Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews
References
References to included reviews
References to excluded reviews
Additional references
References to other published versions of this review
| Criteria | Specific requirements (possible answers: yes, no, cannot answer, not applicable) |
| 1. Was an 'a priori' design used? | The research question and inclusion criteria should be established before the conduct of the review. Note: need to refer to a protocol, ethics approval, or predetermined/a priori published research objectives to score a "yes." |
| 2. Was there duplicate study selection and data extraction? | There should be at least 2 independent data extractors and a consensus procedure for disagreements should be in place. Note: 2 people do study selection, 2 people do data extraction, consensus process or 1 person checks the other person's work. |
| 3. Was a comprehensive literature search performed? | At least 2 electronic sources should be searched. The report must include years and databases used (e.g. CENTRAL, MEDLINE, and Embase). Keywords or MeSH terms (or both) must be stated and where feasible the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialised registers, or experts in the particular field of study, and by reviewing the references in the studies found. Note: if at least 2 sources + 1 supplementary strategy used, select "yes"(Cochrane register/ CENTRAL counts as 2 sources; a grey literature search counts as supplementary). |
| 4. Was the status of the publication (i.e. grey literature) used as inclusion criteria? | The authors should state that they searched for reports regardless of their publication type. The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language, etc. Note: if review indicates that there was a search for "grey literature"or "unpublished literature,"indicate "yes."SIGLE database, dissertations, conference proceedings, and trial registries are all considered grey for this purpose. If searching a source that contains both grey and non‐grey, must specify that they were searching for grey/unpublished literature. |
| 5. Was a list of studies (included and excluded) provided? | A list of included and excluded studies should be provided. Note: acceptable if the excluded studies were referenced. If there was an electronic link to the list but the link is no longer active, select "no." |
| 6. Were the characteristics of the included studies provided? | In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions, and outcomes. The ranges of characteristics in all the studies analysed, e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity, or other diseases should be reported. Note: acceptable if not in table format as long as they are described as above. |
| 7. Was the scientific quality of the included studies assessed and documented? | 'A priori' methods of assessment should be provided (e.g. for effectiveness studies if the author(s) chose to include only randomised, double‐blind, placebo‐controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant. Note: can include use of a quality scoring tool or checklist, e.g. Jadad scale, risk of bias, sensitivity analysis, etc., or a description of quality items, with some type of result for EACH study ("low"or "high"is acceptable, as long as it is clear which studies scored "low"and which scored "high;"a summary score/range for all studies is not acceptable). |
| 8. Was the scientific quality of the included studies used appropriately in formulating conclusions? | The results of the methodological rigor and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations. Note: might say something such as "the results should be interpreted with caution due to poor quality of included studies."Cannot score "yes"for this question if scored "no"for question 7. |
| 9. Were the methods used to combine findings of studies appropriate? | For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi2 test for homogeneity, I2 statistic). If heterogeneity exists, a random‐effects model should be used or the clinical appropriateness of combining should be taken into consideration (i.e. is it sensible to combine?), or both. Note: indicate "yes"if they mention or describe heterogeneity, i.e. if they explain that they cannot pool because of heterogeneity/variability between interventions. |
| 10. Was the likelihood of publication bias assessed? | An assessment of publication bias should include a combination of graphical aids (e.g. funnel plot, other available tests) or statistical tests (e.g. Egger regression test), or both. Note: if no test values or funnel plot included, score "no."Score "yes"if they mention that publication bias could not be assessed because there were fewer than 10 included studies. |
| 11. Was the conflict of interest stated? | Potential sources of support should be clearly acknowledged in both the systematic review and the included studies. Note: to get a "yes,"must indicate source of funding or support for the systematic review AND for each of the included studies. |
| Review | Reason for exclusion from overview |
| Not exercise/physical activity | |
| Protocol stage only ‐ possibly include when published as full review | |
| Protocol stage only ‐ exclude when published as full review | |
| Withdrawn from the Cochrane Library | |
| Not chronic using definition of > 3 months | |
| Protocol stage only ‐ possibly include when published as full review | |
| Physiotherapy ‐ required therapist to perform intervention | |
| Acute pain, not chronic. Intervention was advice | |
| Malignant condition | |
| Drug‐ and surgery‐based interventions | |
| Did not include RCTs (excluded studies with control groups) | |
| Not exercise/physical activity | |
| Physiotherapy ‐ required therapist to perform intervention | |
| Withdrawn from the Cochrane Library | |
| Not exercise/physical activity | |
| Not exercise/physical activity | |
| Protocol stage only ‐ possibly include when published as full review | |
| Withdrawn from the Cochrane Library January 2015 | |
| Not exercise/physical activity | |
| Exercise could not be assessed as stand‐alone intervention | |
| Withdrawn from the Cochrane Library | |
| No exercise intervention, and no pain outcome measure | |
| Protocol stage only ‐ exclude when published as full review | |
| Protocol stage only ‐ exclude when published as full review | |
| Drug‐based interventions | |
| Intervention to improve adherence to exercise, not exercise itself | |
| Exercise could not be assessed as stand‐alone intervention | |
| Exercise could not be assessed as stand‐alone intervention | |
| Exercise could not be assessed as stand‐alone intervention | |
| Chronic fatigue, not chronic pain | |
| Pain in pregnancy only, not chronic pain | |
| Protocol stage only ‐ unsure about inclusion when published as full review | |
| Protocol stage only ‐ exclude when published as full review | |
| Exercise could not be assessed as stand‐alone intervention | |
| No pain outcome measure | |
| Overview of reviews, not systematic review | |
| Protocol stage only ‐ possibly include when published as full review | |
| No pain outcome measure | |
| Manual therapy ‐ required therapist to perform intervention | |
| Exercise could not be assessed as stand‐alone intervention | |
| No pain outcome measure | |
| Exercise could not be assessed as stand‐alone intervention | |
| Drug‐based interventions | |
| Protocol stage only ‐ possibly include when published as full review | |
| Not exercise/physical activity | |
| Not exercise/physical activity | |
| No pain outcome measure | |
| Occupational therapy ‐ exercise could not be assessed as stand‐alone intervention | |
| Exercise cannot be assessed as stand‐alone intervention | |
| Aged < 18 years ‐ not adults | |
| Not chronic pain and no specific pain outcome measure | |
| No pain outcome measure | |
| Not exercise/physical activity | |
| Surgery or required therapist to perform intervention | |
| RCT: randomised controlled trial. | |
| Review and Cochrane Review Group | Assessed as up to date | Chronic pain condition | Duration of pain/ diagnosis | Intervention description | Control description | Outcomes with data reported | Time points reported |
| Cochrane Musculoskeletal Group | Aug 2007 | Hip or knee OA | Not reported | All types of exercises developed in the therapeutic/heated indoor pool (ROM, dynamics, aerobics, etc.) were permitted. | No treatment or other treatment. | Function, quality of life, mental health, pain, adverse events | Post‐intervention (immediate), 6‐month follow‐up |
