Exercise and Chiropractic Care

This section was compiled by Frank M. Painter, D.C.
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Chronic Neck Pain Low Back Pain Whiplash Section

Conditions That Respond Alternative Medicine Approaches to Disease

The Wolfe-Harris Center @ Northwestern Health Sciences University

Our usual Topical Pages list the newest studies first.   This page is different... for a reason.

By tracking the work of a specific research group over a 23-year period, from their first to their most-recent, we can see the evolution of the question they ask, along with their growing precision at revealing the facts. It's a different way of looking at research, and I hope you will find it as fascinating as I did.

Now meet the researchers of the The Wolfe-Harris Center for Clinical Studies
@ Northwestern Health Sciences University.

NOTE: The NCT number next to the title links to the ClinicalTrials.gov grant which funded that study.

Trunk Exercise Combined with Spinal Manipulative or
NSAID Therapy for Chronic Low Back Pain:
A Randomized, Observer-blinded Clinical Trial

J Manipulative Physiol Ther. 1996 (Nov); 19 (9): 570–582

Each of the three therapeutic regimens was associated with similar and clinically important improvement over time that was considered superior to the expected natural history of long-standing CLBP. For the management of CLBP, trunk exercise in combination with SMT or NSAID therapy seemed to be beneficial and worthwhile. The magnitude of nonspecific therapeutic (placebo) effects, cost-effectiveness and relative risks of side effects associated with these types of therapy need to be addressed in future studies.

A Randomized Clinical Trial of Exercise and Spinal
Manipulation for Patients with Chronic Neck Pain

Spine (Phila Pa 1976). 2001 (Apr 1); 26 (7): 788–797

For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone. The effect of low-technology exercise or spinal manipulative therapy alone, as compared with no treatment or placebo, and the optimal dose and relative cost effectiveness of these therapies, need to be evaluated in future studies.

Two-year Follow-up of a Randomized Clinical Trial of
Spinal Manipulation and Two Types of Exercise for
Patients With Chronic Neck Pain

Spine (Phila Pa 1976). 2002 (Nov 1); 27 (21): 2383–2389 ~ FULL TEXT

The results of this study demonstrate an advantage of spinal manipulation combined with low-tech rehabilitative exercise and MedX rehabilitative exercise versus spinal manipulation alone over two years and are similar in magnitude to those observed after one-year follow-up. These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers. Further studies are needed to examine the cost effectiveness of these therapies and how spinal manipulation compares to no treatment or minimal intervention.

What Do Patients Think? Results of a Mixed Methods Pilot
Study Assessing Sciatica Patients' Interpretations
of Satisfaction and Improvement

J Manipulative Physiol Ther. 2003 (Oct); 26 (8): 502–509 ~ FULL TEXT

This study demonstrated that a "mixed methods" approach using qualitative research methods within a clinical trial is not only feasible but can provide interesting and useful information for trial interpretation and future study design. By providing insight to the multidimensional nature of patients' beliefs and perceptions, this technique may not only shape but also redefine the focus of patient-oriented research and health care for low back pain conditions.

Exercises for Mechanical Neck Disorders
Cochrane Database Syst Rev. 2005 (Jul 20); (3): CD004250 ~ FULL TEXT

There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisation or manipulation for subacute and chronic MND with or without headache, in the short and long term. A program of eye fixation or proprioception exercises imbedded in a more complete program shows moderate evidence of benefit for pain [pooled SMD -0.72 (95% CI:-1.12 to -0.32)], function, and global perceived for chronic MND in the short term, and on pain and function for acute and subacute MND with headache or WAD in the long term. There is limited evidence of benefit on pain relief in the short term for a home mobilisation program with other physical modalities over a program of rest then gradual mobilisation for acute MND or WAD. There was evidence of no difference between the different exercise approaches.

Chiropractic and Exercise for Seniors With Low Back Pain
or Neck Pain: The Design of Two
Randomized Clinical Trials
  NCT00269308   and   NCT00269321
BMC Musculoskelet Disord. 2007 (Sep 18); 8: 94 ~ FULL TEXT

To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers. This article presents the rationale and design of two mixed methods clinical trials, each consisting of an RCT, with cost-effectiveness and qualitative studies conducted alongside the central trial. Both are anticipated to be completed in 2007, at which time the results will be made available.

