Physiotherapy Treatment of Lower Back Pain – Research Evidence

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)

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.

• 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.

• 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)

• 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.