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Background research papers


Background research papers on supervised and unsupervised exercise programs

These papers were used to inform the current DVA policy guidelines regarding gymnasium-pool memberships for therapeutic exercise programs.


1. Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence.

Garrett S, Elley CR, Rose SB, O'Dea D, Lawton BA, Dowell AC.

Br J Gen Pract. 2011 Mar; 61(584):e125-33.


Women's Health Research Centre, University of Otago, Wellington, New Zealand.


The health and economic burden of physical inactivity is well documented. A wide range of primary care and community-based interventions are available to increase physical activity. It is important to identify which components of these interventions provide the best value for money.


To assess the cost-effectiveness of physical activity interventions in primary care and the community.

Design of Study

Systematic review of cost-effectiveness studies based on randomised controlled trials of interventions to increase adult physical activity that were based in primary health care or the community, completed between 2002 and 2009.


Electronic databases were searched to identify relevant literature. Results and study quality were assessed by two researchers, using Drummond's checklist for economic evaluations. Cost-effectiveness ratios for moving one person from inactive to active, and cost-utility ratios (cost per quality-adjusted life-year [QALY]) were compared between interventions.


Thirteen studies fulfilled the inclusion criteria. Eight studies were of good or excellent quality. Interventions, study populations, and study designs were heterogeneous, making comparisons difficult. The cost to move one person to the 'active' category at 12 months was estimated for four interventions ranging from €331 to €3673. The cost-utility was estimated in nine studies, and varied from €348 to €86,877 per QALY.


Most interventions to increase physical activity were cost-effective, especially where direct supervision or instruction was not required. Walking, exercise groups, or brief exercise advice on prescription delivered in person, or by phone or mail appeared to be more cost-effective than supervised gym-based exercise classes or instructor-led walking programmes. Many physical activity interventions had similar cost-utility estimates to funded pharmaceutical interventions and should be considered for funding at a similar level.



2. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial.

Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svendsen KH, Grimm RH Jr, Owens EF Jr, Garvey TA, Transfeldt EE.

Spine J. 2011 Jul; 11(7):585-98. Epub 2011 May 31.


Wolfe Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, MN 55431, USA.

Background Context

Several conservative therapies have been shown to be beneficial in the treatment of chronic low back pain (CLBP), including different forms of exercise and spinal manipulative therapy (SMT). The efficacy of less time-consuming and less costly self-care interventions, for example, home exercise, remains inconclusive in CLBP populations.


The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP.

Study Design/Setting

An observer-blinded and mixed-method randomized clinical trial conducted in a university research clinic in Bloomington, MN, USA.

Patient Sample

Individuals, 18 to 65 years of age, who had a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain to the lower extremity were included in this trial.

Outcome Measures

Patient-rated outcomes were pain, disability, general health status, medication use, global improvement, and satisfaction. Trunk muscle endurance and strength were assessed by blinded examiners, and qualitative interviews were performed at the end of the 12-week treatment phase.


This prospective randomized clinical trial examined the short- (12 weeks) and long-term (52 weeks) relative efficacy of high-dose, supervised low-tech trunk exercise, chiropractic SMT, and a short course of home exercise and self-care advice for the treatment of LBP of at least 6-week duration. The study was approved by local institutional review boards.


A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term.


For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favoured the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.



3. Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study.

Medina-Mirapeix F, Escolar-Reina P, Gascon-Canovas JJ, Montilla-Herrador J, Jimeno-Serrano FJ, Collins SM.

BMC Musculoskelet Disord. 2009 Dec 9; 10:155.


Department of Physical Therapy, University of Murcia, Murcia, Spain.


Evidence suggests that to facilitate physical activity sedentary people may adhere to one component of exercise prescriptions (intensity, duration or frequency) without adhering to other components. Some experts have provided evidence for determinants of adherence to different components among healthy people. However, our understanding remains scarce in this area for patients with neck or low back pain. The aims of this study are to determine whether patients with neck or low back pain have different rates of adherence to exercise components of frequency per week and duration per session when prescribed with a home exercise program, and to identify if adherence to both exercise components have distinct predictive factors.


A cohort of one hundred eighty-four patients with chronic neck or low back pain who attended physiotherapy in eight primary care centres were studied prospectively one month after intervention. The study had three measurement periods: at baseline (measuring characteristics of patients and pain), at the end of physiotherapy intervention (measuring characteristics of the home exercise program) and a month later (measuring professional behaviours during clinical encounters, environmental factors and self-efficacy, and adherence behaviour).


