Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. The back home trial: general practitioner-supported leaflets may change back pain behavior. A controlled trial of an educational pamphlet to prevent disability after occupational low back injury. Interferential therapy electrode placement technique in acute low back pain: a preliminary investigation. Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Should we give detailed advice and information booklets to patients with back pain? A randomized controlled factorial trial of a self-management booklet and doctor advice to take exercise for back pain. Mini-intervention for subacute low back pain: two-year follow-up and modifiers of effectiveness. Pitfalls of patient education. Limited success of a program for back pain in primary care. Treating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial. Randomized controlled trial of an educational booklet for patients presenting with back pain in general practice. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Reducing roentgenography use. Can patient expectations be altered? Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice. A randomized controlled trial investigating the efficiency of musculoskeletal physiotherapy on chronic low back disorder. Randomised controlled trial of physiotherapy compared with advice for low back pain. The Swedish back school in chronic low back pain. Part I. Benefits. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Intensive group training versus cognitive intervention in sub-acute low back pain: short-term results of a single-blind randomized controlled trial. Patient educational material in the management of low back pain in primary care. Good prognosis for low back pain when left untampered. A randomized clinical trial.
Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain.
                We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Follow-up was available for 95% of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects.
                Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71, respectively; P =.01) and the disability scale (5.88 vs 8.92, respectively; P<.001). Massage was also superior to acupuncture on the disability scale (5.89 vs 8.25, respectively; P =.01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P =.002; dysfunction scale: 6.29 vs 8.21, respectively; P =.05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care.
                Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain. A single-blind randomized controlled trial of a leaflet developed for people with acute low back pain was compared with the usual general practitioner management of back pain.
                To test the effectiveness of a patient information leaflet on knowledge, attitude, behavior, and function.
                Despite the commonality of back pain in general practice, little evidence on the effectiveness of simple interventions such as leaflets and advice on self-management has been reported. On the basis of a five-stage needs analysis, a simple leaflet was developed that considered the views of patients and health professionals.
                For this study, 64 patients with acute back pain were assigned to the leaflet or control group. The participants were visited at home after 2 days, 2 weeks, then 3, 6, and 12 months, where they completed a range of self-report measures. Behavioral aspects were discretely recorded by a "blinded" researcher. Primary outcomes were knowledge, attitude, behavior, and function.
                In all, 272 home visits were undertaken. The findings show that at 2 weeks, knowledge about sitting posture was greater in the leaflet group (P = 0.006), which transferred to a behavioral difference (sitting with lumbar lordosis support) when participants were unaware that they were being observed (P = 0.009). This difference remained significant at 3 months. Patients in the leaflet group also were better at maintaining a wide base of support when lifting a light object than the control subjects throughout all five assessments. There were no significant differences in the functional outcomes tested.
                This trial demonstrates that written advice for patients can be a contributory factor in the initial general practitioner consultation because it may change aspects of knowledge and behavior. This has implications for the management of acute back pain, with potential health gain. Randomized controlled trial.
                To test the ability of an educational pamphlet to improve recovery in terms of pain, work status, and health care utilization after occupational low back injury.
                Low back pain and disability persist as occupational health problems of epidemic proportions. Because interventions based on biomechanical models have had limited impact, recent educational approaches to preventing back problems have stressed psychosocial recovery issues.
                A pamphlet was developed by compiling activity resumption, self-care, and attitudinal advice from recent publications. The pamphlet was sent at random to half of all consenting workers reporting back pain within 11 days of occupational injury between 7/96 and 6/97. Three and 6 months later, back pain, work status, health care use, and pamphlet impact outcomes were assessed through structured telephone interviews.
                Of the 726 eligible workers, 486 consented to participate. Consenters and nonconsenters and intervention and control groups were similar in initial demographic variables. The pamphlet had no statistically significant impact at the 0.05 significance level on pain severity or reduction, health care visits, or work absence. Of the 229 pamphlet recipients, 129 thought it had provided useful information, but only 25 thought it had helped them return to work more quickly.
