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Multidisciplinary rehabilitation for chronic low back pain: systematic review
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7301.1511 (Published 23 June 2001) Cite this as: BMJ 2001;322:1511
Data supplement
Table A Content of 12 multidisciplinary interventions for the treatment of chronic low back pain (LBP) tested in 10 randomised controlled trials
Intervention Goal and approach Setting and duration Physical component Psychological component Social/occupational component Notes Alaranta 1994 To excel on physical performance and overcome fear of pain. Intensive physical training Two inpatient rehabilitation facilities. 42 h/week for three weeks plus home exercise programme 37 h/week. Aerobic exercise, stretching, weights,
relaxation, rest
5 h/week. Cognitive-behavioural groups
Individual consultation for work problems Fixed duration of components, but individualised exercise loads with gradual increase Basler 1997 Not clear. To improve pain, coping, and disability. Psychological therapy added to medical Three outpatient centres specialising in medical treatment of chronic pain. Twelve 2.5 h sessions Medication, nerve blocks, PM including TENS Cognitive-behavioral groups plus education, relaxation, recreational activities, and posture training Standardised psychological treatment with a manual. Medical treatment prescribed ad hoc Bendix 1996 To restore function. Focus on intensive training in group setting One outpatient centre specialising in treatment of back problems. 39 h/week for three weeks plus 6 h/week for three additional weeks Aerobics, weight training, work simulation, work hardening, stretching, recreation (ball games, swimming)
10 h/week. BT in groups (coping, changing negative sensation of pain, setting goals) plus RT, bio-feedback, and counselling
A 3 h course on job seeking (finding out, applying for, and evaluating job options) Also traditional back school* 1 h per week according to Swedish principles Bendix 1995, I1 Same as Bendix 1996 Same as Bendix 1996 Same as Bendix 1996 Same as Bendix 1996 Same as Bendix 1996 Same as Bendix 1996 Bendix 1995, I2 Same as Bendix 1996 Outpatient LBP centre. 2 h twice a week for 6 weeks 45 minutes of warming up and weights 75 minutes of BT in groups of 7-8 No back school education Harkäpää 1989, I1 Not clear. To improve pain and function. To prevent long term disability 3 weeks of group inpatient therapy at a Spa or rehabilitation centre plus 2 week refresh course 18 months later PM, massage, back exercises, weights, relaxation exercise Two structured group discussions on how to cope with pain Four session back school* Harkäpää 1989, I2 Not clear. To improve pain and function. To prevent long term disability Outpatient group sessions twice a week for 8 weeks plus 8 session refresh course 18 months later PM, back exercises, relaxation exercises Two structured group discussions on how to cope with pain Four session back school* Jückel 1990
Not stated. European Spa treatment Average of 29.7 days in Spa hospital Water exercises, group exercises,
PM, and massage
Type not described. Aimed at decreasing disability, anxiety, and depression Standardised programme. Detailed description not available Lukinmaa 1989 To treat the biological, psychological, and social reasons for patients’ symptoms and signs 5 days of individualised assessment in hospital, plus follow up treatments as needed Assessment by physiatrist with referral for PM, epidural injections, and exercise as needed (11% had inpatient rehabilitation) Cognitive supportive discussions as needed (mean of 3 sessions, 149 minutes) or referral to psychiatrist Contacts with employer and meetings with relatives as needed. Mean of 119 minutes spent with social worker Back school* and video. Regular meetings of multidisciplinary team and patient Mitchel 1994 To restore function and return to work. Sports medicine approach Two outpatient clinics. 280 h of treatment over 8 weeks Ice applications, stretching, weights,
simulation of occupational tasks
BT, CT, RT, biofeedback, individual and group counselling Education and counselling to address attitudinal barriers,
job satisfaction and entitlement, and family problems
General programme agreed for the study. Specific components and early discharge at discretion of clinics Nicholas 1992 Not clear. To control pain and improve coping One 2 h and one 1.5 h session/week for 5 weeks. Outpatient programme in group setting Hydrotherapy, mobilisation, home exercise programme Five 1 h sessions of group CT and BT plus relaxation tapes Education on anatomy, postural advice, medical terms, and common medications Nicholas 1991 To control pain and improve coping One 2 h and one 1.5 h session/week for 5 weeks. Outpatient programme in group setting 2-2.5 h/week. Hydrotherapy, mobilisation, home exercise programme
Five 1 h sessions of four kinds of psychological treatment (BT, BT+RT, CT, CT+RT) Mini back school education* by a physiotherapist PM=physical modalities, such as heat or cold applications, transcutaneous electrical nerve stimulation (TENS) (manual and exercise therapy listed separately); BT=behavioural therapy; RT=relaxation therapy; CT=cognitive therapy.
