Comparison of physical treatments versus a brief pain management programme for back pain in primary care: A randomised clinical trial in physiotherapy practice

Primary Care Sciences Research Centre, Keele University, Staffordshire, UK.
The Lancet (Impact Factor: 45.22). 06/2005; 365(9476). DOI: 10.1016/S0140-6736(05)66696-2
Source: OAI


Recommendations for the management of low back pain in primary care emphasise the importance of recognising and addressing psychosocial factors at an early stage. We compared the effectiveness of a brief pain-management programme with physiotherapy incorporating manual therapy for the reduction of disability at 12 months in patients consulting primary care with subacute low back pain.
For this pragmatic, multicentre, randomised clinical trial, eligible participants consulted primary care with non-specific low back pain of less than 12 weeks' duration. They were randomly assigned either a programme of pain management (n=201) or manual therapy (n=201). The primary outcome was change in the score on the Roland and Morris disability questionnaire at 12 months. Analysis was by intention to treat.
Of 544 patients assessed for eligibility, 402 were recruited (mean age 40.6 years) and 329 (82%) reached 12-month follow-up. Mean disability scores were 13.8 (SD 4.8) for the pain-management group and 13.3 (4.9) for the manual-therapy group. The mean decreases in disability scores were 8.8 (6.4) and 8.8 (6.1) at 12 months (difference 0 [95% CI -1.3 to 1.4], p=0.99), and median numbers of physiotherapy visits per patient were three (IQR one to five) and four (two to five), respectively (p=0.001). One adverse reaction (an exacerbation of pain after the initial assessment) was recorded.
Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care.

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Available from: Chris J Main, Oct 10, 2015
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    • "CLBP may affect both functioning and quality of life mediated by decrease in physical, emotional and social factors. Physiotherapists have accordingly shifted towards a biopsychosocial approach and there is evidence that a biomedical approach is insufficiently effective (Hay et al. 2005). There are multiple biopsychosocial treatment options which are currently evidence based including cognitive therapy combined with exercise therapy, operant approaches or contextual treatment such as mindfulness or acceptance and commitment therapy (ACT) (Keefe et al. 2004). "
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    ABSTRACT: The aim of this study was to explore on which variables a stress reduction program based on heart coherence can enhance the effects of a back school (BS) in patients with chronic non-specific low back pain and to explore possible moderators for treatment success. A retrospective explorative design was carried out with 170 patients with chronic non-specific low back pain. 89 Patients were admitted to BS and 81 patients were selected for BS and heart coherence training (BS-HCT). Six sessions of heart coherence were provided. At T0 (baseline) and T1 (discharge), the Numeric Rating Scale for pain (NRS pain), Roland Morris Disability Questionnaire (RMDQ), Pain Disability Index (PDI) and Rand-36 were administered in both groups. Both groups improved significantly on NRS pain, RMDQ, PDI and most of the Rand-36 subscales. On physical functioning, the BS-HCT group improved significantly more than the BS group (p = 0.02) but not after Bonferroni correction. Significant moderate correlations (r = 0.39 and r = 0.48) were found between the change of heart coherence and change of PDI and RMDQ respectively, but not with other variables. Baseline characteristics were not related to change on heart coherence. Providing HCT was more effective on physical functioning compared to a BS program. Change in heart coherence was related significantly to 2 out of 12 analyses. Placebo controlled and blinded studies are needed to confirm this. Characteristics of individuals who might benefit remain unknown. Evidence of this study is considered a level C, because of its pragmatic clinical character.
    Applied Psychophysiology and Biofeedback 10/2014; 39(3-4). DOI:10.1007/s10484-014-9260-y · 1.13 Impact Factor
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    • "Our definition of attendance at the initial assessment and three or more sessions was based on a collective judgement of the intervention designers that this would provide the essential components of the programme. This is broadly in keeping with other reports in the literature [20]. In those defined as non-compliers, some may have received some elements of the cognitive behavioural intervention, and this could possibly lead to an underestimate of the treatment effect amongst compliers [21]. "
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    ABSTRACT: Group cognitive behavioural intervention (CBI) is effective in reducing low-back pain and disability in comparison to advice in primary care. The aim of this analysis was to investigate the impact of compliance on estimates of treatment effect and to identify factors associated with compliance. In this multicentre trial, 701 adults with troublesome sub-acute or chronic low-back pain were recruited from 56 general practices. Participants were randomised to advice (control n = 233) or advice plus CBI (n = 468). Compliance was specified a priori as attending a minimum of three group sessions and the individual assessment. We estimated the complier average causal effect (CACE) of treatment. Comparison of the CACE estimate of the mean treatment difference to the intention-to-treat (ITT) estimate at 12 months showed a greater benefit of CBI amongst participants compliant with treatment on the Roland Morris Questionnaire (CACE: 1.6 points, 95% CI 0.51 to 2.75; ITT: 1.3 points, 95% CI 0.55 to 2.07), the Modified Von Korff disability score (CACE: 12.1 points, 95% CI 6.01 to 18.17; ITT: 8.6 points, 95% CI 4.58 to 12.64) and the Modified von Korff pain score (CACE: 10.4 points, 95% CI 4.64 to 16.10; ITT: 7.0 points, 95% CI 3.26 to 10.74). People who were non-compliant were younger and had higher pain scores at randomisation. Treatment compliance is important in the effectiveness of group CBI. Younger people and those with more pain are at greater risk of non-compliance.Trial registration: Current Controlled Trials ISRCTN54717854.
    BMC Musculoskeletal Disorders 01/2014; 15(1):17. DOI:10.1186/1471-2474-15-17 · 1.72 Impact Factor
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    • "Low back pain (LBP) is the most common form of back pain. It may be restricted to the back areas (low-back, midback and high-back) or may radiate down one or both legs (Goldestein, 2002), and has been defined as pain or discomfort felt in the area bounded superiorly by T12 and inferiorly by the buttock creases (Watson et al, 2005). Low back pain is the most common cause of absence from work for both men and women between 20 and 65 years of age (Walsh et al, 1990). "
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    ABSTRACT: Little is known about the influence of physiotherapists’ characteristics and treatment modalities on the number of treatment sessions in Nigeria. This study was designed to evaluate the factors influencing the number of treatment sessions for patients with low back pain (LBP). Three hundred and eleven practising physiotherapists based in Nigeria participated in this study (77.8% response rate). They were required to complete a 31-item closed-ended questionnaire, which collected information on demographic data, work experience and treatment activities. Data was represented using bar charts, frequency and percentage. Chi-square was used to determine significant difference at p = 0.05. About 114 (38.10%) of the respondents employed 10 treatment sessions in the treatment of patients with LBP. Gender, age, areas of interest and educational attainment influenced the number of treatment sessions (p<0.05). Older male respondents, with higher educational attainment, especially those who are specialized in orthopaedics had fewer treatment sessions with their patients. However, working experience, acquisition of additional training (through continuous professional education) and types of treatment modalities did not have any significant relationship with number of treatment sessions (p>0.05). The average number of treatment sessions administered to patients with LBP before they are discharged in Nigeria is ten sessions. This was influenced by gender, age, areas of interest and educational attainment. There was a general consensus that a treatment guideline is needed for proper management of patients with LBP.
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