Training protocol or guideline physiotherapy for chronic low back pain
Intensive group training protocol versus guideline physiotherapy for patients with chronic low back pain: a randomised controlled trial
From: Eur Spine J. 2008 Jul 29; [Epub ahead of print]
Intensive group training using principles of graded activity has been proven to be effective in occupational care for workers with chronic low back pain. Objective of the study was to compare the effects of an intensive group training protocol aimed at returning to normal daily activities and guideline physiotherapy for primary care patients with non-specific chronic low back pain. The study was designed as pragmatic randomised controlled trial with a setup of 105 primary care physiotherapists in 49 practices and 114 patients with non-specific low back pain of more than 12 weeks duration participated in the study. In the intensive group training protocol exercise therapy, back school and operant-conditioning behavioural principles are combined. Patients were treated during 10 individual sessions along 20 group sessions. Usual care consisted of physiotherapy according to the Dutch guidelines for Low Back Pain. Main outcome measures were functional disability (Roland Morris disability questionnaire), pain intensity, perceived recovery and sick leave because of low back pain assessed at baseline and after 6, 13, 26 and 52 weeks. Both an intention-to-treat analysis and a per-protocol analysis were performed. Multilevel analysis did not show significant differences between both treatment groups on any outcome measures during the complete follow-up period, with one exception. After 26 weeks the protocol group showed more reduction in pain intensity than the guideline group, but this difference was absent after 52 weeks. We finally conclude that an intensive group training protocol was not more effective than usual physiotherapy for chronic low back pain.
In 2001 the physiotherapy guideline for the assessment and treatment of patients with non-specific low back pain was published in The Netherlands. The recommendations in this guideline were based on scientific evidence where available; otherwise they were based on consensus. The guideline recommends that the diagnostic process should focus on disability and participation problems resulting from back pain. The treatment should consist of an active approach, in which patients learn to take control of their back pain. The main treatment interventions are systematic patient education and exercise therapy aimed at improvement of functioning (Bekkering et al 2003). For patients with a normal course (in whom activities and participation gradually increase)
reassurance, adequate information, and advice to stay active are the most important recommendations. One treatment session should be sufficient; if necessary a second appointment may be made. For patients with an abnormal course, in whom activities and participation do not improve, exercise therapy should be provided, with a behavioural approach if necessary. The guideline does not include a recommendation about the number of sessions in patients with an abnormal course (Bekkering et al 2003).
