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Special Issue |
Clinical Specialty Experts
(Orthopaedic Surgeon), American Academy of Orthopaedic Surgeons, USA
(Internist, Rheumatologist), American College of Physicians, USA
(Physiatrist)
(Internist), University of Pennsylvania, Philadelphia. USA
(Neurologist), American Academy of Neurology, USA
(Physical Therapist), American Physical Therapy Association, USA
(Physical Therapist), American College of Rheumatology, Association of Health Professionals, USA
(Physiatrist), American Academy of Physical Medicine and Rehabilitation, USA
(Internist), Cochrane Back Group
(Family Practice), American Academy of Family Physicians, USA
Ottawa Methods Group
(Public Health, specialization in epidemiology), Career Scientist, Ministry of Ontario Health (Canada), and Assistant Professor, Physiotherapy Program, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
(Epidemiology), Chair, Centre for Global Health, Institute of Population Health
(Epidemiology and Biostatistics), Professor and Chairman, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
(Kinesiology), Research Associate, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Civic Hospital, Ottawa, Ontario, Canada
(Medical Sociology), Medical Research Council Scholar, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
(Epidemiology), Research Associate, Department of Medicine, University of Ottawa, and Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Ontario, Canada
Ottawa Hospital, Ottawa, Ontario, Canada
Research Associate, Department of Medicine, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
Program of Physiotherapy, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
 | Abstract |
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Key Words: Clinical practice guidelines • Evidence-based practice • Low back pain • Meta-analysis • Physical therapy • Practitioner feedback survey • Rehabilitation • Systematic reviews
| INTRODUCTION |
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 TopAbstract INTRODUCTION METHODSSTATISTICAL ANALYSISRESULTSACUTE LBP (<4 WEEKS)SUBACUTE LBP (4-12 Weeks)CHRONIC LBP (>12 WEEKS)POSTSURGERY BACK PAINDISCUSSIONCONCLUSIONAppendix 1.Appendix 2.References |
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A number of different practitioners treat people with LBP. These include physicians, physical therapists, chiropractors, massage therapists, psychologists, kinesiologists, rehabilitation technicians, and others. The treatment goals are to relieve pain, reduce muscle spasm, improve range of motion (ROM) and strength, correct postural problems, and ultimately improve functional status.
A number of rehabilitation interventions are used in the management of people with LBP. Among current musculoskeletal interventions specific for LBP available to rehabilitation specialists, there are body mechanics and ergonomics training, posture awareness training, strengthening exerises, stretching exercises, activities of daily living (ADL) training, organized functional training programs, therapeutic massage, joint mobilizations and manipulations, mechanical traction, biofeedback, electrical muscle stimulation, transcutaneous electrical nerve stimulation (TENS), athermal modalities, cryotherapy, deep thermal modalities, superficial thermal modalities, and work hardening.8
The Philadelphia Panel (see article titled "Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions: Overview and Methodology") was convened to evaluate 9 selected rehabilitation interventions for LBP: thermotherapy, therapeutic massage, therapeutic exercises, electromyographic (EMG) biofeedback, mechanical traction, ultrasound, TENS, electrical stimulation, and combined rehabilitation interventions.
The purpose of this article is to describe the evidence-based clinical practice guidelines (EBCPGs) developed by the panel about rehabilitation interventions for LBP. The aim of developing the guidelines was to improve appropriate use of rehabilitation interventions for low back pain. The target users of these guidelines are physical therapists, physiatrists, orthopedic surgeons, rheumatologists, family physicians, and neurologists.
