- Email: [email protected]
Physiotherapy Management of Chronic Low Back Pain
751
Physiotherapy Management of Chronic Low Back Pain Helen Frost Jennifer Klaber Moffett Key Words Chronic low back pain, disability, rehabilitation programmes, physiotherapy treatment, exercise. Summary Disability reported as a result of low back pain (LBP) has increased dramatically over the last 20 years. This paper reviews some of the scientific evidence currently available for the treatment of patients with LBP. The advantages of a more active approach to the management of this complex problem are discussed and compared with passive forms of treatment. A rehabilitation programme, developed in Oxford over the last four years for chronic LBP (CLBP) sufferers is described. The need for further research to evaluate the current treatment of CLBP is emphasised.
Introduction The disability caused by low back pain (LBP) has escalated dramatically over the last decade. Time off work due to LBP has increased by 40% in comparison to 5.6% for all other complaints (DHSS, 1989). These figures are of concern to all professionals dealing with the problem, and various theories have been put forward to account for this dramatic increase. Allen and Waddell (1989) pointed out that LBP is not a new phenomenon, but the disability caused by mechanical LBP is a growing problem. They hypothesised that the increase in low back pain disability (LBPD) is a product of modern patterns of work and compensation. As members of a profession who play a major role in the care of these patients, physiotherapists should be addressing this issue and re-assessing current management trends. Traditionally, the aims of assessment are to localise the exact area of pain and ask questions about the site, nature, and severity of that pain. Therapists then proceed with various forms of treatment in which the patient has a passive role, eg mobilisation, manipulation, traction, electrotherapy and heat. Relief of pain is often the primary objective of treatment and this is usually considered before relating to functional activities. However, this may not always be the most effective and appropriate approach, especially for patients who have long-standing chronic pain.
Physiotherapy Treatment Over the last two years a research team in Maastricht has reviewed and studied the effects of manipulative therapy, exercise therapy and physiotherapy for LBP patients. Koes et aZ (1991a) reviewed 35 randomised controlled trials comparing spinal manipulative techniques with other forms of therapy. The objective of
SCHOLARLY PAPER
t h e study was to assess t h e efficacy of spinal manipulatiodmobilisation for patients with back and neck problems. The papers assessed included treatment given by physiotherapists, osteopaths and chiropractors. Each paper was scored for quality of the methodology and authors’ conclusions. Koes et aZ(1991a) concluded that the efficacy of manipulation for patients with back and neck pain has not been convincingly demonstrated in the literature they reviewed. They then carried out a similar ‘meta analysis’ on 16 papers using randomised controlled trials to study the effect of specific exercise regimes on patients with LBP. Once again, overall, the standard of these papers was considered by Koes et aZ(1991b) to be poor. They noted that the studies demonstrating a positive effect of exercise were scored higher methodologically than the studies which demonstrated negative results. This conclusion was contrary to the meta analysis carried out on the manipulative therapy studies. In this case, most of the studies that rated highly on methodology reported negative results of treatment. Subsequently Koes et aZ(1992a) themselves carried out a randomised controlled trial to compare the effectiveness of GP management, manual therapy, other forms of physiotherapy (electrotherapy, massage, heat and exercise) and physiotherapy placebo (detuned short-wave or ultrasound) for patients with back and neck complaints. They attempted to avoid many of the methodological flaws that they had previously referred to in other clinical trials (Koes et aZ1991a, 1991b).Their results indicated a more favourable outcome for patients treated by manual therapists and physiotherapists compared with GP management. However, there was no difference between the physiotherapy groups (including placebo treatment) and the manual therapy group at the short-term follow up. The authors concluded from the short-term follow up that a substantial component of the effect of referral for physiotherapy or manual therapy could be explained by placebo effects. It is difficult to reach any firm conclusions regarding the effectiveness of exercise in the physiotherapy group as many different forms of physiotherapy were included, the exercise was not specified and there was no exercise only group for comparison. The authors followed up patients for 12 months (Koes et aZ, 1992b). At that stage, they were unable to analyse results from the placebo and GP group as many of the patients had changed treatment groups. The authors concluded that beneficial results were gained from both the physiotherapy and manipulative therapy groups. The latter was slightly better than the physiotherapy group a t 12 months follow-up.
Psychological Factors An alternative approach to the treatment of chronic low back pain (CLBP) has been described by Fordyce (1976, 1985) and aims to treat excess disability. Over the past 20 years research has shown this approach to be effective
Physiotherapy, October 1992, vol78, no 10
752
and especially useful for the management of chronic back pain (Linton, 1985, 1986, 1987; Lindstrom et al, 1992). Health professionals need to be aware that both the setting and the interaction between therapist and patient may focus attention on the pain, and consequently encourage protective behaviour in some patients. The end result may even be a reduction in normal function. Contact with a therapist may, unless the active component of treatment is emphasised and the patient is given a feeling of control over their problem, encourage the patient to rely heavily on the medical profession. Recent studies support the view that the medical management of more dysfunctional patients with chronic pain may often be inappropriate and may ultimately contribute to their morbidity and distress (Pither and Nicholas, 1991; Linton, 1987). In this respect assessment concentrating on pain followed by passive treatment, eg electrotherapy, may not always be appropriate. In many patients with CLBP, excessive protection of the spine is caused by a n exaggerated fear of pain inducing a deconditioning syndrome (Lethem et al, 1983; Mayer et al, 1985, Flor et al, 1990). The expectation that some activities may cause pain can lead to avoidance of those activities and anything associated with them. This has important practical implications for therapists assessing a patient’s pain and range of movement. Individual beliefs about the capacity to move and be physically active are important aspects of back pain rehabilitation. A recognition of psychological processes that influence the outcome of treatment are important in the acute stage as well as the chronic stage in order to prevent development of CLBP disability (Council et al, 1988).
