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The comparative effectiveness of advice/education compared to active physiotherapy (manual therapy and exercise) in the management of chronic non-specific low back pain

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Background: Low back pain is considered to be one of the leading causes of activity limitation and work absence throughout the world with major consequences for health-care resources. Advice and education, exercise and manual therapy form the most common management recommendations across all international guidelines. However, little is known about the relative merits of exercise and/or manual therapy compared to advice and education for the management of chronic non-specific low back pain (NSLBP). Objectives: The aim of this systematic review was to examine the evidence pertaining to the effects of advice/education versus exercise and/or manual therapy on patients with chronic NSLBP. Methods: Eligible studies were identified by searching MEDLINE, Embase, CINAHL, AMED, SportDiscus, and the Cochrane CENTRAL Register of controlled trials. Randomized controlled trials (RCTs) on patients with chronic NSLBP were considered. Two independent reviewers extracted data and assessed methodological quality. Results: Data from four RCTs (483 participants) were included in this review. All four studies were classified as having low risk of bias. Two studies found a statistically significant improvement in pain and functional capacities at short term in the exercise group (P,0.05). One study reported positive results in favor of the advice group, while the other study reported no significant difference between groups. Heterogeneity in the nature of the interventions, outcome measures, duration and frequency of treatment, and follow-up periods were identified. Conclusion: There is low-quality evidence that exercise is no more effective than advice/education for patients with chronic NSLBP at short-term follow-up (3 months). These results indicate the lack of highquality research in this field and the necessity for high-quality research comparing the effectiveness of guideline-recommended interventions for chronic NSLBP.
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Systematic Review
The comparative effectiveness of advice/
education compared to active physiotherapy
(manual therapy and exercise) in the
management of chronic non-specific low back
pain: a systematic review
Samuel Kweku Wie Otoo
1
, Paul Hendrick
2
, Dan Ribeiro
3
1
Nyaho Medical Centre, Airport Residential Area, Accra, Ghana,
2
Division of Physiotherapy and Rehabilitation
Sciences, School of Health Sciences, The University of Nottingham, UK,
3
Centre for Health, Activity and
Rehabilitation, Research School of Physiotherapy, University of Otago, Dunedin, New Zealand
Background: Low back pain is considered to be one of the leading causes of activity limitation and work
absence throughout the world with major consequences for health-care resources. Advice and education,
exercise and manual therapy form the most common management recommendations across all
international guidelines. However, little is known about the relative merits of exercise and/or manual
therapy compared to advice and education for the management of chronic non-specific low back pain
(NSLBP).
Objectives: The aim of this systematic review was to examine the evidence pertaining to the effects of
advice/education versus exercise and/or manual therapy on patients with chronic NSLBP.
Methods: Eligible studies were identified by searching MEDLINE, Embase, CINAHL, AMED, SportDiscus,
and the Cochrane CENTRAL Register of controlled trials. Randomized controlled trials (RCTs) on patients
with chronic NSLBP were considered. Two independent reviewers extracted data and assessed
methodological quality.
Results: Data from four RCTs (483 participants) were included in this review. All four studies were classified
as having low risk of bias. Two studies found a statistically significant improvement in pain and functional
capacities at short term in the exercise group (P,0.05). One study reported positive results in favor of the
advice group, while the other study reported no significant difference between groups. Heterogeneity in the
nature of the interventions, outcome measures, duration and frequency of treatment, and follow-up periods
were identified.
Conclusion: There is low-quality evidence that exercise is no more effective than advice/education for
patients with chronic NSLBP at short-term follow-up (3 months). These results indicate the lack of high-
quality research in this field and the necessity for high-quality research comparing the effectiveness of
guideline-recommended interventions for chronic NSLBP.
Keywords: Advice, Education, Exercise, Low back pain, Active physiotherapy
Introduction
Low back pain can be classified into three groups:
neurological involvement; severe spinal pathology;
and non-specific low back pain (NSLBP).
1
Non-
specific low back pain forms the majority of all cases
and can be defined as LBP that cannot be attributed
to a recognized or known pathology and as such,
currently, there are diverse prognostic and treatment
protocols in use.
1–3
It is estimated that 50% of NSLBP
patients who seek care experience rapid improvement
in disability and pain within the first 12 weeks.
4
Research, however, suggests that in a subset of
patients, pain persists after 12 weeks and within this
group only about 40% recover within 12 months.
5
The
majority of such patients do not seek further health
interventions after this 12-week period and continue to
experience low levels of disability and pain.
6,7
LBP
that persists for more than 12 weeks is considered
chronic.
8
Correspondence to: Paul Hendrick, Division of Physiotherapy and
Rehabilitation Sciences, School of Health Sciences, The University of
Nottingham B90, Clinical Sciences Building, City Hospital Campus,
Nottingham NG5 1PB, UK. Email: Paul.Hendrick@nottingham.ac.uk
ßW. S. Maney & Son Ltd 2014
DOI 10.1179/1743288X14Y.0000000164 Physical Therapy Reviews 2014 VOL. 000 NO.000 1
Chronic NSLBP has been linked with a number of
factors including incorrect interpretation of pain,
increasing anxiety levels, stress or increased somatic
findings, limitations in physical mobility, and physical
deconditioning, as well as decreased involvement in
social activities.
9,10
The complexity and multifactorial
nature of the condition has led to a number of different
management interventions for patients with chronic
NSLBP. Such heterogeneity in management has been
partly attributed to education and training, as well as
the scope of practice of care providers.
11,12
However, it
is essential that all care providers involved in the
management of this burdensome condition are guided
by best available scientific evidence so as to maximize
the use of effective and less costly interventions.
Numerous evidence-based Clinical Practice Guidelines
(CPGs) are published annually with the potential to
improve the quality and safety of health care.,
3,13,14
Recent reviews of CPGs demonstrate that interven-
tions such as advise to keep active or educating chronic
NSLBP patients about their condition is a common
recommendation.
3,15,16
At the same time, interventions
such as exercise or manual therapy are also included
in the majority of national guidelines.
3,13,14
These
interventions are supported by an extensive body of
research
17–19
and unlike previous reviews,
11
recent
reviews demonstrate consensus among guidelines
regarding the effectiveness of back exercises for
chronic NSLBP, although no specific exercise is
recommended.
16
Spinal manipulative therapy (SMT)
has been shown to be an effective intervention for
patients with chronic NSLBP even though it has
received varied recommendations in clinical guidelines
because of conflicting evidence underlying its usage in
practice.
18,20
A number of systematic reviews have investigated
the effectiveness of interventions such as advice/
education,
21,22
and exercise
23
or manual therapy
18
with most suggesting positive results.
21–23
However,
the comparative effect of advice/education to exercise
and manual therapy based interventions has not been
reviewed. Therefore, this review was carried out to
answer the questions:
1) How effective is advice to remain active/education
in the management of patients with chronic NSLBP
as compared to exercise and/or manual therapy in
terms of pain relief and functional capacities?
2) What are the effects of frequency of intervention on
LBP treatment outcomes?