                In this trial, a pamphlet stressing psychosocial recovery issues did not prevent or reduce postinjury pain, health care use, or work absence. To determine the efficacy of interferential therapy (IFT) electrode placement technique compared with a control treatment in subjects with acute low back pain (LBP).
                Single-blind, randomized, controlled trial with a 3-month follow-up.
                Outpatient physiotherapy departments in hospital and university settings.
                A random sample of 60 eligible patients with back pain (28 men, 32 women) were recruited by general practitioners and self-referral for physiotherapy treatment and randomly assigned to 1 of 3 groups.
                (1) "IFT painful area" and The Back Book, (2) "IFT spinal nerve" and The Back Book, and (3) "Control," The Back Book only. Standardized IFT stimulation parameters were used: carrier frequency 3.85 kHz; 140 Hz constant; pulse duration 130 micros; 30 minutes' duration.
                Pain Rating Index, Roland-Morris Disability Questionnaire (RMDQ), and EuroQol were completed by subjects pretreatment, at discharge, and 3-month follow-up.
                All groups had significant improvements in all outcomes at follow-up. Subjects managed by IFT spinal nerve and The Back Book displayed both a statistically significant (p = .030) and clinically meaningful reduction in functional disability (RMDQ), compared with management via IFT painful area and The Back Book combined or The Back Book alone.
                The findings showed that IFT electrode placement technique affects LBP-specific functional disability, providing preliminary implications for future clinical studies. A single blind randomized controlled trial comparing two models of care for patients with acute simple low back pain.
                To compare two research-based models of care for acute low back pain and investigate the effect of the timing of physical intervention.
                National guidelines offer conflicting information on the delivery of physical treatment in the management of acute low back pain. The guidelines suggest two different models of care. Direct comparisons between these models are lacking in the literature. The present study aims to compare these approaches to the management of acute low back pain.
                Among 804 referred patients, 102 subjects met the specific admission criteria and were randomly assigned to an "assess/advise/treat" group or an "assess/advise/wait" group. The intervention consisted of biopsychosocial education, manual therapy, and exercise. Assessment of short-term outcome enables comparison to be made between intervention and advice to stay active. Assessment of long-term outcome enables comparison to be made between early and late intervention. Study outcomes of reported pain (Visual Analogue Scale), functional disability (the Roland and Morris Disability Questionnaire), mood (Modified Zung Self Rated Depression Score, Modified Somatic Perception Questionnaire, State-Trait Anxiety Inventory), general health (Euroqol), and quality of life (Short Form 36) were assessed at baseline, 6 weeks, 3 months, and 6 months.
                At 6 weeks, the assess/advise/treat group demonstrated greater improvements in disability, mood, general health, and quality of life than patients in the assess/advise/wait group (P < 0.05). Disability and pain were not significantly different between the groups at long-term follow up (P > 0.05). However, mood, general health, and quality of life remained significantly better in the assess/advise/treat group (P < 0.05).
                At short-term, intervention is more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life, and general health. The timing of intervention affects the development of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore, an assess/advise/treat model of care seems to offer better outcomes than an assess/advise/wait model of care. A controlled randomized clinical trial was performed.
                To investigate the effect of a light mobilization program on the duration of sick leave for patients with subacute low back pain.
                Early intervention with information, diagnostics, and light mobilization may be a cost-effective method for returning patients quickly to normal activity. In this experiment, patients were referred to a low back pain clinic and given this simple and systematic program as an outpatient treatment.
                In this study, 457 patients sick-listed 8 to 12 weeks for low back pain, as recorded by the National Insurance Offices, were randomized into two groups: an intervention group (n = 237) and a control group (n = 220). The intervention group was examined at a spine clinic and given information and advice to stay active. The control group was not examined at the clinic, but was treated with conventional primary health care.
