REHABILITATION

PHYSIOTHERAPY GUIDELINES FOR MANAGING PERSISTENT LOW BACK PAIN (LBP):

EXERCISE AND MANUAL THERAPY

WHY DO WE NEED CLINICAL GUIDELINES? Guidelines can be used to demonstrate to health care commissioners that services are evidence based and thus optimally effective. These guidelines are important because back pain affects up to 84% of people in their lifetime (1) and the large number of people affected makes LBP cost- ly to treat, and thus effective treatment extremely important to commissioners.

Guidelines are tools for practice; they present a review of the literature, a consensus of expert opinion, and a series of recommendations for best practice. They are necessary because health care research knowledge is currently incomplete and thus expert opinion forms a part of the best available evidence. Without guidelines there are two major problems for practitioners (see figure 1): ■ the large volume of research literature makes keeping abreast of current best practice by personal study of research papers virtually impossible

■ expert opinion from different clinical specialities eg. the cognitive behavioural approach and the McKenzie system may appear contradictory.

This paper: ■ gives an insight into the recommenda- tions in these guidelines for managing LBP

■ outlines the methods used by the guideline developers to emphasise their validity

■ challenges practitioners to implement the guidelines and share their experi- ences.

SOME KEY RECOMMENDATIONS These guidelines apply to patients aged between 18 and 65 years with non-specif- ic LBP lasting six weeks or more. They consider the effectiveness of exercise and manual therapy for people with persistent LBP. Essentially they ask two clinical

16 By Dr Anne Jackson, PhD, MSc, BA(Hons), MCSP, HT

Earlier this year the Chartered Society of Physiotherapy published a comprehensive practical guide to managing persistent low back pain. This article reviews the key points with specific focus on the role of exercise and manual therapy and outlines how the guidelines were developed and how they can be used. The guidelines are available for purchase. For more information visit www.csp.org.uk

But which expert?

Expert opinion

Evidence based practice

Services commissioned Figure 1: The practitioners’ problem

questions: ■ is exercise effective? ■ is manual therapy effective?

WHAT OTHER RECOMMENDATIONS ARE IN THE GUIDELINES? The guidelines consider both exercise and manual therapy in terms of the following for people with persistent LBP: ■ reducing pain ■ improving psychological status ■ return to work ■ cost-effectiveness ■ safety. They also give further recommendations for the application of exercise and manu- al therapy.

WHO DEVELOPED THESE GUIDELINES? The Chartered Society of Physiotherapy (CSP) commissioned these guidelines. The guideline development group (GDG) was formed of experts in various physiothera- py interventions (exercise including hydrotherapy, manual therapy, patient

views, sports science), researchers and managers from throughout the UK.

HOW WERE THE GUIDELINES DEVELOPED? The evidence came from two sources: ■ a systematic review of the literature ■ a nominal group consensus technique to generate consensus evidence to fill gaps in the literature.

Once the evidence was collated the GDG used the evidence statements to formulate recommendations for clinical practice.

The systematic review The literature was searched for publications from 1966 to June 2005 for randomised controlled trials (RCTs) relating to physio- therapy exercise and manual therapy for LBP that were published in English. The databases searched were: Medline, EMBASE, CINAHL, AMED, PEDro, The Cochrane Library, Sports Discus. In addition, the European guidelines for the management of chronic non-specific LBP were used to identify RCTs (1). The

sportEX medicine 2007;34 (Oct) 20-26

Research evidence

But there’s too much!