Low back pain is one of the most common symptoms prompting adults to seek health care. In the UK, primary-care guidelines for the management of low back pain encourage early referral to a physiotherapist for patients with non-specific pain when first-line management by general practitioners with medication, advice to stay active, and simple messages about self management has not been effective.
Elaine Hay (Keele University, UK) and colleagues did a randomised trial to compare the clinical effectiveness of a brief pain management programme delivered by physiotherapists with that of a programme of physical therapies, including manual therapy, also delivered by physiotherapists, in the treatment of low back pain of less than 12 weeks duration. The pain management programme included general fitness and exercise advice, and educational strategies to overcome psychosocial barriers to recovery. The investigators recruited 400 adults with low back pain between 2000 and 2002 from 28 general practices in the UK. Clinical outcome was the same at 3 months and 12 months for participants randomised to either a brief pain-management programme or to a package of physiotherapy incorporating spinal manual-therapy techniques.
Professor Hay states: "Our findings provide a choice of approach for physiotherapists and suggest that manual therapy is not essential as an initial treatment for patients with subacute low back pain. The pain-management package was delivered in fewer treatment sessions, resulted in fewer referrals to secondary care than the traditional approach, and might be an efficient first-line approach to care of patients with low back pain presenting in primary-care practice."
In an accompanying comment Paul Shekelle (Greater Los Angeles VA Healthcare System, USA) states: "Hay and colleagues' study probably has very good external validity for the UK National Health Service, and pretty fair external validity for health care in other countries. However there are important limitations…Applying a one-size-fits-all approach, and applying the brief pain-management programmes or the manual therapy treatment to everyone regardless of presentation, might have obscured the potential effectiveness of treatment targeted more specifically to patients for whom it is more likely to benefit."
Contact: Professor Peter R Croft, Primary Care Sciences Research Centre, Keele University, Hornbeam Building, Keele, Staffordshire, ST5 5BG,UK. T) 01782 583 920 p.r.croft@cphc.keele.ac.uk
Comment: Dr P G Shekelle, RAND, 1700 Main Street, PO Box 2138, Santa Monica CA 90407, USA. T) +1 310 393 0411 shekelle@rand.org
Journal
The Lancet