Wednesday, October 14, 2015 Activity, Education, and Time May Play Biggest Role in Recovery From LBP According to a new randomized clinical trial, early physical therapy may be related to minor short-term improvements in disability for individuals with low back pain (LBP), but the changes aren't really much different than what patients experience when they receive no treatment—provided those patients have been well-educated on the importance of staying as physically active as possible, that is. The study analyzed data from 207 participants with recent-onset LBP who were divided into 2 groups—1 receiving an education on LBP followed by 4 sessions of physical therapy, and the other group receiving no further care after the education session. To assess improvement, authors of the study looked at patient-reported scores on the Oswestry Disability Index (ODI) at baseline, 4 weeks, 3 months, and 1 year after enrollment, as well as a few other measures, including the Pain Catastrophizing Scale (PCS) and Fear Avoidance Belief Questionnaires for physical activity and work. The study was published in JAMA, the journal of the American Medical Association (abstract only available for free). All participants began by participating in what authors describe as an educational approach "likely beyond what typically occurs," with a session that educated them "about the favorable prognosis of LBP" and "advised [them] to remain as active as possible." Participants also received a book about back care and reviewed its contents with the researcher. After that, the participant groups went their separate ways. The physical therapy groups received sessions that began within 72 hours of enrollment in the trial, and were scheduled over 3 weeks, with 2 sessions in week 1, and a session each in weeks 2 and 3. The first session began with an assessment, followed by spinal manipulation, and instruction on spinal range-of-motion exercises to be performed at home. The second session included manipulation, review of exercises from the previous session, and instruction on trunk-strengthening exercises to be performed at home. The third and fourth sessions included exercise review and progression. The "usual care" group receive no further intervention. After 3 months—the primary outcome target of the researchers—the patients in the physical therapy group showed significant improvement in ODI scores (a 0-100 scale, with lower scores indicating less disability), with a drop in average scores from 41.3 to 6.6. This drop was better than the change recorded by the usual-care group, whose average score dropped from 40.9 to 9.8, but did not exceed the 6 point difference that researchers believe would have constituted a medically clinically important difference (MCID). Currently there is no single agreed-upon MCID score for the ODI. Similar significant changes were seen at 4 weeks, and again, while these changes happened for both groups, the physical therapy group's change was more significant, albeit with a relatively modest between-group difference. By the end of 1 year, no between-group differences were found. Secondary measures were a mixed bag, with some statistically significant outcomes favoring the physical therapy group slightly at 3 months (primarily in PCS scores and fear avoidance beliefs for work), but most others showing no between-group differences. The study has received attention from media outlets including National Public Radio, which quoted lead author Julie Fritz, PT, PhD, FAPTA, as saying that "The average amount of improvement over 100 patients was small, but within that group, there were certainly patients that experienced large improvement and then others who didn't receive much benefit at all." In its report on the study, HealthDay News notes that "the new study results aren't an indictment of physical therapy," adding that physical therapy "can be useful for someone who needs assistance starting to exercise or staying active while recovering from back pain." In that article, Fritz is quoted as saying that while most people can recover from LBP on their own, "physical therapy can help accelerate the process a little bit." Other physical therapist authors of the study include John Magel, PT, PhD, DSc, FAAOMPT, OCS, Anne Thackeray, PT, PhD, Whitney Meier, PT, DPT,COMT, OCS, and Gerard Brennan, PT, PhD. More information on the research is available at the National Institutes of Health clinical trials website. The association's PTNow evidence-based practice resource offers a clinical practice guideline on LBP developed by the association's Orthopaedic Section. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.