Global Postural Reeducation for patients with musculoskeletal conditions: a systematic review of randomized controlled trials

Giovanni E. Ferreira Rodrigo G. P. Barreto Caroline C. Robinson Rodrigo D. M. Plentz Marcelo F. Silva About the authors

ABSTRACT

Objectives

To systematically review randomized controlled trials that assessed the effects of Global Postural Reeducation (GPR) on patient-reported outcomes in conditions of the musculoskeletal system.

Method

An electronic search of MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, and SciELO was performed from their inception to June 2015. Randomized controlled trials that analyzed pain and patient-reported outcomes were included in this review. The Cochrane Collaboration’s Risk of Bias Tool was used to evaluate risk of bias, and the quality of evidence was rated following the GRADE approach. There were no language restrictions.

Results

Eleven trials were included totaling 383 patients. Overall, the trials had high risk of bias. GPR was superior to no treatment but not to other forms of treatment for pain and disability. No placebo-controlled trials were found.

Conclusion

GPR is not superior to other treatments; however, it is superior to no treatment. Due to the lack of studies, it is unknown if GPR is better than placebo. The quality of the available evidence ranges from low to very low, therefore future studies may change the effect estimates of GPR in musculoskeletal conditions.

Keywords:
global posture reeducation; systematic review; physical therapy; low back pain; neck pain; ankylosing spondylitis

Bullet points

  1. 1

    To date, the effects of GPR on patient-reported outcomes have not been summarized.

  2. 2

    GPR is better than no treatment.

  3. 3

    GPR is not better than other treatments.

  4. 4

    The quality of the available evidence ranged from low to very low quality.

Future trials must improve the reporting quality and reduce bias.

Introduction

Disorders of the musculoskeletal system represent a high societal and economic burden, accounting for a high prevalence of disability. In disorders such as low back pain11 Ferrari S, Vanti C, O’Reilly C. Clinical presentation and physiotherapy treatment of 4 patients with low back pain and isthmic spondylolisthesis. J Chiropr Med. 2012;11(2):94-103. http://dx.doi.org/10.1016/j.jcm.2011.11.001. PMid:23204952.
http://dx.doi.org/10.1016/j.jcm.2011.11....
, ankylosing spondylitis22 Ribeiro F, Leite M, Silva F, Sousa O. Physical exercise in the treatment of Ankylosing Spondylitis: a systematic review. Acta Reumatol Port. 2007;32(2):129-37. PMid:17572651.,33 Gyurcsik ZN, Andras A, Bodnar N, Szekanecz Z, Szanto S. Improvement in pain intensity, spine stiffness, and mobility during a controlled individualized physiotherapy program in ankylosing spondylitis. Rheumatol Int. 2012;32(12):3931-6. http://dx.doi.org/10.1007/s00296-011-2325-9. PMid:22198694.
http://dx.doi.org/10.1007/s00296-011-232...
, neck pain44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
, and temporomandibular disorders22 Ribeiro F, Leite M, Silva F, Sousa O. Physical exercise in the treatment of Ankylosing Spondylitis: a systematic review. Acta Reumatol Port. 2007;32(2):129-37. PMid:17572651.,55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,66 Monteiro W, Gama TFOD, Santos RM, Grecco LAC, Neto H No, Oliveira CS. Effectiveness of global postural reeducation in the treatment of temporomandibular disorder: case report. J Bodyw Mov Ther. 2013;17(1):53-8. http://dx.doi.org/10.1016/j.jbmt.2012.05.003. PMid:23294684.
http://dx.doi.org/10.1016/j.jbmt.2012.05...
, physical therapy has been recommended as a first-line treatment.

