Research Review by Dr. Shawn Thistle©



Study Title:

United Kingdom back pain exercise and manipulation (UK BEAM) randomized trial: effectiveness of physical treatments for back pain in primary care


UK BEAM Trial Team

Publication Information:

British Medical Journal 2004


As I have discussed in other reviews posted on my site, and as most therapists and doctors who deal with back pain know - low back pain is somewhat of an enigma in clinical practice. That is, for being such a common, costly, and disabling condition, relatively little is known about the most efficacious treatments to combat it.

Spinal manipulation and exercise are two common methods used to treat low back pain. Little is known however, about the benefit these treatments provide over and above regular care (which includes advice to stay active, and perhaps oral pain or anti-inflammatory medications).

The objective of this study as to estimate the effect adding spinal manipulation, exercise, or a combination of both to "best care" provided within the framework of the British healthcare system (NHS), or in private practices. 1334 patients between the ages of 18-65 consulting their general practices about low back pain were randomized to one of four groups:
  1. general practice care - "best care" according to UK national acute back pain guidelines
  2. exercise - "back to fitness" program including initial assessment followed by group exercise classes administered by a physiotherapist (eight 60 minute classes over 1-2 months)
  3. spinal manipulation - 8 treatments over 12 weeks provided by experienced, qualified practitioners from 3 disciplines (chiropractic, physiotherapy, osteopathy) in one of two settings: NHS facilities or private practice
  4. spinal manipulation plus exercise
Patients were recruited from 181 practices located in 14 centres across the United Kingdom. The primary outcome measure used in this study was the score on the Roland Morris Low Back Pain Questionnaire at 3 and 12 months. Follow-up rates were reasonable - 77% of participants returned questionnaires at 3 months and 75% at 12 months.

Pertinent Results:

  1. all three intervention groups did improve at 3 and 12 months
  2. the best intervention at the 3 month mark was manipulation followed by exercise, showing a moderate benefit (12 month benefit of this intervention was small)
  3. spinal manipulation alone provided a small to moderate benefit at both 3 and 12 months
  4. exercise alone achieved a small benefit at 3 months but not 12 months
  5. there was no difference in the effectiveness of manipulation provided in private practice vs. NHS facilities
All of these results must be considered in light of a couple of things. First, the number of treatments and exercise session provided may not reflect reality in clinical practice.

As is often the case in studies such as these, no concrete reason is provided for choosing 8 treatments as the "magic" number that is hoped to provide the best benefit. Also, nothing is mentioned about active care or preventive advice provided to patients, which may provide additional benefit (most of us do this in a real practice setting).

Lastly, eight months potentially passed between the last treatment and the last point of measurement, which leaves a lot of time for extraneous factors to come into play. Finally, all of these small to moderate benefits must be considered in terms of cost effectiveness discussed in the other part of this project.

Conclusions & Practical Application:

This study provides further evidence that the addition of spinal manipulation and exercise to the treatment of low back pain can have short and long-term benefits. What is emerging in the literature is a shift toward multi-modal, integrated care for low back pain. What remains to be elucidated is the best approach in terms of timing, number of treatments, order of application of treatment techniques etc.

The unfortunate part of researching manual medicine and physical therapy interventions continues to be the difficulty in mimicking the real environment and experience of a treatment. Study design often allows for only certain techniques and interventions to be used while in reality, a given therapist or doctor may choose to individualize therapy regimens using numerous techniques or modalities.