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Combination of exercise and advice was slightly better than placebo for subacute low back pain.

Summary of: Pengel LHM, Refshauge KM, Maher CG, Nicolas MK, Herbert RD, McNair P (2007). Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial. Annals of Internal Medicine 146: 787-796. [Prepared by Gro Jamtvedt and Kare Birger Hagen, CAP Editors.]


This trial is a highly-needed and well-conducted study which highlights a core question in clinical practice with low back pain (LBP) patients: should patients with subacute LBP have advice only, exercises only, or a combination of both? The results are in line with previous studies in subacute LBP concluding that advice and exercise each have beneficial effects. They add important new knowledge to the field, however, by demonstrating that combined exercise and advice is substantially more effective than either intervention alone.

The enhanced effect of combining a cognitive intervention with an exercise intervention may be explained by the complex nature of LBP and the fact that most patients get a nonspecific diagnosis. Hence, combining interventions with different fundamental mechanisms of action (cognitive or exercise) may increase the odds of targeting patients' underlying problems. Additionally, although the underlying mechanisms of action theoretically differ between a cognitive intervention and exercise, the interventions obviously have the potential to complement and heighten each other. A previous study has shown that combining cognitive intervention and exercises, ensuring a good link between the information given and the content of the exercise, can challenge the effect of spinal surgery (Brox 2003). In the present study, potential placebo effects were controlled for by providing sham advice and sham exercise. The fact that the same clinicians provided both the real advice and the sham advice may have introduced a bias. The equivalent problem probably did not occur for the distinction between exercise and sham exercise, because the sham exercise involved a totally different practical procedure. However, the distinction between advice and sham advice would have been much more challenging. Furthermore, to present sham exercises by providing ultrasound and electrotherapy may be questioned. Would not patients with LBP know the difference between exercises and passive treatment modalities? In our opinion, this may have lead to a nocebo effect for this particular intervention.


Brox JI et al (2003) Spine 28: 1913-1921.

Kjersti Storheim and Margreth Grotle

Ulleval University Hospital, Oslo
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Title Annotation:Appraisal: Critically Appraised Papers
Author:Jamtvedt, Gro; Hagen, Kare Birger
Publication:Australian Journal of Physiotherapy
Geographic Code:8AUST
Date:Dec 1, 2007
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