Exercise and Low Back Pain There have been very few well controlled randomised clinical trials comparing different types of exercise for LBP. Belanger et al (1991) reviewed and analysed the scientific publications that support the clinical effectiveness of the McKenzie approach (McKenzie,1981). They concluded that the world-wide popularity of this treatment among physiotherapists is not related to scientifically obtained evidence. However, the advantage of the McKenzie approach is that it advocates actively involving patients in their own management. It recognises the fact that contact time with a therapist will very rarely gain maximum benefit unless self-treatment is encouraged and continued a t home. The mobilising exercises are passive in the sense that they do not use the back muscles, but they do require an active commitment from the patients. Roberts (1991)carried out a randomised controlled trial, including patients with acute LBP, comparing the McKenzie approach with non-steroidal anti-inflammatory drugs. The results demonstrated significantly reduced disability, a t seven weeks following initial pain onset, in the group of patients treated with McKenzie techniques. The difference between the groups was not significant at six months or one year and the benefits may not have been seen in patients with CLBP. Koes et a1 (1991b) concluded that it was uncertain whether execise therapy is better than other conservative treatments for LBF? Evidence to support the effectiveness of any specific type of exercise regime was inconclusive,
as suggested by an earlier review of this literature by Klaber Moffett (1989). These conclusions, although somewhat disappointing, should not deter us from striving to improve our techniques and evaluative methods. The main problem with conducting randomised controlled trials of exercise therapy for LBP is the subject variation within the treatment groups. Due to the difficulty of diagnosis, the inclusion criteria are usually non specific and patient selection relies on exclusion of major pathology. This often results in different types of back problems being treated with the same exercises which may be suitable for one condition but not for another.
Supporting Evidence for Rehabilitation Programmes Another area of research literature suggests a role for the use of exercise programmes aiming to improve function and general fitness. This approach to CLBP has been investigated and encouraged, particularly in America and Scandinavian countries (Mayer et al, 1985; Lindstrom, 1992). Cady et a1 (1979), in a frequently cited study, demonstrated a significant protective effect of high levels of physical fitness in a study of 1,652 fire-fighters and found that an increase in cardiovascular fitness, even without a significant increase in strength and flexibility, was accompanied by a 25%reduction in the cost of workers’ compensation. This evidence encouraged researchers to investigate the effectiveness of exercise, aiming to improve general function, in patients with CLPB. Mayer et a1 (1985) included 104 patients with CLBP in a prospective study to evaluate a programme including exercise, psychological intervention, educatiod, functional tasks and work hardening exercises. They found that return to work was related to increase in muscle strength, range of motion and functional capacity. In a five-year follow-up of this programme Kohles et aZ (1990) concluded that the more vigorous and intensive exercise programme demonstrated beneficial effects. Their results indicated that their functional restoration treatment approach was effective and helped to return deconditioned patients with CLBP to improved levels of physical performance. Lindstrom et aZ(1992)carried out a randomised controlled trial to investigate the effect of graded activity on patients with sub-acute LBP, in which 103 industrial workers with sub-acute LBP were randomly assigned to either a control group (which included care from their regular physician only) or an activity group. The activity group included back school education, work-place visits, an individual, sub-maximal, gradually increased exercise programme and measurements of functional capacity. The main outcome measures in this study were the rate of return to work and the amount of sick leave during the second follow up year. The graded activity programme significantly reduced long-term sick leave and returned the patients to work, on average, 5.1 weeks earlier than the control group. The authors concluded that the patients in the activity programme learnt that it is safe to move while , function. regaining Other studies support the beneficial effects of exercise programmes for patients with CLBP (Harkapaa et cd,
~~
Physiotherapy, October 1992, vol78, no 10
753
1989; Hazard et al, 1989; Thomas et al, 1980; McQuade et al, 1988). The literature suggests that the benefits of increased activity are due to a combination of both physiological and psychological factors.
The Oxford Rehabilitation Programme In response to some of these research findings a rehabilitation programme was established in 1988 at the Nuffield Orthopaedic Centre, Oxford. Even if exercise such as walking or swimming is encouraged, patients who have suffered long periods of inactivity are often fearful of increasing their activity levels. In addition, some patients try too hard and need to learn to pace themselves, while gradually increasing their activities (Flor and Birbaumer, 1991). The programme aims to motivate patients to take up regular exercise, increase their confidence in their ability to carry out normal activities of daily living regardless of their back pain, and help them to take control of their own back problem. It is offered as an adjunct to the back school which has been evaluated and updated since it was first established in 1980 (Klaber Moffett et al, 1986). The patients are assessed individually in the physiotherapy department and given specific exercises for their particular problem before they start the programme. Consent is obtained from the patients’ general practitioners declaring them medically fit to take part. The programme includes functional activities, general aerobic, mobilising and stretching exercises, and is based on the principles of circuit training. It consists of eight sessions over a period of four weeks, during which all participants are encouraged to take up some form of regular exercise outside the hospital. The classes are held in the evenings to promote an informal atmosphere and avoid participants taking time off work. With increasing demands on physiotherapists’ time, it is potentially a n economical way of managing patients, once it has been established. Since the programme was instigated in 1988 it has been received enthusiastically by many patients, and is currently being evaluated in a randomised controlled trial.
