A Systematic Review and Meta-Analysis on the Effectiveness of Graded Activity and Graded Exposure for Chronic Nonspecific Low Back Pain

Objective. Our aim was to systematically review and meta-analyze the effectiveness of graded activity (GA) or graded exposure (GEXP) for chronic nonspecific low back pain (CNSLBP). Methods. A literature search of multiple databases (MEDLINE, EMBASE, PEDro, CINAHL, and PsychINFO) was conducted to identify randomized control trials (RCTs). Standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated for relevant outcome measures (pain intensity, disability, quality of life, and catastrophizing). Results. Thirteen RCTs met the inclusion criteria. Only nine studies were included in the meta-analysis. GA was significantly more effective than the control group (CG) for improvements in disability in the short term (three studies: n = 254, SMD = -0.3, 95% CI -0.55 to -0.05, P = 0.02) and long term (two studies: n = 238, SMD = -0.53, 95% CI -0.79 to -0.27, P < 0.0001). GA was significantly less effective than GEXP for the improvement of disability in the short term (two studies: n = 105, SMD = 0.39, 95% CI 0.003-0.78, P = 0.048). GA was also significantly less effective than GEXP at improving catastrophizing in the short term (two studies: n = 105, SMD = 0.48, 95% CI 0.09-0.87, P = 0.02). Conclusion. Limited evidence has been found to show that GA significantly reduces disability in the short and long term when compared with the CG in CNSLBP. There is moderate evidence that GEXP more effectively decreases catastrophizing than GA in the short term. No difference was found between GA and other exercise for any variable.