⬍LEAP⬎
LINKING EVIDENCE AND PRACTICE
Exercise for Prevention of Recurrences of Nonspecific
Low Back Pain
Luciana Gazzi Macedo, Geoff P. Bostick, Christopher G. Maher
<LEAP> highlights the findings and
application of Cochrane reviews and
other evidence pertinent to the prac-
tice of physical therapy. The
Cochrane Library is a respected
source of reliable evidence related to
health care. Cochrane systematic
reviews explore the evidence for and
against the effectiveness and appro-
priateness of interventions—medica-
tions, surgery, education, nutrition,
exercises—and the evidence for and
against the use of diagnostic tests for
specific conditions. Cochrane reviews
are designed to facilitate the deci-
sions of clinicians, patients, and oth-
ers in health care by providing a care-
ful review and interpretation of
research studies published in the sci-
entific literature.1 Each article in this
PTJ series will summarize a Cochrane
review or other scientific evidence
resource on a single topic and will
present clinical scenarios based on
real patients to illustrate how the
results of the review can be used to
directly inform clinical decisions. This
article focuses on the effectiveness of
exercise for the prevention of recur-
rence of nonspecific low back pain.
Can an exercise program decrease
the number of recurrences in individ-
uals such as this patient with recur-
rent low back pain?
Find the <LEAP> case archive at
http://ptjournal.apta.org/cgi/
collection/leap.
December 2013
Downloaded from http://ptjournal.apta.org/ by Kimber Gerlich on December 28, 2013
Low back pain (LBP) is highly prev-
alent2 and a common reason for pre-
sentation to primary care.3 The
direct and indirect costs associated
with this condition are enormous
and represent a significant economic
burden to health care systems. The
prognosis of those with acute LBP is
generally positive, with approxi-
mately 72% recovering by 1 year.4
For those who recover, recurrences
within the next 12 months following
recovery are common.5,6 It has been
well-established that nonspecific LBP
is often recurrent and that 24% to
87% of those who recover from an
episode of LBP will have a recur-
rence within 1 year.5– 8
A theme that is current among clini-
cians and researchers is the difficulty
in defining a recurrence of LBP. Var-
ious clinicians and researchers
define recurrence differently, which
makes it difficult to compare the
results of studies.9 What makes the
definition of recurrence of LBP so
difficult is the fact that a definition of
recovery and a definition of recur-
rence are needed simultaneously. A
patient can have a recurrence (ie, a
new episode) only once he or she
has recovered from the previous epi-
sode. A few definitions of recurrence
of LBP have been published,10,11 and
the definition provided by de Vet et
al11 is probably the most commonly
used. De Vet et al11 proposed the
definition of a recurrence of LBP as
the return of LBP lasting at least 24
hours following a period of at least 1
month without LBP (pain⫽0). Other
less conservative definitions of recur-
rence and recovery also have been
proposed such as Wasiak and col-
leagues’ definition that recovery is
indicated by a lowering in the cur-
rent symptoms where a patient no
Volume 93 Number 12 Physical Therapy f
longer experiences atypical pain or
pain-related difficulty in performing
tasks and actions.12 Recurrence
would then be a return of atypical
signs and symptoms.
There is interest in preventing recur-
rent episodes because they are com-
mon, they may be more costly than
the original episodes,12 and they can
be as debilitating as an initial epi-
sode. Therefore, the prevention of
such episodes may be an important
component in the management of
patients with LBP. Exercise therapies
are one of the most commonly rec-
ommended treatments for patients
with persistent nonspecific LBP13
with clear evidence for effective-
ness,14 but it is unknown whether
exercise is effective in the preven-
tion of recurrences of LBP. Aiming to
better understand the benefits of
exercise, Choi and colleagues15 con-
ducted a Cochrane systematic
review (latest search July 2009) of
randomized controlled trials evaluat-
ing the effectiveness of exercises on
the prevention of recurrence of LBP
(Table).
Take-Home Message
Thirteen articles reporting on 9 trials
were included in the review. The
exercise programs were divided into
2 types of interventions: (1) treat-
ment interventions that were
defined as “treatment for a current
episode of back pain with the aim to
prevent new episodes” and (2) post-
treatment interventions that were
defined as “interventions that were
provided to patients after their regu-
lar treatment for an episode of back
pain had been finished with the
explicit aim to prevent recurrences
of back pain.”15 To be included in
the posttreatment category, trial
1587
 Table.

