Goertz Et Al 2013 213 Active Duty Military Acute Low Back Pain

Summary of Recommendations

Exercise for Acute Low Back Pain

Physical therapists can use exercise training interventions, including specific trunk muscle activation, for patients with acute low back pain (LBP).

Exercise for Acute Low Back Pain With Leg Pain

Physical therapists may use exercise training interventions, including trunk muscle strengthening and endurance and specific trunk muscle activation, to reduce pain and disability for patients with acute LBP with leg pain.

Exercise for Chronic Low Back Pain

Physical therapists should use exercise training interventions, including trunk muscle strengthening and endurance, multimodal exercise interventions, specific trunk muscle activation exercise, aerobic exercise, aquatic exercise, and general exercise, for patients with chronic LBP.

Physical therapists may provide movement control exercise or trunk mobility exercise for patients with chronic LBP.

Exercise for Chronic Low Back Pain With Leg Pain

Physical therapists may use exercise training interventions, including specific trunk muscle activation and movement control, for patients with chronic LBP with leg pain.

Exercise for Chronic Low Back Pain With Movement Control Impairment

Physical therapists should use specific trunk muscle activation and movement control exercise for patients with chronic LBP and movement control impairment.

Exercise for Chronic Low Back Pain in Older Adults

Physical therapists should use general exercise training to reduce pain and disability in older adults with chronic LBP.

Exercise for Postoperative Low Back Pain

Physical therapists can use general exercise training for patients with LBP following lumbar spine surgery.

Manual and Other Directed Therapies for Acute Low Back Pain

Physical therapists should use thrust or nonthrust joint mobilization to reduce pain and disability in patients with acute LBP.

Physical therapists may use massage or soft tissue mobilization for short-term pain relief in patients with acute LBP.

Manual and Other Directed Therapies for Chronic Low Back Pain

Physical therapists should use thrust or nonthrust joint mobilization to reduce pain and disability in patients with chronic LBP.

Physical therapists may use thrust or nonthrust joint mobilization to reduce pain and disability in patients with chronic LBP with leg pain.

Physical therapists may use soft tissue mobilization or massage in conjunction with other treatments to reduce pain and disability in the short term for patients with chronic LBP.

Physical therapists can consider the use of dry needling in conjunction with other treatments to reduce pain and disability in the short term for patients with chronic LBP.

Physical therapists may use neural mobilization in conjunction with other treatments for short-term improvements in pain and disability in patients with chronic LBP with leg pain.

Physical therapists should not use mechanical traction for patients with chronic LBP with leg pain, based on the lack of benefit when added to other interventions.

Classification Systems for Acute Low Back Pain

Physical therapists may use treatment-based classification (TBC) to reduce pain and disability in patients with acute LBP. This recommendation is unchanged from the 2012 clinical practice guideline.

Physical therapists can use Mechanical Diagnosis and Therapy (MDT) to reduce pain and disability in patients with acute LBP.

Classification Systems for Chronic Low Back Pain

Physical therapists may use MDT, prognostic risk stratification, or pathoanatomic-based classification to reduce pain and disability in patients with chronic LBP.

Physical therapists can use TBC, cognitive functional therapy, or movement system impairment to reduce pain and disability in patients with chronic LBP.

Education for Acute Low Back Pain

Physical therapists may use active education strategies rather than passive strategies (ie, providing access to educational materials only). Active education strategies include one-on-one education on the biopsychosocial contributors to pain and self-management techniques, such as remaining active, pacing strategies, and back-protection techniques. Physical therapists may also incorporate counseling on the favorable natural history of acute LBP as part of the education strategy.

Education for Chronic Low Back Pain

Physical therapists may use standard education strategies for patients with chronic LBP, but not as a stand-alone treatment. Standard education strategies include advice related to exercise and advice about staying active.

Physical therapists should deliver pain neuroscience education alongside other physical therapy interventions, such as exercise or manual therapy, to patients with chronic LBP.

Physical therapists should use active treatments (ie, yoga, stretching, Pilates, and strength training) instead of stand-alone educational interventions for patients with chronic LBP.

Education for Postoperative Low Back Pain

Physical therapists may use general education (ie, postsurgical precautions, exercise, and resuming physical activity) for patients with LBP following lumbar spine surgery. This recommendation applies to those undergoing discectomy or decompression surgery. No specific recommendation is provided for education for patients undergoing other surgical procedures (eg, spinal fusion) due to lack of evidence.

List of Abbreviations

AMSTAR	MeaSurement Tool to Assess Systematic Reviews
AOPT	Academy of Orthopaedic Physical Therapy
APTA	American Physical Therapy Association
CFT	cognitive functional therapy
CI	confidence interval
CPG	clinical practice guideline
ICD	International Classification of Diseases
ICF	International Classification of Functioning, Disability and Health
JOSPT	Journal of Orthopaedic & Sports Physical Therapy
LBP	low back pain
MDT	Mechanical Diagnosis and Therapy
MSI	movement system impairment
NPRS	numeric pain-rating scale
ODI	Oswestry Disability Index
PA	posterior to anterior
PEDro	Physiotherapy Evidence Database
PNE	pain neuroscience education
RCT	randomized clinical trial
RMDQ	Roland-Morris Disability Questionnaire
SMD	standardized mean difference
TBC	treatment-based classification
VAS	visual analog scale

Introduction

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability.¹³⁷ In the United States, LBP remains one of the most common reasons to seek health care and, along with neck pain, is the medical condition associated with the highest overall costs.⁴⁵ ^, ⁵⁰ Surgical cases are the costliest per care episode, but the majority of spending on LBP management can be attributed to the significantly larger volume of nonoperative care episodes.⁸⁹ Costs for LBP are escalating at a faster pace than overall health care spending and come with no evidence suggesting that there are improved outcomes (ie, reduced pain or disability) at a societal level.⁴⁵ In fact, a population-based study has suggested that rates of chronic LBP have been increasing during this period of escalating costs.⁵⁶