| METHODS |
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TopAbstractINTRODUCTIONMETHODSSTATISTICAL ANALYSISRESULTSACUTE LBP (<4 WEEKS)SUBACUTE LBP (4-12 Weeks)CHRONIC LBP (>12 WEEKS)POSTSURGERY BACK PAINDISCUSSIONCONCLUSIONAppendix 1.Appendix 2.References |
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Studies were eligible if they were randomized controlled trials (RCTs), nonrandomized controlled clinical trials (CCTs), or case control or cohort studies that evaluated the intervention of interest in a population with nonspecific LBP. Nonspecific LBP was defined as pain between the gluteal fold and the uppermost lumbar vertebrae and included postsurgery back pain. The outcomes of interest were functional status, pain, ability to work, patient global improvement, patient satisfaction, and quality of life. The interventions included massage, thermal therapy (hot or cold packs), electrical stimulation, EMG biofeedback, TENS, therapeutic ultrasound, therapeutic exercises, and combinations of these rehabilitation interventions. Studies whose control groups received "active" treatments were included. Concurrent treatments (eg, home exercises, educational booklets, advice on posture) were allowed if they were given in the same way to both the experimental and control groups. However, concurrent therapy that was given to one group but not to the other group was not accepted (eg, education by means of lectures for the control group were not accepted). No limitations based on methodological quality were imposed. Only English-, French-, and Spanish-language articles were accepted. Abstracts were not included.
A structured literature search was developed based on the sensitive search strategy for RCTs recommended by the Cochrane Collaboration9 and modifications proposed by Haynes et al.10 The search strategy was expanded to identify case control, cohort, and nonrandomized studies. The search was conducted in the electronic databases of MEDLINE, EMBASE, Current Contents, CINAHL, and the Cochrane Controlled Trials Register up to July 1, 2000. In addition, the registries of the Cochrane Field of Rehabilitation and Related Therapies and the Cochrane Musculoskeletal Group and the Physiotherapy Evidence Database (PEDro) were searched. The references of all included trials were searched for relevant studies. Content experts were contacted for additional studies.
Two independent reviewers (VAR, JP) appraised the titles and abstracts of the literature search, using a checklist with the a priori defined selection criteria. Relevant studies were retrieved and the full articles were assessed by 2 independent reviewers for inclusion. Data were extracted by 2 independent reviewers from included articles, using predetermined extraction forms regarding the population characteristics, details of the interventions, trial design, allocation concealment, and outcomes. Methodological quality was assessed by a 5-point validated scale that assigns 2 points each for randomization and double-blinding and 1 point for description of withdrawals.11,12 Differences in data extraction and quality assessment were resolved by consensus.
Data were analyzed at 3 approximate time points posttherapy: 1 month, 6 months, and 12 months. If outcomes were reported at different intervals, the closest time was used for these time points.
Because prognosis is widely thought to be dependent on disease duration, the analysis was conducted for 3 categories of LBP: acute (<4 weeks duration), subacute (4–12 weeks duration), and chronic (>12 weeks duration). If the population contained individuals with mixed acute and chronic disease durations, the study was excluded. If the population included individuals with mixed subacute and chronic disease durations, the study was classified as chronic.
| STATISTICAL ANALYSIS |
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TopAbstractINTRODUCTIONMETHODSSTATISTICAL ANALYSISRESULTSACUTE LBP (<4 WEEKS)SUBACUTE LBP (4-12 Weeks)CHRONIC LBP (>12 WEEKS)POSTSURGERY BACK PAINDISCUSSIONCONCLUSIONAppendix 1.Appendix 2.References |
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To calculate clinical improvement (defined as 15% improvement relative to a control), the absolute benefit and the relative difference in the change from baseline were calculated. Absolute benefit was calculated as the improvement in the treatment group less the improvement in the control group, in the original units. Relative difference in the change from baseline was calculated as the absolute benefit divided by the baseline mean (weighted for the treatment and control groups). For dichotomous data, the relative percentage of improvement was calculated as the difference in the percentage of improvement between the treatment and control groups.
The recommendations were graded by their level of evidence (I or II) and by the strength of evidence (A, B, or C). This grading system is shown in Table 1 and is described more fully elsewhere (see article titled "Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions: Overview and Methodology"). Briefly, grade A recommendations indicate that a clinically important benefit was shown in one or more RCTs. Grade B recommendations were assigned for interventions with a clinically important benefit shown in nonrandomized trials. Because there is less confidence in the results of nonrandomized studies, grade B recommendations required that the study be assigned a quality score of 3 or more out of 5. Grade C recommendations were assigned to interventions that have been compared with a control and have shown no evidence of effect in controlled trials. A master grid showing each rehabilitation intervention assessed and the strength and level of evidence is shown in Table 2. The report follows the same order as this grid, from left to right, top to bottom.
