Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up

Abstract

Objective: To compare spinal manipulation, back school and individual physiotherapy in the treatment of chronic low back pain.

Design: Randomized trial, 12-month follow-up.

Setting: Outpatient rehabilitation department.

Participants: 210 patients with chronic, non-specific low back pain, 140/210 women, age 59 ± 14 years.

Interventions: Back school and individual physiotherapy scheduled 15 1-hour-sessions for 3 weeks. Back school included: group exercise, education/ ergonomics; individual physiotherapy: exercise, passive mobilization and soft-tissue treatment. Spinal manipulation, given according to Manual Medicine, scheduled 4 to 6 20’-sessions once-a-week.

Outcome: Roland Morris Disability Questionnaire (scoring 0-24) and Pain Rating Scale (scoring 0-6) were assessed at baseline, discharge 3, 6, and 12 months.

Results: 205 patients completed the study. At discharge, disability score decreased by 3.7 ± 4.1 for back school, 4.4 ± 3.7 for individual physiotherapy, 6.7 ± 3.9 for manipulation; pain score reduction was 0.9 ± 1.1, 1.1 ± 1.0, 1.0 ± 1.1, respectively. At 12 months, disability score reduction was 4.2 ± 4.8 for back school, 4.0 ± 5.1 for individual physiotherapy, 5.9 ± 4.6 for manipulation; pain score reduction was 0.7 ± 1.2, 0.4 ± 1.3, and 1.5 ± 1.1, respectively. Spinal manipulation was associated with higher functional improvement and long-term pain relief than back school or individual physiotherapy, but received more further treatment at follow-ups (P<0.001); pain recurrences and drug intake were also reduced compared to back school (P <0.05) or individual physiotherapy (P <0.001).

Conclusions: Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

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References

van Tulder MW , Koes B. , Malmivaara A. Outcome of non-invasive treatment modalities on back pain: an evidence-based review. Eur Spine J 2006; 15(suppl 1): S64-81.

Hayden JA , van Tulder MW , Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med 2005 ; 142: 776-85.

Zachrisson-Forsell M. The Swedish back school. Physiotherapy 1980; 66: 112-14.

Heymans MW , van Tulder MW , Esmail R. , Bombardier C. , Koes BW Back schools for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2005; 30: 2153-63.

Kaapa EH , Frantsi K. , Sarna S. , Malmivaara A. Multidisciplinary group rehabilitation versus individual physiotherapy for chronic nonspecific low back pain: a randomized trial. Spine 2006; 31: 371-76.

Waddel G. A new clinical model for the treatment of low back pain. Spine 1987; 12: 632.

Andersson GBJ , Lucente T. , Davis AM et al. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl Med J 1999; 341: 1426-31.

Niemisto L. , Lahtinen-Suopanki T. , Rissanen P. , Lindgren KA , Sarna S. , Hurri H. A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain. Spine 2003; 28: 2185-91.

Ferreira ML , Ferreira PH , Latimer J. , Herbert R. , Maher CG

Does spinal manipulative therapy help people with chronic low back pain?

Aust J Physiother 2002; 48: 277-84.

10.

Assendelft WJ , Morton SC , Yu EI , Suttorp MJ , Shekelle PG Spinal manipulative therapy for low back pain . Cochrane Database Syst Rev 2004; (1): CD000447.

11.

Harvey E. , Burton AK , Moffett JK , Breen A. , UK BEAM Trial Team. Spinal manipulation for low back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations. Man Ther 2003; 8: 46-51.

12.

Maigne R. Diagnosis and treatment of pain of vertebral origin. A manual medicine approach . Baltimore, Williams & Wilkins , 1996: 339-40.

13.

Maigne JY , Chatellier G. , Faou ML , Archambeau M. The treatment of chronic coccigodynia with intrarectal manipulation: a randomized controlled study. Spine 2006; 31: E621-27.

14.

Cecchi F. , Debolini PL , Molino Lova R. et al. Epidemiology of back pain in a representative cohort of Italian persons aged 65 and older: The InCHIANTI Study. Spine 2006; 31: 1149-55.

15.

Dufur M. Massage. Encycl Med Chir (Paris ) 1998: 25-100-A10: 32 p.

16.

Viel E. le méthode de Kabat, sa specificité en reéducation orthopédique . In La Reprogrammation Neuromotrice Paris , Masson, 1994: 27.

17.

Roland M. , Morris R. A study of the natural history of back pain. I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983; 8: 141-44.

18.

UK BEAM Trial Team. United Kingdom back pain exercise and manipulation randomized trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 2004; 329: 101-136.

19.

Hestbaek L. , Leboeuf-Yde C. , Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 2003; 12: 149-65.

20.

StataCorp. 2001. Stata Statistical Software: Release 7.0. College Station, TX, USA: Stata Corporation. Vol. 4, p. 273-90..

21.

Van der Hulst M. , Vollenbroek-Hutten MM , Ijzerman MJ A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation-or, back school treatment outcome in patients with chronic low back pain. Spine 2005; 30: 813-25.

22.

Kool J. , Bachmann S. , Oesh P. , Knusel O. , Ambergen T. , de Bie R. , van der Brandt P. Function-centered rehabilitation increases work days in patients with nonacute nonspecific low back pain: 1-year results from a randomized controlled trial . Arch Phys Med Rehabil 2007; 88: 1089-94.

23.

Friedrich M. , Gittler G. , Arendasy M. , Friedrich KM Long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain. Spine 2005; 30: 995-1000.

24.

Tuscan Region Resolution 595/30-05-05, COD2005DG00000000661. Accessed 19 September 2008, from www.regione.toscana.it.

25.

Chou R. , Huffman LH American Pain Society; American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007; 147: 492-504.

26.

Von Korff M. , Saunders K. The course of back pain in primary care. Spine 1996; 21: 2833-39.

27.

Bouter LM , van Tulder MW , Koes BW Methodologic issues in low back pain research in primary care. Spine 1998; 23: 2014-20.

28.

Hayden JA , van Tulder MW , Malmivaara A. , Koes BW Exercise therapy for treatment of nonspecific low back pain. Cochrane Database Syst Rev 2005; (3): CD000335.

29.

Von Korff M. Studying the natural history of back pain . Spine 1994; 19: 2041S-6S.

30.

Cleland JA , Fritz JM , Childs JD , Kulig K. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: study protocol of a randomized clinical trial. BMC Musculoskelet Disord 2006; 7: 11-29.

31.

Vollenbroek-Hutten MM , Hermens HJ , Wever D. , Gorter M. , Rinket J. , Ijzerman MJ Differences in outcome of a multidisciplinary treatment between subgroups of chronic low back pain patients defined using two multiaxial assessment instruments: the multidimensional pain inventory and lumbar dynamometry. Clin Rehabil 2004; 18: 566-79.