In 2018, a series of articles in the Lancet called attention to the high priority of improving the quality of care for operative and nonoperative LBP management.²⁹ ^, ⁵⁴ ^, ⁷² Reducing variability of care to better represent evidence-informed approaches is one way quality of care could improve for LBP. Clinical practice guidelines (CPGs) can serve as an important resource in the process of improving quality of care for LBP by synthesizing existing evidence and providing recommendations for evidence-informed treatment options. This information can then be used to assist individual providers with clinical decision making and to encourage health systems to develop clinical pathways that structure care delivery that is aligned with CPG recommendations.⁶⁴ The development of CPGs for LBP is important, but admittedly only the start of improving patient care. Delivering guideline-adherent treatment as part of routine clinical practice remains a continuing challenge for physical therapists.¹⁷² ^, ¹⁷³

Scope and Rationale

Rationale

This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), CPG for LBP.³⁸ The 2012 guidelines made recommendations for LBP that encompassed a broad scope, including risk factors, clinical course, diagnosis/classification, differential diagnosis, examination, and interventions. Several key considerations guided the 2021 update (see box below). Since 2012, many additional CPGs for LBP have been published, and the primary literature related to LBP has expanded exponentially. The proliferation of CPGs has resulted in convergent recommendations for topic areas included in the 2012 AOPT LBP CPG. For example, a 2020 review of 11 high-quality musculoskeletal pain CPGs (including 4 for LBP) identified consistent best-practice recommendations to (1) ensure care is patient centered, (2) screen for red flag conditions, (3) assess psychosocial factors, (4) use imaging selectively, (5) undertake a physical examination to assess impairments, (6) monitor patient progress, (7) provide education and evidence-based information as a treatment supplement, (8) incorporate physical activity/exercise, (9) use manual therapy only as an adjunct to other active treatments, (10) offer high-quality, nonsurgical care prior to surgery, and (11) try to keep patients at work.¹⁰⁰ An in-press review of 5 high-quality CPGs for LBP produced a synthesis of 13 very similar recommendations for screening, assessment, and treatment approaches.¹⁰¹ This consistency of recommendations for LBP across diagnosis, differential diagnosis, and examination was helpful in supporting the decision to de-emphasize these topic areas for the updated AOPT CPG for LBP. That is, a decision to focus the 2021 update on treatments was made because diagnosis, differential diagnosis, and examination recommendations are well covered in other guidelines.

Considerations for the 2021 CPG Update

Recommendations focused on interventions: while there are many other CPGs for LBP, none specifically addresses interventions commonly used by physical therapists
This CPG excluded studies in which interventions were not provided by physical therapists or in care settings that did not include physical therapists
Recommendations were made for specific subgroups (eg, acute or chronic, leg pain, and postoperative care) as allowed by the available literature
Recommendations were further differentiated with World Health Organization ICF terminology as study eligibility criteria allowed
This CPG includes interventions not considered in the 2012 CPG (eg, dry needling, cognitive functional therapy, and pain neuroscience education)
This CPG includes randomized trials published before July 1, 2020. Thus, these guidelines cannot account for any more recent individual studies, systematic reviews, or meta-analyses that could impact recommendations

Abbreviations: CPG, clinical practice guideline; ICF, International Classification of Functioning, Disability and Health; LBP, low back pain.

The importance of nonpharmacologic treatments is another development directly relevant to the 2021 update's focus on treatments. Since the 2012 CPG, recommendations have been made for nonpharmacologic interventions as first-choice treatments for chronic pain conditions and LBP, as opposed to commonly prescribed pharmacologic treatments like opioids.⁴⁷ ^, ¹³¹ However, these recommendations are made broadly, without providing guidance on differentiating the levels of evidence for specific nonpharmacologic treatments.⁴⁷ ^, ¹⁰⁰ ^, ¹³¹ Accordingly, this AOPT CPG update focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments.

Scope

Therefore, the overall objective of the 2021 LBP CPG update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. The health question covered by this CPG was to determine which interventions could be recommended for their potential in providing effective pain relief, functional improvement, and/or disability reduction (ie, the primary outcomes for this CPG). The interventions in the 2021 CPG were reviewed in 1 of the following categories: (1) exercise, (2) manual and other directed therapies, (3) classification systems, and (4) patient education. Our primary goal was to make this CPG update applicable to physical therapists practicing globally, and, as such, our literature search was not limited to studies originating in the United States. We acknowledge that there are likely to be differences in factors that influence care delivery for LBP that influence the applicability of these recommendations. For example, differences in health systems, cultural norms, and social determinants of health could all influence the application of these recommendations. Physical therapists are the intended primary audience, but other stakeholders (eg, patients, the public, other provider types, policy makers, and payers) may find application in the 2021 CPG update if there is interest in defining evidence-informed care for LBP.

Statement of Intent

The 2021 LBP CPG update is not intended to be construed or serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The parameters of practice described in this CPG should be considered as guidelines only. Adherence to them will not ensure a successful outcome in every patient, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made based on clinician experience and expertise in light of the clinical presentation of the patient, in addition to the available evidence, available diagnostic and treatment options, and the patient's values, expectations, and preferences. However, we suggest that the rationale for significant departures from accepted guidelines be documented in the patient's medical records at the time the relevant clinical decision is made.

Methods

Committee members for this CPG update were selected by the AOPT based on content expertise in LBP. The committee was charged with performing a systematic review and evaluation of the literature to produce an updated evidence synthesis for LBP interventions. Meta-analysis of the extracted literature was not performed because it was considered outside the scope of a CPG update. The scope of this update was to consider all relevant literature that has been published since the search for the 2012 CPG. A large body of LBP literature was anticipated, and the committee was subdivided into 4 focus groups, with each category led by a content expert. The 4 intervention categories for this CPG update included (1) exercise, (2) manual and other directed therapies, (3) classification systems, and (4) patient education.

Committee members were required to submit conflict-of-interest forms to the AOPT as a condition of authorship. Funding and support for CPG development were provided through the APTA (CPG grant) and the AOPT, as well as support from a dedicated librarian through Duke University. These sponsors did not have any influence over the recommendations in this updated CPG. The development of the final CPG was guided by an expert in CPG development, following standards set by the Institute of Medicine and the APTA Clinical Practice Guideline Process Manual.

