Abstract
Objective
To assess the efficacy and treatment compliance of a home-based rehabilitation programme for chronic low back pain (CLBP).
Population
CLBP outpatients treated in a Physical Medicine Rehabilitation or Rheumatology unit within a university hospital.
Methods
We performed a prospective, comparative study. The participants were randomly assigned to either a home-based rehabilitation programme (Gp A) or a standard physical therapy (Gp B). The programme included four weekly sessions. In each group, we measured pain intensity (on a visual analogue scale, VAS), flexibility and muscle endurance (the Schöber MacRae test, finger-to-floor distance, thigh-leg angle, the Shirado and Sorensen test), functional and psychological repercussions (the Quebec functional index and the Hospital Anxiety and Depression scale) and handicap (on a VAS). Follow-up examinations took place at baseline and four weeks and three, six and 12 months later.
Results
One hundred and seven patients (82 women) with a mean ± standard deviation (S.D.) age of 35.7 ± 0.8 years were included (with 54 patients in Gp A). At four weeks, a significant improvement (relative to baseline) was observed for all parameters in both study groups but with a significantly greater difference in Gp A, which was maintained at one year (despite an observed regression of the improvement at six months). At one year, compliance with the home-based rehabilitation programme was good (68.1%) and 59.5% of the patients regarded the programme as useful.
Conclusion
Our results suggest that a home-based rehabilitation programme is as effective as standard physical therapy. However, this type of programme requires patient motivation and regular follow-up.
Résumé
Objectif
Évaluer l’efficacité et l’observance à un programme supervisé d’exercices d’autorééducation dans la lombalgie chronique.
Population
Le recrutement est effectué à partir de lombalgiques chroniques suivis en consultation dans le service de médecine physique et de réadaptation et/ou de rhumatologie.
Méthodes
Il s’agit d’une étude prospective, randomisée, comparative, entre un groupe de sujets ayant suivi un programme supervisé d’autorééducation (Gp A) et un groupe traité par rééducation « classique » (Gp B). Les critères d’évaluation étaient l’intensité de la douleur lombaire (échelle visuelle analogique), la mobilité rachidienne (indice de Schober Mac Rae), l’extensibilité et l’endurance musculaire (distance doigt sol, angle jambe cuisse, test de Sorensen et de Shirado), l’état fonctionnel (échelle de Québec), l’état psychologique (Hospital Anxiety and Depression scale) et l’handicap ressenti (échelle visuelle analogique). L’observance a été évaluée par le nombre des séances réalisées. Tous les paramètres étaient évalués à j0, quatre semaines (fin de traitement), trois et six mois et un an.
Résultats
Cent sept patients, 82 femmes et 25 hommes d’âge moyen de 35,7 ± 0,8 ans ont été inclus dans l’étude dont 54 patients dans le Gp A. À quatre semaines, une amélioration significative de l’ensemble des paramètres a été observée pour les deux groupes mais avec une différence significative en faveur du Gp A. Cette amélioration s’est maintenue à un an pour Gp A malgré un fléchissement du gain observé à six mois. À un an, l’observance au programme d’autorééducation était bonne (68,1 %) et 59,5 % des patients ont considéré ce programme comme utile.
Conclusion
Les résultats de cette étude suggèrent qu’un programme d’autorééducation supervisé est aussi efficace qu’une rééducation classique. Cependant, ce type de programme nécessite une motivation suffisante et un suivi régulier.
1
English version
1.1
Introduction
Low back pain (LBP) is a public health problem worldwide because of its socioeconomic and psychological impact and the limitations of the many preventive or curative treatments that have been proposed . In fact, LBP affects up to 50 to 80% of all adults at some point in their life . In Tunisia, the annual prevalence is 50.1% and the incidence is 57% . However, only 6 to 8% of patients progress to chronic disability and will be responsible for more than 70% of direct and indirect medical costs or pose difficulties for care provision procedures . Many differed drug and non drug treatments are used to treat LBP. In contrast to “conventional” programme rehabilitations based on analgesia, improvements in trunk flexibility, muscle strengthening and improved functional capacity, dynamic programmes (in which the subject is active) are now being proposed. These programmes (such as a “Back School”) include the performance of physical exercise, functional restoration and multidisciplinary interventions . The efficacy (in terms of pain relief and functional restoration) of therapeutic approaches based on active exercise has been demonstrated in several studies . A recent literature review concluded that physical exercise can help chronic low back pain (CLBP) sufferers to resume normal activities and return to work . Accordingly, functional restoration programmes have been developed; the philosophy is to restore the patient’s physical, psychosocial and socioeconomic status via a proactive approach.