Methods
Eligibility criteria
Randomized controlled trials (RCTs) written in English
language were considered for inclusion. Included
patients were aged 18 years or above, and there was
no gender restriction. Patients had to be diagnosed
with chronic NSLBP, which was defined as symptoms
being located ‘between the inferior margin of the
twelfth rib and the inferior gluteal folds, with or
without radiation to the lower extremity.’
24
Patients
with serious spinal pathologies such as inflammatory
joint diseases, infections, neoplasms, metastases,
osteoporosis, or even fractures were excluded. Studies
that included pregnant women and patients who had
spinal surgery completed in the previous year were also
not considered for this review.
Studies were considered if they included the
following comparisons:
NAdvice/education versus manual therapy (e.g. SMT,
mobilization, manual traction, massage).
NAdvice/education versus exercise therapy.
NAdvice/education versus both manual therapy and
exercise therapy.
NAdvice/education versus any manual therapy and/or
exercise plus advice/education.
All forms of patient advice (verbal, written, one to
one, and group based) and all health-care practitioner
delivered exercise or manual therapy were included.
Primary outcome measures considered were pain
[frequency and severity: using either the Numeric
Rating Scale or the Visual Analog scale (VAS)] and
back-related function (measured by either the Roland–
Morris or Oswestry Disability Questionnaires). The
effects of the frequency of the various treatment interven-
tions on these outcomes were also considered.
Literature search
A computer-based search was performed up to and
including June 2013 in six databases: MEDLINE,
EMBASE, CINAHL, AMED, Sport Discus, and the
Cochrane Collaboration’s Register of Clinical Trials.
The key search terms used were low back pain,
advice, patient education, exercise, manual therapy,
and SMT. Search terms were appropriately combined
for each database. The complete search strategies
from all databases are included in Appendix 1.
Further searching was performed for gray as well as
unpublished literature using the same search terms
in the following databases: www.opengrey.eu, www.
guidelines.gov, www.controlled-trials.com, and www.
clinicaltrials.com. Additionally, a comprehensive exam-
ination of reference lists from retrieved articles was
performed.
Selection process
Titles and abstracts of each citation were screened by
two authors (SO and PH). Studies were eliminated if
they did not meet the inclusion criteria from the
abstracts of the initial yield. Full articles were
obtained and assessed as to whether the study
fulfilled the inclusion criteria. Any disparities were
resolved by consensus.
Data extraction
A customized form was used to extract data from the
included studies, based on guidelines provided by the
Otoo et al. Comparative effectiveness of advice/education
2Physical Therapy Reviews 2014 VOL.000 NO.000
Centre for Reviews and Dissemination
25
and the
Cochrane Hand book of Systematic Reviews.
26
This
was to aid standardization of the data extraction
process. Data were collected under the following
main headings: Study ID, Title, Method, Participants
(inclusion and exclusion criteria, gender, and age),
Interventions (type, duration, and intensity), Outcomes
(outcome measures) and Notes.
Summary measures
Mean differences and its corresponding 95% con-
fidence interval or P-value were used as summary
measures for assessing the effect of interventions on
primary and secondary outcome measures.
Risk of bias in individual studies
The methodological quality of included studies were
assessed independently by two authors using the criteria
recommended by the Cochrane Back Review Group
(CBRG).
27
This comprises 12 questions with instruc-
tions adapted from various research studies.
26,28,29
The
12 questions are divided into four main areas, which
assess the internal validity in four separate areas:
Selection bias (criteria 1, 2, 9), Performance bias
(criteria 3, 4, 10, 11), Attrition bias (criteria 6, 7), and
Detection bias (criteria 5, 12). Each criterion was
scored either a ‘yes,’ ‘unclear,’ or a ‘no.’ A low risk of
bias was attained in a particular criterion if it had a
‘yes’ response. Differences in assessment were resolved
by discussion and consensus. Based on the recommen-
dations of the CBRG, a study was rated as having a
low risk of bias if it attained a ‘yes’ response in a
minimum of 6 out of the 12 criteria and had no major
flaws such as 20% or greater drop-out rate in one of the
groups in the study.
27
Synthesis of results
The GRADEpro software was used to generate the
quality of the evidence (GRADE) in each outcome as
recommended by the Cochrane group (Table 5).
26
Results
Study selection
The search initially produced a total of 120 results.
Following the screening of titles and abstracts, over
80% (n5104) were excluded as they were not relevant
to the review topic (Fig. 1).
A total of 16 papers were identified as potentially
relevant papers and full text articles were retrieved. A
total of eight articles were identified from the
reference lists of retrieved papers. The full article of
one of these was published in the Korean language
and hence was excluded.
31
After searching for
duplicates, 13 papers were excluded. Six papers were
excluded on the grounds of not meeting the inclusion
criteria of the review.
32–37
Five of these studies were
excluded because of the fact that either the advice
group or the exercise group received other interventions
as well.
32–35,37
The last study was excluded on grounds
that participation was not limited to only chronic low
back pain patients.
36
Four papers met the inclusion
criteria and were, therefore, included in the review.
38–41
The four included studies yielded a total of 483
participants, and compared different forms of advice/
education to physiotherapy led exercise-based inter-
ventions. The search did not identify any study that
compared advice/education to any form of manual
therapy for NSLBP. The age range of participants
was between 18 and 65 years with an average age of
44 years (standard deviation52) (Table 2). Two of
the studies
38,40
recruited participants who may have
received treatment for their back pain from a primary
sector clinician (such as a Physiotherapist, Chiropractor,
or a family Doctor) prior to the start of the study. Two
studies, however, excluded participants who had
received physiotherapy treatment in the past 3 months
for their back pain
41
or were currently receiving back
treatment of any sort.
39
Study characteristics
Validated but different scales were used to measure
both primary and secondary outcomes (Table 2). The
primary outcomes across the four studies included
pain and low back functional status. Secondary
outcome measures varied greatly among studies. Two
studies reported the effect of interventions on well-
being.
39,40
The effects of interventions on disability
were reported in two studies.
38,40
Only one study
reported on participants’ satisfaction with treatment.
38
All four studies measured outcomes at short-term
follow-up periods (closest to 4 weeks (1 month) post-
randomization), and two of the studies took measure-
ments at intermediate time points (closest to 6 months
post-randomization).
39,40
Two studies measured out-
comes at long-term follow-up periods [1 year (12 months)
post-randomization] (Table 2).
38,40
Risk of bias within studies
All included studies answered yes to more than six
questions on the tool and had no serious flaws and
hence a low risk of bias (Table 1).
Results of Individual Studies
Owing to heterogeneity of scales used in the outcome
measures adopted by the included studies, a quanti-
tative synthesis of results was not performed. Various
guidelines as well as other publications have recom-
mended that a meta-analysis should be carried out
only if statistical and clinical heterogeneity are at a
barest minimum.
42–44
Therefore, a narrative synthesis
was conducted with the aim of describing and
comparing the findings found in the primary and
secondary outcomes of the review and are presented
in this section.
Otoo et al. Comparative effectiveness of advice/education
Physical Therapy Reviews 2014 VOL. 000 NO.000 3
Pain
Out of the four studies, only one reported a
statistically significant improvement in pain in favor
of the advice group after treatment (short term)
(P50.025) (Table 2).