                At 12-month follow-up assessment, 68.4% in the intervention group had returned to full-duty work, as compared with 56.4% in the control group.
                Early intervention with examination, information, and recommendations to stay active showed significant effects in reducing sick leave for patients with low back pain. Randomized controlled factorial trial.
                To assess the effectiveness of a booklet and of physician advice to take regular exercise.
                Educational booklets are one of the simplest interventions for back pain but have not been shown to alter pain and function. Although there is evidence that advice to mobilize is effective, doctors have also been advised to encourage regular exercise-but there is no evidence that such advice alone improves outcomes.
                Eight doctors from six practices randomized 311 patients with a new episode of back pain using sealed numbered opaque envelopes to receive a detailed self-management booklet, advice to take regular exercise, both, or neither. All groups were advised to mobilize and to use simple analgesia. Patients were telephoned during the first week after entry into the study, and after 3 weeks to assess a validated numerical pain/function score (0 = no pain normal activities to 100 = extreme pain no normal activities). Patients also returned a postal questionnaire in the first week with the Aberdeen pain and function scale, a knowledge score, and a reliable satisfaction scale (mean score of 4 items: 0 = not satisfied to 100 = extremely satisfied).
                Pain/function scores were obtained in 239 (77%) patients. There were interactions between exercise and booklet groups for both pain/function scores and the Aberdeen scale, which are unlikely to have been chance findings (P = 0.009 and P = 0.012, respectively). In comparison with the control group, there were reductions in the pain/function score in the first week with a booklet (-8.7, 95% CI -17.4 to -0.03) or advice to exercise (-7.9; -16.7 to 0.8) but much less effect with both together (-0.08, -9.0 to 8.9). Similarly, the Aberdeen scale was lower in the booklet group (-3.8, -7.7 to 0.07) and in the exercise advice group (-5.3; -9.3 to -1.38) but much less with both combined (-1.9, -5.8 to 2.1). There was no significant difference between groups in pain/function scores by week 3, when 58% reported being back to normal. Satisfaction was increased in booklet (7.9, 1.3 to 14.4) and exercise groups (7.4, 0.8 to 13.9)), and a booklet also increased knowledge (Kruskal-Wallis chi2 27.2, P = 0.001).
                Doctors can increase satisfaction and moderately improve functional outcomes in the period immediately after the consultation when back pain is worst, by using very simple interventions: either by endorsing a self-management booklet or by giving advice to take exercise. Previous studies suggest that simple advice and the same written information provide reinforcement. This study supports evidence that it may not be helpful to provide a detailed information booklet and advice together, where the amounts or formats of information differ. Randomized controlled trial.
                To Investigate the long-term effectiveness, costs, and effect modifiers of a mini-intervention, provided in addition to the usual care, and the incremental effect of a worksite visit for patients with subacute disabling low back pain (LBP).
                A mini-intervention was earlier proved to be an effective treatment for subacute LBP. Whether the beneficial effect is sustained is not known. Furthermore, modifiers of a treatment effect are largely unknown.
                A total of 164 patients with subacute LBP randomized into a mini-intervention (A, n = 56), a mini-intervention plus a worksite visit (B, n = 51), or the usual care (C, n = 57). Mini-intervention consisted of a detailed assessment of the patients' history, beliefs, and physical findings by a physician and a physiotherapist, followed by recommendations and advice. The usual care patients received the conventional care. Pain, disability, health-related quality of life, satisfaction with care, days on sick leave, and health care consumption and costs were measured during a 24-month follow-up. Thirteen candidate modifiers were tested for each outcome.
