An alternative group physiotherapy programme for the management of chronic low back pain in Primary Care

Objectives: To design, implement and evaluate an alternative physiotherapy group exercise programme used for managing chronic low back pain (CLBP) in Primary Care.
Introduction: CLBP is a disabling condition with no established standard management. Conservative treatments such as supervised exercise and manual therapy have demonstrated some benefit. Group exercise programmes used in physiotherapy practice are a cost effective treatment for managing CLBP but currently lack a combination of individualized specific exercises, one to one education and manual therapy (‘hands on’ techniques). An alternative group programme was designed to address these limitations.
Methods: This thesis consisted of two stages; a survey and a mixed methods design study. The physiotherapy survey was used in stage 1 to investigate what type of exercises are prescribed by physiotherapists and which group programmes are used in clinical practice for managing CLBP. One hundred and fifty-four questionnaires were distributed with a response rate of 63%. Ninety-seven percent of physiotherapists surveyed refer their
CLBP patients to group programmes but only 47% of all respondents were able to refer non-English speaking patients. None of the group programmes offered manual therapy. The alternative group physiotherapy programme was developed using this research, review of the literature and consultation with service providers. In stage 2, the alternative group exercise programme was evaluated using a mixed methods preliminary study consisting of a core quantitative and supplementary qualitative phases. The alternative group programme (Group A) was compared to a standard group exercise programme used in clinical practice (Group B) in a single blinded randomised controlled trial. Participants with CLBP were allocated to the two programme groups by block randomisation. Participants in both groups attended six one-hour programme sessions over a 3-month period. Outcomes measuring function, pain, quality of life (EQ-5D) and satisfaction with treatment were used to evaluate the effectiveness of the programmes pre and post programme attendance and at 6 months. Focus groups in the qualitative phase were used to explore patients’ experiences regarding their treatment in the two group programmes.
Results Stage 2: Eight-one participants were randomised to the two groups (41 in Group A; 40 in Group B). There was a drop-rate of 33% and only 41% were followed up at 6-months (n=10, Group A; n=12, Group B). There were no statistically significant differences between groups in outcome scores and apart from the EQ-5D at six months, the associated effect sizes were small. The within group analysis revealed significantly lower disability and pain scores post-programme compared to pre-programme in both groups. There were significantly higher EQ-5D scores post-programme compared to pre-programme in Group A but not in Group B. Quality of life deteriorated in Group B at 6-months. The focus group interviews showed that patients prefer
individualised exercises and one-to-one education which are components of the alternative programme.
Conclusion: This alternative programme may provide a suitable addition to existing programmes available for managing CLBP. This research may change the way physiotherapists deliver exercise for CLBP patients in a
group setting.