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156 APPENDICES Physiotherapy KCE reports vol.40 Acute low back pain (without radiating pain) The most common treatment modalities applied by Belgian ambulatory physiotherapists to treat patients with acute low back pain are, from the most prevalent to the least: education of the patient, massage, mobilizations, home exercises, and stretching. The following treatment modalities are also frequent but to a lesser extent: thermotherapy, muscle strengthening, electrophysiotherapy, and spinal manipulations. The treatment modalities rarely applied by ambulatory physiotherapists include spinal tractions, muscle chains, proprioceptive rehabilitation, reflexotherapy, relaxation, behavioural therapy, EMG biofeedback, and hydrotherapy. The treatment modalities and the proportion of physiotherapists in our survey treating at least one patient with acute low back pain are confronted in Table 4.9 with the results of the literature review on evidencebased therapeutic modalities. Note that some evidence was only found for chronic low back pain. There is strong to moderate evidence in favour of the most common treatment modalities applied by Belgian ambulatory physiotherapists to treat patients with low back pain. On the contrary, treatment modalities that are ineffective or non-safety or with weak evidence are not frequently used by Belgian physiotherapists. It is important to note that spinal manipulations, which are performed by 38% of the physiotherapists though they are not legally considered as a physiotherapeutic treatment, are efficient but dangerous since they may cause minor (e.g., headache, fatigue) or major (e.g., stroke) secondary effects.
KCE reports vol. 40 APPENDICES Physiotherapy 157 Table 9 Acute low back pain: treatment modalities applied by Belgian ambulatory physiotherapists and evidence-based literature Treatment modality Frequency (proportion ± accuracy) Education of the patient 86 ± 4% Massage 75 ± 5% Mobilizations 74 ± 5% Type of evidence Evidence for (moderate to strong) Evidence for (moderate) ? Evidence for ? (moderate to strong) Evidence available in the literature on physiotherapy of acute low back pain (LBP) There is moderate to strong evidence that educational interventions are effective to reduce disability and increase return to work but are ineffective to reduce pain level. Concerning back schools: There is moderate evidence suggesting that back schools are effective in reducing pain, improving function and return to work rate during short and intermediate-terms follow-up. There is moderate evidence suggesting that back schools have better short- and intermediate-terms effects on pain and function in patients with recurrent or chronic low back pain than other traditional treatments. Back schools programs usually include education, exercise and interventions on movement and postures ergonomics in proportions and quantities that may considerably vary. More studies should be conducted to identify the optimal proportion of the different components of back schools programs as well as the characteristics of the total program in terms of number, frequency, duration and composition of the sessions. Concerning advice to stay active: Educating the patient with acute low back pain on the importance to stay active and to resume normal activities of daily life as soon as possible is effective. Concerning bed rest: There is strong evidence that bed rest is ineffective in acute low back pain and may induce undesirable effects. There is moderate evidence that massage has a superior positive effect on low back pain as compared to passive therapeutic modalities such as relaxation, acupuncture and self-care education. Adopted under the term Exercise therapy (COST B13 Working Group 2004). There is a moderate to strong evidence supporting a positive but modest short-term effect of exercise therapy. There is no clear evidence on the type of exercises that should be recommended. Although low intensity exercises seem ineffective, there is no clear evidence on the frequency, duration and intensity of exercises that should be recommended.
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