1588
Exercise for Prevention of Recurrences of Low Back Pain (LBP): Cochrane Review Results15,a

f
Thirteen articles providing the results of 9 original randomized controlled trials were included in the review. All studies were published before July 2009.

Four studies had low risk of bias, 1 had high risk of bias, and 4 had unclear risk of bias.

Four studies (407 participants) evaluated posttreatment programs, and 5 studies (1,113 participants) evaluated exercise as a treatment modality.

Posttreatment interventions: Studies compared posttreatment intervention versus no intervention and posttreatment intervention plus TerapiMaster machine (Nordisk Terapi of Norway, Staubø, Norway) versus
general exercises. The treatment interventions included stretching and strengthening exercises for the back, abdomen, and lower limbs and relaxation exercises plus education.

Treatment interventions: Studies compared exercise as a treatment versus usual care (education, analgesics, primary health care physician), exercise as a treatment versus sham treatment (sham ultrasound), and
McKenzie exercises versus back pain education. The treatment interventions included general exercises, promotion of physical activity, multifidus muscle exercises, and McKenzie exercises.

The follow-up times were defined as short term (⬍6 months), intermediate (6 months–2 years), and long term (2–5 years).

Posttreatment intervention

Posttreatment intervention versus no intervention Pooled results of 2 studies demonstrated that posttreatment exercises significantly reduced the number of patients
with recurrent LBP (risk ratio⫽0.5, 95% CI⫽0.3 to 0.7, n⫽130); 22 of 67 patients in the exercise group and 41
of 63 patients in the no-intervention group had recurrent LBP), the number of recurrences (mean
difference⫽⫺0.4, 95% CI⫽⫺0.6 to ⫺0.1, n⫽154), and the days of sick leave due to recurrent LBP (mean
difference⫽⫺4.4, 95% CI⫽⫺7.7 to ⫺1.0, n⫽154). The results of single studies demonstrated that
posttreatment exercise was better than no intervention for reducing time to recurrence at intermediate follow-
up (hazard ratio⫽0.4, 95% CI⫽0.2 to 0.8, n⫽69; 32% of patients in the exercise group and 65% in the no-
intervention group had a recurrence by 600 days) and long-term follow-up (hazard ratio⫽0.5, 95% CI⫽0.3 to

Physical Therapy Volume 93 Number 12

0.9, n⫽69; 50% of patients in the exercise group and 72% in the no-intervention group had a recurrence by
900 days) and for reducing number of recurrences at long-term follow-up (mean difference⫽⫺2.0, 95%
CI⫽⫺3.8 to ⫺0.1, n⫽66).

Posttreatment intervention plus TerapiMaster machine (strengthening exercise equipment The results of 1 study with 62 participants demonstrated no difference between the evaluated treatments for
using ropes) versus general exercise number of sick leave days (mean difference⫽⫺0.3, 95% CI⫽⫺0.7 to 0.04).

Treatment intervention

Treatment intervention versus usual care Pooled results demonstrated no difference in number of patients with recurrence at intermediate follow-up (risk
ratio⫽0.6, 95% CI⫽0.2 to 1.8, n⫽348; 113 of 174 patients in the exercise group and 124 of 174 patients in
the usual care group had recurrent LBP) and long-term follow-up (risk ratio⫽0.7, 95% CI⫽0.4 to 1.6, n⫽493;
154 of 257 patients in the exercise group and 147 of 236 patients in the usual care group had recurrent LBP).
Single studies demonstrated no difference between the interventions for duration of recurrence (mean
difference⫽⫺8.0, 95% CI⫽⫺17.6 to 1.6, n⫽154), number of recurrences at intermediate follow-up (mean
difference⫽⫺1.4, 95% CI⫽⫺3.2 to 0.4, n⫽39) and long-term follow-up (mean difference⫽⫺0.4, 95%
CI⫽⫺3.9 to 3.1, n⫽36), and number of patients with sick leave due to recurrent LBP at intermediate follow-up
(risk ratio⫽0.4, 95% CI⫽0.1 to 1.2, n⫽39; 3 of 20 patients in the exercise group and 8 of 19 patients in the
usual care group were on sick leave) and long-term follow-up (risk ratio⫽0.8, 95% CI⫽0.2 to 2.7, n⫽36; 4 of
20 patients in the exercise group and 4 of 16 patients in the usual care group were on sick leave).