                There were no differences between the three treatment arms regarding the intensity of pain, the perceived disability, or the health-related quality of life. However, mini-intervention decreased occurrence of daily (A vs., C, P = 0.01) and bothersome (A vs. C, P < 0.05) pain and increased treatment satisfaction. Costs resulting from LBP were lower in the intervention groups (A 4670 Euros, B 5990 Euros) than in C (C 9510 Euros) (A vs. C, P = 0.04; and B vs. C, not significant). The average number of days on sick leave was 30 in A, 45 in B, and 62 in C (A vs. C, P = 0.03; B vs. C, not significant). The perceived risk for not recovering was the strongest modifier of treatment effect. Mental and mental-physical workers in A and B were less often on sick leave than those in C.
                Mini-intervention is an effective treatment for subacute LBP. Despite lack of a significant effect on intensity of low back pain and perceived disability, mini-intervention, including proper recommendations and advice, according to the "active approach," is able to reduce LBP-related costs. The perceived risk of not recovering was the strongest modifier of treatment effect. In alleviating pain, the intervention was most effective among the patients with a high perceived risk of not recovering. Low back pain patients seen in primary care were allocated randomly to one of two educational interventions or to usual care.
                To evaluate educational interventions designed to improve the outcomes of primary care for low back pain.
                Patients with back pain are frequently dissatisfied with their medical care and identify lack of information as the most insufficient aspect.
                In a large Health Maintenance Organization clinic, 293 subjects were allocated randomly to receive usual care, an educational booklet, or a 15-minute session with a clinic nurse, including the booklet and a follow-up telephone call. Outcome measures included satisfaction with care, perceived knowledge, participation in exercise, functional status, symptom relief, and health care use. Outcomes were assessed 1, 3, 7, and 52 weeks after the intervention.
                The nurse intervention resulted in higher patient satisfaction than usual care (P < 0.001) and higher perceived knowledge (P < 0.001). Self-reported exercise participation was also higher in the nurse intervention group after a 1-week follow-up period (97% vs. 65% in the other groups; P < 0.0001). There were no significant differences among the three groups in worry, symptoms, functional status, or health care use at any follow-up interval. Differences in self-reported exercise and perceived knowledge were no longer significant after 7 weeks.
                These findings challenge the value of purely educational approaches in reducing functional impact or health care use related to back pain and also challenge the value of fitness exercise in the most acute phase of back pain. Restorative exercise and palliative modalities are frequently used together for the treatment of acute low back pain. However, little is known about the effects of combining these treatments.
                To evaluate the efficacy of combining continuous low-level heat wrap therapy with directional preference-based exercise on the functional ability of patients with acute low back pain.
                A randomized controlled trial was conducted at three outpatient medical facilities.
                One hundred individuals (age 31.2+/-10.6 years) with low back pain of less than 3 months duration.
                The primary outcome measure was functional ability assessed by the Multidimensional Task Ability Profile questionnaire. Secondary outcomes were disability assessed by the Roland-Morris Disability Questionnaire and pain relief assessed by a 6-point verbal rating scale.
                Participants were randomized to one of four groups: Heat wrap therapy alone (heat wrap, n=25); directional preference-based exercise alone (exercise, n=25); combination of heat wrap therapy and exercise (heat+exercise, n=24); or control (booklet, n=26). Treatment was administered for five consecutive days and included four visits to the study center over 1 week.
                At 2 days after the conclusion of treatment (Day 7), functional improvement for heat+exercise was 84%, 95%, and 175% greater than heat wrap, exercise, and booklet, respectively (p<.05). Seventy-two percent of the subjects in the heat+exercise group demonstrated a return to pre-injury function compared with 20%, 20%, and 19% for heat wrap, exercise, and booklet, respectively (p<.05). Disability reduction for heat+exercise was 93%, 139%, and 400% greater than heat wrap, exercise, and booklet, respectively (p<.05). Pain relief for heat+exercise was 70% and 143% greater than exercise and booklet, respectively (p<.05).