Literature Search

A research librarian with experience in systematic reviews updated the original searches that had been completed in 2010 for the 2012 CPG. An initial literature search for this CPG was performed in 2016, a revised search was completed early in 2020, and the final search was completed in June 2020. The literature searches completed in 2020 used a more inclusive list of search terms and removed duplicates from the 2016 search results. Several additional key words and subject headings were included to increase comprehensiveness of the final search. For example, key word synonyms for back pain such as "back ache" and "back strain" were added to all searches, and new concepts such as treatment-based classification (TBC), multidimensional clinical framework, and cognitive functional therapy (CFT) were added to the classification search. All searches were limited by a filter to include only randomized clinical trials (RCTs), systematic reviews, CPGs, and meta-analyses.

The final search strategy consisted of a total of 8 subsearches, based on the aforementioned 4 intervention categories. Multiple subsearches were necessary for the larger treatment categories of exercise and manual and other directed therapies, following the previous LBP CPG search strategy. Exercise subsearches included centralization, progressive endurance, and trunk coordination, while subsearches for manual and other directed therapies included manual therapies, traction, and mobilization. The final search was conducted on June 25, 2020, with no date or language limitations, to capture any new articles based on the addition of updated search terms. Each search was conducted in MEDLINE via PubMed, Embase (via Elsevier), CINAHL Complete (via EBSCOHost), and the Cochrane Library. The 4 sets of search results were compiled in separate EndNote X9 (Clarivate Analytics, Philadelphia, PA) libraries before they were added to a Covidence (Veritas Health Innovation Ltd, Melbourne, Australia) project that contained search results from the 2016 update, which allowed Covidence to deduplicate across all searches and filter to a unique set of articles for screening. Additional information on the search strategies is included in APPENDIX A (available at www.jospt.org). EndNote, Covidence, and Excel (Microsoft Corporation, Redmond, WA) were used to manage literature searches, coordinate article selection, and complete critical appraisals. The search results are presented in APPENDIX B (available at www.jospt.org). Four PRISMA figures that describe the results of the literature search for each of the intervention categories are included in APPENDIX C (available at www.jospt.org).

Evidence Selection

The evidence-selection process is summarized in FIGURE 1 and described in more detail in the subsequent sections.

Title and Abstract Screening and Review of Full-Text Articles

Title and abstract screening and full-text article reviews were independently conducted, using prespecified inclusion and exclusion criteria, by 2 team members. Reviewers followed inclusion and exclusion criteria from the 2012 CPG for inclusion in the 2021 CPG update (APPENDIX D, available at www.jospt.org). Conflicts were resolved by a third team member and discussed with content experts as needed.

Extraction

For each extracted full-text article, 2 reviewers evaluated article quality using the Physiotherapy Evidence Database (PEDro) scale for RCTs and the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) for systematic reviews. The PEDro scale rates 10 internal validity criteria from a Delphi list for assessing RCT quality.¹⁶⁴ The AMSTAR rates 11 different criteria for methodological quality in systematic reviews.¹⁴⁶ Any conflicts regarding PEDro scale and AMSTAR scores were resolved by the 2 reviewers assigned to the same article. Disagreements unable to be resolved were discussed with the CPG lead author to arrive at the final decision on article score.

Levels of Evidence

The level-of-evidence table (TABLE 1) used for the 2021 CPG update is provided below, and summary information is in APPENDIX E (available at www.jospt.org). Given the size of the body of LBP literature, the committee made the decision to include all systematic reviews but only higher-quality RCTs (PEDro scale score, 6 or greater) in the 2021 update. Thus, the strength of evidence for all recommendations in this CPG is either I or II. The distinction between level I and II evidence was made by focus group members for each intervention category. Because all studies included in this CPG had PEDro scale scores of 6 or greater, the distinction between level I and II evidence was primarily based on number of studies for a given treatment (level I, multiple individual RCTs or systematic reviews/meta-analyses), sample size of individual RCTs (level I, larger sample size), and length of follow-up times (level I, short- and long-term follow-ups). Disagreements on evidence level were resolved by additional discussion until consensus was reached.

**TABLE 1 Levels of Evidence**
I	Evidence obtained from high-quality diagnostic studies, prospective studies, randomized controlled trials, or systematic reviews
II	Evidence obtained from lesser-quality diagnostic studies, prospective studies, systematic reviews, or randomized controlled trials (eg, weaker diagnostic criteria and reference standards, improper randomization, no blinding, less than 80% follow-up)
III	Case-control studies or retrospective studies
IV	Case series
V	Expert opinion

Strength of Evidence And Recommendations

The strength of recommendations was then given a grade to reflect the confidence in and impact of the included evidence. The strength of recommendation was based on the evidence grade from the 2012 CPG (if available) and the composition of level I and level II studies from the updated literature. Our literature search was limited to RCTs, and there were very few examples of clear superiority for treatment options. Therefore, we modified the language used to avoid any "must" recommendations. Instead, we framed recommendations to range from "should" (grade A) to "should not" (grade D). These grades and how they were determined are summarized in TABLE 2. Further information related to evidence grading is available online ( www.orthopt.org).

**TABLE 2 Grades of Recommendation**
Grades of Recommendation		Strength of Evidence	Level of Obligation
A	Strong evidence	A preponderance of level I and/or level II studies support the recommendation. This must include at least 1 level I study	Should
B	Moderate evidence	A single high-quality randomized controlled trial or a preponderance of only level II studies support the recommendation. This included studies with short-term follow-up (eg, 3 months or less) and smaller sample sizes (eg, fewer than 100 participants)	May
C	Weak evidence	A single level II study supports the recommendation	Can
D	Conflicting or no evidence	Level I and/or level II studies disagree with respect to their conclusions or provide no evidence of benefit	Should not

Patient Subgroups

Patient subgroups were included in the 2021 CPG update to allow for refinement of clinical recommendations. The 2012 CPG³⁸ differentiated acute, subacute, and chronic LBP; however, the 2021 CPG update only differentiates acute from chronic LBP. This decision was based on the lack of an accepted standard for definitions of subacute pain. Since 2012, there have been operational definitions for chronic LBP reported (eg, the National Institutes of Health Task Force on research standards for chronic LBP and the International Classification of Diseases [ICD], 11th revision).⁴² ^, ¹²⁰ The committee decided it would be more practical and consistent with the existing literature to only differentiate acute from chronic LBP in the 2021 CPG update. Additionally, we differentiated presence of leg pain, older adults, and postoperative LBP as study eligibility criteria allowed. Therefore, the patient subgroups in the 2021 CPG update were:

