Summary: A number of treatments may be effective for low back pain with apparent disagreement between studies due to grouping all lower back pain into the same category. Degenerative disc pain should be separated from sciatica and chronic muscle spasm in future studies. Individualized treatment plans beginning with less intrusive mobilization before manipulation would greatly increase chiropractic outcomes. Long term studies incorporating patient self-treatment with passive (neutral pelvis) as well as active (hydrotherapy, lifestyle) interventions are still lacking.

Low back pain: what is the long-term course? A review of studies of general patient populations.

Hestbaek L, Leboeuf-Yde C, Manniche C.

The Backcenter, Ringe Hospital, Odense University Hospital, 5950 Ringe, Denmark, hestbaek@vip.cybercity.dk

It is often claimed that up to 90% of low back pain (LBP) episodes resolve spontaneously within 1 month. However, the literature in this area is confusing due to considerable variations regarding the exact definitions of LBP as well as recovery. Therefore, the claim - attractive as it might be to some - may not reflect reality. In order to investigate the long-term course of incident and prevalent cases of LBP, a systematic and critical literature review was undertaken. A comprehensive search of the topic was carried out utilizing both Medline and EMBASE databases. The Cochrane Library and the Danish Article Base were also screened. Journal articles following the course of LBP without any known intervention were included, regardless of study type. However, the population had to be representative of the general patient population and a follow-up of at least 12 months was a requirement. Data were extracted independently by two reviewers using a standard check list. The included articles were also independently assessed for quality by the same two reviewers before they were studied in relation to the course of LBP using various definitions of recovery. Thirty-six articles were included. The results of the review showed that the reported proportion of patients who still experienced pain after 12 months was 62% on average (range 42-75%), the percentage of patients sick-listed 6 months after inclusion into the study was 16% (range 3-40%), the percentage who experienced relapses of pain was 60% (range 44-78%), and the percentage who had relapses of work absence was 33% (range 26-37%). The mean reported prevalence of LBP in cases with previous episodes was 56% (range 14-93%), which compared with 22% (range 7-39%) for those without a prior history of LBP. The risk of LBP was consistently about twice as high for those with a history of LBP. The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.

PMID: 12709853 [PubMed - in process]

Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group.

Furlan AD, Brosseau L, Imamura M, Irvin E.

Institute for Work & Health, Toronto, Canada. afurlan@iwh.on.ca

BACKGROUND: Low back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability and speed return-to-normal function. OBJECTIVES: To assess the effects of massage therapy for nonspecific LBP. SEARCH STRATEGY: We searched MEDLINE, Embase, Cochrane Controlled Trials Register, HealthSTAR, CINAHL, and dissertation abstracts through May 2001 with no language restrictions. References in the included studies and in reviews of the literature were screened. Contact with content experts and massage associations was also made. SELECTION CRITERIA: The studies had to be randomized or quasirandomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific LBP. DATA COLLECTION AND ANALYSIS: Two reviewers blinded to authors, journals, and institutions selected the studies, assessed the methodologic quality using the criteria recommended by the Cochrane Collaboration Back Review Group, and extracted the data using standardized forms. The studies were analyzed in a qualitative way because of heterogeneity of population, massage technique, comparison groups, timing, and type of outcome measured. RESULTS: Nine publications reporting on eight randomized trials were included. Three had low and five had high methodologic quality scores. One study was published in German, and the rest, in English. Massage was compared with an inert treatment (sham laser) in one study that showed that massage was superior, especially if given in combination with exercises and education. In the other seven studies, massage was compared with different active treatments. They showed that massage was inferior to manipulation and transcutaneous electrical nerve stimulation; massage was equal to corsets and exercises; and massage was superior to relaxation therapy, acupuncture, and self-care education. The beneficial effects of massage in patients with chronic LBP lasted at least 1 year after the end of the treatment. One study comparing two different techniques of massage concluded in favor of acupuncture massage over classic (Swedish) massage. CONCLUSIONS: Massage might be beneficial for patients with subacute and chronic nonspecific LBP, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this needs confirmation. More studies are needed to confirm these conclusions, to assess the effect of massage on return-to-work, and to measure longer term effects to determine cost-effectiveness of massage as an intervention for LBP.