41
This improvement was also
clinically significant with a minimal clinically impor-
tant difference (MCID) of 30.9.
45
The improvement,
which was measured on the Numerical Rating Scale
(NRS) (from 0 to 100) was, however, not sustained
after the 3-month follow-up point. One study
reported a statistically significant reduction in pain,
measured on a VAS (0–100) in favor of the exercise
group [Medical Exercise Therapy (MET)] compared
to the advice group, immediately post-treatment
Figure 1 Flow chart of selection of studies process. Adapted from (CRD’s guidance, 2008).
30
Otoo et al. Comparative effectiveness of advice/education
4Physical Therapy Reviews 2014 VOL.000 NO.000
(P50.01) (Table 2).
38
At 1 year follow-up, however,
the study recorded no significant difference between
the two groups. One of the studies did not record
measurement of outcomes immediately after treat-
ment.
39
They reported a statistically as well as
clinically significant reduction in pain in the yoga
exercise group compared to the advice group (self-
care book) at both 6 and 26 weeks follow-up periods
with mean score difference of 21.6 (95% CI 22.6 to
20.5) and 22.2 (95% CI 23.2 to 21.2), respectively
(Table 2). There was no statistically or clinically
significant difference between the other exercise
group and the advice group at the same follow-up
periods [20.9 (95% CI 21.9 to 20.1) and 20.8 (95%
CI 22.1 to 0.5)] at 6 and 26 weeks follow-up periods,
respectively. Results from the fourth and final study
showed no statistically significant difference between
groups at any of the time points in terms of pain
reduction measured on the NRS (0–10) (Table 2).
40
The largest average improvement recorded on the
pain and function scales were reported consistently in
the exercise group [supervised Nordic Walking (NW)]
at both short- and long-term follow-up points
(Table 2).
Back-specific functional status
Two of the studies reported a statistically significant
improvement in functional status in favor of the
exercise group (Table 2).
38,39
One reported a signifi-
cant difference in function in favor of the MET group
both after treatment (P50.01) and at the end of the 1-
year follow-up period (P50.005) measured using the
Oswestry Low Back Pain Disability Questionnaire
(Table 2).
38
The other study showed a clinically
important and statistically significant improvement
in functional status (Roland Disability Scale) in the
yoga exercise compared to the advice group (back
book group) at all follow-up points [22.6 (95% CI
24.6 to 20.6); 23.4 (95% CI 25.1 to 21.6); 23.6
(95% CI 25.4 to 21.8) at 6, 12, and 26 weeks follow-
up periods].(Table 2).
39
The other exercise group in
this study, however, showed a clinically important
and statistically significant improvement in functional
status compared to the advice group at 26 weeks
follow-up [22.1 (95% CI 24.1 to 20.1)]. The other
two studies reported no statistically significant
improvement in functional levels between groups at
all time points (Table 2).
General health status
Only two studies included general health status as
part of their outcomes measures (Table 2).
39
No
statistically significant differences between the advice
and exercise groups regarding their performance on
the mental and physical components of the Short
Form-36 Health survey were found.
39
One of the
studies measured the general health status of parti-
cipants using the EQ-5D and reported a small and
similarly adjusted mean change scores at all time
points among groups (Table 2).
40
Disability
Only two studies included measures of ‘work-related’
disability (Table 2).
38,40
One of the studies measured
this construct by considering the proportion of
participants who migrated from being on sick leave
to not being on sick leave after the period of
intervention (short term).
40
Seven individuals (27%)
in the advice to remain active group and 12
individuals (57%) in the unsupervised NW group as
compared to six individuals (40%) in the supervised
NW group made this transition. The other study
considered the long-term effects (after 1 year) of the
interventions on the number of participants who had
returned to work. Of the total 208 participants,
123(59.1%) returned to work during this period; 40
patients (57.1%) in the advice group compared to 41
patients (57.7%) in the MET group.
38
Satisfaction with treatment
Only one study reported on patient satisfaction.
38
The authors reported that out of the total number of
participants who were asked whether they were
satisfied with the treatment, 6 patients (9.5%) in the
advice group responded with a yes, compared to 26
Table 1 Methodology assessment score
Studies (Ref. No.)
Selection bias Performance bias Attrition bias Detection bias
1 2 9 3 4 10 11 6 7 5 12 8 Risk of bias
(Torstensen et al., 1998)
38
zzz2zzz z z z z z Low
(Sherman et al., 2005)
39
zz222zz z z 2z2Low
(Hartvigsen et al., 2010)
40
zzz22z2zz?z2Low
(Ryan et al., 2010)
41
z?z2z2zz z ?zz Low
z: yes (criterion achieved); 2: no (criterion not achieved); ?: unclear (insufficient description to determine).
1: Was the method of randomization adequate?; 2: Was the treatment allocation concealed? Was knowledge of the allocated
interventions adequately prevented during the study?; 3: Was the patient blinded to the intervention?; 4: Was the care provider blinded
to the intervention?; 5: Was the outcome assessor blinded to the intervention? Were incomplete outcome data adequately addressed?;
6: Was the drop-out rate described and acceptable?; 7: Were all randomized participants analyzed in the group to which they were
allocated?; 8: Are reports of the study free of suggestion of selective outcome reporting?; 9: Were the groups similar at baseline
regarding the most important prognostic indicators?; 10: Were co-interventions avoided or similar?; 11: Was the compliance
acceptable in all groups?; 12: Was the timing of the outcome assessment similar in all groups?.
Otoo et al. Comparative effectiveness of advice/education
Physical Therapy Reviews 2014 VOL. 000 NO.000 5
Table 2 Characteristics of included studies
Study Risk of bias
Number of
patients Advice group
Frequency of
advice Exercise group
Frequency of
exercise Primary outcome(s) Results (short term)
38
Low 208 Advice to maintain
normal activity level
(self- exercise
by walking) (n570)
Once only Medical Exercise
Therapy (n567)
36 sessions lasting
1 hour each for
12 weeks
Pain (VAS)/Functional
capacity(OLBPDQ)
At 3 months follow-up point
Significant improvement in the
Exercise group
Pain (P50.01)
Function (P50.005)
50.01
39
Low 101 Self-care book
(n530)
N/A 1.Yoga (n536) 12 sessions lasting
75 minutes each
for 12 weeks
(both groups)
Pain (NRS)/back-related
dysfunction (mRDS).
Significant improvement in the
yoga group in
Pain
21.6 (95%CI 22.6 to 20.5)
P50.0025 at 6 weeks
22.2 (95%CI23.2 to 21.2)
P,0.001 at 26 weeks
Function
22.6 (95%CI 24.6 to 20.6)
P50.0095) at 6 weeks
23.6 (95%CI 25.4 to 21.8)
P,0.001) at 26 weeks
2.Exercise
therapy (n535)
,0.05
40
Low 136 1. Information
about active
living and
exercise and
maintaining
functional levels
(n545).
2. Unsupervised
Nordic Walking
(n546)
Once only Supervised
Nordic walking
(n545)
16 sessions each
lasting 45 minutes
for 8 weeks
Pain (VAS)/Functional
limitation (NRS).
