Early physical therapy versus standard care for patients with low back pain

Study Type: Therapy
OE Level of Evidence: 2
Journal Level of Evidence: N/A
Dr. Julie Fritz discusses the efficacy of early physical therapy for patients with low back pain.
220 patients with low back pain for less than 16 days were randomly assigned to receive either early physical therapy (EPT) or usual care for the management of their low back pain. The purpose of this study was to determine whether early physical therapy consisting of exercise and manipulation was advantageous over usual care in improving disability, measured via Oswestry Disability Index (ODI) scores. Significantly greater improvement Please login to view the rest of this report. Please login to view the rest of this report.
Funding: Non-Industry funded
Sponsor: Agency for Healthcare Research and Quality and the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health
Conflicts: Royalties
Why was this study needed now?
Low back pain is a frequent condition that affects approximately 70% of adults at least once in their lifetime. Treatment of low back pain is costly, and patient outcomes continuously fail to show improvement. Current guidelines recommend delaying the referral of patients to physical therapy; however, prior research has found a distinct subgroup of patients that display marked improvement in response to exercise and manipulation, suggesting that early physical therapy may be beneficial. This study aimed to compare early physical therapy to usual care in terms of their ability to improve disability in patients with low back pain, in order to establish a reliable treatment protocol.
What was the principal research question?
Does early physical therapy, consisting of exercise and manipulation, more effectively improve disability in patients with low back pain, when compared to those who received usual care up to 1 year following initiation of treatment?
Population: 220 patients, aged 18-60, with low back pain were selected for inclusion. Patients were required to present with an Oswestry Disability Index score of 20 or greater, no pain/numbness distal to the knee within the past 72 hours, and a symptom duration of fewer than 16 days. Individuals who had previously undergone lumbar surgery or lower back pain treatment with 6 months prior to study enrollment were excluded. (207 completed).
Intervention: Early physical therapy (EPT) group: Patients received early physical therapy for the management of lower back pain. Patients received 4 treatment sessions within 3 weeks. Two sessions consisted of spinal manipulation and spinal range-of-motion (ROM) exercise training. The remaining 2 sessions consisted of exercise review and progression. Spinal manipulation was performed by a trained physiotherapist in a supine position by bending and rotating the patients’ spine while providing high-velocity, low-amplitude thrusts to the pelvis. Patients were instructed to perform ROM exercises 3-4 times a day in repetitions of 10. (n=108, 104 completed, Mean age=38.3 +/- 10.4, 62F/46M).
Comparison: Usual care group: Patients received usual care for the management of lower back pain. Patients were educated on the favourable prognosis of lower back pain and were provided with a copy of "The Back Book", which consisted of messages in alignment with lower back pain guidelines. Additionally, patients were advised to remain as active as possible. (n=112, 103 completed, Mean age= 36.5 +/- 10.2, 53F/59M).
Outcomes: The primary outcome measure was disability, measured via changes in Oswestery Disability Index (ODI) scores from baseline to 3 months. Secondary outcomes of interest included changes in ODI scores from baseline to 4-weeks and 1-year, changes in pain severity, measured via a Numeric Pain Rating (NRS) scale, Pain Catastrophizing Scale (PCS) score, work and physical activity, measured via the fear-avoidance beliefs questionnaire (FABQ), quality of life (EQ-5D questionnaire), patient-reported success, measured via a global rating of change questionnaire, and health care utilization at all time-points. Incidence of adverse events was also recorded.
Methods: RCT: prospective, assessor-blinded
Time: 1 year (assessments were made at baseline, 4 weeks, 3 months and 1 year after initiation of therapy)
What were the important findings?
What should I remember most?
How will this affect the care of my patients?
The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.