Among the various methods of treatment, Global Postural Reeducation (GPR) is of particular interest. This method was empirically developed by Phillippe Souchard in 198177 Souchard P. RPG: principes et originalité de la rééducation posturale globale. Saint Mont: Le Pousoë; 2005. and is currently used in countries like Brazil, Spain, France, and Portugal88 Teodori RM, Negri JR, Cruz MC, Marques AP. Global Postural Re-education: a literature review. Rev Bras Fisioter. 2011;15(3):185-9. http://dx.doi.org/10.1590/S1413-35552011000300003. PMid:21829981.
http://dx.doi.org/10.1590/S1413-35552011...
,99 Fernández-de-las-Peñas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...
. The philosophy of GPR lies in three fundamental principles: (1) Individuality, which considers each person as unique; (2) Causality, which states that the true cause of a musculoskeletal condition may arise from distant sites; and (3) Totality, which determines that a body should be treated in its entirety. Moreover, GPR considers the existence of different muscle chains (i.e. a series of interconnected muscles constituting a continuum along the body that play specific functional roles)1010 Fortin C, Feldman DE, Tanaka C, Houde M, Labelle H. Inter-rater reliability of the evaluation of muscular chains associated with posture alterations in scoliosis. BMC Musculoskelet Disord. 2012;13(1):80. http://dx.doi.org/10.1186/1471-2474-13-80. PMid:22639838.
http://dx.doi.org/10.1186/1471-2474-13-8...
,1111 Bonetti F, Curti S, Mattioli S, Mugnai R, Vanti C, Violante FS, et al. Effectiveness of a’Global Postural Reeducation’program for persistent low back pain: a non-randomized controlled trial. BMC Musculoskelet Disord. 2010;11(1):285. http://dx.doi.org/10.1186/1471-2474-11-285. PMid:21162726.
http://dx.doi.org/10.1186/1471-2474-11-2...
. The main muscle chains are the posterior static chain and the anterior diaphragmatic chain. Based on these principles, it is assumed that pathological conditions may arise due to retractions in the muscle chains. Thus, each patient is treated individually with specific static postures in order to stretch the shortened muscle chains and to enhance co-contraction of the antagonists. By stretching the shortened muscles and enhancing the contraction of the antagonists, the ultimate goal of this approach is to improve postural symmetry, which is believed to mediate the reduction of pain and disability.

The clinical effects of GPR have been investigated on conditions such as temporomandibular disorders, neck pain, ankylosing spondylitis, and low back pain. A literature review88 Teodori RM, Negri JR, Cruz MC, Marques AP. Global Postural Re-education: a literature review. Rev Bras Fisioter. 2011;15(3):185-9. http://dx.doi.org/10.1590/S1413-35552011000300003. PMid:21829981.
http://dx.doi.org/10.1590/S1413-35552011...
published in 2011 identified thirteen papers, among which only four were randomized controlled trials that addressed the influence of GPR on patient-reported outcomes. This review was inconclusive, as some studies showed positive results, while others did not. But the conclusions of this review were drawn based on the results of different study designs on patient-reported outcomes and surrogate outcomes without distinction. This approach hampered a correct judgement regarding the clinical effect of GPR, as surrogate outcomes are potentially misleading and may not predict clinically important outcomes accurately1212 Higgins J. Green S. Cochrane handbook for systematic reviews of interventions Version 5.1. 0 [updated March 2011]. Hoboken: John Wiley & Sons; 2011. [cited 2015 May 07]. Available from: www cochrane-handbook org..

In this sense, there is a need for a systematic review in order to provide an accurate perspective on the current evidence concerning the effects of GPR on conditions of the musculoskeletal system. The conduction of a systematic review including only randomized controlled trials is crucial, as this is the only study design that allows controlling of confounders, such as the natural history, regression to the mean, the Hawthorne effect, placebo effects, among others1313 Herbert R, Jamtvedt G, Mead J, Hagen KB. Practical evidence-based physiotherapy. Oxford: Butterworth-Heinemann; 2005. 234 p.. The goal of this paper is to systematically review randomized controlled trials that assessed the effects of GPR on conditions of the musculoskeletal system.

Method

This systematic review followed the PRISMA recommendations1414 Knobloch K, Yoon U, Vogt PM. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement and publication bias. J Craniomaxillofac Surg. 2011;39(2):91-2. http://dx.doi.org/10.1016/j.jcms.2010.11.001. PMid:21145753.
http://dx.doi.org/10.1016/j.jcms.2010.11...
,1515 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-41. http://dx.doi.org/10.1016/j.ijsu.2010.02.007. PMid:20171303.
http://dx.doi.org/10.1016/j.ijsu.2010.02...
as well as the tutorial for writing systematic reviews of the Brazilian Journal of Physical Therapy1616 Mancini MC, Cardoso JR, Sampaio RF, Costa LC, Cabral CM, Costa LO. Tutorial for writing systematic reviews for the Brazilian Journal of Physical Therapy (BJPT). Braz J Phys Ther. 2014;18(6):471-80. http://dx.doi.org/10.1590/bjpt-rbf.2014.0077. PMid:25590440.
http://dx.doi.org/10.1590/bjpt-rbf.2014....
. The study was prospectively registered under the identifier: CRD42014013787 (PROSPERO).

Literature search strategy

MEDLINE via PubMed, EMBASE, Cochrane CENTRAL, and SciELO were systematically investigated from their inception to June, 2015. Grey literature was searched through OpenGrey and Scholar Google. Websites of the Brazilian and Spanish associations of GPR, as well as specific GPR websites from France and USA were screened. The reference list of the included trials were also screened. There were no restrictions regarding language during the search phase. The search strategy for PubMed is depicted in Appendix 1.