No significant difference
between groups
41
Low 38 Pain biology and
Back book
(n518)
Once only Advice and Exercise
(Circuit training)
(n520) ,0.05
6 sessions lasting
1 hour for 6 weeks
Pain (NRS)/Functional
ability (RMDQ)
Significant improvement in the
Advice/education group
for Pain (P50.025) at 12 weeks
VAS: Visual Analog Scale; NRS: Numeric Rating Scale; OLBPDQ: Oswestry Low Back Pain Disability Questionnaire; mRDS: modified Roland Disability Scale; Gen. H.S: General Health Status; QoL: quality of
life; SF-36: Short Form-36; RMDQ: Roland–Morris Disability Questionnaire; N/A: not applicable.
Otoo et al. Comparative effectiveness of advice/education
6Physical Therapy Reviews 2014 VOL.000 NO.000
Table 3 Summary of findings
Advice compared to Exercise therapy/Manual therapy for Chronic Low Back Pain
Patient or population: patients with Chronic Low Back Pain
Settings: Outpatient
Intervention: Advice to remain active/exercise
Comparison: Exercise therapy/Manual therapy
Outcomes
Illustrative comparative
risks*(95% CI)
Relative
effect (95% CI)
No of
Participants (studies)
Quality of the
evidence (GRADE) Comments
Assumed risk Corresponding risk
Exercise therapy/
Manual
therapy
Advice to remain
active/exercise
Pain
VAS, NRS
1
. Scale from:
0 to 100.
Follow-up: 0–3 months
See comment See comment Not estimable 416 (4 studies) ››fifi
low
2,3
VAS: significant pain reduction in EG at
short-term FU in 2 studies (P,0.05).
NRS: significant pain reduction in AG at
short-term FU in 1 study (P50.0025).
No significant difference between groups in 1 study.
Back-specific functional
status
OLBPDQ, mRDS, NRS,
RMDQ
4
Follow-up: 0–3 months
See comment See comment Not estimable 416 (4 studies) ››fifi
low
2,3,5
OLBPDQ: Significant improvement in EG at both
short- and long-term FU (P50.01).
mRDS: significant improvement in EG at both
short- and long-term FU (P,0.05).
NRS: No significant difference between groups.
RMDQ: No significant difference between groups.
General Health Status
SF-36, EQ-5D
Follow-up: 6–12 months
See comment See comment Not estimable 237 (2 studies) ››fifi
low
3,6,7
SF-36: No significant difference between groups (P.0.05).
EQ-5D: No significant difference between groups (P.0.05).
Disability
Return to work time,
time off work
Follow-up: 2–12 months
See comment See comment Not estimable 277 (2 studies) ›››fi
moderate
3
Statistical comparisons not made among groups.
Patient Satisfaction
unnamed Questionnaire
Follow-up: after
12 months
See comment See comment Not estimable 141 (1 study) ›››fi
moderate
8
Statistical comparisons not made among groups.
*
The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the
comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; EG: Exercise Group; AG: Advice Group; FU: Follow-up.
GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1
VAS: Visual Analog Scale; NRS: Numeric Rating Scale.
2
Statistical inconsistency.
3
Fewer than 75% of the studies presented data that can be included in a meta- analysis.
4
OLBPDQ: Oswestry Low Back Pain Disability Questionnaire; mRDS: modified Roland Disability Scale; NRS: Numeric Rating Scale; RMDQ: Roland–Morris Disability Questionnaire.
5
All four studies used different outcome measures to assess back-specific functional status and provided inconsistent results. Heterogeneity of the findings is explained in Satisfaction with treatment and
Adverse effects sections.
6
Data supporting findings were not provided in both studies (Sherman et al., 2005; Hartvigsen et al., 2010).
7
Different outcome measures used to measure general health status.
8
Only one study reported on patient satisfaction.
Otoo et al. Comparative effectiveness of advice/education
Physical Therapy Reviews 2014 VOL. 000 NO.000 7
patients (34.2%) in the exercise group.
38
It was,
however, not stated whether this was statistically
significant.
Adverse effects
Two studies reported on adverse effects.
39,40
One
reported that there was no adverse effect associated
with the supervised exercise group.
40
The other,
however, reported specifically on two minor adverse
effects in the two exercise groups.
39
The first incident
recorded a patient in the yoga group who discon-
tinued treatment because some of the postures
required her to move head below her heart and that
precipitated her migraine headache.
39
The second
incident was a participant in the exercise group who
strained her back during one of the classes and
thereafter sought care from a chiropractor.
39
No
adverse effects were reported in the advice group.
Following the recommendations by the CBRG
Editorial Board as well as from the Cochrane
Handbook of Systematic Reviews of Interventions, a
rating of the quality of the evidence for patient-
centered outcomes was undertaken in addition to
reporting the results descriptively.
26,27
This was per-
formed on the following five domains: limitations of
the study design, inconsistency, indirectness, impreci-
sion of results, and presence of publication bias across
all studies that measured that particular outcome.
46
The overall summary of results is presented in
Table 3 below.
Discussion
Summary of evidence
This review sought to compare the effectiveness of
two interventions: advice/education versus manual
therapy and exercise in the management of chronic
NSLBP. Two of the studies concluded that there were
statistically significant results (one study specified
clinically significant results) in favor of the exercise
groups in terms of pain and back-specific functional
status at short-term follow-up;
38,39
however, these
were not sustained at long-term follow-up. One study
reported significant results in favor of the advice
group in the short term,
41
while the final study found
no significant difference between groups.
40
Overall,
this review found low-level evidence that these
treatments are no more effective than advice/educa-
tion for patients with chronic NSLBP. The small
number of studies coupled with the considerable
heterogeneity in the study populations and interven-
tions including differences in the nature of advice
given, types of exercises prescribed, and outcome
measures employed mean that results need to be
considered with some caution.
Advice/education
Ryan et al. (2010) reported a clinically significant
decrease in pain in favor of the advice (education)
group at short-term follow-up.
41
A similar but non-
significant trend was recorded in terms of functional
capabilities. The nature of the advice given in this
study was unique in the sense that it was the only
study that focused on educating participants about
the possible cause of their pain in addition to
incorporating a ‘Back Book,’ which educated them
on how to manage their symptoms. The advice given
in the other three studies was more generalized and
focused on how participants should remain active to
minimize their pain. Thus, the type of education may
be a factor in the results for education seen in the
other studies. Evidence has shown that when patients
understand why, and not just what to do, it facilitates
their empowerment and commitment to change.
47
There is evidence to suggest that when patients
understand the biology of their pain, it decreases
their fear and distress and thereby encourages them
to resume their daily activities.
48
The advice given to
the participants in this study was based on the
biopsychosocial model [Pain Neurophysiological
Education (PNE)].
41
Unlike the biomedical model,
which defines pain as being ‘a robust informer of
spinal pathology’, the PNE concept defines pain
as ‘a product of complex neural processing and
adaptation.’
49
It has been explained that a ‘benign’
explanation of symptoms as opposed to the biome-
dical ‘physical damage of tissues,’ can offer signifi-
cant benefits to the level of comfort of the patient.
