A prospective study of patients with chronic back pain randomised to group exercise, physiotherapy or osteopathy

doi:10.1016/j.physio.2007.04.014

Physiotherapy

Volume 94, Issue 1, March 2008, Pages 21-28

https://doi.org/10.1016/j.physio.2007.04.014 Get rights and content

Abstract

Objective

To investigate the difference in outcome between patients treated with group exercise, physiotherapy or osteopathy.

Design

Prospective study of patients referred at random to one of three treatments, with follow-up 6 weeks after discharge and after 12 months.

Setting

National Health Service physiotherapy department at St Albans City Hospital, part of the West Hertfordshire Musculoskeletal Therapy Service.

Participants

Two hundred and thirty-nine patients aged 18–65 years recruited from referrals to the physiotherapy department with chronic low back pain.

Interventions

Eligible patients were randomised to group exercises led by a physiotherapist, one-to-one predominantly manipulative physiotherapy, or osteopathy.

Main outcomes

Oswestry Disability Index (ODI), EuroQol-5D, shuttle walking test and patients’ subjective responses to pain and treatment.

Results

All three treatments indicated comparable reductions in mean (95% confidence intervals) ODI at 6-week follow-up: group exercise, −4.5 (−0.9 to −8.0); physiotherapy, −4.1 (−1.4 to −6.9); and osteopathy, −5.0 (−1.6 to −8.4). Attendance rates were significantly lower among the group exercise patients. One-to-one therapies provided evidence of greater patient satisfaction.

Conclusion

The study supports the use of a variety of approaches for the treatment of chronic low back pain. Particular attention needs to be given to the problems of attracting enough participants for group sessions, as these can be difficult to schedule in ways that are convenient for different participants.

Introduction

Low back pain is a major health problem within Western industrialised populations. In recent studies, it was found that 5 million consultations with general practitioners (GPs) and 1.6 million hospital outpatient attendances in Britain were associated with chronic and acute low back pain. This translates to 180 million lost working days [1]. It is estimated that of an annual cost to the National Health Service (NHS) of £512 million, £150.6 million pays for physiotherapy alone [2].

There is much debate about the effectiveness of different treatment programmes, and despite an abundance of research, the UK BEAM trial suggested that the role of different physical treatments for back pain is unclear [3].

Many systematic reviews into the treatment of low back pain have been published. Evans and Richards investigated a wide variety of interventions. They suggested that physiotherapy and manipulative therapy did have therapeutic benefits [4]. Similarly, Van Tuldar and Boulter found that manipulation and exercise therapy had strong evidence in support of implementation for patients with chronic low back pain [5]. Koes et al. analysed the use of manipulation as an intervention to treat chronic low back pain, and suggested some benefits but with further research required [6]. This was supported by Assendelft et al. in an analysis of spinal manipulation [7]. In a meta-analysis, Hayden et al. provided support for the use of exercises in adults with chronic low back pain, concluding that exercise decreased pain and improved physical function by modest amounts [8].

Many studies look for the most effective intervention over different time frames. Koes et al. suggested that, in the most effective treatments, the effects are only small and short term, and that there is insufficient evidence for longer-term effects [9]. The results of the UK BEAM trial suggest that exercise alone confers only short-term benefit but that manipulation confers longer-term benefit [3].

Departmental statistics show that the most common referral received by St Albans City Hospital Physiotherapy Department is for the patient with low back pain, with chronic low back pain being most prevalent. This department currently offers three treatment paths: group exercise; physiotherapy; and osteopathy. To date, few studies have compared osteopathic treatment with the approaches used by physiotherapists. Thus, the aim of the present study was to compare the effectiveness of these three physical therapy regimes for chronic low back pain within a single NHS trust.

Section snippets

Aims and methods

The research set out to examine two specific research questions:

1.
Is physiotherapy-led group exercise as effective as one-to-one physiotherapy for patients with chronic low back pain?
2.
Is one-to-one physiotherapy as effective as one-to-one osteopathy for patients with chronic low back pain?

Participants at baseline

Table 2 shows that patient randomisation yielded three groups that were highly comparable in terms of basic demography (age and gender) and assessed severity of health, according to the ODI and the two EuroQol measures (EQ-5D and Health Status VAS).

Completion of therapy regime

Patient attendance was monitored. The numbers and percentages completing the therapy regime by group are stated in Table 3. Group therapy had the worst attendance, with only 40% of patients completing all therapy sessions, compared with 74% within

Discussion

This study sought to assess the response of patients with chronic low back pain to each of the treatment regimes available at St Albans City Hospital. The study employed various assessment tools to measure current symptoms and response to therapy.