Discussion The concept of encouraging exercise for patients with LBP is not a new one. Waddell (1987) stated that the patients’ role must change from a passive recipient of treatment to a more active sharing of responsibility for their own management. There has been a clear trend in recent years towards more intensive forms of rehabilitation. Twomey (1991) a t the World Confederation for Physical Therapy emphasised that the musculoskeletal system responds favourably to the stress of exercise and adversely to disuse at all stages of life, including old age.
Koes et al (1992a) have raised the issue that placebo effects may contribute significantly to the outcome of treatment. Physiotherapists should be aware of this issue and concentrate on maximising the effects while at the same time encourage patients to become more active. There are many health benefits to be gained by
exercising, not only for the spine, but for the whole body. Exercise is necessary for the preservation of optimal function and structure of muscle, bone, joints and the cardiovascular system (Fentem and Bassey, 1988)) and physiotherapists are in an ideal position to promote increasing activity in all age groups. The term fitness, particularly in relation to the spine, is ambiguous and difficult to define physiologically. The most important components are probably muscle strength, anaerobic and aerobic power, endurance and neuromuscular coordination (Asmussen, 1969). Further research needs to be carried out to assess which of these factors are most important in the reduction and prevention of CLBP. Equally important are the psychological processes of disability and inactivity. The physiotherapist’s approach to the problem of chronic back pain may be enhanced by a closer consideration of medical and psychological factors (Flor et al, 1990). Functional restoration programmes are becoming increasingly popular in America. They aim to encompass all aspects of the complex interaction of physical and psychosocial factors affecting patients with LBP disability (Kermond et al, 1991). The success of these programmes relies on a multidisciplinary team approach involving physiotherapists, psychologists, occupational therapists, nurses and medical staff. However, they are expensive and a more economical approach, as described above, may be beneficial. In a randomised controlled trial comparing a simple in-patient rehabilitation programme with the same programme including additional psychological components, Altmaier et al (1992) demonstrated that psychological treatment failed to add to the effectiveness of the rehabilitation. Thus, a simple programme including exercise, support and education, although not specifically designed to influence psychological prccesses, may foster improvements in a less targeted manner.
Conclusion The progressive exercise programme described in this paper was established as a result of clinical observation and published research. The approach encourages patients to be more active and responsible for their own management. However, until it has been evaluated, the evidence for its success is subjective. Recent scientific publications support the implementation of exercise programmes for CLBP sufferers and a multicentre trial comparing manual therapy (carried out by qualified manipulative physiotherapists) and progressive exercise programmes for patients with chronic LBP would be beneficial. Electrotherapy equipment, found in most physiotherapy departments, is expensive and has neither the advantage of manual therapy or exercise. Research evaluating the efficacy of electrotherapy treatment is necessary. Physiotherapists should be prepared to be open-minded and aware that passive treatment, as well as some advice, may for some patients lead to reduced activity and fear of spinal movements. Whatever changes occur in the next decade it seems clear that for physiotherapy to progress as a profession more emphasis should be placed on evaluation of our current practice. The road forward is certainly a challenge but health professionals cannot afford to ignore the problem
Physiotherapy, October 1992, vol78, no 10
754 ~
-
of increasing d i s a b i l i t y caused by LBP a n d continue t o teach a n d practise a t r a d i t i o n a l approach regardless of t h e outcome.
Klaber Moffett, J A, Chase, S M, Portek, I and Ennis, J R (1986). ‘A controlled prospective study to evaluate the effectiveness of a back school in the relief of chronic low back pain’, Spine, 11, 120-122.
Acknowledgments
Klaber Moffett, J A (1989). ‘Exercises for back pain’ in: Roland, M 0 and Jenner J R (eds) Back fain. Rehabilitation and education, University of Manchester Press.
Thanks to the National Back Pain Association and the Oxford Regional Health Authority (Locally Organised Research Scheme) for financial support.
Authors Helen Frost MCSP is a senior research physiotherapist and Jennifer Klaber Moffett MSc MCSP is director of the Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford.
Address for Correspondence Helen Frost MCSP, Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Windmill Road, Headington, Oxford OX3 7LD.
