Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability - A pragmatic randomized trial with economic evaluation

Study Design. Pragmatic, randomized, assessor blinded, clinical trial with economic analysis. Objective. To compare the effectiveness and cost-effectiveness of three kinds of physiotherapy commonly used to reduce disability in chronic low back pain. Summary of Background Data. Physiotherapy reduces disability in chronic back pain, but there are several forms of physiotherapy and it is unclear which is most effective or cost effective. Methods. A total of 212 patients referred to physiotherapy with chronic low back pain were randomized to receive usual outpatient physiotherapy, spinal stabilization classes, or physiotherapist-led pain management classes. Primary outcome was Roland Disability Questionnaire score 18 months from baseline; secondary measures were pain, health-related quality of life, and time off work. Healthcare costs associated with low back pain and quality-adjusted life years (QALYs) were also measured. Results. A total of 71 participants were assigned to usual outpatient physiotherapy, 72 to spinal stabilization, and 69 to physiotherapist-led pain management. A total of 160 (75%) provided follow-up data at 18 months, showing similar improvements with all interventions: mean (95% confidence intervals) Roland Disability Questionnaire score improved from 11.1 (9.6-12.6) to 6.9 (5.3-8.4) with usual outpatient physiotherapy, 12.8 (11.4-14.2) to 6.8 (4.9-8.6) with spinal stabilization, and 11.5 (9.8-13.1) to 6.5 (4.5-8.6) following pain management classes. Pain, quality of life, and time off work also improved within all groups with no between-group differences. Mean (SD) healthcare costs and QALY gain were 474 pound (840) and 0.99 (0.27) for individual physiotherapy, 379 pound (1040) and 0.90 (0.37) for spinal stabilization, and 165 pound ( 202) and 1.00 (0.28) for pain management. Conclusions. For chronic low back pain, all three physiotherapy regimens improved disability and other relevant health outcomes, regardless of their content. Physiotherapist-led pain management classes offer a cost-effective alternative to usual outpatient physiotherapy and are associated with less healthcare use. A more widespread adoption of physiotherapist-led pain management could result in considerable cost savings for healthcare providers.