Eligibility criteria

This review included randomized controlled trials that used GPR as a treatment method in individuals with age ≥18 years with any condition affecting the musculoskeletal system published in English, Portuguese, French, and Spanish. The included studies had to compare GPR to no intervention, any other intervention, or sham intervention and had to assess patient-reported outcomes, defined as reports coming directly from patients about how they feel or function in relation to a health condition and its therapy without interpretation by healthcare professionals or any other individual1212 Higgins J. Green S. Cochrane handbook for systematic reviews of interventions Version 5.1. 0 [updated March 2011]. Hoboken: John Wiley & Sons; 2011. [cited 2015 May 07]. Available from: www cochrane-handbook org., with any validated outcome measure.

Study selection

Two independent reviewers (G.F. and R.B.) screened titles and abstracts. Differences were solved by consensus. In the absence of consensus, a third reviewer arbitrated (M.S.).

Risk of bias

Two reviewers (G.F. and R.B.) independently rated risk of bias with the Cochrane Collaboration’s Tool for assessing risk of bias1717 Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:343. http://dx.doi.org/10.1136/bmj.d5928. PMid:22008217.
http://dx.doi.org/10.1136/bmj.d5928...
. This instrument has six domains: selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete data outcome), reporting bias (selective reporting), and other biases. Each item was rated as low, high, or unclear risk of bias.

Data extraction and analysis

Data were independently extracted by two reviewers (G.F. and R.B.) to a spreadsheet containing characteristics of the individuals enrolled, interventions, and comparators. A third reviewer (C.R.) checked the data and arbitrated any disagreements.

Quality of evidence

The quality of evidence across studies followed the principles of the GRADE approach1818 Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-6. http://dx.doi.org/10.1016/j.jclinepi.2010.07.015. PMid:21208779.
http://dx.doi.org/10.1016/j.jclinepi.201...
. The GRADE comprises five items: (1) presence of within-study limitations (risk of bias); (2) inconsistency of results (heterogeneity); (3) indirectness of evidence; (4) imprecision of the effect estimates; (5) risk of publication bias. Each non-satisfied item downgraded the overall quality of evidence for each outcome. The quality of the evidence was classified into four categories: high, moderate, low, and very low. When an outcome was assessed by only one study, the overall quality was initially considered low and the presence of high risk of bias downgraded the quality of evidence to very low1919 Parreira PCS, Costa LCM, Hespanhol LC Jr, Lopes AD, Costa LO. Current evidence does not support the use of Kinesio Taping in clinical practice: a systematic review. J Physiother. 2014;60(1):31-9. http://dx.doi.org/10.1016/j.jphys.2013.12.008. PMid:24856938.
http://dx.doi.org/10.1016/j.jphys.2013.1...
.

Data analysis

All outcomes reported were considered to be primary. For each outcome, point estimates and its respective 95% confidence intervals were calculated in Review Manager Version 5.2 (The Nordic Cochrane Centre, The Cochrane Collaboration). As the calculated estimates were based on raw means and standard deviations, slight differences were noted in some publications44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
,2020 Cabral CM, Yumi C, Sacco ICN, Casarotto RA, Marques AP. Efficacy of two muscle stretching modalities in treating the patellofemoral syndrome: a comparative study. Fisioter Pesqui. 2007;14(2):48-56.

21 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
-2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70.. A descriptive analysis was employed, since pooling revealed high levels of statistical heterogeneity (I2 >90% regardless of the chosen effect measure).

Results

Study Selection

Up to June 2015, the database search retrieved 165 articles. After duplicates removal, 109 titles and abstracts were screened for eligibility. Of those, 16 were selected for full-text reading. Two conference abstracts were screened2323 Santos MM, Guimaraes LS, Souza LO, Vasconcelos MM, Camargo TM, Develly PC, et al. Effectiveness of the Global Posture Reeducation Method (GPR) and segmental stretching in the treatment of chronic back pain: a randomized controlled trial [abstract]. In: Rheum A, editor. The 2013 American College of Rheumatology/Association of Rheumatology Health Professionals Annual Meeting; 2013 October 25-30; San Diego, CA. San Diego: Arthritis Rheumatism; 2013. p. 1458.,2424 Dönmez U, Ozturk C, Kocanaogullari H, Gucenmez S, Hepguler S. Do pyhsical therapy modalities have additional benefit over exercise therapy in the management of ankylosing spondylitis? A randomized controlled trial [abstract]. Ann Rheum Dis. 2014;73(Suppl2):727. but eventually excluded since the authors could not be contacted. After four additional exclusions2525 Bonetti F, Curti S, Mattioli S, Mugnai R, Vanti C, Violante FS, et al. Effectiveness of a ‘Global Postural Reeducation’ program for persistent low back pain: a non-randomized controlled trial. BMC Musculoskelet Disord. 2010;11(1):285. http://dx.doi.org/10.1186/1471-2474-11-285. PMid:21162726.
http://dx.doi.org/10.1186/1471-2474-11-2...

