Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations.

Trials of manipulative treatment have been compromised by, amongst other things, different definitions of the therapeutic procedures involved. This paper describes a spinal manipulation package agreed by the UK professional bodies that represent chiropractors, osteopaths and physiotherapists. It was devised for use in the UK Back pain Exercise And Manipulation (UK BEAM) trial--a national study of physical treatments in primary care funded by the Medical Research Council and the National Health Service Research and Development Programme. Although systematic reviews have reported some beneficial effects of spinal manipulation for low-back pain, due to the limited methodological quality of primary studies and difficulties in defining manipulation, important questions have remained unanswered. The UK BEAM trial was designed to answer some of those questions. Early in the design of the trial, it was acknowledged that the spinal manipulation treatment regimes provided by practitioners from the three professions shared more similarities than differences. Because the trial design specifically precluded comparison of the effect between the professions, it was necessary to devise a homogenous package representative of, and acceptable to, all three. The resulting package is 'pragmatic', in that it represents what happens to most people undergoing manipulation, and 'explanatory' in that it excludes discipline-specific variations and other ancillary treatments.

Guidelines for low back pain: changes in GP management.

BACKGROUND: Management guidelines are aimed at reducing inappropriate practice and improving efficiency; however, the effectiveness of many guidelines has yet to be confirmed. This study targets GPs' management of back pain and its relationship with the recent management guidelines. OBJECTIVES: We aimed to investigate changes in GP management of low back pain, low back pain episode duration and time before consultation, over a 5-year period. METHOD: A case series report of 574 patient notes was collected from a large practice in North Yorkshire (January 1992-March 1997). In addition, 713 referral notes from 26 practices across North Yorkshire were collected. The patients were potential subjects for a larger randomized controlled trial evaluating the effectiveness of an exercise programme. Both groups of data were analysed by identifying trends over time and using log linear regression. RESULTS: Recommendation of activity or exercise was found to be a trend increasing over time. In contrast, recommendation to rest was found to be a trend decreasing over time. Activity or exercise was more frequently recommended to younger patients. There was evidence that individuals are seeking a GP consultation more quickly. CONCLUSIONS: The gap between GP practice and the recent guidelines appears to be reducing. However, many variations in practice still exist. Evidence of decreasing time before consultations may indicate that the level of self-care by low back pain patients is decreasing. Although management guidelines may have some effect, there is some way to go before back pain management is optimized.

Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences.

OBJECTIVE: To evaluate effectiveness of an exercise programme in a community setting for patients with low back pain to encourage a return to normal activities. DESIGN: Randomised controlled trial of progressive exercise programme compared with usual primary care management. Patients' preferences for type of management were elicited independently of randomisation. PARTICIPANTS: 187 patients aged 18-60 years with mechanical low back pain of 4 weeks to 6 months' duration. INTERVENTIONS: Exercise classes led by a physiotherapist that included strengthening exercises for all main muscle groups, stretching exercises, relaxation session, and brief education on back care. A cognitive-behavioural approach was used. MAIN OUTCOME MEASURES: Assessments of debilitating effects of back pain before and after intervention and at 6 months and 1 year later. Measures included Roland disability questionnaire, Aberdeen back pain scale, pain diaries, and use of healthcare services. RESULTS: At 6 weeks after randomisation, the intervention group improved marginally more than the control group on the disability questionnaire and reported less distressing pain. At 6 months and 1 year, the intervention group showed significantly greater improvement in the disability questionnaire score (mean difference in changes 1.35, 95% confidence interval 0.13 to 2.57). At 1 year, the intervention group also showed significantly greater improvement in the Aberdeen back pain scale (4.44, 1.01 to 7.87) and reported only 378 days off work compared with 607 in the control group. The intervention group used fewer healthcare resources. Outcome was not influenced by patients' preferences. CONCLUSIONS: The exercise class was more clinically effective than traditional general practitioner management, regardless of patient preference, and was cost effective.