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| RESULTS |
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TopAbstractINTRODUCTIONMETHODSSTATISTICAL ANALYSISRESULTSACUTE LBP (<4 WEEKS)SUBACUTE LBP (4-12 Weeks)CHRONIC LBP (>12 WEEKS)POSTSURGERY BACK PAINDISCUSSIONCONCLUSIONAppendix 1.Appendix 2.References |
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| ACUTE LBP (<4 WEEKS) |
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TopAbstractINTRODUCTIONMETHODSSTATISTICAL ANALYSISRESULTSACUTE LBP (<4 WEEKS)SUBACUTE LBP (4-12 Weeks)CHRONIC LBP (>12 WEEKS)POSTSURGERY BACK PAINDISCUSSIONCONCLUSIONAppendix 1.Appendix 2.References |
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was excluded because the exercise groups also received an educational booklet on posture, which was not given to the control group). In the included RCTs, the exercises included McKenzie, back extension, Kendall flexion, and strengthening exercises (described in Appendix 2). The treatment schedule ranged from 1 to 3 sessions per week for 4 to 8 weeks.
Efficacy:
None demonstrated. Therapeutic exercises were no better than control therapy at improving function, ability to work, or reducing pain at 1 or 12 months. The pooled estimates at 1 month were not clinically important for pain (Fig. 2), function, or return to work. There was no difference in effect between types of exercise (McKenzie, Kendall, or strengthening). At 12 months after the start of therapy, there was no clinically important benefit on pain compared with untreated patients13,19 and no effect on sick leave days in 1 year (WMD=3 days, 95% confidence interval [CI] = –22 to 28 days).16
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommended there is poor evidence to include or exclude stretching or strengthening exercises alone (grade C for pain, function, and return to work) as an intervention for acute LBP. This recommendation agrees with the AHCPR21 and BMJ22 guidelines. In contrast, the QTF20 recommended the prescription of general exercises as an option to increase strength, ROM, and endurance but did not discriminate between different types of exercise. The BMJ22 reported that increased stress from therapeutic exercises may be harmful in acute conditions based on the RCT by Malmivaara et al15 that was included in our study.
Continuation of Normal Activities Versus Enforced Bed Rest for Acute LBP (<4 Weeks), Level I (RCT), Grade A for Return to Work (Clinically Important Benefit), Grade C for Pain and Function (No Benefit Demonstrated)
Summary of Trials:
One RCT (N=186)15 of continuing normal activities versus 2 days of enforced bed rest was included.
Efficacy:
Clinically important benefit was found for return to work. Continuation of normal activities resulted in 49% fewer sick days after 3 weeks relative to the enforced bed rest group, with an absolute difference of 3.4 sick days (95% CI=1.6–5.2 days) (Tab. 6, Fig. 3). The relative change with continuing normal activities was 10% better for functional status (Fig. 4) and 5% lower for pain relative to bed rest (Fig. 5). After 3 months, the normal activities group had 51% fewer sick days (4.5 days less, 95% CI=3–6 days), better function by 10% on the Oswestry scale, and 5% less pain on a 10-cm visual analog scale (VAS).
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel concluded that there is good evidence to include continuation of normal activities (grade A for return to work, grade C for pain and function) as an intervention for people with acute LBP. This conclusion agrees with the AHCPR21 guidelines. The BMJ22 guidelines do not discuss normal activities as an intervention. The QTF20 did not discriminate between normal activities and stretching and strengthening programs.
Practitioner Agreement
Practitioner Comments
Panel's Response:
The trial on which this recommendation is based excluded patients with disk involvement; therefore, the effects of continuing normal activity in patients with acute herniated disk involvement cannot be assessed. The Philadelphia Panel did not assess whether bed rest is an effective therapy for patients with acute LBP, but a Cochrane review on bed rest has just been completed. The results suggest that 2 to 7 days of bed rest has no effect on pain or functional status in patients with acute LBP and that there is no difference between short (2 days) or long (7 days) bed rest.23
Mechanical Traction for Acute LBP (<4 Weeks), Level I (RCT), Grade C for Pain and Patient Global Assessment (No Benefit Demonstrated)
Summary of Trials:
Three RCTs (N=176) of intermittent mechanical traction versus placebo for acute LBP were included.24–26 One RCT (N=16) compared vertical traction with bed rest.27 Disease duration was not well reported, but all patients were hospitalized. All trials included patients with back pain radiating below the knee.