Individualized Chiropractic and Integrative Care for
Low Back Pain: The Design of a Randomized Clinical
Trial Using a Mixed-methods Approach
Trials. 2010 (Mar 8); 11: 24 ~ FULL TEXT

This mixed-methods randomized clinical trial assesses clinical effectiveness, cost-effectiveness, and patients' and providers' perceptions of care, in treating non-acute LBP through evidence-based individualized care delivered by monodisciplinary or multidisciplinary care teams.

Integrative Care for the Management of Low Back Pain:
Use of a Clinical Care Pathway
BMC Health Serv Res. 2010 (Oct 29); 10: 298 ~ FULL TEXT

Thirteen providers representing 5 healthcare professions collaborated to provide integrative care to study participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into treatment plans.

Chiropractic and Self-care for Back-related Leg Pain:
Design of a Randomized Clinical Trial
Chiropractic & Manual Therapies 2011 (Mar 22); 19: 8 ~ FULL TEXT

Back-related leg pain (BRLP) is a costly and often disabling variation of the ubiquitous back pain conditions. As health care costs continue to climb, the search for effective treatments with few side-effects is critical. While SMT is the most commonly sought CAM treatment for LBP sufferers, there is only a small, albeit promising, body of research to support its use for patients with BRLP.This study seeks to fill a critical gap in the LBP literature by performing the first full scale RCT assessing chiropractic SMT for patients with sub-acute or chronic BRLP using important patient-oriented and objective biomechanical outcome measures.

Supervised Exercise, Spinal Manipulation, and Home Exercise
for Chronic Low Back Pain: A Randomized Clinical Trial
Spine J. 2011 (Jul); 11 (7): 585–598

A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term.

Spinal Manipulation, Medication, or Home Exercise
with Advice for Acute and Subacute Neck Pain:
A Randomized Trial
Annals of Internal Medicine 2012 (Jan 3); 156 (1 Pt 1): 1–10 ~ FULL TEXT

For participants with acute and subacute neck pain, SMT was more effective than management with medication in both the short and long term; however, a few sessions of supervised instruction in HEA resulted in similar outcomes at most time points.

Supervised Exercise With And Without Spinal Manipulation
Performs Similarly And Better Than Home Exercise For
Chronic Neck Pain: A Randomized Controlled Trial
Spine (Phila Pa 1976). 2012 (May 15); 37 (11): 903–914 ~ FULL TEXT

Our study found that groups receiving high-dose supervised ET with and without spinal manipulation performed similarly, reporting less pain, greater global perceived effect, and more satisfaction than the low-dose home exercise group, particularly in the short term. The supervised exercise groups also demonstrated greater gains in blinded assessment of neck endurance and strength, supporting the patient-self report measures. The results of qualitative interviews suggest that personal attention played an important role in the supervised exercise groups. Various stakeholders’ perspectives should be considered carefully when making recommendations regarding these therapies for chronic neck pain patients, taking into account side effects, preferences, and costs.

P02.129. Individualized Chiropractic and Integrative Care
for Low Back Pain: A Randomized Clinical Trial
BMC Complementary and Alternative Medicine 2012 (Jun 12); 12; P185

Two hundred patients participated. Mixed model longitudinal analysis showed that the integrative care group had statistically significant more pain reduction, perceived global improvement and satisfaction with care in both the short- (up to 12 weeks) and long-term (through 52 weeks; p≤ 0.05). The group differences were relatively small.

"I Know It's Changed": A Mixed-methods Study of the Meaning
of Global Perceived Effect in Chronic Neck Pain Patients

European Spine Journal 2014 (Apr); 23 (4): 888–897 ~ FULL TEXT

This work provides a better understanding of the meaning of Global Perceived Effect (GPE) and influencing factors, than what was previously known. The GPE appears to capture chronic neck pain patient perceptions of change in different domains important to their individual pain experiences which may not be captured by other outcome instruments. Thus, the GPE scales are useful measurement tools for clinical practice and research.

