2 Discussion / Physiotherapy 91 (2005) 1–5

analysis was not pre-specified, and was correctly avoided inanalysing and reporting the results[3]. The trial has also beencriticised for providing too many different types of treatmentby varying grades of staff. It is important to remember thatthe trial was designed and did reflect the everyday lottery ofphysiotherapy provision in the NHS. If most therapists takea step back, they will recognise the methods of provision asbeing common in many departments. The trial cannot tell uswhich treatments work best for low back pain, but what theydo indicate is that widely practised models of physiotherapyprovision are overall no better than a simple intervention ofassessment and advice.

Although the results might be disappointing, this is a high-quality trial that reflects treatment available in the NHS[4].For patients with similar symptom profiles, physiotherapistsshould consider one session of assessment and advice ratherthan prolonged treatment. The trial results have been consid-ered in the context of the wider research literature in the re-cently published European guidelines for the management oflow back pain, commissioned by the European Co-operation

There is no panacea for low back pain

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in the field of Scientific and Technical Research (C.O.S.T.,www.backpaineurope.org). Physiotherapists should continueto engage in the very important process of generating high-quality research evidence for emerging models of care. Re-search should be viewed as a strength and not a weakness ofa profession if the needs of the patients and populations weserve are to be met.

References

[1] Maniadakis N, Gray A. The economic burden of back pain in theUK. Pain 2000;84:95–103.

[2] Frost H, Lamb SE, Doll H, Taffe Carver P, Stewart-Brown S. Ran-domised controlled trial of physiotherapy compared with advice forlow back pain. BMJ 2004;329:708–11.

[3] Collins R, Gray R, Godwin J, Peto R. Avoidance of large biases andlarge random errors in the assessment of moderate treatment effects:the need for systematic overview. Stat Med 1987;6:245–50.

[4] Foster N, Thompson K, Baxter G, Allen JM. Management of non-specific low back pain by therapist in Britain and Ireland. Spine1999;24:1332–42.

p as-s tientsw ntsw hism f ourp feelc coulda ourc hem tice,d beeng

stic‘ ines[ pro-p ean-i willf p isl udedw hys-i e theirc orep n ofN

Chris M

The Centre for Rehabilitation Science, The University of Manch

‘For one of the most common and debilitating conditiowe have no real answer’ wrote the Editor of theBritish Med-ical Journal (BMJ) in an editorial entitled ‘Back pain andphysiotherapy: NHS treatment is of little value’[1]. The ed-itorial accompanied the paper by Frost et al.[2] and stokedthe fires of rapid response on theBMJ’s website. The Editorof this journal has discussed the merits of this paper in acent edition ofPhysiotherapy[3] and most of us would agreethat the paper has significantly contributed to the discussion the value of physiotherapeutic treatment in low back p(LBP). The paper achieved what it was designed to do, alwith some procedural problems that typically beset clinictrials. The results of the trial have been obtained in a mner that should give the reader confidence in their validHowever, some features of reporting the trial that may haprovided the reader with even more confidence were misspresumably due to the tight word limit enforced by theBMJ.For example, it may have been helpful for the reader tothe analysis of the patients who actually adhered to the tprotocol, as 36% of the patients did not, and received mintervention than they were intended to have a priori.

In short, the paper demonstrated that the addition of 2–of common practice ‘outpatient’ physiotherapy to an initihour of physiotherapy consisting of advice and educat

r, Manchester Royal Infirmary, Oxford Road, Manchester M139WL, U

rovided no greater improvement in disability whenessed 12 months later. The sample consisted of paith non-specific low back pain (NSLBP) and patieith nerve root pain with low levels of disability. Does tean that we need only assess the disability levels oatients and, if low, give them an hour of advice andonfident that we have best served their needs? Onergue that this is probably an oversimplification oflinical interaction with patients with LBP, and thus if tethods of this trial do not represent our clinical praco the results have as much impact as they haveiven?

Low back pain is standardly classified using a diagnotriage’ process, advocated by various clinical guidel4], into one of three classifications. By far the largestortion of the three categories is the NSLBP category, m

ng that the majority of a physiotherapist’s LBP patientsall into this category. It is well recognised that this grouarge and diverse and that the clinical presentations inclithin this classification are extremely heterogeneous. P

otherapists, as a consequence of this heterogeneity, uslinical reasoning skills to form clinical diagnoses beflanning treatment. Thus, a process of subclassificatioSLBP is undertaken on an individual clinical level.

