Implementing Evidence-Based Physiotherapy Practice for Treating Children with Low Back Pain: Are We There Yet?

Abstract

Purpose: 

This article reports on the process used to appraise evidence-based physiotherapy practice when treating nonspecific low back pain (LBP) in children and adolescents.

Method: 

Best clinical practices were identified using 9 systematic reviews reporting on effectiveness of physiotherapy for individuals with nonspecific LBP. Fifty medical charts were reviewed to appraise practice.

Results: 

All literature reviews reported solely on adult treatment, none included children or adolescents. Strong evidence supported the effectiveness of therapeutic exercises and education. There was insufficient evidence to support the effectiveness of thermotherapy, transcutaneous electrical nerve stimulation, or ultrasound. Chart reviews indicated therapeutic exercises were prescribed for all 50 pediatric patients and postural education was provided to 48 patients. Eleven patients received thermotherapy, three received transcutaneous electrical nerve stimulation, and none was treated with ultrasound.

Conclusions: 

Published literature reviews enabled physiotherapists to appraise evidence-based practices. Clinical guidelines for treating nonspecific LBP in children and adolescents are needed.

In Brief

The authors were able to use published literature reviews to appraise evidence-based practices in their hospital. The only available evidence however was based on studies of adults. The authors point to the need for clinical guidelines for treating nonspecific low back pain in children and adolescents.

INTRODUCTION

Nonspecific back pain of at least moderate intensity is a major problem among adults, causing significant distress and disability.¹ Studies have demonstrated that 70% to 85% of the general adult population in the Western world is likely to experience low back pain at some time in life.^2,3 More than two thirds of the adult population has suffered or currently suffers from back pain causing activity limitations,^4,5 which results in considerable costs to society,⁶ and in frequent use of the health care system (visits to the physician, admission to hospital, and surgical procedures).² Low back pain has been considered a widespread public health concern.⁶

The literature on adult low back pain has grown recently, addressing topics such as risk factors, etiology, and treatment options for this multifaceted problem.^1,7 More recently, the focus has turned to the prevention of low back pain.^4,6 One of the predisposing factors studied in the current literature is the presence of back pain in childhood and adolescence.⁸ In Quebec, the prevalence of back pain among 9-year-old children has been estimated to be 35%, increasing to 50% among adolescents between 11 and 15 years of age.⁹ Other studies have reported prevalence of back pain in children ranging from 26% to 36%.^10–12 It is estimated that nonspecific low back pain is the most common diagnosis among pediatric patients reporting pain.¹³

At the Shriners Hospital for Children, Canadian Unit (SCH-CU), the number of children presenting with nonspecific LBP prompted physiotherapists to explore the evidence available regarding best practices for this population. Today, many health care professionals are faced with increasing pressure to base their practice on scientific evidence.¹⁴ Choices regarding the use of limited health care resources need to be increasingly justified and based on evidence demonstrating the effectiveness of interventions used.¹⁵ Indeed, evidence-based health care has been a growing topic of interest in research, clinical, and public domains in recent years. In Canada, the National Forum on Health concluded that “… a key objective for the health sector should be to move rapidly toward the development of an evidence-based health system, in which decisions are made by health care providers, administrators, policy makers, patients, and the public on the basis of appropriate, balanced, and high quality evidence.”¹⁶

Guyatt et al¹⁷ describe evidence-based medicine as a paradigm for clinical practice that stresses the “examination of evidence from clinical research” while deemphasizing the reliance on “intuition, unsystematic clinical experience, and pathophysiologic rationale as being sufficient grounds for clinical decision-making and practice.” Sackett et al¹⁸ define it as a process that integrates the best available research evidence with both clinical expertise and patients’ values. Evidence-based health care therefore requires clinicians to acquire skills for searching the literature efficiently and for applying formal rules to evaluate the literature. To incorporate evidence-based practice strategies in their clinical practice, physiotherapists must overcome challenges that are common to most health care professionals, including the complexity of physical therapist practice, incomplete access to the evidence, and difficulty interpreting the evidence.¹⁹ However, methods that can facilitate this process for physiotherapists have been described in the literature.¹⁵

This article describes the process used to determine the extent to which a pediatric physiotherapy department has adopted strategies of evidence-based practice in the treatment of nonspecific low back in children and adolescents. We also present results of secondary analyses conducted to examine the effectiveness of physiotherapy with these patients.

METHODS

We first set out to search the current literature to identify the best clinical practice. Two physiotherapists working at the SCH-CU searched the literature using three databases (Medline, Cumulative Index to Nursing, and Allied Health Literature and MD Consult). The search was conducted using the specific key word “non-specific low back pain,” but was limited to the following type of articles: “EBM reviews,” “review articles,” or “practice guidelines.” This method of extracting evidence regarding the effectiveness of specific medical interventions has been suggested to be an efficient approach for therapists seeking to incorporate evidence into their practice.^14,19 The therapists at the SCH-CU documented findings from 9 systematic reviews that evaluated the effectiveness of physiotherapy for nonspecific low back pain.^20–29 All systematic reviews included in this article described rigorous, recognized, or previously validated methods that minimize bias by using a systematic approach to literature searches, study selection, data extraction, and data synthesis (Table 1).

