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100 APPENDICES Physiotherapy KCE reports vol. B pain and improves function in patients with CLBP (level A) and that there is strong evidence that intensive multidisciplinary biopsychosocial interventions are effective in terms of return to work, work-readiness (level A). Comparaison avec les autres traitements: According to COST B13 2004, there is moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach improves pain when compared with outpatient non multidisciplinary rehabilitation or usual care (level B). Based on the Cochrane systematic review that evaluated the effectiveness of physical conditioning programs for workers with back and neck pain in reducing time lost from work (Schonstein et al 2003), COST B13 2004 concluded that there is strong evidence that work hardening programs with a cognitive-behavioural component are more effective than usual care in reducing work absenteeism in workers with back pain (level A). Types d interventions et intensité du programme : Le rapport du NHS centre for reviews and dissemination (2000) base ses conclusions sur une systematic review de Tulder 2000. They concluded that multidisciplinary treatment programmes, involving components such as education, active exercise programmes, behavioural treatment, relaxation exercises, and work-place visits, can improve long-term outcomes for pain, functional status and sick leave compared with other treatments for chronic low back pain. According to COST B13 2004, one high quality study of 26 patients (Rose et al 1997) shows no difference between group or individual programs. According to COST B13 2004, the additional studies strengthen the evidence of the Cochrane reviews (Guzman et al 2001, Schonstein et al 2003) for the greater effectiveness of intensive multidisciplinary treatments compared with less intensive treatments, especially in relation to return to work or work capacity (level A). La Cochrane systematic review (Guzman 2006) confirme ces conclusions. Cette intervention concerne des adultes avec low back pain depuis plus de 3 mois. Intervention is defined as patients who had to be assessed and treated by qualified professionals according to a plan that addresses physical and at least one of psychological, or social/occupational dimensions. The reviewed trials provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. Less intensive interventions did not show improvements in clinically relevant outcomes. Conclusion The definition of multidisciplinary programs for patients with low back pain may vary considerably between studies. Generally such programs include graded activity, physical reconditioning, work hardening using a behavioural approach and other more conventional approaches as back schools, traditional physiotherapy, medications There is strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration are more effective in reducing pain and improving function in patients with chronic low back pain than more conventional treatments alone (level A). More intensive programs seem more effective than less intensive ones, especially in terms of return to work and improvement of physical capacity (level A). There is moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach improves pain when compared with outpatient non multidisciplinary rehabilitation or usual care (level B). There is contradictory evidence regarding occupational outcomes of intensive multidisciplinary bio-psycho-social intervention(level C). 1.7. Spinal manipulation Ce point est abordé dans les guidelines: SBU 2000, ANAES 2000, CBO 2003 (sur base de 4 SR : Assendelft 1995, Koes 1996, Van Tulder 1997 et Bronfort 1997), COST 13 2004, PRODIGY 2005 (UK BEAM trial 2004). Notre recherche complémentaire a trouvé une Cochrane systematic review (Assendelft 2006 data search 2000), ainsi qu une systematic review d Assendelft 2003, Bronfort 2004 (ces 3 SR incluent des RCTs de qualité méthodologique inégales allant de faibles à bonnes), Kent 2005 et Licciardone 2005 (ces 2 études n ont pas été retenues car elles considèrent la LBP en général et pas le patient chronique), ainsi qu un rapport HTA (HNS CRD 2000) According to COST B13 2004, spinal manipulation is defined as a high velocity thrust to a joint beyond its restricted range of movement. Spinal mobilization involves low-velocity, passive movements within or at the limit of joint range (Brox et al 1999, Koes et al 1996 in Cost 13 2004). Le type varie selon les etudes: rotational manipulation; manipulation and mobilization according to Cyriax, Kaltenborn, Lewit and Janda ; or to Maitland; or to Maigne; or to Kaltenbon, Evjent and Hamberg; rotational thrust manipulation to both sides; or in pain free direction; long-lever high-velocity thrust manipulation; Side-Lying manipulation. Les études utilisent des techniques parfois fort différentes. In the studies, comparison are made with sham procedure; or conventional general practitioner care and analgesics; or Physical therapy and exercise; or treatments considered as ineffective (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage; or back school. Results
