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

Discussion

This study was undertaken in the physiotherapy department of a U.K. metropolitan National Health Service hospital. Patient baseline characteristics ( Table 3 ) indicated that on average patients fell within the normal range of distress or illness behavior.[35] However, 41% (n = 38) of patients were assessed at baseline as either at Risk for Depression or Distressed-Depressive.[35] Similarly, 31 patients (30%) demonstrated risk of long-term work loss as assessed by the Acute Low Back Pain Screening Questionnaire.[34] These findings indicated that an important proportion of patients with ALBP referred for physiotherapy in a primary care setting exhibited psychosocial features associated with poor outcome.[28,34]

This study was driven largely by the discrepancies that exist in recently published LBP guidelines.[1] In this study, the definition of simple low back pain offered by these reports was used as the inclusion criteria for the study, yet relatively few ALBP patients referred to the department fulfilled these criteria. Based on our data, 74% of ALBP patients referred fell outside the criteria for simple ALBP ( Table 1 ). These findings have clear implications for the utility of these guidelines in primary care, as the population presenting for treatment might not represent the population from which the evidence base is derived. Our first recommendation therefore is that healthcare professionals become aware of the demographics of their client group and interpret and implement guidelines in keeping with these characteristics.

Analysis at this time point enabled comparison between advice on staying active and active physiotherapy treatment. Our findings suggested that early active physiotherapy treatment led to improved outcomes in disability, general health, social function, anxiety, depressive symptoms, mental health, and vitality. In the short-term, it appears that physiotherapy is a superior intervention to advice on staying active for patients with ALBP. This is in keeping with findings on subacute LBP.[29]

A number of reviews have concluded that the evidence for the use of physical interventions in ALBP is negative, or at best, weak.[3,5,36,37,38] This is reflected in the Dutch and Australian guidelines where physiotherapy is not recommended in the acute stage.[1] Our findings challenge these recommendations. We have shown that patients obtain significant benefit from being involved in an early active physiotherapy program. Further research is being undertaken to thoroughly analyze the content of treatment and the clinical reasoning process used by the treating therapists so that the aspect or aspects of care that led to such favorable outcomes can be identified. It is our impression, however, that effective intervention needs to be multimodal and delivered within a rehabilitative framework, with the individual interventions themselves probably of less importance than the philosophical construct in which the treatment is delivered.

Neither pain nor disability was significantly different between the groups during the course of the long-term follow-up, indicating that these parameters were unaffected by the treatment model. Assess/advise/wait led to a delay in improvement of disability, but with no long-term consequences.

A number of other important outcome variables, however, were adversely affected by an assess/advise/wait approach. Patients seen promptly had significantly less anxiety, depressive symptoms, and distress. They also had better general health, social functioning, and mental and emotional health. Very few studies of physiotherapy intervention for ALBP have assessed psychosocial variables as part of long-term follow-up. This study provides evidence that early active treatment can improve psychosocial outcomes and that the effect on psychosocial function appears to be dependent on the timing of intervention. Delaying the onset of treatment does not provide the opportunity for physiotherapy intervention to have this favorable effect.

Overall, our study supports the hypothesis that assess/advise/treat produces better long-term outcomes than an assess/advise/wait approach. Furthermore, as it is recognized that psychosocial variables are predictive of chronicity in ALBP,[28] early active treatment may have the potential to reduce the risk of chronicity developing.

All our sensitivity analyses to examine the consequences of missing follow-up data suggested that, although it comprised approximately one third of the randomized cases, this was unlikely to result in substantial bias to the results of the study.

The amount of missing data were similar for both groups at both 6 weeks and the long-term follow-up. Furthermore, there was no difference between responders or nonresponders in any of the baseline variables. For those patients for whom data were available, nonresponders at 6 weeks did not differ significantly from the rest of the cohort at long-term follow-up. Similarly, nonresponders at long-term follow-up for whom there were 6-week data available are not significantly different from the rest of the cohort at 6 weeks. The results of a sensitivity analysis using last value carried forward indicated little change in the regression coefficients. Finally, the finding that 16 patients (42%) were lost to follow-up due to changes of their address provided further evidence that data were missing at random. However, despite these results and the strenuous efforts made to obtain follow-up information on all randomized patients, bias is always a possibility when follow-up rates are low.

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