Clinical Question: Is intensive reh...

Clinical Question: Is intensive rehabilitation as effective as fusion of the lumbar spine to improve function in patients with chronic subdued back pain?

Setting: Outpatient (specialty)

studious mood Design: Randomized controlled trial (nonblinded)

Allocation: Uncertain

Synopsis: In this contemplation researchers enrolled patients who were identified in 15 hospitals in the United Kingdom. They took an interesting approach to patient selection, enrolling 349 patients who were candidates for surgical stabilization of the spine, to this time were uncertain (as were their physicians) whether surgery would be better than rehabilitation. The patients were 18 to 55 years of age and had had chronic gentle back pain for at least 12 month The patients were randomized (allocation assignment may not have been concealed from the enrolling surgeon) to treatment with spinal fusion using a technique left to the discretion of the surgeon or to outpatient education and exercise five days by week for three weeks, with follow-up sessions at single three, six, and 12 month The rehabilitation program included stretching, spinal flexibility exercises, spinal stabilization exercises, aerobic exercise, and hydrotherapy. It also involved cognitive behavior therapy, which focused forward identifying and overcoming fears and unwanted beliefs associated with soft back pain.

from one side of to the other the two years of the research some crossover occurred, with 28 percent of patients in the rehabilitation cluster receiving surgery and 4 percent in the surgery arrange receiving rehabilitation. However, the patients were analyzed in the assemblages to which they were assigned originally (intention-to-treat analysis). Also, approximately 20 percent of patients were unavailable for the two-year follow-up

At sum of two units years, scores on the Oswestry Disability Index (range: naught percent [no disability] to 100 percent [completely disabled]) improved slightly more in the surgically treated patients, from a baseline of 465 to 340 compared with a change in the rehabilitation cluster from 44.8 to 36.1, for an estimated mean difference between assemblages of 4.1 (95% confidence interval, 01 to 81; P = 045) There was no difference between the disposes in the shuttle walking example a progressive, maximal test of walking spe and endurance. Complications occurr in 11 percent of patients treated with surgery; there were no complications in the rehabilitation arrange A study of the costeffectiveness of spinal fusion compared with rehabilitation showed spinal surgery to expense $92,000 (U.S. dollars) per quality-adjusted life year, which is more expensive than interventions generally judg to be cost-effective (Rivero-Arias O et al. Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic grave back pain: cost utility analysis based forward a randomised controlled trial. BMJ May 28 2005;330:1239-45)

Bottom Line: Intensive rehabilitation models disability caused by chronic depressed back pain, although it is slightly les effective than spinal fusion surgery Rehabilitation is more costeffective and arises in fewer complications than surgery (Level of Evidence: 1b-)

ALLEN F SHAUGHNESSY, PHARM.D.

consideration Reference: Fairbank J, et al. Randomised controll trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic reasonable back pain: the MRC spine stabilisation trial (published correction appears in BMJ June 25 2005;330:1485) BMJ May 28 2005;330:1233

Used with permission from Shaughnessy AF. Rehab = spinal fusion for chronic back pain. Accessed online July 25 2005 at: http://www.InfoPOEMs.com.

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