Acute or chronic LBP

- Studies that specifically recruited patients with symptoms for less than or equal to 6 weeks were grouped as acute LBP (ie, this was clearly indicated in the eligibility criteria). All other studies were classified as chronic LBP

LBP with leg pain

- Studies that specifically recruited patients with LBP, buttock pain, and/or symptoms extending into the leg (above or below the knee) were grouped as LBP with leg pain (ie, this was clearly indicated in the eligibility criteria)

LBP in older adults

- Studies that specifically recruited patients with LBP who were aged 60 years or older

Postoperative LBP

- Studies that intentionally recruited patients having surgery for LBP in conjunction with the treatment of interest were grouped as postoperative LBP (ie, this was clearly indicated in the eligibility criteria). Studies that included patients with a history of surgery for LBP were included in other subgroups as indicated (eg, in chronic LBP if meeting the symptom duration criterion)

International Classification of Function

An International Classification of Functioning, Disability and Health (ICF) LBP category was included with the recommendation when a study provided enough information in the eligibility criteria. This information was presented to be consistent with the 2012 CPG and to match recommendations to the current CPG's ICF system. Briefly, the rationale for including an ICF category is that it provides additional signs and symptoms to support clinical decision making at the individual patient level. The ICF subgroups in this updated CPG remain unchanged from the 2012 version, except for omitting the subacute group. Refer to the 2012 CPG³⁸ for more details on ICF categories for LBP.

Classification Codes

There have been no changes in ICD-10 codes that would impact the 2021 CPG update. Therefore, this part of the CPG was not updated or revised, as ICD-10 codes were part of the 2012 CPG. There is a transition planned to ICD-11 codes, which will include coding for primary chronic pain and secondary chronic pain conditions (eg, musculoskeletal).¹²⁰ ^, ¹²⁵ Changes to the ICD-11 codes are likely to be included in a future CPG update, as we expect that the opportunity to directly code chronic pain will have a noticeable impact on clinical classification of LBP.

Treatment Description

It was outside the scope of the 2021 CPG update to provide detailed descriptions for each of the individual treatments included in RCTs. However, for the intervention categories with many different treatment approaches (ie, exercise, manual and other directed therapies), we provide operational definitions that summarized key treatment characteristics. These intervention category sections include a table providing the treatments and their supporting operational definitions.

Guideline Review Process And Validation

Drafts of the CPG update were reviewed by multiple stakeholder groups to ensure that the goals and priorities of this publication were appropriately developed. Stakeholder groups include additional health care providers and organizations, consumers, patient representatives, and experts in physical therapy practice guideline methodology. The AOPT provides a network of external stakeholders who regularly participate in formal reviews of CPGs, including consumer/patient representatives and claims reviewers, medical coding experts, academic educators, clinical educators, physician specialists, and researchers. The guideline draft was also posted for public comment and review on www.orthopt.org, and a notification of this posting was sent to the members of the AOPT. All comments, suggestions, and feedback from the expert reviewers, the public, and consumer/patient representatives were provided to the authors and editors for consideration and revisions. Additional health care providers who reviewed this CPG methodology and publication include physical therapists and assistants, physicians and assistants, and chiropractors. Acknowledgments of external stakeholders and reviewers are provided at the end of the CPG.

There is an annual review of the AOPT CPG performed by experts in physical therapy practice guideline methodology. This review provides feedback to the CPG coordinator and editors to continue to improve and develop APTA guidelines.

Dissemination and Implementation Tools

The APTA developed a process of endorsing CPGs to increase the reach and adoption of evidence-based practice information. The updated CPG will also be presented at the next Combined Sections Meeting in 2022. Future plans for dissemination include other educational conferences and webinars for clinicians.

In addition to publishing these guidelines in the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), these guidelines will be posted on CPG areas of the JOSPT, AOPT, and APTA websites, and made available for free (open access) on the ECRI Guidelines Trust ( guidelines.ecri.org) and the PEDro ( https://pedro.org.au/) websites. The implementation tools planned to be available for patients, clinicians, educators, payers, policy makers, and researchers, and the associated implementation strategies, are listed in TABLE 3.

**TABLE 3 Planned Strategies and Tools to Support the Dissemination and Implementation of This CPG**
Tool	Strategy
JOSPT's "Perspectives for Patients" and/or "Perspectives for Practice" articles	Patient-oriented guideline summary available on www.jospt.org
Mobile app of guideline-based exercises for patient/clients and health care practitioners	Marketing and distribution of app via www.orthopt.org
Clinician's Quick-Reference Guide	Summary of guideline recommendations available on www.orthopt.org
JOSPT's Read for Credit^SM continuing education units	Continuing education units available for physical therapists and athletic trainers on www.jospt.org
Webinars and educational offerings for health care practitioners	Guideline-based instruction available for practitioners on www.orthopt.org
Mobile and web-based app of guideline for training of health care practitioners	Marketing and distribution of app via www.orthopt.org

Organization of the Guideline

Recommendations and accompanying evidence statements are presented in separate sections for (1) exercise, (2) manual and other directed therapies, (3) classification systems, and (4) patient education. Each section has the same format. First, the 2012 CPG recommendations are reviewed, then a review of the literature supporting the 2021 updated recommendation is provided, and finally a distillation of the evidence is presented to summarize recommendations. Please see the recommendation guidance for key elements.

Intervention: Exercise

Evidence Statements and Recommendations

2012 Recommendations

The 2012 recommendations were not divided by patient subgroup (eg, they did not include separate recommendations for acute and chronic LBP).

Progressive Endurance Exercise and Fitness Activities

Physical therapists should consider (1) moderate-to high-intensity exercise for patients with chronic LBP without generalized pain, and (2) incorporating progressive, low-intensity, submaximal fitness and endurance activities into pain management and health promotion strategies for patients with chronic LBP with generalized pain.

Trunk Coordination, Strengthening, and Endurance Exercises

Physical therapists should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce LBP and disability in patients with subacute and chronic LBP with movement coordination impairments and in patients post lumbar microdiscectomy.

Centralization and Directional Preference Exercises and Procedures

Physical therapists should consider utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute LBP with related (referred) lower extremity pain. Physical therapists should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute, subacute, or chronic LBP with mobility deficits.

Flexion Exercises

Physical therapists can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic LBP with radiating pain.

Exercise training interventions were categorized using the operational definitions displayed in TABLE 4.

