Published: 11/11/2004, Volume II4, No. 5931 Page 27
The issue Patients with low back pain are routinely referred for physiotherapy on the NHS. As a GP, initiating a physiotherapy referral for me is easy. The question is: should I?
Physiotherapy for back pain cost the NHS£251m in 1998, but is this money wisely spent? A recent study addressed this.
The study The BMJ study was a pragmatic randomised, controlled trial (BMJ 2004; 329: 708-711). It involved 286 patients with low back pain, referred to 76 physiotherapists within seven NHS physiotherapy departments in Oxfordshire and Berkshire by GPs or consultants.
To be included, patients had to be over 18 with a history of at least six weeks of low back pain. Patients with leg pain or neurological signs were only excluded if there was an indication of serious underlying conditions such as ankylosing spondylitis, tumours or infection. Also excluded were patients who had received physical treatment in the preceding month or who had had spinal surgery.
All patients received written and verbal advice to remain active, but the 'therapy' group also received a standard course of physiotherapy. The trial was pragmatic in that it sought to reflect routine NHS practices. Physiotherapists were permitted to tailor treatment to the individual within the therapy group: 72 per cent underwent joint mobilisation using low velocity thrusts, 94 per cent were given various exercises and 9 per cent heat/cold treatments. The median number of physiotherapy sessions received was five (range one-12).
From the primary care perspective a key feature was the pragmatic design of the study and the fact that 90 per cent of the patients were referred by GPs.Moreover, patients were representative of those encountered in day-to-day practice: the mean age was 41 years and a third of patients were smokers.
At one year, no significant differences were recorded in either diseasespecific or generic outcome measures, although patients in the therapy group reported significantly enhanced perceptions of benefit.
In practice The BMJ study reflected real NHS practice. Patients' satisfaction with the treatment needs to be considered in relation to the other outcome measures.Many patients like using topical non-steroidal antiinflammatory drugs, and yet the consensus among primary care trust medical advisers is that such treatments should not be prescribed.
The evidence base for physiotherapy and some specific physical techniques has always been deficient. In the light of this new evidence, we must take some hard investment-disinvestment decisions and give patients access to more appropriate interventions, such as chiropractic approaches, where there is much clearer evidence of effectiveness (BMJ 1990; 300: 1431-1437).
Dr Nick Summerton is a GP, reader in primary care medicine and medical director of Yorkshire Wolds and Coast PCT.