Point of View

This interesting randomized clinical trial (RCT) provides further evidence that both multidisciplinary rehabilitation using a biopsychosocial approach, and single-discipline exercise therapy (similar to what is called “work conditioning” in the United States) can be effective in reducing pain self-report in CLBP. The multidisciplinary program was both more costly and effective, but both groups appeared satisfied and improved up to 2 years after the onset of the RCT. They note similarities to prior studies on effectiveness of such programs, including prior European trials. A potential problem exists regarding the generalizability and relevance of the trial for CLBP associated with disability. This study focuses more on subjective self-report of pain and function stated by the patients themselves (validated questionnaires), rather than on objective outcomes such as work return, future health utilization or recurrent injury. Although subjective information is still the predominant outcome data provided in most spine treatment outcome studies, it is noteworthy to highlight the author’s discussion of work. Table 1 demonstrates about 55% of both groups are working at onset of the trial, but the text shows that “ability to work” varied highly during the course of the study, with this term never clearly defined (i.e., actually working, or simply deemed capable of working). Immediately after treatment, the “ability to work” increased 11% for the multidisciplinary rehabilitation group (from 29% to 40%), but only 2% for the single-discipline group (from 36 to 38%). By the 2-year follow-up, both groups had shown almost a 20% increase in “ability to work,” but the relationship to the treatment process by then is unclear. Since most of the cost generated by CLBP in industrial countries is related more to the disability than to “pain,” both in financial benefits paid for work absence or presenteeism and for medical care to resolve it, it would have been useful if the authors had provided more information on the effect of these 2 programs on objective disability-related outcomes, rather than simply on self-reported pain and function questionnaires. A related issue of concern is the limited characterization of the patients referred with “chronic” LBP. Patients in this study averaged nearly 10 years of LBP, but it appears most patients had only episodic problems, since the length of pain report for the current episode averaged only 1.5 years. Patients were included if they had a minimum of 3 months of pain, so it is unclear whether the natural history of recovery might have led to improvement without any treatment at all for many of these patients (due either to relatively acute or brief episodic pain). The authors claim “clinical relevance” for some of the self-report findings without stating the basis for this judgment. They also appear to suggest some preference for single-discipline exercise therapy despite lack of evidence to support this position. Why is this study, and the additional points being made, of importance? At a time of changing healthcare patterns, assessment of medical evidence and burgeoning technology, high-quality rehabilitation has been definitively shown to have an important place in improving spine care for subacute, chronic, and postoperative patients. Patients for whom CLBP is merely an annoyance for which they pay an occasional visit to a general practitioner, are far different from those who are completely disabled, have sustained multiple hospitalizations and surgeries, and who may be using high doses of opioid medications, while having developed extreme levels of physical deconditioning and psychosocial distress. The former group of patients is generally easy to satisfy, cost little individually, remain nondisabled and very functional, and respond well to limited single-discipline exercise therapy. The latter, more complex group tends to become worse with increasing chronicity, and is unlikely to respond well to a simple reconditioning approach. We simply do not know which type of patient (or mixture thereof) was included in the present study, and this detracts from the utility of the conclusions. The challenge to this group of authors, and to others working in this important area of spine care, is to clearly characterize the population they are studying, and then use the most objective outcomes possible. Despite these shortcomings, the authors have advanced the science of spine care.