50
Although the beneficial effects of PNE on chronic
low back pain have been widely reported in the
literature.
51–54
However, reviews in this field have
previously found that individual education program
is not as effective for either pain or function when
compared to intensive interventions in chronic LBP
populations and the evidence for the effectiveness for
any specific type of education for the management of
LBP has also not been demonstrated.
55
Also, a recent
review found that a combination of post-treatment
exercises in combination with additional advice or
information on back pain were more effective than no
intervention for reducing rates of recurrence at 1 year
(rate ratio 0.50; 95% confidence interval 0.34–0.73).
However, there was conflicting evidence for the
effectiveness of exercise treatment and advice in
reducing the number of recurrences or the recurrence
rate when compared to other interventions.
56
Thus,
the evidence for the optimal types of advice/education
and its role in the management of LBP remains
unclear.
Exercise therapy
Two of the studies reported significant improvements
in terms of pain and back-specific functional status in
favor of the exercise groups at short-term follow-
up.
38,39
Exercise therapy has been reported across a
Otoo et al. Comparative effectiveness of advice/education
8Physical Therapy Reviews 2014 VOL.000 NO.000
number of clinical guidelines as being effective for the
management of chronic NSLBP; however, no one
particular form of exercise has been shown to be
more efficacious than another.
16
Evidence suggests
that chronic NSLBP patients have a high frequency
of weakness in specific trunk muscles,
57
and there-
fore, targeting of this physiological strength deficit
has been suggested.
58
However, the majority of
exercises administered has the ability to strengthen
these muscles and hence the potential similar effect of
numerous exercise interventions. This may partially
explain the significant improvement reported in these
studies in favor of the exercise groups.
38,39
It is worth
noting that the exercises employed in the other two
studies had an aerobic focus rather than specifically
targeting the spinal stabilizers.
40,41
Aerobic exercises
also may have an important role to play in the
management of LBP, and research has suggested that
aerobic exercises such as circuit training and NW
have the ability to enhance protein synthesis and may
eventually minimize pain because of ‘worn out’
tissues.
59
Intervention – frequency of delivery
An important consideration for any health interven-
tion is the frequency of the intervention in terms of
intervention-effect duration, particularly in the man-
agement of a chronic condition. Three of the four
studies included only one session of advice/education
with the patient,
38,40,41
while one study used a patient
education booklet.
40
It can be argued that a single
dose of advice or education may have been too short
to maximize changes in the CNS. Previous reviews
have suggested that increasing the frequency of
advice may help maintain the positive results of
treatment for chronic NSLBP patients.
21
The reduc-
tion in clinically significant improvement at follow-up
could also be an indication that education may
not be sufficient to obtain a permanent positive
effect, but rather lays a good foundation for other
active cognitive and behavioral pain management
strategies.
49
Comparative evaluation of these studies
does not allow dose–response relationships between
the number of advice sessions and its effects on
outcomes. Further reviews are warranted to investi-
gate such a phenomenon.
Two of the studies incorporated structured and
supervised exercise sessions twice per week,
38,40
while
the other studies included one session per week.
39,41
This may suggest effectiveness geared toward increased
dose or frequency of exercise. Similarly, various clinical
guidelines have not been specific on this issue. The
European guidelines for instance suggest that there is
limited evidence supporting the effectiveness of one
exercise dose (frequency) over another.
13
The NICE
guidelines recommend offering exercise programs
comprising up to a maximum of eight sessions over a
period of up to 12 weeks.
60
Again, evaluation of these
studies does not allow any potential dose–response
relationships between exercise sessions (types, fre-
quency, duration) and its effects on outcomes and
further study and evaluation of potential dose–response
relationships will be a key direction for LBP research.
Only one study specified that the advice/education
was delivered by a therapist, and it is unknown
whether the knowledge base and delivery skill may
have contributed to the positive results seen in this
group.
41
Research suggests that the beliefs and
attitudes of the therapist have an effect on the
information given to patients.
61,62
All the exercise
groups in the four studies worked under the super-
vision of qualified therapists. Supervision has been
recommended as part of exercise therapy in clinical
guidelines,
13
as it enhances patient adherence and also
ensures that patients perform the exercises correctly.
63
It is not clear whether this had any part to play in these
studies since significant improvement in favor of the
advice groups was not recorded in all four studies.
The findings of this review suggest low-quality
evidence that exercise is not more effective than
advice/education for pain reduction and enhancing
functional capabilities for chronic NSLBP. These
findings agree with findings in a review conducted in
2010, which reported very low-quality evidence that
no statistically significant difference existed between
exercise and education at short-term follow-up in
patients with chronic NSLBP.
23
A recent review on
the effectiveness of physical and rehabilitation inter-
ventions for patients with chronic NSLBP also
reported no statistically significant difference between
exercise and education in terms of pain and disability
at short and intermediate follow-up.
64
This advice/
education groups in the studies included in this
review included back school education as well as
usual care, both of which are not exclusive to advise
and education only. Also a review, which focused
purely on advice for patients with LBP suggested that
there was strong evidence that exercise therapy and
patient advice/education are most effective when they
are prescribed together.
21
This is further supported
by the evidence for the use of advice and education in
patient health care in which active engagement in the
process by both the health practitioner and the
patient is required to effect a change in health
behaviors.
65
There is, therefore, a need for future
research in this area of LBP to focus on subgrouping
patients to enhance effectiveness. Research studies
have suggested that to observe clinically important
effects, treatment should be matched to the patient’s
signs and symptoms rather than provided to all
patients with LBP.
66
Perhaps patients with chronic
NSLBP with more physical and psychosocial indicators
Otoo et al. Comparative effectiveness of advice/education
Physical Therapy Reviews 2014 VOL. 000 NO.000 9
may benefit more from advice/education based on the
biopsychosocial model while patients with more
physical derangement may benefit from exercise
therapy. Research in this field shows potential promise
for subgrouping based on risk stratification, and as
such, there is potential to look at whether targeted
advice and/or exercise, manual therapy is more
appropriate in patients based on their risks of
developing chronic LBP.
67
However, the long-term
effects of both interventions require further study
based on the available evidence in this review. It is also
difficult to draw definitive conclusions on the most
cost effective interventions because of the low-quality
of evidence and the lack of cost effectiveness measures
employed in the included studies.
There is an indication for more high-quality studies
in this field of low back pain. The lack of studies
comparing manual therapy to advice/education for
chronic NSLBP as well as the fact that only four
studies were identified that compared advice/educa-
tion to exercise reveals the dearth of knowledge in
this area. This review also brings to light the need to
consider measuring both the health outcomes and the
comparative cost effectiveness of interventions at
long-term follow-up. Such an approach would
enhance the decision-making process on the choice
of interventions for clinicians and researchers.
Limitations
Statistical information for some of the outcomes was
not made available in some of the primary studies.
Efforts were, however, made to obtain these details
from the authors of these primary studies but were
not successful. Only studies published in the English
language were considered and this may have intro-
duced a language bias.
Conclusion
The results from this review suggest that there is low-
quality evidence that exercise is more effective than
advice/education for patients with chronic NSLBP.