Efficacy:
None demonstrated. For intermittent traction, there was no difference at 1 month between traction and placebo for number of patients with improved pain (relative risk [RR]=0.88, 95% CI=0.50–1.55) (Fig. 6) or pain (-3.4 mm on a 100-mm VAS, 95% CI = –21.2 to 14.5) (Fig. 7). For vertical traction at 1 month, there was no difference in pain (0.1 cm on a 10-cm VAS, 95% CI = –2.6 to 2.8) or patient global improvement (RR=1.14, 95% CI=0.88–1.49). No data were reported beyond 1 month.
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude mechanical traction alone (grade C for pain and patient global assessment) as an intervention for acute LBP. This recommendation is in accord with AHCPR21 and BMJ22 clinical recommendations compared with other guidelines. In contrast, the QTF20 recommended mechanical traction as an option to increase ROM. The BMJ22 reported potential harms, not validated in trials, including: (1) debilitation, (2) loss of muscle tone, (3) bone demineralization, and (4) thrombophlebitis.
Therapeutic Ultrasound for Acute LBP (<4 Weeks), Level II (CCT), Grade C for Pain (No Benefit Demonstrated)
Summary of Evidence:
One nonrandomized controlled trial (N=73) of continuous ultrasound versus placebo was included.28
Efficacy:
None demonstrated. There was no difference between continuous ultrasound and no treatment for pain improvement (Fig. 8). However, range of flexion and extension was improved after 1 month by 28 degrees (95% CI=26°–29°).28 No data were available for functional status, strength, quality of life, or return to work at 1 month, and no data were available beyond 1 month.
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude therapeutic ultrasound alone (grade C for pain) as an intervention for acute LBP. This EBCPG agrees with AHCPR21 and BMJ22 guidelines, even though they make general statements to consider physical interventions, including therapeutic ultrasound. In contrast, the QTF20 recommended therapeutic ultrasound as an option to diminish muscle spasm and relieve symptomatic pain. However, ultrasound was classified as thermotherapy, which is misleading, because pulsed ultrasound does not produce thermal effects. There is insufficient information regarding adverse effects.22
TENS for Acute LBP (<4 Weeks), Level I (RCT), Grade C for Pain or Function (No Benefit Demonstrated)
Summary of Trials:
One RCT (N=58) compared TENS and placebo for the management of people with acute LBP.29 All patients were treated with mobility and strengthening exercises. The TENS consisted of 15 minutes of high-frequency TENS followed by 15 minutes of acupuncture-like TENS.
Efficacy:
None demonstrated. There was no difference in self-rated VAS pain (Fig. 9), functional status, strength, or ROM at 1 month.29
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude TENS alone (grade C for pain) as an intervention for acute LBP. This EBCPG agrees with the AHCPR21 and BMJ22 recommendations. In contrast, the QTF20 recommended TENS as a useful modality for symptomatic pain relief, but this may refer to electroanalgesia rather than TENS specifically. Insufficient information is available regarding adverse effects.22
Interventions With Insufficient Data for Acute LBP (<4 Weeks)
No evidence with acceptable research design, interventions, group comparisons, and outcomes were identified for thermotherapy, electrical stimulation, therapeutic massage, or EMG biofeedback. This lack of evidence concurs with both the QTF20 and AHCPR21 guidelines. However, the QTF20 recommended thermotherapy, massage, and EMG biofeedback as potential interventions for acute LBP.