KCE reports vol. 40 APPENDICES Physiotherapy 101 La littérature considérée s accorde à reconnaître une effet antalgique à court terme. Le niveau de preuve reste cependant modéré en raison de la qualité des études de base. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises or back school, AINS et ondes courtes. Efficacité sur les outcomes SBU 2000 concluded that there is strong evidence for spinal manipulation. ANAES 2000 relate un effet antalgique à court terme versus placebo (3 études de faible à moyenne qualité méthodologique). CBO 2003 conclut à des preuves modérées de l efficacité des manipulations vertébrales (versus placebo et versus soins usuels en médecine générale), surtout à court terme (sur base de 4 SR : Assendelft 1995, Koes 1996, Van Tulder 1997 et Bronfort 1997) According to COST B13 2004, manipulation is superior to sham manipulation for improving short term pain and function (consistent findings 4 studies of middle quality) (level B). Manipulation is superior versus treatments considered to be ineffective (such as traction, corset, topical gels) for short term pain relief and for short-term improvement of function (Assendelft et al 1994 sur base de 5 études dont 3 de bonne qualité). The pooled difference in pain intensity (on a 0-100 mm VAS) was just 4 mm (95% CI , 0-8mm) and in function on the 24-Point Roland Morris disability scale, 2.6 points (95% CI, 0,5 4.8). There were no significant benefits in relation to long-term pain and function. The UK BEAM trial (cited by prodigy 2005) evaluated the additional benefit to best practice care provided by general practitioners, by exercises and/or spinal manipulation therapy. (UK BEAM trial 2004). However, participants were people with simple low back pain of at least one month duration, not CLBP. Le rapport du NHS centre for reviews and dissemination (NHS CRD 2000) conclut that manipulation can provide shortterm improvement in pain and activity levels and higher patients satisfaction. They are however contradictory results between the studies. The Cochrane systematic review (Assendelft 2006) and the meta-analysis (Assendelft 2003) identified thirty-nine RCTs. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10mm difference (95% CI 2 to 17mm) on a 100mm visual analogue scale) or therapies judged to be ineffective or harmful. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not effect the results. The systematic review of Bronfort 2004 concluded that there is moderate evidence that spinal manipulation therapy/mobilization is effective in the short term when compared with placebo (3 études de qualité faible à moyenne) or general practitioner care (1 étude de qualité moyenne), and in the long term compared with physical therapy (1 étude de qualité moyenne). Manipulations vertébrales versus autres traitements : The Cochrane systematic review (Assendelft 2006) and the meta-analysis (Assendelft 2003) concluded that spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises or back school. COST B13 2004 has the same conclusion (based on the SR Assendelft 2004) avec un niveau de preuve A pour la comparaison with general practitioner or analgesics et B pour les autres comparaisons. La systematic review de Bronfort 2004 concluded that there is moderate evidence that spinal manipulation therapy has an effect similar to an efficacious prescription AINS (One good quality study). L ANAES 2000 conclut que les manipulations sont aussi efficaces que les AINS lorsque les patients font par ailleurs des exercices dans les 2 cas (1 essai contrôlé randomisé en simple aveugle non évalué) mais supérieures aux AINS seuls (1 essai randomisé prospectif non évalué pour les AINS et une étude de faible qualité pour le diclofenac). L ANAES 2000 rapporte des résultats contradictoires versus les ondes courtes, pour la douleur (études de qualité moyenne) La systematic review de Bronfort 2004 concluded that there is limited evidence than spinal manipulation therapy is superior to sham spinal manipulation therapy in the short term (one poor quality study) and superior to chemonucleolysis for disc herniation in the short term (One poor quality study) Type de manipulation Notre recherche de littérature n a pas mis en évidence d articles de bonne qualité comparant les techniques de manipulation entre elles. Safety 3 SRs focused on the safety. Elles ne traitent pas spécifiquement du CLBP; les effets sévères sont accidents vertébrobasilaires, hernie discale ou syndrome de la queue de cheval. Leur incidence est estimée entre 1 pour 2 millions de manipulations à 1 pour 400.000 Des effets mineurs et transitoires sont signalés par un patient sur 2 : inconfort local, maux de tête, fatigue et inconfort.(COST B13 2004)
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