Adherence to duration per session (70.9% +/- 7.1) was more probable than adherence to frequency per week (60.7% +/- 7.0). Self-efficacy was a relevant factor for both exercise components (p < 0.05). The total number of exercises prescribed was predictive of frequency adherence (p < 0.05). Professional behaviors have a distinct influence on exercise components. Frequency adherence is more probable if patients received clarification of their doubts (adjusted OR: 4.1; p < 0.05), and duration adherence is more probable if they are supervised during the learning of exercises (adjusted OR: 3.3; p < 0.05).


We have shown in a clinic-based study that adherence to exercise prescription frequency and duration components have distinct levels and predictive factors. We recommend additional study, and advise that differential attention be given in clinical practice to each exercise component for improving adherence.



4. Effectiveness of a home exercise programme in low back pain: a randomized five-year follow-up study.

Kuukkanen T, Malkia E, Kautiainen H, Pohjolainen T.

Physiother Res Int. 2007 Dec;12(4):213-24.


School of Health and Social Studies, Jyvaskyla University of Applied Sciences, Jyvaskyla, Finland.

Background and Purpose

Therapeutic exercise has been shown to be beneficial in decreasing pain and in increasing functioning in patients with chronic low back pain. However, longitudinal follow-up studies are small in number, and often limited in the numbers of subjects due to drop-outs. In addition there is a shortage of real control groups in most cases. The purpose of the present study was to describe long-term changes in intensity of low back pain and in functioning for two study groups five years after undertaking a home exercise programme.


This was a randomized follow-up study over five years. Fifty-seven subjects were reassessed with questionnaires five years after their initial recruitment for an intervention study. A home exercise group (n = 29), with training once a day, and a control group (n = 28), without exercise, were included in the present study protocol. The primary outcome measurements included a questionnaire on the intensity of low back pain (Borg CR-10 scale) and on functioning (Oswestry Disability Index; ODI). The confounding physical activity was controlled with metabolic unit (MET) values.


The CR-10 and ODI scores decreased during the first three months in both study groups. During the follow-ups, the corresponding indicators of the home exercise group remained below baseline values. The CR-10 score was significantly lower in the home exercise group (p = 0.01) during the last five-year follow-up session compared with the control group. Overall physical activity decreased slightly during the five-year follow-up, but there were no differences between the two study groups.


The present randomized study indicates that supervised, controlled home exercises lead to reduced low back pain, and that positive effects were preserved over five years.



5. Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial

Gill SD, McBurney H, Schulz DL

Archives of Physical Medicine and Rehabilitation 2009 Mar; 90(3):388-394


Clinical trial

Clinical trial

7/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind subjects: No; Blind therapists: No; Blind assessors: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*


To compare the preoperative effects of multidimensional land-based and pool-based exercise programs for people awaiting joint replacement surgery of the hip or knee.


Randomized, single-blind, before-after trial.


Physiotherapy gymnasium and hydrotherapy pool.


Patients awaiting elective hip or knee joint replacement surgery.


Land-based (n = 40) or pool-based exercise program (n = 42). Each 6-week program included an education session, twice-weekly exercise classes, and an occupational therapy home assessment.

Main Outcome Measures

Participants were assessed immediately before and after the 6-week intervention, then 8 weeks later. Primary outcomes were pain and self-reported function (Western Ontario and McMaster Universities Osteoarthritis Index) and patient global assessment. Secondary outcomes were performance-based measures (timed walk and chair stand) and psychosocial status (Medical Outcomes Study 36-Item Short-Form Health Survey mental component score). Pain was also measured before and after each exercise class on a 7-point verbal rating scale.


Although both interventions were effective in reducing pain and improving function, there were no post intervention differences between the groups for the primary and secondary outcomes. However, the pool-based group had less pain immediately after the exercise classes.


While our multidimensional exercise-based interventions appeared to be effective in reducing disability in those awaiting joint replacement surgery of the hip or knee, there were no large differences in the post intervention effects of the interventions. However, pool-based exercise appeared to have a more favourable effect on pain immediately after the exercise classes.



6. Exercise: A Risky Business

Exercise is not a substitute for Exercise Rehabilitation - A White Paper by Riseley Physiotherapy Pty Ltd.
8 Riseley Street, Applecross WA 6153, T 08 9364 4073
Published 10th May 2011


Overwhelming evidence exists for the use of exercise in the rehabilitation of many musculoskeletal and chronic pain conditions. The form that the exercise should take is less obvious. Exercise, using gym based protocols of quantity, are inappropriate where retraining of correct movement patterns is required. Twelve key elements of rehabilitative exercise are provided to give clinicians insight into appropriate quality-based exercise rehabilitation programs for their clients.