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88 APPENDICES Physiotherapy KCE reports vol. B Aucune étude de bonne qualité méthodologique n est identifiée dans le cas des CLBP. Il y a des preuves importantes que le repos au lit n est pas efficace en cas de lombalgies aspécifiques de moins de 12 semaines. Le repos au lit peut être source d effets indésirables. 1.3 Lumbar supports Ce point est abordé dans les guidelines de bonne qualité méthodologique: SBU 2000, ANAES 2000, CBO 2003 et COST B13 2004. Notre recherche de littérature a mis en évidence une Cochrane systematic review (van Tulder 2006), ainsi qu un rapport HTA (NHS CRD 2000). The intervention is the use of a rigid or semi rigid lumbar support as treatment by a patient with chronic low back pain compared with a lumbar corset without support or no treatment. The outcomes are the pain, the function and the return to work. Results : There is limited and conflicting evidence that lumbar supports are more effective than no treatment. There is no evidence or conflicting low quality evidence that lumbar supports are more effective than other interventions for the treatment of low back pain. There is no evidence on the effectiveness of lumbar supports for secondary prevention. The studies are of low of middle quality and include often patients with acute or subacute low back pain. Selon l ANAES 2000, l intérêt d une contention lombaire reste à démonter (3 études de faible qualité). Le rapport HTA SBU 2000 mentionne une limited evidence en faveur du support lombaire (1 étude de qualité moyenne). Le guideline CBO 2003 s appuie sur une étude de qualité moyenne pour indiquer qu un support lombaire pourrait réduire la douleur (versus pas de prise en charge). Comparé aux autre formes de prise en charge, le guideline CBO 2003 conclut que le support lombaire n est pas efficace sur la réduction de la douleur (4 études de qualité moyenne), qu il y a des preuves contradictoires qu un patient avec support lombaire a une fonction améliorée (3 études de qualité moyenne) et que les patients avec support lombaire retournent plus vite au travail (2 études de qualité moyenne). The COST B13 2004 guideline concludes that there is no evidence for the effectiveness of lumbar supports compared with sham/placebo treatments and no evidence for the effectiveness of lumbar support compared with other treatment (6 études dont une seule inclut uniquement des patients chroniques). Le rapport du NHS centre for reviews and dissemination (2000) base ses conclusions sur la Cochrane systematic review de Tulder 2000. Cette SR retient 6 essais thérapeutiques randomises, de qualité plutôt faible. No evidence was found on the effectiveness of lumbar supports for secondary prevention. The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, while it is still unclear if lumbar supports are more effective than other interventions for the treatment of low back pain. Il est à noter que cette SR ne concerne pas spécifiquement le patient chronique. Le guideline CBO 2003 indique, à partir d un étude de qualité moyenne, qu un support lombaire rigide améliore plus la situation globale (algehele toestand) du patient qu un support non rigide. Safety COST B13 2004 related that adverse effects of lumbar supports have been reported in the literature : skin lesions, gastrointestinal disorders, muscle wasting, higher blood pressure and higher heart rates. Conclusion There is no evidence or conflicting poor quality evidence that lumbar supports are effective in patients with chronic low back pain. Likewise, no evidence was found suggesting that such devices may be effective for secondary prevention of low back pain. Adverse effects (skin lesions, gastro-intestinal disorders, elevated blood pressure and heart rate and trunk muscle wasting) have been reported. 1.4 Rehabilitation 1.4.1 Massage Ce point est traité dans les guidelines de bonne qualité: SBU 2000, ANAES 2000, Philadelphia 2001, CBO 2003, (based on Ernst 1999 et Furlan 2001) COST 13 2004 (based on 2 SR de bonne qualité Ernst 1999 et Furlan 2002, reprenant les études Cherkin et al 2001, Franke et al 2000, Hernandez-Reif et al 2001, Hoehler et al 1981, Hsieh et al 1992, Melzack et al 1983, Pope et al 1994, Preyde 2000, Hsieh 2004), KNGF 2005. Notre recherche a trouvé une mise à jour de la Cochrane systematic review (Furlan 2006). The intervention consists in soft tissue manipulation using the hands or a mechanical device (Furlan et al 2002). Different techniques can be used, such as: effleurage, petrissage, friction, kneading or hacking (COST B13 2004). Results