26 Garrido-Marín A, Román-Guzón D, Encinas-López P, Fernández-Serrano M, Serrano-Imedio A, Ortega-Santiago R. Effectiveness of the global postural re-education versus proprioceptive neuromuscular facilitation, to increase the extensibility of the hamstrings in healthy subjects. A pilot study. Cuest Fisioter. 2013;42(2):98-106.

27 Rossi LP, Brandalize M, Gomes ARS. Acute effect of global posture reeducation technique in the posture of women with anterior muscular chain shortening. Fisioter Mov. 2011;24(2):255-63.
-2828 Castagnoli C, Cecchi F, Del Canto A, Paperini A, Boni R, Pasquini G, et al. Effects in short and long term of Global Postural Reeducation (GPR) on chronic low back pain: a controlled study with one-year follow-up. The Scientific World Journal. 2015;2015:271436., 10 trials were included in this step. Grey literature yielded 3173 citations, none of which were additional randomized controlled trials. We therefore concluded that the probability of publication bias was reduced. There were no exclusions due to language restrictions2929 Shiwa SR, Moseley AM, Maher CG, Pena Costa LO. Language of publication has a small influence on the quality of reports of controlled trials of physiotherapy interventions. J Clin Epidemiol. 2013;66(1):78-84. http://dx.doi.org/10.1016/j.jclinepi.2012.08.004. PMid:23177897.
http://dx.doi.org/10.1016/j.jclinepi.201...
. Citation tracking in the reference list of potential papers and a previous review88 Teodori RM, Negri JR, Cruz MC, Marques AP. Global Postural Re-education: a literature review. Rev Bras Fisioter. 2011;15(3):185-9. http://dx.doi.org/10.1590/S1413-35552011000300003. PMid:21829981.
http://dx.doi.org/10.1590/S1413-35552011...
found one additional trial2020 Cabral CM, Yumi C, Sacco ICN, Casarotto RA, Marques AP. Efficacy of two muscle stretching modalities in treating the patellofemoral syndrome: a comparative study. Fisioter Pesqui. 2007;14(2):48-56.. Thus, 11 trials were included in this systematic review. The study flow diagram is depicted in Figure 1.

Figure 1
PRISMA flow diagram.

Study characteristics

Table 1 outlines the characteristics of the included studies. This review included 383 participants (mean of 35 patients per trial, ranging from 26 to 61 patients). Of these, 355 participants presented follow-up data (92.68%). A mean of 10 weeks of treatment were provided among studies, ranging from six44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
to 16 weeks3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...
. A mean of 15 treatment sessions were provided, ranging from eight55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70. to 602121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
. In ten trials44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
,55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,2020 Cabral CM, Yumi C, Sacco ICN, Casarotto RA, Marques AP. Efficacy of two muscle stretching modalities in treating the patellofemoral syndrome: a comparative study. Fisioter Pesqui. 2007;14(2):48-56.,2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70.,3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...

31 Adorno MLGR, Brasil-Neto JP. Avaliação da qualidade de vida com o instrumento SF-36 em lombalgia crônica. Acta Ortop Bras. 2013;21(4):202-7. http://dx.doi.org/10.1590/S1413-78522013000400004. PMid:24453669.
http://dx.doi.org/10.1590/S1413-78522013...

32 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...

33 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...

34 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
-3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
, GPR was supervised by a physical therapist. Only Durmus et al.2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
engaged patients in a home exercise program without supervision. Eight trials55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70.,3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...

31 Adorno MLGR, Brasil-Neto JP. Avaliação da qualidade de vida com o instrumento SF-36 em lombalgia crônica. Acta Ortop Bras. 2013;21(4):202-7. http://dx.doi.org/10.1590/S1413-78522013000400004. PMid:24453669.
http://dx.doi.org/10.1590/S1413-78522013...

32 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...

33 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...

34 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
-3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
delivered treatment sessions once a week, while two trials44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
,2020 Cabral CM, Yumi C, Sacco ICN, Casarotto RA, Marques AP. Efficacy of two muscle stretching modalities in treating the patellofemoral syndrome: a comparative study. Fisioter Pesqui. 2007;14(2):48-56. treated patients twice a week.

