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Better than what? Comparisons in low back pain clinical trials
  1. Mervyn J Travers1,2,
  2. Matthew K Bagg3,4,5,
  3. William Gibson1,
  4. Kieran O’Sullivan6,7,
  5. Thorvaldur Skuli Palsson8
  1. 1School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
  2. 2School of Physiotherapy and Exercise Science, Curtin University, Bentley, Western Australia, Australia
  3. 3Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
  4. 4Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
  5. 5New College Village, University of New South Wales, Sydney, New South Wales, Australia
  6. 6Department of Sports Spine Centre, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  7. 7Department of Clinical Therapies, University of Limerick, Limerick, Ireland
  8. 8Department of Health Science and Technology, SMI, Aalborg University, Aalborg, Denmark
  1. Correspondence to Mervyn J Travers, School of Physiotherapy, University of Notre Dame Australia, Fremantle, Western Australia 6959, Australia ; mervyn.travers{at}

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Low back pain (LBP) has a significant impact on the sufferer and society as a whole. Therefore, we read with great interest the Specific Treatment of Problems of the Spine (STOPS) trial1 suggesting that an individualised physiotherapy approach had a favourable outcome when compared with advice in a cohort of participants with LBP lasting for more than 6 weeks. These findings highlight important issues in the design and subsequent interpretation of randomised controlled trials (RCTs) in this area.

The primary purpose of RCTs is to determine if an intervention meaningfully improves clinical outcomes. This is realised by comparing the intervention with an appropriate control.2 To determine efficacy, the ideal control is a credible placebo, but this is often difficult to design for non-pharmacological treatments. Thus, an alternative intervention is frequently used as the control. This design does not estimate efficacy; rather, it compares whether one approach is superior to another. Therefore, it is possible for an intervention to be deemed effective when compared with a control for which outcomes are suboptimal. This is relevant in LBP clinical trials and in other …

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