Exercise as an intervention for non-specific low back pain

Abstract

Invited Commentary on ‘Exercise interventions for non-specific low back pain: an overview of systematic reviews’, Swinkels et al. The purpose of the review, as described by the authors, was to complete a focused, systematic appraisal and summary of systematic reviews (i.e. review of reviews) pertaining to the influence of exercise on non-specific low back pain (NSLBP). To collate, evaluate, and summarise such a large volume of potential research is an enormous and timeconsuming task. Thus, the authors, through thoughtful and attentive work, have provided a valuable service and resource to physical therapists, exercise therapists, researchers, and graduate students for which I would like to thank them. The authors employed a rigorous systematic review process, with clearly identified and pilot tested criteria, which focused on NSLBP treatment, not diagnosis. The limitations associated with the review are acknowledged, as they should be, and the authors have diligently addressed these shortcomings. The review also provides an explanation and evidence for the methodological change in the contemporary systematic review process, and identifies the current lack of agreement in the most appropriate qualitative appraisal tools. Further, as with any research process, there are always methodological shortcomings and systematic reviews are no different. The classification of NSLBP is straightforward from a clinical perspective. The definition selected by the authors is clear and relatively commonplace. Typically, the classification of NSLBP does not include nerve root compression, nor serious underlying conditions (e.g. tumours). Thus, NSLBP generally pertains to pain associated with the musculature of the low back (lumbar 1 to 5). However, the challenge in the literature review process was the search for articles pertaining to NSLBP. In order to encompass all relevant NSLBP articles, a variety of search terms were required (e.g. low back pain, lumbar pain), aside from the obvious NSLBP. Frequently, research articles relevant to a review of the NSLBP literature are missed in the search process because of the key terms selected, but that was not the case with this systematic review. The discussion of the cognitive processing of pain is important, and cannot be overstated. Back pain is widely considered a multidimensional issue. No matter the aetiology of the low back pain, often a cognitive component must be addressed by the practitioner. Moreover, the cognitive component becomes more serious as the pain becomes chronic. Much research has been published discussing the relevance of the cognitive processes in addressing pain/back pain. I am in agreement that the cognitive component of the pain needs to be considered by the practitioner when addressing all NSLBP patients, and that the sub-grouping of NSLBP into acute, sub-acute, and chronic is integral when moving forward with treatment; the reason for this is that if the NSLBP presents as chronic, the cognitive component is likely larger than if the patient presents as acute. The patient’s cognitive processes will influence their perceptions, and thus influence the treatment protocol. Additionally, the need to acknowledge the cognitive process associated with the pain, especially that which is chronic, establishes the need to carefully consider the proper outcome measures (e.g. muscular strength, pain, disability) when conducting NSLBP research. The evidence for exercise as an intervention for NSLBP is clear and concise in nature, and reflects the current state of the NSLBP literature. The authors indicate that the research literature addressing exercise demonstrates variance in mode, setting, dosage, intensity and supervision, and that this diversity makes determining the effectiveness of exercise as a treatment for NSLBP more difficult. It was suggested that the actual exercise is more important than the nature of the exercise, but I would suggest that this is not the case. I believe it would be easier, and provide more information to practitioners, students, and researchers to categorise and analyse the exercise literature by mode. It is my experience in reading the literature and conducting research that not all modes of exercise are equally effective in treating NSLBP. Possibly other researchers would disagree, or suggest that NSLBP reviews should be sorted by more than just mode, e.g. Robert Kell, University of Alberta, Augustana Campus, 490146 Ave., Camrose, Alberta, Canada Email: rob.kell@ualberta.ca