Table 1
Study characteristics.

Risk of bias

Eight studies reported adequate randomization procedures44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
,55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70.,3131 Adorno MLGR, Brasil-Neto JP. Avaliação da qualidade de vida com o instrumento SF-36 em lombalgia crônica. Acta Ortop Bras. 2013;21(4):202-7. http://dx.doi.org/10.1590/S1413-78522013000400004. PMid:24453669.
http://dx.doi.org/10.1590/S1413-78522013...

32 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...

33 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...

34 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
-3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
, whereas only three studies55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...
,3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
reported adequate allocation concealment procedures. Four studies2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70.,3333 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...

34 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
-3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
adequately reported blinding of the outcome assessor. Seven studies44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
,55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
,3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...
,3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...

33 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...
-3434 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
had sample loss but did not perform intention-to-treat analysis and were therefore classified as having high risk of bias for incomplete outcome data reporting. Only one trial performed intention-to-treat analysis3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
. Only one trial was prospectively registered3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
. Ten studies were considered to have high risk of bias due to the lack of at least one of the following items: allocation concealment, blinding of the outcome assessor, or intention-to-treat analysis, and only one trial was considered to have low risk of bias3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
(Table 2).

Table 2
Risk of bias summary. “Low” denotes low risk of bias; “High” denotes high risk of bias; “Unclear” denotes unclear risk of bias.

GPR versus no treatment

Three studies comprising 136 individuals compared GPR versus no treatment for pregnancy-related low back pain2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70., chronic low back pain3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
, and ankylosing spondylitis2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
(Table 3). Of these, 126 individuals presented follow-up data (92.64%). Two trials had high risk of bias and one had low risk of bias3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
.

Table 3
Results and conclusions of studies of GPR versus (A) no treatment; (B) segmental stretching; (C) other treatments.

Pregnancy-related low back pain

In the trial by Gil et al.2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70., GPR was more effective than no treatment for pain and disability reduction, and the effect was clinically relevant in both outcomes. There was very low quality evidence (GRADE) from a single study with high risk of bias that GPR significantly reduced pain and improved disability in patients with pregnancy-related low back pain.

Chronic low back pain

In the trial by Lawand et al.3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
, GPR was more effective than no intervention for pain and disability reduction at twelve weeks and six months. However, pain reduction was clinically relevant only at twelve weeks. There was low quality evidence (GRADE) from a single study with low risk of bias that GPR reduced pain and disability compared to no treatment for chronic low back pain.

Ankylosing Spondylitis

In the trial by Durmus et al.2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
, GPR was more effective than no treatment for pain and disease activity reduction, but only pain reduction was clinically relevant. There was very low quality evidence (GRADE) from a single study with high risk of bias showing that GPR significantly reduced pain and disease activity and did not change functional capacity status in patients with ankylosing spondylitis.

GPR versus segmental stretching alone

Four studies44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
,55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,2020 Cabral CM, Yumi C, Sacco ICN, Casarotto RA, Marques AP. Efficacy of two muscle stretching modalities in treating the patellofemoral syndrome: a comparative study. Fisioter Pesqui. 2007;14(2):48-56.,3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...
comprising 121 patients, of which 105 (86.77%) were followed-up, compared GPR to segmental stretching alone in neck pain44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
,3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...
, patellofemoral pain syndrome2020 Cabral CM, Yumi C, Sacco ICN, Casarotto RA, Marques AP. Efficacy of two muscle stretching modalities in treating the patellofemoral syndrome: a comparative study. Fisioter Pesqui. 2007;14(2):48-56., and temporomandibular disorders (Table 3)55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
.

Neck pain

In the trial by Amorim et al.3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...
, GPR was more effective than segmental stretching for pain and disability reduction, whereas in the trial by Cunha et al.44 Cunha AC, Burke TN, Franca FJ, Marques AP. Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial. Clinics (Sao Paulo). 2008;63(6):763-70. http://dx.doi.org/10.1590/S1807-59322008000600010. PMid:19060998.
http://dx.doi.org/10.1590/S1807-59322008...
, segmental stretching was more effective than GPR at six and twelve weeks for pain reduction. Both trials had high risk of bias as well as imprecise and inconsistent findings, therefore the evidence was rated as “very low quality” (GRADE) (Figure 2).

Figure 2
Descriptive forest-plots (pooling was not possible due to very high levels of statistical heterogeneity) for the outcomes (A) pain in trials comparing GPR versus segmental stretching for neck pain; (B) functional capacity in trials comparing GPR versus other treatments for ankylosing spondylitis; (C) disease activity in trials comparing GPR versus other treatments for ankylosing spondylitis.

