Jane Latimer

Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial

Abstract Practice guidelines recommend various types of exercise and manipulative therapy for chronic back pain but there have been few head‐to‐head comparisons of these interventions. We conducted a randomized controlled trial to compare effects of general exercise, motor control exercise and manipulative therapy on function and perceived effect of intervention in patients with chronic back pain. Two hundred and forty adults with non‐specific low back pain ⩾3 months were allocated to groups that received 8 weeks of general exercise, motor control exercise or spinal manipulative therapy. General exercise included strengthening, stretching and aerobic exercises. Motor control exercise involved retraining specific trunk muscles using ultrasound feedback. Spinal manipulative therapy included joint mobilization and manipulation. Primary outcomes were patient‐specific function (PSFS, 3–30) and global perceived effect (GPE, −5 to 5) at 8 weeks. These outcomes were also measured at 6 and 12 months. Follow‐up was 93% at 8 weeks and 88% at 6 and 12 months. The motor control exercise group had slightly better outcomes than the general exercise group at 8 weeks (between‐group difference: PSFS 2.9, 95% CI: 0.9–4.8; GPE 1.7, 95% CI: 0.9–2.4), as did the spinal manipulative therapy group (PSFS 2.3, 95% CI: 0.4–4.2; GPE 1.2, 95% CI: 0.4–2.0). The groups had similar outcomes at 6 and 12 months. Motor control exercise and spinal manipulative therapy produce slightly better short‐term function and perceptions of effect than general exercise, but not better medium or long‐term effects, in patients with chronic non‐specific back pain.

Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review

Background: Previous systematic reviews have concluded that the effectiveness of motor control exercise for persistent low back pain has not been clearly established. Objective: The objective of this study was to systematically review randomized controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain. Methods: Electronic databases were searched to June 2008. Pain, disability, and quality-of-life outcomes were extracted and converted to a common 0 to 100 scale. Where possible, trials were pooled using Revman 4.2. Results: Fourteen trials were included. Seven trials compared motor control exercise with minimal intervention or evaluated it as a supplement to another treatment. Four trials compared motor control exercise with manual therapy. Five trials compared motor control exercise with another form of exercise. One trial compared motor control exercise with lumbar fusion surgery. The pooling revealed that motor control exercise was better than minimal intervention in reducing pain at short-term follow-up (weighted mean difference=−14.3 points, 95% confidence interval [CI]=−20.4 to −8.1), at intermediate follow-up (weighted mean difference=−13.6 points, 95% CI=−22.4 to −4.1), and at long-term follow-up (weighted mean difference=−14.4 points, 95% CI=−23.1 to −5.7) and in reducing disability at long-term follow-up (weighted mean difference=−10.8 points, 95% CI=−18.7 to −2.8). Motor control exercise was better than manual therapy for pain (weighted mean difference=−5.7 points, 95% CI=−10.7 to −0.8), disability (weighted mean difference=−4.0 points, 95% CI=−7.6 to −0.4), and quality-of-life outcomes (weighted mean difference=−6.0 points, 95% CI=−11.2 to −0.8) at intermediate follow-up and better than other forms of exercise in reducing disability at short-term follow-up (weighted mean difference=−5.1 points, 95% CI=−8.7 to −1.4). Conclusions: Motor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise.

The reliability and validity of the Biering-Sorensen test in asymptomatic subjects and subjects reporting current or previous nonspecific low back pain.

STUDY DESIGN A reliability study and case-control study were conducted. OBJECTIVES To determine the reliability and discriminative validity of the Biering-Sorensen test. SUMMARY OF BACKGROUND DATA A low Biering-Sorensen score has been found to predict who will have nonspecific low back pain. However, the reliability of the test remains controversial, implying that some studies may have produced results that underestimated the magnitude of the predictive validity of this test. METHODS Two raters measured the time holding a specific position (holding time) of 63 subjects (23 currently experiencing nonspecific low back pain, 20 who had had an episode, and 20 who were asymptomatic) while they performed the Biering-Sorensen test twice, 15 minutes apart. A standardized protocol was followed. Test-retest reliability was evaluated by calculating intra-class correlation coefficients (ICC 1,1), 95% confidence intervals (CI), and standard errors of the measurement (SEM) for the total group and for the subgroups. A three-way analysis of variance was used to determine whether test order, subject gender, or symptom status affected holding time. RESULTS High reliability indices were obtained for the Biering-Sorensen test in subjects with current nonspecific low back pain (ICC [1,1], 0.88; 95% CI, 0.73-0.95; SEM, 11.6 seconds), in subjects who had had nonspecific low back pain (ICC [1,1], 0.77; 95% CI, 0.52-0.90; SEM, 17.5 seconds), and in asymptomatic subjects (ICC [1,1], 0.83; 95% CI, 0.62-0.93; SEM, 17.4 seconds). Results of an analysis of variance showed that subjects asymptomatic for low back pain had a significantly longer holding time than the other two groups (P < 0.05). CONCLUSIONS The Biering-Sorensen test provides reliable measures of position-holding time and can discriminate between subjects with and without nonspecific low back pain.