These programmes can significantly improve a patient’s quality of life and social reintegration . However, functional restoration programmes are burdensome and costly; there is thus an incentive to choose simple, effective, and inexpensive treatment protocols but the latter must be dynamic and active involve the patient.
The purpose of the present study was to assess the efficacy and treatment compliance of a home-based rehabilitation programme for CLBP.
1.2
Patients and methods
1.2.1
Population
The study population comprised all CLBP patients referred to the Physical Medicine and Rehabilitation Department at Monastir Hospital (Tunisia) between January 2006 and December 2007. All patients gave their informed consent to participation in the study.
Patients were excluded from the study if they were under 20 or over 60 years or had a history of symptomatic LBP (trauma, infection, tumours, inflammatory), sciatica and psychiatric disorders and/or behaviour precluding participation in group therapy.
1.2.2
Study protocol
1.2.2.1
Procedure
We performed a randomized, prospective clinical trial with two parallel groups:
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group A (Gp A) performed a home-based rehabilitation programme;
- •
group B (Gp B) received a standard rehabilitation programme.
1.2.2.2
Programme content
1.2.2.2.1
Home-based rehabilitation programme
Patients were assigned to groups of five or six subjects and received four practical training sessions of supervised, rehabilitation exercises. The weekly, 2-hour sessions were led by the same physiotherapist (AH) in the Physical Medicine and Rehabilitation Department’s outpatient service. Initially, the programme included 18 exercises: four self-positioning exercises for pain management (two in extension and two in flexion), eight muscle stretching exercises (lumbar spine, quadriceps, psoas and hip adductors) and four other muscle strengthening exercises (abdominal and trunk muscles). The exercises were learnt during the first three sessions (i.e. 6 per session).
We asked patients to perform these exercises daily at home. By way of a reminder, a booklet given to each patient featured illustrations of each exercise. The fourth session included a review of the previous lessons and the establishment of the final home-based programme, which contained nine exercises for each patient (to be performed for 30 minutes a day for a month).
1.2.2.2.2
The standard rehabilitation programme
The standard rehabilitation programme lasted four weeks and involved 90 minutes of treatment a day, three times a week. The programme included analgesic electrotherapy, flexibility training, pain management, stretching and proprioception exercises and muscle strengthening exercises. All patients received an individual session by the same physiotherapist (BS).
1.2.3
Evaluation parameters
1.2.3.1
Impairments
We have evaluated the following parameters:
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average pain intensity over the previous week, as assessed on a visual analogue scale (VAS);
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the MacRae Schöber index and finger-to-floor (FTF) distance measured in centimetres, to evaluate trunk flexibility;
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measurement of the thigh-leg (TL) angle, which evaluates hamstring flexibility. We have considered the average value for the two legs;
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back flexor and back extensor endurance, assessed with the Shirado test and the Sorensen test , respectively.
1.2.3.2
Disability and handicap
Functional status was assessed using the Quebec functional index . Perceived disability was assessed using a VAS. The psychological impact of CLBP was analyzed using the Hospital Anxiety and Depression (HAD) scale .
1.2.3.3
Satisfaction and compliance with the home-based rehabilitation programme
Patient satisfaction with the home-based rehabilitation programme was score on a semi-quantitative scale with three classes (useful/useless/indifferent). Patient compliance was assessed by the physician by determining the relationship between actual session performance at home and the total number of possible sessions. For a given group, all parameters were evaluated by the same physician: FY for Gp A and BSZ for Gp B. Patient follow-up was performed before the start of the programme (t0), at the end of the 4-week programme (t4) and after three months (M3), six months (M6) and twelve months (M12) of follow-up.
1.3
Statistical analysis
Statistical analysis was performed with SPSS ® for Windows ® (version 11). The descriptive analysis used the mean, standard deviation (S.D.), range and percentage. Intergroup differences in the evaluated parameters were examined using the t test and the chi-square test. The change over time in measured parameters for t0, t4, M3, M6 and M12 were examined using a paired t test and the McNemar test. The significance threshold was set to p = 0.05.
