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98 APPENDICES Physiotherapy KCE reports vol. B
differences in short-term and long-term effectiveness when behavioural components are added to usual treatments
programs for CLBP (i.e. physiotherapy, back education) on pain, generic functional status and behavioural outcomes.
Comparaison des différentes techniques comportementales entre elles
ANAES 2000 conclut qu au total, aucune technique comportementale n apparaît supérieure à une autre dans la prise ne
charge des lombalgiques chroniques. Toutefois, les études ((cognitive versus operant (1 étude), cognitive versus
respondent (2 études), cognitive-behavioural versus cognitive (2 études), cognitive-behavioural versus operant (2 études),
cognitive behavioural versus respondent (1 étude)) sont de faible qualité méthodologique et portent sur un petit nombre
de patients.
CBO 2003 confirme la non différence d efficacité entre les méthodes utilisées sur base de la systematic review de Van
Tulder 2001 (21 RCTs)
COST 13 2004 aboutit aux mêmes conclusions avec un niveau de preuve important (level A). (2 high quality RCTs: Kole-
Snijders et al 1999, Turner and Clancy 1988 and 5 low quality RCTs):
Conclusion
There is strong evidence (level A) that most behavioural interventions are more effective that no treatment in reducing
pain and improving function in patients with chronic low back pain.
There is limited evidence (level C) that behavioural interventions are equivalent in terms of effectiveness as compared with
exercise therapy. Noteworthy one good quality study suggests that cognitive-behavioural therapy is as effective as lumbar
disc fusion surgery in reducing disability, at one-year follow-up (level C).
There is strong to moderate evidence (level A to B) that there is no difference in terms of effectiveness between the
different types of behavioural interventions.
There is moderate evidence (level B) that adding a behavioural intervention to more traditional treatments is not effective
in improving function as compared to the traditional treatment alone. However, graded activity programs using a
behavioural approach seem more effective than traditional care for returning patients to work (level B).
1.5.2. Brief educational interventions to promote self-care
Ce point est abordé uniquement dans le guideline COST B13 2004.
COST B13 2004 defined the brief educational interventions (as distinct from back schools) as interventions that involve
minimal contact with a healthcare professional (normally just one or two sessions), the use of self-management patient-led
groups, the provision of educational booklets, and the use of internet and e-mail discussion groups. The interventions aims
to encourage active self-management and to reduce concerns. Some such interventions are described as mobilisation in
some studies, to indicate the attempt to encourage the patient to become more active; this should not be confused with
the manual therapy treatment of spinal mobilisation.
Results
Un bref conseil encourageant la reprise des activités quotidiennes a un impact chez les patients avec chronic low back pain.
Le niveau de preuve est surtout important quand le conseil est donné le physiothérapeute ou par le physiothérapeute et
par le médecin.
COST B 13 2004 concludes (based on 10 RCTs, which 4 of good methodological quality) that there is moderate evidence
that brief intervention addressing concerns and encouraging a return to normal activities are better than usual care in
increasing return to work rates (level B), that there is moderate evidence that brief interventions encouraging self-care are
more effective than usual care in reducing disability (up to 6 months) but not pain (level B).
Other conclusions concern minimal contact defined as internet-based discussion groups/educational interventions. There is
limited evidence they are more effective than no intervention, in reducing disability (level C) and there is conflicting
evidence they are more effective than no intervention, in reducing pain (level C).
Brief interventions provided by a physiotherapist, or a physician and physiotherapist, and encouraging a return to normal
activities, are as effective in reducing disability as routine physiotherapy or aerobic exercise (strong evidence level A)
There is limited evidence that brief self-care interventions are as effective as massage or acupuncture in terms of reducing
pain and disability (level C)
Conclusion
There is moderate to strong evidence (levels A to B) that brief educational interventions that may be provided bay varied
care providers (GP, physiotherapist ) are effective to reduce disability and increase return to work but are ineffective to
reduce pain level.
There is limited (level C) or conflicting evidence that internet-based interventions based on discussion groups are effective
to reduce disability and pain level.
There is limited evidence (level C) that brief self care interventions are effective to reduce pain and disability.