                Combining continuous low-level heat wrap therapy with directional preference-based exercise during the treatment of acute low back pain significantly improves functional outcomes compared with either intervention alone or control. Either intervention alone tends to be more effective than control. A randomized controlled trial was used to evaluate an educational booklet on back pain for patients presenting to five group practices during one calendar year. The booklet had no immediate effect on consultations for back pain, but in the period from two weeks to one year after presentation significantly fewer patients in the group receiving the booklet consulted with back pain (35.6%) than in the control group (42.2%) (P less than 0.05). There were no significant differences between the booklet and control groups in certified absence from work owing to back pain. Referral to hospital, referral to physiotherapy, admissions to hospital and laminectomies were all less common in the booklet group. The reduction in the combined referral rate to physiotherapy and hospital, and the reduction in laminectomy rate almost reached statistical significance at the 5% level. In replying to a questionnaire sent one year after entry to the study 94.1% of respondents in the booklet group said that they had read the book, 84.0% said that they found it useful, and 68.0% said that they still had a copy. Scores on a 15-item test of knowledge about back pain were significantly higher in the group of patients who had received the booklet than in the control group. The results suggest that the booklet had some effect in altering both the knowledge and behaviour of patients with back pain. The provision of an educational booklet was a method of giving information which was appreciated by both patients and doctors. There are few data on the relative effectiveness and costs of treatments for low back pain. We randomly assigned 321 adults with low back pain that persisted for seven days after a primary care visit to the McKenzie method of physical therapy, chiropractic manipulation, or a minimal intervention (provision of an educational booklet). Patients with sciatica were excluded. Physical therapy or chiropractic manipulation was provided for one month (the number of visits was determined by the practitioner but was limited to a maximum of nine); patients were followed for a total of two years. The bothersomeness of symptoms was measured on an 11-point scale, and the level of dysfunction was measured on the 24-point Roland Disability Scale.
                After adjustment for base-line differences, the chiropractic group had less severe symptoms than the booklet group at four weeks (P=0.02), and there was a trend toward less severe symptoms in the physical therapy group (P=0.06). However, these differences were small and not significant after transformations of the data to adjust for their non-normal distribution. Differences in the extent of dysfunction among the groups were small and approached significance only at one year, with greater dysfunction in the booklet group than in the other two groups (P=0.05). For all outcomes, there were no significant differences between the physical-therapy and chiropractic groups and no significant differences among the groups in the numbers of days of reduced activity or missed work or in recurrences of back pain. About 75 percent of the subjects in the therapy groups rated their care as very good or excellent, as compared with about 30 percent of the subjects in the booklet group (P<0.001). Over a two-year period, the mean costs of care were $437 for the physical-therapy group, $429 for the chiropractic group, and $153 for the booklet group.
                For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question. A randomized controlled design superimposed on treatment as usual was used to compare the effects of a cognitive-behavior intervention aimed at preventing chronicity with two different forms of information.
                To develop a coping-oriented preventive intervention applicable in primary care, and to compare its impact with educational information.
                Preventing long-term disability resulting from spinal pain has proved difficult. The information provided by health care professions and early interventions aimed at preventing long-term disability may be important, but little scientific evidence exists concerning their use.
                A protocol for a six-session cognitive-behavior group intervention was developed on the basis of earlier research. The main focus was to prevent long-term disability by changing patients' behaviors and beliefs so they can cope better with their problems. Comparison groups received either a pamphlet shown earlier to have an effect, or a more extensive information package consisting of six installments. All the groups continued to receive treatment as usual in primary care. There were 243 patients with acute or subacute spinal pain who perceived that they were at risk for developing a chronic problem. These patients were randomized to the cognitive-behavioral intervention or one of the two information groups. Because the aim was to prevent long-term disability, the key outcome variables at the 1-year follow-up assessment were sick absenteeism and health care use. Other variables were pain, function, fear-avoidance beliefs, and cognitions.
                The comparison groups reported benefits. However, the risk for a long-term sick absence developing was lowered ninefold for the cognitive-behavior intervention group as compared with the risk for the information groups (relative risk, 9.3). Participants in the cognitive-behavior group also reported a significant decrease in perceived risk. In addition, the cognitive-behavior group demonstrated a significant decrease in physician and physical therapy use as compared with two groups receiving information, in which such use increased. All three groups tended to improve on the variables of pain, fear-avoidance, and cognitions.