1.4
Results
1.4.1
Pretreatment characteristics
One hundred and seven patients were recruited into the study (82 women and 25 men with mean ± S.D. age of 35.7 ± 0.8). Group A comprised 54 patients (including 41 women) and had a mean age of 34.7 ± 1.2. Ten of these patients performed some leisure sporting activity and two had a history of spinal surgery. The mean time since LBP onset was 64.5 ± 8.7 months. Group B comprised 53 patients (including 39 women) with a mean age of 36.9 ± 1.3. Twelve of these performed a leisure sporting activity and seven had a history of spinal surgery. The mean time since LBP onset was 67.7 ± 10.7 months. There were no significant differences between the two groups in terms of epidemiological factors (age, gender, history of spinal surgery, sporting activities), clinical examination (trunk flexibility and muscle endurance) and the functional and psychological impact of LBP. These data are given in Tables 1 and 2 .
| Group A [ n = 54] | Group B [ n = 53] | p | |
|---|---|---|---|
| Age (years) | 34.7 ± 1,14 [20–48] | 36.9 ± 1.29 [22–50] | NS |
| Sex, n (%) | |||
| Man | 13 (24.1%) | 14 (26.4%) | NS |
| Woman | 41 (75.9%) | 39 (73.6%) | |
| Spine Surgery | |||
| Yes | 2 (3.7%) | 7 (13.2%) | NS |
| No | 52 (96.3%) | 46 (86.8%) | |
| Sport activity | |||
| Yes | 10 (18.5%) | 12 (22.6%) | NS |
| No | 44 (81.5%) | 41(77.4%) |
| Group A [ n = 54] | Group B [ n = 53] | p | |||
|---|---|---|---|---|---|
| Mean | Extreme value | Mean | Extreme value | ||
| Age (years) | 34.7 ± 1.14 | 20–48 | 36.9 ± 1.29 | 22–50 | NS |
| Duration LBP(months) | 64.5 ± 8.7 | 3–360 | 67.7 ± 10.7 | 3–264 | NS |
| VAS pain (mm) | 54.7 ± 18.1 | 20–90 | 53.6 ± 16.2 | 20–70 | NS |
| Schober Mac-Rae | 20.7 ± 1.5 | 17–23 | 20.5 ± 2.3 | 16–23 | NS |
| FTF distance (cm) | 13.2 ± 13.4 | 0–50 | 16.5 ± 9.5 | 0–35 | NS |
| Angle thigh-leg(°) | 15.8 ± 10,4 | 0–45 | 18.3 ± 12.2 | 0–45 | NS |
| Schirado (s) | 28.2 ± 22.2 | 0–88 | 25.9 ± 32.2 | 0–120 | NS |
| Sorensen (s) | 24.9 ± 21.5 | 0–79 | 23.3 ± 13.8 | 10–60 | NS |
| Quebec (0–100) | 33.2 ± 12.2 | 11–60 | 35.9 ± 9.3 | 10–48 | NS |
| HAD D (0–21) | 5.5 ± 3.4 | 0–13 | 6.7 ± 3.6 | 1–11 | NS |
| HAD A (0–21) | 8.5 ± 3.8 | 0–18 | 9.5 ± 4.6 | 4–17 | NS |
| VAS handicap (mm) | 48.2 ± 27.2 | 0–100 | 42.5 ± 22.6 | 0–80 | NS |
1.4.2
Evaluation at the end of the rehabilitation programme (t4)
Between the t0 and t4 time points, the pain intensity decreased in Gp A (−25.1; p < 0.001) and Gp B (−13.9; p < 0.001). FTF distance decreased by 7.3 cm ( p < 0.001) in Gp A and 5 cm ( p < 0.001) in Gp B. The TL angle also decreased by 8.4° in Gp A ( p < 0.001) and 9.9° in Gp B ( p < 0.001). We did not observe a significant improvement of the Schöber index in either group.
The values of the Shirado and Sorensen tests increased in both groups, with respectively 13.5 s ( p < 0.001) and 12.5 s ( p = 0.001) in Gp A and 26.1 s ( p < 0.001) and 13.9 s ( p = 0.001) in Gp B.
The Quebec functional index fell by 13.7 ( p < 0.001) in Gp A and 9.2 ( p < 0.001) in Gp B.
Along with improving the pain and functional parameters and muscle endurance, we observed for both groups, a non significant regression of perceived disability and scores of anxiety and depression of HAD.