| Cochrane Musculoskeletal Group | Oct 2013 | Fibromyalgia | 12 yr (range 6 to 24) | Aquatic exercise training intervention defined as "exercise conducted in a vertical standing position." | Treatment as usual, physical activity as usual, wait list control, placebo or sham, education‐only, water immersion‐only, and attention only. | Multi‐dimensional function (wellness), self‐reported physical function (wellness), pain (symptoms), stiffness (symptoms), muscle strength (physical fitness), submaximal cardiorespiratory function (physical fitness), withdrawals (safety and acceptability), adverse effects (safety and acceptability) | Post‐intervention (4 to 32 wk) |
| Cochrane Injuries Group | Mar 2011 | Spinal cord injury | Mean 66 months, and 1 to 24 yr when reported | "Exercise": stretching and strengthening exercises aimed at mobilising painful shoulder joint. | Wait list control or no intervention. | Pain, depression, quality of life, adverse effects | Short term (within 24 hours of last intervention, i.e. post‐intervention) and intermediate term (1 to 6 wk post‐intervention) and long term (> 6 wk post‐intervention) |
| Cochrane Menstrual Disorders and Subfertility Group | Aug 2009 | Primary dysmenorrhoea in the majority (≥ 50%) of cycles | Ongoing/not appropriate | 12‐wk walk or jog training programme at an intensity of 70% to 85% of the HR range. Training for 3 days/wk and duration of aerobic phase was 30 minutes with 15‐minute warm‐up and cool‐down periods. | Asked not to exercise during the experimental period. | Pain: menstrual disorders questionnaire (MDQ) score | Ongoing ‐ over 3 menstrual cycles |
| Cochrane Musculoskeletal Group | Aug 2007 | Fibromyalgia | Not reported | Exercise‐only interventions included aerobic‐only training, strength‐only training, flexibility‐only training, or mixed exercise‐only interventions. | "Untreated." | Pain, global wellbeing, objectively measured physical function | Post‐intervention (strength exercise 21 wk, aerobic exercise 6 to 23 wk) |
| Cochrane Musculoskeletal Group | Mar 2013 | Fibromyalgia | mean range from 4 yrs (SD 3.1) to 12 yrs (SD 4) | Defined resistance training as exercise performed against a progressive resistance on a minimum of 2 days/wk (on non‐consecutive days) with the intention of improving muscle strength, muscle endurance, muscle power, or a combination of these. | Untreated control conditions (treatment as usual, activity as usual, wait list control, and placebo), other types of exercise or physical activity interventions (e.g. aerobic, flexibility), and other resistance training interventions (head‐to‐head comparisons). | Multi‐dimensional function, self‐reported physical function, pain, tenderness, muscle strength, adverse effects, all‐cause attrition | Post‐intervention, follow‐up (12 wk) in 1 study only |
| Cochrane Musculoskeletal Group | Oct 2012 | Rheumatoid arthritis | Not reported | Included pool‐based therapy (twice/wk, moderate intensity, music‐paced), yoga (6 wk, twice/wk, 1.5‐hour sessions), dynamic strength training (home‐based after inpatient programme, all main muscle groups using dumbbells and elastic bands), stationary cycling (70% HRmax, 5 minute excluding: 1‐minute of rest, increased duration), low‐impact aerobics (class at fitness centre and video at home, individual HR targets), tai chi (1‐hour group sessions). | "Could have been placebo, an alternative intervention (pharmacological or non‐pharmacological) or usual care." | Fatigue, pain, anxiety, depression, disability, tender and swollen joints, adverse events | Post‐intervention (only a single time point analysed) |
| Cochrane Musculoskeletal Group | May 2013 | Hip OA | Not reported | Any land‐based therapeutic exercise regimens aiming to relieve the symptoms of hip OA, regardless of content, duration, frequency, or intensity. This included any exercise designed to improve muscle strength, range of joint movement or aerobic capacity (or combinations of the three). Programmes could be designed and supervised by physiotherapists or other professionals, or provided as a home programme with minimal monitoring. | Wait‐list control, usual care, GP education. | Self‐reported pain, physical function, quality of life, withdrawal or dropouts, adverse events | post‐intervention (immediate in 9/10 studies) follow‐up 3 to 6 months |
| Cochrane Musculoskeletal Group | May 2013 | Knee OA | Often not reported: some less than 1yr, others over 10yr | "land‐based therapeutic exercise." Along with delivery mode and content, treatment 'dosage' (duration, frequency, intensity) varied widely between studies. | No exercise: active (any no‐exercise intervention) or no treatment (including waiting list). | Knee pain, self‐reported physical function, quality of life | Immediately at the end of treatment (post‐treatment), 2 to 6 months after cessation of monitored study treatment and longer than six months after cessation of monitored study treatment |
| Cochrane Back Group | May 2014 | Mechanical neck disorders | "Chronic" (not subacute or acute) | Cervical stretch/ROM exercises + cervical/scapulothoracic strengthening + static/dynamic cervical/shoulder stabilisation. | Wait list control. | Pain intensity, function, quality of life, global perceived effect, adverse effects | Immediately post‐treatment (≤ 1 day), |
| Cochrane Musculoskeletal Group | Apr 2004 | Rheumatoid arthritis | Not reported | Only trials of exercise programmes with tai chi instruction or incorporating principles of tai chi philosophy. | Not reported. | Function, tender and swollen joints, ROM, strength, enjoyment, withdrawals, adverse effects | Post‐intervention (8 to 10 wk) |
| Cochrane Back Group | Sep 2004 | Non‐specific low back pain | Chronic, i.e. longer than 12 wk: 5.6 yr (95% CI 3.4 to 7.8) | Exercise therapy defined as "a series of specific movements with the aim of training or developing the body by a routine practice or as physical training to promote good physical health;" only 54% adequately described the exercise intervention. | No exercise: no treatment or placebo treatment, other conservative therapy, or another exercise group. | Pain, functional ability, work status, global assessment, adverse events | Earliest, 6 wk, 6 months, 12 months |
| Cochrane Musculoskeletal Group | Jun 2009 | Rheumatoid arthritis | 5 to 14 yr | Dynamic exercise programmes ‐ aerobic capacity and muscle strength training; short‐term muscle strength training (high quality); short‐term dynamic exercise to improve aerobic capacity (not high methodological quality); exercise frequency of at least 20 minutes twice a week. Duration of exercise programme at least 6 wk (duration < 3 months was considered short‐term; duration > 3 months was considered long‐term). Exercise programme performed under supervision. Aerobic exercise intensity at least 55% of the maximum HR; or intensity starting at 40% to 50% of the maximum oxygen uptake reserve or HR maximum reserve. Furthermore, the intensity was increased up to 85% during the intervention. Progressively strengthening exercise loads starting at 30% to 50% and increasing to 80% of maximum (defined as the percentage of either 1 repetition maximum, 1 MVC, maximum speed, or as maximal subjective exertion). | Not reported | Functional ability, aerobic capacity, muscle strength, safety (pain and radiological damage) | Follow‐up (12 wk and 24 months) |
| Cochrane Neuromuscular Group | Jul 2014 | Postpolio syndrome (PPS) | Not reported | Exercise therapy (e.g. aerobic exercise, muscle strengthening exercise, respiratory muscle training, warm climate training, hydro training). | Placebo, usual care or no treatment. | Self‐perceived activity limitations, muscle strength, muscle endurance, fatigue, pain, adverse events (minor and serious) | 3 and 6 months |
| Cochrane Peripheral Vascular Diseases Group | Sep‐2013 | intermittent claudication | not reported | Any exercise programme used in the treatment of intermittent claudication was included, such as walking, skipping and running. Inclusion of trials was not affected by the duration, frequency or intensity of the exercise programme but these issues were taken into account in the meta‐analysis | Exercise was compared to six different modes of treatment, the most common being usual care or placebo. Two early trials compared exercise with placebo tablets but in more recent studies usual care was used as the control comparator. Exercise was compared with the following drug therapies: antiplatelet agents pentoxifylline, iloprost, and vitamin E. One study compared exercise with pneumatic foot and calf compression. | maximal walking time, pain‐free walking time, pain‐free walking distance, maximum walking distance, ankle brachial index (ABI), peak exercise calf blood flow, mortality, amputation | Post‐intervention, 3‐month follow up, six‐month follow up |
| Cochrane Peripheral Vascular Diseases Group | Jul 2013 | Intermittent claudication | Not reported | Supervised walking programme needed to be supervised at least twice a week for a consecutive 6 wk of training. | Alternative exercise. | Maximum walking distance (METs), pain‐free walking distance (METs), health‐related quality of life and functional impairment | n/a |
