reviews comparing whether the combination of exercise plus education is more effective for the prevention of NBP than such interventions taken separately.”

  • The paper relies on this without support.

    The positive effect of education on non-specific back pain prevention remains unclear.

    “However, the positive effect of education on NBP prevention remains unclear.”

  • The paper relies on this without support.

    No previous meta-analysis has compared the combination of exercise therapy and health education with either exercise therapy alone or health education alone for preventing non-specific back pain.

    “It should be noted that this is the first meta-analysis analyzing the effects of the combination of exercise therapy and health education compared to exercise therapy alone or health education alone for the prevention of NBP.”
3 of 3

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Kinesiophobia confidence interval has opposite signs in two sections

    Minor

    The GRADE table gives a positive lower confidence limit of 2.537 for a negative effect estimate, while the abstract reports the corresponding limit as negative. The positive value also places the reported effect estimate outside its own interval.

  • Kinesiophobia subgroup estimate is not centered in its confidence interval

    Minor

    The reported estimate of -1.99 differs from the midpoint of its stated 95% confidence interval, -2.22. The other reported SMD intervals are centered on their estimates to rounding precision.

    Reported -1.99 · recomputed -2.22

  • Screening counts leave 322 papers unaccounted for

    Minor

    Subtracting the 1,744 papers excluded at title and abstract screening from the 2,082 screened leaves 338, not the 16 reported as assessed for full-text eligibility. The text does not account for the other 322 papers.

    Reported 16 · recomputed 338

  • GRADE table reverses the sign of a kinesiophobia confidence limit

    Minor

    The GRADE table prints the first confidence limit as positive 2.537, while the results give the corresponding limit as negative 2.54. The positive limit also conflicts with the table's negative effect estimate.

4 of 4

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Baumann, 2020, Prevention: Primary, secondary, tertiary. In: Encyclopedia of behavioral medicine, Springer, 1738

Cited by

Sorted by citations

Related

Authors
Hernandez-Lucas, P., Leirós-Rodríguez, R., Lopez-Barreiro, J., & García-Soidán, J. L.
Affiliations
  • Department of Functional Biology and Health Sciences, Faculty of Physiotherapy, University of Vigo, Pontevedra, Spain
  • SALBIS Research Group, Nursing and Physical Therapy Department, University of León, Ponferrada, Spain
  • Universidade de Vigo (ES)
  • Faculty of Education and Sport Sciences, University of Vigo, Pontevedra, Spain
ORCID
Venue
Journal of Back and Musculoskeletal Rehabilitation
Publisher
SAGE Publications
Published
2024-05-10
Volume
37
Issue
3
Pages
585-598
ISSN
  • 1053-8127 (ISSN-L)
  • 1878-6324
DOI
10.3233/bmr-230252
OpenAlex
W4390733581
Cited by
10
References
56
Citations by year
2026: 5 · 2025: 4 · 2024: 1
FWCI
0.62
Type
journal article
Language
en
Open access
Locations
  • Journal of Back and Musculoskeletal Rehabilitation (publishedVersion)
  • PubMed (publishedVersion)
  • Buleria (Universidad de León) (submittedVersion, cc-by-nc-nd)
  • Investigo Institutional repository of UVigo (Universidade de Vigo) (submittedVersion)
Topics
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Pregnancy-related medical research
  • Health Sciences › Medicine › Pathology and Forensic Medicine › Spine and Intervertebral Disc Pathology
Keywords
non-specific low back pain, back pain prevention, exercise therapy, patient education, kinesiophobia, disability, pain intensity, primary prevention, secondary prevention, tertiary prevention
MeSH terms
Back Pain, Exercise Therapy, Humans, Patient Education as Topic

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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