French Physical Therapy Technique Effective in Patients With Refractory Chronic Back Pain

Paula Moyer, MA

April 14, 2005

April 14, 2005 (Miami Beach) — A physical therapy technique known as Souchard's global postural re-education (GPR) restores most people to complete activities of daily living and therefore produces results that are superior to other conservative interventions or surgery, according to a team of Argentine investigators whose findings were presented here today at the 57th annual meeting of the American Academy of Neurology.

"Among 102 patients who had exhausted all other options, 92 returned to complete activities of daily living," said principal investigator Conrado J. Estol, MD. "These patients had lived with back pain for an average of nine months and all been treated with multiple modalities before being treated with GPR." Dr. Estol is director of the Neurologic Center for Treatment and Rehabilitation in Buenos Aires, Argentina.

GPR consists of a series of maneuvers in which the patient is in the supine, sitting, and standing positions. The physical therapist's maneuvers involve stretching the paraspinal muscles and those of the abdominal wall so that the joints are relieved of the compression that is typically the source of their pain. The technique is named after the French physical therapist who developed it, Philippe Souchard, and was originally intended as a treatment for scoliosis. Treatment is typically at least four months in duration, with two to four sessions or more the first week, depending on the severity of the patient's condition, and then once weekly thereafter.

The investigators conducted the study because of the limited outcomes that had been seen with several conservative interventions for chronic back pain, including rest, various physical therapy interventions, chiropractic manipulation, traction, and epidural steroid injections, as well as surgery. Whether treated conservatively or with surgery, long-term outcomes are similarly disappointing, Dr. Estol said.

Unlike patients with acute injury, who typically recover spontaneously with minimal or no intervention, some patients with chronic back pain have a limited recovery, if any, Dr. Estol said. Therefore, in their study they recruited 102 consecutive patients whose clinical findings and magnetic resonance imaging studies had shown that they had disc protrusions, canal stenosis, and other changes affecting the joints and bone.

All patients selected for the study had either moderately or severely limited activities of daily living, as identified in the qualifying consultation. Those with moderate restrictions (75%) could walk no more than 10 blocks without pain, and those with severe restrictions could walk no more than five blocks and either had to quit working or have restrictions on their activities at work. The patients were 25 to 91 years old (average age, 43 years); 48 were women and 56 were men. The patients had cervical pain in 20 cases and lumbar pain in 82 cases. Treatment duration was an average of five months.

All patients had received different combinations of treatment for an average of seven months. Prior therapies consisted of conventional physical therapy, McKenzie method therapy, rest, oral and intramuscular medications, acupuncture, and epidural steroid injections.

Of these patients, 92 (90%) were able to return to full activities of daily living and four patients (4%) had slight discomfort with strenuous sport activity. Six patients (6%) did not respond to therapy, of whom four had had previous back surgery, one had a Chiari malformation and one improved after quitting a job in which she was dissatisfied. Most patients (85%) noted considerable improvement by three weeks. After an average follow-up of 22 months, no responders reported pain recurrence in either clinic visits or telephone interviews.

The results were very promising, Dr. Estol said, noting that the patients' own prior refractory pain could be seen as a historical control group. However,he stressed that the results need to be validated in a randomized controlled trial. He also cautioned that physical therapists in the U.S. have just begun getting the additional training required to deliver GPR, and it may be a year or more before U.S. physicians can more easily refer patients to such therapists.

The findings show promise for chronic back pain, according to Albert Lo, MD, PhD. He moderated the session during which Dr. Estol presented his findings. "A success rate of 90% in people with chronic back pain is very unusual and warrants further investigation," Dr. Lo said. He is an assistant professor of neurology at Yale University in New Haven, Connecticut.

But Dr. Lo agreed with Dr. Estol that a randomized controlled trial would be necessary in order for physicians to have confidence in GPR. "If the findings are reproducible [in the setting of a randomized controlled trial], GPR could be a very exciting adjunctive therapy for patients with chronic neck and back pain," he said.

AAN 57th Annual Meeting: Abstract S51.003. Presented April 14, 2005.

Reviewed by Gary D. Vogin, MD

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