Physiotherapy Treatment of Lower Back Pain – Research Evidence

Another Research Evidence post. This time in regards to Physiotherapy Treatment of Lower Back Pain.

Once again I have tried to compile some of the most recent systematic reviews in regards to this topic.

The point of this post, and all of the other Research Evidence posts, being to guide us in the management of our patients. Remember the 3 components of Evidence Based Practice (EBP) from this post? Research Evidence is not the only component of EBP!

General Recommendations

Dagenais et al (2010)

  • Systematic review.
  • Recommendations for assessment of LBP emphasized the importance of:
    • Ruling out potentially serious spinal pathology, specific causes of LBP, and neurologic involvement
    • Identifying risk factors for chronicity
    • Measuring the severity of symptoms and functional limitations, through the history, physical, and neurologic examination.
  • Recommendations for management of acute LBP emphasised:
    • Patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy.
  • For chronic LBP, the addition of back exercises, behavioral therapy, and short-term opioid analgesics was suggested.
  • Management of LBP with neurologic involvement was similar, with additional consideration given to:
    • magnetic resonance imaging or computed tomography to identify appropriate candidates willing to undergo epidural steroid injections or decompression surgery if more conservative approaches are not successful.

Koes et al (2010)

  • Clinical Guidelines Review
  • Consistent features of management for acute low back pain were the:
    • Early and gradual activation of patients.
    • Discouragement of prescribed bed rest.
    • Recognition of psychosocial factors as risk factors for chronicity.
  • For chronic low back pain, consistent features included:
    • Supervised exercises
    • Cognitive behavioural therapy
    • Multidisciplinary treatment.
  • There are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain.

Physical Therapy, Motor Control and Therapeutic Exercise

Richards et al (2013)

  • Systematic Review
  • To determine the effects of Physiotherapy Functional Rehabilitation (PFR) for post-acute LBP.
  • Sixteen trials were included.
  • Conclusions:
    • Moderate to high quality evidence was found of small effects favouring PFR compared with advice.
    • Preliminary evidence suggested PFR is not different to other treatment types.
    • Further high quality research is required replicating existing trial protocols.

Vibe Fersum et al (2012)

  • Randomised Controlled Trial
  • Aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise.
  • The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically.

Macedo et al (2012)

  • Randomised controlled trial.
  • The objective of this study was to compare the effectiveness of motor control exercises and graded activity for patients with chronic nonspecific low back pain.
  • Patients were randomly assigned to receive either motor control exercises or graded activity. There was no attempt to subclassify patients to match them to a treatment.
  • A linear mixed models analysis showed that there were no significant differences between treatment groups at any of the time points for any of the outcomes studied.
  • Results of this study suggest that motor control exercises and graded activity have similar effects for patients with chronic nonspecific low back pain.

van Middelkoop et al (2011)

  • Systematic Review
  • The objective to determine the effectiveness of physical and rehabilitation interventions (i.e. exercise therapy, back school, transcutaneous electrical nerve stimulation (TENS), low level laser therapy, education, massage, behavioural treatment, traction, multidisciplinary treatment, lumbar supports, and heat/cold therapy) for chronic LBP.
  • In total 83 randomized controlled trials met the inclusion criteria.
  • Conclusions:
    • Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function.
    • Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no treatment/waiting list controls.
    • Multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls. Overall, the level of evidence was low.
    • Low quality evidence for the effectiveness of exercise therapy compared to usual care.
    • Low evidence for the effectiveness of behavioural therapy compared to no treatment.
    • Moderate evidence for the effectiveness of a multidisciplinary treatment compared to no treatment and other active treatments at reducing pain at short-term in the treatment of chronic low back pain.
    • Based on the heterogeneity of the populations, interventions, and comparison groups, we conclude that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.

 van Middelkoop et al (2010)

  • Systematic review
  • An overview on the effectiveness of exercise therapy in patients with low back pain.
  • 37 randomised controlled trials met the inclusion criteria.
  • Conclusions:
    • Exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain.
    • There is no evidence that one particular type of exercise therapy is clearly more effective than others.
    • However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

Macedo et al (2010)

  • Systematic Review
  • The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain.
  • Fifteen trials with 1,654 patients were included.
  • Conclusions:
    • The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain.
    • The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.

