Evidence-based physiotherapy for patients with low-back pain

This report is intended to be used as reference and educational material. It represents one of two documents that critically review the scientific evidence underlying the therapies and interventions provided by physiotherapists. The report presents a systematic literature review of the scientific basis for treating low-back problems by physiotherapy. It reveals a need for further research and more studies to strengthen the foundation for evidence-based physiotherapy. The report is published in collaboration with the federation of licensed physiotherapists in Sweden (LSR) and a Swedish foundation that supports research in health care and allergy care (Vårdalstiftelsen).

Summary, Conclusions, and Recommendations

In summary, the literature review supports the following conclusions and recommendations for interventions in patients who self-refer or are referred to a physiotherapist for low-back problems.

• Patients with acute problems that have persisted less than 3 weeks should be thoroughly examined by a physiotherapist to identify their mobility-related condition (impairment), capability (activity), and behavior (participation), and be given the opportunity to discuss attitudes and possible apprehension toward their problem. Considering the findings from examination, the physiotherapist should challenge the patient to continue to be physically active. The physiotherapist should offer personalized, oral (in addition to written) advice on the importance of changing positions often, suggest how the patient can find positions that generate less pain where movement can be carried out, encourage the patient to think about how he/she can move different parts of the body without increasing pain, and suggest how tasks might be modified so the patient can continue working. During the first days, excessive physical activity or treatments which subject body tissue to major stress should be avoided.
• Patients with sub-acute problems lasting 3 to 6 weeks should be examined thoroughly by a physiotherapist to identify their mobility-related condition (impairment), capability (activity), and behavior (participation), and be given the opportunity to discuss attitudes and possible apprehension toward their problem. Manual treatment methods and certain behavioral modification methods may be valuable complements to physiotherapy for some groups of patients. Treatment and intervention should be goal related, and the physiotherapist should set appropriate limits so the patient can carry out the exercises independently, regularly, and over a long period. Exercises my cover different types of activity that engage major muscle groups and continue for at least 20 minutes per occasion, during work-time or free time, and over a longer period, ie, for as long as the patient wants to see results from training. Different means should be used to monitor patient training, since changes in exercise habits appear to depend on the physiotherapist taking notice of the patients exercise habits. In cases where work capability is impaired, the interventions should also be work-oriented.
• Patients with chronic problems that last more than 12 weeks should be thoroughly examined by a physiotherapist to identify their mobility-related condition (impairment), capability (activity), and behavior (participation), and be given the opportunity to discuss attitudes and possible apprehension toward their problem. Treatment and intervention should be goal related, and the physiotherapist should set appropriate limits so the patient can carry out the exercises independently, regularly, and over a long period. Methods aimed exclusively at pain relief have fewer, if any, effects, eg, manual treatment methods. The focus should be placed on function-oriented exercises in combination with behavioral modification aimed at increasing the patients ability to be active. Patient compliance with treatment is higher with individual treatment (or if the individual has access to a physiotherapist) than with group treatment. Multi-program treatment, where physiotherapy interventions are carried out in collaboration with other team members and people at the workplace, has an impact on work capacity.