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

Abstract Study Design – Pragmatic, randomised, 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 – 212 patients referred to physiotherapy with chronic low back pain were randomised to receive usual out-patient physiotherapy, spinal stabilisation classes, or physiotherapist-led pain management classes. Primary outcome was Roland disability questionnaire score eighteen 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 – 71 participants were assigned to usual out-patient physiotherapy, 72 to spinal stabilisation and 69 to physiotherapist-led pain management. 160 (75%) provided follow-up data at eighteen months showing similar improvements with all interventions: mean (95% Confidence intervals) Roland disability score improved from 11.1 (9.6-12.6) to 6.9 (5.3-8.4) with usual out-patient physiotherapy, 12.8 (11.4 -14.2) to 6.8 (4.9-8.6) with spinal stabilisation 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 (840) and 0.99 (0.27) for individual physiotherapy, £379 (1040) and 0.90 (0.37) for spinal stabilisation and £165 (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 out-patient physiotherapy and are associated with less healthcare use. A more widespread adoption of physiotherapist-led pain management could result in considerable cost-savings for health-care providers.