| Cochrane Musculoskeletal Group | Jun 2014 | Hip or knee OA | > 6 months | High‐intensity physical activity or exercise programme. | Low‐intensity physical activity or exercise programme and control (no‐exercise) group in 1 study. | Pain, physical function, quality of life, adverse effects (related to intervention), severe adverse events or withdrawal (due to intervention) | Post‐intervention, intermediate term (6 to 12 months), long‐term (over 12 months) follow‐up |
| Cochrane Back and Neck Group | Apr 2015 | Low back pain | > 12 wk | MCE: activation of the deep trunk muscles, targeting the restoration of control and co‐ordination of these muscles. | Placebo, no treatment, another active treatment, or when MCE was added as a supplement to other interventions. When MCE was used in addition to other treatments, it had to represent at least 50% of the total treatment programme to be included. | Pain intensity and disability, function, quality of life, global impression of recovery, return to work, adverse events and recurrence | Post‐intervention, short term (4 to 10 wk), intermediate term (3 to 6 months), long term (12 to 36 months) |
| Cochrane Musculoskeletal Group | Jun 2009 | Rheumatoid arthritis | No studies found | Balance training (proprioceptive training). | No intervention or other intervention. | ACR‐50, pain, disease activity score (DAS), Health Assessment Questionnaire (HAQ for function), gait, adverse effects, discontinuation rate | n/a |
| Cochrane Bone, Joint and Muscle Trauma Group | May 2014 | Adolescents and adults with patellofemoral pain | 3 wk to 8 months (as minimum requirement); reported pain 4 wk to 9 yr | Exercise therapy for patellofemoral pain syndrome; exercises could be performed at home or under supervision of a therapist ‐ various descriptions in the included trials, including knee exercises, hip and knee exercises, home exercises, supervised exercises, closed kinetic chain, open kinetic chain. | No treatment, placebo, or waiting list controls. This also included 'exercise therapy + another intervention (e.g. taping) versus the other intervention alone (e.g. taping).' | Pain during activity, usual pain, functional ability, recovery | 4‐ to 12‐wk follow‐up (short term) and 16 wk to 12 months (long term) |
| Cochrane Back Group | Mar 2014 | Low back pain | Acute, subacute, chronic (i.e. no minimum) | Explicitly stated as based on Pilates principles, or the therapists who provided the interventions had previous training in Pilates exercises or the therapists were described as certified Pilates instructors | No intervention, placebo, or other interventions. | Pain intensity, disability, global impression of recovery, quality of life, return to work, adverse effects | Short term (4 to 8 wk), intermediate term (3 to 6 months) |
| ACR: American College of Rheumatology; GP: general practitioner; HR: heart rate; MCE: motor control exercise; MET: metabolic equivalents; n/a: not applicable; OA: osteoarthritis; ROM: range of motion; wk: week; yr: year. | |||||||
| Review | Number of trials included | Total number of participants | Gender distribution | Participants ages |
| 6 (4 exercise vs no exercise) | 800 (674 exercise vs no exercise) | 50% to 86% Female | Means ranged from 66 to 71 yr | |
| 16 (9 exercise vs no exercise) | 881 (519 exercise vs no exercise) | 513 female, 6 male | Means ranged from 46.3 to 48.3 yr | |
| 16 (3 exercise vs no exercise) | 616 (149 exercise vs no exercise) | 115 male, 41 female across 3 studies | Range 19 to 65 yr and mean 35 to 45 yr | |
| 1 | 36 | 100% female | Not reported | |
| 34 (in meta‐analysis ‐ strength training vs control: 2; | 2276 total (in meta‐analysis ‐ strength: 47, aerobic: 269) | 96.4% female when reported (in 2197 participants) | Range reported as 27.5 to 60.2 yr | |
| 5 studies as 7 publications (exercise vs control: 3 publications, 2 studies) | 219 with fibromyalgia (exercise vs control: 81) | 100% female | Not reported | |
| 24 (only 6 using physical activity interventions) | 2882 (physical activity interventions: 371) | "A higher percentage of females"… when reported | "Mainly within the fifth decade" | |
| 10 | > 549 | 75% to 80% female when reported | 58 to 70 yr (means) when reported | |
| 54 | 5362 | When reported 55% to 100% female | When reported mean age 60 to 70 yr | |
| 27 (16 chronic pain) | 2485 | Not reported | Not reported | |
| 4 (3 RCTs). Pain not reported in any included study | 206 total; pain not reported in any included study | Not reported | Range 38 to 72 yr | |
| 61 (43 chronic low back pain) | 6390 (3907 chronic low back pain) | Chronic: 46% male (95% CI 39 to 52) | Chronic: 42 yr (95% CI 40 to 44) | |
| 8 RCTs (5 exercise vs no‐exercise) | 575 | "Mainly female" | 52 yr | |
| 13 (2 exercise vs no exercise) | 675 (68 exercise vs no exercise) ‐ 1 study used 3 arms (no treatment in cold, exercise in cold, exercise in warm; we have excluded the warm exercise arm as cannot compare directly to the control) | ˜ 25% male | Mean 58 and 65 yr | |
| 30 | 1822 total | Not reported | Mean > 65 yr | |
| 5 (0 for exercise vs no exercise) | 184 (0 for exercise vs no exercise) | n/a | n/a | |
| 6 (1 for exercise vs no exercise) only 1 study that had a no exercise control | 656 (102 for exercise vs no exercise) | 79 female | 62.6 yr | |
| 29 (7 for exercise vs no exercise/minimal intervention) | 2431 (671 for exercise vs no exercise) | "Mixed" | Median 40.9 yr (IQR 11.2) (range 20.8 to 54.8) | |
| None | None | n/a | n/a | |
| 31 (10 for exercise vs control) | 1690 | 0% to 100% female; equally distributed across range | Mean 25 to 50 yr | |
| 10 (6 exercise vs minimal intervention (control)) | 478 (265 exercise vs control) | 2 trials were all female, the others included both genders | Mean 38 yr (range 22 to 50) | |
| CI: confidence interval; GP: general practitioner; IQR: interquartile range; OA: osteoarthritis; RCT: randomised controlled trial; ROM: range of motion; wk: week; yr: year. | ||||
| Review | Duration | Frequency | Intensity | Duration | Other description |
| Not reported | Not reported | "Muscle maintenance" and "range of motion" | Not reported | No minimum requirement for inclusion. | |
| 17 wk (range 4 to 32) | 1 to 4/wk | Very light (< 57% HRmax) to vigorous (95% HRmax), self‐selected, and not specified | 45 minutes (range 30 to 70) | No minimum requirement for inclusion. None of the studies met the ACSM exercise guidelines specified for aerobic or strength training. Only 1 study met the ACSM guidelines for flexibility training. | |
| 12 wk to 9 months | 2/day to 2/wk | Not reported | Reported for 1 study only (90 to 120 minutes) | No minimum requirement for inclusion. Stretching and strengthening exercises aimed at mobilising painful shoulder joint. | |
| ≥ 12 wk | 3/wk | 70% to 85% HRR | 1 hour | No minimum requirement for inclusion. | |
| 3 wk to 6 months | 1 to 5/wk | Not reported | Not reported | No minimum requirement for inclusion. | |
| 8 to 21 wk (median 16 wk) | ≥ 2/wk | > 4/10 RPE rating progressing to 70% to 80% 1RM | 40 to 90 minutes | Assessed as whether they "met ACSM recommendations." | |
| 6 wk (when reported) | 2/wk | "Low impact", "moderate", and 70% HRmax | 1 to 1.5 hours, when reported | No minimum requirement for inclusion. | |
| 6 to 12 wk (median 8) | 1 to 3/wk | "Low intensity" to "max effort" | 30 to 60 minutes | No minimum requirement for inclusion. | |
| single session to 30 months | 1 to 5/wk | "Moderate to moderately high intensity" | 15 to 60 minutes | No minimum requirement for inclusion. | |
| 2 wk to 3 months | 5/wk to every 15 minutes/day | Low intensity | 2 to 20 minutes | ‐ | |
| 8 to 10 wk (when reported) | 1 to 7/wk (median 1/wk) | Tai chi = low intensity | 1 to 1.5 hours | No minimum requirement for inclusion. | |
| Not reported | Not reported | Not reported | Not reported | No minimum requirement for inclusion. | |
| ≥ 6 wk | 2/wk | Aerobic: ≥ 55% HRmax increasing to 85% HRmax | 20 minutes | ‐ | |
| 4 to 12 wk | Daily to 3/wk | Reported in 1 study: 50% to 70% MVC | 45 minutes | No minimum requirement for inclusion. 1 study: supervised progressive resistance training consisting of 3 sets of 8 isometric contractions of the thumb muscles. 1 study: combination of individual and group therapy with daily treatment in a swimming pool (45 minutes), physiotherapy, individually adapted training programme. | |
| 3 to 12 months | ≥ 2/wk | "Variable" | ˜ 60 minutes | No minimum requirement for inclusion. | |
| ≥ 6 wk | ≥ 2/wk | Not reported | Not reported | No minimum requirement for inclusion. | |
| 8 wk | 3/wk | Compared high vs low intensity vs control | 30 to 50 minutes | Every 2 wk 1RM was retested and increased by 5% as tolerated in each group. Supervision: an experienced therapist. 3 arms (n=34 per arm): high intensity, low intensity, control (no exercise). | |