Patellofemoral pain syndrome

In individuals with patellofemoral pain syndrome2020 Cabral CM, Yumi C, Sacco ICN, Casarotto RA, Marques AP. Efficacy of two muscle stretching modalities in treating the patellofemoral syndrome: a comparative study. Fisioter Pesqui. 2007;14(2):48-56., GPR was not more effective than segmental stretching for pain and disability reduction. There was very low quality evidence (GRADE) from a single trial with high risk of bias that GPR did not reduce pain or disability compared to segmental stretching in patellofemoral pain syndrome.

Temporomandibular disorders

In a trial assessing the effects of GPR versus segmental stretching in patients with temporomandibular disorders55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
, GPR was not more effective than segmental stretching for temporomandibular joint pain. There was very low quality evidence (GRADE) from a single trial with high risk of bias that GPR was not more effective than segmental stretching alone for pain reduction in temporomandibular disorders.

GPR versus other treatments

Five trials, involving 152 patients, among which 143 were followed up (94.07%) compared GPR to other treatment strategies in chronic low back pain3131 Adorno MLGR, Brasil-Neto JP. Avaliação da qualidade de vida com o instrumento SF-36 em lombalgia crônica. Acta Ortop Bras. 2013;21(4):202-7. http://dx.doi.org/10.1590/S1413-78522013000400004. PMid:24453669.
http://dx.doi.org/10.1590/S1413-78522013...
and ankylosing spondylitis (Table 3)2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
,3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...
,3333 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...
,3434 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
.

Chronic low back pain

A single trial showed that GPR was not more effective than Isostretching for pain reduction at twelve and twenty months3131 Adorno MLGR, Brasil-Neto JP. Avaliação da qualidade de vida com o instrumento SF-36 em lombalgia crônica. Acta Ortop Bras. 2013;21(4):202-7. http://dx.doi.org/10.1590/S1413-78522013000400004. PMid:24453669.
http://dx.doi.org/10.1590/S1413-78522013...
. There was very low quality evidence (GRADE) from a single trial with high risk of bias that GPR was not more effective than Isostretching for pain reduction in chronic low back pain.

Ankylosing Spondylitis

Four trials2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
,3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...
,3333 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...
,3434 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
were conducted in participants with ankylosing spondylitis. GPR was not more effective than a comprehensive exercise program in the trial by Durmus et al.2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
In the trial by Silva et al.3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...
, segmental stretching plus breathing exercises were superior to GPR for cervical pain reduction, whereas no effect for dorsal pain and a significant effect for lumbar pain reduction favoring GPR occurred, but none of the differences were clinically relevant. There was very low quality evidence (GRADE) based on two trials with high risk of bias with inconsistent and imprecise results that GPR was more effective than other interventions for pain reduction in patients with ankylosing spondylitis.

Functional capacity and disease activity were assessed in four trials2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
,3030 Silva EM, Andrade SC, Vilar MJ. Evaluation of the effects of Global Postural Reeducation in patients with ankylosing spondylitis. Rheumatol Int. 2012;32(7):2155-63. http://dx.doi.org/10.1007/s00296-011-1938-3. PMid:21544639.
http://dx.doi.org/10.1007/s00296-011-193...
,3333 Fernandez-de-Las-Penas C, Alonso-Blanco C, Morales-Cabezas M, Miangolarra-Page JC. Two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2005;84(6):407-19. http://dx.doi.org/10.1097/01.phm.0000163862.89217.fe. PMid:15905654.
http://dx.doi.org/10.1097/01.phm.0000163...
,3434 Fernandez-de-Las-Penas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra-Page JC. One-year follow-up of two exercise interventions for the management of patients with ankylosing spondylitis: a randomized controlled trial. Am J Phys Med Rehabil. 2006;85(7):559-67. http://dx.doi.org/10.1097/01.phm.0000223358.25983.df. PMid:16788386.
http://dx.doi.org/10.1097/01.phm.0000223...
. Overall, there were conflicting and imprecise findings regarding the ability of GPR to improve these outcomes (Figure 2). Based on four trials with high risk of bias, inconsistent and imprecise findings, evidence that GPR did significantly improve functional capacity and did not reduce disease activity compared to other intervention was rated as “very low quality” (GRADE).