References Allen, D B and Waddell, G (1989). ‘An historical perspective on low back pain and disability’, Acta Orfhopaedica Scandinavica, 60 (SUPPI 234), 1-23. Altmaier, E M, Lehmann, T R, Russell, D W, Weistein, J N and Kao, C F (1992). ‘The effectiveness of psychological interventions for the rehabilitation of low back pain: A randomised controlled trial evaluation’, Pain, 49, 329-335. Asmussen, E (1969). ‘Some physiological aspects of fitness for sport and work’, Proceedings of the Royal Society of Medicine, 62, 1160-63. Belanger, A Y, Despres, M C, Goulet, H and Trottier, F (1991). ‘The McKenzie approach: How many clinical trials support its effectiveness?’ Proceedings of the 11th Congress of the World Confederation for Physical Therapy, 111, 1334-36. Cady, L, Bishop, F D and O’Connel, E (1979). ‘Strength and fitness and subsequent back injuries in fire-fighters’, Journal of Occupational Medicine, 21, 269-272. Council, J R, Ahern, D K, Follick, M J and Kline, C L (1988). ‘Expectancies and functional impairment in chronic low back pain’, Pain, 33, 323-331. Department of Health and Social Security (1989). Report on low back pain, DHSS, London. Fentem, P H and Bassey, E J (1988). The New Case for Exercise, Sports Council and the Health Education Authority, London. Flor, H, Birbaumer, N and Turk, D C (1990). ‘The psychobiology of chronic pain’, Advances in Behavioural Research Therapy, 12, 47-84. Flor, H and Birbaumer, N (1991). ‘Comprehensive assessment and treatment of chronic back pain patients without physical disabilities’, Proceedings of the Vlfh World Congress on Pain, 4229-34. Fordyce, W E (1976). Behavioral Methods for Chronic Pain and Illness, C V Mosby Co, Illinois. Fordyce, W E (1985). ‘The behavioural management of chronic pain: A response to critics’, Pain, 22, 113-125. Harkapaa, J, Arvikoski, A, Mellin, G and Hurri, H (1989). ‘A controlled study on the outcome of in-patient and out-patient treatment of low back pain’, Scandinavian Journal of Rehabilitation Medicine, 21, 81-89. Hazard, R G, Fenwick, J W, Kalisch, S M, Redmond, J, Reeves, V, Reid, S and Frymoyer, J W (1989). ‘Functional restoration with behavioural support. A one-year prospective study of patients with chronic low back pain’, Spine, 14, 157-161. Kermond, W, Gatchel, R J and Mayer, T G (1991). ‘Functional restoration treatment for chronic spinal disorders of failed surgery’ in: Mayer, T G, Mooney, V and Gatchel, R J (eds) Contemporary Conservative Care for Spinal Disorders, Part VII, Lea and Febiger, Philadelphia-London.
Physiotherapy, October 1992, vol78, no 10
Koes, B W, Assendelft, W J J, Van Der Heijden, G J M G and Knipschild, P G (1991a). ‘Spinal manipulation and mobilisation for back and neck pain: A blinded review’, British Medical Journal, 303, 1298-1303. Koes, B W, Boulter, L M, Beckerman, H, Van Der Heijden, G J M G and Knipschild, P G (1991b). ‘Physiotherapy exercise and back pain: A blinded review’, British Medical Journal, 302, 1572-76. Koes, B W, Boulter, L M, Mameren, H V, Essers, A H M, Verstegens, G M J R, Hofhuinzen, D, Houbens, J Pand Knipschild, P G (1992a). ‘The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for non-specific back and neck complaints’, Spine, 17, 28-35. Koes, B W, Boulter, L M, Mameren, H V, Essers, A H M, Verstegens, G M J R, Hofhuinzen, D, Houbens, J P and Knipschild, P G (1992b). ’Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: Results of one-year follow up’, British Medical Journal, 304, 601-605. Kohles, S, Barnes, D, Gatchel, R J and Mayer, T G (1990). ‘Improvement in physical performance outcomes after functional restoration treatment in patients with chronic low back pain. Early versus recent training results’, Spine, 15, 1321-24. Lethem, J, Slade, P D, Troup, J D G and Bentley, G (1983). ’Outline of a fear-avoidance model of exaggerated pain perception’, Behaviour Research and Therapy, 21, 401 - 408. Lindstrom, I, Ohlund, C, Eeek, C, Wallin, L, Peterson, L E, Fordyce, W E and Nachemson, A L (1992). ‘The effect of graded activity on patients with sub-acute low back pain: A randomised prospective clinical study with an operant conditioning behavioural approach’, Physical Therapy, 72, 279-293. Linton, S J (1985). ‘The relationship between activity and chronic back pain’, Pain, 21, 289-294. Linton, S J (1986). ‘Behavioural remediation of chronic pain. A status report’, Pain, 24, 125-214. Linton, S J (1987). ‘Chronic pain: The case for prevention’, Behaviour Research and Therapy, 25, 313 - 317. Mayer, T G, Gatchel, R J, Kishino, N, Keeleym, J, Capra, P, Mayer, H, Barnett, M A and Mooney, V (1985). ‘Objective assessment of spine function following industrial injury. A prospective study with comparison group and one year follow up’, Spine, 10, 482-493. McQuade, K J, Turner, J A and Buchner, D M (1988). ‘Physical fitness and chronic low back pain. An analysis of the relationship among fitness, functional limitation, and depression’, Clinical Orfhopaedics and Related Research, 233, 198-204. McKenzie, R A (1981). The Lumbar Spine: Mechanical diagnosis and therapy, Spinal Publications, Waikanae, New Zealand. Pither, C E and Nicholas, M K (1991). ‘The identificationof iatrophic factors in the development of chronic pain syndromes: Abnormal treatment behaviour’, Proceedings of the Vlfh World Congress on Pain, 429-434. Roberts, A (1991). ‘The conservative treatment of low back pain. A study of McKenzie physiotherapy and slow release ketoprofen’, DM thesis, Queens Medical Centre, University of Nottingham, p 165. Thomas, L K, Hislop, S and Wates, R L (1980). ‘Physiologicalwork performance in chronic low back pain disability. Effects of a progressive activity programme’, Physical Therapy,60,407-411. Evomey, L T, (1991). ‘Musculoskeletal physiotherapy: The age of reason’, Proceedings of the 11th Congress of the World Confederation for Physical Therapy, I , 343-347. Waddell, G (1987). ‘A new clinical model for the treatment of chronic low back pain’, Spine, 12, 632-644.