| 20 days to 12 wk (median 8 wk (IQR 2.0)) | 1 to 5/wk (median 12 sessions (IQR 6.0)) | Not reported | 20 to 90 minutes (median 45 (IQR 30) minutes) | MCE is usually delivered in 1:1 supervised treatment sessions, and sometimes involves ultrasound imaging, the use of pressure biofeedback units or palpation to provide feedback on the activation of trunk muscles. | |
| ≥ 6 wk | 2/wk | Balance training only | ≥ 30 minutes | No studies found. | |
| 3 to 16 wk | 2/wk to daily | Not reported | Not reported | No minimum requirement for inclusion. | |
| 10 to 90 days (mostly 8 wk) | 2/wk (mean session number 15.3, range 6 to 30) | Not reported | 1 hour | No minimum requirement for inclusion. | |
| 1RM: one repetition maximum; ACSM: American College of Sport Medicine; HRmax: maximum heart rate; HRR: heart rate reserve, IQR: interquartile range; MCE: motor control exercise; MVC: maximum voluntary contraction; RPE: rating of perceived exertion; wk: week. | |||||
| Review | Criteria | Total "Y" | Total "N" | Total "n/a" | ||||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | ||||
| Y | Y | Y | Y | Y | N | Y | Y | Y | N | N | 8 | 3 | ‐ | |
| N | Y | Y | Y | Y | Y | Y | Y | Y | N | N | 8 | 3 | ‐ | |
| Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | 10 | 1 | ‐ | |
| Y | Y | Y | N | Y | Y | Y | Y | n/a | N | N | 7 | 3 | 1 | |
| Y | Y | Y | N | Y | Y | Y | Y | Y | N | N | 8 | 3 | ‐ | |
| Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | 10 | 1 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | Y | N | 9 | 2 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | N | N | 8 | 3 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | N | N | 8 | 3 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | Y | N | 9 | 2 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | N | N | N | 7 | 4 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | 10 | 2 | ‐ | |
| Y | Y | Y | Y | Y | Y | Y | Y | Y | N | N | 9 | 2 | ‐ | |
| Y | Y | Y | Y | Y | Y | Y | Y | Y | N | Y | 10 | 1 | ‐ | |
| Y | Y | Y | Y | Y | Y | Y | Y | N | Y | N | 9 | 2 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | Y | N | 9 | 2 | ‐ | |
| Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | 10 | 1 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | Y | N | 9 | 2 | ‐ | |
| Y | Y | Y | Y | Y | n/a | n/a | n/a | n/a | n/a | Y | 6 | 0 | 5 | |
| Y | Y | Y | Y | Y | Y | Y | Y | Y | N | N | 9 | 2 | ‐ | |
| Y | Y | Y | Y | Y | N | Y | Y | Y | Y | N | 9 | 2 | ‐ | |
| Total "Y" | 20 | 21 | 21 | 19 | 21 | 10 | 20 | 20 | 17 | 10 | 3 | ‐ | ‐ | ‐ |
| Total "N" | 1 | ‐ | ‐ | 2 | ‐ | 10 | ‐ | ‐ | 2 | 10 | 18 | ‐ | ‐ | ‐ |
| Total "n/a" | ‐ | ‐ | ‐ | ‐ | ‐ | 1 | 1 | 1 | 2 | 1 | ‐ | ‐ | ‐ | ‐ |
| N: no; n/a: not applicable; Y: yes; out of maximum summative score of 11. Following arbitration, the authors removed the response "cannot answer" due to no responses as such. | ||||||||||||||
| Review | Number of studies in assessment | Selection bias | Performance bias | Detection bias | Attrition bias | Reporting bias | Other bias | ||
| Random sequence generation (studies) | Allocation concealment (studies) | Blinding of participants and personnel (studies) | Blinding of outcome assessment (studies) | Incomplete outcome data (studies) | Selective reporting (studies) | Sample size | Other biases (studies) | ||
| 6 | Not reported | 3 | Not reported | 2 | 3 | Not reported | 2, n > 100 per arm | ‐ | |
| 9 | 5 | 3 | 2 | 8 | 8 | 5 | 1, n > 50 per arm | 7 | |
| 3 | 1 | 1 | 0 | 1 | 2 | 3 | 0 | 1 | |
| 1 | 0 | 0 | 0 | 0 | 1 | 1 | 1, n > 50 per arm | ‐ | |
| 34 | 17 | 10 | 8 | 20 | Unclear | 32 | 5, n > 50 per arm | ‐ | |
| 5 | 4 | 2 | 1 | 2 | 5 | 3 | 0, n > 50 per arm | ‐ | |
| 7 | 5 | 2 | 0 | Not reported | 6 | 4 | 1 | ||
| 10 | 8 | 7 | 0 | 0 | 7 | 4 | 1, n > 50 per arm | 7 | |
| 54 | 40 | 22 | 3 | 4 | 29 | 10 | 5, total n > 200 | ||
| 16 | 8 | 8 | 1 | 0 | 11 | 0 | 0 | 11 | |
| 4 | 2 | 0 | 0 | 0 | 0 | Not reported | 0 | ||
| 43 | 27 | 22 | Not reported | 12 | 29 | Not reported | 10, total n > 100 | ‐ | |
| 8 | 8 | 1 | ‐ | 4 | 5 | ‐ | 1, total n > 200 | 1 | |
| 2 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | |
| 30 | 16 | 14 | 30 | 7 | 19 | 29 | 3, total n > 100 | ||
| 5 | 4 | 2 | 5 | 3 | 4 | 5 | 1, total n > 100 | 4 | |
| 1 | 1 | 0 | 0 | 1 | 0 | 0 | 1, total n > 100 | 1 | |
| 7 | 5 | 4 | 1 | 1 | 2 | 7 | 1, total n > 100 + 1, total n > 200 | 7 | |
| 0 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | |
| 10 | 8 | 6 | 0 | 0 | 6 | 9 | 2, total n > 100 | 10 | |
| 9 | 5 | 5 | 2 | 7 | 7 | 9 | 0 | 9 | |
| Studies with low risk of bias (number) | 264 | 165 | 112 | 53 | 72 | 144 | 121 | total n > 100: 26 | 71 |
| Studies with low risk of bias (percentage) | ‐ | 63% | 42% | 20% | 27% | 55% | 46% | total n > 100: 10% | 27% |
| n: number of participants, n/a: not applicable. | |||||||||
| Review | Review authors' conclusions | Overview authors' assessment of conclusions |
| "Aquatic exercise has some short‐term beneficial effects on the condition of OA patients with hip or knee OA or both. The controlled and randomised studies in this area are still too few to give further recommendations on how to use this therapy... No long‐term effects have been found." | Appropriate conclusions based on available data. No mention of quality/risk of bias in conclusions, though found to be high quality in results section. | |
| "Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. Very low to low quality evidence suggests that there are benefits of aquatic and land‐based exercise, except in muscle strength (very low quality evidence favoring land). No serious adverse effects were reported." | Appropriate conclusions based on available data. | |
| "Evidence is insufficient to suggest that non‐pharmacological treatments are effective in reducing chronic pain in people living with SCI. The benefits and harms of commonly used non‐pharmacological pain treatments should be investigated in randomised controlled trials with adequate sample size and study methodology" | Appropriate conclusions based on available data. | |
| "There is a lack of available evidence to support the use of exercise in the alleviation of symptoms associated with dysmenorrhoea. The limited evidence implies that there are no adverse effects associated with exercise." | Review authors should not have commented on lack of adverse events as this was not reported in the included study. The comment on lack of adverse events contravened present Cochrane guidance. | |
| "There is moderate quality evidence that short‐term aerobic training (at the intensity recommended for increases in cardiorespiratory fitness) produces important benefits in people with FM in global outcome measures, physical function, and possibly pain and tender points. There is limited evidence that strength training improves a number of outcomes including pain, global wellbeing, physical function, tender points and depression. There is insufficient evidence regarding the effects of flexibility exercise. Adherence to many of the aerobic exercise interventions described in the included studies was poor." | Appropriate conclusions based on available data. | |
| "We have found evidence in outcomes representing wellness, symptoms, and physical fitness favoring resistance training over usual treatment and over flexibility exercise, and favoring aerobic training over resistance training. Despite large effect sizes for many outcomes, the evidence has been decreased to low quality based on small sample sizes, small number of randomized clinical trials (RCTs), and the problems with description of study methods in some of the included studies." | Appropriate conclusions based on available data. | |
| "There is some evidence that physical activity interventions ... may help to reduce fatigue in RA. However, the optimal parameters and components of these interventions are not yet established." | Appropriate conclusions based on available data. However, no mention of quality/risk of bias of studies in conclusion despite low/unclear quality score in results and discussion sections. No conclusions about effect on pain (insufficient data). | |
| "There is currently high‐level evidence that land‐based exercise will reduce hip pain, and improve physical function, among people with symptomatic hip osteoarthritis." | Evidence was good quality though sample sizes were often small (i.e. it is debatable if this was high level evidence as claimed by authors). Agree that results demonstrate small but significant benefit from intervention. | |
| "High‐quality evidence suggests that land‐based therapeutic exercise provides benefit in terms of reduced knee pain and quality of life and moderate‐quality evidence of improved physical function among people with knee OA… Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias." | Appropriate conclusions based on available data. May have been generous with quality assessment but this was stated in conclusions for transparency. | |
