Low back pain longer than 6 weeks? Try physiotherapy functional restoration rather than advice

Have you ever had low back pain lasting longer than 6 weeks? I know a few elves who have. Did you know it is estimated that 28% of people will experience disabling low back pain (LBP) sometime during their lives and that 80% to 90% of attacks of low back pain resolve in about 6 weeks? The effectiveness of multidisciplinary treatment for LBP has been established.

Chronic back pain can result in; heightened anxiety, stress and depression and the fear of pain and bad posture.

Functional Restoration is a common form of treatment for LBP in the United States, Australia and more recently Europe. It includes a cognitive-behavioural component that explores thoughts, images, beliefs and attitudes and identifies potential barriers to recovery that have long been recognised as playing an important role in chronic back pain typically; heightened anxiety, increased body awareness, stress and depression and the fear of pain and subsequent avoidance, causing bad posture. A recent systematic review by authors from Australia, and published in Manual Therapy, sought to evaluate the effectiveness of physiotherapy functional restoration (PFR) for this condition.

Here’s what they did

They undertook a literature search of a wide variety of databases, search strategy provided, conducted up until 31 December 2011 and did not have any language restrictions. Detailed eligibility criteria were provided, the physiotherapy treatment included combining exercise and cognitive-behavioural interventions and was compared with other interventions, no intervention or placebo. Two authors independently extracted data.
Risk of bias was assessed using the PEDro scale and overall quality of the body of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Sixteen randomised controlled trials trials were included and outcomes of interest included pain, function and sick leave.

Here’s what they found

versus advice there was moderate to high quality evidence of significant but small effects favouring PFR for intermediate term function and intermediate and long term pain.
versus other cognitive-behavioural therapy there was moderate quality evidence showing no difference for long term pain.
versus other exercise therapy there was moderate quality evidence showing no difference for short term pain, function and sick leave.
versus other therapy there was moderate quality evidence showing no difference for intermediate and long term pain, long term function and intermediate and long term sick leave.
versus minimal intervention there was moderate quality evidence showing no difference for intermediate and long term pain, and intermediate and long term function.

The authors concluded

“Moderate to high quality evidence was found of small effects favouring PFR compared with advice. Preliminary evidence suggested PFR is not different to other treatment types. Further high quality research is required replicating existing trial protocols.”

Musculoskeletal Elf’s thoughts

This high quality review provides an overview on the effect of physiotherapy functional restoration for low back pain over 6 weeks in duration. In the 16 included trials there were nine different types of PFR, 11 different comparison treatments, five measures of pain, five measures of function, and follow up at 14 different time points. When conducted, meta-analyses showed effect sizes of questionable clinical importance. So would our Elves provide PFR? Well this preliminary evidence suggested PFR is not different to other treatment types that have been shown to be effective, with no evidence of harm, so its another tool in the Elf toolbox.

Do you use PFR? What is your view on this review, will it change your clinical practice? Send us your views on this blog and become part of the Musculoskeletal Elf community.

On another note in common with other reviews of therapeutic interventions heterogeneity within included trails is a serious issue. This situation could be improved by consistency in approach to measures for pain and function and surveillance time points beyond the end of the intervention. Furthermore, detailed descriptions of the content of the interventions, including information about the setting, duration, frequency, intensity, progression, level and type of supervision and supervisor.

However achieving consistency of use of outcomes and reporting will require consensus, guidelines and adherence and this is the aim of the recently established COMET (Core Outcome MEasures in Trials) Initiative.

The Musculoskeletal Elf