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Treat Reduced Comfortable Activity Intolerance 
Panel recommendations and findings: 
 -   Low-stress aerobic exercise can prevent debilitation due to inactivity during the first month of symptoms and thereafter may help to return patients to the highest level of functioning appropriate to their circumstances.  (Strength of Evidence = C.) 
 -   Aerobic (endurance) exercise programs, which minimally stress the back (walking, biking, or swimming), can be started during the first 2 weeks for most patients with low back problems.  (Strength of Evidence = D.) 
 -   Conditioning exercises for trunk muscles (especially back extensors), gradually increased, are helpful for patients with low back problems, especially if symptoms persist.  During the first 2 weeks, these exercises may aggravate symptoms since they mechanically stress the back more than endurance exercises.  (Strength of Evidence = C.) 
 -   Back-specific exercise machines provide no apparent benefit over traditional exercise in the treatment of patients with low back problems.  (Strength of Evidence = D.) 
 -   Evidence does not support stretching of the back muscles in the treatment of patients with low back problems.  (Strength of Evidence = D.) 
 -   Recommended exercise quotas that are gradually increased result in better outcomes than telling patients to stop exercising if pain occurs. (Strength of Evidence = C.)  
  Various types of exercise programs have been advocated for patients with low back problems.  The most commonly studied types focus on back flexion, back extension, generalized strengthening, endurance (aerobic conditioning), stretching, or some combination of these.  Authors also reported exercises for low back problems as dynamic (isotonic) and static (isometric).  Most of these exercises can be either taught to the patient for home use or performed under supervision in a clinical setting. Commonly reported therapeutic objectives of exercise programs for low back problems are improvements in endurance, muscle strength, and flexibility presumably leading to reduced symptoms, improved level of functioning, and fewer or less severe future back problems. Concentrating on the pain can actually increase the patient's risks to livelihood, health and even of early mortality,  A prudent clinician will not focus on treating the pain where risks pale in comparison to the risks of limited activity on health, livelihood and even early death. (See Off Work Risk),  
Literature Reviewed     Evidence on Efficacy   Potential Harms and Costs      Summary of Findings      Author's Example 
  Literature Reviewed.  Of 92 articles screened, 20 RCTs met criteria for review.74, 75, 76, 83, 84, 86, 131, 155, 157, 233, 234, 235, 236, 237, 238, 239, 240, 241, 242, 243 
  Other articles contained information used by the panel, but did not meet article selection criteria.221,226, 232, 244, 245, 246, 247, 248, 249, 250, 251, 252, 253 
  Only six of the articles reviewed involved studies of exercise as a treatment for patients with low back problems.75, 83, 86, 131, 234, 243 
  Two other studies evaluated the efficacy of exercises for preventing or reducing the impact of low back problems in workers whose jobs involved frequent lifting.236, 237  The remaining articles all evaluated exercise as a treatment for groups that contained only patients with chronic pain or a mix of patients with acute and chronic problems. These were given less weight by the panel as there were enough studies using patients with low back problems. 
 Evidence on Efficacy.   Of the six articles evaluating patients with low back problems, only one was considered well designed.83 Swedish auto workers who had been off work for 6 weeks due to low back problems were randomized to either a control group with no recommendations for exercise or an exercise group with a program of gradually increased aerobic and back-strengthening exercises.  At 1-year followup, patients in the exercise group had lost significantly less time from work due to back pain and had achieved a significantly higher level of fitness compared with the control group. That was 1994 before work of Malmivaara et al, '95 primary prevention study opened the floodgates condentrating on the benefits of activity to prevent chronic back problems, including Indahl et al,`98, Burton et al,`99,Hagan et al,`00, Buchbinder et al,`01, McGuirk et al,`01 concentrating treatment on treating the reduced activity tolerance rather than just chasing the pain.   
  The other five articles dealing with low back problems included interventions that made the effect of exercise difficult to determine.75, 86, 131, 234, 243 
  Stankovic and Johnell86 compared McKenzie extension exercises to a 45-minute educational session and found that the exercise group stopped medication use earlier and reported more pain relief and fewer days off work.  Evans, Gilbert, Taylor, et al.75 found that patients who received a flexion exercise program plus a 30-minute educational program stopped using medication sooner than did patients in bed rest and control groups.  However, no differences were found between groups in reported degree of pain relief or activities of daily living. 
  The other three of these five studies showed no significant differences in outcomes between the treatment groups.131, 234, 243 
  Davies, Gibson, and Tester,234  compared groups receiving short-term diathermy and either extension or flexion exercises.  Zylbergold and Piper243 compared flexion exercises to manual therapy in combination with home back care instructions.  Coxhead, Meade, Inskip, et al.131 compared groups receiving various combinations of exercise (not otherwise specified), traction, manipulation, and lumbar corset use in a multifactorial study with 16 cells. 
  In summary, the six studies, which evaluated exercise for treating low back problems, used different forms of flexion or extension exercises, different treatment or control groups, different outcome measures, and different assessment periods.  For this reason, no attempt was made to quantitatively combine these data. 
