Little Difference in Treating Chronic Lower Back Pain Intensively With Therapist or Group Multidisciplinary ApproachLower back pain - everyone knows someone who has experienced lower back pain at one time or another. Chronic low back pain is a major health issue in our society today and it is the most common musculoskeletal reason doctors are visited. Chronic low back pain doesn't just affect a person physically, it has an big impact on society as it costs money for the person living with it, as well as their employers. Geography doesn't protect against back pain as it happens around the world. In Denmark, for example, chronic low back pain is said to affect 10 percent of the adult population.
Despite the commonality of chronic low back pain, there isn't a lot of agreement on the best methods of treatment and management. Exercise has been shown to be quite effective in helping patients regain strength, reduce pain and disability. The type and duration of exercise isn't always agreed upon though. The authors of this article investigated the difference in outcomes of patients with chronic low back pain who underwent multidisciplinary biopsychosocial rehabilitation and those who underwent an intensive therapist-assisted individual back muscle exercise program.
Researchers recruited 286 patients who had been experiencing low back pain for at least 12 weeks, with or without pain radiating down one or both legs. The patients ranged in age from 18 years to 60 year. They were assessed through the usual testing procedures, x-rays and computed tomography (CT) scan or magnetic resonance imaging (MRI), as well as physical examination. The patients informed the researchers whether they were working and they completed the visual analog scale (VAS), a scale from zero to 100, indicating what level they rated their pain. The patients were evaluated at the start of the study (baseline), at three months after the start, and again at six, 12, and 24 months after the start.
The groups were assigned randomly to group A (multidisciplinary, or team approach) and they worked in groups of six patients. They were given a program of combined exercise, eduction and pain management for a 12-week period, divided into three periods of four weeks. The patients worked on warm-up and stretching exercises, aerobic training, as well as strengthening of the back, upper buttocks, and abdominal muscles. There were 22 exercises in all to be completed, plus there were ball games, hot water training, and ball stick training. In addition to these exercises, the patients also were taught anatomy, postural techniques and pain management, by a physiotherapist, and back care and lifting techniques, by an occupational therapist. Ultimately, the patients benefitted from about 12 hours of therapist assistance.
Group B were the patients who received individual treatment, with a program of specific and intensive muscle training exercises to strengthen and shorten the muscles in the back and upper buttocks region, but did not include strengthening the abdominal muscles or stretching exercises. The patients were attended to on a one-on-one basis with the therapist and they were seen about one hour, two times per week, over a period of 12 weeks. They benefitted from about 24 hours of therapist assistance.
The researchers assessed change and improvement in back pain using the visual analog scale and the Roland-Morris Disability Questionnaire (RMDQ), as well as two other more generic questionnaires and the medical outcomes study 36-item short form general healthy survey. At the end of treatment, the researchers found a 20 percent to 30 percent improvement in visual analog scored pain in both groups. This continued through the follow-up as well. There was no real difference in the number of analgesics, pain medications, taken between the two groups. There was, however, a noticeable difference in the improvement in disability. While both groups improved, those in group A improved more and continued this improvement over the follow-up period. Both groups also improved in the general health and emotional aspects after treatment, but again, group A patient showed more improvement than those in group B.
When the study first began, only 29 percent of the patients in group A were able to work and 36 percent of those in group B. At the end of treatment, both percentages rose: group A to 40 percent and group B to 38 percent. This continued to improve throughout the follow-up period to 48 percent for group A and 54 percent in group B.
Not all patients completed the study. Eleven in each group dropped out. In group A, one patient required back surgery and one had sustained a concussion after a fall. Seven patients in group A and five in group B withdrew because they experienced either delayed onset of muscle soreness or a worsening of leg pain. The other patients who withdrew had other reasons not related to the study, were lost to follow-up, or became ill.
Despite the drop outs and a few limitations to the study, such as the large number of dropouts from the group-based management, the authors wrote that the study did show a slight superiority to the multidisciplinary approach, but not enough to come out with a recommendation that it is a better treatment program. Some factors to consider include how many people are needed for the team approach and availability, and the amount of time that the patients must invest versus the number of hours one therapist needs to invest for the one-on-one treatment.
Ninna Dufour, MD, et al. Treatment of Chronic Low Back Pain. In Spine. March 1, 2010. Vol. 35. No. 5. Pp. 469 to 476.
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