TABLE 1: Methods Used in Systematic Reviews

Next, a retrospective chart review was conducted to identify patient management techniques utilized in the physiotherapy department at the SCH-CU. The hospital is an elective-based orthopedic institution providing care to children from birth to the age of 21 years. This university affiliated hospital offers services to children from around the world, with a specific catchment area of Canada and the New England States. Physiotherapy services are available to all patients referred to the department by physicians at the SCH-CU.

Subjects

Medical records archivists identified all patient files coded for “low back pain” during a 4-year period, June 1997 to December 2001. Patients referred for physiotherapy services during the study period were included in the study if they had a diagnosis of nonspecific low back pain (ie, no mention of a specific orthopedic diagnosis involving the spine, such as scoliosis, spondylolysis, spondylolisthesis, fracture, and disc herniation). Fifty patients were eligible for inclusion based on the above criteria.

The following information on the patient’s history and clinical evaluation was extracted from the charts:

1. Age of patient (in years) at the time of referral to physiotherapy
2. Gender
3. Pain history (in months) was obtained by the following question: “For how long did you have pain prior to your initial physiotherapy visit?”
4. Pain intensity (verbal pain scale, VPS). This was a scale from 0 to 10 (0 = no pain, 10 = worst pain imaginable). Data were collected at every visit to the department.
5. Participation in organized sports outside of school.
6. Use of medication to determine whether change in pain status over time was being influenced by the use of medication. A differentiation was also made between prescription and nonprescription medication, as it was thought that prescription medication might effect a more significant change.
7. Flexibility evaluation. Movement restrictions were measured using published conventions.³⁰
1. Hamstring flexibility using either the straight leg raise (SLR) or the popliteal angle (90–90 SLR). Normal range cut point used by therapists at the SCH-CU was 90° for SLR or 180° for popliteal angle.
2. Quadriceps flexibility using the Ely test. Inability for the heel to touch the buttocks was considered to represent restricted movement.
3. Hip flexor flexibility using the Thomas test position. The normal range was 0° of hip flexion in the leg being tested.

Information on patient management techniques that was extracted from the charts was then compared with best clinical practices identified in the literature.

Finally, to illustrate the effectiveness of physiotherapy in our center, four measures were compared at initial and final physiotherapy assessments: pain levels, participation in organized sports, medication intake, and hamstring flexibility. A secondary analysis was conducted for a subgroup of 35 patients for whom complete data were available.

Pain levels were measured using the VPS. Pain, participation in organized sports, and medication intake were compared between the first and last physiotherapy visits using the dependent t test. Pearson correlation coefficients were used to describe the association between pain and length of treatment, number of physiotherapy visits, and age. Hamstring flexibility was compared at initial and final assessments using the Wilcoxon test.

All tests were two-tailed and significance was tested using a p < 0.05 level.

RESULTS

Literature Review Results

The literature search conducted for this study revealed all systematic reviews had been reported only for adults. Table 2 presents the information extracted from these systematic reviews, including the types of interventions reviewed and the corresponding level of scientific evidence supporting their effectiveness. Details regarding the systematic review methodology and the criteria upon which evidence of effectiveness of treatment was appraised are presented in each of the referenced studies.^1,20–28,31 All reviews cited in this present study have been published in peer-reviewed journals.

TABLE 2: Findings of the Literature Search

Therapeutic exercise can include specific back, abdominal, flexion, extension, static, dynamic, stretching, strengthening, or aerobic exercises. Several reviews reported strong evidence that therapeutic exercise is effective.^{1,23,25,26,28,31} One review reported limited evidence of the effectiveness of therapeutic exercise²¹ although the review attributed the results to low method scores and a short follow-up period in studies reviewed. Another review found conflicting evidence regarding the effectiveness of therapeutic exercise in the treatment of chronic nonspecific low back pain.²²

Back school and postural education can combine exercises with education (anatomy, body mechanics, and psychological factors), behavioral therapy, and relaxation exercises.²⁸ Two reviews, which included 10 and 13 studies evaluating the effectiveness of back schools, reported strong evidence of effectiveness compared with no treatment, but limited evidence of effectiveness when compared with other conservative treatment.^20,28 For the purpose of our study, we used postural education as an element that can be considered effective in the treatment of nonspecific low back pain.

The effectiveness of three other interventions was also reported in reviews used in this article. Thermotherapy (hot or cold packs), transcutaneous electrical nerve stimulation, and ultrasound were all reported to have insufficient evidence available to demonstrate their effectiveness.^22,25–28

Patient Information and Chart Review Results

The charts of 50 patients referred for physiotherapy services in our center between June 1997 and December 2001 were reviewed. All patients included in the study had a diagnosis of nonspecific low back pain.

Table 3 describes the demographic and clinical characteristics of the study sample. Patient ages ranged from 7 to 17 years (mean 13.6) and patients reported experiencing pain for an average of 15 months duration and an intensity rating of 6 of 10. The study sample consisted of 60% females. All patients experienced movement restrictions in one or more of the three sites assessed (hamstrings, quadriceps, and hip flexors).

