I don't know what the article in Spine covered--the series showed the
effects of a relatively "comprehensive" PT intervention of therapeutic
modalities, massage, exercise, aquatic therapy as compared to all of those
interventions with the addition of joint mobilization and an occasional
cortisone injection (average of 1 per patient) with 6, 12 and 24 month
follow up. What was found was that the incorporation of joint mobilization
(various techniques at the descretion of the PT based on the evaluation
which is the typical manner in which mobilization is used--what is used
depends on the objective findings that day and changes from visit to visit)
and, when needed, cortisone injection, allowed for statistically better
results than without joint mobilization and cortisone injections. In
Sweden, the use of "active" interventions is standaard of care, with
outcomes that are better than "passive" interventions. Furthermore, the
benefit of these studies is they acknowledge that back pain is multifaceted
(pardon the pun) and requires joint mobility, muscle flexibility, muscle
strengthening both dynamically and aerobically and at times requires the
use of modalities to control pain and inflammation. Any one treatment in
isolation will not show statistical significance on a large population of
patients. This is one of the points made in the research and the reason
they did not try and isolate one treatment by itself but rather one
treatment IN
ADDITION to a standard protocol. If spine research went this direction,
there would be many more answers than questions. This is the main
criticism I have of Deyo's research is that it has tried to look at "one
intervention" which may work for disease but, from my experience, does not
work for musculoskeletal. Just as an example, take the typical acute
injury intervention (RICE for rest, ice, compression and elevation and
exercise) All of this interventions have an impact on swelling--the
combination has a dramatic influence. If you looked at any of these alone,
the effects aren't as dramatic (which I have done. For those interested,
compression and elevation have the most immediate effect, exercise the most
long term effect at keeping the swelling down, with ice coming in last but
having the effect of preventing further fluid leakage). Anyway, these are
some of my thoughts on back research.
At 01:13 PM 2/25/99 EST, you wrote:
>Herb:
>
>The only article I could find from your list (thanks for the
>references) was the one from Spine.
>
>Correct me if I am wrong (i mean it - I am no expert on research
>methods), but this study showed that a specific manual therapy
>treatment was superior to standard physiotherapy. That doesn't really
>show that getting Physio Rx is any better than any other option,
>including no treatment at all. It may well be that "usual" PT is
>actually harmful !! (as suggested by Deyo I think ) Usual
>Physio treatment can be harmful by emphasizing a passive role for
>the patient in recieving treatments such as ice, heat, "myofascial
>release", short-wave etc. thus delaying resumption of normal activity
>and promoting the "sick role" for the LBP sufferer. However it may be
>true that the specific Rx given in the study is superior to letting
>the natural Hx of the disorder take its course - can't tell.
>
>Is there anything to say that PT is better than no treatment at all
>in acute or sub acute LBP, aside from manip/mobilization??
>
>If you find that reference from Britain please let me know.Thanks
>
>
>Michael Meddows
>Virginia Beach
>
>> Date: Wed, 24 Feb 1999 17:16:48 -0500
>> Subject: RE: BACK CARE BIAS?
>> From: Herb Silver <[log in to unmask]>
>> To: [log in to unmask]
>> Reply-to: [log in to unmask]
>
>
>
>> >Is there any evidence that conclusively supports what you seem to imply -
>> >i.e. that physio is HIGHLY effective for low back pain?
>>> Michael Meddows
>
>> The BEST studies that I have seen were studies performed by the Department
>> of Family Medicine Uppsala University, Uppsal Sweden. The primary
>> researcher was Stefan Blomberg. They are published in book form under the
>> title "A pragmatic approach to low-back pain including manual therapy and
>> steroid injections: A multicentre Study in pPrimary Health Care" ACTA
>> UNIVERSITATIS UPSALIENSIS Comprehensive Summaries of Uppsala Dissertations
>> from the Faculty of Medicine 394, 1993. The specific articles are as
follows
>>
>> Blomberg S, et al. A controlled, multicentre trial of manuall therapy in
>> low-back pain; iniitial status, sick-leave and pain score during follow-up.
>> Scandianaviouan Journal of Prmary Health CAre 1992; 10:170-78
>>
>> Blomberg S Eet al. A randomized study of manual therapy with steroid
>> injections i low-back pain; telephone interview folow-up pain, disabliity,
>> recovery and rug consumption. European Spine Journal 1994;3:246-54
>>
>> Blomberg S, et al. Manual therapy with steroid injections-a new approach
>> to treatment of low back pain; a controlled multicenter trial with an
>> evaluation by orhtopedic surgeons. Spine 1994;19:569-77
>>
>> Blomberg S, Tibblin G. A controlled, multicnetre trial of manual therpay
>> with steroid injections in low back pain; function variables, side effects
>> and complications during four months follow-u. Clinical Rehabilitation
>> 1993;7:49-62
>>
>> Blomberg S, et al. manual therapy with steroid injections in low back
>> pain; improvement of quality of life in a controlled trial with four
>> months' follow-up. Scandinavian Journal of Primary Health Car
1993;11:83-90
>>
>> This was a very interesting series of well performed research that suggests
>> a "pragmatic approach". In other words, treatment must take into account
>> that back pain has multiple etiologies. Other studies that I don't have in
>> front of me are the studies so often cited by chiropractors on the efficacy
>> of "manipulation" on acute back pain. The studies which were referenced
>> were actually studies performed in England by PHYSICAL THERAPISTS using
>> Maitland mobilization techniques (as I remember the studies). Since so
>> many members of this board are based in England, maybe someone could give
>> those references--I don't have them off hand. Hope this helps clear up
>> that there are studies that show statistical and clinical evidence of the
>> efficacy of physical therapy (the studies although stating "manual therapy"
>> actually used a mutltifaceted approach of PT including exercise...Also, the
>> number of injections used was less than an average of 1/patient--this
>> people were not given a lot of cortisone.
>
>> >
>
>
Herb Silver
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