| "…there is still no high quality evidence and uncertainty about the effectiveness of exercise for neck pain… Moderate quality evidence supports the use specific strengthening exercises as a part of routine practice … Moderate quality evidence supports the use of strengthening exercises, combined with endurance or stretching exercises may also yield similar beneficial results. However, low quality evidence notes when only stretching or only endurance type exercises … there may be minimal beneficial effects for both neck pain and function." | Appropriate conclusions based on available data. | |
| "Tai chi appears to have no detrimental effects on the disease activity of RA in terms of swollen/tender joints and activities of daily living…tai chi appears to be safe, since only 1 participant out of 121 withdrew due to adverse effects and withdrawals were greater in the control groups than the tai chi groups." | Appropriate conclusions based on available data. However, no mention of quality/risk of bias in conclusion despite very low quality score in results section. | |
| "Evidence from randomized controlled trials demonstrates that exercise therapy is effective at reducing pain and functional limitations in the treatment of chronic low‐back pain, though cautious interpretation is required due to limitations in this literature." | Appropriate conclusions based on available data. However, no mention of quality/risk of bias of studies in conclusion despite low quality score in results and discussion sections. | |
| "Short‐term, land‐based dynamic exercise programs have a positive effect on aerobic capacity (aerobic capacity training whether or not combined with muscle strength training) and muscle strength (aerobic capacity training combined with muscle strength training) immediately after the intervention, but not after a follow‐up period. Short‐term, water‐based dynamic exercise programs have a positive effect on functional ability and aerobic capacity directly after the intervention but it is unknown whether these effects are maintained after follow‐up. Long‐term, land‐based dynamic exercise programs (aerobic capacity and muscle strength training) have a positive effect on functional ability, aerobic capacity, and muscle strength immediately after the intervention but it is unknown whether these effects are maintained after follow‐up... Based on the evidence, aerobic capacity training combined with muscle strength training is recommended for routine practice in patients with RA." | Appropriate conclusions based on available data. However, no mention of quality/risk of bias of studies in conclusion. No conclusions regarding pain severity. | |
| "Data from two single trials suggested that muscle strengthening of thumb muscles (very low‐quality evidence) ... are safe and beneficial for improving muscle strength ... with unknown effects on activity limitations." "We found evidence varying from very low quality to high quality that ... rehabilitation in a warm or cold climate are not beneficial in PPS." "Due to a lack of good‐quality data and randomised studies, it was impossible to draw definitive conclusions about the effectiveness of interventions in people with PPS." | Appropriate conclusions based on available data. | |
| "… Exercise therapy should play an important part in the care of selected patients with intermittent claudication, to improve walking times and distances. Effects were demonstrated following three months of supervised exercise although some programmes lasted over one year." | Appropriate conclusions based on available data. However, no mention of quality/risk of bias of studies in conclusion. No conclusions regarding pain severity. | |
| "There was no clear evidence of differences between supervised walking exercise and alternative exercise modes in improving the maximum and pain‐free walking distance of patients with intermittent claudication…. The results indicate that alternative exercise modes may be useful when supervised walking exercise is not an option for the patient." | Appropriate conclusions based on available data. However, no mention of quality/risk of bias of studies in conclusion (in discussion). | |
| "We found very low‐ to low‐quality evidence for no important clinical benefit of high‐intensity compared to low‐intensity exercise programs in improving pain and physical function in the short term.... The included studies did not provide any justification for the levels of intensity of exercise programs. No authors reported evidence for the minimal and maximal intensity that could be delivered." | Appropriate conclusions based on available data. This overview has only used one study of the six included as it alone included a control group, for which we could not extract data as the control comparison was not used in the analysis by the review authors. | |
| "There is very low to moderate quality evidence that MCE has a clinically important effect compared with a minimal intervention for chronic low back pain... As MCE appears to be a safe form of exercise and none of the other types of exercise stands out, the choice of exercise for chronic low back pain should depend on patient or therapist preferences, therapist training, costs and safety." | Appropriate conclusions based on available data. | |
| "We were not able to provide any evidence to support the application of balance exercises (proprioceptive training) alone in patients with RA." | Appropriate conclusions based on available data (no included studies). | |
| "This review has found very low quality but consistent evidence that exercise therapy for patellofemoral pain syndrome (PFPS) may result in clinically important reduction in pain and improvement in functional ability." | No subgroup analysis to differentiate between acute, subacute, and chronic pain made it difficult to extract appropriate data for this review. | |
| "No definite conclusions or recommendations can be made as we did not find any high quality evidence for any of the treatment comparisons, outcomes or follow‐up periods investigated. However, there is low to moderate quality evidence that Pilates is more effective than minimal intervention in the short and intermediate term as the benefits were consistent for pain intensity and disability, with most of the effect sizes being considered medium." | Appropriate conclusions based on available data. There was no subgroup analysis to differentiate between acute, subacute, and chronic pain made it difficult to extract appropriate data for this review (one included study had subacute back pain (> 6 weeks), all others were chronic back pain (> 12 weeks)) but results are presented altogether as chronic pain. | |
| FM: fibromyalgia; MCE: motor control exercise; OA: osteoarthritis; PPS: postpolio syndrome; RA: rheumatoid arthritis; SCI: spinal cord injury. | ||
| Review | Number of trials (and participants) assessing 'pain severity' | Baseline pain score | Post‐intervention reported result or change data (or if only one data point reported in review) | Follow‐up | Overall comment/statement |
| (osteoarthritis) | Hip + knee OA: Post‐intervention: 4 (638) Follow‐up: 1 (310) Hip only: follow‐up: 1 (17) Knee only: post‐intervention: 1 (46) | Control baseline: Hip + knee OA WOMAC 0 to 20 (2 studies): 9.10 (SD 3.14) VAS 0 to 100 (1 study): 55.3 (SD 24.6) HAQ 0 to 3 (1 study): 1.05 (SD 0.61) Hip only VAS 0 to 100 (1 study): 56 (SD 21.89) Knee only VAS 0 to 10 (1 study): 5.6 (SD 1.4) | Hip + knee OA A minor effect of a 3% absolute reduction (0.6 fewer points on WOMAC 0 to 20 scale) and 6.6% relative reduction SMD 0.19 (95% CI 0.04 to 0.35) (P = 0.02) Knee only SMD 0.86 (95% CI 0.25 to 1.47) (P = 0.005) Absolute difference 12% (1.2 fewer points on a 0 to 10 scale) Relative change 22% improvement | Hip + knee OA Follow‐up at 6 months: SMD 0.11 (95% CI ‐0.12 to 0.33) (ns) No difference Hip only SMD 1.00 (95% CI ‐0.04 to 2.04) (P = 0.06, ns) | Statistically significant post‐intervention in hip + knee OA group, but not clinically significant. Knee‐only OA had moderate to large effect size (statistically significant) immediately post‐intervention. |
| (fibromyalgia) | Post‐intervention: 7 (382) | Weighted mean score at baseline (all participants): 69.59 | On 100‐point scale: MD ‐6.59 (95% CI ‐10.71 to ‐2.48) SMD ‐0.53 (95% CI ‐0.76 to ‐0.31) NNTB 5 (95% CI 3 to 8) | 3 studies at 12, 48, or 52 weeks' post‐intervention | "We found a moderate effect favouring the aquatic exercise training for pain" …"similar improvements in pain in the low pain groups (SMD ‐0.60, 95% CI ‐0.98 to ‐0.23) and in the high pain groups (SMD ‐0.57, 95% CI ‐1.11 to ‐0.03)." Among the major wellness outcomes, none of the outcomes met the threshold for clinically relevant differences (15%). |