Spinal Manipulation and Exercise for Low Back Pain in Adolescents:
Study Protocol for a Randomized Controlled Trial
Chiropractic & Manual Therapies 2014 (May 23); 22: 21 ~ FULL TEXT

This is the first randomized clinical trial assessing the effectiveness of combining spinal manipulative therapy with exercise for adolescents with low back pain. The results of this study will provide important evidence on the role of these conservative treatments for the management of low back pain in adolescents.

Short Term Treatment Versus Long Term Management of Neck
and Back Disability in Older Adults Utilizing Spinal
Manipulative Therapy and Supervised Exercise:
A Parallel-group Randomized Clinical Trial
Evaluating Relative Effectiveness and Harms
Chiropractic & Manual Therapies 2014 (May 23); 22: 21 ~ FULL TEXT

This is one of the first full-scale randomized clinical trials to compare short term treatment and long term management using SMT and exercise to treat spine-related disability in older adults. It builds on previous research by the investigative team showing improvement with three months of SMT and exercise in similar populations, which regressed to baseline values in long term follow up without further intervention. [88] As back and neck pain in older adults are often chronic and among several co-morbidities [6, 8], we theorized that long term management may result in sustained improvement compared to short term treatment. Identifying the most favorable duration of treatment is a pragmatic question common to patients, clinicians, policy makers, and third-party payers alike. [25, 89] This is especially important to address in an older population, whose long term functional ability is essential to maintaining vitality and independence.

Spinal Manipulative Therapy and Exercise For
Seniors with Chronic Neck Pain

Spine J. 2014 (Sep 1); 14 (9): 1879–1889   NCT00269308

Spinal manipulative therapy (SMT) with home exercise resulted in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone. Supervised exercise sessions added little benefit to the HE-alone program.

Spinal Manipulation and Home Exercise With Advice for
Subacute and Chronic Back-related Leg Pain:
A Trial With Adaptive Allocation
Annals of Internal Medicine 2014 (Sep 16); 161 (6): 381—391 ~ FULL TEXT

Of the 192 enrolled patients, 191 (99%) provided follow-up data at 12 weeks and 179 (93%) at 52 weeks. For leg pain, SMT plus HEA had a clinically important advantage over home exercise and advice (HEA) (difference, 10 percentage points [95% CI, 2 to 19]; P=0.008) at 12 weeks but not at 52 weeks (difference, 7 percentage points [CI, -2 to 15]; P=0.146). Nearly all secondary outcomes improved more with SMT plus HEA at 12 weeks, but only global improvement, satisfaction, and medication use had sustained improvements at 52 weeks. No serious treatment-related adverse events or deaths occurred.   For patients with back-related leg pain (BRLP), SMT plus home exercise and advice (HEA) was more effective than HEA alone after 12 weeks, but the benefit was sustained only for some secondary outcomes at 52 weeks.

Perceived Value of Spinal Manipulative Therapy and
Exercise Among Seniors With Chronic Neck Pain:
A Mixed Methods Study

J Rehabil Med. 2014 (Nov); 46 (10): 1022–1028 ~ FULL TEXT

Participants placed high value on their relationships with health care team members, supervision, individualized care, and the exercises and information provided as treatment. Change in symptoms did not figure as prominently as social and process-related themes. Percpetions of age, activities, and co-morbities influenced some seniors' expectations of treatment results, and comorbidities impacted perceptions of their ability to participate in active care.   Relationship dynamics should be leveraged in clinical encounters to enhance patient satisfaction and perceived value of care.

Adverse Events Among Seniors Receiving Spinal Manipulation
and Exercise in a Randomized Clinical Trial

Man Ther. 2015 (Apr); 20 (2): 335–341 ~ FULL TEXT

Non-serious AE were reported by 130/194 participants. AE were reported by three times as many participants in supervised plus home exercise, and nearly twice as many as in SMT with home exercise, as in home exercise alone. The majority of AE were musculoskeletal in nature; several participants associated AE with specific exercises. One incapacitating AE occurred when a participant fell during supervised exercise session and fractured their arm. One serious adverse event of unknown relationship occurred to an individual who died from an aneurysm while at home. Eight serious, non-related AE also occurred. Musculoskeletal AE were common among elderly participants receiving SMT and exercise interventions for NP. As such, they should be expected and discussed when developing care plans.