                This study demonstrates that a cognitive-behavior group intervention can lower the risk of a long-term disability developing. These findings underscore the significance of early interventions that specifically aim to prevent chronic problems. This approach might be applied to primary care settings. Cognitive-behavioral pain management programs typically achieve improvements in pain cognitions, disability, and physical performance. However, it is not known whether the neurophysiology education component of such programs contributes to these outcomes. In chronic low back pain patients, we investigated the effect of neurophysiology education on cognitions, disability, and physical performance.
                This study was a blinded randomized controlled trial. Individual education sessions on neurophysiology of pain (experimental group) and back anatomy and physiology (control group) were conducted by trained physical therapist educators. Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)), and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1) straight leg raise (SLR), (2) forward bending range, and (3) an abdominal "drawing-in" task, which provides a measure of voluntary activation of the deep abdominal muscles. Methodological checks evaluated non-specific effects of intervention.
                There was a significant treatment effect on the SOPA(R), PCS, SLR, and forward bending. There was a statistically significant effect on RMDQ; however, the size of this effect was small and probably not clinically meaningful.
                Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability. The results suggest that pain neurophysiology education, but not back school type education, should be included in a wider pain management approach. Many roentgenographic tests, including lumbar spine roentgenograms, may be overutilized. We examined the psychological, functional, and financial consequences of omitting spine films for patients with back pain with little risk of underlying systemic illness. Patients were randomized to receive immediate roentgenograms (n = 49) or a brief educational intervention, with roentgenography only for failure to improve (n = 52). After three weeks, 73% of the roentgenography group believed "everyone with back pain should have an x-ray," vs 44% of the education group. After three months, although 31% in the education group had received roentgenograms, overall radiology charges were still far less than those of the roentgenography group. No serious diagnoses were missed, and symptom resolution, functional improvement, and satisfaction were similar for the two groups. Thus, eliminating or delaying spine films need not cause anxiety, dissatisfaction, or dysfunction. This strategy may modify future expectations of roentgenography use and reduce health care costs. To compare the effects of a minimal intervention strategy aimed at assessment and modification of psychosocial prognostic factors and usual care for treatment of (sub)acute low back pain in general practice.
                Cluster randomised clinical trial.
                60 general practitioners in 41 general practices.
                314 patients with non-specific low back pain of less than 12 weeks' duration, recruited by their general practitioner.
                In the minimal intervention strategy group the general practitioner explored the presence of psychosocial prognostic factors, discussed these factors, set specific goals for reactivation, and provided an educational booklet. The consultation took about 20 minutes. Usual care was not standardised.
                Functional disability (Roland-Morris disability questionnaire), perceived recovery, and sick leave because of low back pain assessed at baseline and after 6, 13, 26, and 52 weeks.
                The dropout rate was 8% in the minimal intervention strategy group and 9% in the usual care group. Multilevel analyses showed no significant differences between the groups on any outcome measure during 12 months of follow-up in the whole group or in relevant subgroups (patients with high scores on psychosocial measures at baseline or a history of frequent or prolonged low back pain).
                This study provides no evidence that (Dutch) general practitioners should adopt our new treatment strategy aimed at psychosocial prognostic factors in patients with (sub)acute low back pain. Further research should examine why our new strategy was not more effective than usual care. Randomized, single blind, controlled trial.
                To determine the efficacy of 2 components of musculoskeletal physiotherapy on chronic low back disorder.
                Musculoskeletal physiotherapy encompasses many treatment methods, however, manual therapy and exercises to rehabilitate spinal stabilization are the most frequently used. Despite their popularity, scant evidence supports their use on subjects with chronic low back disorder.