**TABLE 4 Operational Definitions for Exercise**
Intervention	Operational Definition
Trunk muscle strengthening and endurance exercise	Exercise training prescribed to restore or improve strength, endurance, or power of trunk muscles or muscle groups
Specific trunk muscle activation exercise	Exercise training prescribed to target specific deep trunk muscles (eg, transversus abdominis, multifidus) using cocontraction to alter or restore control or coordination of the lumbopelvic region
Movement control exercise	Exercise training prescribed to alter, restore, or retrain control of functional movements and tasks, with feedback on movement patterns
General exercise	Exercise training prescribed to restore or improve overall strength or endurance of the major muscle groups of the upper/lower extremities and trunk, including exercises for flexibility/mobility and aerobic/conditioning exercises
Trunk mobility exercise	Exercise training prescribed to restore trunk range of motion or to repeatedly move the trunk in a specific direction to achieve a reduction of symptoms
Aerobic exercise	Exercise training prescribed to restore or enhance capacity or efficiency of the cardiovascular system
Multimodal exercise	Exercise training that combines 2 or more of the interventions described above

Evidence Update

Based on the results of our literature search, the 2021 update will include some of the same, but also different, treatment categories as did the 2012 CPG.

Exercise Training for Acute LBP

General Exercise Training

Aluko et al⁷ compared 6 weeks of specific trunk muscle activation exercises added to a trunk strengthening and endurance exercise program with the exercise program alone in 33 participants with acute LBP. This RCT reported no between-group differences at assessments conducted 3, 6, and 12 weeks after enrollment.

Evidence Synthesis and Rationale

There is a lack of RCTs examining exercise training interventions for patients with acute LBP who do not have related leg pain. This paucity of clinical trials is the primary limiting factor in making a stronger recommendation for exercise training. A stronger recommendation will require the completion of level I RCTs investigating the effects of exercise training in patients with acute LBP.

2021 Recommendation

Physical therapists can use exercise training interventions, including specific trunk muscle activation, for patients with acute LBP.

Exercise Training for Acute LBP With Leg Pain

Muscle Strengthening and Endurance

Huber et al⁷⁹ compared a muscle strengthening and endurance exercise intervention, consisting of supine isometric back extension and abdominal exercises, to advice to reduce activity and loading of the spine in 52 patients with acute back pain with leg pain. Assessments were made before treatment and after 20 days. Patients in the muscle strengthening and endurance exercise group had a greater reduction of pain intensity after 20 days (mean difference, −1.7 on the numeric pain-rating scale [NPRS]).

Specific Trunk Muscle Activation

Ye et al¹⁷⁰ compared 2 different exercise training interventions in 63 young male participants (age, 20–29 years) with diagnosed lumbar disc herniation. Patients were randomized to general exercise or specific trunk muscle activation exercises for 3 months. Outcomes were assessed after 3 months and 1 year. There were no differences at the 3-month assessment; however, at 1 year, those receiving specific trunk muscle activation had greater improvement in back pain and disability (mean group difference, - 6.7 on the Oswestry Disability Index [ODI]).

Evidence Synthesis and Rationale

These 2 RCTs provide evidence of short-term benefit of exercise training interventions, specifically muscle strengthening and endurance versus advice only. There was support for specific trunk muscle activation having a superior long-term benefit when compared to general exercise. The reviewed RCTs had methodologic limitations in the duration of follow-up and generalizability of the study participants. Based on the available evidence, there is support for incorporating muscle strengthening and endurance and specific trunk muscle activation exercise training interventions for patients with acute LBP with leg pain. This would include patients with ICF categories of LBP with related lower extremity pain and radiating pain. A stronger recommendation will require more level I RCTs.

2021 Recommendation

Gaps in Knowledge

More research is needed to examine exercise training interventions for patients with acute LBP with and without leg pain. There is a need for level I RCTs comparing exercise training interventions against usual care or other control interventions to clarify whether exercise training interventions provide benefit beyond the favorable natural history of acute LBP. There is also a need for direct comparisons of different exercise training interventions for patients with acute LBP with leg pain. Effort should be made to ensure that individuals recruited into exercise RCTs match demographic and clinical characteristics of those seeking care for LBP.

Exercise for Chronic LBP

Muscle Strengthening and Endurance

Rantonen et al¹³³ compared a muscle strengthening and endurance exercise intervention to either a multidisciplinary rehabilitation program or a self-care program in an RCT involving 126 patients with chronic LBP in an occupational health setting. The group receiving muscle strengthening and endurance exercise had greater improvement in pain compared to the self-care group after 3 and 6 months (pain visual analog scale [VAS] between-group mean difference, −10 mm for both follow-up occasions; ODI between-group mean difference, −4 and −5, respectively). There were no differences among the groups after 24 months.

Specific Trunk Muscle Activation

An RCT by Macedo et al¹⁰⁴ compared specific trunk muscle activation exercise to a general exercise program with cognitive behavioral principles in 172 patients with chronic LBP. Assessments at 2, 6, and 12 months found no difference in pain or disability between groups.

Nine RCTs⁶ ^, ⁹ ^, ¹³ ^, ³⁹ ^, ⁹⁵ ^, ¹¹¹ ^, ¹¹⁵ ^, ¹⁵³ ^, ¹⁵⁹ with small sample sizes and primarily short-term follow-up compared specific trunk muscle activation exercise to other exercise or an active intervention. Comparison exercise training interventions were general exercise,⁶ yoga,³⁹ manual therapy,¹⁵⁹ movement control exercise using proprioceptive neuromuscular facilitation,¹³ and muscle strengthening and endurance.⁹ ^, ⁹⁵ ^, ¹¹¹ ^, ¹¹⁵ ^, ¹⁵³ Results were mixed, with some studies finding differences favoring specific trunk muscle activation exercise for pain or disability after 4 to 12 weeks⁶ ^, ⁹⁵ ^, ¹¹⁵ ^, ¹⁵³ and others finding no between-group differences.⁹ ^, ¹³ ^, ¹¹¹ Demirel et al³⁹ found yoga to have a greater effect on pain than specific trunk muscle activation exercise after 6 weeks (mean difference, −1.4 on the NPRS). Tagliaferri et al¹⁵³ found that a muscle strengthening and endurance exercise intervention combined with manual therapy had a greater effect on disability than specific trunk muscle activation exercise after 6 months. Ulger et al¹⁵⁹ found that manual therapy had a greater effect on pain and disability after 6 weeks than specific trunk muscle activation exercise (mean difference, −7.5 on the ODI).

