Evaluation of Physical exercise, Physiotherapy and Chiropractic in the Management of Back Pain

Abstract: The lack of evidence concerning the effectiveness of most existing interventions for back pain, has created room for the expansion of a variety of interventions and the need to evaluate these.The general aim of this thesis was to assess three interventions used for health promotion (exercise programme) and treatment (chiropractic and physiotherapy) of musculoskeletal pain, primarily back pain, and to identify potential predictors of long-term outcome in the treatment of back pain.The thesis consists of material from two studies. Firstly, a health promotion study assessing the effects of a moderate weekly exercise programme among nursing personnel (n=86), during work time, using a cross-over design. Self-reported questionnaires were used to follow the effects on perceived musculoskeletal and psychosomatic symptoms and work conditions. As a complement, physical capacity was tested. Secondly, a randomised, pragmatic treatment study comparing the short-term and long-tenn (one-year) effects and costs of chiropractic and physiotherapy as first-line treatment for 323 patients with back pain seeking care at ten primary health care centres. Self-reported questionnaires were used to follow the effects on perceived health (pain, function and general health) and costs.The exercise programme decreased the number of musculoskeletal symptoms and increased the physical capacity among the 50 subjects who participated regularly. The effects were primarily explained by the subgroups: those who were non-regular exercisers in their spare time and those ~40 years of age, i.e. those who initially had low physical capacity. The results suggested a relationship between the number of musculoskeletal symptoms and physical capacity as well as a relationship between changes in these factors that need further evaluation. Besides the positive effect, a negative effect was seen in perceived work planning, suggesting that exercise during work time must be well organised so as not to add extra stress.Chiropractic and physiotherapy resulted in significant effects. The effects and costs were equal at short-term and long-term follow-ups. In other words neither strategy was more cost-effective than the other according to the total groups. However, subgroup analyses showed that patients with acute back pain (duration of current episode ≤ week) benefit more from chiropractic and patients with chronic back pain (duration of current episode ≥ 1 month) benefit more from physiotherapy, and at similar costs. Chiropractic consisted mainly of spinal manipulation, and physiotherapy of a great variety of treatment forms. Recurrence was common among patients visiting primary health care for back pain, and a high proportion, higher in the chiropractic group than in the physiotheraPy group, consumed additional health care during the follow-up year. Five prognostic factors ("duration of current episode", "Oswestry score at entry", "number of localisations", "expectations of treatment" and "well-being") for disability at the one-year follow-up were identified. The factors were of similar importance in the two treatment strategies, chiropractic and physiotherapy.Both studies showed that the outcome differed among subgroups of subjects. This suggests that potential predictive factors for outcome need to be considered in the development of intervention policies and in clinical decision models conceming back pain patients.