Changing with the times.

To the, Editor:

I am responding to the excellent Guest Editorial by Anthony Delitto rifled "Research in Low Back Pain: Time to Stop Seeking the Elusive 'Magic Bullet'" (1) in the March 2005 issue of the Journal. In it, he lists 2 possible explanations "for the persistent shortfalls in the well-documented failure to implement evidence in practice, a problem that certainly is not unique to physical therapy." (l(P206)) The first explanation he offers is professional rigidity and unwillingness to change with the times. The second reason suggested is the possibility that there are deficiencies in the evidence.

I would like to offer 3 other possibilities for the relative absence of evidencebased practice for benign back pain in the physical therapy community. First, physical therapists may be limiting themselves with respect to where they look for the evidence. Second, even when physical therapists read relevant literature regarding evidence-based practice for benign back pain, they may not understand how to put it into practice. Third, physical therapists may not want to implement evidence-based practice for benign back pain. Such practice is considered to be effective and efficient. In fact, according to more than one study, it is possible that the average number of visits for an episode of evidence-based practice for benign back pain is no more than 3 or 4 visits. That is much less remunerative than current practice. Could resistance to evidence-based practice, therefore, be morivated by profit? Perhaps all 5 explanations interact to prevent implementation of evidence-based practice for benign back pain in the physical therapy community.

With respect to a "magic bullet," I must say that my reading of existing evidence leads me to believe that a "magic bullet" has already been found. I have learned that the crucial element in timely recovery from benign back pain is the patient's attitude toward back pain. A study by Mannion et al (2) was the Volvo Award Winner in Clinical Studies in 1999. These researchers found that all exercise modalities--group aerobics, specific back exercises, and equipment-assisted exercise--demonstrated the same improvements, with aerobics being the most economical. Their abstract stated: "The general lack of treatment specificity suggests that the main effects of the therapies were educed not through the reversal of physical weaknesses targeted by the corresponding exercise modality, but rather through some 'central' effect, perhaps involving an adjustment of perception in relation to pain and disability." (2(p2435)) One sample of studies (3-5) reinforces the finding that outcome (return to work and regular activity) is profoundly related to patients' understanding of and attitude toward back pain. The excellent results demonstrated in studies such as these, among many others, convinced me that, when I work with a patient with back pain, I should first attend to his or her beliefs about the condition and pain. That approach has rewarded me with average care episodes of only a few visits in addition to considerable patient satisfaction.

I believe physical therapists could and should be at the center of evidencebased practice for benign back pain. To do it, however, will require the hardest element of all to achieve--a change in beliefs and attitudes.

References

(1) Delitto A. Research in low back pain: time to stop seeking the elusive "magic bullet" [guest editorial]. Phys Ther. 2005;85:206-208.

(2) Mannion AF, Muntener M, Taimala S, Dvorak J. A randomized clinical trial of three active therapies for chronic low back pain. Spine. 1999;24:2435-2448.

(3) Al-Obaidi SM, Nelson RM, Al-Awadhi S, Al-Shuwaie N. The role of anticipation and fear of pain in the persistence of avoidance behavior in patients with chronic low back pain. Spine. 2000:25:1126-1131.

(4) Indahl A, Halderson EH, Holm S, et al. Five year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine. 1998;23:2625-2630.

(5) Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. Spine. 1995;20:473-477.

Donna Kimmel, PT PhD

Psychologist and Physical Therapist

2906 Aquarius Ave

Silver Spring, MD 20906-1813

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