Early Intervention for the Management of Acute Low Back Pain

Benedict M. Wand, BAppSc, GradDip(ExSpSc), MAppSc, PhD; Christien Bird, MSc, MCSP; James H. McAuley, BSc, PgDip, PhD; Caroline J. Doré, BSc; Maureen MacDowell, MCSP; Professor Lorraine H. De Souza

Disclosures

Spine. 2004;29(21) 

In This Article

Abstract and Introduction

Study Design: A single blind randomized controlled trial comparing two models of care for patients with acute simple low back pain.
Objectives: To compare two research-based models of care for acute low back pain and investigate the effect of the timing of physical intervention.
Summary of Background Data: National guidelines offer conflicting information on the delivery of physical treatment in the management of acute low back pain. The guidelines suggest two different models of care. Direct comparisons between these models are lacking in the literature. The present study aims to compare these approaches to the management of acute low back pain.
Methods: Among 804 referred patients, 102 subjects met the specific admission criteria and were randomly assigned to an assess/advise/treat group or an assess/advise/wait group. The intervention consisted of biopsychosocial education, manual therapy, and exercise. Assessment of short-term outcome enables comparison to be made between intervention and advice to stay active. Assessment of long-term outcome enables comparison to be made between early and late intervention. Study outcomes of reported pain (Visual Analogue Scale), functional disability (the Roland and Morris Disability Questionnaire), mood (Modified Zung Self Rated Depression Score, Modified Somatic Perception Questionnaire, State-Trait Anxiety Inventory), general health (Euroqol), and quality of life (Short Form 36) were assessed at baseline, 6 weeks, 3 months, and 6 months.
Results: At 6 weeks, the assess/advise/treat group demonstrated greater improvements in disability, mood, general health, and quality of life than patients in the assess/advise/wait group (P < 0.05). Disability and pain were not significantly different between the groups at long-term follow up (P > 0.05). However, mood, general health, and quality of life remained significantly better in the assess/advise/treat group (P < 0.05).
Conclusions: At short-term, intervention is more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life, and general health. The timing of intervention affects the development of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore, an assess/advise/treat model of care seems to offer better outcomes than an assess/advise/wait model of care.

Evidence-based guidelines for the management of acute low back pain (ALBP) have been formulated by the Health Authorities of a number of countries.[1] Clear evidence has emerged that advice on staying active and appropriate drug therapies are effective interventions for ALBP and that bed rest and general back exercises are not.[2,3,4,5]

A major discrepancy between guidelines is in the use of physical therapy, particularly the timing of physical intervention. Based on the inconclusive evidence for physical therapy, the potential negative effect of treatment dependency, the cost, and the sometimes passive nature of the treatment, the Dutch and Australian authorities propose a wait and see approach during the first 6 weeks.[1,6] More recent reviews have further strengthened this approach.[3,5] Alternatively, the U.K. Clinical Standards Advisory Committee (CSAG) report,[7] the American guidelines,[2] and the more recent U.K. guidelines[4] recommend various forms of early physical intervention.

The discrepancies between these guidelines represent two different models of care for ALBP. In one system, patients are assessed and advised to stay active and active treatment is commenced early (assess/advise/treat). In the alternative model, active treatment is delayed (assess/advise/wait).

Direct comparisons between these two models are lacking in the literature. The present study aims to compare these two approaches to the management of ALBP.

The present study addressed three major research questions:

  1. Do patients treated with an active intervention program differ significantly at 6 weeks in outcome from patients who have received advice on staying active only?

  2. At long-term follow-up, do patients who received treatment early differ significantly in outcome from patients who were asked to wait 6 weeks for their treatment?

  3. Are there any meaningful differences in outcome between an assess/advise/treat model and an assess/advise/wait model of care for ALBP?

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