Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

A supervised progressive fitness program reduced pain and disability in chronic low-back pain

ACP J Club. 1995 July-Aug;123:7. doi:10.7326/ACPJC-1995-123-1-007


Source Citation

Frost H, Klaber Moffett JA, Moser JS, Fairbank JC. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. BMJ. 1995 Jan 21;310:151-4.


Abstract

Objective

To evaluate the effectiveness of a supervised progressive fitness program to decrease functional disability in patients with chronic low-back pain.

Design

Randomized, single-blind, controlled trial with 6-month follow-up.

Setting

Physiotherapy department of an orthopedic hospital in Oxford, England, UK.

Patients

81 patients aged 18 to 55 years (mean age 36 y, 52% women) with somatic low-back pain for ≥ 6 months who were referred to the physiotherapy department. Exclusion criteria were medical conditions that precluded exercise; no radiograph examination of the lumbar spine within the past year; pain caused by nerve root irritation; inflammatory arthritis; other musculoskeletal disabilities that would affect ability to cope with the fitness program; major surgery within the past year; current involvement in a regular and frequent sporting activity; physiotherapy within the past 3 months; spinal infection, fractures, spondylolisthesis, or malignancy; pregnancy; or inability to walk without a walking aid. 71 patients (88%) completed the study.

Intervention

All patients were taught specific home exercises and attended the backschool, an education program. 36 patients were also assigned to a fitness program, which included 8 supervised exercise classes over a 4-week period.

Main outcome measures

Revised Oswestry low-back pain disability index, pain reports, self-efficacy reports, walking distance, general health status, and pain locus of control.

Main results

Scores on the disability index were reduced in patients who attended the fitness program compared with those in the control group (P < 0.005), and a benefit of 6 percentage points on the index was maintained at 6 months by patients in the fitness group (P < 0.03). A 42% (sensory) and 49% (affective) reduction in pain was reported by patients attending the fitness program compared with a 21% (P < 0.05) and 0.02% (P < 0.005) reduction in the control group. Participation in the fitness program led to improved self-efficacy and functional ability (P < 0.05). Patients who attended the fitness program increased their walking capacity by 25% compared with no change in the control group (P < 0.005). The treatment groups did not differ for general health status or pain locus of control.

Conclusion

A supervised progressive fitness program, in addition to backschool and independent exercise at home, reduced pain and disability and improved self-confidence in moderately disabled patients with chronic low-back pain.

Sources of funding: National Back Pain Association and Oxfordshire locally organized research scheme.

For article reprint: Ms. H. Frost, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, England, United Kingdom.


Commentary

Finally, some good news for practitioners working with patients who have chronic low-back pain. The trial by Frost and colleagues offers the prospect of moderate improvement in patients' functional status using available, relatively inexpensive approaches. All patients had chronic low-back pain and had been referred to an orthopedic center.

Participants in the fitness program had 8 additional hours with a physiotherapist, and it is possible that some of the positive effects of the intervention were nonspecific because of this extra contact. Previous work by Faas and colleagues (1) showed that an exercise program run by a physiotherapist for acute back pain was not better than a simple visit for encouragement. This study also found a nonspecific effect because of additional contact with the physiotherapist.

In the United States, some positive exercise studies have used intensive gymnasium and work-hardening programs that are expensive to implement (2). The intervention in the study by Frost and colleagues is low in technology, requires no physician time, and can be implemented among groups of patients by a physiotherapist. If 4 patients are in each class, and if the reimbursement to the physiotherapy office is $75 per 1-hour class, then the charge to the patient would be only $150 for 8 sessions. To maintain the low-cost approach advocated in this study, the right physiotherapist must be found. Some physiotherapists favor using multiple "modality" therapies. These modalities, including local heat, cold, ultrasound, diathermy, and transcutaneous electrical nerve stimulation, generally result in only transient pain relief, do not improve functional status, and add to the visit charge by $25 per modality.

Tim Carey, MD
University of North Carolina Chapel Hill, North Carolina, USA


References

1. Faas A, Chavannes AW, van Eijk JT, Gubbels JW. A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine. 1993;18:1388-95.

2. Mayer TG, Gatchel RJ, Kahino N, et al. Objective assessment of spine function following industrial injury. A prospective study with comparison group and one-year follow-up. Spine. 1985;10:482-93.