Some trials of combinations of rehabilitation interventions for acute LBP were identified, but these trials were excluded due to poor definitions of the interventions, populations, or nonstandard outcomes. The Philadelphia Panel rated the evidence as insufficient for a recommendation. In contrast, both QTF20 and BMJ22 recommended that rehabilitation specialists use physical interventions at their own discretion to relieve spasm; reduce inflammation and pain; increase strength, ROM, and endurance; and improve functional status.
| SUBACUTE LBP (4–12 Weeks) |
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TopAbstractINTRODUCTIONMETHODSSTATISTICAL ANALYSISRESULTSACUTE LBP (<4 WEEKS)SUBACUTE LBP (4-12 Weeks)CHRONIC LBP (>12 WEEKS)POSTSURGERY BACK PAINDISCUSSIONCONCLUSIONAppendix 1.Appendix 2.References |
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Efficacy:
Clinically important benefit on pain relief and patient-assessed global condition was demonstrated by meta-analysis. Therapeutic exercises provided more pain relief relative to the control by 10% for strengthening exercises alone,30 11% for Kendall flexion,32 50% for McKenzie exercises,32 and 57% for McKenzie exercises31 after 1 month (P<.05) (Tab. 7). Functional status was improved relative to the control by 11% with McKenzie exercises31 and 15% with strengthening exercises30 (Fig. 10). Patient global improvement was 17% to 24% better with Kendall exercises relative to the control, but not statistically different32 (Tab. 8). We could not assess the use of these interventions in patients with neurological or radicular pain, as these diagnostic groups were excluded from the original trials.
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is good evidence to include extension, flexion, and strengthening exercises as interventions for subacute LBP (grade A for pain, function, and patient global assessment). However, we did not assess the use of these interventions for patients with neurological or radicular pain, as these diagnostic groups were excluded from the original trials. This is in partial concordance with AHCPR,21 which recommended low-stress aerobic exercises within the first 4 weeks (acute LBP). The BMJ22 is also in agreement with our EBCPG concerning extension, flexion, and strengthening exercises. The QTF20 recommended the prescription of general exercises as an option to increase strength, ROM, and endurance. The BMJ reported that the increased stress of therapeutic exercise is potentially harmful in subacute conditions.
Practitioner Agreement
Practitioner Comments
Panel's Response:
The guideline has been modified to specify that we did not assess the use of these interventions for patients with neurological/radicular pain. The individualized approach to exercise prescription is a widespread clinical opinion but has little empiric evidence. The effects of individualized approaches could not be assessed, because the trials report group outcomes. Education was not assessed by the Philadelphia Panel. An educational booklet on posture and biomechanics was provided to the patients in both groups of 1 trial,31 but not to the other 2 trials. When the Davies et al study32 was excluded from the analysis, the results remained the same; therefore, exclusion of this study would not change the recommendation.
Mechanical Traction for Subacute LBP (4–12 Weeks), Level 1 (RCT), Grade C for Patient Global Assessment and Return to Work (No Benefit Demonstrated)
Summary of Trials:
Two RCTs (N=212) of static traction compared with a placebo were included.33,34 One trial was excluded due to lack of a control group (traction was compared with heat).35 Both trials included patients with radiating pain.
Efficacy:
None demonstrated. There was no clinically important benefit for patient global assessment at 1 month (Fig. 11) or for return to work at 12 months (Fig. 12).34
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude mechanical traction alone (grade C for patient global assessment and return to work) as an intervention for subacute LBP. This EBCPG agrees with AHCPR21 and BMJ22 recommendations. The QTF20 recommended mechanical traction as an option to increase ROM. The BMJ22 reported the following potential harms of traction: (1) debilitation, (2) loss of muscle tone, (3) bone demineralization, and (4) thrombophlebitis.
| CHRONIC LBP (>12 WEEKS) |
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TopAbstractINTRODUCTIONMETHODSSTATISTICAL ANALYSISRESULTSACUTE LBP (<4 WEEKS)SUBACUTE LBP (4-12 Weeks)CHRONIC LBP (>12 WEEKS)POSTSURGERY BACK PAINDISCUSSIONCONCLUSIONAppendix 1.Appendix 2.References |
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Efficacy:
Clinically important benefit was demonstrated for pain relief and functional status. Five RCTs (N=361) demonstrated percentage reductions in pain relative to the control group of 7%,50 20%,44 23%,45 26%,46 and 60%47 (Tab. 9, Fig. 13). Two RCTs of nursing aides with back pain showed no difference in number of patients with pain improvement after 1 month (RR=1.45, 95% CI=0.59–3.56).48,49 Functional status was improved in 3 RCTs (N=209) relative to the control group by 7% with stretching exercises50; 17% with strengthening, stretching, and aerobics45; and 47% with strengthening exercises46 (Tab. 10). The pooled meta-analysis results were statistically significant for function (standardized mean difference [SMD]=0.36, 95% CI=0.1–0.6). There was no difference in ROM, strength, or return to work. One RCT (N=56)52 found no difference between flexion and extension exercises for pain or patient global assessment at 1 month posttherapy.