  As noted previously, two studies evaluated exercise for preventing acute or recurrent episodes of low back problems.  Gundewall, Liljeqvist, and Hansson,236 in a RCT, evaluated 60 nursing personnel working at a geriatric hospital.  Subjects were randomized to receive either no intervention or a supervised exercise program during work six times per month for 13 months (emphasizing isometric and dynamic exercises conditioning the back extensor muscles). 
  At the end of the study, the exercise group had a significantly lower incidence of new low back problem episodes when compared with the control group (4 percent compared with 38 percent), fewer days lost from work, fewer days with back pain complaints, and a lower average duration of low back pain complaints (1/5th days off work).  Trunk extensor strength measured with a spring gauge was not different between groups at the start of the study, but at the end of the study average trunk strength was significantly greater in the exercise group compared with the control group.  The authors noted that the exercise group did receive more attention than the control group, which could account for some of the positive effect.  Results were not reported separately for those with and without prior low back problems. 
  In the second study, Kellett, Kellett, and Nordholm,237 in a RCT, evaluated 60 workers at a kitchen cabinet manufacturing company in Sweden. All were working at the start of the study and reported having either current or prior back pain.  Subjects were randomly assigned to a control group or an exercise group.  The exercise group was offered an exercise program at work once per week (30 minutes of aerobic movements of the arms, legs, and trunk followed by 10 minutes of relaxation) and were asked to do 30 minutes of aerobic exercise (such as walking, jogging, or cycling) on their own at least once per week. 
  Although subjects in the exercise group were encouraged to progressively increase their effort level during exercise, no direct measures of exertion (such as heart rate) were recorded.  The exercise group was also given lectures about back problems and proper lifting techniques.  There were no significant differences between exercise and control groups in incidence rates or days lost from work for episodes of back pain in the 1.5 years before the intervention.  The incidence rate and days lost from work for episodes of back pain decreased in the exercise group during the subsequent 1.5-year intervention period.  In the control group, absenteeism attributable to back pain increased during the intervention period.  There were no significant differences, either before or after the study, between groups in cardiovascular fitness as measured by a suboptimal bicycle ergometer. 
  Deyo232 remarked that, although there seems to be a consensus among experts that exercise plays a major role in the treatment of low back symptoms, most treatment programs prescribe a combination of exercises and there is little agreement on specific regimens.  He also offered an opinion that additional benefits of aerobic exercise may include weight loss and favorable psychological effects, such as reduction of anxiety and depression.  Other studies have shown that patients improve faster when given specific quotas of exercises to do rather than being told to stop exercise when it produces pain.83, 246 
  One study,251 found a back-specific exercise machine (the B-200) does not provide added benefit over traditional exercise in improving the objective back strength and flexibility (as measured by functional lifting capacity) of low back patients. 
  Potential Harms and Costs.  Potential harms of exercise are usually not discussed.  However, one RCT found that extension exercises caused increased symptoms in chronic low back pain patients.238  Another study suggests that abdominal flexion (Williams flexion) exercises and stretching can increase mechanical stress on the spine as observed by intradiscal pressure measurements.248 
  Many methods have been proposed to evaluate mechanical stress on the back in different postures and activities.221, 226, 244, 245, 247, 248, 249, 250, 252   A biomechanical model by Schultz directly correlates with in vivo measurements of intradiscal pressure and myoelectric signals.253  The measurements of relative stress on the spine during postures and activities generally relate to increased and decreased symptoms experienced by patients with back problems.  Thus, this information can be used for recommendations about safety and altering activity. 
  The costs of exercise programs can vary depending upon the setting. Those performed at home are inexpensive, whereas those done in supervised clinical settings are more costly.  Exercise programs using back- specific computerized exercise machines can be very expensive.  No studies meeting review criteria were found that provided evidence of any of these exercise settings being more effective than the others. 
  Summary of Findings.  In 1994 there are only a few RCTs that have evaluated exercise as a treatment for low back problems, and these are limited by small numbers of patients and inadequate descriptions of specific exercise regimens. The one well-designed RCT of patients limited for less than 3 months by low back symptoms found that a program of gradually increased aerobic and back-strengthening exercises was superior to doing no exercise at all.83 Now there are many beginning with Malmivaara et al, '95, Indahl et al,`98, Burton et al,`99, Hagan et al,`00, Buchbinder et al,`01, McGuirk et al,`01   
  In 1994 exercise programs aimed at improving general endurance (aerobic fitness) and muscular strength (especially of the back and abdomen) have been shown in some published studies to benefit patients with low back problems. No evidence supports stretching as effective treatment for low back problems. The panel offered the opinion that patients with low back problems would benefit from exercise programs if endurance programs are started early, using exercises that cause minimal mechanical stress on the back; if patients are given set exercise quotas gradually increased with time; and if later strengthening programs are individualized based on the level of activity to which patients wish to return. The panel suggested that the early goal of exercise programs is to prevent debilitation due to inactivity and then to improve activity tolerance to return patients to their highest level of functioning as soon as possible. Now we have better defined issues, benefits and opportunities offered by concentrating on activity limitation rather than only chasing pain with our treatment especially to avoid serious long term problems. (See Off Work Risk) Whether primary prevention, prevention of disability as noted above or reducing chronic pain, exercise and conditioning demonstrate physical and functional benefit with diminishing impact the later the problem is addressed. 
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