Medical Matters: The typical patient with low back pain is aged 35-55 and hobbles into the consulting room in obvious distress.
The acute pain and stiffness have started within the last few days and attempts at a home remedy have failed.
Often there is no obvious precipitating event, although sometimes an unusual burst of physical activity such as gardening or house painting is the culprit.
Back pain is a significant problem: more than 70 per cent of people in developed countries will experience low back pain at some time in their lives. Up to 7 per cent of patients with acute low back pain will go on to become chronic, which is defined as low back pain that has persisted for 12 weeks or longer.
What does a doctor usually do with the patient who has had back pain for say six weeks? He provides adequate pain relief, prescribes anti-inflammatory drugs, gives advice on the importance of remaining mobile and exercising and refers the person to a physiotherapist.
However, a research paper by a team headed by Dr Helen Frost, in last week's British Medical Journal, has challenged the role of physiotherapy for low back pain.
A randomised controlled trial of physiotherapy compared with advice for low back pain, it followed 286 patients with pain of more than six weeks duration to see whether "routine" physiotherapy was better than simple advice from a physiotherapist.
The researchers, from Warwick and Oxford, followed the patients for 12 months and somewhat surprisingly found that routine physiotherapy, for mild to moderate low back pain, was no more effective in the long term than just giving advice.
The patients in the control group had a physical examination by a physiotherapist and were given general advice to remain active, in a session lasting one hour.
Those in the treatment group were given a variety of standard treatments including joint mobilisation and manipulation; stretching; spinal mobility and strengthening exercises and hot and cold treatment.
They too received advice and were limited to an additional five treatment sessions lasting 30 minutes each.
Addressing the question of what this means for patients, Dr Domhnall McAuley, a Belfast GP and exercise specialist, says in an accompanying editorial: "The best option is to follow an advice sheet and remain active. If the best outcomes are from exercise then perhaps we need a new model of healthcare for patients with back pain."
But he makes the important point that although the patients given physiotherapy treatment showed no objective improvement using disability scales, they reported feeling better and felt they had benefited from the treatment.
Not surprisingly, the Irish Society of Chartered Physiotherapists(ISCP) has reacted to the research.
Its spokeswoman,Louise Kennedy, points to a number of flaws in the study. "In Frost's study, the subjects had low back pain with or without neurological signs. They also varied from being sub-acute to chronic low back pain sufferers of varied durations... this was not a homogenous group of subjects and the relevance of this trial is severely hampered as a result."
She also criticises the researchers for choosing patients with mild to moderate disability as not being representative of a group usually seen by physiotherapists.
In addition, she says: "The advice group also received a manual physical examination from a physiotherapist which would also have had a treatment affect."
Returning to work is now accepted as a key measure of outcome when studying low back pain and Kennedy rightly points out it was ignored in this research.
Where to for physiotherapy in low back pain in the light of this research? Well, certainly, there can be no question of not referring patients with the condition to physios. Examination and advice from physiotherapists have a proven value and as the ISCP says, the interventions used in the British study are not the most up to date. Australian researchers have recently shown the value of a specific exercise programme aimed at the deep muscles that stabilise the lower spine.
But a key measure of treatment success must be the ability of people with low back pain to regain their day-to-day function. At present, one in 10 are not able to return to work two months after back pain started. This group of patients need help in the form of early exercise and mobility training. It really does not matter if this intervention takes place inside or outside the medical setting as long as it works.
• Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he cannot answer individual queries.