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Strength of Published Evidence in Comparison With Other Guidelines:
The Philadelphia Panel found good scientific evidence (level I) of clinically important benefit on pain and function with stretching or strengthening exercises. In contrast, the QTF20 found no scientific evidence for general exercises. The QTF20 reviewed only one of the trials that was included in our meta-analysis.
Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is good evidence to include stretching, strengthening, and mobility exercises (grade A for pain and function, grade C for return to work) as interventions for chronic LBP. The BMJ22 is in agreement with this EBCPG concerning strengthening exercises. The QTF20 also recommended the prescription of general exercises as an option to increase strength, ROM, and endurance. The BMJ22 reported that exercise could have adverse effects due to increased stress on the spine.
Practitioner Agreement
Practitioner Comments
Panel's Response:
The evidence for functional status is based on 3 RCTs, 2 of which demonstrated greater than 15% improvement in function relative to the control group. Different exercises were not lumped; each article is presented separately in Tables 9 and 10. The McKenzie approach was evaluated for chronic LBP by one trial, which showed a 20% relative improvement in pain compared with the control, thus meeting the Philadelphia Panel criteria for clinically important improvement.44 The study by O'Sullivan et al53 was excluded because neuromotor retraining was compared with a combined approach using exercises, heat, massage, and ultrasound, but not the control. The panel was not able to make any recommendations about neuromotor retraining, as there are no controlled studies evaluating the effectiveness of this intervention.
Mechanical Traction for Chronic LBP (>12 Weeks), Level I (RCT), Grade C for Pain, Function, Patient Global Assessment, and Return to Work (No Benefit Demonstrated)
Summary of Trials:
Four RCTs (N=176) of mechanical traction (2 intermittent and 2 static) versus placebo or untreated were included.54–57 One RCT was excluded because it was impossible to separate the data for each treatment group.58 One RCT was excluded because the traction force was only 10% of body weight and considered a placebo therapy.47
Efficacy:
None demonstrated. There was no difference in pain, function, or patient global assessment. The point estimate for pain at 3 months favored the control group in the pooled analysis (WMD = –6.3, 95% CI=–15.8 to –3.1) (Fig. 14). However, work absence was shorter in the traction group after 6 months (35 days with traction versus 45 days without traction, but this was not statistically significant).
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude mechanical traction alone (grade C for pain, function, patient global assessment, and return to work) as an intervention for chronic LBP. This EBCPG is in accordance with BMJ22 clinical recommendations compared with other EBCPGs, but not the QTF,20 which recommended mechanical traction as an option to increase ROM. According to the BMJ,22 potential harms, not validated in trials, include (1) debilitation, (2) loss of muscle tone, (3) bone demineralization, and (4) thrombophlebitis.
Therapeutic Ultrasound for Chronic LBP (>12 Weeks), Level II (CCT), Grade C for Pain (No Benefit Demonstrated)
Summary of Trials:
One RCT (N=36) of continuous therapeutic ultrasound versus a placebo59 was included.
Efficacy:
None demonstrated. There was no difference in pain improvement between continuous therapeutic ultrasound and sham therapeutic ultrasound after 1 month of therapy (Fig. 15).59 No data were reported for functional status, ROM, strength, quality of life, or return to work, and no data were available beyond 1 month.
