Treatment for Back Pain: What Works Best?Massage, rehabilitation, yoga, exercise, back school, rest, or do nothing -- what's the best way to approach back pain? These are just a few of the treatment options patients have to choose from. What's the evidence to support one over another? That's what this study attempted to sort out.
The authors conducted a systematic review to compare the effectiveness of three specific treatments for low back pain (back school, fear-avoidance training, and patient education). A systematic review is one of the most respected types of studies. It involves a careful search of all the studies published on a single topic. Once those studies have been identified, they are reviewed for design, content, patient base, and quality. Only high-quality studies are included.
In this study, effectiveness of treatment was measured by pain, disability, and sick leave. Cost effectiveness and the use of health care resources were also evaluated. The type of professional who provided and supervised the treatment was recorded along with the setting in which patients were treated.
The authors compared each one and reported on whether the evidence was limited or conflicting, no evidence, or conclusive (moderate-to-strong evidence). Whenever possible, the data was combined or pooled to give greater statistical validity. This could only be done when the studies involved reported results in a similar way and when like groups of patients were tested. Each of the treatment approaches was described in detail. Here's a brief review:
Based on the evidence gathered from the systematic review, recommendations are made. For example, the evidence supports a recommendation for brief education in a clinical setting (doctor's office or physical therapy clinic). The goal is to reduce disability and get the patient back to work. It is not recommended that patients rely on Internet discussions or reading a book on back care as an effective way to manage low back pain. The lack of personal face-to-face communication and absence of personal caring with printed advice either read from a book or downloaded from an on-line source may be a factor.
Fear-avoidance training should be included in a rehab program and even considered as an alternative to spinal fusion. Evidently the results were just as good with fear-avoidance training as with surgery to fuse the spine. With equal evidence to support a noninvasive approach, fear-avoidance training got a thumbs-up approval.
Although there is general agreement as to the value of fear-avoidance training, it's unclear how soon this should be done. We also don't know how many sessions are needed. Should everyone be given this training, or just those patients who test high for pain-related fear? And finally, what's the best way to accomplish this task? Would a brief educational session be enough? Or is a more specific training program needed?
The authors conclude by encouraging a more consistent approach to future studies that compare treatment approaches and the cost-effectiveness of each program. If enough studies are done with a similar design, patient population, and methodology, then data from future systematic reviews can be pooled and evidence-based recommendations offered.
J. I. Brox, PhD, et al. Systematic Review of Back Schools, Brief Education, and Fear-Avoidance Training for Chronic Low Back Pain. In The Spine Journal. November 2008. Vol. 8. N. 6. Pp. 948-958.
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