Treatment intervention versus sham ultrasound The results of one study with 154 participants demonstrated no significant differences between the evaluated
treatments for number of patients with recurrent LBP (risk ratio⫽1.1, 95% CI⫽0.9 to 1.2; 107 of 154 patients in
the exercise group and 107 of 162 patients in the sham ultrasound group had recurrent LBP) and duration of
recurrent LBP (standardized mean difference⫽0.1, 95% CI⫽⫺0.1 to 0.3).

Treatment intervention (McKenzie exercises) versus back school
Pooled results (2 studies) demonstrated that McKenzie therapy was no better than back schools for reducing the
number of patients with recurrence LBP at intermediate follow-up (risk ratio⫽0.8, 95% CI⫽0.4 to 1.4, n⫽294;
89 of 182 patients in the McKenzie therapy group and 70 of 112 patients in the back school group had
recurrent LBP). The results of a single study demonstrated that the McKenzie therapy group had fewer patients
with recurrence of LBP at long-term follow-up (risk ratio⫽0.7, 95% CI⫽0.6 to 0.9, n⫽89; 30 of 47 patients in

Downloaded from http://ptjournal.apta.org/ by Kimber Gerlich on December 28, 2013

the McKenzie group and 37 of 42 patients in the back school group had recurrent LBP) but that McKenzie
therapy was no better than back school in decreasing the number of sick leave days due to a recurrent episode
<LEAP> Case #19 Exercise for Prevention of Recurrences of Nonspecific Low Back Pain

at intermediate follow-up (mean difference⫽⫺13.1, 95% CI⫽⫺30.8 to 4.6, n⫽95) and long-term follow-up
(mean difference⫽⫺19.8, 95% CI⫽⫺86.5 to 46.9, n⫽93).

Interpretation of results: There was moderate-quality evidence that posttreatment exercise can prevent recurrences of LBP, although only 2 small-scale studies were included in the meta-analysis.

Interpretation of results: There was unclear evidence on the effectiveness of exercise as a treatment modality. All pooled analyses of this treatment modality included a maximum of 2 studies, with 1 study
clearly favoring exercises and the other study showing no difference between treatments that ultimately led to a nonsignificant pooled result. Other large-scale and high-quality randomized controlled trials are
needed to clarify the findings of this review.
a
95% CI⫽95% confidence interval.