In terms of key health outcomes, the three groups reported comparable overall levels of change at 6-week follow-up. Mean ODI scores decreased from baseline to 6-week follow-up by around four or five percentage points, while mean EQ-5D scores increased

Conclusion

This study has not provided any evidence that any one single therapy confers therapeutic advantages over the others. There are issues with maintaining attendance at group exercise sessions. Overall, the levels of improvement as assessed by a decrease in mean ODI score are of a moderate level (four percentage points). Furthermore, in the absence of a control group, it was not possible to assess the possible contribution of spontaneous improvement over time.

The study department has gained

Acknowledgements

The authors are indebted to the University of Hertfordshire Research Support and Development Unit for their tireless support.
Ethical approval: St Albans and Hemel Hempstead NHS Trust R&D Consortium (no. 107SAHH). West Hertfordshire Health Authority local research ethics committee (WHO33/98).
Funding: St Albans and Hemel Hempstead NHS Trust R&D Consortium.
Conflict of interest: None.

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There were not significant differences between groups at baseline. After the intervention both groups obtained better results in the Neck Disability Index but there were not significant differences between them (p > 0.05). At follow-up, the self-management group obtained significant better results compared to the control group (95 % CI: -5.20(-6.8 to -1.5), p = 0.032).
An individualized self-management program added to a physical therapy program led to a greater improvement in disability at 3 months follow up compared to a physical therapy program alone. Catastrophizing, pain, and health-related quality of life improved significantly after the intervention and at follow-up compared to the standard care alone.
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Exercise Interventions for Persistent Non-Specific Low Back Pain – Does Matching Outcomes to Treatment Targets Make a Difference? A Systematic Review and Meta-Analysis
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At an individual trial level, only 22% of trials2,25,44,48,74,76 (n = 6) demonstrated overall low risk of bias with 5 of the risk of bias domains met. Most trials described adequate sequence generation (22/27).2,12,46,48,50,52,65,67,74,76,13,8,14,6,16,18,22,25,33,39,44 No trials had low risk of bias for blinding, despite trial-specific measures specifically described by Costa et al 25 The lack of blinding was agreed by the team due to the nature of participating in an exercise intervention in comparison to a nonexercise control.
Exercise is a core treatment for persistent non-specific low back pain (NSLBP), but results from randomised controlled trials (RCTs) of exercise typically show only small to moderate standardised mean differences (SMDs) compared to nonexercise controls. The choice of primary outcome, and relationship to the specific targets of exercise may influence this. This systematic review aimed to explore whether primary outcomes match the exercise treatment targets used in NSLBP RCTs and the potential impact of matching on SMDs. Included RCTs were conducted with patients with persistent NSLBP, compared exercise to no exercise, with sample sizes >60 per arm. Screening, data extraction and risk of bias assessment were independently undertaken by paired reviewers. Of 19272 initial titles, 27 RCTs were included with 31 treatment targets and 6 primary outcome domains identified. Only 25% of included RCTs had primary outcomes that matched the treatment targets. SMDs of exercise versus comparison arms were observed to be larger in the matched (SMD .54 (95% Confidence Interval .23 to.85), P =.0006) compared to the unmatched category (SMD 0.22 (95% Confidence Interval .01, .44) P = .04) but this difference was not statistically significant (P = .10). These exploratory findings may have implications for future teams developing RCTs of exercise for NSLBP and warrant further investigation in larger datasets.
This review was an exploratory study that investigated the primary outcome and treatment targets used in RCTs of exercise for NSLBP. The SMDs of the matched group were descriptively larger than those of the unmatched group, but further analysis with larger sample sizes is required to have confidence in these results.
Effectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis
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Results of this evaluation and specific judgement for each study are shown in Fig. 2 and Fig. 3 Osteopathic interventions resulted substantially safe: seven studies35–38,41–43 (70%) did not report any adverse effect, Ajimsha and coll.39 reported an increasing of pain in 10 subjects during the first week of MFR treatment, Licciardone’s 2013 study40 indicated “increased back muscle spasticity” in one occasion; Santos et al.44 did not collect any data.
Chronic low back pain (CLBP) is a frequent cause of disability and it represents a medical, social and economic burden globally. Therefore, we assessed effectiveness of osteopathic interventions in the management of NS-CLBP for pain and functional status.
A systematic review and meta-analysis were conducted. Findings were reported following the PRISMA statement. Six databases were searched for RCTs. Studies were independently assessed using a standardized form. Each article was assessed using the Cochrane risk of bias (RoB) tool. Effect size (ES) were calculated at post-treatment and at 12 weeks’ follow up. We used GRADE to assess quality of evidence.
