Evidence of the Efficacy of Exercise Therapy and Manual Therapy in the Management of Chronic Non-specific Low Back Pain - Presentation of the European Guidelines

Background: Chronic non-specific low back pain is common in the general population. Objective: The primary objective of the European evidencebased guidelines on low back pain is to provide a set of recommendations that can support existing and future national and international guidelines, thus allowing an approach to effective treatment of non-specific chronic low back pain. The main focus of this article is to describe the efficacy of exercise therapy and manual therapy. Methods: A systematic literature review was conducted at the databases of Medline, Embase, Cochrane Library, CINAHL, HealthStar, Pascal, PEDro, Psyclit, Biosis, Lilacs and IME (Indice Medico Espanol). The methodological quality of the systematic review articles was assessed by the Oxman & Guyatt Index. Randomised controlled trials were examined for their internal validity. Results: 54 articles were identified, 30 of them were of high methodological quality. Supervised exercise therapy is recommended as the most important treatment for chronic non-specific low back pain. Exercise therapy does not require expensive training machines. The application of a cognitive-behavioural approach, in which graded exercises are performed, using exercise quotas, appears to be the most useful concept. Group therapy should be preferred due to lower cost. Recommendations on specific types of exercise (i. e. strengthening/muscle conditioning, aerobic, McKenzie, flexion exercises) can not be given; they depend on the Physiotherapists' education and the patients' needs. The effect of exercise therapy is not clear: There is no connection between the improvement of pain/disability and physical performance capacity. The role of manual therapy in the treatment of chronic low back pain is not quite clear. It is only a treatment option as an additional measure with only moderate efficacy, like many other treatments. The course of spinal manipulation/mobilisation should only be short term. Conclusion: Passive interventions seem to have no effect on chronic non-specific low back pain. An active exercise program with slowly increased intensity should be favoured. Future studies should include cost-benefit and risk-benefit analysis.