| (spinal cord injury) | Post‐intervention: 3 (149) | WUSPI score 22.6 (exercise group) to 11.05 (control group) in 1 group at baseline Not reported for 2 studies | WUSPI change score: Exercise group: ‐7.7 (SD 19.01) Control group: 12.8 (SD 12.74) SF‐36 (pain experience): ‐1.9 (95% CI ‐3.4 to ‐0.4) favoured exercise (P = 0.01) VAS (0 to 10): MD ‐2.8 (95% CI ‐3.77 to ‐1.83) favoured exercise (P < 0.00001) | 1 study at 4 weeks: VAS (0 to 10): ‐2.50 (95% CI ‐3.48 to ‐1.52) (P < 0.00001) WUSPI: ‐26.40 (95% CI ‐37.62 to ‐15.18favoured exercise (P < 0.00001) | "All three studies were fraught with high overall risk of bias. In particular, the comparison with 'no treatment' or waiting lists as control interventions likely leads to an overestimation of the effectiveness of the exercise programmes provided in these studies. Consequently, no conclusion on their effectiveness can be drawn." |
| (fibromyalgia) | Strength training: 1 (21) Aerobic training: 3 (183) | Control baseline: Aerobic: 6.1/10 (VAS) (SD 1.97) Strength: 35/100 (VAS) (SD 19) | Aerobic training: SMD 0.65 (95% CI ‐0.09 to 1.39) (ns) Weighted absolute change 13% (1.3 cm lower on 10‐cm scale) Relative change 21% Strength training: SMD 3.00 (95% CI 1.68 to 4.32) (ns) Weighted absolute change 49% (49 points lower on 100‐point scale) Relative change 140%, NNTB 2 | n/a | ">30% improvement was seen in the strength training group as compared to an untreated control group in pain." Aerobic training led to an improvement of 1.3/10. |
| (fibromyalgia) | Post‐intervention: 2 (81) Follow‐up at 8 weeks, 16 weeks, 28 weeks: 1 (60) | Not reported ‐ change data only | Change score on VAS (in cm): SMD ‐1.89 (95% CI ‐3.86 to 0.07) Relative % change 44.6% (95% CI 3.5 to 85.9) favoured exercise NNTB 2 (95% CI 1 to 34) | 8 weeks: MD ‐0.68 (95% CI ‐1.62 to 0.26) (ns) 16 weeks: MD ‐1.79 (95% CI ‐2.70 to ‐0.88) (P < 0.001) 28 weeks: MD ‐0.85 (95% CI ‐1.77 to 0.07) (P = 0.07, ns) Overall (n = 180): MD ‐1.12 (95% CI ‐1.65 to ‐0.58) (P < 0.0001) | > 30% improvement post‐intervention. |
| (rheumatoid arthritis) | 4 (not reported) | Not reported | In narrative only ‐ Harkcom 1985: statistics not reported separately for pain data, but reported as improvement over time; Hakkinen 2003: "stat significant improvement in 24 months"; Evans 2012 and Wang 2008: no statistically significant effects | Not reported | "Improvement over time" with "significant improvement in 24 months." No actual data available. |
| (OA) | End of treatment: 9 (549) 3 to 6 months: 5 (391) | Not reported; land based exercise vs no exercise: mean pain in control group ˜ 29/100 (based on 9 studies' control values) | End of treatment: SMD ‐0.38 (95% CI ‐0.55 to ‐0.20) "small to moderate" favoured exercise (P < 0.0001) | 3 to 6 months: SMD ‐0.38 (95% CI ‐0.58 to ‐0.18) "small to moderate" favoured exercise (P = 0.0002) | "Small to moderate" statistically significant improvement, but only mild pain at baseline. |
| (OA) | End of treatment: 44 (3537) Follow‐up (2 to 6 months): 12 (1468) Follow‐up (> 6 months): 8 (1272) | Not reported; land‐based exercise vs no exercise: mean pain in control group 44/100 (based on 1 study control values) | Land‐based exercise vs no exercise: Mean pain in intervention groups was 0.49 SDs lower (95% CI 0.39 to 0.59 lower). SMD ‐0.49 (95% CI ‐0.39 to ‐0.59) (P < 0.00001) Absolute reduction 12% (95% CI 10% to 15%) Relative change 27% (95% CI 21% to 32%) NNTB 4 (95% CI 3 to 5) | 2 to 6 months: SMD ‐0.24 (95% CI ‐0.35 to ‐0.14) favoured exercise (P < 0.00001) > 6 months: SMD ‐0.52 (95% CI ‐1.01 to ‐0.03) favoured exercise (P = 0.04) | Absolute improvement of 12/100 post‐intervention (statistically significant). |
| (mechanical neck disorders) | 12‐week treatment: 2 (147) 24 week (or 12‐week treatment + 12‐week follow‐up): 2 (140) | Not reported, but control scores at end of treatment 40 to 60/100 (moderate pain) | 12 weeks: pooled MD ‐14.90 (95% CI ‐22.40 to ‐7.39) favoured exercise (P = 0.0001) | 24 weeks: pooled MD ‐10.94 (95% CI ‐18.81 to ‐3.08) favoured exercise (P = 0.0064) | 2 trials showed a moderate (statistically significant) reduction in pain post‐intervention (14.9/100). |
| (low back pain) | Earliest follow‐up: 8 (370) Follow‐up (time since randomisation) Short term (6 weeks): 6 (268) Intermediate term (6 months): 5 (249) Long term (12 months): 2 (126) | "Chronic group" at baseline: mean 46/100 (95% CI 41 to 50) (moderate pain) | Earliest: MD ‐10.20 (95% CI ‐19.09 to ‐1.31) (P = 0.02) | Short term: MD ‐8.58 (95% CI ‐18.46 to 1.29) (P = 0.09, ns) Intermediate term: MD ‐12.48 (95% CI ‐22.69 to ‐2.27) (P = 0.02) Long term: MD ‐3.93 (95% CI ‐9.89 to 2.02) (P = 0.2, ns) | Reduction of ˜ 10/100 at earliest measurement point. |
| (rheumatoid arthritis) | 4 studies (total 188 participants) in different categories (results not combined) | Not reported | Short‐term (12 weeks): Short‐term land‐based (aerobic and strength training) SMD ‐0.53 (95% CI ‐1.09 to 0.04) Short‐term land‐based (aerobic only) Short‐term water‐based SMD 0.06 (95% CI ‐0.43 to 0.54) | Long‐term (24 months) SMD 0.35 (95% CI ‐0.46 to 1.16) | No significant difference between control and intervention. |
| (postpolio syndrome) | 1 (55) | Not reported, but control scores at end of treatment mean 44 (SD 24) on a 0 to 100 scale (moderate pain) | 3 months post‐intervention: VAS (0 to 100): MD 11.00 (95% CI ‐0.98 to 22.98) (P = 0.072) | n/a | No significant effect/no difference between groups. |
| (OA) | Only 1 study that had a no‐exercise control: 1 (68) ‐ excluded data for control (no exercise) from analysis (n = 34) | Not reported | Post‐intervention: WOMAC (0 to 20) Change data presented for high‐ vs low‐intensity groups only, not compared to control | n/a | Actual individual study data was extracted (where possible) instead of pooled MD or SMD due to comparison this overview wishes to make (exercise vs no‐exercise only). Could not extract exercise vs control data. |
| (low back pain) | Short term (< 3 months): 4 (291) Intermediate term (3 to 12 months): 4 (348) Long term (> 12 months): 3 (279) | Not reported, but control scores at follow‐up range 25 to 56/100 (mild‐moderate pain) | Short term: MD ‐10.01 (95% CI ‐15.67 to ‐4.35) favoured exercise (P < 0.001) | Intermediate term: MD ‐12.61 (95% CI ‐20.53 to ‐4.69) favoured exercise (P = 0.002) Long term: MD ‐12.97 (95% CI ‐18.51 to ‐7.42) favoured exercise (P < 0.001) | Medium effect size favouring exercise at all follow‐up assessments (moderate quality evidence at short‐ and long‐term, low quality evidence at intermediate term). Clinically important effect. |
| (patellofemoral pain syndrome) | 3 studies with pain > 3 months (135 participants), 2 studies used in analysis (41 participants) Long‐term follow‐up: 1 (94) | Not reported, but control scores at follow‐up range 2.1 to 6.0/10 (mild‐moderate pain) | Short‐term (4 to 8 weeks): MD for usual pain in the exercise group was 0.93 (95% CI 1.60 to 0.25) SDs lower SMD ‐0.93 (95% CI ‐1.60 to ‐0.25) (P = 0.008) | "Long term" (16 weeks) VAS (0 to 10): MD ‐4.42 (95% CI ‐7.75 to ‐0.89) favoured exercise (P = 0.01) | Reduction in pain of 4/10 at 16 weeks' follow‐up. |
| (low back pain) | Short term: 6 (265) Intermediate term: 2 (148) | Not reported, but control scores at earliest follow‐up range 18 to 52/100 (mild‐moderate pain) | Short‐term follow‐up (< 3 months): MD ‐14.05 (95% CI ‐18.91 to ‐9.19) (P < 0.001) | Intermediate term (3 to 12 months): MD ‐10.54, (95% CI ‐18.54 to ‐2.62) (P = 0.009) | "Low quality evidence (downgraded due to imprecision and risk of bias) that Pilates reduces pain compared with minimal intervention at short‐term follow‐up, with a medium effect size... intermediate‐term follow‐up, two trials, provided moderate quality evidence (downgraded due to imprecision) that Pilates reduces pain compared with minimal intervention, with a medium effect size" |
| CI: confidence interval; HAQ: Health Assessment Questionnaire; MD: mean difference; n/a: not applicable; NNTB: number needed to treat for an additional beneficial outcome; ns: not significant; OA: osteoarthritis; SD: standard deviation; SF‐36: 36‐item Short Form; SMD: standardised mean difference; VAS: visual analogue score; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; WUSPI; Wheelchair User Shoulder Pain Index. | |||||
| Review | Outcome measure | Number of trials (and participants) used in analysis | Post‐intervention result (or if only 1 result reported) | Short‐term follow‐up (or if only 1 follow‐up point reported) | Intermediate‐term follow‐up | Long‐term follow‐up | Overall comment/statement |
