Low back pain is one of the most costly conditions in musculoskeletal health care. The issue of safe, efficacious and cost-effective management for low back pain has never been more critical.
Role of Physiotherapy
One of the principal questions addressed by physiotherapists is how to provide the most appropriate management for low back pain. Through highly skilled clinical practice and well designed research, physiotherapists are able to provide evidence for physiotherapy as a safe, low cost management approach.
Physiotherapists are skilled in the assessment, diagnostic decision-making and treatment of patients with low back pain arising from a musculoskeletal disorder. Approaches to management in the field of manipulative physiotherapy involves not only ‘manipulation’, but also manual handling with passive examination and treatment techniques, therapeutic exercise and advice on posture and movement disorders. There is also a large emphasis on systematic assessment and clinical reasoning.
Physiotherapists have undertaken much research investigating the practice of physiotherapy. The research into low back pain is conducted according to strict research guidelines and, as such, is subjected to peer review and must gain approval from ethic committees.
Evidence Based Physiotherapy for Low Back Pain
Level I (systematic reviews) and level II evidence (randomised controlled trials) with specific reference to physiotherapeutic interventions have been evaluated. The following conclusions are evident from the evaluation of these studies.
Acute Low Back Pain
There is considerable evidence to support that spinal manipulative therapy (SMT – including both passive mobilisation and manipulation), McKenzie therapy and promoting early activity is effective in the short term management of low back pain. For example SMT provides better short term improvement in pain and activity levels than the comparison regimens of traction, massage, epidural injections and short-wave. Physiotherapists were involved as the providers of SMT in 7 of the 13 trials supporting the use of SMT (AHCPR, 1994). A recent meta-analysis reports twelve out of sixteen trials as positive for SMT, compared to placebo or other conservative treatment. Again, physiotherapists were the primary providers of SMT in at least 50% of the trials (van Tulder et al 1997). There is insufficient evidence to support that interventions such as shortwave, heat and massage are effective in the management of the acute low back pain patient.
Chronic Low Back Pain
There is also strong evidence to support that general exercise programs result in reduced disability, reduced absenteeism and faster return to work rate compared to control groups (Frost et al 1995, Gundewall et al, 1993; Kellett et al 1991, Mitchell et al 1990, Moffett et al 1999). Physiotherapists have the necessary training and skills to design, implement and supervise such exercise programs. Physiotherapists are also pioneering investigations into the proposed mechanisms contributing to chronic and recurrent low back pain by evaluating the effects of specific exercise programs. Evidence to support their efficacy is mounting (O’Sullivan et al, 1997). There is strong evidence that SMT is more effective in the management of chronic low back pain than bed rest, analgesics, and massage, with six out of eight trials supporting this evidence (van Tulder et al). More importantly, the combination of SMT and exercise has increasing support in the management of low back pain (Ottenbacher and Difabio 1994; Scheer et al, 1995).
Agency for Heath Care Policy and Research (ACHPR) (1994): Acute low back problems in adults. Clinical Practice Guideline no 14. US department of Health and Human Services, Public Health Services. December, Rockville MD USA.
Frost, Moffett, Moser and Fairbank (1995): Random ised controlled trial for evaluation of fitness program for patients with chronic low back pain. British MedicalJourna1310(21): 151-154.
Gundewall, Liljeqvist and Hansson (1993): Primary prevention of back symptoms and absence from work. Spine 18(5)_587-594.
Kellett, Kellett and Nordholm (1991). Effects of an exercise program on sick leave due to back pain. Physical Therapy 71(4) 283-293.
Moffet, Torgerson, Bell-Syer, Jackson, Llewlyn-Phillips, Farrin and Barber (1999): Randomised controlled trial of exercise for low back pain: clinical outcomes, costs and preferences. British Medical Journal 319: 279-283.
Mitchell and Carmen (1990): Results of a multicentre trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine 15(6): 514-521.
O’Sullivan, Twomey and Allison (1997): Evaluation of specific stabilising exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 22: 29592967.
Ottenbacher and Difabio (1994): Efficacy of Spinal Manipulation/ Mobilisation Therapy. A meta-analysis. Spine 10 (9) 833-837.
Scheer, Radack and O’Brien (1995). Randomized controlled trials in industrial low back pain relating to return to work. Part 1. Acute Interventions. Arch Phys Med. Rehab, Vol. 76, 966-973.
van Tulder, Koes and.Bouter (1997): Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomised controlled trials of the most common interventions. Spine 22 (18) 2128-2156.