The treatment effect of exercise programmes for chronic low back pain

Rationale This paper summarizes evidence of long-term effectiveness of physiotherapy exercise therapy for chronic low back pain (LBP). Methods A literature search was undertaken for experimental studies (2001–2007), which reported any post-intervention (follow-up) outcomes. Studies were critically appraised using the PEDro instrument. Comparative statistics were calculated, relative to the type of follow-up outcome data. Results Fifteen moderate quality trials were included [mean PEDro score 7.7, SD 1.3 (range 5–10)]. Nine trials reported pain scales, and six reported LBP reoccurrence. Trials which reported on pain scales at 6-month follow-up found significant differences in favour of exercise [standardized mean differences -0.57, 95%CI -0.75 to -0.39 (555 participants)]. At 12-month follow-up, a small pain scale benefit from exercise persisted [standardized mean differences -0.25, 95%CI -0.44 to 0.06 (434 participants)]. There was unconvincing evidence of exercise effectiveness on pain scales after this time. Three of the four trials which reported dichotomous outcomes at 6-month follow-up demonstrated large clinical benefits of exercise (relative risk reduction of reoccurrence 45–246%, absolute risk reduction of reoccurrence 36–42 for every 100 patients; and number needed to treat approximating 3, to prevent one patient suffering a LBP recurrence). The effect of exercise on LBP reoccurrence was variably reported beyond 6 months. Conclusion Exercise programmes are effective for chronic LBP up to 6 months after treatment cessation, evidenced by pain score reduction and reoccurrence rates. The way in which follow-up data are reported assists clinical interpretation of research findings.

Pulmonary rehabilitation: overwhelming evidence but lost in translation?

Purpose: This report highlights the current international gap between the availability of high-quality evidence for pulmonary rehabilitation (PR) and its low level of implementation. Key barriers are outlined, and potentially effective strategies to improve implementation are presented. Summary of key points: Although pulmonary rehabilitation (PR) is recommended by international guidelines as part of the management of patients with chronic obstructive pulmonary disease (COPD), participation in PR remains low. Physician referral to PR ranges from 3% to 16% of suitable patients. Barriers to participation include limited availability of suitable programmes and interrelated issues of referral and access. Individual patient barriers, including factors relating to comorbidities and exacerbations, perceptions of benefit, and ease of access, contribute less overall to low participation rates. Chronic care programmes that incorporate self-management support have some benefit in patients with COPD. However, the demonstrated costeffectiveness of PR is substantial, and efforts to improve its implementation are urgently indicated. Conclusion: To improve implementation, a holistic examination of the key issues influencing a patient’s participation in PR is needed. Such an examination should consider the relative influences of environmental (e.g., health-service-related) factors, organizational factors (e.g., referral and intake procedures), and individual factors (e.g., patient barriers) for all participants. On the basis of these findings, policy, funding, service delivery, and other interventions to improve participation in PR can be developed and evaluated.