The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review

Background The working alliance, or collaborative bond, between client and psychotherapist has been found to be related to outcome in psychotherapy. Purpose The purpose of this study was to investigate whether the working alliance is related to outcome in physical rehabilitation settings. Data Sources A sensitive search of 6 databases identified a total of 1,600 titles. Study Selection Prospective studies of patients undergoing physical rehabilitation were selected for this systematic review. Data Extraction For each included study, descriptive data regarding participants, interventions, and measures of alliance and outcome—as well as correlation data for alliance and outcomes—were extracted. Data Synthesis Thirteen studies including patients with brain injury, musculoskeletal conditions, cardiac conditions, or multiple pathologies were retrieved. Various outcomes were measured, including pain, disability, quality of life, depression, adherence, and satisfaction with treatment. The alliance was most commonly measured with the Working Alliance Inventory, which was rated by both patient and therapist during the third or fourth treatment session. The results indicate that the alliance is positively associated with: (1) treatment adherence in patients with brain injury and patients with multiple pathologies seeking physical therapy, (2) depressive symptoms in patients with cardiac conditions and those with brain injury, (3) treatment satisfaction in patients with musculoskeletal conditions, and (4) physical function in geriatric patients and those with chronic low back pain. Limitations Among homogenous studies, there were insufficient reported data to allow pooling of results. Conclusions From this review, the alliance between therapist and patient appears to have a positive effect on treatment outcome in physical rehabilitation settings; however, more research is needed to determine the strength of this association.

Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial

BACKGROUND We aimed to investigate whether the addition of non-steroidal anti-inflammatory drugs or spinal manipulative therapy, or both, would result in faster recovery for patients with acute low back pain receiving recommended first-line care. METHODS 240 patients with acute low back pain who had seen their general practitioner and had been given advice and paracetamol were randomly allocated to one of four groups in our community-based study: diclofenac 50 mg twice daily and placebo manipulative therapy (n=60); spinal manipulative therapy and placebo drug (n=60); diclofenac 50 mg twice daily and spinal manipulative therapy (n=60); or double placebo (n=60). The primary outcome was days to recovery from pain assessed by survival curves (log-rank test) in an intention-to-treat analysis. This trial was registered with the Australian Clinical Trials Registry, ACTRN012605000036617. FINDINGS Neither diclofenac nor spinal manipulative therapy appreciably reduced the number of days until recovery compared with placebo drug or placebo manipulative therapy (diclofenac hazard ratio 1.09, 95% CI 0.84-1.42, p=0.516; spinal manipulative therapy hazard ratio 1.01, 95% CI 0.77-1.31, p=0.955). 237 patients (99%) either recovered or were censored 12 weeks after randomisation. 22 patients had possible adverse reactions including gastrointestinal disturbances, dizziness, and heart palpitations. Half of these patients were in the active diclofenac group, the other half were taking placebo. One patient taking active diclofenac had a suspected hypersensitivity reaction and ceased treatment. INTERPRETATION Patients with acute low back pain receiving recommended first-line care do not recover more quickly with the addition of diclofenac or spinal manipulative therapy.