Unsgaard-Tondel et al (2010)

  • Randomised controlled trial comparing outcomes after motor control exercises, sling exercises, and general exercises for low back pain.
  • This study gave no evidence that 8 treatments with individually instructed motor control exercises or sling exercises were superior to general exercises for chronic low back pain.

Macedo et al (2009)

  • Systematic Review
  • The objective of this study was to systematically review randomized controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain.
  • Fourteen trials were included.
  • Conclusions:
    • Motor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise.

Psychosocial

Kent and Kjaer (2012)

  • Systematic Review
  • There are no published systematic reviews of the efficacy of targeted psychosocial interventions.
  • This review aimed to determine if the efficacy of interventions for psychosocial risk factors of persistent NSLBP is improved when targeted to people with particular psychosocial characteristics.
  • Four studies met the inclusion criteria.
  • Conclusions:
    • Graded activity plus Treatment Based Classification targeted to people with high movement-related fear was more effective than Treatment Based Classification at reducing movement-related fear at 4 weeks.
    • Active rehabilitation (physical exercise classes with cognitive-behavioural principles) was more effective than usual GP care at reducing activity limitation at 12 months, when targeted to people with higher movement-related pain.
    • Few studies have investigated targeted psychosocial interventions in NSLBP, using trial designs suitable for measuring treatment effect modification, and they do not provide consistent evidence supporting such targeting. There is a need for appropriately designed and adequately powered trials to investigate targetedpsychosocial interventions.

Pharmacotherapy

Peniston (2012)

  • Review
  • Pharmacotherapies for cLBP include acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids.
  • Acetaminophen is a well-tolerated first-line pharmacotherapy, but high-dose, long-term use is associated with hepatic toxicity.
  • Nonsteroidal anti-inflammatory drugs can be an effective second-line option if acetaminophen proves inadequate but they have well-known risks of gastrointestinal, cardiovascular, and other systemic adverse effects that increase with patient age, dose amount, and duration of use.
  • The serotonin-norepinephrine reuptake inhibitor, duloxetine, has demonstrated modest efficacy and is associated with systematic adverse events, including serotonin syndrome, which can be dose related or result from interaction with other analgesics.
  • Opioids may be an effective choice for moderate to severe pain but also have significant risks of adverse events and carry a substantial risk of addiction and abuse.
  • Because the course of cLBP may be protracted, patients may require treatment over years or decades, and it is critical that the risk/benefit profiles of pharmacotherapies are closely evaluated to ensure that short- and long-term treatments are optimized for each patient. This article reviews the clinical evidence and the guideline recommendations for pharmacotherapy of cLBP.

Kuijpers et al (2011)

  • Systematic Review
  • The objective of this review was to determine the effectiveness of pharmacological interventions [i.e., non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and opioids] for non-specific chronic low-back pain (LBP).
  • NSAIDs and opioids seem to lead to a somewhat higher relief in pain on the short term, as compared to placebo, in patients with non-specific chronic low back pain; opioids seem to have a small effect in improving function for a selection of patients who responded with an exacerbation of their symptoms after stopping their medication.
  • However, both types of medication show more adverse effects than placebo. There seems to be no difference in effect between antidepressants and placebo in patients with non-specific chronic LBP.

Radiological Findings

Jarvik et al (2001)

  • Longitudinal Study
  • Prevalence of the following findings in patients without low back pain:
    • Disc Degeneration – 91%
    • Disc Signal Loss – 83%
    • Disc Height Loss – 56%
    • Disc Bulge – 64%
    • Disc Protrusion – 32%
    • Annular Tear – 38%

McCullough et al (2012)

  • A retrospective study.
  • During 3 years, the following epidemiologic statement (based on the Jarvik study above) was routinely but arbitrarily included in lumbar spine MR imaging reports.