The quality of the evidence and the methodological
heterogeneity of included studies limit the strength of
findings. Also, the nature of the evidence available
makes it difficult to be specific about the most
effective content as well as frequency of both
interventions.
Disclaimer Statements
Contributors Samuel Kweku Wie Otoo and Paul
Hendrick undertook the literature search, study
design, data collection, data analysis, data interpreta-
tion, and writing of the manuscript. Dan Ribeiro
undertook the data analysis, data interpretation, and
writing of the manuscript.
Funding
Conflicts of interest There are no conflicts of interest.
Ethics approval
References
1 Moffett J, McLean S. The role of physiotherapy in the
management of non-specific back pain and neck pain.
Rheumatology. 2006;45:371–8.
2 Balague´ F, Mannion AF, Pellise´ F, Cedraschi C. Non-specific
low back pain. Lancet. 2012;379:482–91.
3 Koes BW, van Tulder M, Lin CWC, Macedo LG, McAuley J,
Maher C. An updated overview of clinical guidelines for the
management of non-specific low back pain in primary care. Eur
Spine J. 2010;19:2075–94.
4 Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute
low back pain: systematic review of its prognosis. BMJ.
2003;327:323–5.
5 Costa Lda C, Maher CG, McAuley JH, Hancock MJ, Herbert
RD, Refshauge KM, et al. Prognosis for patients with chronic
low back pain: inception cohort study. BMJ. 2009;339:b3829.
6 Kent PM, Keating JL. The epidemiology of low back pain in
primary care. Chiropr Osteopat J. 2005;13:13.
7 Carey TS, Garrett JM, Jackman AML. Beyond the good
prognosis: examination of an inception cohort of patients with
chronic low back pain. Spine. 2000;25(Suppl 1):115–20.
8 Simpson AK, Cholewicki J, Grauer J. Chronic low back pain.
Curr Pain Headache Rep. 2006;10:431–6.
9 Berker E, Dincer N. Chronic pain and rehabilitation. Agri.
2005;17:10–6.
10 Waddell G, Burton AK. Concepts of rehabilitation for the
management of low back pain. Best Pract Res Clin Rheumatol.
2005;19:655–70.
11 Koes BW, van Tulder MW, Ostelo R, Burton KA, Waddell G.
Clinical guidelines for the management of low back pain in
primary care: an international comparison. Spine. 2001;26:
2504–13.
12 Haldeman S, Dagenais S. A supermarket approach to the
evidence- informed management of chronic low back pain.
Spine. 2008;8:1–7.
13 Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-
Moffett J, Kovacs F, et al. European guidelines for the
management of chronic non-specific low back pain. Eur.
Spine J. 2006;15:S192–300.
14 Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr., Shekelle P,
et al. Clinical Efficacy Assessment Subcommittee of the
American College of Physicians. American College of
Physicians American Pain Society. Low back pain Guidelines
Panel Diagnosis and treatment of low back pain: a joint clinical
practice guideline from the American College of Physicians and
the American Pain Society. Ann Intern Med. 2007;147(7):478–91.
15 Dagenais S, Tricco AC, Haldeman S. Synthesis of recommen-
dations for the assessment and management of low back pain
from recent practice guidelines. Spine J. 2010;10:514–29.
16 Pillastrini P, Gardenghi I, Bonetti F, Capra F, Guccione A,
Mugnai R, et al. An updated overview of clinical guidelines for
chronic low back pain management in primary care. Joint Bone
Spine. 2012;79:176–85.
17 Fersum KV, Dankaerts W, O’Sullivan PB, Maes J, Skouen JS,
Bjordal JM, et al. Integration of sub-classification strategies in
randomized controlled trials evaluating manual therapy and
exercise for non-specific chronic low back pain; a systematic
review. Br J Sports Med. 2010;44:1054–62.
18 Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer
MR, van Tulder MW. Spinal manipulative therapy for chronic
low back pain. Spine. 2011;36(Suppl 13):E825–46.
19 Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive
clinical outcome after exercise therapy for chronic non-specific
low back pain contingent upon a corresponding improvement
in the targeted aspect(s) of performance? A systematic review.
Eur Spine J. 2012;21:575–98.
20 Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of
the evidence for the effectiveness, safety and cost of acupunc-
ture, massage therapy and spinal manipulation for back pain.
Ann Intern Med. 2003;138(11):898–906.
21 Liddle SD, Gracey JH, Baxter GD. Advice for the management
of low back pain: a systematic review of randomised controlled
trials. Man Ther. 2007;12:310–27.
Otoo et al. Comparative effectiveness of advice/education
10 Physical Therapy Reviews 2014 VOL.000 NO.000
22 Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to
rest in bed versus advice to stay active for acute low-back pain
and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612.
23 van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW,
Koes BW, van Tulder MW. Exercise therapy for chronic non-
specific low-back pain. Best Pract Res Clin Rheumatol.
2010;24(Suppl 2):193–204.
24 Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder
R, Walker BF, et al. A consensus approach toward the
standardization of back pain definitions for use in prevalence
studies. Spine. 2008;33(Suppl 1):95–103.
25 Centre for Reviews and Dissemination. Systematic Reviews-
CRD’s guidance for undertaking reviews in health care. CRD:
University of York; 2008. Available from: http://www.york.ac.
uk/inst/crd/pdf/Systematic_Reviews.pdf (Accessed: 2013 July 26).
26 Higgins JPT, Green S. Cochrane handbook for systematic
reviews of interventions. Version 5.1.0. The Cochrane
Collaboration; 2011. Available from: www.cochrane-handbook.
org (Accessed: 2013 August 5).
27 Furlan AD, Pennick RN, Bombardier C, van Tulder M. 2009
Updated method guidelines for systematic reviews in Cochrane
Back Review Group. Spine. 2009;34(Suppl 18):1929–41.
28 van Tulder MW, Furlan A, Bombardier C, Bouter L. Updated
method guidelines for systematic reviews in the Cochrane
collaboration back review group. Spine. 2003;28:1290–9.
29 Boutron I, Moher D, Tugwell P, Giraudeau B, Poiraudeau S,
Nizard R, et al. A checklist to evaluate a report of a
nonpharmacological trial (CLEAR NPT) was developed using
consensus. J Clin Epidemiol. 2005;58:1233–40.
30 Centre for Reviews and Dissemination. Systematic Reviews-
CRD’s guidance for undertaking reviews in health care. CRD:
University of York; 2008. Available from: http://www.york.ac.
uk/inst/crd/pdf/Systematic_Reviews.pdf (Accessed: 2013 July 24).
31 Hyoung H-K. Effects of a strengthening program for lower
back in older women with chronic low back pain. J Korean
Acad Nurs. 2008;38(Suppl 6):902–13.
32 Cherkin DC, Deyo RA, Battie´ M, Street J, Barlow W. A
comparison of physical therapy, chiropractic manipulation, and
provision of an educational booklet for the treatment of
patients with low back pain. N Engl J Med. 1998;339:1021–9.
33 Frost H, Klaber Moffett JA, Moser JS, Fairbank JC.
Randomised controlled trial for evaluation of fitness pro-
gramme for patients with chronic low back pain. BMJ.