Discussion

This systematic review showed that GPR was more effective than no treatment for pain and disability in pregnancy-related low back pain, chronic low back pain, and ankylosing spondylitis, but not for disease activity in ankylosing spondylitis. Conversely, GPR was not more effective for pain and disability reduction in patellofemoral pain syndrome, temporomandibular disorders, and neck pain. Likewise, GPR was not more effective than other treatments for pain in chronic low back pain and ankylosing spondylitis, as well as for functional capacity and disease activity in ankylosing spondylitis. Some of the presented findings appear to reflect the current knowledge on the therapeutic effect of exercise modalities on musculoskeletal conditions. For instance, Yamato et al.3636 Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo RW, Cabral CM, et al. Pilates for low back pain. Cochrane Database Syst Rev. 2015;7:CD010265. PMid:26133923. found that Pilates is probably more effective than minimal intervention and probably not more effective than other exercises for pain and disability reduction in patients with low back pain. Likewise, Dagfinrud et al.3737 Dagfinrud H, Kvien TK, Hagen KB. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev. 2008;(1):CD002822. PMid:18254008. found that either home or supervised exercises were superior to no treatment for physical function improvement. Overall, it was demonstrated that GPR was superior to no treatment and not superior to segmental stretching alone or other treatment regimens in patient-reported outcomes.

GPR compared to no treatment resulted in clinically important differences in some outcomes. Patients with pregnancy-related low back pain undergoing GPR2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70. achieved a between-group reduction of 5.5 points in pain (visual analogue scale) and 9.10 points in disability (Rolland-Morris questionnaire), which is far beyond the minimum clinically important difference values for each outcome measure, set at 1.5 and 5 points, respectively3838 Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976). 2008;33(1):90-4. http://dx.doi.org/10.1097/BRS.0b013e31815e3a10. PMid:18165753.
http://dx.doi.org/10.1097/BRS.0b013e3181...
. Patients with chronic low back pain treated with GPR in the trial by Lawand et al.3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
had a between-group reduction of 3.1 points in pain (visual analogue scale) at three months, which is considered to be a clinically important change. At six months, however, this difference was no longer clinically important3838 Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976). 2008;33(1):90-4. http://dx.doi.org/10.1097/BRS.0b013e31815e3a10. PMid:18165753.
http://dx.doi.org/10.1097/BRS.0b013e3181...
. Conversely, the point estimate for disease activity in the Durmus et al.2121 Durmuş D, Alayli G, Uzun O, Tander B, Canturk F, Bek Y, et al. Effects of two exercise interventions on pulmonary functions in the patients with ankylosing spondylitis. Joint Bone Spine. 2009;76(2):150-5. http://dx.doi.org/10.1016/j.jbspin.2008.06.013. PMid:19084457.
http://dx.doi.org/10.1016/j.jbspin.2008....
trial did not reach the minimum clinically important difference (1 point for the Bath Ankylosing Spondylitis Disease Activity Index)3939 Pavy S, Brophy S, Calin A. Establishment of the minimum clinically important difference for the bath ankylosing spondylitis indices: a prospective study. J Rheumatol. 2005;32(1):80-5. PMid:15630730., but the confidence interval included some clinically important effects.

GPR compared to segmental stretching alone for neck pain in the Amorim et al.3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...
trial resulted in a between-group reduction of 2.06 points in pain and 7.3 points in disability (Neck Disability Index) favoring GPR, whose minimum clinically important difference is 3.5 points. This finding must be interpreted with caution, as a recent Cochrane Review4040 Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1:CD004250. PMid:25629215. found that stretching alone did not result in additional benefit for chronic mechanical neck pain compared to strengthening and endurance training. Therefore, future high-quality trials should compare GPR to effective treatment strategies for neck pain, such as manual therapy or strengthening exercises. In this review, we found no studies demonstrating clinically important benefits of GPR compared to treatment strategies other than segmental stretching alone.

The majority of the included studies was rated as very low quality, which means that there is substantial uncertainty in their results. This might be explained by the high risk of bias inherent to most of the included studies (ten trials failed to address selection, performance, or attrition), the presence of high statistical heterogeneity (which precluded pooling), and the presence of imprecise estimates (little or no overlap between confidence intervals), which downgraded the evidence for within-study limitations, inconsistency, and imprecision, respectively. Conversely, considering that only three studies55 Maluf SA, Moreno BG, Crivello O, Cabral CM, Bortolotti G, Marques AP. Global postural reeducation and static stretching exercises in the treatment of myogenic temporomandibular disorders: a randomized study. J Manipulative Physiol Ther. 2010;33(7):500-7. http://dx.doi.org/10.1016/j.jmpt.2010.08.005. PMid:20937428.
http://dx.doi.org/10.1016/j.jmpt.2010.08...
,3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...
,3535 Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7. http://dx.doi.org/10.1016/j.jbspin.2015.01.015. PMid:25881758.
http://dx.doi.org/10.1016/j.jbspin.2015....
adequately reported sample size calculation and all studies had small sample sizes, type II error may have emerged in many trials. However, the latter possibility would affect only the direction and the magnitude of the findings, not the quality of the summarized evidence. Furthermore, despite the fact that small sample sizes, lack of outcome assessor blinding, allocation concealment, and intention-to-treat analysis may overestimate the true effect size of an intervention4141 Dechartres A, Trinquart L, Boutron I, Ravaud P. Influence of trial sample size on treatment effect estimates: meta-epidemiological study. BMJ. 2013;346:f2304. http://dx.doi.org/10.1136/bmj.f2304. PMid:23616031.
http://dx.doi.org/10.1136/bmj.f2304...