TABLE 3: Demographic and Clinical Characteristics of the Study Sample (N = 50)

Patients attended an average of three visits to the physiotherapy department (range from 1 to 10 visits). The information extracted from the medical charts regarding treatment is presented in Table 4.

TABLE 4: Information Extracted from the Medical Charts Regarding Physiotherapy (N = 50)

In our center, therapeutic exercises were prescribed within an individually designed home program for all 50 patients. For this study, we obtained information on six types of exercises prescribed: three types of flexibility exercises (hamstrings, quadriceps, and hip flexors) and three types of strengthening exercises (abdominals, back extensors, and rhomboids). Each patient was prescribed an average of three exercises (ranging from 1 to 5 exercises per patient). Thirty-nine patients (78% of the total sample) were asked to report the degree to which they complied with the home program. Eight patients reported a compliance of 0 to 2 times/week, 24 reported a compliance of 3 to 5 times/week, and 7 reported a compliance of 6 to 7 times/week.

Postural education was provided to 48 patients (96% of the study sample). Eleven patients received thermotherapy, three received transcutaneous electrical nerve stimulation, and none was treated with ultrasound.

In summary, physiotherapy practice when treating nonspecific LBP in children and adolescents at the SCH-CU reflects the evidence identified in the literature on management of adult patients.

Effectiveness of Physiotherapy

VPS values improved significantly after physiotherapy with a mean difference of 3.88 ± 2.22 (p < 0.05). No significant association was found between the change in VPS and length of treatment (r = −0.22, p = 0.10) and between VPS and the number of physiotherapy visits (r = −0.14, p = 0.20). No significant changes occurred with respect to sports participation or medication intake. There was a significant increase in bilateral hamstring flexibility.

DISCUSSION

This article describes the process used by physiotherapists working in a pediatric orthopedic setting to identify best practices documented in the literature for treating patients who had a diagnosis of nonspecific low back pain. The aim of this undertaking was to determine the extent to which their practice is based on scientific evidence.

Several issues posed challenges in this project. Principally, there exists little consensus on best practices, which explains why there is considerable variation in physiotherapy practice when treating patients with nonspecific low back pain.³ Furthermore, although the literature is growing in the area of nonspecific low back pain in children and adolescents, several articles pertaining to this population tended to investigate the etiology and course of the condition. The systematic reviews included in this project reported on the effectiveness and efficacy of physiotherapy for nonspecific low back pain in adults. Until researchers address questions pertaining to the effectiveness of physiotherapy for the pediatric population, therapists may be restricted to using available evidence for adults, assuming that the results can be generalized to children. However, based on reported similarities in the etiology of nonspecific low back pain among children and adults,³² it seemed reasonable, for the purpose of this article, to make the assumption that treatments deemed effective for the adult population would apply to the pediatric population.

Although an improvement in the VPS results between the first and last physiotherapy visits was noted, it was not possible to ascertain whether or not this improvement was associated with any specific intervention. Two recent studies that examine the prevalence of nonspecific low back pain in school age children conclude that psychological or psycho-social factors play a prominent role in a child’s experience and reporting of his/her pain.^33,34 It is therefore possible that the experience of being treated by a health professional may have contributed to the child reporting a reduced level of pain. Without a control group, it was not possible to determine whether or not the children may have simply gotten better over time.

Limitations

The assumption that the etiology and course of low back pain are similar in children and adults is based on findings reported in a single article. Until this issue is investigated further or until clinical trials and systematic reviews are conducted specifically for children and adolescents, the evidence supporting best practices in this population remains weak.

A secondary analysis was conducted to illustrate the effectiveness of treatment. As this study was based on a retrospective chart review, there were limitations in the degree of uniformity with which therapists measured and collected information. Effectiveness was illustrated using a subgroup of 35 patients for whom complete data were available.

Some patients whose charts were reviewed did not appear to have restrictions in movement according to published guidelines for determining normal values,³⁰ but were nevertheless given home programs as these values were considered borderline by the therapist. Although the level of efficiency of physiotherapy services may have been at issue, this question was beyond the scope of this study.

CONCLUSIONS

Using the information reported in published literature reviews, physiotherapists at the SCH-CU demonstrated they have adhered to best practices for the treatment of nonspecific low back pain as reported for adults. Practices identified as most effective in the literature, namely therapeutic exercise and postural education, were used more frequently in our clinic than other types of intervention for which little evidence for effectiveness was reported.

This study provided physiotherapists at the SCH-CU the opportunity to develop mechanisms to critically appraise the degree to which evidence is implemented into their practice. An unexpected obstacle was the lack of clinical guidelines for treatment of nonspecific back pain in children and adolescents. Given the prevalence of this condition and the frequent referral to physiotherapy, there is clearly a need for further clinical research to substantiate best practice interventions. Without such studies, therapists will continue to be limited in their ability to integrate evidence within their practice. As far as implementing evidence-based physiotherapy practice for treating children with low back pain; are we there yet? No, pediatric studies are urgently needed.