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude therapeutic ultrasound alone (grade C for pain) as an intervention for chronic LBP. This EBCPG is in concordance with BMJ22 guidelines, despite a general statement on physical interventions, including therapeutic ultrasound. In contrast, the QTF20 recommended the prescription of therapeutic ultrasound grouped with thermotherapy as an option to diminish muscle spasm and relieve symptomatic pain. There is insufficient information regarding adverse effects.22
TENS for Chronic LBP (>12 Weeks), Level I (RCT), Grade C for Pain and Function (No Benefit Demonstrated)
Summary of Trials:
Four CCTs (N=235) of TENS versus a placebo were included.50,60–62 One observational study (N=78) was included, although some patients did not have LBP (but had other pain syndromes such as cervicalgia or phantom limb pain).63 This study also allowed patients to self-select TENS based on its perceived effectiveness during 2 weeks of in-hospital therapy. One CCT was excluded because, of the 16 patients assigned to the treatment group, only 6 had LBP.64 One RCT was excluded because the patient population was people with chronic myalgia and the etiology was not described.65 Two RCTs were excluded due to lack of an appropriate control group (both used a form of massage as the comparison intervention).66,67 Two crossover RCTs were excluded because both the treatment and placebo groups received acupuncture needles. Acupuncture is thought to have an effect of its own and was excluded from the scope of this review.68,69
The method of application was acupuncture-like in one RCT.50 Two trials used high-frequency (>10 Hz) TENS,60,61 2 trials used low-frequency (4 Hz) TENS,62 1 trial alternated between both low- and high-frequency TENS,50 and the other trial did not report the characteristics in sufficient detail.63
Efficacy:
None demonstrated (Fig. 16). There was no difference in the pooled estimate of patient-rated pain at 1 month posttherapy (SMD=–0.2, 95% CI=–0.4 to 0.1). This SMD is equivalent to a difference between treatment and control groups of 4 mm on a 100-mm VAS for pain. In addition, there were no differences between placebo and TENS for functional status, ROM, or strength at 1 month posttherapy. At 3 to 6 months posttherapy, there was no difference in self-rated pain or activity level in any study. The pooled results were not affected by the quality of the trial, the frequency of TENS, or whether acupuncture or traditional TENS was applied. No side effects were reported for TENS.
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude TENS alone (grade C for pain and function) as an intervention for chronic LBP. This EBCPG is in concordance with the BMJ22 recommendations. In contrast, the QTF20 recommended TENS as a rehabilitation modality for symptomatic pain relief, but this recommendation may include other forms of electroanalgesia. Insufficient information regarding adverse effects was reported by the BMJ.22
EMG Biofeedback for Chronic LBP (>12 Weeks), Level I (RCT), Grade C for Pain and Function (No Benefit Demonstrated)
Summary of Trials:
Five RCTs (N=162) of EMG biofeedback versus a control for chronic LBP were included.72–76
Efficacy:
None demonstrated. Meta-analysis showed no effect on pain relief, functional status, or ROM after 1 month of therapy (Fig. 17). There were no data for quality of life or return to work. There were no data beyond 1 month.
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Clinical Recommendations Compared With Other Guidelines:
The Philadelphia Panel recommends that there is poor evidence to include or exclude EMG biofeedback alone (grade C for pain and function) as intervention for chronic LBP. The BMJ22 made no recommendation due to conflicting evidence related to EMG biofeedback. The QTF20 recommended EMG biofeedback as an option to reduce muscle spasm. Postural exercises were not studied by the QTF.20 There is insufficient information regarding adverse effects for EMG biofeedback.22
Interventions for Chronic LBP With Insufficient Data
No eligible studies were found on which to base recommendations for thermotherapy, massage, or electrical stimulation (Tab. 5). This lack of evidence was also reported by the BMJ22 and QTF20 guidelines. However, both the QTF20 and BMJ22 recommend massage as an intervention for chronic LBP. Massage may have beneficial effects, as shown in an RCT published in abstract format.75
Combinations of rehabilitation interventions were classified by the Philadelphia Panel as having insufficient data to make a recommendation due to different combinations, unvalidated outcomes, and poor description of the actual interventions. This is in disagreement with the BMJ22 and the QTF,20 which both make general statements about the use of physical interventions in combination at the discretion of the rehabilitation specialist.
Deep abdominal stabilization exercises for patients