| (OA) | Self‐reported function (WOMAC and HAQ) and walking ability, and DRI | Post‐intervention Hip + knee Hip only function: 1 (28) Follow‐up function hip + knee: 1 (306) | Function (hip + knee): SMD 0.26 (95% CI 0.11 to 0.42) favoured exercise (P < 0.001) Walking (hip + knee): SMD 0.18 (95% CI ‐0.03 to 0.39) favoured exercise (P = 0.08, ns) Function (hip only): SMD 0.76 (95% CI ‐0.02 to 1.53) favours exercise (P = 0.06, ns) | Hip only | Hip + knee (6 months) Function, SMD 0.10 (95% CI ‐0.12 to 0.33) (ns) | n/a | Function was significantly improved in people with hip + knee OA immediately post‐intervention only ‐ small effect size only. |
| (fibromyalgia) | Self‐reported physical function (0 to 100 scale) | 5 (285) | MD ‐4.35 (95% CI ‐7.77 to ‐0.94) SMD ‐0.44 (95% CI ‐0.76 to ‐0.11) Absolute difference ‐4 (95% CI ‐8 to ‐1) NNTB 6 (95% CI 3 to 22) | n/a | n/a | n/a | Small difference (improvement) in aquatic exercise group. Among the major wellness outcomes, none of the outcomes met the threshold for clinically relevant differences (15%). |
| (fibromyalgia) | Physical function | Aerobic: 4 (253) Strength: 2 (47) | Aerobic: SMD 0.66 (95% CI 0.41 to 0.92) favoured exercise (P < 0.0001) Strength: SMD 0.52 (95% CI ‐0.07 to 1.10) favoured exercise (P = 0.08, ns) | n/a | n/a | n/a | Function was significantly improved from aerobic exercise training, strength training neared significance. Moderate effect size. |
| (fibromyalgia) | HAQ and SF‐36 for function | 3 (107) | Change score MD ‐6.29 (95% CI ‐10.45 to ‐2.13) favoured exercise (P < 0.01) | n/a | n/a | n/a | Significantly favourable effect of exercise. |
| (rheumatoid arthritis) | Disability | 4 (not reported) | n/a | n/a | n/a | n/a | "Studies investigating hydrotherapy and tai chi demonstrated statistically significant improvements in the intervention arm compared to the control arm between baseline and follow‐up. |
| (OA) | Physical function | Post‐intervention: 9 (521) Follow‐up (3 to 6 months): 5 (365) | SMD ‐0.30 (95% CI ‐0.54 to ‐0.05) "significant benefit" favoured exercise (P = 0.02) | SMD ‐0.37 (95% CI ‐0.57 to ‐0.16) favoured exercise (P < 0.001) | n/a | n/a | Statistically significant, but small effect size only. |
| (OA) | Physical function | Post‐intervention: 44 (3913) Follow‐up (2 to 6 months): 10 (1279) Follow‐up (> 6 months): 8 (1266) | SMD ‐0.52 (95% CI ‐0.64 to ‐0.39) favoured exercise (P < 0.0001); an improvement of 10 points (95% CI 8 to 13) on a 0‐ to 100‐point scale | SMD ‐0.15 (95% CI ‐0.26 to ‐0.04) favoured exercise (P = 0.008) | SMD ‐0.57 (95% CI ‐1.05 to ‐0.10) favoured exercise (P = 0.02) | n/a | Significant effect from exercise at every follow‐up point. Moderate effect size at short‐ and long‐term follow‐up, but only small effect at intermediate‐term follow‐up. |
| (mechanical neck disorders) | Physical function | 12 wk: 2 (147) 24 wk: 2 (140) | 12 wk treatment: pooled SMD ‐0.50 (95% CI ‐1.04 to 0.03) favoured exercise (P = 0.07, ns) | 24 wk treatment (or 12 wk' treatment + 12 wk follow‐up): pooled SMD ‐0.40 (95% CI ‐0.74 to ‐0.06) favoured exercise (P = 0.02) | n/a | n/a | 2 trials showed a moderate (statistical) improvement in function. |
| (rheumatoid arthritis) | Functional assessment and 50‐feet walk test | Function: 2 (52) Walk test: 2 (48) | Function: MD 0.01 (95% CI ‐2.94 to 2.97) (ns) Walk test: MD 0.35 seconds (95% CI ‐1.14 to 1.84) (ns) | n/a | n/a | n/a | No significant effect. |
| (low back pain) | Function | Earliest: 7 (337) Short term: 6 (268) Intermediate term: 4 (216) Long term: 2 (126) | Earliest: MD ‐2.98 (95% CI ‐6.48 to 0.53) favoured exercise (P = 0.09, ns) | Short term: MD ‐3.03 (95% CI ‐6.35 to 0.53) favoured exercise (P = 0.07, ns) | Intermediate term: MD ‐3.84 (95% CI ‐7.06 to ‐0.61) favoured exercise (P = 0.02) | Long term: MD ‐4.22 (95% CI ‐7.99 to ‐0.46) favoured exercise (P = 0.03) | Favoured exercise from the earliest measure, but only reached statistical significance at intermediate and long term after randomisation. |
| (rheumatoid arthritis) | Functional ability | Land‐based aerobic: 2 (66) Land‐based aerobic + strength: 2 (74) | n/a | Short‐term training (12 wk) Land‐based aerobic only training Land‐based aerobic and strength training SMD ‐0.4 (95% CI ‐0.86 to 0.06) (ns) | n/a | n/a | No significant difference between control and intervention groups. |
| (postpolio syndrome) | Muscle strength; and activity limitation (Sunnaas ADL‐index range 0 to 36; Rivermead Mobility Index (RMI) range 0 to 15) | Strength: 1 (10) Activity limitation: 1 (53) | Isometric muscle strength (postintervention): MD 39.00% (95% CI 6.12 to 71.88) Activity limitation: 3 months' postintervention: ADL‐index: MD ‐2.70 (95% CI ‐4.53 to ‐0.87) Rivermead Mobility Index (RMI): MD ‐1.50 (95% CI ‐2.93 to ‐0.07) | Activity limitation: 6‐months post‐intervention: ADL‐index: MD ‐2.90 (95% CI ‐4.73 to ‐1.07) RMI: MD ‐1.80 (95% CI ‐3.19 to ‐0.41) | n/a | n/a | Activity limitation: favoured intervention at both assessment points. "The baseline imbalance in favour of the usual care group probably biased these results." |
| (intermittent claudication) | Maximal walking time and maximal walking distance | Post‐intervention Walking distance: 9 (480) 3‐month follow‐up Walking distance: 3 (116) 6‐month follow‐up | Time: MD 4.51 minutes (95% CI 3.11 to 5.92) favoured exercise (P < 0.00001) Distance: 108.99 m (95% CI 38.20 to 179.78) favoured exercise (P = 0.003) | Time: MD 6.05 minutes (95% CI 5.47 to 6.62) favoured exercise (P < 0.00001) Distance: MD 104.46 m (95% CI ‐64.33 to 273.24) favoured exercise (ns) | Time: MD 3.20 minutes (2.04 to 4.36) favoured exercise (P < 0.0001) Distance: MD 138.36 m (95% CI 22.39 to 254.34) favoured exercise (P = 0.02) | n/a | Objectively measured walking time and distance showed significant improvement. |
| (intermittent claudication) | Maximal walking time (mins) and maximal walking distance (metres) | No relevant studies | n/a | n/a | n/a | n/a | No relevant studies. |
| (OA) | WOMAC (0 to 68) disability scale, and muscle strength | 1 (68) ‐ excluded control (no‐exercise data: n = 34) | n/a | n/a | n/a | n/a | Could not extract exercise vs control data ‐ data presented for high vs low intensity groups only, not compared to control. |
| (low back pain) | Disability (Oswestry Disability Index, Roland Morris Disability Questionnaire) | Short‐term follow‐up (< 3 months): 5 (332) Intermediate term (3 to 12 months): 4 (348) Long term (> 12 months): 3 (279) | ‐ | MD ‐8.63 (95% CI ‐14.78 to ‐2.47) (P < 0.01) | MD ‐5.47 (95% CI ‐9.17 to ‐1.77) (P = 0.004) | MD ‐5.96 (95% CI ‐9.81 to ‐2.11) (P = 0.002) | Small effect sizes, favoured exercise. Short term: CI included a clinically important effect. |
| (rheumatoid arthritis) | HAQ function | No studies found | n/a | n/a | n/a | n/a | No studies found. |
| (patellofemoral pain syndrome) | Functional ability | Short‐term follow‐up: 7 (483) Long‐term follow‐up: 3 (274) | n/a | Short‐term (4 to 8 wk): SMD 1.10 (95% CI 0.58 to 1.63) favoured exercise (P < 0.0001) | n/a | SMD 1.62 (95% CI 0.31 to 2.94) favoured exercise (P = 0.02) | Significant effect of exercise. Very large effect size at short‐ and long‐term follow‐up. |
| (low back pain) | Disability (all measures converted to 0 to 100 scale) | Short‐term (< 3 months) follow‐up: 5 (248) ‐Intermediate‐term (3 to 12 months) follow‐up: 2 (146) | n/a | MD ‐7.95 (95% CI ‐13.23 to ‐2.67) (P = 0.003) | MD ‐11.17 (95% CI ‐18.41 to ‐3.92) (P = 0.0025) | n/a | "Low quality evidence (downgraded due to imprecision and inconsistency) that Pilates improves disability at short‐term follow‐up compared with minimal intervention, with a small effect size .... intermediate‐term follow‐up, two trials provided moderate quality evidence (downgraded due to imprecision) of a significant effect in favour of Pilates, with a medium effect size" |
| ADL: activities of daily living; CI: confidence interval; DRI: Disability Rating Index; HAQ: Health Assessment Questionnaire; MD: mean difference; n/a: not applicable; NNTB: number needed to treat for an additional beneficial outcome; ns: not significant; OA: osteoarthritis; SF‐36: 36‐item Short Form; SMD: standardised mean difference; wk: week; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index, | |||||||
| Review | Outcome measure | Number of trials (and participants) reporting psychological function | Outcome result (postintervention or if only one measurement point) | Follow‐up | Additional statement/comment |
| Mental health | |||||
| ‐ | 4 studies | SMD 0.16 (95% CI 0.01 to 0.032) favoured aquatic exercise | No significant difference at 6 months, 1 study | Very small effect size postintervention. | |
| SF‐36 ‐ Mental health scale | 1 study | ‐ | n/a | No group differences. | |
| SF‐36 ‐ mental Health scale SF‐12 ‐ Mental Health scale | 4 studies, n = 243 | MD ‐3.03 (95% CI ‐8.06 to 2.01) | n/a | No effect. | |
| Anxiety | |||||
| Brief Symptom Inventory | 1 study | "No significant effect" | n/a | ‐ | |
| Depression | |||||
| CES‐D | 1 study, n = 34 | MD ‐6.0 (95% CI ‐15.87 to 3.87) (P = 0.23) | n/a | No effect. | |