42 Hrobjartsson A, Thomsen AS, Emanuelsson F, Tendal B, Hilden J, Boutron I, et al. Observer bias in randomized clinical trials with measurement scale outcomes: a systematic review of trials with both blinded and nonblinded assessors. CMAJ. 2013;185(4):E201-11. http://dx.doi.org/10.1503/cmaj.120744. PMid:23359047.
http://dx.doi.org/10.1503/cmaj.120744...

43 Nuesch E, Reichenbach S, Trelle S, Rutjes AW, Liewald K, Sterchi R, et al. The importance of allocation concealment and patient blinding in osteoarthritis trials: a meta-epidemiologic study. Arthritis Rheum. 2009;61(12):1633-41. http://dx.doi.org/10.1002/art.24894. PMid:19950329.
http://dx.doi.org/10.1002/art.24894...
-4444 Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA. 1995;273(5):408-12. http://dx.doi.org/10.1001/jama.1995.03520290060030. PMid:7823387.
http://dx.doi.org/10.1001/jama.1995.0352...
, all studies had small sample sizes and most studies failed to adequately report these three domains of bias assessment, but only two trials showed large effect sizes favoring GPR2222 Gil VFB, Osis MJD, Faúndes A. Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment. Fisioter Pesqui. 2011;18(2):164-70.,3232 Amorim CS, Gracitelli ME, Marques AP, Alves VL. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: a preliminary clinical trial. J Manipulative Physiol Ther. 2014;37(6):441-7. http://dx.doi.org/10.1016/j.jmpt.2013.08.011. PMid:25092553.
http://dx.doi.org/10.1016/j.jmpt.2013.08...
.

This review has limitations. The small number of included studies and participants yielded comparisons derived from single studies, which hampered the generalizability of some findings and the conduction of the pre-planned subgroup analysis. Despite the language restrictions in the selection of studies, this systematic review included a comprehensive search within several databases in order to enhance its sensitivity. Still, some evidence from non-peer reviewed randomized controlled trials may have been missed. Furthermore, it was not possible to undertake meta-analysis due to high levels of statistical heterogeneity and because the majority of the included studies had high risk of bias, and therefore statistical pooling was not recommended for some comparisons1212 Higgins J. Green S. Cochrane handbook for systematic reviews of interventions Version 5.1. 0 [updated March 2011]. Hoboken: John Wiley & Sons; 2011. [cited 2015 May 07]. Available from: www cochrane-handbook org..

Conclusion

GPR was effective for pain and disability reduction in pregnancy-related low back pain, chronic low back pain, and ankylosing spondylitis compared to no treatment, but not superior to segmental stretching and other treatments for pain and disability in neck pain, temporomandibular disorders, and patellofemoral pain syndrome, chronic low back pain, and ankylosing spondylitis. Moreover, GPR was more effective than other treatments for functional capacity improvement but not more effective for disease activity reduction in ankylosing spondylitis. Based on this, characteristics such as patient preferences, care provider’s expertise, preference, and costs should aid the decision to use GPR in these conditions. These results must be interpreted with caution, due to the low to very low quality evidence. It is very likely that future trials should change the estimates of the effect of GPR on patient-reported outcomes in the studied conditions.

Appendix 1   Search strategy on MEDLINE (via PubMed).

Acknowledgements

We would like to thank Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Ministry of Education, Brazil.

  • HOW TO CITE THIS ARTICLE Ferreira GE, Barreto RGP, Robinson CC, Plentz RDM, Silva MF. Global Postural Reeducation for patients with musculoskeletal conditions: a systematic review of randomized controlled trials. Braz J Phys Ther. ano xxxx Mês-Mês; xx(x):xx-xx. 10.1590/bjpt-rbf.2014.0153

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Publication Dates

  • Publication in this collection
    01 Apr 2016
  • Date of issue
    May-Jun 2016

History

  • Received
    03 Aug 2015
  • Reviewed
    06 Nov 2015
  • Accepted
    12 Nov 2015
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