Research Review by Dr. Shawn Thistle©

Date:

2004

Study Title:

Randomised controlled trial of physiotherapy compared with advice for low back pain.

Authors:

Frost H, Lamb SE, Doll HA, Taffe Carver P, Stewart-Brown S

Publication Information:

British Medical Journal 2004; 329: 708.

Summary:

Low back pain is a major public health concern in western society. It is one of the most common causes of long-term disability in working age people. Despite its impact on society, both personal and financial, surprisingly little is known regarding the actual pathology and treatment of this common condition.

Most generally employed treatments such as joint mobilization/manipulation, electric modalities, acupuncture, massage, and specific rehabilitation exercises have been researched, but in many cases consistency and quality of studies make it difficult to draw solid conclusions regarding the most effective intervention.

At the same time, the commonly held belief that most back pain will resolve on it's own has recently been challenged in the epidemiological literature (see Pengel et al. 2003), suggesting that recurrence of pain remains a large problem.

This study compared routine physiotherapy care to a single assessment and advice session with a physiotherapist in the treatment of patients with low back pain. In this study, routine physiotherapy included anything the particular practitioner would do (exercise, soft tissue therapy, manual therapy etc.). This study was conducted as a multi-centre, investigator-blinded, randomized controlled trial.

Patients included in the study were at least 18 years of age and had back pain for a minimum of 6 weeks (no specific comment was made as to the severity of their pain however). Patients underwent an initial assessment and then were randomized to receive advice to stay active or advice plus standard physiotherapy.

The primary outcome measure used in this study was the score on the Oswestry Disability Index - a pen and paper questionnaire regarding back pain - at 12 months (measures were also taken at 2 and 6 months).

In total, 286 patients participated in this study (144 for advice plus therapy and 142 for advice only). These patients were treated by 76 unique physiotherapists using a variety of techniques and modalities including:
  • joint mobilization (low velocity) ... 72%
  • McKenzie or stabilization exercise ... 94%
  • soft tissue techniques ... 14%
  • heat (6%) or cold ... (3%)
There was a compliance rate of 82% with treatment, but only 70% of patients provided data at 12 months. Furthermore, 26 patients in the advice only group received more than one session at the discretion of the physiotherapist - potentially contaminating the results of this paper.

The results indicated that there was no difference between the two groups in the primary outcome - the Oswestry score at 12 months. They went on to conclude that this indicates a standard physiotherapy treatment is no more beneficial than one advice session for patients with mild to moderate low back pain.

This proves quite problematic, to me, as I explain below.

Conclusions & Practical Application:

I would debate the conclusion of this study based on the following shortcomings of the project:
  • treatment was provided by 76 different physiotherapists - this raises concerns about treatment, reporting and note-taking inconsistencies that may affect results and delivery of care (keep in mind only 144 patients received therapy - almost one therapist per 2 patients!)
  • all indices in the outcome measures have confidence intervals that pass the zero mark - simply put, this means that some patients improved, while others worsened on an individual basis which does not equate to "no difference
  • 30% of patients provided no data at 12 months - this can greatly affect the outcome of a study this small and the authors made little effort to statistically account for this (at least they did not describe their methods in this regard)
I am very much in favor of letting practitioners "do what they do normally" so to speak in clinical studies such as this one, rather than trying to isolate single treatment options. However, putting forward a conclusion that routine physiotherapy is no more effective than one advice session for patients with low back pain is in my opinion not warranted based on this study.

I review this paper here to debate the interpretation of these results. This study was reported on the nightly news in Canada, where such a brash statement can profoundly influence patient decisions. More care should be taken in the future to carefully evaluate the data on which such statements are based, and to conduct well designed trials to answer important clinical questions such as the most effective treatment for low back pain.