Four RCTs¹² ^, ¹²¹ ^, ¹³⁰ ^, ¹⁶⁹ compared specific trunk muscle exercise with a wait-list group,¹²¹ modalities alone,¹³⁰ modalities and trunk exercise,¹² or trunk endurance exercises.¹⁶⁹ All 4 RCTs found greater improvement in pain and disability in patients receiving specific trunk muscle activation exercise at short-term follow-ups ranging from 4 to 11 weeks.

Movement Control

Four RCTs with only short-term outcomes compared movement control exercise to other exercise training interventions. Gatti et al⁶³ compared movement control exercise (balance exercise) to a general exercise program in 79 patients with chronic LBP. Both groups received flexibility exercises as well. Greater improvement of pain and disability occurred in the movement control exercise group after 6 weeks (mean difference, - 2.1 on the Roland-Morris Disability Questionnaire [RMDQ]). Three separate RCTs by Areeudomwong and Buttagat¹² ^, ¹³ and Areeudomwong et al¹⁵ examined movement control exercise using proprioceptive neuromuscular facilitation compared to specific trunk muscle activation and a control group in 55 patients,¹² compared to a control group in 42 patients,¹⁵ and compared to general exercise in 44 patients.¹³ Results favored movement control exercise versus control or general exercise after 3 to 4 weeks and after 12 weeks for pain and disability,¹² ^, ¹³ ^, ¹⁵ and no differences were found when compared to specific trunk muscle activation after 4 weeks.¹³

Aerobic Exercise

Sitthipornvorakul et al¹⁴⁹ performed a systematic review and meta-analysis of aerobic exercise using a walking intervention for chronic LBP. Nine RCTs were included; 4 compared walking intervention alone to other interventions. Five studies compared walking as an intervention alone to walking in addition to other interventions. For walking alone versus other interventions (general exercise, education), the review found moderate-quality evidence of no significant difference between groups for pain in the short term (pooled standardized mean difference [SMD], 0.07) or long term (pooled SMD, 0.06). Similarly, no differences were found between groups for disability level in the short term (pooled SMD, 0.03) or long term (pooled SMD, 0.15). For walking plus other interventions versus other interventions alone, the review found low- to moderate-quality evidence of no significant difference between groups for pain intensity in the short term (pooled SMD, 0.04) or long term (pooled SMD, 0.00). Consistent with other findings, low- to moderate-quality evidence found no differences between groups for disability level in the short term (pooled SMD, −0.08) or long term (pooled SMD, −0.19).

Two RCTs compared aerobic exercise to minimal intervention or control groups. Bruehl et al²⁸ compared aerobic exercise to a usual activity control group in 82 patients with chronic LBP. Posttreatment comparisons (6 weeks) found greater reductions in pain intensity and pain interference in the group receiving aerobic exercise (NPRS between-group mean difference, −1.5 for average pain and −1.7 for worst pain). Cuesta-Vargas et al³⁴ compared a deep water–running aerobic exercise program along with care from a general practice physician to general practice care alone in 58 patients with chronic LBP and found differences favoring the group receiving the deep water–running aerobic exercise program in pain (pain VAS between-group mean differences: −14.8 mm at 4 months, −14.2 mm at 6 months, −26.0 mm at 12 months) and disability (RMDQ score between-group mean differences: −3.4 at 4 months, −3.8 at 6 months, −2.5 at 12 months).

General Exercise

Four RCTs compared general exercise interventions to other exercise training interventions. Iversen et al⁸² found no differences in pain and function across 1 year between general exercise and muscle strengthening and endurance using resistance bands in 99 patients. Harris et al⁷¹ compared general exercise to cognitive behavioral therapy or a brief cognitive intervention in 214 patients and found no differences in pain and function at 1-year follow-up. Bello et al²⁰ compared a general exercise program to a general exercise program using graded activity and found no difference between groups after 4 or 12 weeks. Monticone et al¹¹⁴ compared a group-based general exercise program to a group-based general exercise program combined with cognitive behavioral therapy principles in 150 patients with chronic LBP. The group receiving general exercise with cognitive behavioral principles had greater improvements in pain and disability after 5 weeks and 1 and 2 years (NPRS [0–10] between-group mean differences: −3.1 postintervention, −1.8 at 12-month follow-up, and −1.9 at 24-month follow-up; ODI score [0–100] between-group mean differences: −9.8 postintervention, −15.8 at 12-month follow-up, and −15.0 at 24-month follow-up).

Two RCTs compared general exercise to control conditions. An RCT by Masharawi and Nadaf¹⁰⁹ compared group-based, non- weight-bearing general exercise to a control group in 40 female nurses with chronic LBP. Assessments at 4 and 8 weeks found greater improvement in pain (mean difference, −2.2 on the NPRS) and disability (mean difference, −5 on the RMDQ) in the group receiving general exercise. Jensen et al⁸³ compared general exercise to advice to rest and use of a back brace for 100 patients with chronic LBP and Modic changes on imaging. There were no differences between groups after 10 weeks or 1 year.

Trunk Mobility

Segal-Snir et al¹⁴³ compared trunk mobility using rotational exercises to a wait-list control in 50 women (aged 40 to 70 years) with chronic LBP. Both groups received education and advice. There were no differences between groups for either pain or disability postintervention or at 8-week follow-up.

Shah and Kage¹⁴⁵ compared trunk mobility exercise consisting of repeated prone extension to manual therapy in 40 patients with LBP lasting less than 3 months. Results after 7 treatment sessions showed greater improvement in pain (mean differences, −1.1 and −2.5 on the NPRS) and disability (mean differences, −9.3 and −15.9 on the ODI) in the group receiving manual therapy.

Multimodal

Bronfort et al²⁷ conducted an RCT (n = 301) comparing a multimodal exercise training intervention, including specific trunk muscle activation and muscle strength and endurance training, to spinal manipulation and a group receiving instruction in a home-based general exercise program. There were no differences among the 3 treatment groups at the 3-month or 1-year follow-up.