What Do Patients Value About Spinal Manipulation and
Exercise for Back-related Leg Pain? A Qualitative
Study Within a Controlled Clinical Trial

Man Ther. 2016 (Dec); 26: 183–191 ~ FULL TEXT

This qualitative study illustrates that patient satisfaction is rooted in the quality of the patienteprovider relationship, although perceived symptom improvements, relevant clinical information about sciatica and its treatment, and the distinct qualities of those treatments are important drivers of satisfaction for patients who received non-pharmacological treatments for their back-related leg pain. Global measures of satisfaction may not adequately represent the range of patients' experiences and perceptions of spinal manipulative therapy or home exercise. In addition to providing insight to the quantitative results of the parent trial, these findings suggest that tailored interventions to enhance patienteprovider relationships may facilitate compliance and enhance satisfaction with care.

Spinal Manipulation and Exercise for Low Back Pain
in Adolescents: A Randomized Trial

Pain. 2018 (Jul); 159 (7): 1297–1307 ~ FULL TEXT

For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a 1–year period, with the largest differences occurring at 6 months. These findings warrant replication and evaluation of cost effectiveness.

Cost-effectiveness of Spinal Manipulation, Exercise, and
Self-management for Spinal Pain Using an Individual
Participant Data Meta-analysis Approach:
A Study Protocol

Chiropractic & Manual Therapies 2018 (Nov 13); 26: 46 ~ FULL TEXT

Combined analyses of economic data are rarely possible due to differences in resource utilization outcomes, costs and healthcare settings. [56, 57] Additionally, individual clinical trials rarely include a sufficient number of participants to detect important differences in economic outcomes. This project represents a unique opportunity to potentially combine clinical and economic data collected in eight randomized clinical trials using an IPDMA approach. This will provide more precise estimates of the cost-effectiveness of spinal manipulation, exercise therapy, and self-management compared to analysis of the individual trials. Further, an IPDMA approach has many advantages over traditional meta-analysis including the ability to conduct standardized within-study analyses, account for missing data at the individual level, and investigate potential sub-group effects at the participant level which may account for heterogeneity in estimates across studies. [52]

Spinal Manipulative Therapy and Exercise for Older Adults
with Chronic Low Back Pain: A Randomized Clinical Trial
Chiropractic & Manual Therapies 2019 (May 15); 27: 21 ~ FULL TEXT

241 participants were randomized and 230 (95%) provided complete primary outcome data. The primary analysis showed group differences in pain over the one-year were small and not statistically significant. Pain severity was reduced by 30 to 40% after treatment in all 3 groups with the largest difference (eight percentage points) favoring SMT and home exercise over home exercise alone. Group differences at other time points ranged from 0 to 6 percentage points with no consistent pattern favoring one treatment. One-year post-treatment pain reductions diminished in all three groups. Secondary self-report outcomes followed a similar pattern with no important group differences, except satisfaction with care, where the two combination groups were consistently superior to home exercise alone.

Short or Long-term Treatment of Spinal Disability
in Older Adults with Manipulation and Exercise
Arthritis Care Res (Hoboken). 2019 (Nov); 71 (11): 1516–1524 ~ FULL TEXT

182 participants were randomized. The short-term and long-term groups demonstrated significant improvements in back (–3.9, 95% confidence interval (CI) –5.8 to –2.0 versus –6.3, 95% CI –8.2 to –4.4) and neck disability (–7.3, 95% CI –9.1 to –5.5 versus –9.0, 95% CI = –10.8 to –7.2) after 36 weeks, with no difference between groups (back 2.4, 95% CI –0.3 to 5.1; neck 1.7, 95% CI –0.8 to 4.2). The long-term management group experienced greater improvement in neck pain at week 36, self-efficacy at week 36 and 52, functional ability and balance.


Other Exercise Studies

Global Recommendations on Physical Activity for Health
Geneva: WHO; 2010: ISBN: 978 92 4 159 997 9

Physical inactivity is now identified as the fourth leading risk factor for global mortality. Physical inactivity levels are rising in many countries with major implications for the prevalence of noncommunicable diseases (NCDs) and the general health of the population worldwide.