Motor control exercise for chronic low back pain: A randomized placebo-controlled trial

Background The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled. Objective The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain. Design This was a randomized, placebo-controlled trial. Setting The study was conducted in an outpatient physical therapy department in Australia. Patients The participants were 154 patients with chronic low back pain of more than 12 weeks’ duration. Intervention Twelve sessions of motor control exercise (ie, exercises designed to improve function of specific muscles of the low back region and the control of posture and movement) or placebo (ie, detuned ultrasound therapy and detuned short-wave therapy) were conducted over 8 weeks. Measurements Primary outcomes were pain intensity, activity (measured by the Patient-Specific Functional Scale), and patients global impression of recovery measured at 2 months. Secondary outcomes were pain; activity (measured by the Patient-Specific Functional Scale); patients global impression of recovery measured at 6 and 12 months; activity limitation (measured by the Roland-Morris Disability Questionnaire) at 2, 6, and 12 months; and risk of persistent or recurrent pain at 12 months. Results The exercise intervention improved activity and patients global impression of recovery but did not clearly reduce pain at 2 months. The mean effect of exercise on activity (measured by the Patient-Specific Functional Scale) was 1.1 points (95% confidence interval [CI]=0.3 to 1.8), the mean effect on global impression of recovery was 1.5 points (95% CI=0.4 to 2.5), and the mean effect on pain was 0.9 points (95% CI=−0.01 to 1.8), all measured on 11-point scales. Secondary outcomes also favored motor control exercise. Limitation Clinicians could not be blinded to the intervention they provided. Conclusions Motor control exercise produced short-term improvements in global impression of recovery and activity, but not pain, for people with chronic low back pain. Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups.

Clinimetric testing of three self-report outcome measures for low back pain patients in Brazil. Which one is the best?

Study Design. Translation, cross-cultural adaptation, and clinimetric testing of self-report outcome measures. Objective. The aims of this investigation were to perform the translation and cross-cultural adaptation of the Patient-Specific Functional Scale (PSFS) into Brazilian-Portuguese and to perform a head-to-head comparison of the clinimetric properties of the Brazilian-Portuguese versions of the PSFS, the Roland-Morris Disability Questionnaire (RMDQ) and the Functional Rating Index (FRI). Summary of Background Data. To date, there is no Brazilian-Portuguese version of the PSFS available and no head-to-head comparison of the Brazilian-Portuguese versions of the PSFS, RMDQ, and FRI has been undertaken. Methods. The PSFS was translated and adapted into Brazilian-Portuguese. The PSFS, the RMDQ, and the FRI were administered to 99 patients with low back pain to evaluate internal consistency, reproducibility, ceiling and floor effects, construct validity, internal and external responsiveness. To fully test the construct validity and external responsiveness of these measures, it was necessary to cross-culturally adapt the Pain Numerical Rating Scale and the Global Perceived Effect Scale. Results. All measures demonstrated high levels of internal consistency (Cronbachs α range = 0.88–0.90) and reproducibility (Intraclass Correlation Coefficient2,1 range = 0.85–0.94). High correlations among the disability-related measures were observed (Pearsons r ranging from 0.51 to 0.71). No ceiling or floor effects were detected. The PSFS was consistently more responsive than the other measures in both the internal responsiveness and external responsiveness analyses. Conclusion. The results from this study demonstrate that the Brazilian-Portuguese versions of the RMDQ, the FRI and the PSFS have similar clinimetric properties to each other and to the original English versions. Of allthe measures tested in this study the PSFS seems the most responsive. These measures will enable international comparisons to be performed, and encourage researchers to include Portuguese speakers in their clinical trials.

Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial

BACKGROUND Regular paracetamol is the recommended first-line analgesic for acute low-back pain; however, no high-quality evidence supports this recommendation. We aimed to assess the efficacy of paracetamol taken regularly or as-needed to improve time to recovery from pain, compared with placebo, in patients with low-back pain. METHODS We did a multicentre, double-dummy, randomised, placebo controlled trial across 235 primary care centres in Sydney, Australia, from Nov 11, 2009, to March 5, 2013. We randomly allocated patients with acute low-back pain in a 1:1:1 ratio to receive up to 4 weeks of regular doses of paracetamol (three times per day; equivalent to 3990 mg paracetamol per day), as-needed doses of paracetamol (taken when needed for pain relief; maximum 4000 mg paracetamol per day), or placebo. Randomisation was done according to a centralised randomisation schedule prepared by a researcher who was not involved in patient recruitment or data collection. Patients and staff at all sites were masked to treatment allocation. All participants received best-evidence advice and were followed up for 3 months. The primary outcome was time until recovery from low-back pain, with recovery defined as a pain score of 0 or 1 (on a 0-10 pain scale) sustained for 7 consecutive days. All data were analysed by intention to treat. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTN 12609000966291. FINDINGS 550 participants were assigned to the regular group (550 analysed), 549 were assigned to the as-needed group (546 analysed), and 553 were assigned to the placebo group (547 analysed). Median time to recovery was 17 days (95% CI 14-19) in the regular group, 17 days (15-20) in the as-needed group, and 16 days (14-20) in the placebo group (regular vs placebo hazard ratio 0·99, 95% CI 0·87-1·14; as-needed vs placebo 1·05, 0·92-1·19; regular vs as-needed 1·05, 0·92-1·20). We recorded no difference between treatment groups for time to recovery (adjusted p=0·79). Adherence to regular tablets (median tablets consumed per participant per day of maximum 6; 4·0 [IQR 1·6-5·7] in the regular group, 3·9 [1·5-5·6] in the as-needed group, and 4·0 [1·5-5·7] in the placebo group), and number of participants reporting adverse events (99 [18·5%] in the regular group, 99 [18·7%] in the as-needed group, and 98 [18·5%] in the placebo group) were similar between groups. INTERPRETATION Our findings suggest that regular or as-needed dosing with paracetamol does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group. FUNDING National Health and Medical Research Council of Australia and GlaxoSmithKline Australia.

Low Back Pain and Best Practice Care A Survey of General Practice Physicians

BACKGROUND Acute low back pain (LBP) is primarily managed in general practice. We aimed to describe the usual care provided by general practitioners (GPs) and to compare this with recommendations of best practice in international evidence-based guidelines for the management of acute LBP. METHODS Care provided in 3533 patient visits to GPs for a new episode of LBP was mapped to key recommendations in treatment guidelines. The proportion of patient encounters in which care arranged by a GP aligned with these key recommendations was determined for the period 2005 through 2008 and separately for the period before the release of the local guideline in 2004 (2001-2004). RESULTS Although guidelines discourage the use of imaging, over one-quarter of patients were referred for imaging. Guidelines recommend that initial care should focus on advice and simple analgesics, yet only 20.5% and 17.7% of patients received these treatments, respectively. Instead, the analgesics provided were typically nonsteroidal anti-inflammatory drugs (37.4%) and opioids (19.6%). This pattern of care was the same in the periods before and after the release of the local guideline. CONCLUSIONS The usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time. The unendorsed care may contribute to the high costs of managing LBP, and some aspects of the care provided carry a higher risk of adverse effects.

After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought

Study Design. Inception cohort study. Objective. To provide the first reliable estimate of the 1-year incidence of recurrence in subjects recently recovered from acute nonspecific low back pain (LBP) and to determine factors predictive of recurrence in 1 year. Summary of Background Data. Previous studies provide potentially flawed estimates of recurrence of LBP because they do not restrict the cohort to those who have recovered and are therefore eligible for a recurrence. Methods. We identified 1334 consecutive patients who presented to primary care with acute LBP; of these 353 subjects recovered before 6 weeks and entered the current study. The primary outcome measure was recurrence of LBP in the next year. Specifically, an episode of recurrence was defined in 2 ways: recall of recurrence at the 12-month follow-up and report of pain at the 3- or 12-month follow-up. Risk factors for recurrence were assessed at baseline. Pain intensity was assessed at 6 weeks, 3 months, and 12 months and recurrence at 12 months. Factors that could plausibly affect recurrence were chosen a priori and evaluated using a multivariable regression analysis. Results. Recurrence of LBP was found to be much less common than previous estimates suggest, ranging from 24% (95% CI = 20%–28%) using “12-month recall” definition of recurrence, to 33% (95% CI = 28%–38%) using “pain at follow-up” definition of recurrence. However, only 1 factor, previous episode(s) of LBP, was consistently predictive of recurrence within the next 12 months (odds ratio = 1.8–2.0, P = 0.00–0.05). Conclusion. This study challenges the assumption that the majority of subjects will have a recurrence of LBP in a 1-year period. After the resolution of an episode of acute LBP, about 25% of subjects will have a recurrence in the next year. It is difficult to predict who will have a recurrence within the next year.