Topical Seminar: PHYSIOTHERAPY: MORE EFFECTIVE THAN SIMPLE ADVICE? S23

disability. Despite a huge body of research in the area of LBP, optimummanagement remains elusive, in part due to the complex multidimensional(bio-psycho-social) nature of the problem. In recent years a number ofcritical reviews and randomized controlled trials (RCT) have evaluatedand compared different physiotherapy interventions and approaches. Theresults from most reviews are inconclusive and invariably suggest theneed for further research. Likewise the results of many RCTs struggleto demonstrate differences in outcomes between specific interventions.One exception is the finding that activity is generally better than rest.However most studies that have compared active protocols have foundlittle if any difference in outcomes between the different protocol groups.The lack of specific effects are helpful in that they take the ‘mystery’ outof exercise therapy and back pain. Common sense can be introduced into acommon problem. The fact that any activity is beneficial for most patientswith back pain, but the specific type of activity is not important, suggeststhat personal preference for specific or general activity may be the mostimportant consideration for treatment – not least because this increasesthe probability that the individual will actually engage in the activity. It isaxiomatic that the generalized physical, psychological and social benefitsof activity will only accrue if the activity is done.Notwithstanding the above, serious health practice questions are raisedwhen simple verbal advice is shown to be as effective as a more ex-pensive course of physiotherapy. Research studies that have demonstratedminimal benefit from traditional medical or physical therapy practices havegenerated a great deal of written and verbal opinion and commentaryamongst all stakeholders. Unfortunately the interesting questions raisedby the original study are missed as the debate is often polemic andtends towards oversimplification of the problem and overinterpretation ormisinterpretation of the results. Education and advice is actually a keycomponent of best physiotherapy practice.Speakers in this workshop will debate the pertinent issues of LBP and man-aging the patient with LBP in a complex (and sometimes flawed) healthcare system. Specifically they will discuss the evidence for and againstthe efficacy and effectiveness of different physiotherapy interventions forLBP.

78PHYSIOTHERAPY IS NO MORE EFFECTIVE THAN SIMPLEADVICE FOR LOW BACK PAIN, . . . OR IS IT?

M.J. Simmonds °. Canada

Abstract not available at time of printing.

79EVIDENCE FOR PHYSIOTHERAPY FOR BACK PAIN: BRIEFINTERVENTIONS VS MORE INTENSIVE MANAGEMENT

J.A. Klaber Moffett °. University of Hull, Hull, UK

Background and Aims: Physiotherapy is very commonly used for man-aging back pain and encompasses a wide range of approaches. Differentpractitioners favour different methods. Claims of effectiveness are howeveroften not substantiated. The aim of this review is to interpret the availableevidence and recommendations on physiotherapy management of backpain and suggest a way forward.Method: As part of the development of European guidelines for themanagement of back pain, representatives from 12 European countries pro-duced guidelines for the management of acute and chronic back pain basedon systematic reviews and individual randomised trials (Cost B13 2006).Physical treatments including exercise, manual therapy, and behaviouraltreatments were considered. Patient education and brief interventions werealso reviewed.Results: On the basis of their findings this guideline group were unable torecommend physical therapy modalities such as interferential therapy, lasertherapy, short wave diathermy, ultrasound or heat therapy. However, theydid recommend supervised exercise therapy and behavioural therapy suchas graded activity as a first line approach for chronic back pain. Theysuggested that manipulation/mobilisations should be considered. Briefinterventions of various kinds including those provided by physiotherapists

were recommended, in particular where a return to normal activities isencouraged.Conclusions: A stepped approach may be most appropriate. Back painpatients first need to be triaged to exclude any potential red flags. For nonspecific low back pain, it is important not to over-medicalise the problemand avoid unnecessary referrals to hospital. Many patients respond to abrief educational intervention encouraging a return to usual activities assoon as possible. If the patient is still not improving after a few weeks,at least sufficiently to allow a return to activities, then a short course ofphysiotherapy should be considered. This could include pain managementtechniques, manual therapy and exercise. Beliefs, including expectations,fears and wider concerns related to their back pain need to be addressed.These may be related to the treatment, or concerns about the familyand/or work situation. Patients with persistent and disabling pain may needmore intensive interventions such as a functional restoration programme.This can be as effective as surgical spinal fusion The chosen interventionwhether a brief intervention or a more intensive hands on approach is alsolikely to depend on:• Patient preference;• Practitioner preference.Some patients will prefer to have a brief intervention which could helpthem take control of their problem reducing dependency on the healthcare system. They should be given this option. Physiotherapists generallyuse a treatment approach with which they are most familiar and thereforemost experienced at. This may imply a limitation in choice for the patient.However, credibility and faith in the treatment always play an importantrole in the success of the treatment. The attitude and beliefs of both thepractitioner and the patient have an impact.

References

COST B13: (2006). “European Guidelines for the Management of Low Back Pain.”European Spine Journal 15 (Suppl 2): 169–300.

80THERE IS A GAP BETWEEN EVIDENCE AND PRACTICE

H.M. Wittink1,2 °. 1Dept Physiotherapy, Hogeschool Utrecht, Utrecht,2Dept of Physiotherapy Research, Utrecht University, Utrecht, TheNetherlands

Systematic reviews and meta-analyses are meant to make our life easieras they represent a literature synthesis of the best available evidence, thushelping us make sense of the avalanche of new and important researchpublished every day. Systematic reviews make use of an evidence hierarchyin which the Randomized Controlled Trial (RCT) continues to be the “goldstandard” research design. Systematic reviews seem a wonderful tool forfinding and then implementing research findings into practice.Then why is evidence based practice so difficult for physiotherapists? Thismay not have anything to do with physiotherapists not being interested,but rather that the research findings advocated have no meaning to themand their daily practice. RCTs only represent about 10% of our body ofknowledge (papers published in a given year). RCTs often involve a selectgroup of patients that are treated in a highly protocolized manner, which inno way reflects daily clinical practice. One of the assumptions underlyingthese studies is the assumption of homogeneity; all patients are the sameand are therefore treated the same. None of us treat this way in the clinic.We need to develop our own physiotherapy research design, one thatis much closer to daily clinical practice and that is able to bridge thegap between research and real world practice. Some of the featureswould involve a varied approach to the patient within an episode ofcare, (change of intervention as symptoms change) and individualizedoutcome measures, targeted to the patient’s goals. Some of these designsare emerging. Several papers have now appeared that discuss classificationschemes, other papers are looking at prognostic or risk factors. These mayin time allow us to better match treatment to the individual patient andtarget those who need our treatment the most.