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PMID: 12221356 [PubMed - indexed for MEDLINE]

A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study.

Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Belin TR, Yu F, Adams AH; University of California-Los Angeles.

Department of Epidemiology, University of California-Los Angeles School of Public Health, Los Angeles, California 90095-1772, USA. ehurwitz@ucla.edu

STUDY DESIGN: A randomized clinical trial. OBJECTIVES: To compare the effectiveness of medical and chiropractic care for low back pain patients in managed care; to assess the effectiveness of physical therapy among medical patients; and to assess the effectiveness of physical modalities among chiropractic patients. SUMMARY OF BACKGROUND DATA: Despite the burden that low back pain places on patients, providers, and society, the relative effectiveness of common treatment strategies offered in managed care is unknown. METHODS: Low back pain patients presenting to a large managed care facility from October 30, 1995, through November 9, 1998, were randomly assigned in a balanced design to medical care with and without physical therapy and to chiropractic care with and without physical modalities. The primary outcome variables are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire. RESULTS: Of 1,469 eligible patients, 681 were enrolled; 95.7% were followed through 6 months. The mean changes in low back pain intensity and disability of participants in the medical and chiropractic care-only groups were similar at each follow-up assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95% confidence interval, -0.32-0.86; average pain, 0.22, -0.25-0.69; and disability, 0.75, -0.29-1.79). Physical therapy yielded somewhat better 6-month disability outcomes than did medical care alone (1.26, 0.20-2.32). CONCLUSIONS: After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

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PMID: 12394892 [PubMed - indexed for MEDLINE]

Erratum in:

Comment in:

Second Prize: The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: findings from the UCLA low back pain study.

Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Belin TR, Yu F, Adams AH, Kominsky GF.

UCLA School of Public Health, Department of Epidemiology, Los Angeles, Calif. 90095-1772, USA. ehurwitz@ucla.edu

BACKGROUND: Although chiropractors often use physical modalities with spinal manipulation, evidence that modalities yield additional benefits over spinal manipulation alone is lacking. OBJECTIVE: The purpose of the study was to estimate the net effect of physical modalities on low back pain (LBP) outcomes among chiropractic patients in a managed-care setting. METHODS: Fifty percent of the 681 patients participating in a clinical trial of LBP treatment strategies were randomized to chiropractic care with physical modalities (n = 172) or without physical modalities (n = 169). Subjects were followed for 6 months with assessments at 2, 4, and 6 weeks and at 6 months. The primary outcome variables were average and most severe LBP intensity in the past week, assessed with numerical rating scales (0-10), and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire. RESULTS: Almost 60% of the subjects had baseline LBP episodes of more than 3 months' duration. The 6-month follow-up was 96%. The adjusted mean differences between groups in improvements in average and most severe pain and disability were clinically insignificant at all follow-up assessments. Clinically relevant improvements in average pain and disability were more likely in the modalities group at 2 and 6 weeks, but this apparent advantage disappeared at 6 months. Perceived treatment effectiveness was greater in the modalities group. CONCLUSIONS: Physical modalities used by chiropractors in this managed-care organization did not appear to be effective in the treatment of patients with LBP, although a small short-term benefit for some patients cannot be ruled out.

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PMID: 11898014 [PubMed - indexed for MEDLINE]

Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA low-back pain study.

Hertzman-Miller RP, Morgenstern H, Hurwitz EL, Yu F, Adams AH, Harber P, Kominski GF.

Department of Epidemiology, UCLA School of Public Health, University of California-Los Angeles, Los Angeles, CA, USA. hertzman_miller@post.harvard.edu

OBJECTIVES: This study examined the difference in satisfaction between patients assigned to chiropractic vs medical care for treatment of low back pain in a managed care organization. METHODS: Satisfaction scores (on a 10-50 scale) after 4 weeks of follow-up were compared among 672 patients randomized to receive medical or chiropractic care. RESULTS: The mean satisfaction score for chiropractic patients was greater than the score for medical patients (crude difference = 5.5; 95% confidence interval = 4.5, 6.5). Self-care advice and explanation of treatment predicted satisfaction and reduced the estimated difference between chiropractic and medical patients' satisfaction. CONCLUSIONS: Communication of advice and information to patients with low back pain increases their satisfaction with providers and accounts for much of the difference between chiropractic and medical patients' satisfaction.

