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Integration of sub-classification strategies in RCTs evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain (NSCLBP): a systematic review
  1. Kjartan Vibe Fersum1,*,
  2. Wim Dankaerts2,
  3. Peter Bruce O'Sullivan3,
  4. Jonas Maes4,
  5. Jan Sture Skouen1,
  6. Jan Magnus Bjordal1,
  7. Alice Kvåle1
  1. 1 University of Bergen, Norway;
  2. 2 University College Limburg and K.U.Leuven, Leuven, Belgium;
  3. 3 School of Physiotherapy, Curtin University, Australia;
  4. 4 K.U.Leuven, Leuven, Belgium
  1. Correspondence to: Kjartan Vibe Fersum, Section for Physiotherapy Science, University of Bergen, Kalfarveien 31, Bergen, 5018, Norway; kjartan.fersum{at}


Background: There is lack of evidence for specific treatment interventions for patients with non-specific chronic low back pain (NSCLBP) despite the substantial amount of Randomised Controlled clinical Trials (RCTs) evaluating treatment outcome for this disorder.

Hypothesis: It has been hypothesised that this vacuum of evidence is caused by the lack of sub-classifying the heterogeneous population of patients with CLBP for outcome research.

Study design: A systematic review (SR).

Methods: A systematic review with a meta-analysis (MA) was undertaken to determine the integration of sub-classification strategies with matched interventions in RCTs evaluating manual therapy treatment and exercise therapy for NSCLBP. A structured search for relevant studies in Embase, Cinahl, Medline, PEDro and the Cochrane Trials Register database, followed by hand searching all relevant studies in English up till December 2008.

Results: Only 5 out of 68 studies (7.4%) sub-classified patients beyond applying general in- and exclusion criteria. In the few studies where classification and matched interventions have been utilised, our meta-analysis showed a statistical difference in favour of the classification based intervention for reductions in pain (p= 0.004) and disability (p= 0.0005), both for short and long-term reduction in pain (p= 0.001). Effect sizes ranged from moderate (0.43) short term, to minimal (0.14) for long-term.

Conclusion: A better integration of sub-classification strategies in NSCLBP outcome research is needed. We propose the development of explicit recommendations for the use of sub-classification strategies and evaluation of targeted interventions in future research evaluating NSCLBP.

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