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


Therapeutics

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

ACP J Club. 1995 Sept-Oct;123:33. doi:10.7326/ACPJC-1995-123-2-033

Related Content in this Issue
• Companion Abstract and Commentary: An instructional program that encouraged light normal activity reduced sick leave in acute low-back pain


Source Citation

Stankovic R, Johnell O. Conservative treatment of acute low back pain. A 5-year follow-up study of two methods of treatment. Spine. 1995 Feb 15; 20:469-72.


Abstract

Objective

To compare the long-term effectiveness of the McKenzie method with patient education for acute low-back pain.

Design

Randomized controlled trial with 5-year follow-up.

Setting

Community study in Sweden.

Patients

89 patients (mean age 40 y, 67 men) were assessed. {All had acute low-back pain and were employed. Exclusion criteria were chronic low-back pain; pregnancy; back surgery; spondylolisthesis; tumors; fractures; or neck, shoulder, or thoracic pain.}* 27 patients were interviewed and examined, and 62 patients were interviewed by telephone.

Intervention

Patients were allocated to the McKenzie method of acute low-back pain treatment (6 to 8 sessions/d of repetitive movements of flexion, extension, and side gliding, 10 to 15 times/session) (n = 47) or to education without exercises in a mini back school at the time of the index episode of acute low-back pain (n = 42).

Main outcome measures

Recurrence of back pain and duration of sick leave (sick leave information was provided by the Swedish National Health Insurance office). Results of the 5-year follow-up were compared with results of the 1-year follow-up.

Main results

At 5 years, 30 recurrences of back pain occurred among patients in the McKenzie group compared with 37 recurrences among patients in the education group (P = 0.008) (Table). Fewer patients in the McKenzie group took sick leave in the preceding 4 years compared with patients in the education group (P = 0.03) (Table). Among patients who took sick leave, the groups did not differ for duration (84.1 d vs 103.9 d). Patients who were contacted by telephone reported fewer recurrences of pain during the past 4 years than patients who were seen and examined (P < 0.01), but no differences in sick leave were noted. The 5-year results for the patients in the McKenzie group for pain recurrence, need for help with treatment, and ability to provide self-help were similar to the 1-year results for those measures for the patients in the education group.

Conclusions

After 5 years, the McKenzie method of acute low-back pain treatment was more effective than patient education. The effect deteriorated between 1 and 5 years.

Source of funding: Not stated.

For article reprint: Mr. R. Stankovic, Department of Orthopaedics, Malmö General Hospital, S-214 01 Malmö, Sweden. FAX 46-40-33-6200.

*Information from: Stankovic R. Spine. 1990;15:120-3.


Table. McKenzie method vs patient education for acute low back pain†

Outcomes McKenzie method Patient education RRR (95% CI) NNT (CI)
Recurrence of back pain at 5 y 64% 88% 28% (9 to 45) 4 (2 to 15)
Sick leave at 4 y 51% 74% 31% (4 to 51) 4 (2 to 39)

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


Commentary

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.