Abstract
Introduction: Practice guidelines recommend functional restoration as a cardinal intervention for chronic low back pain. Published studies attest variously to either modest or good efficacy for functional restoration programs. However, although published data might set a benchmark of what outcomes can be achieved in research studies, they do not necessarily indicate what is actually achieved in conventional practice.
Methods: A prospective audit was undertaken of all patients referred for functional restoration in a rehabilitation service dedicated primarily to the treatment of low back pain. In accordance with published principles 1, the program provided education and physical rehabilitation in a cognitive-behavioural milieu. Before treatment, immediately after treatment, and three months and six months later, patients were assessed, by a research nurse not involved in the patients’ care, using a visual analogue scale for pain, the SF36 for function, a patient-specified functional outcome scale, and the treatment helpfulness questionnaire. As well, the need for other care was recorded.
Results: Forty-six patients enrolled in the study, but nine did not complete the rehabilitation program, and five withdrew their consent. Only two were lost to follow-up. Before treatment, those patients who withdrew and those who participated did not differ in presenting features. All had a moderate level of pain; they were moderately disabled in physical functioning, social functioning, and vitality; but were only slightly impaired in general health and mental health. All could nominate four activities of daily living that were impaired by their pain and which most dearly they would want restored. After treatment, median pain scores did not improve; nor was physical functioning, or social functioning, or vitality improved. Only one patient restored their desired activities of daily living. The majority of patients (25/30) restored no activity. These outcomes did not improve at the 3-month or 6 month-review. Patients previously unemployed remained unemployed. The proportion of patients previously employed (80%) fell immediately after treatment (70%) and remained stable thereafter. All patients required some form of continuing care from their general practitioner. Notwithstanding these outcomes, the majority of patients rated the program as helpful (57%) or extremely helpful (33%).
Discussion: The sample size in the present study was similar to that used in the original studies that promoted functional restoration. Statistically and clinically, the outcomes in this audit are incompatible and totally dissonant with published claims of 80% success rates for functional restoration programs. The 95% confidence intervals of a success rate of zero are 0 to 11%, which fails to reach the lower 95% confidence interval of 80%, which is 66%. These results warn that what is achieved in conventional practice may not reflect the benchmarks established in the literature. Evidence from research may not translate into standards of practice. Citing the literature is not a substitute or surrogate for auditing one’s own outcomes.
Correspondence should be addressed to Dr Owen Williamson, Editorial Secretary, Spine Society of Australia, 25 Erin Street, Richmond, Victoria 3121, Australia.
