by Peter Ward MCSP Senior Physiotherapist, Tameside General Hospital, Ashton under Lyne
No Easy Answer to Back Pain Physiotherapists should abandon out-dated and unproven approaches to treating low back pain, and adopt the methods which have been shown to be most effective.
The overall message of the leading article by Mark Pinnington in the February 2001 issue of Physiotherapy needs to be heard, particularly with regard to treatments of proven ineffectiveness. My reaction to certain aspects of the article is – it’s not that simple. For example, McKenzie therapy is mentioned and it is implied that its effectiveness has not been proven conclusively. This is probably right. However, the Royal College of General Practitioners (RCGP) Guidelines on Acute Low Back Pain (LBP) classify McKenzie therapy under ‘exercises’ and state: ‘On the evidence available at present, it is doubtful that specific back exercises produce significant improvement in acute LBP.’
Further: ‘McKenzie exercises may produce some short-term symptomatic improvement in acute LBP.’
The RCGP’s conclusions on exercise therapy are based on reviews of a number of randomised controlled trials (RCTs) undertaken by Faas et al (1996), Lewis (1995) and others. Four RCTs mentioning McKenzie were included. Three of these trials compared the effect of extension exercises with other interventions. However, it should be noted that the McKenzie method does not comprise just extension exercises. The McKenzie method involves tailoring exercises to individual patients, changing the exercises in response to changes in the patients’ symptoms and adding extra force by means of mobilisation and manipulation if necessary. The only trial in the RCGP’s evidence base which appears to have evaluated the actual McKenzie method was that by Stankovic and Johnell (1990) which compared the McKenzie method with ‘mini back school’. The McKenzie method was shown to be significantly superior at three months, one year and five years. This study is not without its deficiencies, however, and more research is certainly needed. The inconsistency regarding what is deemed to be an acceptable trial for inclusion in the RCGP guidelines is also a cause for concern. For example, Physiotherapy April 2001/vol 87/no 4
the results of the Stankovic study are virtually disregarded due to what is described as poor methodology, citing poor sample size (there were 89 patients in the study), and the lack of placebo. However, a study by Erhard et al (1994) comparing manipulation plus ‘flexion-extension exercises’ with extension exercises is included as one of only three among 99 meeting the selection criteria. This trial started with only 24 patients and there was a 50% drop-out at one month. It also had no placebo group. Pinnington expresses surprise that few physiotherapists use manipulation as a first line of treatment, and implies that it is a change in our practice that we ought to embrace. So what does the evidence actually say? The RCGP guidelines suggest that the evidence in favour of manipulation is reasonably clear. Nevertheless, if one looks at the evidence behind the guidelines, a different picture emerges. The RCGP guidelines’ evidence on manipulation is based largely on a meta-analysis by Koes et al (1996) plus two additional studies. One of these is the study by Erhard whose shortcomings I have already mentioned. The other is a study by Pope et al (1994) which compared manipulation with TENS, massage and a corset. The authors conclude: ‘None of the changes in outcome measures … were significantly different between any of the groups.’
The Koes meta-analysis evaluated 36 RCTs on manipulation. Its main conclusion reads: ‘The efficacy of spinal manipulation for patients with acute or chronic LBP has not been demonstrated with sound randomised, controlled trials.’
It also says: ‘We could not find conclusive evidence in favour of manipulation in patients with acute LBP.’
And, referring to the CSAG report: ‘This finding may be somewhat surprising given the clinical guidelines for the management of acute LBP in the United Kingdom.’
Indeed! After reading the evidence one wonders whose interests are being served in recommending manipulation so strongly for acute LBP, particularly since current thinking on the management of LBP clearly advocates empowering the patient. This will be more difficult to achieve if manipulative therapy, reinforcing the idea of a quick fix, has been used as a first-line approach to management. In choosing not to use manipulation as a firstchoice treatment for LBP, I am not ignoring the evidence. I am weighing the inconclusive evidence regarding manipulation and the drawbacks of creating therapist dependency against the very clear and well documented benefits of treating patients in a way which gives them control of the problem. The RCGP Guidelines are a very useful contribution to the literature on LBP. However, they are not rigid protocols written on tablets of stone. We are right to question them. How was the evidence interpreted? What were the inclusion/exclusion criteria? If the conclusions are not justified in terms of the evidence, as thinking professionals, we are right to challenge them. Pinnington also points out that the Foster survey shows that McKenzie is one of the most popular approaches to managing LBP. He also states that few therapists use active rehabilitation based on a psychosocial model. Although McKenzie therapy is still my first line of treatment for acute LBP, there have been significant changes in the way I use this approach. These changes have been brought about by the very evidence that Pinnington describes. (The work of the Physiotherapy Pain Association has been a major influence.) For example: ■ I include psychosocial factors in my assessment. ■ I use non-threatening explanations of pain to reduce fear of activity. ■ I advocate the restoration of normal activity and function in conjunction with specific therapy. ■ Rather than ‘prescribing’ exercises I agree with the patients what would be appropriate for them.
Since the McKenzie concept advocates selfmanagement it is a simple step to combine this approach with active rehabilitation based on the biopsychosocial model. This is an example of how treatment concepts can be adapted in response to the evidence rather than changed outright. I cannot say how widespread these changes are on an individual level, but many of these concepts are now being embraced in the way McKenzie therapy is being taught. These important changes may not always show through in the type of survey which Pinnington mentions. I agree that we do need to reflect constantly on the way we work, and to make changes in the face of compelling evidence. However, the driver for change should always be sound evidence, and logical consistent interpretation of that evidence.
References Erhard et al (1994). ‘Relative effectiveness of an extension programme and a combined programme of manipulation and flexion and extension exercises in patients with acute low back syndrome’, Physical Therapy, 74, 12, 1093-1100. Faas et al (1996). ‘Exercises: Which ones are worth trying, for which patients and when?’ Spine, 21, 24, 2874-79. Koes et al (1996). ‘Spinal manipulation for low back pain: An updated systematic review of randomised clinical trials’, Spine, 21, 24, 2864-71. Lewis, M (1995). ‘Medline reviews of RCTs on exercise and manipulation’, available from RCGP. Pinnington, M A (2001). ‘Why are we finding it so hard to change our approach to low back pain?’ Physiotherapy, 87, 2, 58-59. Pope et al (1994). ‘A prospective, randomised three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain’, Spine, 19, 22, 2571-77. Royal College of General Practitioners (1996). Clinical Guidelines for the Management of Acute Low Back Pain, RCGP, London. Stankovic and Johnell (1990). ‘Conservative treatment of acute low back pain: A prospective randomised trial: McKenzie method of treatment versus patient education in mini-back school’, Spine, 15, 2, 120-123.
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