1334 patients who participated in the 2004 UK Beam Trial (pdf).  This is quite a number! For quick summary, it is a randomized trial of patients with low back pain who were divided between a “back to fitness” exercise program, spinal manipulation, and exercise + spinal manipulation.  Multiple outcomes were measured at 1, 3 and 12 months via Roland-Morris disability questionnaire, modified Von Korff scale, back belief questionnaire, fear avoidance belief questionnaire, and SF-36 and EuroQol (refer back to paper for more details).

Here is a summary of findings:

BMJ UK Beam Trial 2004

As expected, all groups showed improvement in primary and secondary outcomes, but biggest shocker is that no additional benefit of exercise group at 12 months compared to best care advice (2nd statement above).  Also, manipulation alone is same at 12 months as manipulation + exercise. Best care defined as continuing normal activities and avoiding rest.

This may open up more questions than answers but is interesting from a physical therapist’s perspective.  Does this mean patients will have lower disability at 3 and 12 months with manipulation?  Yes.  Does this mean we need manipulation and exercise for decreased disability at 3 and 12 months? Yes.  Does this mean just exercise will reduce disability at 12 months? No.

I normally state something to the extent of, “you need to keep performing these exercises for long-term control”.  Is this statement wrong?

What are your thoughts? 

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7 comments

  1. Interesting read Harrison and like you pointed out significant sample size.
    “They agreed to do high velocity thrusts
    on most patients at least once.” I’d like more info on this statement. What is “most” (>50%) and how many times average was it performed on those who did receive it.

  2. Also a good read is “Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manip to c spine” in current JOSPT which found a significant clinical prediction rule (3/4 attributes increased successful outcome from 39 to 90%!) I find interesting and also of possible good use is the treatment expectation (appendix) which asks the patient how they feel different types of treatment will help or not help them. I could probably predict how a patient may answer these questions after the evaluation but knowing the answers prior may change my plan of care and/or expectations/prognosis. A question i propose is that If a patient stated that he/she completely agreed that modalities would significanlty help their case would it make you rely more or less on them? I know I would be more less inclined and probably would never use manipulation if I knew they “completley disagreed” on the questionaire that manip would not help them. Also brings in the topic and power of placebo. (sorry getting off on tangent) have great day!

  3. @ John T,
    You make good points. I do not know the answer to the first question. I haven’t had a chance to read the new CPR study but it is on my list! I did glance over the appendix and find the expectation section interesting. Never seen this before, has it been used in the past?
    I agree with you in that we can usually pick up ‘what’ the patient wants but can be useful to help with patient satisfaction. Next question would be does patient satisfaction = optimal outcomes?

    Hv

  4. I also want to know what types of exercises were given, MDT, stabilization, general exercise or stretches? That can make a big difference on long term outcomes. Last study I read, albeit with a smaller n, MDT had better outcomes for long term at 1 year than SMT.

    1. “Back to fitness” protocol was used. I could not find that online. But, I am assuming it is very general; not specific. As you mentioned on your quick link page, more questions than answers. Would be nice to reproduce study with more specific treatment parameters.

  5. I don’t think it’s possible to draw conclusions about the effectiveness of exercise from this study. Looking at the numbers, only 63% of the people assigned to the exercise group actually went to an exericse class. The study defined exercise as attending one 60 minute class and there is no discussion in the write up regarding compliance or what exercises were performed. I woulnd’t expect 60 minutes of exercise to have a huge impact at 12 months.

    1. I agree James. As mentioned in the post, I do think this study creates more questions than answers. I know the study went on for a 2nd part to look at the economic value of treatment for LBP. Basically it stated that spinal manipulation alone may be financially more feasible than combining it and exercise (in terms of paying for time of a clinician, etc.).

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