Physiotherapy Management of Chronic Low Back Pain Helen Frost Jennifer Klaber Moffett Key Words Chronic low back pain, disability, rehabilitation programmes, physiotherapy treatment, exercise. Summary Disability reported as a result of low back pain (LBP) has increased dramatically over the last 20 years. This paper reviews some of the scientific evidence currently available for the treatment of patients with LBP. The advantages of a more active approach to the management of this complex problem are discussed and compared with passive forms of treatment. A rehabilitation programme, developed in Oxford over the last four years for chronic LBP (CLBP) sufferers is described. The need for further research to evaluate the current treatment of CLBP is emphasised.
Introduction The disability caused by low back pain (LBP) has escalated dramatically over the last decade. Time off work due to LBP has increased by 40% in comparison to 5.6% for all other complaints (DHSS, 1989). These figures are of concern to all professionals dealing with the problem, and various theories have been put forward to account for this dramatic increase. Allen and Waddell (1989) pointed out that LBP is not a new phenomenon, but the disability caused by mechanical LBP is a growing problem. They hypothesised that the increase in low back pain disability (LBPD) is a product of modern patterns of work and compensation. As members of a profession who play a major role in the care of these patients, physiotherapists should be addressing this issue and re-assessing current management trends. Traditionally, the aims of assessment are to localise the exact area of pain and ask questions about the site, nature, and severity of that pain. Therapists then proceed with various forms of treatment in which the patient has a passive role, eg mobilisation, manipulation, traction, electrotherapy and heat. Relief of pain is often the primary objective of treatment and this is usually considered before relating to functional activities. However, this may not always be the most effective and appropriate approach, especially for patients who have long-standing chronic pain.
Physiotherapy Treatment Over the last two years a research team in Maastricht has reviewed and studied the effects of manipulative therapy, exercise therapy and physiotherapy for LBP patients. Koes et aZ (1991a) reviewed 35 randomised controlled trials comparing spinal manipulative techniques with other forms of therapy. The objective of
SCHOLARLY PAPER
t h e study was to assess t h e efficacy of spinal manipulatiodmobilisation for patients with back and neck problems. The papers assessed included treatment given by physiotherapists, osteopaths and chiropractors. Each paper was scored for quality of the methodology and authors’ conclusions. Koes et aZ(1991a) concluded that the efficacy of manipulation for patients with back and neck pain has not been convincingly demonstrated in the literature they reviewed. They then carried out a similar ‘meta analysis’ on 16 papers using randomised controlled trials to study the effect of specific exercise regimes on patients with LBP. Once again, overall, the standard of these papers was considered by Koes et aZ(1991b) to be poor. They noted that the studies demonstrating a positive effect of exercise were scored higher methodologically than the studies which demonstrated negative results. This conclusion was contrary to the meta analysis carried out on the manipulative therapy studies. In this case, most of the studies that rated highly on methodology reported negative results of treatment. Subsequently Koes et aZ(1992a) themselves carried out a randomised controlled trial to compare the effectiveness of GP management, manual therapy, other forms of physiotherapy (electrotherapy, massage, heat and exercise) and physiotherapy placebo (detuned short-wave or ultrasound) for patients with back and neck complaints. They attempted to avoid many of the methodological flaws that they had previously referred to in other clinical trials (Koes et aZ1991a, 1991b).Their results indicated a more favourable outcome for patients treated by manual therapists and physiotherapists compared with GP management. However, there was no difference between the physiotherapy groups (including placebo treatment) and the manual therapy group at the short-term follow up. The authors concluded from the short-term follow up that a substantial component of the effect of referral for physiotherapy or manual therapy could be explained by placebo effects. It is difficult to reach any firm conclusions regarding the effectiveness of exercise in the physiotherapy group as many different forms of physiotherapy were included, the exercise was not specified and there was no exercise only group for comparison. The authors followed up patients for 12 months (Koes et aZ, 1992b). At that stage, they were unable to analyse results from the placebo and GP group as many of the patients had changed treatment groups. The authors concluded that beneficial results were gained from both the physiotherapy and manipulative therapy groups. The latter was slightly better than the physiotherapy group a t 12 months follow-up.
Psychological Factors An alternative approach to the treatment of chronic low back pain (CLBP) has been described by Fordyce (1976, 1985) and aims to treat excess disability. Over the past 20 years research has shown this approach to be effective
Physiotherapy, October 1992, vol78, no 10
752
and especially useful for the management of chronic back pain (Linton, 1985, 1986, 1987; Lindstrom et al, 1992). Health professionals need to be aware that both the setting and the interaction between therapist and patient may focus attention on the pain, and consequently encourage protective behaviour in some patients. The end result may even be a reduction in normal function. Contact with a therapist may, unless the active component of treatment is emphasised and the patient is given a feeling of control over their problem, encourage the patient to rely heavily on the medical profession. Recent studies support the view that the medical management of more dysfunctional patients with chronic pain may often be inappropriate and may ultimately contribute to their morbidity and distress (Pither and Nicholas, 1991; Linton, 1987). In this respect assessment concentrating on pain followed by passive treatment, eg electrotherapy, may not always be appropriate. In many patients with CLBP, excessive protection of the spine is caused by a n exaggerated fear of pain inducing a deconditioning syndrome (Lethem et al, 1983; Mayer et al, 1985, Flor et al, 1990). The expectation that some activities may cause pain can lead to avoidance of those activities and anything associated with them. This has important practical implications for therapists assessing a patient’s pain and range of movement. Individual beliefs about the capacity to move and be physically active are important aspects of back pain rehabilitation. A recognition of psychological processes that influence the outcome of treatment are important in the acute stage as well as the chronic stage in order to prevent development of CLBP disability (Council et al, 1988).
