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


Therapeutics

An instructional program that encouraged light normal activity reduced sick leave in acute low-back pain

ACP J Club. 1995 Sept-Oct;123:32. doi:10.7326/ACPJC-1995-123-2-032


Source Citation

Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine. 1995 Feb 15;20:473-7.


Abstract

Objective

To evaluate the effectiveness of an instructional program stressing light normal activity for the treatment of acute low-back pain.

Design

Randomized controlled trial with 200-day follow-up.

Setting

A spine clinic in Norway.

Patients

975 patients (mean age 42 y, 61% men) with acute low-back pain with or without radiation who had been on sick leave from work for > 8 weeks. Exclusion criteria were pregnancy or ≥ 12 weeks of sick leave. All but 26 patients (3%) participated in the study.

Intervention

Patients were allocated to a 2-step consultation (n = 463) or to a control group receiving conventional care (n = 512). The intervention consisted of a clinical examination and a follow-up appointment during which patients were educated about the examination results, the causes of their low-back pain, and the importance of lessening their fear of it. Patients in the intervention group were encouraged to mobilize the lumbar spine by light activity and to set their own exercise goals.

Main outcome measure

Reduction in sick leave (sick leave information was provided by the Norway National Insurance Offices of the County of Oestfold).

Main results

At 200 days 30% of patients in the intervention group were still on sick leave compared with 60% of patients receiving conventional care (P < 0.001) (Table). Multivariate analysis showed that sex had no effect on the duration of sickness, and the treatment effect was maintained in various age groups.

Conclusion

A patient instructional program that encouraged light normal activity and focused on the abatement of fear was effective in reducing sick leave among patients with subchronic low-back pain.

Source of funding: None.

For article reprint: Dr. A. Indahl, Nordstrandveien 26C, N-1163, Oslo, Norway. FAX 011-47-22-74-27-46.


Table. Instructional program that encouraged light normal activity vs conventional care in subchronic low-back pain*

Outcome at 200 d Instructional program Conventional care RRR (95% CI) NNT (CI)
Still on sick leave 30% 60% 50% (43 to 58) 3 (3 to 4)

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


Commentary

Conservative exercises were more effective than patient education for acute low-back pain after 5 years

Low-back pain is one of the most common symptoms causing adult patients to seek medical attention. Most patients choose primary care physicians, orthopedic surgeons, and chiropractors for care. The economic consequences of low-back pain are staggering, measuring in the tens of billions of dollars. Despite this, few good scientific studies have addressed the diagnosis, management, and prevention of this condition. Recently, however, several reports of good studies on low-back pain have been published. In the Jul/Aug 1995 issue of ACP Journal Club, we reviewed a randomized controlled trial on the treatment of acute low-back pain (1), and this issue contains 2 more. What can be learned from these and other studies about reasonable treatment approaches for patients with low-back pain?

First, most of the important information about back pain comes from history and physical examination (2). Key questions need to be asked about age, history of cancer, trauma, unexplained weight loss, immunosuppression, duration of symptoms, responsiveness to previous therapy, pain that is worse at rest, history of intravenous drug use, and urinary or other infection. This history, together with a targeted physical examination that looks for fever, vertebral tenderness, and bilateral or saddle neurologic deficits, is usually sufficient to ensure that a "red flag" is not missed. The judicious use of lumbosacral radiography may be needed in some cases. After excluding the "red flags," the symptom of pain that radiates into the leg, particularly if it goes below the knee, and findings of a positive straight-leg raising test or its equivalent, help to separate patients with radicular back pain from those with other types of back pain.

The prognosis for patients with either mechanical or radicular back pain is very good. About 50% return to normal activities within 4 weeks, and 95% return by 6 months. This favorable prognosis and the fact that history and physical examination indicate nothing serious is wrong need to be stressed to the concerned patient. For those with mechanical back pain, the treatment should emphasize an early return to usual activities (as tolerated) and the use of non-narcotic analgesics or spinal manipulations for symptom control (3). "Over-medicalizing" acute low-back pain through an emphasis on prolonged bed rest, continued passive treatments, or the restriction of usual activities probably prolongs rather than shortens the time to improvement, as shown in the study by Malmivaara and colleagues (1) and the study by Indahl and colleagues. These same recommendations apply to radicular back pain, although these patients may improve more slowly.

For the patient who is slow to recover, a reevaluation that again considers the "red flags" should be done, followed by a careful search for underlying psychosocial problems. The best predictor of failure to return to work after an episode of back pain is job dissatisfaction rather than any anatomical abnormality. For the patient with radicular symptoms who is slow to recover and is willing to consider surgery as a treatment option, anatomical imaging and referral to a spine surgeon is indicated.

After the acute exacerbation has subsided, back exercises should be prescribed if they are not already being done. The study by Stankovic and Johnell supports the view that back exercises (in this case McKenzie routines) are helpful in preventing recurrences of back pain. The patient should be informed that recurrences are common but that they may be treated in the same fashion. Over time, however, a gradual loss of function is probable. It is not reasonable for the patient or physician to judge the performance of a 50-year-old spine against the memory of a 21-year-old spine.

A realistic approach to a patient's fears and expectations, combined with appropriate conservative care, should improve care of low-back pain.

Paul Shekelle, MD
RANDSanta Monica, California, USA


References

1. Ordinary activity was best for acute low-back pain [abstract]. ACP J Club. 1995 Jul-Aug. Abstract of: Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain—bed rest, exercise, or ordinary activity? N Engl J Med. 1995;332:351-5.

2. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low-back pain? JAMA. 1992;268:760-5.

3. Acute low back problems in adults: assessment and treatment. Agency for Health Care Policy and Research. Clin Pract Guidel Quick Ref Guide Clin. 1994 Dec;(14):iii-iv, 1-25.


Update note

Upon review in March 2000, the authors and the commentator indicated that the articles and commentary are still relevant to relevant practice. New relevant references include:

1. Indahl A, Haldorsen EH, Holm S, Reikeras O, Ursin H. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine 1998;23:2625-30.

2. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339:1021-9.