Jarvik (2001) and McCullough (2012)

  • Two hundred thirty-seven reports documenting uncomplicated degenerative changes on initial lumbar spine MR images were identified, 71 (30%) of which included the statement (statement group) and 166 (70%) did not (non-statement group). The rates of repeat cross-sectional imaging and treatments within 1 year were compared between groups by using logistic regression controlling for severity of MR imaging findings.
  • Patients in the statement group were significantly less likely to receive a prescription for narcotics for their symptoms than patients in the non-statement group.
  • Repeat cross-sectional imaging and physical therapy referrals were also less common in the statement group than in the nonstatement group but these differences were not statistically significant.
  • Rates of steroid injections, surgical consultations, and surgeries were similar between groups.
  • Conclusion:
    • Patients were less likely to receive narcotics prescriptions from primary care providers when epidemiologic information was included in their lumbar spine MR imaging reports.

Jensen et al (2008)

  • Systematic Review
  • The prevalence of “vertebral endplate signal changes” (VESC) and its association with low back pain (LBP) varies greatly between studies. This wide range in reported prevalence rates and associations with LBP could be explained by differences in the definitions of VESC, LBP, or study sample. The objectives of this systematic critical review were to investigate the current literature in relation to the prevalence of VESC (including Modic changes) and the association with non-specific low back pain (LBP).
  • This systematic review shows that VESC is a common MRI-finding in patients with non-specific LBP and is associated with pain. However, it should be noted that VESC may be present in individuals without LBP.

Jensen et al (2012)

  • Cohort study
  • Aims of this study were to investigate how Modic Changes (MCs) developed over a 14-month period and if changes in the size and/or the pathological type of MCs were associated with changes in clinical symptoms in a cohort of patients with persistent LBP and MCs.
  • Conclusions:
    • The presence of MCs type I at both baseline and follow-up is associated with a poor outcome in patients with persistent LBP and MCs.

Surgery vs Non-Surgery

Brox et al (2010)

  • Two merged randomised clinical trials compared instrumented transpedicular fusion with cognitive intervention and exercises in 124 patients with disc degeneration and at least 1 year of symptoms after or without previous surgery for disc herniation. The main outcome measure was the Oswestry disability index.
  • Long-term improvement (at 4 years) was not better after instrumented transpedicular fusion compared with cognitive intervention and exercises.

References:

Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010 Sep;69(9):1643-8.

Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recentclinical practice guidelines. Spine J. 2010 Jun;10(6):514-29.

Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine (Phila Pa 1976). 2001 May 15;26(10):1158-66.

Jensen TS, Karppinen J, Sorensen JS, Niinimäki J, Leboeuf-Yde C. Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J. 2008 Nov;17(11):1407-22.

Jensen RK, Leboeuf-Yde C, Wedderkopp N, Sorensen JS, Jensen TS, Manniche C. Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. Eur Spine J. 2012 Nov;21(11):2271-9.

Kent P, Kjaer P. The efficacy of targeted interventions for modifiable psychosocial risk factors of persistentnonspecific low back pain – a systematic review. Man Ther. 2012 Oct;17(5): 385-401.

Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010 Dec;19(12):2075-94.

Kuijpers T, van Middelkoop M, Rubinstein SM, Ostelo R, Verhagen A, Koes BW, van Tulder MW. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J. 2011 Jan;20(1):40-50.

Macedo LG, Latimer J, Maher CG, Hodges PW, McAuley JH, Nicholas MK, Tonkin L, Stanton CJ, Stanton TR, Stafford R. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther. 2012 Mar;92(3):363-77.

Macedo LG, Smeets RJ, Maher CG, Latimer J, McAuley JH. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Phys Ther. 2010 Jun;90(6):860-79.

Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009 Jan;89(1):9-25.

McCullough BJ, Johnson GR, Martin BI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology. 2012 Mar;262(3):941-6.

Peniston JH. A review of pharmacotherapy for chronic low back pain with considerations for sports medicine. Phys Sportsmed. 2012 Nov;40(4):21-32.

Richards MC, Ford JJ, Slater SL, Hahne AJ, Surkitt LD, Davidson M, McMeeken JM. The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review. Man Ther. 2013 Feb;18(1):4-25.

Unsgaard-Tøndel M, Fladmark AM, Salvesen Ø, Vasseljen O. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Phys Ther. 2010 Oct;90(10):1426-40.

Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2012 Dec 4. doi: 10.1002/j.1532-2149.

van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW. A systematic review on the effectiveness of physical and rehabilitation interventions for chronicnon-specific low back pain. Eur Spine J. 2011 Jan;20(1):19-39.

van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):193-204.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

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