Association Between Physical Activity,
Sedentary Behaviour and the
Trajectory of Low Back Pain

Spine J 2023 (Mar 20); S1529-9430(23)00110-9 ~ FULL TEXT

Moderate-to-vigorous intensity physical activity was significantly associated with the probability of having a severe LBP trajectory (unadjusted β –0.0276; 95%CI –0.0456 to –0.0097, p=0.003). For every one-minute increase in moderate-to-vigorous intensity physical activity per week, there was a 2.8%–point reduction in a participant's probability of having a severe LBP trajectory. No significant associations were identified between sedentary behavior or light intensity physical activity, and the probability of having a severe LBP trajectory.

Conclusion:   In people with a lifetime history of LBP, engagement in higher volumes of moderate to vigorous intensity physical activity at baseline was associated with a lower probability of developing a severe trajectory of LBP over one year.

Treatment Targets of Exercise for Persistent
Non-specific Low Back Pain: A Consensus Study

Physiotherapy 2021 (Sep); 112: 78–86

A total of 39 participants contributed to the consensus (15 in the national workshop and 24 in the international workshop), comprising two people with NSLBP, six clinicians and 31 researchers/clinicians. A total of 40 exercise treatment targets were generated, and 25 were retained after voting and ranking. The prioritised targets of exercise for persistent NSLBP were: improving function, improving quality of life, reducing pain, meeting patient-specific goals and reducing fear of movement.

"Like Peanut Butter and Jelly": A Qualitative Study of
Chiropractic Care and Home Exercise Among Older Adults
with Spinal Disability

BMC Geriatrics 2021 (Apr 23); 21 (1): 271

Older adults valued non-pharmacological treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complimentary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.

Exercise Treatment Effect Modifiers in Persistent
Low Back Pain: An Individual Participant Data
Meta-analysis of 3514 Participants From 27
Randomised Controlled Tials

British J Sports Medicine 2019 (Nov 28) [Epub] ~ FULL TEXT

Our IPD meta-analysis combined data from 27 randomised trials, which allowed us to examine a large sample with consistent data. We assessed the effectiveness of exercise therapy to provide context to our study and explored the impact of potential treatment effect modifiers. In our sample, exercise therapy was minimally effective for persistent non-specific low back pain outcomes, and it appears that for individuals using medication for low back pain, and possibly for those with no heavy physical demands at work, they may benefit more from exercise than other treatments. This study provides potentially useful information to help design future studies of exercise interventions that are better matched to specific subgroups.

The Fear Reduction Exercised Early (FREE) Approach to
Management of Low Back Pain in General Practice:
A Pragmatic Cluster-randomised Controlled Trial

PLoS Med. 2019 (Sep 9); 16 (9): e1002897 ~ FULL TEXT

Findings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP.

Cost-effectiveness of Spinal Manipulation, Exercise, and
Self-management for Spinal Pain Using an Individual
Participant Data Meta-analysis Approach:
A Study Protocol

Chiropractic & Manual Therapies 2018 (Nov 13); 26: 46 ~ FULL TEXT

This project capitalizes on a unique opportunity to combine clinical and economic data collected in a several clinical trials that used similar methods. The findings will provide important information on the value of spinal manipulation, exercise therapy, and self-management for spinal pain management in the U.S.

'I Didn't Pay Her to Teach Me How to Fix My Back':
A Focused Ethnographic Study Exploring Chiropractors'
and Chiropractic Patients' Experiences and Beliefs
Regarding Exercise Adherence

J Can Chiropr Assoc. 2017 (Dec); 61 (3): 219–230 ~ FULL TEXT

This study is based on interviews with 6 chronic LBP patients with a mean duration of low back pain of 10.0 years. You can just imagine the blame-gaming to come... patients who expect a quick fix coupled with DC too busy to take the time. In reality, exercise is not a panacea. At best it helps patients learn that pain does not mean they have been injured again, that it is just a side-effect of something we don't completely understand. The term ethnographic study suggests that the authors submerged themselves into the "lives, culture, or situation they are studying." I seriously doubt that interviewing 6 chronic patients comes close to that rarified definition. Even so, this article merits review.