*Most back school education consisted of theoretical classes in small groups on back anatomy, causes of low back pain, diagnosis, medication use, and postural or ergonomic advice.
Table B Outcomes of multidisciplinary treatment in patients with chronic low back pain (LBP) reported in 10 randomised controlled trials. Outcomes are reported for the compared intervention (I) and control (C) groups in the original units measured in the trials. All numbers have been rounded to one decimal place
Trial Global improvement Pain severity Functional status Quality of life Employment Other Alaranta 1994 No of patients with WHO occupational handicap 3-5 at baseline, 1 year: I=22/150, 17/150; C=6/138, 22/138 Part of the pain and function Million index Mean Million index (100=worst) at baseline, 3 months, 1 year: I=45.1, 28, 29.2; C=44.5, 35.4, 35.6 No of patients retired with disability at 1 year: I=4; C=7 Mean No of sick days/year at baseline, 1 year: I=57.8, 33.9; C=58.5, 36.9
Of six psychological scales, improvement on social desirability and socialisation in males <40 years old Basler 1997 Mean pain score (10=worst) at baseline, post-treatment: I=4.6, 4.1; C=4.0, 4.2 Mean physical functioning score (5=worst) at baseline, post-treatment: I=2.0, 1.6; C=1.8, 1.8 Improvement on social roles, mental performance, and 3/7 coping sub-scales Bendix 1996 Median back pain score (10=worst) at baseline, 4 months, 2 years, 5 years: I=6, 5.7, 6, 5; C=6, 6.9, 6.5, 5 Median functional score (30=worst) at baseline, 4 months, 2 years, 5 years: I=17, 12.1, 16, 12; C=16, 16.8, 15, 16 No of patients working, in school, or seeking job at baseline, 4 months, 2 years, 5 years: I=12/45, 29/45, 26/45, 23/46; C=8/49, 14/49, 25/49, 21/42 No of patients on permanent pension at baseline, 4 months, 2 yeard, 5 years: I=0, 6/45, 19/50, 22/46; C=0, 8/49, 20/49, 21/42
Median No of days on sick leave for those working at 4 months, 2 years: I=10, 15; C=122, 123 Intervention decreased No of contacts with health system
Bendix 1995, I1 Median back pain score (10=worst) at baseline, 4 months, 1 year, 2 years, 5 years: I=5.3, 2.7, 3.3, 3, 4; C=5.4, 4.4, 5.3, 5, 5 Median functional score (30=worst) at baseline, 4 months, 1 years, 2 years, 5 years: I=15, 8.5, 8.9, 10, 8; C=14.4, 13.5, 13.7, 14, 14 No of patients working, in school, or seeking job at baseline, 4 months, 1 year, 2 years, 5 years: I=9/40, 30/40, 34/38, 32/40, 25/37; C=13/31, 15/31, 18/31, 15/28, 11/29 No of patients on permanent pension at baseline, 2 years, 5 years: I=0/40, 7/40, 11/37; C=0/35, 9/28, 17/29
Median No of sick leave days for those working at 4 months, 1 year, 2 years, 5 years: I=25, 52, 2.5, 13; C=13, 100, 11, 11 Intervention decreased No of contacts with health system
Bendix 1995, I2 Median back pain score (10=worst) at baseline, 4 months, 1 year, 2 years, 5 years: I=5.7, 5.6, 6.5, 5, 6; C=5.4, 4.4, 5.3, 5, 5 Median functional score (30=worst) at baseline, 4 months, 1 year, 2 years, 5 years: I=14.8, 16.1, 16.4, 17, 16; C=14.4, 13.5, 13.7, 14, 14 No of patients working, in school, or seeking job at baseline, 4 months, 1 year, 2 years, 5 years: I=8/35, 14/35, 12/34. 15/34, 10/31; C=13/31, 15/31, 18/31, 15/28, 11/29 No. of patients on permanent pension at baseline, 2 years, 5 years: I=0/31, 17/34, 21/31; C=0/35, 9/28, 17/29