KCE reports vol. 40 APPENDICES Physiotherapy 89 2 SR récentes COST B13 2004 et Furlan 2006, concluent à la supériorité du massage versus pas de traitement, versus sham placebo, ou versus relaxation therapy, acupuncture and self-care education. Pour les comparaisons du massage avec les autres traitements (manipulation and TENS), les résultats sont contradictoires. En ce qui concerne le type de massage, les 2 SR concluent in favour of acupuncture massage versus classic Swedish massage. Les guidelines (SBU 2000, ANAES 2000, Philadelphia 2001, KNGF 2005) considèrent qu il n y a pas d études démontrant l efficacité des massages chez le patient avec lombalgies chroniques. Le guideline CBO 2003 inclut 2 SR de bonne qualité (Ernst 1999 et Furlan 2001) reprenant les 4 même RCTs. Le massage y est étudié comme intervention-contrôle et non comme intervention expérimentale. La qualité méthodologique des études est faible. Aucune conclusion ne peut dès lors être tirée. COST B13 2004, however, concludes that the effectiveness of massage is significantly better than sham laser therapy with regard to both pain and function up to 1 month after treatment (limited evidence based on one high quality RCT Preyde 2000), that immediately after treatment, massage therapy led to significantly greater disability and pain improvements compared with remedial exercise and posture education (limited evidence based on one high quality RCT Preyde 2000), that there is more pain relief after massage therapy in comparison to progressive relaxation therapy (limited evidence based on one low quality study Hernandez-Reif et al 2001), that massage is more effective than acupuncture in reducing pain (long term = 52 weeks) and improving function (shortterm =10 weeks and long-term) (limited evidence based on one high quality study: Cherkin et al 2001), that massage is better than self care education in reducing pain and improving function in the short term but not in the longer term (limited evidence based on one high quality study: Cherkin et al 2001), that effectiveness of massage is equally effective in pain relief than spinal manipulation, but that spinal manipulation results in better function versus spinal manipulation, that acupressure massage is more effective in mid-term pain relief versus general physical therapies, that there is no difference between massage and transcutaneous muscle stimulation with regards to improvements in either pain or function, that there is no difference versus corset (niveaux de preuves limités COST B13 2004), that massage in combination with remedial exercises and education is better than massage alone, remedial exercises alone or sham laser therapy for short term pain relief and improved function (limited evidence based on one high quality RCT Preyde 2000), that therapeutic acupuncture massage is more effective than classical massage (limited evidence based on one high quality study Franke et al 2000). Il est à noter qu aucune des études citées ci-dessus par COST B13 n est reprise dans la synthèse de CBO 2003. Recherche complémentaire : La Cochrane systematic review (Furlan 2006) traite du non-specific low-back pain. Nine publications reporting on eight randomized trials were included. Three had low and five had high methodological quality scores. Massage was compared to an inert treatment (sham laser) in one study that showed that massage was superior, especially if given in combination with exercises and education. In the other seven studies, massage was compared to different active treatments. They showed that massage was inferior to manipulation and TENS; massage was equal to corsets and exercises; and massage was superior to relaxation therapy, acupuncture and self-care education. The beneficial effects of massage in patients with CLBP lasted ad least one year after the end of the treatment. One study comparing two different techniques of massage concluded in favour of acupuncture massage with classic (Swedish) massage. (Furlan 2006) Conclusion There is a moderate level of evidence (level B) 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. 1.4.2. Heat and cold therapy Ce point est abordé dans les guidelines de bonne qualité: SBU 2000, ANAES 2000, CBO 2003 et COST B13 2004. Notre recherche a également trouvé une Cochrane systematic review (French 2005). Results All the mentioned guidelines conclude that there is no studies for the efficacy of cold or heat treatment in patients with chronic low back pain (SBU 2000, ANAES 2000, CBO 2003, COST B13 2004). La Cochrane systematic review (French 2005) concerne des patients en phase aigue ou subaigue. Elle ne mentionne pas d étude chez des patients chroniques. Conclusion There is no evidence available for or against the effectiveness of heat and/or cold therapies in patients with chronic low back pain.
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