Contemporary Biopsychosocial Exercise Prescription for
Chronic Low Back Pain: Questioning Core Stability
Programs and Considering Context

J Can Chiropr Assoc. 2017 (Mar); 61 (1): 6–17 ~ FULL TEXT

Evidence keeps building about the multi-system benefits of exercise [109]; this includes therapeutic exercise for chronic low back pain (CLBP). As suggested throughout this commentary, a focus on gross biological changes alone (muscle strength, endurance etc.) has limited value. Instead, more research is needed to examine the interplay between biological, psychological, and social factors - as this may have novel exercise prescription implications for patients with CLBP. This commentary provided an overview of some of the contextual factors that have biopsychosocial implications. It was described how these contextual factors can facilitate placebo or nocebo effects, impacting patients’ behaviors and outcomes.

Is Exercise Effective for the Management of Neck Pain and
Associated Disorders or Whiplash-associated Disorders?
A Systematic Review by the Ontario Protocol for
Traffic Injury Management (OPTIMa) Collaboration

Spine J 2016 (Dec); 16 (12): 1503–1523 ~ FULL TEXT

We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone.

Is Strength Training Associated With Mortality Benefits?
A 15 year Cohort Study of US Older Adults

Prev Med. 2016 (Jun); 87: 121–127 ~ FULL TEXT

Despite guidelines, only 21.7% of older adults currently meet recommendations of strength training at least twice each week, substantially lower than the 2010 national objective of 30%. [54] This underscores the need for additional programs to increase strength training among older adults to help engage patients in the “Exercise is Medicine” campaign. [34] This study further demonstrates the importance of encouraging doctors to recommend physical activity to patients as they would any other effective treatment, particularly since exercise has been shown to be as effective as some medications. [55] Identifying interventions to successfully engage older adults in guideline-concordant strength training has the potential to significantly reduce all-cause mortality in this population.

One- and Two-year Follow-up of a Randomized Trial of
Neck-specific Exercise with or without a Behavioural
Approach Compared with Prescription of Physical
Activity in Chronic Whiplash Disorder

J Rehabil Med 2016 (Jan); 48 (1): 56–64 ~ FULL TEXT

After 1-2 years, participants with chronic whiplash who were randomized to neck-specific exercise, with or without a behavioural approach, remained more improved than participants who were prescribed general physical activity.

A Tailored Exercise Program Versus General Exercise for a
Subgroup of Patients with Low Back Pain and Movement
Control Impairment: A Randomised Controlled Trial
with One-year Follow-up

Manual Therapy 2015 (Oct); 20 (5): 672–679 ~ FULL TEXT

Patient Specific Function Scale (PSFS) showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year.   This study found no additional benefit of specific exercises targeting movement control impairment (MCI)

Exercise, Not to Exercise, or How to Exercise in Patients
with Chronic Pain? Applying Science to Practice

Clinical J Pain 2015 (Feb); 31 (2): 108–114 ~ FULL TEXT

Given the body of evidence demonstrating the beneficial clinical effects of exercise in many different chronic pain (CP) disorders, exercise therapy is regarded as the cornerstone of conservative management in those with chronic musculoskeletal pain. The main goals of exercise in these patient groups are to reduce pain, improve physical fitness, and optimize participation in social, professional, and domestic activities. Improved physical fitness allows that daily activities can be performed at a lower percentage of maximum capacity and, possibly, with less likelihood of increasing symptoms.

What Are Patient Beliefs and Perceptions About Exercise
for Nonspecific Chronic Low Back Pain? A Systematic
Review of Qualitative Studies

Clin J Pain. 2014 (Nov); 30 (11): 995–1005 ~ FULL TEXT

Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue.   People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

The Efficacy of Manual Therapy and Exercise for
Different Stages of Non-specific Low Back Pain:
An Update of Systematic Reviews

J Man Manip Ther. 2014 (May); 22 (2): 59–74 ~ FULL TEXT

This systematic review updates the evidence for manual therapy (MT) with exercise or usual medical care (UMC) for different stages of LBP and provides recommendations for future studies.