Discussion / Physiotherapy 91 (2005) 1–5 3

Naturally, as the process of clinical reasoning is infinitelyadaptable and is influenced by multiple biopsychosocialinteractions between the patient and the therapist, theclinical diagnoses produced are infinitely varied. Thisflexibility makes the matching of suitable treatment toindividual patient requirements much more efficient butmakes it impossible to standardise the process. The natureof clinical trials requires that variables that may confoundthe analysis of the experimental variable are controlledor standardised across both groups. This allows the ef-fects of the experimental variable, typically the treatmentintervention, to be analysed efficiently.

Consequently, clinical trials typically have stringent in-clusion and exclusion criteria for subjects to be eligible toparticipate. Stringent selection criteria ensure a homogenousgroup of clinical presentations with whom the experimentalintervention can be assessed. Having homogenous groupsof subjects in the trial design increases the probability ofdemonstrating a significant effect between feasibly sizedgroups that can be attributed to the intervention. The effectof any intervention on a heterogeneous group will appearless, on average, as whilst the intervention will work wellwith some clinical presentations, it will not with others, andthe overall effects are ‘washed out’. This phenomenon iswell recognised and has major implications in estimatingt ered,f

rver ted.O LBPa GPc t’p iesh onew caset forc s ofN ultst

We may have to accept that there is no panacea forNSLBP, and that there will be no individual approach orcombination of approaches that will work for all clinicalpresentations of NSLBP. It would seem appropriate for ourefforts to be focussed on identifying which homogenousgroups of patients are suited to which approach and then as-sess the effects of treatment with the groups most likely torespond. Perhaps then we will provide evidence to supportour arguments that certain treatments are clinically effectivefor some but not others. After all, this process of ‘matching’is what we do on a day-to-day basis with our patients. It issobering to note that at a prestigious international primarycare conference held in 1995[7], establishing the prioritiesfor research into LBP, the highest priority was ‘to estab-lish valid subgroups of LBP’. Ten years on, there appears tobe no evidence that subgroups are being discovered or thatNSLBP has become any more specific. Be prepared for thereport of more non-specific treatment effects from trials thathave been searching for a panacea to cure all.

References

[1] MacAuley D. Back pain and physiotherapy. Br Med J 2004;329:694–5.

[2] Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Ran-for

[ apy

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[ ondain.

he size of samples required to provide adequately poweasible clinical trials.

In Frost et al.’s study, patients with NSLBP and neoot pain (two of the three triage groups) were selecther recent studies have also taken patients with NSnd either applied additional ‘outpatient’ treatment toare [5] or compared ‘waiting’ with early ‘outpatienhysiotherapy[6]. Both of these recent UK-based studave shown very small improvements in disability andonders if a pattern is becoming evident here. Is it the

hat until we develop more stringent selection criterialinical trials and establish valid homogenous subgroupSLBP, we can expect more clinical trials returning res

hat show no significant clinical differences?

∗ Tel.: +44 161 276 5035.E-mail address:christopher.mccarthy@man.ac.uk (C. McCarthy).doi:10.1016/j.physio.2005.01.004

domised controlled trial of physiotherapy compared with advicelow back pain. Br Med J 2004;329:708.

3] Harms M. Back pain—knowing is half the battle. Physiother2005;90:173.

4] European Commission COST B13 Management Committee. Euroguidelines for the management of low back pain. Acta Orthop SSuppl 2002;73:20–5.

5] UKBEAM Team. United Kingdom back pain exercise and mnipulation (UK BEAM) randomised trial: effectiveness of phycal treatments for back pain in primary care. Br Med J 2(doi:10.1136/bmj.38282.669225.AE.).

6] Wand BM, Bird C, McAuley JH, Dore CJ, MacDowell M, De SouLH. Early intervention for the management of acute low back pasingle-blind randomized controlled trial of biopsychosocial educamanual therapy, and exercise. Spine 2004;29:2350–6.

7] Borkan J, Koes B, Reis S, Cherkin D. A report from the SecInternational Forum for Primary Care Research on Low Back PSpine 1998;23:1992–6.