December 2013
 <LEAP> Case #19 Exercise for Prevention of Recurrences of Nonspecific Low Back Pain
participants had to have recovered
as defined by Wasiak et al.12 Then,
in addition to the use of the
term “recovery,” recovery also was
defined as successful return to work
after an initial intervention and the
diagnosis of recurrent LBP.
Posttreatment exercise included
stretching and strengthening exer-
cises for the back, abdomen, and
lower limbs and relaxation exercises
plus education. Treatment interven-
tions included general exercises,
promotion of physical activity, mul-
tifidus muscle exercises, and McKen-
zie exercises. There was moderate
evidence that posttreatment exer-
cises were more effective than no
intervention for reducing the num-
ber of patients with recurrent LBP,
the number of recurrences, and the
number of days of sick leave due to
recurrent LBP. For example, the
number of patients with recurrent
LBP was halved (risk ratio⫽0.5, 95%
confidence interval⫽0.3– 0.7) in the
2 years following the initial episode
(22 of 67 patients in the exercise
group had recurrent LBP, and 41 of
63 patients in the control group had
recurrent LBP). This effect is large
enough to be considered clinically
worthwhile. In contrast, exercise
delivered during the initial treatment
phase was not found to be effective.
For example, the risk ratio for reduc-
ing the number of patients experi-
encing recurrent LBP up to 2 years
was 0.6 (95% confidence inter-
val⫽0.2–1.8) (113 of 174 patients
who exercised had recurrent LBP,
and 124 of 174 patients who
received usual care had recurrent
LBP). See the Table for results.
A limitation of the review was that
each pooled effect is based upon
only 1 or 2 small trials; therefore, the
estimates of treatment effects are
very imprecise. For example, the
95% confidence interval for the risk
ratio for treatment interventions
cited above includes an important
December 2013
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protective effect (risk ratio⫽0.2) and
an important harmful effect (risk
ratio⫽1.8). The appropriate conclu-
sion is that there is considerable
uncertainty regarding the effect of
treatment interventions and that
larger studies are needed to resolve
this uncertainty. Additionally, the
small number of trials means that
there should be some caution with
generalizability.
The literature search of the review
was performed in July 2009, and at
least 4 other studies were published
since then. Three studies on the
effectiveness of treatment interven-
tions16 –18 and a study on the effec-
tiveness of posttreatment interven-
tions19 were published up to January
2013. The postintervention studies
and 2 of the treatment studies com-
pared one form of exercise with
another; therefore, they do not pro-
vide any information about the
impact of exercises on recurrence.
The remaining study demonstrated
that exercise as a treatment inter-
vention significantly reduced the
number of patients with recurrent
LBP over the long term (1 year) com-
pared with a placebo intervention.18
Case #19: Applying
Evidence to a
Patient With LBP
Can exercise help this patient?
“Ms B” is a 55-year-old woman with
a 7-year history of recurrent LBP.
She had a laminectomy and fusion of
L5/S1 four years previously because
of radicular symptoms. She experi-
ences 3 to 4 episodes of LBP per
year, and each episode lasts approx-
imately 3 weeks. Three weeks pre-
viously, she experienced another
acute episode, which occurred after
swinging a large briefcase over
her shoulder. The pain was located
in the right lower back and radi-
ated into the right buttock. Ms B
described the pain quality as throb-
bing and aching, and she rated the
intensity, on average, as 5/10 on a 0
Volume 93 Number 12 Physical Therapy f
to 10 numeric rating scale (NRS).
Her current pain intensity was rated
as 3/10. The pain woke her when
turning in bed. It was aggravated by
twisting (right or left) and prolonged
sitting (⬎10 minutes). Her pain was
eased in lying and standing positions.
Ms B completed, at the time of initial
assessment, the STarT Back Screen-
ing Tool (SBST), which is a tool used
to allocate patients to different treat-
ments based on their prognosis (low,
medium, or high risk or poor prog-
nosis).20 She also completed the
Oswestry Disability Index (ODI),
which is an LBP-specific question-
naire to evaluate pain-related disabil-
ity. The SBST suggested minimal
intervention (2/9) and a good prog-
nosis. The ODI score characterized