                A total of 346 subjects were randomized to manual therapy, a 10-week spinal stabilization rehabilitation program, or a minimal intervention control group. Data were collected at baseline, and 3, 6, 12, and 24 months after intervention. Outcome measures recorded intensity of low back pain, disability, handicap, medication, and quality of life. There were 4 main variables combined in a primary component analysis to form a single outcome measure (i.e., a measure of dysfunction).
                The results indicated statistically significant improvements in favor of the spinal stabilization group at the 6-month stage in pain (65.9% reduction in symptoms) and dysfunction (combined mean reduction of 134, standard error 23.84), and at the 1-year stage in medication (34.3% reduction in medication), dysfunction (combined mean reduction of 134, standard error 18.2), and disability (mean difference in change 15.71 Oswestry Disability Index, 95% confidence interval 19.3-10.01).
                As a component of musculoskeletal physiotherapy, the spinal stabilization program is more effective than manually applied therapy or an education booklet in treating chronic low back disorder over time. Both manual therapy and the spinal stabilization program are significantly effective in pain reduction in comparison to an active control. To our knowledge and up until now, this result has not been shown in patients with chronic low back disorder. To measure the effectiveness of routine physiotherapy compared with an assessment session and advice from a physiotherapist for patients with low back pain.
                Pragmatic, multicentre, randomised controlled trial.
                Seven British NHS physiotherapy departments.
                286 patients with low back pain of more than six weeks' duration.
                Routine physiotherapy or advice on remaining active from a physiotherapist. Both groups received an advice book.
                Primary outcome was scores on the Oswestry disability index at 12 months. Secondary outcomes were scores on the Oswestry disability index (two and six months), scores on the Roland and Morris disability questionnaire and SF-36 (2, 6 and 12 months), and patient perceived benefit from treatment (2, 6, and 12 months).
                200 of 286 patients (70%) provided follow up information at 12 months. Patients in the therapy group reported enhanced perceptions of benefit, but there was no evidence of a long term effect of physiotherapy in either disease specific or generic outcome measures (mean difference in change in Oswestry disability index scores at 12 months -1.0%, 95% confidence interval -3.7% to 1.6%). The most common treatments were low velocity spinal joint mobilisation techniques (72%, 104 of 144 patients) and lumbar spine mobility and abdominal strengthening exercises (94%, 136 patients).
                Routine physiotherapy seemed to be no more effective than one session of assessment and advice from a physiotherapist. The aim of this 12-month follow-up study was to evaluate the effect of the Swedish-type back school in chronic low back pain. 188 subjects completed the study (95 in the treatment group and 93 in the control group). The following were assessed: 1) subjective scores of pain and disability; 2) clinical measurement and evaluation including spinal mobility and strength measurement; 3) number and length of sick-leaves. At 12 months, subjective scores of pain and disability, and mobility of the lumbosacral section of the spine showed differences in the favour of the treatment group. There was no difference, however, in the number or the length of sick-leaves after the back school. It was concluded that patients with chronic or recurrent low back pain may get relief of subjective symptoms of low back pain from the back school. In addition to chronicity, there may be other factors affecting the outcome of treatment. Chronic low back pain is a common problem that has only modestly effective treatment options.
                To determine whether yoga is more effective than conventional therapeutic exercise or a self-care book for patients with chronic low back pain.
                Randomized, controlled trial.
                A nonprofit, integrated health care system.
                101 adults with chronic low back pain.
                12-week sessions of yoga or conventional therapeutic exercise classes or a self-care book.
                Primary outcomes were back-related functional status (modified 24-point Roland Disability Scale) and "bothersomeness" of pain (11-point numerical scale). The primary time point was 12 weeks. Clinically significant change was considered to be 2.5 points on the functional status scale and 1.5 points on the bothersomeness scale. Secondary outcomes were days of restricted activity, general health status, and medication use.
