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94 APPENDICES Physiotherapy KCE reports vol. B
In the more recent Cochrane systematic review, exercise therapy appears to be slightly effective at decreasing pain and
improving function in adults with CLBP, particularly in healthcare populations. Evidence was found of effectiveness in
chronic populations relative to comparisons at all follow-up periods; pooled mean improvement was 7.3 points (95% CI,
3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) at earliest follow-up. In studies
investigating patients (i.e. presenting for health care providers) mean improvement was 13.3 (5.5 to 21.1) for pain, 6.9 (2.2
to 11.7) for function, representing significantly greater improvement over studies where participants included those
recruited from a general population (e.g. with advertisements) (Hayden 2005a et 2006).
Limitations of this results may be. The Cochrane review largely reflects limitations of the literature, including low quality
studies with heterogeneous outcome measures, inconsistent and poor reporting, and possibility of publication bias (Hayden
2005a et 2006). The ICSI guideline 2005 insists too on the point that studies of the Cochrane SR 2006 and of the
NHSCRD HTA report 2000 were limited by inconsistent and poor reporting, publication bias and the use of
heterogeneous outcome measures and concludes that exercise therapy provide at best only modest clinical benefits (at
decreasing pain and improving function in adults with chronic low back pain).
There is conflicting evidence for exercise therapy and return to work.
The Philadelphia méta-analysis show no difference on the return to work after 1 month (méta-analyse de 3 RCTs de
qualité bonne à moyenne). The CBO 2003 concludes that there is no difference on return to work versus other
physiotherapy treatment. COST B13 2004 concludes that exercise therapy is more effective than GP care on the return to
work in at least the mid-term (3-6 months) (RCTs de bonne qualité).
The metaanalysis of Kool concluded that the qualitative and the quantitative analysis showed strong evidence (multiple
relevant, high quality RCTs) that exercises reduces sick days during the first follow-up year, the effect size was 0.24 (95%
CI 0.36, -0.11). In a subgroup of studies on the treatment of severly disabled patients (>90 sick days under usual care) the
effect size is -0.30 (-0.42, -0.17). The effect size of the number of patients receiving a disability allowance was small and not
significant (Kool 2004).
The HTA report of NHS centre for reviews and dissemination (NHS CRD 2000) based on the Cochrane systematic
review of van Tulder 2000 conclude that there is strong evidence that exercise therapy may help chronic low back pain
patients return to normal daily activities and work.
Comparison exercise therapy versus other treatments.
L exercice therapy a la même efficacité que les différentes combinaisons de physiothérapie : ANAES 2000 (17 RCTs de
qualité faible à bonne), CBO 2003 (2 SR de bonne qualité), COST B13 2004 (RCTs de bonne qualité). Level A
L exercice therapy est plus efficace que les GP care habituels (prescription médicamenteuse) : CBO 2003 (SR Van Tulder
1999), COST B13 2004 (RCTs de bonne qualité), que le thermalisme et les exercices à domicile ANAES 2000 (17 RCTs de
qualité faible à bonne).
There is conflicting evidence regarding the effectiveness of exercise (outpatient) as compared with intensive multi
disciplinary programmes COST B13 2004 (RCTs de bonne qualité avec résultats contradictoires).
Type d exercices
There is no evidence for an exercise type. As many varied exercise types led to comparable positive effects improvements
it may be hypothesized that reduction of pain an improvement of function is obtained through general and aspecific physical
reconditioning which should be the main goal of such programs.
Il n y a pas de forme spécifique d exercice plus efficace qu une autre CBO 2003 (2 SR de bonne qualité Van Tulder 1999,
Hilde 1998). Muscle reconditioning/strengthening exercises is no more effective than other types of exercise COST B13
2004 (RCTs de bonne qualité). For aerobic exercises versus other types of exercise, flexion exercises versus others types
of exercise, flexion versus extension exercises, there is limited (small number of studies) or conflicting evidence : COST
B13 2004, ANAES 2000.
The Hayden s systematic review (including some poor quality studies) found that individually designed programs including
stretching or strengthening, and is delivered with supervision may improve pain and function.(Hayden 2005 b).
The Liddle s systematic review (including only good or middle quality studies) search to identify what treatment
characteristics are essentials to achieve and maintain successful results. Exercise quality was subsequently assessed
according the predominant exercise used. Despite the variety offered, exercise has a positive effect on CLBP patients, and
results are largely maintained at follow-up. Strengthening is a common component of exercise programmes, however, the
role of exercise co-interventions must not be overlooked (Liddle 2004).
According to COST B13 2004, there is moderate evidence that individually supervised exercise therapy is not more
effective than supervised groups exercises (one low quality RCT N=190 and one high quality RCT N=148).
Duration of the exercise therapy
Le rapport HTA du Centre for Clinical Effectiveness (Jackson 2002) se base sur la Cochrane systematic review (van Tulder
2002) et 8 RCTs de bonne qualité méthodologique. It conclude that 1) A 3-month program of gym workouts was shown
to reduce pain and improve spinal and muscle flexibility significantly more than a home exercise program ; 2) A 3-month
program of muscle reconditioning using training devices was equally effective as physiotherapy or aerobics in reducing pain