Exercise and Low Back Pain There have been very few well controlled randomised clinical trials comparing different types of exercise for LBP. Belanger et al (1991) reviewed and analysed the scientific publications that support the clinical effectiveness of the McKenzie approach (McKenzie,1981). They concluded that the world-wide popularity of this treatment among physiotherapists is not related to scientifically obtained evidence. However, the advantage of the McKenzie approach is that it advocates actively involving patients in their own management. It recognises the fact that contact time with a therapist will very rarely gain maximum benefit unless self-treatment is encouraged and continued a t home. The mobilising exercises are passive in the sense that they do not use the back muscles, but they do require an active commitment from the patients. Roberts (1991)carried out a randomised controlled trial, including patients with acute LBP, comparing the McKenzie approach with non-steroidal anti-inflammatory drugs. The results demonstrated significantly reduced disability, a t seven weeks following initial pain onset, in the group of patients treated with McKenzie techniques. The difference between the groups was not significant at six months or one year and the benefits may not have been seen in patients with CLBP. Koes et a1 (1991b) concluded that it was uncertain whether execise therapy is better than other conservative treatments for LBF? Evidence to support the effectiveness of any specific type of exercise regime was inconclusive,
as suggested by an earlier review of this literature by Klaber Moffett (1989). These conclusions, although somewhat disappointing, should not deter us from striving to improve our techniques and evaluative methods. The main problem with conducting randomised controlled trials of exercise therapy for LBP is the subject variation within the treatment groups. Due to the difficulty of diagnosis, the inclusion criteria are usually non specific and patient selection relies on exclusion of major pathology. This often results in different types of back problems being treated with the same exercises which may be suitable for one condition but not for another.
Supporting Evidence for Rehabilitation Programmes Another area of research literature suggests a role for the use of exercise programmes aiming to improve function and general fitness. This approach to CLBP has been investigated and encouraged, particularly in America and Scandinavian countries (Mayer et al, 1985; Lindstrom, 1992). Cady et a1 (1979), in a frequently cited study, demonstrated a significant protective effect of high levels of physical fitness in a study of 1,652 fire-fighters and found that an increase in cardiovascular fitness, even without a significant increase in strength and flexibility, was accompanied by a 25%reduction in the cost of workers’ compensation. This evidence encouraged researchers to investigate the effectiveness of exercise, aiming to improve general function, in patients with CLPB. Mayer et a1 (1985) included 104 patients with CLBP in a prospective study to evaluate a programme including exercise, psychological intervention, educatiod, functional tasks and work hardening exercises. They found that return to work was related to increase in muscle strength, range of motion and functional capacity. In a five-year follow-up of this programme Kohles et aZ (1990) concluded that the more vigorous and intensive exercise programme demonstrated beneficial effects. Their results indicated that their functional restoration treatment approach was effective and helped to return deconditioned patients with CLBP to improved levels of physical performance. Lindstrom et aZ(1992)carried out a randomised controlled trial to investigate the effect of graded activity on patients with sub-acute LBP, in which 103 industrial workers with sub-acute LBP were randomly assigned to either a control group (which included care from their regular physician only) or an activity group. The activity group included back school education, work-place visits, an individual, sub-maximal, gradually increased exercise programme and measurements of functional capacity. The main outcome measures in this study were the rate of return to work and the amount of sick leave during the second follow up year. The graded activity programme significantly reduced long-term sick leave and returned the patients to work, on average, 5.1 weeks earlier than the control group. The authors concluded that the patients in the activity programme learnt that it is safe to move while , function. regaining Other studies support the beneficial effects of exercise programmes for patients with CLBP (Harkapaa et cd,
~~
Physiotherapy, October 1992, vol78, no 10
753
1989; Hazard et al, 1989; Thomas et al, 1980; McQuade et al, 1988). The literature suggests that the benefits of increased activity are due to a combination of both physiological and psychological factors.
The Oxford Rehabilitation Programme In response to some of these research findings a rehabilitation programme was established in 1988 at the Nuffield Orthopaedic Centre, Oxford. Even if exercise such as walking or swimming is encouraged, patients who have suffered long periods of inactivity are often fearful of increasing their activity levels. In addition, some patients try too hard and need to learn to pace themselves, while gradually increasing their activities (Flor and Birbaumer, 1991). The programme aims to motivate patients to take up regular exercise, increase their confidence in their ability to carry out normal activities of daily living regardless of their back pain, and help them to take control of their own back problem. It is offered as an adjunct to the back school which has been evaluated and updated since it was first established in 1980 (Klaber Moffett et al, 1986). The patients are assessed individually in the physiotherapy department and given specific exercises for their particular problem before they start the programme. Consent is obtained from the patients’ general practitioners declaring them medically fit to take part. The programme includes functional activities, general aerobic, mobilising and stretching exercises, and is based on the principles of circuit training. It consists of eight sessions over a period of four weeks, during which all participants are encouraged to take up some form of regular exercise outside the hospital. The classes are held in the evenings to promote an informal atmosphere and avoid participants taking time off work. With increasing demands on physiotherapists’ time, it is potentially a n economical way of managing patients, once it has been established. Since the programme was instigated in 1988 it has been received enthusiastically by many patients, and is currently being evaluated in a randomised controlled trial.
