Thanks to the
The Back Letter July, 2000 for premission to reproduce this article!
When it comes to the treatment of chronic low back pain, low-cost exercise programs--either group aerobic programs or group isoinertial device training--appear more effective over the long term than individualized physical therapy. All three interventions resulted in a long-term benefit in terms of lessening the intensity and frequency of pain. However, only the two exercise training groups produced a long-term benefit in disability.
"Possibly the patients' experience in these small-group active therapies provoked a change in their beliefs about physical activity and low back pain, whilst those receiving one-to-one physiotherapy were more inclined to depend on the guidance of the physiotherapist," suggest Anne Mannion and colleagues. "The precise mode of exercise employed appears to be of less importance than simply challenging the patients' misconception that exercise is contra-indicated in low back pain" they added. (See Mannion et al., 2000.)
This study is a particular boost for aerobic training, which cost one-sixth the amount of the physical therapy intervention and one-fourth the amount of the isoinertial device training program. "When budgets are restricted, low-cost programs using aerobic exercise are recommended as an effective treatment for low back pain," according to Mannion et al.
If this study sounds familiar, these same authors reported six-month results at last year's annual meeting of the International Society for the Study of the Lumbar Spine in Hawaii. The 12-month results, reported at this year's ISSLS meeting in Adelaide, Australia, are even more surprising.
To recap the study design, Mannion and colleagues employed advertisements to recruit 148 individuals (mean age 45.1) with persistent or intermittent back pain lasting more than three months (volunteers typically had 10 or more years of back pain).
The subjects were randomly allocated to participate twice per week for three months in one of the following treatment programs: (1) individualized physical therapy, which included exercises, passive modalities, and instruction in home exercises; (2) training on isoinertial devices in groups of two or three, which involved progressive muscle conditioning and strengthening using the David Back Clinic system (David Fitness and Medical Ltd, UK); or (3) group aerobic training in larger groups, involving hour-long sessions of low-impact aerobics supplemented by whole-body stretching.
The researchers assessed the subjects' progress with analog pain scales, the Roland-Morris questionnaire, and the Fear-Avoidance Beliefs questionnaire, among other measures.
No Differences in Six-Month Outcomes
There were no significant differences among the three intervention groups in any outcome measure at the six-month mark. "Post-therapy, significant reductions were observed in pain intensity and frequency, and self-rated disability" according to Mannion et al.
A different pattern emerged at the 12-month follow-up mark. AH three groups maintained similar improvements in pain intensity and frequency at this juncture, but only the two group exercise programs maintained long-term gains in self-reported disability.
"In the devices and aerobics groups, the reduced disability observed immediately post-therapy was retained over the subsequent 12 months," according to Mannion et al. "In the physiotherapy group, however, the mean disability score began to regress back toward the pre-therapy level ..."
Senior author Jiri Dvorak, MD, noted that the mechanisms of improvement regarding disability in the exercise groups may be related to a reduction in fear-avoidance beliefs (changes in fear-avoidance beliefs followed a similar pattern to the disability scores). He also suggested that patient dependence on physical therapists in one-on-one therapy programs may hinder long-term progress in self-related disability.
A Change in Attitude
Overall, the study underlines the importance of changing attitudes about back pain in addition to alleviating physical discomfort. "Patients' interpretation of the disabling effects of low back pain may be more important than the pain itself," noted Dvorak.
Study results should be interpreted in light of a few caveats. The study subjects were motivated volunteers who responded to a newspaper advertisement, complied with the study protocol, and remained in the study group for more than a year (there was an 86% rate of follow-up at one year). As Dvorak noted, these study subjects may differ substantially from other groups of patients, such as workers with work-place disability dilemmas.
This study also lacked an untreated control group. Therefore, it is impossible to conclude that the exercise interventions themselves were the cause of the improvements. It is possible that the improvements in the two group exercise cohorts reflected the favorable natural history of chronic low back pain.
Dvorak said that the research group believed it would be unethical to invite patients into a study via a newspaper advertisement and then offer them no treatment at all. They actually included the aerobic training group as a quasi-control group, imagining that this intervention would have a minimal impact on chronic low back pain. In fact, it was the most cost-effective of the three treatments, by a substantial margin.
Any caveats aside, these findings are consistent with recent recommendations in evidence-based guidelines that the treatment of persistent back pain should focus more on functional rehabilitation and less on the palliation of symptoms. "Letting pain be the guide" is often a recipe for inactivity and a slide into invalidism.
Mannion AF et al., Changes in pain and disability one year after active therapy for chronic low back pain: A randomized clinical trial of three different management programs, presented at the annual meeting of the International Society for the Study of the Lumbar Spine, Adelaide, Australia, 2000; as yet unpublished.
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