10 articles were included. Studies investigated osteopathic manipulative treatment (OMT, n = 6), myofascial release (MFR, n = 2), craniosacral treatment (CST, n = 1) and osteopathic visceral manipulation (OVM, n = 1). None of the study was completely judged at low RoB. Osteopathy revealed to be more effective than control interventions in pain reduction (ES: -0.59; 95% CI: -0.81, -0.36; P < 0.00,001) and in improving functional status (ES: -0.42; 95% 95% CI: -0.68, -0.15; P = 0.002). Moderate-quality evidence suggested that MFR is more effective than control treatments in pain reduction (ES: -0.69; 95% CI: -1.05, -0.33; P = 0.0002), even at follow-up (ES: -0.73; 95% CI: -1.09, -0.37; P < 0.0001). Low-quality evidence suggested superiority of OMT in pain reduction (ES: -0.57; 95% CI: -0.90, -0.25; P = 0.001) and in changing functional status (ES: -0.34; 95% CI: -0.65, -0.03; P = 0.001). Very low-quality evidence suggested that MFR is more effective than control interventions in functional improvements (ES: -0.73; 95% CI: -1.25, -0.21; P = 0.006).
Results strengthen evidence that osteopathy is effective in pain levels and functional status improvements in NS-CLBP patients. MFR reported better level of evidence for pain reduction if compared to other interventions. Further high-quality RCTs, comparing different osteopathic modalities, are recommended to produce better-quality evidence.
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The aim was to examine the health and economic consequences of osteopathic care for low back pain and neck pain in addition to usual care compared to usual care alone.
A decision tree model considering a one-year time horizon was applied. The analysis occurred from a health insurance perspective only considering direct medical costs. The health effects were expressed as quality-adjusted life years (QALYs).
The main outcome was the incremental cost-effectiveness ratio (ICER). The uncertainty around key input parameters was addressed applying one-way and probabilistic sensitivity analyses (5000 simulations).
For low back pain, osteopathy resulted in cost savings (€385.1 vs €501.8/patient) at improved QALYs (0.666 vs. 0.614) compared to usual care. For neck pain, osteopathy resulted in additional costs (€577.3 vs. €521.0) and improved QALYs (0.639 vs. 0.609) resulting in an ICER of €1,870/QALY. The one-way sensitivity analysis identified the hospitalization cost (back) and osteopathy cost (neck) as major cost drivers. The probabilistic sensitivity analysis resulted in an average net saving of €163 (95%CI–€260, -€49.1) and a QALY gain of 0.06 (95%CI –0.06, 0.17) for low back pain and an average additional cost of €55.1 (95%CI €20.9, €129) and improved QALY gain of 0.03 (95%CI–0.06, 0.12) for neck pain.
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To investigate the effects of an osteopathic manipulative treatment (OMT), which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic nonspecific low back pain (NS-CLBP).
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Private and institutional health centers.
Participants (N=66) (18-60y) with a diagnosis of NS-CLBP lasting at least 3 months.
Participants were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks.
The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland–Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12.
A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12 (SF-MPQ [mean difference −6.2; 95% confidence interval, −8.6 to −3.8]; VAS [mean difference −2.7; 95% confidence interval, −3.6 to −1.8]; RMQ [mean difference −3.8; 95% confidence interval, −5.4 to −2.2]; ODI [mean difference −10.6; 95% confidence interval, −14.9 to 6.3]). Moreover, improvements in pain and disability were clinically relevant.
An OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.
Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis
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Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies.
The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain.
This is a systematic literature review and meta-analysis.
The present study measures self-reported pain, function, health-related quality of life, and adverse events.
We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912.
Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=−0.28, 95% confidence interval (CI) −0.47 to −0.09, p=.004; I²=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=−0.33, 95% CI −0.63 to −0.03, p=.03; I²=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=−0.43, 95% CI −0.86 to 0.00; p=.05, I²=79%; SMD=−0.86, 95% CI −1.27 to −0.45; p<.0001, I²=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=−0.20, 95% CI −0.35 to −0.04; p=.01; I²=0%) but not disability (SMD=−0.10, 95% CI −0.28 to 0.07; p=.25; I²=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described.
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A prospective study of patients with chronic back pain randomised to group exercise, physiotherapy or osteopathy

Abstract

Objective

Design

Setting

Participants

Interventions

Main outcomes

Results

Conclusion

Introduction

Section snippets

Aims and methods

Participants at baseline

Completion of therapy regime

Discussion

Conclusion

Acknowledgements

Chest

Conservative treatment of acute and chronic non-specific low back pain: a systemic review of randomised controlled trials

Spine

Spinal manipulation for low back pain: an updated systemic review of randomised controlled trials

Spine

Spinal manipulative therapy for low back pain: a meta-analysis of effectiveness relative to other therapies

Ann Intern Med