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Early Intervention for the Management of Acute Low Back Pain: A Single-Blind Randomized Controlled Trial of Biopsychosocial Education, Manual Therapy, and Exercise

Wand, Benedict M. BAppSc, GradDip(ExSpSc), MAppSc, PhD*; Bird, Christien MSc, MCSP†; McAuley, James H. BSc, PgDip, PhD‡; Doré, Caroline J. BSc§; MacDowell, Maureen MCSP†; De Souza, Lorraine H.¶

Randomized Trial

Study Design. A single blind randomized controlled trial comparing two models of care for patients with acute simple low back pain.

Objectives. To compare two research-based models of care for acute low back pain and investigate the effect of the timing of physical intervention.

Summary of Background Data. National guidelines offer conflicting information on the delivery of physical treatment in the management of acute low back pain. The guidelines suggest two different models of care. Direct comparisons between these models are lacking in the literature. The present study aims to compare these approaches to the management of acute low back pain.

Methods. Among 804 referred patients, 102 subjects met the specific admission criteria and were randomly assigned to an “assess/advise/treat” group or an “assess/advise/wait” group. The intervention consisted of biopsychosocial education, manual therapy, and exercise. Assessment of short-term outcome enables comparison to be made between intervention and advice to stay active. Assessment of long-term outcome enables comparison to be made between early and late intervention. Study outcomes of reported pain (Visual Analogue Scale), functional disability (the Roland and Morris Disability Questionnaire), mood (Modified Zung Self Rated Depression Score, Modified Somatic Perception Questionnaire, State-Trait Anxiety Inventory), general health (Euroqol), and quality of life (Short Form 36) were assessed at baseline, 6 weeks, 3 months, and 6 months.

Results. At 6 weeks, the assess/advise/treat group demonstrated greater improvements in disability, mood, general health, and quality of life than patients in the assess/advise/wait group (P < 0.05). Disability and pain were not significantly different between the groups at long-term follow up (P > 0.05). However, mood, general health, and quality of life remained significantly better in the assess/advise/treat group (P < 0.05).

Conclusions. At short-term, intervention is more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life, and general health. The timing of intervention affects the development of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore, an assess/advise/treat model of care seems to offer better outcomes than an assess/advise/wait model of care.

In Brief

The timing of intervention affects the development of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Although disability showed more rapid improvement at 6 weeks with early active intervention, there were no differences at long-term follow-up where both groups showed minimal disability. Pain was not affected by the timing of intervention.

Author Information

From the *School of Physiotherapy, University of Notre Dame, Fremantle, WA, Australia; †Central Middlesex Hospital Trust, London, UK; ‡Spinal Research Group, School of Physiotherapy, University of Sydney, NSW Australia; §MRC Clinical Trials Unit, London, UK; and ¶Department of Health Studies, Brunel University, Middlesex, UK.

All the authors took part in the design and analysis of the study and jointly wrote the paper.

Acknowledgment date: April 30, 2003. First revision date: November 5, 2003. Acceptance date: November 17, 2003.

Supported by the NHS Executive, South West Regional Office, and Physical and Complex Disabilities National Programme. Caroline Doré is funded by the Arthritis Research Campaign.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Federal funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence to Christien Bird, Sc, MCSP, White Hart Lane Therapy Centre, 10 White Hart Lane, Barnes, London SW13 OPY, UK; E-mail:

© 2004 Lippincott Williams & Wilkins, Inc.