her current disability as minimal (20/
100). Neurological examination of
the lower limbs was normal. The
physical examination (active and
passive mobility tests) revealed
impairments in spine mobility and
control of deep and superficial trunk
muscles. The working diagnosis was
recurrent nonspecific LBP. Ms B’s
primary goal was to minimize the
number and impact of recurrences.
Summary of Management
and Follow-up
Treatment intervention to con-
trol pain and disability. For her
current episode of LBP, Ms B was
recommended to remain active
within her tolerance of pain and
gradually increase her activity
weekly. In addition, spinal manipula-
tion was provided once weekly for 3
visits. At her 6-week follow-up, Ms
B’s pain intensity (on a 0 –10 NRS)
decreased from 5 to 1. Her ODI score
(0 –100) decreased from 20 to 6.
Both changes were above the mini-
mal clinically important difference
reported for pain (2 points)21 and
disability (6 points).22 Thus, she was
classified as recovered based on her
current episode. Because preventing
or minimizing recurrence was a goal
1589
<LEAP> Case #19 Exercise for Prevention of Recurrences of Nonspecific Low Back Pain
of Ms B, we then implemented a
posttreatment exercise program as
described below.
Posttreatment intervention to
minimize recurrence. Ms B was
given a structured exercise program
to perform after symptoms of the
current acute episode had subsided.
This exercise program included a
gradual increase in the frequency
and duration of cycling, as well as
the following exercises 3 times per
week: abdominal side plank on both
sides (2 sets, 5 repetitions with a
5-second hold), bridge on ball (2
sets, 10 repetitions), and standing
hip hike on both sides (2 sets, 8 rep-
etitions). In addition, Ms B was pro-
vided a lumbar spine range-of-
motion exercise in 4-point-kneeling
(cat-cow exercise). These exercises
were chosen based on the muscle
function impairments identified dur-
ing the assessment of her most
recent episode. Ms B also was
encouraged to re-engage with other
activities she enjoys such as hiking
and Pilates. Two and 4 weeks follow-
ing discharge, Ms B returned for
follow-up visits to make sure she was
performing the exercises correctly.
Three months postdischarge, Ms B
was telephoned to discuss the pro-
gram and offered the opportunity for
additional follow-up. Ms B did not
feel she needed follow-up and
reported generally adhering to the
posttreatment exercise recommen-
dations.
Response to posttreatment inter-
vention. One month and 1 year
after discharge from active treat-
ment, Ms B’s pain intensity remained
at 1/10. The ODI also remained at
6/100 at the 1-month follow-up and
further decreased to 4 at the 1-year
follow-up. Ms B reported no exacer-
bations (pain that lasted more than a
few minutes and did not interfere
with function). Qualitatively, Ms B
reported that this has been the first
time she has consistently performed
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“specific exercises” for her back out-
side of a recurrence.
How did the results of the
Cochrane review apply to Ms B?
After assessing Ms B, her clinician
asked the following question: For
patients with chronic nonspecific
recurrent LBP, is exercise better
than no exercise or other forms of
exercise in reducing the number
of recurrent episodes? The clini-
cian then conducted a literature
search using the PICO (Patient, Inter-
vention, Comparison, Outcome) ele-
ments and identified the systematic
review by Choi et al.15
Patients: The systematic review
included adult patients with nonspe-
cific LBP or with recurrent LBP like
Ms B.
Intervention: The review consid-
ered the impact of exercise per-
formed during a recurrent episode
and following resolution of that epi-
sode on recurrence of back pain.
Based upon the review, the clinician
considered that prescribing exercise
while Ms B was experiencing a
recurrence of symptoms may not
have any value in reducing the like-
lihood of recurrence. However, par-
ticipation in exercise once she had
recovered from the current epi-
sode may be protective. The clini-
cian, therefore, prescribed a range
of home exercises to be performed
following discharge. Ms B reported
that she had continued to perform
both the specific and nonspecific
exercises recommended since recov-
ering from her recent episode.
Comparison: The review suggests
that posttreatment exercises are bet-
ter than no exercises in reducing
the number of recurrences. Thus,
