Effective physical treatment for chronic low back pain

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The problem of chronic low back pain

Low back pain (LBP) is the main cause of absenteeism and disability in industrialized societies. Approximately 10%–20% of patients with LBP develop chronic LBP, defined as pain and disability persisting for more than 3 months. Chronic LBP is a major health problem with enormous economic and social costs. These patients use more than 80% of all healthcare costs for back trouble, and treatment for this group has a low success rate [1]. Unfortunately chronic LBP is prevalent in many countries

Judging treatment efficacy

The best evidence about the effectiveness of therapy is provided by well designed systematic reviews and randomized controlled trials (RCTs). Theoretically these study types provide unbiased estimates of the effects of therapy. More recently there is some empiric evidence that lower levels of evidence (eg, studies with historical controls) and poorly conducted randomized controlled trials tend to produce inflated estimates of the size of treatment effects [8], [9], [10], [11]. Because lower

Exercise

Exercise is one of the few clearly effective treatments for chronic LBP. The four most recent systematic reviews of exercise have each concluded that exercise is an effective therapy for chronic LBP [12], [13], [14], [15]. Also, the effect of exercise seems sufficiently large and durable to be clinically important. As an illustration, in Kankaanpaa et al's RCT [16] at 12-month follow-up, the subjects who undertook the exercise program had on average halved their pain and disability, whereas

Hydrotherapy

Hydrotherapy or exercise in water has a long history of use as a treatment for musculoskeletal conditions. A typical program for a patient with chronic LBP might be eight 1-hour sessions over a month [37].

There are two RCTs that have evaluated hydrotherapy for chronic LBP, both finding no difference between hydrotherapy and the control treatment. McIlveen and Robertson's study [37] found that subjects randomized to a 1-month program of hydrotherapy had no better outcomes at 1 month follow-up

Acupuncture

Acupuncture involves the insertion of needles into precise points on the skin surface. The needles may be stimulated manually or with electricity, and the acupuncture treatment may be combined with moxibustion and cupping. A typical course of treatment may involve eight sessions at a cost of approximately AUS $400.

The Cochrane review [45] and three other systematic reviews [27], [46], [47] have each concluded that there is no convincing scientific evidence that acupuncture is an effective

Summary

It is now feasible to adopt an evidence-based approach when providing physical treatment for patients with chronic LBP. A summary of the efficacy of a range of physical treatments is provided in Table 1.

The evidence-based primary care options are exercise, laser, massage, and spinal manipulation; however, the latter three have small or transient effects that limit their value as therapies for chronic LBP. In contrast, exercise produces large reductions in pain and disability, a feature that

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