| HADS ‐ Depression Beck Depression Index | 1 study, n = 21 | MD ‐3.70 (95% CI ‐6.37 to ‐1.03) Relative difference 57% | n/a | Significant effect, favoured resistance training. | |
| CES‐D | Not reported | "Variable effect" reported in text only | n/a | ‐ | |
| CES‐D: Centre for Epidemiological Studies‐Depression; CI: confidence interval; HADS: Hospital Anxiety and Depression Scale; MD: mean difference; n: number of participants; n/a: not applicable; SF‐12: 12‐item Short Form; SF‐36: 36‐item Short Form; SMD: standardised mean difference. | |||||
| Review | Outcome measure | Number of trials (and participants) reporting Quality of Life (QoL) | Outcome result | Additional statement/comment |
| (Health‐related) Quality of Life | ||||
| QoL: SF‐12 (Physical), PQoL, EuroQoL | Hip + knee OA (post‐intervention): 3 studies, n = 599 Hip only OA (post‐intervention): 1 study, n = 28 Hip only OA (follow‐up): 1 study, n = 17 | Hip + knee (post‐intervention): SMD 0.32 (95% CI 0.03 to 0.61) (P = 0.028) Hip only (post‐intervention): SMD 0.76 (95% CI ‐0.02 to 1.53) (ns) Hip only (follow‐up): SMD 1.00 (95% CI ‐0.04 to 2.04) (ns) | Significantly favoured aquatic exercise post‐intervention in hip + knee OA. Small effect size only (when statistically significant). | |
| PQoL (perceived quality of life) SQoL (subjective quality of life) | Post‐intervention: 1 study, n = 34, PQoL; 1 study, n = 80, SQoL Follow‐up (intermediate term): 1 study, n = 80, SQoL | Post‐intervention: PQoL MD 10.8 (95% CI ‐4.2 to 25.8) (P = 0.16) SQoL MD 0.3 (95% CI ‐0.22 to 0.82) (P = 0.25) Follow‐up: SQoL MD 0.5 (95% CI ‐0.03 to 1.03) (P = 0.07) | No difference between groups. | |
| QoL | Post‐intervention: 3 studies, n = 183 | SMD 0.07 (95% CI ‐0.23 to 0.36) (ns) | No difference between groups. | |
| QoL: self‐report questionnaire, scale 0 to 100 (100 is maximum QoL) | Post‐intervention: 13 studies, n = 1073 | SMD 0.28 (95% CI 0.15 to 0.40) (P < 0.0001) Absolute difference 4% (95% CI 2% to 5%) relative difference 9% (95% CI 5% to 13%) | Statistically significant, but equates to an absolute improvement of 4 points (95% CI 2 to 5) on a 0 to 100 scale. Small effect size only. | |
| QoL: SF‐36 (Physical Function subscale) | Post‐intervention: 2 studies, n = 143 | 12‐wk intervention: MD ‐2.22 (95% CI ‐5.17 to 0.72) (ns) 24‐wk intervention: MD 0.06 (95% CI ‐4.06 to 4.17) (ns) | No significant difference between groups. | |
| HRQoL | No relevant studies | n/a | n/a | |
| Global assessment | ||||
| Global wellbeing | Strength: 2 studies, n = 47 Aerobic: 4 studies, n = 269 | Strength: SMD 1.43 (95% CI 0.76 to 2.10) Aerobic: SMD 0.49 (95% CI 0.23 to 0.75) | Favoured exercise ‐ higher score showed better QoL, Strength: very large effect size. Aerobic: small‐to‐moderate effect size only. | |
| Participant‐rated global (10‐cm VAS) | 1 study, n = 46 | MD ‐0.87 (95% CI ‐1.74 to 0.00) | No effect. | |
| Global perceived effect | 1 study, n = 70 | "No significant difference" | No significant difference. | |
| Global assessment | 7 studies, n = 16 | Not reported | n/a | |
| Global impression of recovery | 1 study, n = 154 | Short term, MD 1.30 (95% CI 0.30 to 2.30) (P = 0.01) Intermediate term, MD 1.20 (95% CI 0.31 to 2.09) (P = 0.008) Long term, MD 1.50 (95% CI 0.61 to 2.39) (P < 0.001) | Medium effect size. | |
| Global impression of recovery | 1 study, n = 86 | Short term (< 3 months): MD 1.50 (95% CI 0.70 to 2.30) Intermediate term (3 to 12 months): MD 0.70 (95% CI ‐0.11 to 1.51) | "Low quality evidence (downgraded due to imprecision and inconsistency), we found a significant short‐term effect, with a small effect size, but not for intermediate/mid‐term follow up." | |
| Other method of assessment | ||||
| Multi‐dimensional function‐ FIQ | 7 studies, n = 367 | MD ‐5.97 (95% CI ‐9.06 to ‐2.88) SMD ‐0.55 (95% CI ‐0.83 to ‐0.27) Absolute difference ‐6 (95% CI ‐9 to ‐3) NNTB 5 (95% CI 3 to 9) | Favoured aquatic exercise ‐ lower score showed reduced impact of pain on life. "Moderate difference." | |
| Multi‐dimensional function ‐ FIQ | 1 study, n = 60 | SMD ‐1.27 (95% CI ‐1.83 to ‐0.72) Absolute difference ‐16.75 FIQ units (95% CI ‐23.31 to ‐10.19) | Favoured exercise ‐ lower score showed reduced impact of pain on life. Very large effect size. | |
| Work status | 9 studies, n = 21 | Not reported | n/a | |
| Health Assessment Questionnaire (HAQ) | No included studies | n/a | n/a | |
| FIQ: Fibromyalgia Impact Questionnaire; HRQoL: health‐related quality of life; MD: mean difference; n: number of participants; n/a: not applicable; NNTB: number needed to treat for an additional beneficial outcome; OA: osteoarthritis; PQoL: perceived quality of life; QoL: quality of life; SF‐36: 36‐item Short Form; SMD: standardised mean difference; SQoL: subjective quality of life; VAS: visual analogue scale. | ||||
| Review | Number of trials (and participants) reporting withdrawals | Number withdrawn (per 1000) ‐ intervention group | Number withdrawn (per 1000) ‐ control group | RR or OR |
| (fibromyalgia) | 8 studies, n = 472 | 151 (imputed from reported 38/252) | 129 (imputed from reported 30/232) | RR 1.13 (95% CI 0.73 to 1.77) (P = 0.45) |
| (fibromyalgia) | 3 studies, n = 107 | 134 (95% CI 30 to 439) | 39 | RR 3.50 (95% CI 0.79 to 15.49) |
| (osteoarthritis) | 7 studies, n = 715 | 59 (95% CI 30 to 114) | 34 | OR 1.77 (95% CI 0.86 to 3.65) |
| (rheumatoid arthritis) | 4 studies, n = 189 | 109 (imputed from reported 11/101) | 284 (imputed from reported 25/88) | RR 0.37 (95% CI 0.19 to 0.72) |
| (osteoarthritis) | 1 study, n = 102 | 44 (imputed from reported 3/68 (4%); all from high‐intensity group) | 0 | Calculated RR 3.55 (95% CI 0.19 to 66.8) |
| (low back pain) | 7 studies, n = 671 | 0 | 0 | ‐ |
| (rheumatoid arthritis) | No included studies | n/a | n/a | n/a |
| Total | 30 studies, n = 2256 | 82.8/1000 | 81/1000 | Calculated RR 1.02 (95% CI 0.94 to 1.12) Calculated OR 1.05 (95% CI 0.88 to 1.25) |
| CI: confidence interval; n: number of participants; n/a: not applicable; OR: odds ratio; RR: risk ratio. | ||||
| Review | Total number of trials (and participants) in review reporting exercise vs control in chronic pain population | Number of trials (and participants) reporting adverse events | Number of adverse events | Overall statement |
| 4 (674) | 2 (148) | 0 | Adverse events were recorded (and reported), but none occurred. | |
| 9 (519) | 0 | 0 | Review stated that no included studies actively reported on adverse events (some reported withdrawal). | |
| 3 (149) | 2 (115) | 5 events over 2 studies | "Neck, shoulder and elbow injuries in five participants in the intervention group." | |
| 34 (2276) | 6 (strength training: 115, aerobic: 1264) | Strength training: 3 | ‐ | |
| 3 (81) | 2 (86 exercising participants) | 0 | Adverse events were recorded (and reported), but none occurred. | |
| 6 (371) | 3 | 0 | Adverse events were recorded (and reported), but none occurred. | |
| 10 (> 549) | 5 | 7 events over 3 studies | ‐ | |
| 54 (5362) | 11 | 42 events over 8 studies | ‐ | |
| 16 (2485) | 11 | 41 events over 6 studies | ‐ | |
| 3 (206) | 2 | 1 event in 1 study | In narrative: "approximately one‐third of the patients complained of soreness in the knee, shoulder or lower back during the first 3 weeks… pain eventually subsided for all patients… only exception was one patient, who complained of knee pain." | |
| 43 (3907) | 10 | 23 events over 10 studies | "Negative reported: 16 events over 7 trials." | |
| 5 (575) | 2 | 0 | Adverse events were recorded (and reported), but none occurred. | |
| 2 (68) | 1 (10) | 0 | Adverse events were recorded (and reported), but none occurred. "The study investigated deleterious effects of this training on motor unit survival through motor unit number estimates (MUNE). Results showed that the MUNE did not change at the end of the training." | |
| 30 (1822) | 1 (88 exercising participants) | 2 events in control group in 1 study | RR 0.20 (95% CI 0.01 to 4.15) in favour of exercise group. | |
| 1 (102) | 1 (68 exercising participants over 2 groups: low and high resistance) | 3 events in 1 study | "3 participants in high resistance group discontinued the exercise intervention due to severe knee pain." | |
| 7 (671) | 1 (154) | 5 events in 1 study | "Five patients (three from the MCE [motor control exercise] group and two from the minimal intervention group) had mild adverse effects during the study (all temporary exacerbations of pain)." | |
| 10 (1690) | 0 | 0 | Of the relevant studies, none actively reported on adverse events. | |
| 6 (265) | 1 (86) | 0 | Adverse events were recorded (and reported), but none occurred. | |
| Total | 246 studies (> 21,772) | 61 studies (> 2134 participants) | 137 events over 39 studies | 61/246 (25%) of studies have reported on adverse events; of which 39/61 (64%) did have adverse events occur as a result of the intervention or control. |
| n: number of participants; RR: risk ratio. | ||||