Ms B was encouraged to perform a
structured exercise program after
discharge.
Outcomes: Ms B’s primary goal
was to reduce the number of recur-
rent episodes. The identified sys-
tematic review suggests that postin-
tervention exercises can significantly
decrease the number of recurrences
for patients with her condition. After
the treatment of the episode and
performing her posttreatment exer-
cises after discharge, at the 1-year
follow-up, Ms B had not experi-
enced a recurrence, whereas her
previous history was 3 to 4 recur-
rences per year. Given that Ms B
had not changed her work or com-
menced any other preventative
treatment beyond the exercise, it is
reasonable to attribute her good out-
come to the exercise program. How-
ever, other possible explanations for
this recurrence-free period include a
placebo effect, natural history, and
regression to the mean.
How well do the outcomes of the
prevention provided to Ms B
match those suggested in the
review?
Ms B made a good recovery from her
most recent recurrence of LBP, as
indicated by the measured improve-
ments in pain and disability. Over
the course of the next year, her pain
and disability remained minimal, and
there was no recurrence. These out-
comes may be attributed to the exer-
cise program she maintained and are
consistent with the results of the
review that suggested that an exer-
cise program instituted following an
episode of LBP may reduce number
of recurrences.
Can we apply the result of the
review to Ms B?
The results of the review suggest
that posttreatment exercises are
effective in reducing the number of
recurrences in patients with chronic
or recurrent nonspecific LBP. As
the participants of the different ran-
domized controlled trials included in
the review were somewhat hetero-
geneous (patients both on and not
on sick leave, patients with and with-
out current pain), it is difficult to
December 2013
 <LEAP> Case #19 Exercise for Prevention of Recurrences of Nonspecific Low Back Pain
draw conclusions regarding whether
the exercise intervention suits
patients with specific characteris-
tics. In this case study, Ms B was
working and had moderate levels of
pain and mild disability. The SBST
score demonstrated that she was
likely to recover from this episode
with minimal intervention. It is not
known whether a good prognosis for
recovery within an episode is likely
to change the number or intensity of
recurrences. It is possible that an
uneventful recovery also may be pro-
tective against recurrence. However,
the systematic review included a
broad range of patients with various
levels of pain and disability, and, on
average, posttreatment exercise
appears to be protective for the num-
ber and severity of recurrences.
As with much of the literature on
exercise interventions, parameters
can be vague. The prescribed post-
treatment exercises for Ms B did
not precisely match the exercise
parameters in the systematic review.
However, the literature on exer-
cises for the treatment of LBP does
not favor one exercise approach
over another.13,23 Because the type
of exercise and parameters to be pre-
scribed are unclear, Ms B chose to
modify the prescribed intervention
in a manner that suited her lifestyle.
The ability to adhere to an exercise
program is what is perhaps most
important.
What can be advised based on
the results of this systematic
review?
It is recommended that the empha-
sis on exercise for prevention of
recurrences should likely be shifted
toward posttreatment exercise
adherence. Mechanisms of LBP and
how various interventions affect
recovery and recurrences remain
unclear. However, exercise is the
most consistent intervention in opti-
mizing recovery from LBP, and this
systematic review suggests exercise
December 2013
Downloaded from http://ptjournal.apta.org/ by Kimber Gerlich on December 28, 2013
also is likely effective in minimizing
the number and severity of recur-
rences. The precise parameters
needed to achieve this effect or the
appropriate dose to achieve the
desired outcome are not yet known.
L.G. Macedo, PT, PhD, Common Spinal Dis-
orders Research Group, Department of Phys-
ical Therapy, University of Alberta, 2-50 Cor-
bett Hall, Edmonton, Alberta, Canada T6G
2G4. Address all correspondence to Dr
Macedo at: lmacedo@ualberta.ca.
G.P. Bostick, PT, PhD, Department of Physi-
cal Therapy, University of Alberta.
C.G. Maher, PT, PhD, The George Institute
for Global Health, Sydney, Sydney Medical
