Exercise is the most widely recommended intervention for persistent non-specific low back pain (NSLBP). Despite efforts to improve the reporting of exercise interventions, the treatment targets of exercise interventions remain poorly described. The aim of this study was to assess whether trial authors identified treatment target(s) for the exercise intervention included in their randomised controlled trial (RCT) in an ongoing update of a Cochrane review of exercise interventions for persistent NSLBP. A further objective was to categorise these extracted treatment targets according to previously described mechanisms of action of exercise interventions.
The ongoing updated Cochrane database of exercise RCTs for persistent NSLBP was used. Two independent reviewers extracted whether treatment targets were specified, inferred or not present. These were categorised according to previously described mechanisms of exercise interventions: mechanical, neurological, cognitive, functional, pain and health-related quality of life. A third reviewer was available for mediation where there was disagreement.
Results: The analysis includes 265 RCTs. Of the 403 exercise arms included, 41% did not state any treatment targets, 36% clearly specified a treatment target and 23% inferred targets in the background or rationale. The most frequently reported treatment targets were: improving strength (n=83; 35%) and improving flexibility (n=58; 24%).
Conclusion(s): The majority of RCTs included in the ongoing Cochrane review of exercise interventions for persistent NSLBP did not identify any treatment targets for their exercise interventions. Of those that did, mechanical targets were predominantly used. Clear specification of the treatment targets of exercise interventions are required in both the delivery and design of exercise interventions in trials for persistent NSLBP.
Cost and savings
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This work highlights the absence of identified treatment targets in exercise RCTs for persistent NSLBP. This absence may reflect a poor understanding of what the most appropriate treatment targets for persistent NSLBP are, to ensure a favourable outcome in the core domains of pain, physical function and health-related quality of life. Further work is required to agree on the possible treatment targets of exercise to ensure consistent measuring and reporting, which is likely to benefit patients. Further work is also required to understand the potential mechanisms of action of exercise so that specified treatment targets are better aligned with current understanding of the proposed mechanisms.
Top three learning points
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This work was a result of the funding L Wood received as part of a Travel Fellowship from the Society of Back Pain Research. Prof. Hayden reports a grant from Nova Scotia Health Research Foundation (now Research Nova Scotia) (2011), which partially funded the ongoing Cochrane review update providing data for this study. Ms. Ogilvie reports grants from Nova Scotia Health Research Foundation (2011), received by her institution, during the conduct of the study.