                After adjustment for baseline values, back-related function in the yoga group was superior to the book and exercise groups at 12 weeks (yoga vs. book: mean difference, -3.4 [95% CI, -5.1 to - 1.6] [P < 0.001]; yoga vs. exercise: mean difference, -1.8 [CI, -3.5 to - 0.1] [P = 0.034]). No significant differences in symptom bothersomeness were found between any 2 groups at 12 weeks; at 26 weeks, the yoga group was superior to the book group with respect to this measure (mean difference, -2.2 [CI, -3.2 to - 1.2]; P < 0.001). At 26 weeks, back-related function in the yoga group was superior to the book group (mean difference, -3.6 [CI, -5.4 to - 1.8]; P < 0.001).
                Participants in this study were followed for only 26 weeks after randomization. Only 1 instructor delivered each intervention.
                Yoga was more effective than a self-care book for improving function and reducing chronic low back pain, and the benefits persisted for at least several months. To evaluate the short-term effect of physical exercise and a cognitive intervention in low back pain.
                Randomized controlled trial.
                Ninety-three patients sick-listed for 8-12 weeks for sub-acute low back pain were randomized to an exercise regime (n = 30), a cognitive intervention (n = 34) or a control group (n = 29).
                Primary outcome measures were pain, disability, sick-listing and satisfaction with care. Secondary outcome measures were self-efficacy for pain and for function, fear-avoidance beliefs, emotional distress, generic health status and life satisfaction.
                Eighteen percent of subjects dropped out. Drop-out was most frequent in the exercise group. At 18 weeks after inclusion fear-avoidance beliefs were reduced in both intervention groups. The cognitive group demonstrated significant improvement in disability, self-efficacy for pain, emotional distress, general health and life satisfaction. Patients in the exercise group were significantly more satisfied with the treatment, and patients following the exercise protocol reduced pain significantly. No effect on sick-listing was seen.
                Cognitive intervention improved disability and may be feasible for most patients sick-listed in the sub-acute phase. Physical exercise reduced patients' symptoms, but requires high motivation by patients. Despite positive effects in intervention groups on variables considered as negative prognostic factors for long-term disability and sickness absence, interventions had no effect on sick-listing. Distributing educational material about low back pain to patients is increasingly seen as a possible adjunct to clinical management and a potential means of reducing the risk of the progression of the disorder toward chronic disability. Most back pain is managed in the primary care setting, where such material could save time and support the efforts of these practitioners. Recent evidence-based clinical guidelines for acute low back pain in U.S. and U.K. have advocated the use of educational material, but most of the available booklets are based on traditional biomedical theory about back pain and are neither evidence-based nor in line with recent guidelines. The few of these booklets that have been tested have had inconsistent effects. A new booklet has been developed which is evidence-based, in line with recent guidelines, and states its messages in a firm, uncluttered, and unambiguous manner. Preliminary studies show that it is readily accepted by patients, that they understand the messages, and that it creates a positive shift in beliefs about low back pain. Further studies regarding the use of this booklet are required to determine its effect on clinical outcomes. This randomized clinical trial was designed to determine the effect of treating low back pain as a benign, self limiting condition by light normal activity.
                Patients on sickness leave from work for more than 8 weeks were randomized into two groups: intervention (n = 463) and control (n = 512). Those in the intervention group were examined, provided information, and given instruction. Outcome was measured by return or failure to return to work (still on sickness leave).
                Survival analysis showed a highly significant (P = 0.000) reduction in sickness leave in the intervention group as compared with the control group. At 200 days 60% were still on sickness leave in the control group vs. 30% in the intervention group. A multivariate analysis with age, sex, and treatment as cofactors showed that sex had no effect on length of sickness leave and that treatment retained its effect when adjusting for differences in age composition.
                This study indicates that low back pain treated as a benign, self limiting condition recommended to light mobilization gives superior results as compared to treatment within a conventional medical system.
For patients with acute or subacute LBP, intensive patient education seems to be effective. For patients with chronic LBP, the effectiveness of individual education is still unclear.