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Physiotherapist-Directed Exercise, Advice, or Both for Subacute Low Back Pain: A Randomized Trial

Liset H.M. Pengel, PhD; Kathryn M. Refshauge, PhD; Christopher G. Maher, PhD; Michael K. Nicholas, PhD; Robert D. Herbert, PhD; and Peter McNair, PhD
[+] Article and Author Information

From the Royal College of Surgeons of England, London, United Kingdom; University of Sydney, Sydney, Australia; Royal North Shore Hospital, St. Leonards, Australia; and Auckland University of Technology, Auckland, New Zealand.


Acknowledgments: The authors thank the staff at the physiotherapy departments at Bankstown Hospital, Concord Repatriation General Hospital, Royal Prince Alfred Hospital, Royal North Shore Hospital, and St. George Hospital, Sydney, Australia; New Lambton Physiotherapy Centre, Newcastle, Australia; and Middlemore Hospital, Auckland, New Zealand. They also thank Ms. Lois Tonkin and Ms. Judy Chen for their advice on treatment and Dr. Tim Dobbins for conducting the statistical analyses.

Grant Support: In part by a National Health and Medical Research Council of Australia Project grant (no. 107203) and the Australasian Low Back Pain Trial Committee. The Australasian Low Back Pain Trial Committee comprises Musculoskeletal Physiotherapy Australia, Physiotherapy Business Australia, and the New Zealand Manipulative Physiotherapists Association. Drs. Maher and Herbert hold research fellowships funded by the National Health and Medical Research Council of Australia.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Christopher G. Maher, PhD, Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, New South Wales 1825, Australia; e-mail, c.maher@usyd.edu.au.

Current Author Addresses: Dr. Pengel: Centre for Evidence in Transplantation, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London WC2A 3PE, United Kingdom.

Drs. Refshauge, Maher, and Herbert: Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, New South Wales 1825, Australia.

Dr. Nicholas: Pain Management and Research Institute E25, University of Sydney, Royal North Shore Hospital, St. Leonards, New South Wales 2065, Australia.

Dr. McNair: School of Physiotherapy, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand.

Author Contributions: Conception and design: K.M. Refshauge, C.G. Maher, M.K. Nicholas, P. McNair.

Analysis and interpretation of the data: L.H.M. Pengel, K.M. Refshauge, C.G. Maher, R.D. Herbert.

Drafting of the article: L.H.M. Pengel, K.M. Refshauge, C.G. Maher, M.K. Nicholas, R.D. Herbert.

Critical revision of the article for important intellectual content: L.H.M. Pengel, K.M. Refshauge, C.G. Maher, M.K. Nicholas, R.D. Herbert, P. McNair.

Final approval of the article: L.H.M. Pengel, K.M. Refshauge, C.G. Maher, M.K. Nicholas, R.D. Herbert, P. McNair.

Provision of study materials or patients: M.K. Nicholas.

Statistical expertise: R.D. Herbert.

Obtaining of funding: K.M. Refshauge, C.G. Maher, M.K. Nicholas, P. McNair.

Administrative, technical, or logistic support: L.H.M. Pengel, M.K. Nicholas.

Collection and assembly of data: L.H.M. Pengel, K.M. Refshauge, C.G. Maher, P. McNair.


Ann Intern Med. 2007;146(11):787-796. doi:10.7326/0003-4819-146-11-200706050-00007
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Our study provides evidence on the effects of physiotherapist-prescribed exercise and advice, alone and in combination, on pain, function, and global perceived effect for persons with moderately painful and mildly disabling subacute low back pain. Advice was slightly more effective than placebo in improving pain, function, and global perceived effect at 6 weeks of follow-up. Exercise was more effective than placebo in improving pain and global perceived effect at 6 weeks of follow-up. However, the effects of each treatment were smaller at 3 months and were smaller again and not statistically significant at 12 months. When both treatments were combined, the effect was larger and significant at 6 weeks, 3 months, and 12 months for function and at 6 weeks and 3 months for pain and global perceived effect. This result is important because no other efficacious treatments for subacute low back pain are known (7).

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Grahic Jump Location
Figure 2.
Outcomes in the 4 treatment groups.

Values shown are unadjusted means (SDs). Measurements were obtained at baseline, 6 weeks, 3 months, and 12 months, but the data are slightly offset in the figure for clarity.

Grahic Jump Location

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Comments

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Physiotherapist-Directed Exercise
Posted on June 19, 2007
Brian R. Duncan
Harris County Hospital District
Conflict of Interest: None Declared

After a quick read of your article I am confused about the choice of physiotherapist-directed exercise. The treatment regimen does not seem to represent current best evidence. The lack of sub-grouping/classification of the low back pain patients seems to be a strong limitation in the study as is the assumption that the patients simply need exercise. However, I do appreciate your efforts and am happy to see that no longer do we simply tell patients to go home and heal thyself.

Thanks

Brian

Conflict of Interest:

None declared

Physical Therapy In Australia Differs Widely From the US
Posted on June 24, 2007
Daniel G. Arkfeld
USC Keck School of Medicine
Conflict of Interest: None Declared

It is with great interest that I read the article entitled "Physiotherapist-Directed Exercise, Advice, or Both for Subacute Low Back Pain: A Randomized Trial" by Pengal et al. I commend the attempt to show the benefit of physical therapy in treating the enigmatic area of back pain. However, I am concerned about the cotherapies used by patients in this study.They state that at baseline, nearly two thirds (64%) of the participants had received some form of treatment for their current episode of low back pain. Additionally between 5% to 13% of patients received co- interventions including massage and spinal manipulation during the treatment phase. These 2 facts cloud the issue of benefit with physiotherapy alone especially since physical therapists in Australia are able to perform spinal manipulation and therapeutic massage is a covered benefit. An advantage of physical therapists in Australia and New Zealand has been their ability to incorporate multiple modalities in managing back pain. This area does not appear to have been fully studied to it's full benefit. Perhaps further studies could explore the role of multidisciplinary therapy in helping suffers of low back pain.

Conflict of Interest:

None declared

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Summary for Patients

Physiotherapist-Directed Exercise, Advice, or Both for Low Back Pain

The summary below is from the full report titled “Physiotherapist-Directed Exercise, Advice, or Both for Subacute Low Back Pain. A Randomized Trial.” It is in the 5 June 2007 issue of Annals of Internal Medicine (volume 146, pages 787-796). The authors are L.H.M. Pengel, K.M. Refshauge, C.G. Maher, M.K. Nicholas, R.D. Herbert, and P. McNair.

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