Clinical Question: Do patients with back pain who undergo physical therapy benefit more than those simply given advice to remain active?

Setting: Outpatient (specialty)

Study Design: Randomized controlled trial (single-blinded)

Allocation: Concealed

Synopsis: Investigators started with 286 patients with low back pain in the United Kingdom who were referred by their general practitioner or a subspecialist for physical therapy. The patients were invited to participate in the study and were randomized (allocation assignment was concealed) to receive a booklet from a physical therapist advising them to remain active or the booklet plus six treatment sessions of physical therapy using joint mobilization and manipulation, soft tissue techniques, and strengthening exercises. Analysis was by intention to treat, although follow-up after one year was only 70 percent. Approximately 10 percent of the patients randomized to receive advice-only also received physical therapy.

The primary outcome was the change in the Oswestry Disability Index, a scale completed by patients that ranges from zero percent (no disability) to 100 percent (totally disabled). Levels of disability were similar one year after treatment assignment. Quality-of-life scores were the same at one year as measured by the 36-item Short-Form Health Survey. Patients reported significantly more benefit at two and six months if they received physical therapy, but it is very possible—given that patients were aware of their treatment—that this finding reflects a placebo effect. Other research also has not shown a benefit of physical therapy for low-back pain (Fritz JM, et al. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine July 1, 2003; 13:1363–72).

Bottom Line: Physical therapy sessions do not offer additional long-term benefit over simple advice to remain active in patients referred for physical therapy. Patients initially perceive a benefit while being treated, but this benefit disappears by one year. (Level of Evidence: 2b)