Discussion The concept of encouraging exercise for patients with LBP is not a new one. Waddell (1987) stated that the patients’ role must change from a passive recipient of treatment to a more active sharing of responsibility for their own management. There has been a clear trend in recent years towards more intensive forms of rehabilitation. Twomey (1991) a t the World Confederation for Physical Therapy emphasised that the musculoskeletal system responds favourably to the stress of exercise and adversely to disuse at all stages of life, including old age.
Koes et al (1992a) have raised the issue that placebo effects may contribute significantly to the outcome of treatment. Physiotherapists should be aware of this issue and concentrate on maximising the effects while at the same time encourage patients to become more active. There are many health benefits to be gained by
exercising, not only for the spine, but for the whole body. Exercise is necessary for the preservation of optimal function and structure of muscle, bone, joints and the cardiovascular system (Fentem and Bassey, 1988)) and physiotherapists are in an ideal position to promote increasing activity in all age groups. The term fitness, particularly in relation to the spine, is ambiguous and difficult to define physiologically. The most important components are probably muscle strength, anaerobic and aerobic power, endurance and neuromuscular coordination (Asmussen, 1969). Further research needs to be carried out to assess which of these factors are most important in the reduction and prevention of CLBP. Equally important are the psychological processes of disability and inactivity. The physiotherapist’s approach to the problem of chronic back pain may be enhanced by a closer consideration of medical and psychological factors (Flor et al, 1990). Functional restoration programmes are becoming increasingly popular in America. They aim to encompass all aspects of the complex interaction of physical and psychosocial factors affecting patients with LBP disability (Kermond et al, 1991). The success of these programmes relies on a multidisciplinary team approach involving physiotherapists, psychologists, occupational therapists, nurses and medical staff. However, they are expensive and a more economical approach, as described above, may be beneficial. In a randomised controlled trial comparing a simple in-patient rehabilitation programme with the same programme including additional psychological components, Altmaier et al (1992) demonstrated that psychological treatment failed to add to the effectiveness of the rehabilitation. Thus, a simple programme including exercise, support and education, although not specifically designed to influence psychological prccesses, may foster improvements in a less targeted manner.
Conclusion The progressive exercise programme described in this paper was established as a result of clinical observation and published research. The approach encourages patients to be more active and responsible for their own management. However, until it has been evaluated, the evidence for its success is subjective. Recent scientific publications support the implementation of exercise programmes for CLBP sufferers and a multicentre trial comparing manual therapy (carried out by qualified manipulative physiotherapists) and progressive exercise programmes for patients with chronic LBP would be beneficial. Electrotherapy equipment, found in most physiotherapy departments, is expensive and has neither the advantage of manual therapy or exercise. Research evaluating the efficacy of electrotherapy treatment is necessary. Physiotherapists should be prepared to be open-minded and aware that passive treatment, as well as some advice, may for some patients lead to reduced activity and fear of spinal movements. Whatever changes occur in the next decade it seems clear that for physiotherapy to progress as a profession more emphasis should be placed on evaluation of our current practice. The road forward is certainly a challenge but health professionals cannot afford to ignore the problem
Physiotherapy, October 1992, vol78, no 10
754 ~
-
of increasing d i s a b i l i t y caused by LBP a n d continue t o teach a n d practise a t r a d i t i o n a l approach regardless of t h e outcome.
Klaber Moffett, J A, Chase, S M, Portek, I and Ennis, J R (1986). ‘A controlled prospective study to evaluate the effectiveness of a back school in the relief of chronic low back pain’, Spine, 11, 120-122.
Acknowledgments
Klaber Moffett, J A (1989). ‘Exercises for back pain’ in: Roland, M 0 and Jenner J R (eds) Back fain. Rehabilitation and education, University of Manchester Press.
Thanks to the National Back Pain Association and the Oxford Regional Health Authority (Locally Organised Research Scheme) for financial support.
Authors Helen Frost MCSP is a senior research physiotherapist and Jennifer Klaber Moffett MSc MCSP is director of the Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford.
Address for Correspondence Helen Frost MCSP, Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Windmill Road, Headington, Oxford OX3 7LD.
