Objective Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP). Design Network meta-analysis (NMA). Data sources MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL. Eligibility criteria Exercise training randomised controlled/clinical trials in adults with NSCLBP. Results Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): −1.86 (–2.54 to –1.19)), resistance (SUCRA=80%; −1.14 (–1.71 to –0.56)) and stabilisation/motor control (SUCRA=80%; −1.13 (–1.53 to –0.74)) for physical function and resistance (SUCRA=80%; −1.26 (–2.10 to –0.41)) and aerobic (SUCRA=80%; −1.18 (–2.20 to –0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (–0.71 to 0.89)) and physical function (SUCRA=20%; −0.31 (–0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; −0.31 (–1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria. Summary/conclusion There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.

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Test-retest intrarater reliability study. To examine reliability of abdominal musculature measurements across a broad range of conditions for a physical therapist newly trained in assessment using rehabilitative ultrasound imaging (RUSI). RUSI has previously been used to assess abdominal muscle function during a drawing-in maneuver of the anterior abdominal wall, and measurements conducted by an experienced assessor have been validated by comparison with magnetic resonance imaging. Few studies have examined the reliability of less experienced operators, and only in isolated measurement conditions. Nineteen subjects (11 female, 8 male) without a history of low back pain performed the abdominal drawing-in maneuver in a supine hook-lying position. RUSI was used bilaterally to assess the thickness of the internal oblique (IO) and transversus abdominis (TrA) muscles at rest and on contraction, as well as changes in the length of the TrA muscle (indicated by slide of the anterior abdominal fascia). The reliability of a novice rater who received 8 hours of training was examined (a) across 3 measurements of the same ultrasound image, (b) across 3 separate ultrasound images (averaged for days and sides of abdomen), and (c) across 2 days (averaged for images and sides). Reliability of assessing muscle thickness was very high across 3 measurements of the sale image (intrarater correlation coefficients [ICC3.1] were all greater than 0.97), fair to high across 3 images (ICC(3,4) = 0.62-0.82), and fair to high across 2 days (ICC(3,6) = 0.63-0.85). Reliability of measuring the slide of the anterior abdominal fascia was very high across measurements from the same image (ICC(3,1) = 0.98) but very low across images (ICC(3,4) = 0.44) and across 2 days (ICC(3,6) = 0.36). High reliability of a novice rater was demonstrated for some measurement conditions. Measures of reliability for recapturing the image and repetition across days ranged from low to high. Inconsistencies in the pattern of results suggest that for a novice assessor using RUSI, training should be performed and reliability assessed for each abdominal muscle and measurement condition intended to be used for research and clinical practice.

Prospective longitudinal study. To investigate, using magnetic resonance imaging (MRI), the influence of bed rest on the lumbopelvic musculature. Reduced gravitational loading and inactivity (bed rest) are known to result in significant change in musculoskeletal function, although little is known about its effects on specific muscles of the lumbopelvic region. Ten healthy male subjects underwent 8 weeks of bed rest with 6 months of follow-up. MRI of the lumbopelvic region was conducted at regular time-points during and after bed rest. Using uniplanar images at L4, cross-sectional areas (CSAs) of the multifidus, lumbar erector spinae, quadratus lumborum, psoas, anterolateral abdominal, and rectus abdominis muscles were measured. Multifidus CSA decreased by day 14 of bed rest (F = 7.4, P = 0.04). The lumbar erector spinae and quadratus lumborum CSA showed no statistically significant difference to baseline across the time of bed rest (P > 0.05). The anterolateral abdominal, rectus abdominis, and psoas CSA all increased over this time. Psoas CSA increased by day 14 (F = 6.9, P = 0.047) and remained so until day 56, whereas the anterolateral abdominal CSA (F = 29.4, P = 0.003) and rectus abdominis CSA (F = 8.9, P = 0.03) were not statistically larger than baseline until day 56. On reambulation after completion of the bed rest phase, multifidus, anterolateral abdominal, and rectus abdominis CSA returned to baseline levels (P > 0.05) by day 4 of follow-up, whereas psoas CSA returned to baseline level after day 28 of the follow-up period. Bed rest resulted in selective atrophy of the multifidus muscle. An increased CSA of the trunk flexor musculature (increases in psoas, anterolateral abdominal, and rectus abdominis muscles) may reflect muscle shortening or possible overactivity during bed rest. Some of the changes resemble those seen in low back pain and may in part explain the negative effects of bed rest seen in low back pain sufferers.