Efficiency and Costs of Medical Exercise Therapy, Conventional Physiotherapy, and Self-Exercise in Patients With Chronic Low Back Pain: A Pragmatic, Randomized, Single-Blinded, Controlled Trial With 1-Year Follow-Up.

Efficiency and Costs of Medical Exercise Therapy, Conventional Physiotherapy, and Self-Exercise in Patients With Chronic Low Back Pain: A Pragmatic, Randomized, Single-Blinded, Controlled Trial With 1-Year Follow-Up

Torstensen TA, Ljunggren AE, Meen HD, et al (Norwegian Center for Physiotherapy Research and Division of Physiotherapy Science, University of Bergen, Bergen; The Norwegian University of Sports and Physical Education, Oslo; Astra Norg A/S, Skarer, Norway), Spine. 1998;23:2616-2624.

This study compared the efficiency of 3 different interventions for chronic low back pain regarding outcome measures and costs at 3 functional levels. These interventions were (1) medical exercise therapy (MET), (2) conventional physical therapy (CP), and (3) self-exercise (SE), which involved walking and maintaining an ordinary activity level.

Patients with chronic low back pain or radicular pain who were sick-listed between 8 and 52 weeks (age range=20-65 years) were included in the study. Other inclusion criteria included having been employed, having completed other types of treatment, and having no preference regarding the 3 treatment alternatives.

The design was a controlled, randomized, single-blinded, multicenter study with a 1-year follow-up period. After selection, all patients completed a thorough standardized assessment by a physician and were assigned to 1 of 3 intervention groups. Thirty-three physiotherapists from 20 private practice physical therapy clinics in Oslo participated in the study. All patients in the 2 treatment groups received 36 treatments, each lasting 1 hour (3 treatments per week for 12 weeks). Patients in the SE group (n=70) walked for 1 hour 3 times a week for 12 weeks. Follow-up assessments for all patients took place at the termination of treatment and at 1 year later.

The progressively graded exercise MET system used in the study sought to normalize function by using (1) specific exercises that mobilized hypomobile areas in the spine and (2) stabilizing exercises for other parts. Patients in this group (n=71) were given 7 to 9 different exercises and performed 2 to 3 sets of 20 to 30 repetitions each. The grading of the exercises made it possible to exercise with virtually no increase in pain. Patients assigned to the CP group (n=67) received a combination of conventional therapy, such as heat or cold, massage, stretching, electrotherapy, traction, and a few exercises on a treatment table.

The efficiency of the 3 different interventions was assessed by measuring pain, functional activities of daily living, and return to work and by using cost-benefit analysis. Pain intensity was recorded using 2 visual analog scales, 1 for back pain and 1 for leg pain. Functional capacities and disability level were measured using the Oswestry Low Back Pain Disability Questionnaire. Patients also rated their satisfaction with the treatment. At the end of 15 months, return to work status and total costs were recorded for each patient. One-way ANOVAs were used for differences between the 3 different intervention groups at any given time, and repeated measures ANOVAs were used for differences over time. The level of significance was set at .05.

In comparison with the SE group, the pain intensity after treatment was significantly reduced in the low back and the lower extremities in both the MET and CP groups. There was no difference, however, in pain intensity between the MET and CP groups after treatment. At the 1-year follow-up, pain intensity in the low back showed no significant difference among the groups, whereas pain intensity in the lower extremity was still significantly lower in the MET and CP groups in comparison with the SE group.

When the pretreatment and posttreatment values were compared within each group, pain occurring after treatment ended showed a significant difference in favor of the MET and (;P groups over the SE group. Again, no difference was found between the MET and CP groups. The results were similar at the end of the 1-year follow-up period. After treatment, a difference in function existed in favor of the MET and CP groups compared with the SE group. Function, however, was similar between the MET and CP groups after treatment. At the end of the 1-year follow-up period, function remained significantly higher in the MET and CP groups compared with the SE group, but no difference was seen between the MET and CP groups.

When the costs of treatment were added to the costs of sick leave and compared, the MET group had costs that were $122,531 less and the CP group had costs that were $254,200 less than those in the SE group. Return-to-work rates were equal for all 3 intervention groups at assessment 15 months after therapy began. The authors felt that the study showed the efficiency of medical exercise therapy and conventional physical therapy in treating low back pain compared with untreated patients.

William J Barnes, PT
Lincoln Physical Therapy Associates
and Work Adjustment Center
Lincoln, Neb