Mannion AF, Müntener M, Taimela S, Dvorak J. A
randomized clinical trial of three active therapies for chronic
low back pain. Spine. 1999 Dec 1; 24:2435-48.
Question: In patients with chronic low back pain
(LBP), what is the relative efficacy of physiotherapy, muscle conditioning
using training devices, and aerobics/stretching for pain and disability?
Design: Randomized (unclear allocation concealment), unblinded,
controlled trial with 6-month follow-up.
Setting: A hospital in Zürich, Switzerland.
Patients: 148 patients who were <65 years of
age (mean age, 45 years) and had continual or recurrent low back
pain for 3 months that was serious enough to cause absence from
work or require medical attention. Other inclusion criteria were
the ability to read and write German or English and the ability
to perform the planned functional outcome tests. Exclusion criteria
were constant severe pain; nonmechanical LBP; pregnancy; previous
spinal surgery; current nerve root entrapment; spinal cord compression;
tumors; cardiovascular or metabolic disease; severe structural deformity;
or severe diseases or disorders of the spine, bones, or joints.
132 patients (89%) completed the treatment; follow-up data were
available for 137 patients (93%).
Intervention: Patients were allocated to physiotherapy
(n = 49), muscle reconditioning using training
devices (n = 49), or low-impact aerobics/stretching
classes (n = 50). Treatments were administered
twice per week for 3 months. Physiotherapy included isometric exercises
and exercises using Therabands and strength-training devices, prescriptions
for home exercises, and such passive therapies as ultrasound or
electrotherapy. Muscle reconditioning involved controlled, progressive
exercises on training devices following the David Back Clinic program.
Aerobics classes involved stretching and aerobic and muscle-toning
exercises done to music.
Main outcome measures: Before and after therapy
and at 6 months, patients completed questionnaires that included
questions on pain, disability, and psychosocial disturbance. Lumbar
spine range of motion (flexion and extension, lateral bending, and
axial rotation) was measured using the CA-6000 Spine Motion Analyzer (Orthopaedic
Systems, Hayward, CA, USA).
Results: At the completion of the treatment period,
all 3 groups improved in flexion and extension with no differences
among them (P = 0.48). Lateral bending and axial
rotation increased to the greatest extent in the aerobics group with
a modest increase in the devices group. A statistically significant
difference existed in the extent of change between the aerobics
and devices groups and the physiotherapy group for lateral bending
(P = 0.04) and axial rotation (P =
0.02). All 3 groups reported a reduction in the greatest and average
pain after treatment with no differences among them (P >
0.50). The post-therapy pain reduction persisted at 6 months. At
post-therapy, all 3 groups reported decreased disability with no
differences among groups (P = 0.08). At 6 months,
there were further decreases in the devices and aerobics groups
whereas the scores increased in the physiotherapy group (P =
0.02). Fear avoidance beliefs about physical activity were reduced
after treatment in all 3 groups and were further reduced at 6 months
in the devices and aerobics groups but not in the physiotherapy group
(P = 0.04).
Conclusion: In patients with chronic LBP, physiotherapy,
muscle conditioning using training devices, and aerobics were equally
efficacious in reducing pain, disability, and fear avoidance beliefs.
Many improvements in outcomes were maintained at 6 months, especially
with training devices and aerobics.