Physiotherapy added to GP care results in long-term improvements for sciatica.

[ARRs and 95% CIs calculated by the CAP editor.]

Summary of: Luijsterburg PA, Verhagen AP, Ostelo RW, van den Hoogen HJ, Peul WC, Avezaat CJ, Koes BW (2008) Physical therapy plus general practitioners' care versus general practitioners' care alone for sciatica: a randomised clinical trial with a 12-month follow-up. European Spine Journal 17: 509-517. [Prepared by Julia Hush, CAP Editor.]

Commentary

Recent reviews have highlighted the lack of good quality evidence upon which to base clinical decision-making with patients who have lumbosacral radicular syndrome (LRS) (Luijsterburg et al 2007). This patient group is not addressed specifically in many current guidelines (van Tulder et al 2006). Therefore, this trial is timely.

The findings, from 135 patients, support other trials that show the tendency for patients in all groups to improve over time. However, more patients perceived themselves to be 'improved', in the longer-term, in the group that received active exercise therapy from a physiotherapist. In addition, significantly more patients with higher baseline disability were 'improved' in the physiotherapy group, suggesting the need to identify this subgroup of LRS patients before onward referral to physiotherapists. The lack of significant differences between groups on all other measures (leg pain, disability, absence from work, fear of movement) raises questions about whether the sample size was adequate in this trial to show relatively small differences between groups. It also asks what outcomes physiotherapy actually affects. Patients' overall view of their improvement, as measured by global perceived effect, may be capturing other related constructs such as patient satisfaction with treatment.

A minor issue is that participating GPs (n = 112) invited patients with acute LRS to participate in the trial. Most GPs would have referred only 1 or 2 patients to this trial, introducing potential for recruitment bias. For example, they may have approached patients with particular characteristics and avoided approaching others with more complex or difficult symptoms or case histories. A second issue is that, in this trial, physiotherapy consisted of the provision of advice and information about LRS and exercise therapy, not manual therapy approaches that are recommended for acute back pain in some guidelines.

Overall this trial shows that for some outcomes of relevance to patients, active exercise led by physiotherapists provides more benefit than GP care alone, however, more research is required, particularly with the LRS patient group who have high disability levels.

Nadine E Foster

Arthritis Research Campaign National Primary Care

Centre, Keele University, UK

References

Luijsterburg PA et al (2007) Eur Spine J 16: 881-899.

Van Tulder MW et al (2006) Eur Spine J 15: S169-S191.