Nazzal et al¹¹⁹ compared a general exercise program to a multimodal exercise program, including general exercise, muscle endurance, and strengthening, along with manual therapy in 100 patients and found greater improvements in the multimodal group in pain and disability after 6, 12, and 24 weeks. Two additional RCTs found no benefit to adding general exercise (deep-water running or aerobic exercise training) to a multimodal treatment that included education, manual therapy, specific trunk muscle activation, and passive modalities.³¹ ^, ³⁵

Magalhães et al¹⁰⁶ ^, ¹⁰⁷ compared 2 different multimodal exercise programs in 66 patients with chronic LBP. One program used aerobic exercise and muscle strengthening and endurance provided with cognitive behavioral principles. The other program used a general exercise program and specific trunk muscle activation exercise. There were no differences in pain and disability between groups at 6-week, 3-month, and 6-month follow-ups.

Evidence Synthesis and Rationale

There are a large number of RCTs examining exercise interventions for patients with chronic LBP. However, most are level II studies with high heterogeneity in patient populations, small sample sizes, and short-term follow-up, including several trials that reported null findings. The available level I RCTs support using multimodal programs and trunk muscle strengthening and endurance exercise interventions for chronic LBP generally and with older adults specifically. No studies reported harm from exercise training interventions. Therefore, exercise training interventions can be broadly recommended for chronic LBP. More level I RCTs are needed to directly compare different types of exercise, as there is no clear evidence of the superiority of one form of exercise training intervention over another. The duration, dosing, and intensity of exercise interventions were highly variable across studies, and controlling this variability should be a focus in future RCTs.

2021 Recommendations

Physical therapists may provide movement control exercise or trunk mobility exercise for patients with chronic LBP.

Gaps in Knowledge

There is a need for additional level I RCTs evaluating exercise training interventions for patients with chronic LBP. In particular, RCTs are needed that directly compare different types of exercise, examine the optimal way to deliver exercise training interventions with respect to dosage and intensity, and target exercise interventions to particular subgroups of patients with chronic LBP. In addition, the effects of contextual, medical, and/or social factors (eg, expectations for treatment, fear of movement, comorbid conditions, socioeconomic status) that modulate the effects of exercise should also be explored.

Exercise for Chronic LBP With Leg Pain

Specific Trunk Muscle Activation

One RCT by França et al⁵⁵ compared specific trunk muscle activation exercise to transcutaneous electrical nerve stimulation in 40 patients with chronic LBP with leg pain and found greater improvements in pain (adjusted mean difference, −2.6 on the NPRS) and disability (adjusted mean difference, −5.7 on the ODI) posttreatment (8 weeks) for the specific trunk muscle activation exercise group.

Multimodal

Two RCTs examined multimodal exercise training interventions versus minimal treatment for patients with chronic LBP with leg pain. Hahne et al⁶⁷ compared a multimodal exercise training intervention including trunk mobility exercise and specific trunk muscle activation exercise and advice to advice only in 54 patients. Greater improvements in back pain (adjusted mean difference, −1.4 points on the NPRS) and disability (adjusted mean difference, −7.7 on the ODI) favoring the multimodal exercise training intervention were observed after 10 weeks, and in disability (adjusted mean difference, −8.2 on the ODI) after 1 year. Albert and Manniche³ compared a multimodal exercise training intervention including general exercise, trunk strengthening and endurance, and specific trunk exercises to a sham exercise program in 181 patients. All patients received education and advice. There were no differences between groups in disability at follow-ups of 8 weeks and 1 year. There was a trend toward small differences in leg pain favoring the multimodal exercise training group.

Moustafa and Diab¹¹⁶ compared a multimodal exercise training intervention that included general exercise and specific trunk muscle activation exercise to that intervention plus exercise intended to correct forward head posture in 154 patients with LBP with leg pain who were randomly assigned to either intervention. There were no differences between groups at 8 weeks after treatment. Differences favoring the group including the postural exercise were reported for disability (mean difference, - 11.8 points on the ODI), back pain, and leg pain (mean difference, - 1.6 on the NPRS) after 2 years.

Evidence Synthesis and Rationale

A total of 3 RCTs comparing exercise training interventions to minimal treatment generally support the use of exercise training interventions for patients with chronic LBP with leg pain. One study examined a specific trunk muscle activation exercise program, while the remaining studies used multimodal exercise approaches. The studies do not clearly support one type of exercise training intervention. One RCT with a larger sample size supported the inclusion of postural exercise along with a multimodal exercise training intervention.

2021 Recommendation

Physical therapists may use exercise training interventions, including specific trunk muscle activation and movement control, for patients with chronic LBP with leg pain.

Exercise for Chronic LBP With Movement Control Impairment

Four RCTs¹⁴ ^, ⁸⁸ ^, ¹²⁴ ^, ¹²⁹ compared specific trunk muscle activation exercise to other exercise interventions in patients with chronic LBP who also had signs associated with the ICF category of movement control impairment. Khodadad et al⁸⁸ compared specific trunk muscle activation exercise to cognitive functional training and a control group in 52 patients and found no differences among the groups after 8 weeks. Three RCTs¹⁴ ^, ¹²⁴ ^, ¹²⁹ compared specific trunk muscle activation exercises to stretching exercises in studies with small sample sizes ranging from 20 to 42 patients. These RCTs each found better outcomes for the group receiving specific trunk muscle activation exercise in the short term (6–10 weeks), with 1 RCT¹²⁹ showing continued benefit for disability in the specific trunk muscle activation group after 6 months.

Macedo et al¹⁰⁵ conducted a preplanned secondary analysis of an RCT not included in the systematic review by Luomajoki et al.¹⁰³ The RCT compared specific trunk muscle activation and a general exercise program provided with cognitive behavioral principles in 172 patients with chronic LBP. Patients with clinical signs of movement control impairment via a questionnaire had greater improvement in function after 12 months than patients with fewer signs of movement control impairment on the questionnaire.

Movement Control

One systematic review and meta-analysis included 11 RCTs that examined movement control exercise training intervention programs for patients with chronic LBP and movement control impairment.¹⁰³ The systematic review found that movement control exercise had a small effect on pain postintervention (SMD, −0.39; 95% confidence interval [CI]: −0.73, −0.04), with no effect after 1 year. For disability, movement control exercise had a small effect postintervention in 4 of 11studies (SMD, −0.38; 95% CI: −0.68, −0.09), with a small effect maintained after 1 year (n = 212; SMD, −0.37; 95% CI: −0.69, −0.04).

