RE: “EXERCISE FOR THE PREVENTION OF LOW BACK PAIN: SYSTEMATIC REVIEW AND META-ANALYSIS OF CONTROLLED TRIALS”

RE: “EXERCISE FOR THE PREVENTION OF LOW BACK PAIN: SYSTEMATIC REVIEW AND META-ANALYSIS OF... 1340 Letters to the Editor © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. RE: “EXERCISE FOR THE PREVENTION OF LOW BACK PAIN: SYSTEMATIC REVIEW AND META-ANALYSIS OF CONTROLLED TRIALS” Shiri et al. (1) recently conducted a systematic review and Finally, the authors include studies with different intensities of meta-analysis that discusses the effect of different exercise in- exercise (3), such as yoga, a light-intensity activity. Including dif- terventions to prevent low back pain (LBP). It is encouraging to ferent intensities means that the review and meta-analysis include see how well exercise interventions prevent LBP and decrease heterogeneous types of intervention, which makes firm conclu- disability. Evaluating the effectiveness of exercise may increase sion about the impact, optimum type, and intensity of the exercise the understanding of these nonpharmacological interventions to interventions to prevent LBP very difficult. prevent LBP. Although these interventions are commendable for LBP, there are necessary comments that need to be made regarding this review. ACKNOWLEDGMENTS The review is reported according to PRISMA guidelines, but Conflict of interest: none declared. the inclusion criteria are ambiguous. The authors do not suffi- ciently follow the PICO format (Participants, Intervention, Com- parison, Outcomes). The authors state the inclusion criteria REFERENCES as: “Trials were eligible for inclusion in the review if they compared an exercise intervention with usual daily activities” (1). 1. Shiri R, Coggon D, Falah-Hassani K. Exercise for the Additionally, the authors state, “Our primary aim in the current prevention of low back pain: systematic review and meta- meta-analysis of controlled trials was to determine the effect of analysis of controlled trials. Am J Epidemiol. 2018;87(5): 1093–1101. exercise in population-based interventions designed to prevent 2. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement LBP. In addition, as secondary objectives, we assessed the effects for reporting systematic reviews and meta-analyses of studies of exercise on intensity of LBP, disability due to LBP, health-care that evaluate health care interventions: explanation and consultation for LBP, and sick leave due to LBP” (1). Surpris- elaboration. J Clin Epidemiol. 2009;62(10):e1–e34. ingly, the review did not clearly report the other components of 3. Hartfiel N, Burton C, Rycroft-Malone J, et al. Yoga for reducing inclusion criteria, such as participant and outcome measures. perceived stress and back pain at work. Occup Med (Lond). The articles included were randomized, controlled trials that 2012;62(8):606–612. compared the effect of different types of exercise—such as strengthening, stretching, yoga, postural exercise, balance exercise, Mohammad Alwardat (e-mail: wardatm1@gmail.com) endurance exercise, functional exercise, and aerobic exercise—in School of Neuroscience, Faculty of Medicine and Surgery, comparison with no exercise intervention or conventional in- University of Rome Tor Vergata, Rome, Italy terventions. Thus, knowledge of the eligibility criteria is essential in appraising the validity, applicability, and comprehensiveness of the systematic review and meta-analysis (2). DOI: 10.1093/aje/kwy042; Advance Access publication: March 20, 2018 © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. THE AUTHORS REPLY We thank Alwardat (1) for his interest in our meta-analytic LBP, health-care consultation for LBP, and sick leave due to review (2). PICO or PICOT (Participants, Intervention, Compari- LBP. With regard to participants, we reported that we included son, Outcomes, Time frame/Type of study) is routinely used in interventions that targeted defined population groups with no systematic reviews and meta-analyses of controlled trials (3, 4). attempt to screen out participants with LBP at the time of recruit- Although, as reported, we used the Preferred Reporting Items for ment, but we excluded controlled trials in which participants all Systematic Reviews and Meta-Analyses (PRISMA) statement (4) had LBP at baseline. We were also clear that controlled trials when developing our review protocol, the information that we were eligible for inclusion in the review if at least some of presented in our introduction and methods sections accords with the participants were free from LBP at baseline. PICOT, as Alwardat (1) quotes from our inclusion and exclu- To date, only a limited number of controlled trials on the effec- sion criteria: “Trials were eligible for inclusion in the review if tiveness of exercise in the primary prevention of LBP and associ- they compared an exercise intervention with usual daily activi- ated disability have been published. We therefore included trials ties.” Three components of PICOT are defined in that sentence: on different types and intensities of exercise. However, for the I (exercise intervention), C (usual daily activities), and Type of primary outcome of the review, despite heterogeneous inter- study (trials). We clearly defined our outcomes in the introduc- ventions, the amount of between-study heterogeneity was low. tion. Low back pain (LBP) was the primary outcome, while the Moreover, we performed subgroup analyses by type and fre- secondary outcomes were intensity of LBP, disability due to quency of exercise. For the primary outcome, we reported Am J Epidemiol. 2018;187(6):1336–1343 Downloaded from https://academic.oup.com/aje/article-abstract/187/6/1340/4924567 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Epidemiology Oxford University Press