Median No of sick leave days for those working at 4 months, 1 year, 2 years, 5 years: I=122, 295, 37, 88; C=13, 100, 11, 11 Intervention increased No of contacts with health system
Harkäpää 1989, I1 No of patients with no gain over 30 months: I=96/152; C=102/144 Mean pain index (400=worst) at baseline, 3 months, 18 months, 30 months: I=184.9, 128, 157, 162; C=175.8, 161, 161, 158 Mean LBP disability index (45=worst) at baseline, 3 months, 18 months, 30 months: I=16.7, 13.7, 15.5, 15.4; C=16.7, 16.2, 16, 15.7 Mean No of sick days/year for LBP at baseline, 30 months: I=5.2, 6.8; C=3.7, 8.5 No of patients on disability pension 4.5 years after treatment: I=15/157; C=18/160
Marked improvement in trunk strength, other physical measures, and compliance with self care programme Harkäpää 1989, I2 No of patients with no gain over 30 months: I=100/137; C=102/144 Mean pain index (400=worst) at baseline, 3 months, 18 months, 30 months: I=178.6, 144, 173, 168; C=175.8, 161, 161, 158 Mean LBP disability index (45=worst) at baseline, 3 months, 18 months, 30 months: I=17.6, 14.6, 17, 16.5; C=16.7, 16.2, 16, 15.7 Mean No of sick days/year for LBP at baseline, 30 months: I=6.0, 8.2; C=3.7, 8.5 No of patients on disability pension 4.5 years after treatment: I=12/159; C=18/160
Improvement in trunk strength, other physical measures, and compliance with self care programme Jückel 1990 Mean pain score (10=worst) at baseline, post-treatment: I=4.6, 3.7; C=5.8, 5.9 Mean AIMS score (10=best) at baseline, post-treatment: I=8.3, 8.6; C=8.2, 7.7 Improvements on depression and anxiety scores Lukinmaa 1989 No of patients cured at 1 year: I=16/86; C=15/72 Mean pain VAS (100=worst) at baseline, 1 year: I=50, 47.3; C=47.9, 44.6 Mean R&M index (24=worst) at baseline, 1 year: I=10.9, 8.0; C=11.2, 8.3. No of patients on permanent pension at 1 year: I=17/91; C=14/95 No of patients with sick leaves ³ 10 days: I=56/91; C=37/95
Mean healthcare cost/year in Finnish currency: I=8300; C=8100 Mitchel 1994 Reported for subset,32 but no specific data for LBP available Mean No of days on benefits at 4 months, 12 months, 24 months after injury: I=130, 315, 410; C=125, 325, 454 Mean insurer’s cost in Canadian currency: I=$41 000;
C=$43 500
Nicholas 1992 Mean pain rating (5=worst) at baseline, 5 weeks, 6 months: I=3.1, 3.1, 2.9; C=2.8, 2.7, 2.7 Mean self SIP (100=worst) at baseline, 5 weeks, 6 months: I=30.9, 18.8, 18.3; C=32.1, 26.1, 25.3 Improvements in coping and self efficacy Nicholas 1991* Mean pain rating (5=worst) at baseline, 5 weeks, 6 months, 12 months: I=3.0, 2.5, 2.4, 2.5; C=2.8, 3.1, 2.9, 2.9 Mean self SIP (100=worst) at baseline, 5 weeks, 6 months, 12 months: I=31.8, 19.4, 20.3, 15.8; C=27.6, 23.9, 23.8, 17.3 Improvements in coping and self efficacy WHO=World Health Organization; AIMS=arthritis impact measurement scales; VAS=visual analogue scale; R&M index=Roland and Morris disability index; SIP=sickness impact profile.
*Values are the weighted means of four intervention groups versus two control groups.
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