8/6/2014 0 Comments
Special thanks to star physical therapist Brace Hayden, DPT, CSCS of Alpine Physical Therapy for providing this write up on a recent article from Spine.
It is widely accepted that low back pain is one of the most common orthopedic pains we will experience in a given year. It is also a highly scrutinized and researched health condition, as it is a very costly public health problem that affects a third of all adults.
Treatments for low back pain range from medication, to surgery, to therapist-delivered care. Recently, Dipesh Mistry and a team of health scientists from the UK’s Warwick Medical School, performed a systematic review of the research on the quality and effectiveness of low back pain treatments performed by therapists. Acceptable therapies for low back pain included a lot of treatments from psychological interventions to intensive rehabilitation programs, from laser acupuncture in Australia to high velocity thrust manipulation in Sweden.
The targeted types of low back pain were classified as ‘nonspecific’, meaning they do not come from a likely cause such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.
Mistry’s team combed through the research to select only high-quality, randomized controlled trial-based articles on subjects older than 18 with a history of nonspecific low back pain. Their results largely followed the prior literature reviews consensus small, rather than the conventionally-accepted moderate positive effective gains from therapeutic treatments. They were able to use a total of 39 articles from various search engines (ie. Medline and Cochrane Controlled Trial Register) completed between the years of 1948 to 2013.
They divided the articles into two sub-classifications as either a confirmatory finding or an exploratory finding. Confirmatory are more rigorous, follow-up research that strides to confirm or test the hypothesis. Exploratory are more preliminary research that aims to generate future hypotheses or build a base for future research.
Of the accepted, high-quality studies, only 3 studies (8%) tested hypotheses and were classified as confirmatory. Eighteen studies (46%) were classified as exploratory findings. The remaining 18 (46%), fell short of a substantive conclusion and were given the ‘insufficient findings’ status.
The researchers further tweezed each articles’ respective study methods for appropriate statistical testing for each interaction between studied variables. Fortunately, appropriate stats were employed in 27 of the 39 of the articles. The remaining articles had sub-classification reporting deficiencies or other areas deemed too weak to qualify for this paper’s systematic review.
They concluded that the sub-classified (either the confirmatory or exploratory findings) therapies for treating nonspecific low back pain have been ‘severely underpowered’ in their analysis. In other words, over the past 65 years, the 39 acceptable high-quality articles were only able to provide exploratory class research with insufficient evidence to boot. Moreover, they had poor quality data in their reported findings.
Mistry’s team also generalized that if we hope to better identify which form of low back pain treatment will be the most economical and effective, then we need to better classify which subgroup of persons with back pain are appropriate for each treatment.
Future research was suggested here to develop new methods to effectively identify subgroups in back pain research. Furthermore, they recommended that the low back pain research community needs to collectively revise their current approach to subgrouping the back pain studies. Continued perpetuations of exploratory class research won’t help improve the care for our substantial population of persons with back aches looking for effective therapies.
Dipesh Mistry, MSc, et al. Evaluating the Quality of Subgroup Analyses in Randomized Controlled Trials of Therapist-Delivered Interventions for Nonspecific Low Back Pain. A Systematic Review. In Spine. 2014, Volume 39, Number 7, pp 618 – 629.
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