Effectiveness and Cost-Effectiveness of Three Types of Physiotherapy Used to Reduce Chronic Low Back Pain Disability: A Pragmatic Randomized Trial With Economic Evaluation

Duncan J. Critchley, MSc; Julie Ratcliffe, PhD; Sandra Noonan, BSc; Roger H. Jones, FFRCGP; Michael V. Hurley, PhD


Spine. 2007;32(14):1474-1481. 

In This Article

Abstract and Introduction


Study Design: Pragmatic, randomized, assessor blinded, clinical trial with economic analysis.
Objective: To compare the effectiveness and cost-effectiveness of three kinds of physiotherapy commonly used to reduce disability in chronic low back pain.
Summary of Background Data: Physiotherapy reduces disability in chronic back pain, but there are several forms of physiotherapy and it is unclear which is most effective or cost effective.
Methods: A total of 212 patients referred to physiotherapy with chronic low back pain were randomized to receive usual outpatient physiotherapy, spinal stabilization classes, or physiotherapist-led pain management classes. Primary outcome was Roland Disability Questionnaire score 18 months from baseline; secondary measures were pain, health-related quality of life, and time off work. Healthcare costs associated with low back pain and quality-adjusted life years (QALYs) were also measured.
Results: A total of 71 participants were assigned to usual outpatient physiotherapy, 72 to spinal stabilization, and 69 to physiotherapist-led pain management. A total of 160 (75%) provided follow-up data at 18 months, showing similar improvements with all interventions: mean (95% confidence intervals) Roland Disability Questionnaire score improved from 11.1 (9.6-12.6) to 6.9 (5.3-8.4) with usual outpatient physiotherapy, 12.8 (11.4-14.2) to 6.8 (4.9-8.6) with spinal stabilization, and 11.5 (9.8-13.1) to 6.5 (4.5-8.6) following pain management classes. Pain, quality of life, and time off work also improved within all groups with no between-group differences. Mean (SD) healthcare costs and QALY gain were £474 (840) and 0.99 (0.27) for individual physiotherapy, £379 (1040) and 0.90 (0.37) for spinal stabilization, and £165 (202) and 1.00 (0.28) for pain management.
Conclusions: For chronic low back pain, all three physiotherapy regimens improved disability and other relevant health outcomes, regardless of their content. Physiotherapist-led pain management classes offer a cost-effective alternative to usual outpatient physiotherapy and are associated with less healthcare use. A more widespread adoption of physiotherapist-led pain management could result in considerable cost savings for healthcare providers.


Throughout the industrialized world, chronic low back pain is a common, disabling, and costly problem. The annual cost of low back pain to the U.K. public healthcare provider, the National Health Service (NHS), has been estimated at £1.1 billion, with chronic problems responsible for 80% of these costs.[1]

International guidelines recommend active physiotherapy, treatment emphasizing exercise, as a key component in chronic low back pain management.[2] In the United Kingdom, around 1.3 million people per year receive NHS physiotherapy for low back pain, costing an estimated £150 million.[3] However, there are several types of physiotherapy for low back pain. Usual outpatient physiotherapy involves individual advice, exercises, and joint manipulation or mobilizations aimed at specific impairments.[4] Other treatments include physiotherapist-led outpatient pain management programs, which use education, general exercise, and a paced return to usual activities to reduce the emotional distress and unhelpful beliefs associated with back pain and aim to improve coping and self-management. Physiotherapist-led general exercise and brief education in small groups reduce disability and healthcare costs compared with primary care.[5] A third treatment, spinal stabilization training, involves very specific exercises of deeper trunk muscles that are dysfunctional in chronic low back pain and proposed to actively stabilize the lumbar spine.[6,7] Spinal stabilization reduces pain and disability in lumbar instability and recurrence following first-episode pain but, while in widespread use, its efficacy is unproven in chronic nonspecific back pain.[6,7] Whether one form of physiotherapy is more effective or cost-effective than another is unknown.[8]

To help inform decision makers, we compared the clinical effectiveness and costs of spinal stabilization and physiotherapist-led pain management classes with usual outpatient physiotherapy for people with chronic low back pain.


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