School, The University of Sydney, New South
Wales, Australia.
[Macedo LG, Bostick GP, Maher CG. Exer-
cise for prevention of recurrences of non-
specific low back pain. Phys Ther. 2013;93:
1587–1591.]
© 2013 American Physical Therapy Association
Published Ahead of Print: June 27, 2013
Accepted: June 23, 2013
Submitted: November 15, 2012
DOI: 10.2522/ptj.20120464
References
1 The Cochrane Library. Available at: http://
www.thecochranelibrary.com/view/0/
index.html.
2 van Tulder M, Becker A, Bekkering T, et al.
Chapter 3. European guidelines for the
management of acute nonspecific low
back pain in primary care. Eur Spine J.
2006;15(suppl 2):S169 –S191.
3 Williams CM, Maher CG, Hancock MJ, et al.
Low back pain and best practice care: a sur-
vey of general practice physicians. Arch
Intern Med. 2010;170:271–277.
4 Henschke N, Maher CG, Refshauge KM,
et al. Prognosis in patients with recent
onset low back pain in Australian primary
care: inception cohort study. BMJ. 2008;
337:a171.
5 Pengel LH, Herbert RD, Maher CG, Ref-
shauge KM. Acute low back pain: system-
atic review of its prognosis. BMJ. 2003;
327:323–327.
6 Stanton TR, Henschke N, Maher CG, et al.
After an episode of acute low back pain,
recurrence is unpredictable and not as
common as previously throught. Spine
(Phila Pa 1976). 2008;33:2923–2928.
7 Von Korff M, Deyo RA, Cherkin D, Barlow
W. Back pain in primary care: outcomes at
1 year. Spine (Phila Pa 1976). 1993;18:
855– 862.
8 Faas A, Chavannes AW, van Eijk JT,
Gubbels JW. A randomized, placebo-
Volume 93 Number 12 Physical Therapy f
controlled trial of exercise therapy in
patients with acute low back pain. Spine
(Phila Pa 1976). 1993;18:1388 –1395.
9 Stanton TR, Latimer J, Maher CG, Hancock
M. Definitions of recurrence of an episode
of low back pain: a systematic review. Spine
(Phila Pa 1976). 2009;34:E316 –E322.
10 Stanton TR, Latimer J, Maher CG, Hancock
MJ. A modified Delphi approach to stan-
dardize low back pain recurrence termi-
nology. Eur Spine J. 2011;20:744 –752.
11 de vet HC, Heymans MW, Dunn KM, et al.
Episodes of low back pain: a proposal for
uniform definitions to be used in research.
Spine (Phila Pa 1976). 2002;27:2409 –
2416.
12 Wasiak R, Kim J, Pransky G. Work disabil-
ity and costs caused by recurrence of low
back pain: longer and more costly than in
first episodes. Spine (Phila Pa 1976).
2006;31:219 –225.
13 Koes BW, van Tulder M, Lin C, et al. An
updated overview of clinical guidelines for
management of non-specific low back
pain in primary care. Eur Spine J. 2010;
19:2075–2094.
14 Hayden JA, van Tulder MW, Malmivaara A,
Koes BW. Exercise therapy for treatment
of non-specific low back pain. Cochrane
Database Syst Rev. 2005;(3):CD000335.
15 Choi BK, Verbeek JH, Tam WW, Jiang JY.
Exercises for prevention of recurrences of
low back pain. Cochrane Database Syst
Rev. 2011;(1):CD006555.
16 Macedo LG, Latimer J, Maher CG, et al.
Effects of motor control exercises versus
graded activity in patients with chronic non-
specific low back pain: a randomized con-
trolled trial. Phys Ther. 2012;92:363–377.
17 Roche-Leboucher G, Petit-Lemanac’h A,
Bontoux L, et al. Multidisciplinary intensive
functional restoration versus outpatient
active physiotherapy in chronic low back
pain: a randomized controlled trial. Spine
(Phila Pa 1976). 2011;36:2235–2242.
18 Costa LO, Maher CG, Latimer J, et al. Motor
control exercise for chronic low back pain:
a randomized placebo-controlled trial. Phys
Ther. 2009;89:1275–1286.
19 Ciriello VM, Shaw WS, Rivard AJ, Woiszwillo
MJ. Dynamic training of the lumbar muscu-
lature to prevent recurrence of acute low
back pain: a randomized controlled trial
using a daily pain recall for 1 year. Disabil
Rehabil. 2012;34:1648 –1656.
20 Hill JC, Whitehurst DG, Lewis M, et al. Com-
parison of stratfied primary care manage-
ment for low back pain with current best
practice (STarT Back): a randomised con-
trolled trial. Lancet. 2011;378:1560 –1571.
21 Farrar J, Young J, LaMoreaux L, et al. Clinical
importance of changes in chronic pain
intensity measured on a 11-point numerical
pain rating scale. Pain. 2001;94:149 –158.
22 Fritz JM, Irrgang JJ. A comparison of a
modified Oswestry Low Back Pain Dis-
abilty Questionnaire and the Quebec Back
Pain Disability Scale. Phys Ther. 2001;81:
776 –788.
23 Macedo LG, Maher CG, Latimer J, McAuley
J. Motor control exercise for persistent
non-specific low back pain: a systematic
review. Phys Ther. 2009;89:9 –25.
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