RE: “EXERCISE FOR THE PREVENTION OF LOW BACK PAIN: SYSTEMATIC REVIEW AND META-ANALYSIS OF CONTROLLED TRIALS”

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Abstract

1340 Letters to the Editor © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. RE: “EXERCISE FOR THE PREVENTION OF LOW BACK PAIN: SYSTEMATIC REVIEW AND META-ANALYSIS OF CONTROLLED TRIALS” Shiri et al. (1) recently conducted a systematic review and Finally, the authors include studies with different intensities of meta-analysis that discusses the effect of different exercise in- exercise (3), such as yoga, a light-intensity activity. Including dif- terventions to prevent low back pain (LBP). It is encouraging to ferent intensities means that the review and meta-analysis include see how well exercise interventions prevent LBP and decrease heterogeneous types of intervention, which makes firm conclu- disability. Evaluating the effectiveness of exercise may increase sion about the impact, optimum type, and intensity of the exercise the understanding of these nonpharmacological interventions to interventions to prevent LBP very difficult. prevent LBP. Although these interventions are commendable for LBP, there are necessary comments that need to be made regarding this review. ACKNOWLEDGMENTS The review is reported according to PRISMA guidelines, but Conflict of interest: none declared. the inclusion criteria are ambiguous. The authors do not suffi- ciently follow the PICO format (Participants, Intervention, Com- parison, Outcomes). The authors state the inclusion criteria REFERENCES as: “Trials were eligible for inclusion in the review if they compared an exercise intervention with usual daily activities” (1). 1. Shiri R, Coggon D, Falah-Hassani K. Exercise for the Additionally, the authors state, “Our primary aim in the current prevention of low back pain: systematic review and meta- meta-analysis of controlled trials was to determine the effect of analysis of controlled trials. Am J Epidemiol. 2018;87(5): 1093–1101. exercise in population-based interventions designed to prevent 2. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement LBP. In addition, as secondary objectives, we assessed the effects for reporting systematic reviews and meta-analyses of studies of exercise on intensity of LBP, disability due to LBP, health-care that evaluate health care interventions: explanation and consultation for LBP, and sick leave due to LBP” (1). Surpris- elaboration. J Clin Epidemiol. 2009;62(10):e1–e34. ingly, the review did not clearly report the other components of 3. Hartfiel N, Burton C, Rycroft-Malone J, et al. Yoga for reducing inclusion criteria, such as participant and outcome measures. perceived stress and back pain at work. Occup Med (Lond). The articles included were randomized, controlled trials that 2012;62(8):606–612. compared the effect of different types of exercise—such as strengthening, stretching, yoga, postural exercise, balance exercise, Mohammad Alwardat (e-mail: wardatm1@gmail.com) endurance exercise, functional exercise, and aerobic exercise—in School of Neuroscience, Faculty of Medicine and Surgery, comparison with no exercise intervention or conventional in- University of Rome Tor Vergata, Rome, Italy terventions. Thus, knowledge of the eligibility criteria is essential in appraising the validity, applicability, and comprehensiveness of the systematic review and meta-analysis (2). DOI: 10.1093/aje/kwy042; Advance Access publication: March 20, 2018 © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. THE AUTHORS REPLY We thank Alwardat (1) for his interest in our meta-analytic LBP, health-care consultation for LBP, and sick leave due to review (2). PICO or PICOT (Participants, Intervention, Compari- LBP. With regard to participants, we reported that we included son, Outcomes, Time frame/Type of study) is routinely used in interventions that targeted defined population groups with no systematic reviews and meta-analyses of controlled trials (3, 4). attempt to screen out participants with LBP at the time of recruit- Although, as reported, we used the Preferred Reporting Items for ment, but we excluded controlled trials in which participants all Systematic Reviews and Meta-Analyses (PRISMA) statement (4) had LBP at baseline. We were also clear that controlled trials when developing our review protocol, the information that we were eligible for inclusion in the review if at least some of presented in our introduction and methods sections accords with the participants were free from LBP at baseline. PICOT, as Alwardat (1) quotes from our inclusion and exclu- To date, only a limited number of controlled trials on the effec- sion criteria: “Trials were eligible for inclusion in the review if tiveness of exercise in the primary prevention of LBP and associ- they compared an exercise intervention with usual daily activi- ated disability have been published. We therefore included trials ties.” Three components of PICOT are defined in that sentence: on different types and intensities of exercise. However, for the I (exercise intervention), C (usual daily activities), and Type of primary outcome of the review, despite heterogeneous inter- study (trials). We clearly defined our outcomes in the introduc- ventions, the amount of between-study heterogeneity was low. tion. Low back pain (LBP) was the primary outcome, while the Moreover, we performed subgroup analyses by type and fre- secondary outcomes were intensity of LBP, disability due to quency of exercise. For the primary outcome, we reported Am J Epidemiol. 2018;187(6):1336–1343 Downloaded from https://academic.oup.com/aje/article-abstract/187/6/1340/4924567 by Ed 'DeepDyve' Gillespie user on 21 June 2018

Journal

American Journal of EpidemiologyOxford University Press

Published: Mar 20, 2018

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