Abstract: The problem of low back pain is growing, costly, and disabling, and it seems that the majority of patients entering the healthcare system for low back pain develop persistent, chronic symptoms. A recent study out of La Trobe University is the first randomised controlled trial to compare guideline-based advice to individualised physiotherapy. Patients receiving physiotherapy prove 1.5 times more likely to enjoy clinically significant improvement in disability at 52 weeks.
While authors often describe low back pain as benign and self-limiting, the medical complaint proves costly and a major cause of disability, with up to 71% of people with acute low back disorders experiencing persistent symptoms at 12 months.1-3 The majority of health care costs related to low back pain stem from chronicity and reuse of the system, so long-term assessment of treatment interventions must be considered.3 One method for cost reduction in use today is to simply provide patients with advice and instruction, both as a first-line treatment and as the treatment for back pain lasting longer than six weeks.4-5 Advice as treatment for back pain persists despite the fact that a 2012 systematic review finds self-care alone unable to achieve clinically important results.6 More recently, a study out of La Trobe University and The University of Melbourne is the first randomised, controlled trial to directly compare advice for low back pain to individualised physiotherapy.7
This trial randomised 300 participants to sixteen different physiotherapy practices and nineteen different treating physios. All patients had back pain lasting six weeks to six months, a pain intensity of two or greater on a zero-to-ten scale, and greater than minimal activity limitation. All participants received two sessions of guideline-based advice, and 156 participants additionally received an average of eight, 30-minute physiotherapy sessions over ten weeks. The authors defined clinically significant improvement as greater than 50% in each scale. While all patients showed some level of improvement over time, the patients receiving physiotherapy got better faster and achieved a greater level of improvement. Statistically significant differences in favour of physiotherapy persisted at the 52-week followup. For instance, at ten weeks, patients receiving physiotherapy prove 1.8 times more likely to demonstrate clinically significant improvement in back pain ratings. At 52 weeks, participants receiving physiotherapy prove 1.5 times more likely to have clinically significant improvement in the Oswestry Disability Index. On a one-to-four scale, median patient satisfaction in the physio group was a four compared to a two in the advice group.
Interestingly, the two sessions of advice in the current study proved much more effective than more involved self-care programs included in the 2012 systematic review, where self-care only created an average reduction in pain of 4.8 on a 100-point scale.6 Nevertheless, the advice group lagged significantly behind the physiotherapy group in improvement. Additionally, an important aspect of the physiotherapy treatment in this study likely blunted the results available through physiotherapy. In the present study, physiotherapy began only after back pain had become chronic - with symptom durations ranging from six weeks to six months. However, two important studies show that the sooner physiotherapy begins, the better the results.8,9 Fritz and colleagues examined the billing records of 32,070 workers with low back pain. Compared to later referrals, patients who received physiotherapy within 14 days of their primary care consult realised numerous advantages:
- Medical costs reduced by $3,058 per patient
- Use of advanced imaging reduced by 74%
- Need for surgery reduced by 55%
- Need for injections reduced by 58%
- Use of opioids reduced by 22%
Gelhorne and colleagues found similar results among a Medicare population. The evidence suggests that patients with non-specific low back pain should receive a referral for individualised, active physiotherapy as soon as possible after presenting the back pain complaint to a healthcare practitioner.
- Itz C, Geurts J, van Kleef M, et al. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain. 2013; 17: 5-15.
- Murray C, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study. Lancet. 2010; 380: 2197-223.
- Degenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine. 2008: 8-20.
- Maher C, Williams C. Managing low back pain in primary care. Aust Prescr. 2011; 34: 128-32.
- Dagenais S, Tricco A, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010; 10: 514-29.
- Oliveira V, Ferreira P, Maher C, et al. Effectiveness of self-management of low back pain: systematic review with meta-analysis. Arthritis Care & Research. 2012; 64 (11): 1739-1748.
- Ford J, Hahne A, Surkitt L, et al. Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial. Br J Sports Med. 2016; 50: 237-245.
- Fritz J, Childs J, Wainner R, Flynn T. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012; 37 (25): 2114-21.
- Gelhorn A, Chan L, Martin B, Friedly J. Management patterns in acute low back pain: the role of physical therapy. Spine. 2012; 37 (9): 775-782.