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


Therapeutics

Exercise was no more effective than standard care for acute low-back pain

ACP J Club. 1994 Mar-April;120:39. doi:10.7326/ACPJC-1994-120-2-039


Source Citation

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 Nov;18:1388-95.


Abstract

Objective

To evaluate the effectiveness of exercise for acute low-back pain.

Design

12-month randomized, placebo-controlled, single-blind trial.

Setting

40 general practices in the Netherlands.

Patients

473 patients (mean age 36 y, 57% men) with back pain for ≤ 3 weeks located between T12 and the gluteal folds. Exclusion criteria were pain radiating below the knee, nerve root compression or neurologic deficit, trauma-induced back pain, previous back pain within 2 months before entry, previous back surgery, suspected malignancy, ankylosing spondylitis, or other rheumatic diseases. Follow-up was 87%.

Intervention

All patients received standardized advice for back pain from the general practitioner and analgesics (acetaminophen). They were then randomized to a usual-care group receiving no further therapy (n = 155), a placebo group receiving placebo ultrasound therapy twice weekly for 5 weeks (n = 162), or an exercise group receiving exercise therapy twice weekly from a physiotherapist for 5 weeks (n = 156).

Main outcome measures

Number and duration of pain episodes were recorded. Change in functional health status from baseline and functional health during back pain were assessed using the Nottingham Health Profile questionnaire. An intention-to-treat analysis was done.

Main results

The 3 groups (usual care, placebo, and exercise) did not differ in percentage of patients with 1 or more back pain recurrences (70%, 66%, and 70%) (Table) or in the mean duration of pain episodes (57, 54, and 58 d). 33% of exercise patients were less tired during the first 3 months compared with 19% of usual-care patients (P = 0.03) and 28% of the placebo recipients (P = 0.21) (Table). No difference existed among groups in functional status during back pain. The power of the study to detect a 20% difference between the treatment groups was 95%.

Conclusions

Exercise therapy was no more effective than standard care provided by general practitioners in treating acute low-back pain. For outcomes where exercise therapy was more effective than usual care, no difference existed between exercise and placebo.

Source of funding: Dutch College of General Practitioners.

For article reprint: Dr. A. Faas, Department of General Practice and Nursing Home Medicine, Institute for Research in Extramural Medicine, Vrije University of Amsterdam, vd Boechorststraat 7, 1081 BT Amsterdam, the Netherlands. FAX 31-20-777-208.


Table. Exercise vs standard care in acute low-back pain*

Outcomes Exercise Usual care Placebo RRI (95% CI) NNH (CI)
Back-pain recurrence at 1 year 69% 66% 5% (-10 to 23) Not significant
RRR (CI) NNT (CI)
69% 70% 0.3% (-15.8 to 14.1) Not significant
RBI (CI)
Decrease in tiredness in 3 months 33% 19% 72% (13 to 165) 8 (5 to 32)
33% 28% 20% (-17 to 72) Not significant

*Abbreviations defined in Glossary; RRI, RRR, RBI, NNT, NNH, and CI calculated from data in article.


Commentary

Acute low-back pain is common, causes great distress to our patients, and has an uncommon but feared outcome: chronic back pain and disability. Physicians have few therapeutic tools: reassurance, analgesics, muscle relaxants, and time. Spinal manipulation may be effective, but few physicians use the technique (1). Exercise and stretching therapy are effective in some cases of back pain (2). A common strategy is to immediately refer the patient to a physical therapist for exercise instruction. The study by Faas and colleagues shows no statistically significant benefit from twice weekly physical therapy for 5 weeks. The setting was generalizable, the intervention was realistic, and the outcomes were appropriate. The exercise group had improved feelings of well-being but so did the group receiving sham ultrasound; therefore, just visiting a practitioner has a substantial therapeutic effect. The exercise program consisted predominantly of flexion exercises, which are often called "Williams-type exercises" in the United States. It is unclear whether these findings apply to other types of exercise (extension exercise of the "McKenzie" type or instruction in general aerobic exercise). Before routinely recommending alternative exercises, the interventions should be tested using randomized trial methods similar to those in this study.

This study should discourage primary care physicians from referring most patients with acute low-back pain to a physical therapist for exercise instruction. These findings, however, should not be interpreted as a triumph of therapeutic nihilism: Prolonged bed rest is ill advised for most patients with back pain; early mobilization and a graduated return to work are best for the patient and society (3). Physical therapy modalities (heat, cold, ultrasound, traction, and so on) may offer transient relief but often have not been properly evaluated. Self-care by the patient after the initial physician contact is likely the best and most cost-effective course during the first 4 to 6 weeks of back pain.

Timothy S. Carey, MD
University of North CarolinaChapel Hill, North Carolina, USA


References

1. Hadler NM, Curtis P, Gillings DB, Stinnett S. A benefit of spinal manipulation as adjunctive therapy for acute low-back pain: a stratified controlled trial. Spine. 1987;12:702-6.

2. Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med. 1990;322:1627-34.

3. Hadler NM. Regional musculoskeletal diseases of the low back. Cumulative trauma versus single incident. Clin Orthop. 1987:221:33-41.