BMJ  2004;329:694-695 (25 September), doi:10.1136/bmj.329.7468.694

Editorial

Back pain and physiotherapy

NHS treatment is of little value

My next patient: looking hopeful, hobbling in. Six weeks of pain and no respite. Referral to physiotherapy was the obvious option for such patients, but now I know from a paper in this issue that providing routine physiotherapy in the NHS is no better than advice to remain active (p 708).¹ Six weeks is a long time to be in pain, unable to work, and relatively immobile. Most patients will still be experiencing low back pain and related disability one year after their first consultation, and unfortunately we can do little about it.^w1 Although in this study patients felt better, objective outcomes did not improve—and, in a resource limited health service, can we make referral decisions based on subjective measures?¹

What are the implications for physiotherapy? Not all interventions can stand up to critical appraisal,² and this paper shows that our traditional model of physiotherapy for back pain is ineffective. But let us look more closely at this study.¹ The control group had a physical examination and was given general advice to remain active, in a session that lasted one hour. This is not a "no treatment" option, and what this study shows is that the additional treatment or usual treatment available in typical physiotherapy departments in the NHS was ineffective. The treatment strategy itself, however, was dependent on the physiotherapist. Each therapist chose a treatment based on his or her findings. But the study had 76 physiotherapists—a heterogeneous group, each with different training and background. Patients in the intervention arm had various treatments, including interventions that are inherently very different, such as mobility and strengthening, heat and cold, and combinations of treatment in no particular order. An optimistic interpretation of the study may be that this strategy of ad hoc treatment is ineffective, although some component interventions could still be effective. This study confirms only that physiotherapy given in an NHS department adds little to the management of back pain, and we need to look more closely at individual treatment options before deciding that all physiotherapy for back pain is ineffective. Progressive exercise classes run by a physiotherapist have been shown to help, but spinal manipulative therapy seems not to produce clinically worthwhile changes in pain or function.^3-5

What are the options for the general practitioner? Pain relief, anti-inflammatory drugs, and reassurance that the pain is self limiting, looks fine in writing. But the annual consultation rate for acute low back pain is at least 35 per 1000 adults.⁶ That we have no answers for a common condition comes as a surprise to a frustrated patient with high expectations of medical intervention. The Royal College of General Practitioners has issued guidelines for the management of acute back pain, and advice is available from the Clinical Standards Advisory Group. Although management by general practitioners does not always match the guidelines, physiotherapy has always been an important component.^{7 8 w2} Radiography is not recommended, except in particular circumstances where serious illness is suspected (known as red flag indications) and helps little, and orthopaedic surgeons don't wish to see patients with low back pain where surgery is not an option.^{9 w3} General practitioners have few alternatives, which leads to frustration on all sides, unsatisfactory consultations, and unhappy patients.

What are the alternatives for the patient? The best option is to follow an advice sheet and remain active. If the best outcomes are from exercise then perhaps we need a new model of health care for patients with back pain.¹⁰ Perhaps we should attempt to demedicalise back pain and refer patients to specially trained fitness instructors at a gym. Patients may have other ideas and are often anxious about physical activity with back pain.¹¹ In the study by Frost et al, although the validated disease specific measures showed no improvement, patients seemed to feel better and reported benefit from treatment. This may give a clue to why patients seek help from alternative practitioners; evidence does exist that chiropractic confers worthwhile long term benefit mainly in patients with chronic or severe pain.¹² Traditional health care may have little to offer.

Back pain is a difficult problem. Referral to physiotherapy is an easy option. It gives the doctor some time, and the patient is having treatment. But NHS physiotherapy adds little to an advice sheet. In a resource limited health service we should ask serious questions about the use of resources, appropriate management of patients, and referral patterns. Is back pain an occupational health, a lifestyle, or even a medical problem? Should we question the use of resources in ineffective physiotherapy practice and suggest diverting the resources to lifestyle and activity instructors? For one of the most common and debilitating conditions in the community, we have no real answer.

Hillhead Family Practice, 33 Stewartstown Road, Belfast BT11 9FZ (domhnall.macauley{at}ntlworld.com)

---

Paper p 708

Additional references w1-w3 are on bmj.com

Competing interests: None declared.

References

1. Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004;329: 708-11.[Abstract/Free Full Text]
2. Herbert RD, Maher CG, Moseley AM, Sherrington C. Regular review: Effective physiotherapy. BMJ 2001;323: 788-90.[Free Full Text]
3. Klaber Moffett J, Torgerson D, Bell-Syer S, Jackson D, Llewlyn-Phillips H, Farrin A, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ 1999;319: 279-83.[Abstract/Free Full Text]
4. Ferreira M, Ferreira P, Latimer J, Herbert R, Maher CG. Does spinal manipulative therapy help people with chronic low back pain? Aust J Physiothe 2002;48: 277-84.
5. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev 2004;(1): CD000447.
6. Dey P, Simpson CW, Collins SI, Hodgson G, Dowrick CF, Simison AJ, et al. Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. Br J Gen Pract 2004;54: 33-7.[Medline]
7. Clinical Standards Advisory Group (CSAG). Back pain. London: HMSO, 1994.
8. Little P, Smith L, Cantrell T, Chapman J, Langridge J, Pickering R. General practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines. BMJ 1996;312: 485-8.[Abstract/Free Full Text]
9. Royal College of Radiologists. Making the best use of a department of clinical radiology: guidelines for doctors. 4th ed. London: Royal College of Radiologists, 1998.
10. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain 2004;107: 176-90.[CrossRef][ISI][Medline]
11. Keen S, Dowell AC, Hurst K, Klaber Moffett JA, Tovey P, Williams R. Individuals with low back pain: how do they view physical activity? Fam Pract 1999;16: 39-45.[Abstract/Free Full Text]
12. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300: 1431-7.

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