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Grande-Alonso M, Suso-Marti L, Cuenca-Martinez F, et al. Physiotherapy Based on a Biobehavioral Approach with or Without Orthopedic Manual Physical Therapy in the Treatment of Nonspecific Chronic Low Back Pain: A Randomized Controlled Trial. Pain Med. 2019 May 7. pii: 5487811. doi: 10.1093/pm/pnz093. (Original study)
Abstract

OBJECTIVE: To compare the effectiveness of a biobehavioral approach with and without orthopedic manual physical therapy on the intensity and frequency of pain in patients diagnosed with nonspecific chronic low back pain.

METHODS: A single-blind randomized controlled trial. Fifty patients were randomly allocated into two groups: one group received biobehavioral therapy with orthopedic manual physical therapy, and the other group received only biobehavioral therapy. Both groups completed a total of eight sessions, with a frequency of two sessions per week. The somatosensory, physical, and psychological variables were recorded at baseline and during the first and third month after initiation of treatment.

RESULTS: In both groups, the treatment was effective, presenting significant differences for all the variables in the time factor. There were no significant differences between groups in intensity or frequency of pain, with a large effect size (>0.80), but there were intragroup differences for both intervention groups at one- and three-month follow-up. There were also no significant differences between groups in the secondary variables during the same follow-up period.

CONCLUSIONS: The results of this study suggest that orthopedic manual physical therapy does not increase the effects of a treatment based on biobehavioral therapy in the short or medium term, but these results should be interpreted with caution.

Ratings
Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 5 / 7
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  Back Pain   Chronic Low Back Pain
Comments from MORE raters

Physician rater

Although it is very interesting there is a small sample size.

Physician rater

Chronic low back pain is a common problem with uncertainty about the efficacy of treatment modalities. This randomised study looked at the efficacy of physiotherapy based on a biobehavioral model and whether the addition of orthopaedic manual physical therapy is of additional benefit. There was a large number of primary and secondary variables assessed in the study with all improving in both treatment groups with large effect sizes and no significant differences in outcomes between the two treatment groups. The study was of small size with short duration of follow up so larger studies with longer duration of follow up are needed before these results can be confidently adopted in clinical treatment of patients with chronic low back pain.

Physician rater

Interesting study addressing one of the most common conditions encountered in primary care: low back pain. Randomized study compares behavioral therapy + physical therapy vs behavioral therapy alone. While patients in all groups improve, there was no statistically significant difference between the two groups. This study supports the importance of incorporating behavioral training in the management of chronic back pain. However, I would caution that PT is does not add benefit due to its short duration.

Physician rater

There are benefits of an intensive bio-behavioural approach to back pain management. The study shows that added physio intervention brought little benefit.

Rehab Clinician (OT/PT) rater

The article shows some interesting results, in that the application of manual physical therapy did not significantly facilitate improvement in individuals with chronic low back pain. It seemed like there were almost too many variables examined, which made the understanding of the article a little difficult.

Rehab Clinician (OT/PT) rater

This is an interesting and thought provoking study; although, one is concerned that it may be underpowered and that important opportunities may have been missed, namely an intervention arm of nil treatment and an intervention arm with non-specific massage or touch therapy.

Rehab Clinician (OT/PT) rater

The findings of this study should not be considered to be indicative of what might occur in practice. Although the biobehavioral approach is highly individualised, the manual therapy intervention that is being compared consists of four predetermined techniques at predetermined grades. Some of these techniques would be likely to aggravate some patients and most would not be indicated or expected to be effective for all or even most of a group of patients. The authors also state that, because both groups improved over time, both treatments were effective which ignores natural progression of the disorder and the statement cannot be justified from the data.

Rehab Clinician (OT/PT) rater

The findings are in line with current understanding.
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