Physical Exercise Interventions for Improving Performance-based
Measures of Physical Function in Community-dwelling, Frail
Older Adults: A Systematic Review and Meta-analysis

Arch Phys Med Rehabil. 2014 (Apr); 95 (4): 753-769 ~ FULL TEXT

Exercise has some benefits in frail older people, although uncertainty still exists with regard to which exercise characteristics (type, frequency, intensity, duration, setting, combinations) are most effective. When compared with control interventions, exercise has shown to improve gait speed and the Short Physical Performance Battery (SPPB) in the frail elderly. However, results are inconclusive for endurance outcomes, and no consistent effect was observed on balance and functional mobility.

Predictors of Response to Exercise Therapy for Chronic
Low Back Pain: Result of a Prospective Study
With One Year Follow-up

Eur J Phys Rehabil Med. 2014 (Apr); 50 (2): 143–151 ~ FULL TEXT

The individually designed exercise therapy program for chronic LBP was associated to clinically significant functional improvement both on discharge and at 1 year. Only severe pain intensity predicted poor treatment response on discharge. At one year, younger age and better mental health predicted improved outcome, while use of drugs and previous LBP treatments were associated with worse response. Adherence to the exercise program almost doubled the probability of a favorable outcome.

A Meta-analysis of Core Stability Exercise versus
General Exercise for Chronic Low Back Pain

PLoS One. 2012 (Dec 17); 7 (12): e52082 ~ FULL TEXT

Compared to general exercise, core stability exercise is more effective in decreasing pain and may improve physical function in patients with chronic LBP in the short term. However, no significant long-term differences in pain severity were observed between patients who engaged in core stability exercise versus those who engaged in general exercise.

Manual Therapy Followed by Specific Active Exercises
Versus a Placebo Followed by Specific Active
Exercises on the Improvement of Functional
Disability in Patients with Chronic
Non Specific Low Back Pain: A
Randomized Controlled Trial

BMC Musculoskelet Disord. 2012 (Aug 28); 13: 162 ~ FULL TEXT

This study confirmed the immediate analgesic effect of manual therapy (MT) over sham therapy (ST). Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic mechanisms at cortical level should be investigated more thoroughly.

Comparative Effectiveness of Exercise, Acupuncture,
and Spinal Manipulation for Low Back Pain

Spine (Phila Pa 1976). 2011 (Oct 1);   36 (21 Suppl):   S120–130 ~ FULL TEXT

Two studies were identified comparing the use of structured exercise with SMT that met our inclusion criteria. Although these studies utilized different approaches for the exercise and SMT treatment groups, patients in both groups improved in terms of pain and function in both studies. Using random-effects modeling, there was no difference between the exercise and SMT groups when the data from these studies were pooled. We identified no studies meeting our inclusion criteria that compared acupuncture with either structured exercise or SMT or that addressed the relative cost-effectiveness of these approaches in the treatment of patients with chronic LBP.

Manual Therapy and Exercise for Neck Pain:
A Systematic Review

Manual Therapy 2010 (Aug);   15 (4):   334–354

Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias.

Exercise Therapy for Chronic Nonspecific Low-back Pain
Best Pract Res Clin Rheumatol. 2010 (Apr);   24 (2):   193–204 ~ FULL TEXT

In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

A Randomized Trial of Combined Manipulation, Stabilizing
Exercises, and Physician Consultation Compared to
Physician Consultation Alone for Chronic
Low Back Pain

Spine (Phila Pa 1976) 2003 (Oct 1);   28 (19):   2185–2191 ~ FULL TEXT

For patients with chronic low back pain (CLBP), the short, specific manipulative treatment program with stabilizing exercises and a physician’s clinical examination, information, encouragement, and simple advice was more effective in reducing pain and disability than was merely a physician’s consultation and an educational booklet. Both treatment methods enhanced HRQoL and reduced the use of health-care services and costs. Results within these groups seem clinically significant. Whether the difference in 1–year outcomes between the groups is clinically significant remains debatable. However, patients recovered with no greater costs by the short manipulative-treatment method. We believe that our treatment modality is effective for most mechanical-origin CLBP patients.

Effect of Aerobic Exercise on Blood Pressure
Annals of Internal Medicine 2002: 136 (7): 493–503

Even a small decrease in average BP can dramatically lower your risk for cardiovascular disease and death. Whether or not you currently have high blood pressure, maintain a consistent regimen of aerobic exercise to ward off disease, premature death, and obesity.

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