1995;310:151–4.
34 Hagen EM, Eriksen HR, Ursin H. Does early intervention with
a light mobilization program reduce long-term sick leave for
low back pain? Spine. 2000;25(Suppl 15):1973–6.
35 Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S.
Randomized controlled trial of physiotherapy compared with
advice for low back pain. BMJ. 2004;329(Suppl 7468):708.
36 Paatelma M, Kilpikoski S, Simonen R, Heinonen A, Alen M,
Videman T. Orthopaedic manual therapy, McKenzie method or
advice only for low back pain in working adults: a randomized
controlled trial with one year follow-up. J Rehabil Med.
2008;40:858–63.
37 Sorensen PH, Bendix T, Manniche C, Korsholm L, Lemvigh D,
Indahl A. An educational approach based on a non-injury
model compared with individual symptom-based physical
training in chronic LBP. A pragmatic, randomised trial with a
one-year follow-up. BMC Musculoskelet Disord. 2010;11:212.
38 Torstensen TA, Ljunggren AE, Meen HD, Odland E,
Mowinckel P, Geijerstam S. Efficiency and costs of medical
exercise therapy, conventional physiotherapy, and self-exercise
in patients with chronic low back pain. A pragmatic,
randomized, single-blinded, controlled trial with 1-year fol-
low-up. Spine. 1998;23(Suppl 23):2616–24.
39 Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA.
Comparing yoga, exercise, and a self-care book for chronic low
back pain. A randomized controlled trial. Ann Intern Med.
2005;143:849–56.
40 Hartvigsen J, Morso L, Bendix T, Manniche C. Supervised and
non-supervised Nordic walking in the treatment of chronic low
back pain: a single blind randomized clinical trial. BMC
Musculoskelet Disord. 2010;11:30.
41 Ryan CG, Gray HG, Newton M, Granat MH. Pain biology
education and exercise classes compared to pain biology
education alone for individuals with chronic low back pain: a
pilot randomized controlled trial. Man Ther. 2010;15:382–7.
42 Alderson P, Green S. Cochrane Collaboration open learning
material for reviewers; 2002. Available from: http://www.
cochrane-net.org/openlearning (Accessed: 2013 August 26).
43 Ghersi D, Berlin J, Askie L. On behalf of the Cochrane
prospective meta-analysis in: Cochrane hand book for systema-
tic reviews of interventions. The Cochrane Library. Issue 3,
2005. Chichester, UK: John Wiley and Sons Ltd; 2005.
Available from: http://onlinelibrary.wiley.com/doi/10.1002/
9780470712184, ch19/pdf (Accessed 2013 July 23).
44 Akobeng AK. Evidence-based child health 2: understanding
randomized controlled trials. Arch Dis Child. 2005;90:840–4.
45 Maughan EF, Lewis JS. Outcome measures in chronic low back
pain. Eur Spine J. 2010;19(9):1484–94.
46 Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp
S, et al. Grading quality of evidence and strength of
recommendations. BMJ. 2004;328:1490.
47 Poulter D. Letters to the editor-in-chief; empower the patient. J
Orthop Sports Phys Ther. 1999;29:616–7.
48 Butler DS, Moseley L. Explain pain. Adelaide: Noigroup; 2003.
49 Moseley GL, Nicholas MK, Hodges PW. A randomised
controlled trial of intensive neurophysiology education in
chronic low back pain. Clin J Pain. 2004;20:324–30.
50 Moseley GL. Combined physiotherapy and education is
efficacious for chronic low back pain. Aust J Physiother.
2002;48:297–302.
51 Martin SD, Martin E, Santoch SR, Richardson MA, Royall R.
Brain blood flow changes in depressed patients treated with
interpersonal therapy or venlafaxine hydrochloride. Arch Gen
Psychiatry. 2001;58:641–8.
52 Moseley GL. Joining forces – combining cognition-targeted
motor control training with group or individual pain neuro-
physiology education. J Man Manip Ther. 2003;11:88–94.
53 Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology
education for the management of individuals with chronic
low back pain: a systematic review and meta-analysis. Man
Ther. 2011;16:544–9.
54 Moseley GL. Evidence for a direct relationship between
cognitive and physical change during an education intervention
in people with chronic low back pain. Eur J Pain. 2004;8:39–45.
55 Engers A, Jellema P, Wensing M, van der Windt DA, Grol R,
van Tulder MW. Individual patient education for low back
pain. Cochrane Database Syst Rev. 2008;23;(1):CD004057.
56 Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for
prevention of recurrences of low-back pain. Occup Environ
Med. 2010;67(11):795–6.
57 Rainville J, Hartigan C, Martinez E, Limke J, Jouve C, Finno
M. Exercise as a treatment for chronic low back pain. Spine J.
2004;4:106–15.
58 Rainville J, Jouve CA, Hartigan C, Martinez E, Hipona M.
Comparison of short- and long-term outcomes for aggressive
spine rehabilitation delivered two versus three times per week.
Spine J. 2002;2:402–7.
59 Short KR, Vittone JL, Bigelow ML, Proctor DN, Nair KS. Age
and aerobic exercise training effects on whole body and muscle
protein metabolism. Am J Physiol Endocrinol Metab.
2004;286:E92–101.
60 Savigny P, Watson P, Underwood M. Early management of
persistent non-specific low back pain: summary of NICE
guidance. BMJ. 2009;338:B1805.
61 Linton SJ, Vlaeyen J, Ostelo R. The back pain beliefs of health
care providers: are we fear-avoidant? J Occup Rehabil.
2002;12:223–32.
62 Rainville J, Carlson N, Polatin P, Gatchel RJ, Indahl A.
Exploration of physicians’ recommendations for activities in
chronic low back pain. Spine. 2000;25:2210–20.
63 Hayden JA, van Tulder MW, Tomlinson G. Systematic review:
strategies for using exercise therapy to improve outcomes in
chronic low back pain. Ann Intern Med. 2005;142:776–85.
64 van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP,
Ostelo R, Koes BW, et al. A systematic review on the
effectiveness of physical and rehabilitation interventions for
chronic non-specific low back pain. Eur Spine J. 2011;20:19–39.
65 Rao JK, Anderson LA, Inui TS, Frankel RM. Communication
interventions make a difference in conversations between
physicians and patients: a systematic review of the evidence.
Med Care. 2007;45(4):340–9.
66 Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A,
Erhard RE. Identifying subgroups of patients with acute/
subacute ‘nonspecific’ low back pain. Spine. 2006;31:623–31.
67 Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster
NE, et al. Comparison of stratified primary care management
for low back pain with current best practice (STarT Back): a
randomised controlled trial. Lancet. 2011;378(9802):1560–71.
Otoo et al. Comparative effectiveness of advice/education
Physical Therapy Reviews 2014 VOL. 000 NO.000 11
... There was evidence that overall, clients benefited from the CPMP. This is consistent with previous literature that has shown education addressing the neurobiology and physiology of pain can have a positive effect on pain levels, physical performance, pain catastrophizing (Otoo et al., 2015), improving pain function, lowering disability, and enhancing movement (Louw et al., 2011). There was also evidence that some clients experienced a positive shift in their conceptualization of their pain, which has been previously shown to result in lower pain intensity levels and better recovery (Mittinty et al., 2018). ...