References Allen, D B and Waddell, G (1989). ‘An historical perspective on low back pain and disability’, Acta Orfhopaedica Scandinavica, 60 (SUPPI 234), 1-23. Altmaier, E M, Lehmann, T R, Russell, D W, Weistein, J N and Kao, C F (1992). ‘The effectiveness of psychological interventions for the rehabilitation of low back pain: A randomised controlled trial evaluation’, Pain, 49, 329-335. Asmussen, E (1969). ‘Some physiological aspects of fitness for sport and work’, Proceedings of the Royal Society of Medicine, 62, 1160-63. Belanger, A Y, Despres, M C, Goulet, H and Trottier, F (1991). ‘The McKenzie approach: How many clinical trials support its effectiveness?’ Proceedings of the 11th Congress of the World Confederation for Physical Therapy, 111, 1334-36. Cady, L, Bishop, F D and O’Connel, E (1979). ‘Strength and fitness and subsequent back injuries in fire-fighters’, Journal of Occupational Medicine, 21, 269-272. Council, J R, Ahern, D K, Follick, M J and Kline, C L (1988). ‘Expectancies and functional impairment in chronic low back pain’, Pain, 33, 323-331. Department of Health and Social Security (1989). Report on low back pain, DHSS, London. Fentem, P H and Bassey, E J (1988). The New Case for Exercise, Sports Council and the Health Education Authority, London. Flor, H, Birbaumer, N and Turk, D C (1990). ‘The psychobiology of chronic pain’, Advances in Behavioural Research Therapy, 12, 47-84. Flor, H and Birbaumer, N (1991). ‘Comprehensive assessment and treatment of chronic back pain patients without physical disabilities’, Proceedings of the Vlfh World Congress on Pain, 4229-34. Fordyce, W E (1976). Behavioral Methods for Chronic Pain and Illness, C V Mosby Co, Illinois. Fordyce, W E (1985). ‘The behavioural management of chronic pain: A response to critics’, Pain, 22, 113-125. Harkapaa, J, Arvikoski, A, Mellin, G and Hurri, H (1989). ‘A controlled study on the outcome of in-patient and out-patient treatment of low back pain’, Scandinavian Journal of Rehabilitation Medicine, 21, 81-89. Hazard, R G, Fenwick, J W, Kalisch, S M, Redmond, J, Reeves, V, Reid, S and Frymoyer, J W (1989). ‘Functional restoration with behavioural support. A one-year prospective study of patients with chronic low back pain’, Spine, 14, 157-161. Kermond, W, Gatchel, R J and Mayer, T G (1991). ‘Functional restoration treatment for chronic spinal disorders of failed surgery’ in: Mayer, T G, Mooney, V and Gatchel, R J (eds) Contemporary Conservative Care for Spinal Disorders, Part VII, Lea and Febiger, Philadelphia-London.
Physiotherapy, October 1992, vol78, no 10
Koes, B W, Assendelft, W J J, Van Der Heijden, G J M G and Knipschild, P G (1991a). ‘Spinal manipulation and mobilisation for back and neck pain: A blinded review’, British Medical Journal, 303, 1298-1303. Koes, B W, Boulter, L M, Beckerman, H, Van Der Heijden, G J M G and Knipschild, P G (1991b). ‘Physiotherapy exercise and back pain: A blinded review’, British Medical Journal, 302, 1572-76. Koes, B W, Boulter, L M, Mameren, H V, Essers, A H M, Verstegens, G M J R, Hofhuinzen, D, Houbens, J Pand Knipschild, P G (1992a). ‘The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for non-specific back and neck complaints’, Spine, 17, 28-35. Koes, B W, Boulter, L M, Mameren, H V, Essers, A H M, Verstegens, G M J R, Hofhuinzen, D, Houbens, J P and Knipschild, P G (1992b). ’Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: Results of one-year follow up’, British Medical Journal, 304, 601-605. Kohles, S, Barnes, D, Gatchel, R J and Mayer, T G (1990). ‘Improvement in physical performance outcomes after functional restoration treatment in patients with chronic low back pain. Early versus recent training results’, Spine, 15, 1321-24. Lethem, J, Slade, P D, Troup, J D G and Bentley, G (1983). ’Outline of a fear-avoidance model of exaggerated pain perception’, Behaviour Research and Therapy, 21, 401 - 408. Lindstrom, I, Ohlund, C, Eeek, C, Wallin, L, Peterson, L E, Fordyce, W E and Nachemson, A L (1992). ‘The effect of graded activity on patients with sub-acute low back pain: A randomised prospective clinical study with an operant conditioning behavioural approach’, Physical Therapy, 72, 279-293. Linton, S J (1985). ‘The relationship between activity and chronic back pain’, Pain, 21, 289-294. Linton, S J (1986). ‘Behavioural remediation of chronic pain. A status report’, Pain, 24, 125-214. Linton, S J (1987). ‘Chronic pain: The case for prevention’, Behaviour Research and Therapy, 25, 313 - 317. Mayer, T G, Gatchel, R J, Kishino, N, Keeleym, J, Capra, P, Mayer, H, Barnett, M A and Mooney, V (1985). ‘Objective assessment of spine function following industrial injury. A prospective study with comparison group and one year follow up’, Spine, 10, 482-493. McQuade, K J, Turner, J A and Buchner, D M (1988). ‘Physical fitness and chronic low back pain. An analysis of the relationship among fitness, functional limitation, and depression’, Clinical Orfhopaedics and Related Research, 233, 198-204. McKenzie, R A (1981). The Lumbar Spine: Mechanical diagnosis and therapy, Spinal Publications, Waikanae, New Zealand. Pither, C E and Nicholas, M K (1991). ‘The identificationof iatrophic factors in the development of chronic pain syndromes: Abnormal treatment behaviour’, Proceedings of the Vlfh World Congress on Pain, 429-434. Roberts, A (1991). ‘The conservative treatment of low back pain. A study of McKenzie physiotherapy and slow release ketoprofen’, DM thesis, Queens Medical Centre, University of Nottingham, p 165. Thomas, L K, Hislop, S and Wates, R L (1980). ‘Physiologicalwork performance in chronic low back pain disability. Effects of a progressive activity programme’, Physical Therapy,60,407-411. Evomey, L T, (1991). ‘Musculoskeletal physiotherapy: The age of reason’, Proceedings of the 11th Congress of the World Confederation for Physical Therapy, I , 343-347. Waddell, G (1987). ‘A new clinical model for the treatment of chronic low back pain’, Spine, 12, 632-644.