Reviews of randomised controlled trials have shown that functional restoration therapy is an effective treatment for chronic low back pain. Evidence supporting the efficacy of the DBC method system that realises the benefits of functional restoration therapy by combining the benefits of exercise treatments and the cognitive behavioural approach has been accumulating in medical research and clinical practice.
Data on treatment results obtained in DBC clinics show that the well-being of a large majority of patients is improved even in severe cases. DBC treatments have been proven effective in chronic pain. (Kankaanpää et al. 1999.) The DBC rehabilitation programmes have been shown to increase strength, mobility and endurance as well as reduce pain (Härkäpää and Taimela 1996; Taimela and Härkäpää 1996).
The benefits obtained during the DBC programmes can be sustained for a long time, especially if the patient continues to exercise after the treatment (Kankaanpää et al. 1999; Mannion et al. 1999; Taimela et al. 2000). Of significance is the impact of cognitive behavioural approach on work absenteeism. A Cochrane Review published in 2002 (updated in 2003) concluded that significant reductions can be obtained with functional restoration therapy: ``There is evidence that physical conditioning programs that include a cognitive behavioural approach can reduce the number of sick days lost at 12 months follow-up by an average of 45 days, when compared to general practitioner usual care or advice, for workers with chronic back pain.`` (Schonstein et al. 2002.)
Strong evidence from multiple relevant, high quality randomised controlled trials:
- Exercise therapy is effective
- Manipulation is more effective than placebo in pain reduction
- Intensive back school in occupational setting is more effective than no actual treatment
A large body of evidence confirms that for a majority of patients exercise therapy reduces impairments in back flexibility and strength and improves endurance. Most studies have noted that after exercise treatment the overall reduction in back pain intensity ranges from 10 % to 50 %. (Rainville et al. 2004.) In 16 high-quality randomised controlled trials, exercise therapy produced positive effects in each and every study (Liddle et al. 2004).
Moderate evidence from other randomised controlled trials:
- Manipulation is more effective than usual care by general practitioner, bed rest, analgesics and massage
- Epidural steroid injections are more effective than placebo, NSAIDs
- Antidepressants are not effective
- Behavioral therapy is effective
- Muscle relaxants are effective
- Traction is not effective
- Biofeedback is not effective
While chronic neck conditions have been subjected to less medical research than low back pain, the available evidence supports the DBC approach. In chronic neck pain, continuation of normal physical activities is recommended. Ergonomic factors at work and at home should be considered. In chronic pain, medication is not as straightforward or beneficial as in acute pain. For instance, nonsteroidal anti-inflammatory drugs (NSAID) cannot be recommended for chronic pain. The efficacy of muscle relaxants has not been proven in patients with chronic pain.
ACTIVE MULTIMODAL TREATMENT EMPHASIZING PROPRIOCEPTIVE EXERCISES AND THERAPEUTIC EXERCISES
A randomised comparative study with a 1-year follow-up produced some evidence for active multimodal treatment strategy emphasising proprioceptive training. Active multimodal treatment was more efficacious than activated home exercises that were in turn clearly more beneficial than mere advice given to patients. (Taimela et al. 2000.)
In a review by the Philadelphia Panel, only proprioceptive exercises and therapeutic exercises showed clinical benefits in chronic neck pain. Exercise also improved function. On the basis of these results, it was concluded that therapeutic exercises are the only intervention that have clinically important benefits regarding neck pain and function. (Philadelphia Panel 2001; Harris and Susman 2002.)
There are many kinds of physical therapies available for neck pain, but comparative trials involving individual therapies have not been carried out. There is inadequate evidence regarding the efficacy of therapeutic ultrasound, massage, thermotherapy, and electrical stimulation. (Philadelphia Panel 2001.)
In October 2001, the American Physical Therapy Association (APTA) unveiled the society’s evidence-based guidelines for clinical practice. The conclusion was that there is scientific evidence to support proprioceptive exercises and therapeutic exercises for chronic neck pain. However, there is a lack of evidence to include or exclude the use of thermotherapy, therapeutic massage, EMG biofeedback, mechanical traction, therapeutic ultrasound, TENS, electrical stimulation, and combined rehabilitation interventions. (Bagnall 2002.)