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... A clear understanding of chiropractic and osteopathic practice and how they compare with physiotherapy practice is called for. There is a growing body of research investigating the effectiveness of physiotherapy care (e.g., manual therapy and exercise compared to patient advice for chronic nonspecific low back pain [35]), but there has been little comparison between physiotherapy and other manual therapies. It appears that some GPs require further education in the range of healthcare practitioners who deliver evidencebased treatments for musculoskeletal conditions. ...
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Introduction Lumbar radicular syndrome (LRS) can be a painful and debilitating condition. The optimum management strategies and their timing remain elusive despite extensive research. Surgery provides good short-term outcomes but has concomitant risks and costs. Physiotherapy is commonly practised for patients with LRS but its effects remain equivocal and there is a lack of consensus on the type, duration and timing of physiotherapy intervention. There is a lack of high-quality evidence into new and innovative management strategies and the timings of those strategies for LRS. This pilot trial is an essential preliminary to a definitive randomised controlled trial (RCT) assessing the effectiveness and cost-effectiveness of early physiotherapy intervention for patients with LRS. The study will test the protocol, the intervention, the use of outcome measures and the ability to set-up and run the trial to enable refinement of a future definitive RCT. Methods and analysis This is a mixed-methods study encompassing an external pilot RCT with integrated qualitative interviews with patients, clinicians and other key stakeholders. 80 patients will be recruited from primary care and randomised, after consent into 1 of 2 groups. Both groups will receive individually tailored, goal orientated physiotherapy. The usual care group will begin their physiotherapy 6 weeks after randomisation and the intervention group at 2 weeks after randomisation. Outcome measures will primarily be feasibility parameters including the ability to recruit and retain patients and to deliver the intervention. Data will be collected at baseline, and 6, 12 and 26 weeks following randomisation. Ethics and dissemination The study has received favourable ethical review from the East of Scotland Research Ethics Service (EoSRES) on the 20 August 2015 (15/ES/0130). Recruitment began on the 1 March 2016 and is expected to close in January 2017. Data collection is anticipated to be complete in July 2017. The study results will be made available to participants, clinicians involved in the study and the wider clinical community through publication in a peer reviewed journal and at conference presentations. Trial registration number ISRCTN: 25018352, Pre-results; Clinical Trials.Gov: NCT02618278 Document version V1.1 23.9.2016.
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The effect size for exercise therapy in the treatment of chronic non-specific low back pain (cLBP) is only modest. This review aims to analyse the specificity of the effect by examining the relationship between the changes in clinical outcome (pain, disability) and the changes in the targeted aspects of physical function (muscle strength, mobility, muscular endurance) after exercise therapy. We searched for exercise therapy trials for cLBP published up to 15 April 2010 in Medline, Embase, Cochrane Library, Cinahl, and PEDro. Two independent reviewers selected studies according to the inclusion criteria. Data extraction: one author extracted the data of the articles. Data synthesis: 16 studies with a total of 1,476 participants met the inclusion criteria. There was little evidence supporting a relationship between the changes in pain or physical function and the changes in performance for the following measures: mobility (no correlation in 9 studies, weak correlation in 1 study), trunk extension strength (7 and 2, respectively), trunk flexion strength (4 and 1, respectively) and back muscle endurance (7 and 0, respectively). Changes in disability showed no correlation with changes in mobility in three studies and a weak correlation in two; for strength, the numbers were four (no correlation) and two (weak correlation), respectively. The findings do not support the notion that the treatment effects of exercise therapy in cLBP are directly attributable to changes in the musculoskeletal system. Future research aimed at increasing the effectiveness of exercise therapy in cLBP should explore the coincidental factors influencing symptom improvement.
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Background: Chronic low back pain is a common problem that has only modestly effective treatment options. Objective: To determine whether yoga is more effective than conventional therapeutic exercise or a self-care book for patients with chronic low back pain. Design: Randomized, controlled trial. Setting: A nonprofit, integrated health care system. Patients: 101 adults with chronic low back pain. Intervention: 12-week sessions of yoga or conventional therapeutic exercise classes or a self-care book. Measurements: Primary outcomes were back-related functional status (modified 24-point Roland Disability Scale) and bothersomeness of pain (11-point numerical scale). The primary time point was 12 weeks. Clinically significant change was considered to be 2.5 points on the functional status scale and 1.5 points on the bothersomeness scale. Secondary outcomes were days of restricted activity, general health status, and medication use. Results: After adjustment for baseline values, back-related function in the yoga group was superior to the book and exercise groups at 12 weeks (yoga vs. book: mean difference, -3.4 [95% Cl, -5.1 to-1.6] [P< 0.001]; yoga vs. exercise: mean difference, -1.8 [Cl, -3.5 to - 0.1] [P= 0.034]). No significant differences in symptom bothersomeness were found between any 2 groups at 12 weeks; at 26 weeks, the yoga group was superior to the book group with respect to this measure (mean difference, -2.2 [Cl, -3.2 to - 1.2]; P < 0.001). At 26 weeks, back-related function in the yoga group was superior to the book group (mean difference, -3.6 [Cl, -5.4 to - 1.8]; P< 0.001). Limitations: Participants in this study were followed for only 26 weeks after randomization. Only 1 instructor delivered each intervention. Conclusions: Yoga was more effective than a self-care book for improving function and reducing chronic low back pain, and the benefits persisted for at least several months.
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Study Design. A multicenter, randomized, single‐blinded controlled trial with 1‐year follow‐up. Objectives. To evaluate the efficiency of progressively graded medical exercise therapy, conventional physiotherapy, and self‐exercise by walking in patients with chronic low back pain. Summary and Background Data. Varieties of medical exercise therapy and conventional physiotherapy are considered to reduce symptoms, improve function, and decrease sickness absence, but this opinion is controversial. Methods. Patients with chronic low back pain or radicular pain sick‐listed for more than 8 weeks and less than 52 weeks (Sickness Certificate II) were included. The treatment lasted 3 months (36 treatments). Pain intensity, functional ability, patient satisfaction, return to work, number of days on sick leave, and costs were recorded. Results. Of the 208 patients included in this study, 71 were randomly assigned to medical exercise therapy, 67 to conventional physiotherapy, and 70 to self‐exercise. Thirty‐three (15.8%) patients dropped out during the treatment period. No difference was observed between the medical exercise therapy and conventional physiotherapy groups, but both were significantly better than self‐exercise group. Patient satisfaction was highest for medical exercise therapy. Return to work rates were equal for all 3 intervention groups at assessment 15 months after therapy was started, with 123 patients were back to work. In terms of costs for days on sick leave, the medical exercise therapy group saved 906,732 Norwegian Kroner (NOK) ($122,531.00), and the conventional physiotherapy group saved NOK 1,882,560 ($254,200.00), compared with the self‐exercise group. Conclusions. The efficiency of medical exercise therapy and conventional physiotherapy is shown. Leaving patients with chronic low back pain untampered poses a risk of worsening the disability, resulting in longer periods of sick leave.
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Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).