|Low Back Pain
Low back pain is one of the most costly conditions in
musculoskeletal health care. The issue of safe, efficacious and
cost-effective management for low back pain has never been more
Role of physiotherapy
One of the principal
questions addressed by physiotherapists is how to provide the most
appropriate management for low back pain. Through highly skilled
clinical practice and well designed research, physiotherapists are
able to provide evidence for physiotherapy as a safe, low cost
Physiotherapists are skilled in the
assessment, diagnostic decision making and treatment of patients
with low back pain arising from a musculoskeletal disorder.
Approaches to management in the field of manipulative physiotherapy
involves not only 'manipulation', but also manual handling with
passive examination and treatment techniques, therapeutic exercise
and advice on posture and movement disorders. There is also a large
emphasis on systematic assessment and clinical reasoning.
Physiotherapists have undertaken much research investigating
the practise of physiotherapy. The research into low back pain is
conducted according to strict research guidelines and, as such, is
subjected to peer review and must gain approval from ethic
Evidence based physiotherapy for low back
Based on a comprehensive review of the scientific literature
the APA, with assistance from the Manipulative Physiotherapists
Association of Australia (MPAA), has developed a position statement
on the treatment of low back pain. The MPAA is a special group of
the APA representing the group of physiotherapists with postgraduate
qualifications in manipulative physiotherapy and is active in
supporting research into low back pain to ensure professional
practice reflects best practice based on research evidence from
Level I (systematic reviews) and
level II evidence (randomised controlled trials) with specific
reference to physiotherapeutic interventions have been evaluated.
The following conclusions are evident from our evaluation of these
Acute Low Back Pain
There is considerable
evidence to support that spinal manipulative therapy (SMT including
both passive mobilisation and manipulation), McKenzie therapy and
promoting early activity is effective in the short term management
of low back pain. For example SMT provides better short term
improvement in pain and activity levels than the comparison regimens
of traction, massage, epidural injections and short-wave.
Physiotherapists were involved as the providers of SMT in 7 of the
13 trials supporting the use of SMT (AHCPR, 1994). A recent
meta-analysis reports twelve out of sixteen trials as positive for
SMT, compared to placebo or other conservative treatment. Again,
physiotherapists were the primary providers of SMT in at least 50%
of the trials (van Tulder et al 1997). There is insufficient
evidence to support that interventions such as shortwave, heat and
massage are effective in the management of the acute low back pain
Chronic Low Back Pain
There is also strong
evidence to support that general exercise programs result in reduced
disability, reduced absenteeism and faster return to work rate
compared to control groups (Frost et al, 1995, Gundewall et al 1993,
Kellett et al 1991, Mitchell et al 1990, Moffett et al 1999).
Physiotherapists have the necessary training and skills to design,
implement and supervise such exercise programs. Physiotherapists are
also pioneering investigations into the proposed mechanisms
contributing to chronic and recurrent low back pain by evaluating
the effects of specific exercise programs. Evidence to support their
efficacy is mounting (O'Sullivan et al 1997). There is strong
evidence that SMT is more effective in the management of chronic low
back pain than bed rest, analgesics, and massage, with six out of
eight trials supporting this evidence (van Tulder et al).
More importantly, the combination of SMT and exercise has
increasing support in the management of low back pain (Ottenbacher
and Difabio 1994, Scheer et al 1995).
||Agency for Heath Care Policy and Research (ACHPR)
(1994): Acute low back problems in adults. Clinical Practice
Guideline no 14. US department of Health and Human Services,
Public Health Services. December, Rockville MD USA.
||Frost, Moffett, Moser and Fairbank (1995):
Randomised controlled trial for evaluation of fitness program
for patients with chronic low back pain. British Medical
Journal, 310 (21): 151-154.
||Gundewall, Liljeqvist and Hansson (1993): Primary
prevention of back symptoms and absence from work.
Spine 18(5) 587-594.
||Kellett, Kellett and Nordholm (1991): Effects of an
exercise program on sick leave due to back pain. Physical
Therapy 71 (4) 283-293.
||Moffet, Torgerson, Bell-Syer, Jackson,
Llewlyn-Phillips, Farrin and Barber (1999). Randomised
controlled trial of exercise for low back pain: clinical
outcomes, costs and preferences. British Medical
Journal 319: 279-283.
||Mitchell and Carmen (1990): Results of a
multicentre trial using an intensive active exercise program
for the treatment of acute soft tissue and back injuries.
Spine 15(6): 514-521.
||O'Sullivan, Twomey and Allison (1997): Evaluation
of specific stabilising exercise in the treatment of chronic
low back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine 22: 2959-2967.
||Ottenbacher and Difabio (1994): Efficacy of Spinal
Manipulation/ Mobilisation Therapy. A meta-analysis.
Spine 10 (9) 833-837.
||Scheer , Radack and O'Brien (1995): Randomized
controlled trials in industrial low back pain relating to
return to work. Part 1. Acute Interventions. Arch Phys Med.
Rehab, Vol. 76, 966-973.
Tulder, Koes and Bouter (1997): Conservative treatment of
acute and chronic nonspecific low back pain. A systematic
review of randomised controlled trials of the most common
interventions. Spine 22 (18) 2128-2156. |
Finding a physiotherapist
Members of the MPAA
have postgraduate experience in low back pain management. Full
copies of the Australian Physiotherapy Association's Position
Statement on low back pain can be obtained by contacting the APA
office in your state.
This is under the category of
musculoskeletal and pain management. Call us on (03) 9527 7532 or contact us here.