Evidence statementsEvidence to recommendations

A systematic review evaluated the effectiveness of exercise therapy and found insufficient evidence to support or refute the effectiveness of exercise in patients with subacute low back pain. In patients with chronic low back pain, exercise therapy was found to be slightly effective at decreasing pain and improving function relative to other comparisons (no treatment, sham, placebo, other conservative treatments) (1++) (Hayden, J. A., van Tulder, M. W., Malmivaara, A. et al, 2005)

One large well-conducted RCT evaluated the effectiveness of adding exercise, spinal manipulation package or a combination of both to Best Care in general practice. Relative to best care exercise significantly improved disability and pain at 3 months but not at12 months follow-up. No effect on mental health was observed(1++) (UK Back pain exercise and manipulation (UKBEAM) Trial Team., 2004)

One RCT assessed the effectiveness of a home exercise programme and found that after 5 years, pain intensity was significantly lower in the exercise group. No significant difference in function was found after 5 years (1-) (Kuukkanen, T. and Mälkiä, E., 2000; Kuukkanen, Tiina, Mälkiä, Esko, Kautiainen, Hannu et al, 2007)

One RCT compared Alexander Technique and exercise prescription to usual care (ATEAM trial). At 3 months exercise and lessons in the Alexander Technique significantly reduced functional disability and days of pain compared to normal care. At 1 year follow-up exercise prescription and Alexander Technique lessons still reduced disability, but exercise did not significantly affect days in pain anymore. (1+)(Little, P., Lewith, G., Webley, F. et al, 2008)

One RCT compared the effectiveness of adding exercise to a back school and found that exercise was associated with significantly reduced pain and disability after 1 year follow-up (1-) (Maul, I., Läubli, T., Oliveri, M. et al, 2005)

One RCT evaluated the effectiveness of hydrotherapy and found it was associated with a significant difference in function at 4 weeks. No significant difference in pain was found (1-)(McIlveen, B. and Robertson, V. J., 1998)

One RCT compared yoga, exercise and a self-care book. At 12 and 26 weeks, function was significantly better in the yoga group than in the booklet group (1+) (Sherman, Karen J., Cherkin, Daniel C., Erro, Janet et al, 2005)

One RCT compared graded activity to usual care and showed that at 26 weeks graded activity did not improve pain or function significantly (1-)(Steenstra, I. A., Anema, J. R., Bongers, P. M. et al, 2006)

There is evidence for clinical effectiveness of structured exercise programmes.
There is evidence of improved function and reduced disability and reduced pain. No evidence was found of an effect on psychological distress. The size of effect however, is generally small. Most of the recent studies have used advice to remain active as part of a controlled intervention.
There is variability in the intensity of exercise within the trials.
Number of sessions recommended comes from UK BEAM and A-TEAM trials which have cost effectiveness analysis. Number of people in a group was taken from the UK BEAM trial.
Components of the exercise interventions varied between trials but the GDG agreed a recommendation could be made indicating what the programmes should comprise of taken from what was delivered in the A-TEAM trial.
There is evidence of cost effectiveness of exercise alone compared to best care in general practice.
The GDG were also presented with the economics of the combined treatment option as once manipulation is included in the analysis, the exercise alone option is dominated by the manipulation (either alone or in combination with exercise) treatment options.
In a probabilistic analysis, best care plus exercise alone had a less than10% chance of being the most cost- effective treatment option at the£20,000 per QALY threshold. However, if manipulation is not available, providing exercise interventions in addition to usual care is likely to be a cost effective use of NHS resources.
The GDG felt that the evidence was insufficient to make a recommendation against making an exercise programme available for people for whom manipulation was not suitable or who preferred exercise. This meant that exercise alone would remain an option for this patient population.

One health economics analysis was found in the literature. This was a cost per QALY analysis based on the clinical and resource use outcomes from the UK BEAM clinical trial. It compared exercise and manipulation (alone or in combination) added to best care. The base case analysis took an UK NHS costing perspective. This analysis suggested that the cost-effectiveness of the included exercise programme when added to best care had an ICER of£8,300 compared to best care alone, and there was about a 60% chance that the estimated ICER was less than £20,000 per QALY (UK Back pain exercise and manipulation (UKBEAM) Trial Team, 2004).

One 12-month, UK-based economic evaluation compared the Alexander technique either 6 lessons (AT-6 lessons) or 24 lessons (AT-24 lessons), with normal care, with massage and with an exercise prescription. (Hollinghurst, S, Sharp, D., Ballard, K. et al, 2008)

The exercise prescription dominated AT-6 lessons using QALY or disability score as the outcome. That is, AT-6 lessons cost more and produced fewer benefits, as measured by both health outcomes, than the exercise prescription. The cost per QALY gained from AT-24 lessons was£45,600, and the cost per one point improvement in the disability score was£168, compared to the exercise prescription. The cost per pain-free day from the AT-24 lessons intervention was £56 compared to AT-6 lessons (Hollinghurst, S, Sharp, D., Ballard, K. et al, 2008)

There is evidence that a supervised exercise programme in the form of the Alexander technique (6 lessons) is not cost-effective when compared with GP advice to exercise.
However, if the Alexander technique is delivered in 24 lessons, this results in additional benefits and costs compared to GP advice to exercise.
The cost per QALY gained from 24 lessons is £45,600 compared to GP advice to exercise.

From: 6, Physical activity and exercise

Cover of Low Back Pain
Low Back Pain: Early Management of Persistent Non-specific Low Back Pain [Internet].
NICE Clinical Guidelines, No. 88.
National Collaborating Centre for Primary Care (UK).
Copyright © 2009, Royal College of General Practitioners.

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