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PMID: 12356612 [PubMed - indexed for MEDLINE]

Low back pain recollection versus concurrent accounts: outcomes analysis.

Dawson EG, Kanim LE, Sra P, Dorey FJ, Goldstein TB, Delamarter RB, Sandhu HS.

UCLA Comprehensive Spine Center and Department of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90404, USA. lkanim@espineinstitute.com

STUDY DESIGN: Patients with low back pain were asked to recall the pain and impaired functioning that they reported 5-10 years previously as part of the National Low Back Pain prospective follow-up study. In 1998, patients completed an additional follow-up. OBJECTIVES: To compare outcomes using patient-recalled data and prospectively collected data from patients with low back pain and to identify simple, symptom-specific questions that yield reliable responses over an extended period of time. SUMMARY OF BACKGROUND DATA: Outcome assessment based on patient recall may be influenced by a patient's age, gender, reporting tendency, and current health status. The impact of data collected retrospectively on outcome analyses in spinal patients has not been addressed. METHODS: Patients enrolled in the National Low Back Pain study from 1986 to 1991 completed a self-administered questionnaire at their initial visit. A sample was interviewed by telephone in 1996 and asked to recall pain characteristics and impaired functioning reported at initial examination. A 10-year follow-up (1998) on current health status was conducted by mail. The 1998 follow-up response was separately compared with recalled and initial responses, such that two patient outcome status values were calculated for each question. Agreement was evaluated using Cohen's kappa. RESULTS: The follow-up evaluation was completed by 144 patients, with a mean interval of 9.4 years. The overall simple kappa was 0.37, indicating "fair" agreement between outcomes based on initial and recalled accounts of pain. Questions on location of pain had kappa values of 0.12-0.58, radicular symptoms 0.28-0.48, and severity of pain 0.11-0.30. CONCLUSIONS: "Fair" to "moderate" agreement was found between outcomes determined by recalled versus initial reports. Accuracy was greatest for queries on frequency, location of pain, and activities affecting pain. Discrepancies were noted for queries on severity of pain, with error bias toward less pain when using the recalled data. Careful selection of questions may yield more accurate outcome measures.

PMID: 11979175 [PubMed - indexed for MEDLINE]

Systematic review of conservative interventions for subacute low back pain.

Pengel HM, Maher CG, Refshauge KM.

School of Physiotherapy, University of Sydney, Sydney, NSW, Australia. hpen1533@mail.usyd.edu.au

OBJECTIVE: To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. DESIGN: Systematic review of randomized controlled trials. MAIN OUTCOME MEASURES: Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. RESULTS: Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g. manipulation, exercise, TENS) may be effective. CONCLUSIONS: Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence.

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PMID: 12501942 [PubMed - indexed for MEDLINE]

[The Efficacy of homeopathy in the treatment of chronic low back pain compared to standardized physiotherapy]

[Article in German]

Gmunder R, Kissling R.

Abteilung fur Physikalische Medizin und Rheumatologie, Orthopadische Universitatsklinik Balgrist, Zurich, Switzerland.

AIM: The aim of this pilot project was to evaluate the efficacy of treatment of chronic low back pain during two months either by homeopathy or by standardised physiotherapy. METHOD: 43 patients suffering from chronic low back pain were included in this controlled, randomised prospective study. They were divided in two treatment groups: homeopathy and standardised physiotherapy. Based on the initial and final clinical investigations, the Oswestry questionnaire and the visual analogue scale, that were assessed at the beginning, at the end and 18.5 months after therapy, the results were statistically evaluated. A further questionnaire documented the acceptance of treatment. RESULTS: A comparison of the groups from the beginning to the end of treatment reveals a significant decrease of the Oswestry score in patients treated by homeopathy. This tendency could not be confirmed 18.5 months later. Homeopathy was well accepted by most of the patients. CONCLUSIONS: Based on these results, nothing can be said against attempting treatment of chronic low back pain by means of homeopathy. Further research is recommended to confirm the results of our investigation, using a larger number of patients, a third treatment group, homeopathy double blinded.

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