Evidence Synthesis and Rationale

For patients with clinical findings consistent with movement control impairment, there is consistent evidence supporting specific trunk activation exercise and movement control exercise interventions.

2021 Recommendation

Physical therapists should use specific trunk muscle activation and movement control exercise for patients with chronic LBP and movement control impairment.

Gaps in Knowledge

Additional level I RCTs are needed to clarify which movement control exercise approaches are the most effective and/ or which patient characteristics are indicative of positive treatment outcomes.

Exercise Recommendations for Chronic LBP in Older Adults

Two RCTs examined multimodal exercise programs for older adults. Ammendolia et al⁸ compared a multimodal general exercise and aerobic exercise program to a self-directed exercise program in 104 adults with lumbar spinal stenosis (mean age, 71 years). The group receiving multimodal exercise had greater improvements in pain and disability after 6 months (adjusted mean difference, −1.4 on the NPRS). Schneider et al¹⁴² compared a group-based general exercise program to an individually delivered general exercise program with manual therapy and to usual medical care from a physiatrist in 259 adults over the age of 60 with lumbar spinal stenosis. The group receiving individualized general exercise with manual therapy had greater improvement in disability after 2 months than either the usual medical care or group-based general exercise group (adjusted mean differences: medical care, −2.0; 95% CI: −3.6, −0.4; group exercise, −2.4; 95% CI: −4.1, −0.8). There were no differences between groups after 6 months.

Hicks et al⁷⁵ compared a muscle strengthening and endurance exercise intervention augmented with neuromuscular electrical stimulation to passive modalities in 64 older adults (age, 60–85 years). The muscle strengthening and endurance exercise group had greater improvements in pain and function 12 weeks and 6 months post intervention (adjusted mean difference at immediate follow-up, −4.8; at 6 months, −5.1 on the ODI).

Three RCTs with small sample sizes and short-term follow-ups examined general exercise programs in older adults with chronic LBP. Vincent et al¹⁶⁶ examined 49 older adults with abdominal obesity (age, 60–85 years), comparing 3 groups: (1) a general exercise program consisting of total body progressive resistance exercises, (2) an isolated trunk extensor muscle strengthening exercise program, and (3) a control group. The general exercise group had greater improvement in disability after treatment (4 months) than the muscle strengthening group (mean difference, −2.6 on the ODI and −3.2 on the RMDQ). Both the general exercise and muscle strengthening groups had greater reduction in pain during movement than the control group (mean difference, −0.6 on the NPRS). Zadro et al¹⁷⁴ examined 60 older adults (age, older than 55 years), comparing a general exercise program provided using video game technology to usual care. The group receiving general exercise had greater improvements in pain (mean difference, less than 1 point on the NPRS) and disability (mean difference, −1.5 points on the RMDQ) after 8 weeks. There were no differences between groups after 6 months. No adverse events were reported. Homayouni et al⁷⁸ compared an aquatic general exercise program to a trunk mobility exercise program using flexion and extension, along with passive modalities, in 50 patients with chronic LBP diagnosed with lumbar spinal stenosis. The study found that the aquatic exercise program provided a slight benefit for pain and disability outcomes after 8 weeks, with no differences between groups after 3 months (mean difference, 2.5 on the pain VAS).

Evidence Synthesis and Rationale

There is strong evidence to support the use of general exercise training (including aquatic exercise) for the management of chronic LBP in the older adult population. However, benefits within these studies appear to be more related to exercise prescription (ie, the need to have appropriate volume/intensity and incorporate principles of exercise progression intensity) than to a given exercise type.

2021 Recommendation

Physical therapists should use general exercise training to reduce pain and disability in older adults with chronic LBP.

Exercise for Postoperative LBP

General Exercise

Aalto et al¹ performed an RCT examining 102 patients receiving open or microscopic decompression surgery for lumbar spinal stenosis (19 of the enrolled patients had additional fusion surgery). A general exercise program was compared to standard postoperative treatment. No differences between groups were observed at 3 and 6 months, and at 1- and 2-year follow-ups.

Hebert et al⁷³ performed an RCT examining a general exercise program with and without the addition of specific trunk muscle activation exercises started 2 weeks post surgery in 61 patients after lumbar disc surgery. Both groups demonstrated a 50% reduction in disability, but no additional benefit was gained from adding the specific trunk muscle activation when assessed at 10 and 26 weeks.

An RCT by Ogutluler Ozkara et al¹²² examined 30 patients following microdiscectomy and compared a general exercise program beginning immediately after surgery to a control group. The general exercise group had greater improvements in disability at 6 and 12 weeks (mean difference, −10.4 and −12.6 on the ODI, respectively) and in pain at 12 weeks (mean difference, −0.8 on the VAS).

Evidence Synthesis and Rationale

There are few studies examining exercise training interventions for patients following spine surgery. The results provide inconsistent evidence regarding general exercise interventions. None of the RCTs reported harm to patients with exercise training interventions following spine surgery.

2021 Recommendation

Physical therapists can use general exercise training for patients with LBP following lumbar spine surgery.

Gaps in Knowledge

To better inform postoperative care, there is a need for level I RCTs evaluating the effects of different exercise training interventions in patients following surgery for LBP.

Key Points for Exercise Interventions

Acute LBP

Many exercise training interventions potentially reduce pain and disability for individuals with acute LBP; however, given the available evidence, it is not possible to recommend any one type of exercise.
Muscle strength and endurance and specific trunk muscle activation exercise interventions have demonstrated some benefit for individuals with acute LBP and related leg pain.

Chronic LBP

Exercise training interventions can be broadly recommended to reduce pain and disability for individuals with chronic LBP.
There is no clear evidence of superiority of one exercise type or approach over another when exercise protocols are directly compared.

Older Adults With Chronic LBP

Progressive exercise training can be recommended to reduce pain and disability in older adults with chronic LBP.

Postoperative LBP

Exercise training interventions may be recommended to reduce pain and disability for individuals with LBP following lumbar spine surgery.
Surgeries in the literature search included lumbar discectomy, spinal fusion, and decompressive surgery (eg, laminotomy, hemilaminectomy, or laminectomy).