The comparison between the two groups regarding the improvement in measured parameters has objectified a significant difference for pain intensity ( p = 0.003) in favour of Gp A and improvement in the Shirado test score ( p = 0.008) in favour of Gp B ( Table 3 ).
| Gp A | Gp B | Comparison Gp A/Gp B; p | |||
|---|---|---|---|---|---|
| Difference t4–t0 | p | Difference t4–t0 | p | ||
| VSA pain (mm) | −25.1 ± 20.3 | < 0.001 | −13.9 ± 17.3 | < 0.001 | 0.003 |
| Schober (cm) | 0.6 ± 1.2 | NS | 0.9 ± 2.2 | NS | NS |
| FTF distance (cm) | −7.3 ± 11.2 | 0.001 | −5 ± 10.3 | 0.001 | NS |
| Angle thigh-leg (°) | −8.4 ± 8.1 | < 0.001 | −9.9 ± 9.7 | < 0.001 | NS |
| Schirado (s) | 13,5 ± 18,1 | < 0.001 | 26.1 ± 29.2 | < 0.001 | <0.008 |
| Sorensen (s) | 12.5 ± 19.8 | 0.001 | 13.9 ± 21.2 | 0.001 | NS |
| Quebec (0–100) | −13.7 ± 11.2 | 0.001 | −9.2 ± 13.7 | < 0.001 | NS |
| HAD D (0–21) | −1.4 ± 0.4 | NS | −2.1 ± 0.5 | NS | NS |
| HAD A (0–21) | −1.8 ± 0.5 | NS | −2.4 ± 0.6 | NS | NS |
| VAS H(mm) | −23.4 ± 3.7 | < 0.001 | −17.2 ± 3.1 | < 0.001 | NS |
1.4.3
Change over time during the follow-up programme (M3, M6, M12)
These results are shown in Tables 4 and 5 and are summarized below.
| Parameters | Difference M3–t0 | Difference M6–t0 | Difference M6–M3 | Difference M12–t0 | Difference M12–M6 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Gp A | Gp B | p | Gp A | Gp B | p | Gp A | Gp B | p | Gp A | Gp B | p | Gp A | Gp B | p | |
| VAS pain (mm) | −27.1* | −10.9* | § | −22.1* | −10.2* | § | 5.1* | 0 | # | −19* | −4.5* | § | 3.1 | 6.4* | NS |
| Schober (cm) | 0.8 | 0.7 | NS | 1 | 0.3 | NS | 0.1 | −0.4 | # | 1.1 | −0.2 | # | 0.1 | −0.5 | NS |
| FTF distance (cm) | −8.7* | −5.4* | NS | −7.6* | −4.6* | NS | 1.1 | 0.8 | NS | −5.5* | −1.6* | § | 2.1 | 3 | NS |
| Angle TL (°) | −9.6* | −10* | NS | −10.6* | −10* | NS | −0.9 | 0 | NS | −8.1* | −5.3 | § | 2.4 | 4.6 | # |
| Schirado (s) | 36.2* | 22.7* | § | 36.2* | 20.6* | § | 0 | −2.1* | § | 30.3* | 19.6* | NS | −5.9* | −1 | § |
| Sorensen (s) | 31.9* | 20.3* | NS | 32* | 20.4* | NS | 4.9 | 0.1 | § | 26.6* | 19.2* | NS | −5.8 | −1.2 | § |
| Parameters | Difference M3–t0 | Difference M6–t0 | Difference M6–M3 | Difference M12–t0 | Difference M12–M6 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Gp A | Gp B | p | Gp A | Gp B | p | Gp A | Gp B | p | Gp A | Gp B | p | Gp A | Gp B | p | |
| Quebec | −15.1** | −18.5** | NS | −16.3** | −20.4** | NS | −1.2 | −1.9 | NS | −17** | −16.5** | NS | −0.5 | 3.9** | # |
| VAS H | −18.6** | −2.3 | § | −22.1** | −10.9 | § | −0.8 | 4.5 | NS | −25.9** | 9.8** | § | −6.5** | 7.5* | § |
| HAD D | −1.1 | −2.9 ** | # | −1.3* | −1.5** | NS | −0.3 | 1.4* | # | −1.4* | 0.9** | § | −0.1 | 2.4** | § |
| HAD A | −2.7** | −4.2** | NS | −3.2** | −2.6** | NS | −0.5 | 1.5** | § | −2.6** | −0.8 | § | 0.7 | 1.8** | # |
1.4.3.1
Pain severity
In Gp A, the decrease in pain severity continued until M3 (−27.1; p < 0.05). However, the pain intensity increased between M3 and M6 (5.1; p < 0.05) and between M6 and M12 (3.1; p = 0.199).
For Gp B, the decrease in pain severity was lower at M3 and remained stable up to M6. Between M6 and M12, the pain intensity increased (+6.4; p = 0.046). In both groups, there was a significant difference between t0 and M12 ( Table 4 ).
A comparison of the respective decreases in pain severity in Gp A and Gp B showed a significant difference in favour of Gp A (at all assessment times other than M6–to–M12) ( Table 4 ).
1.4.3.2
Lumbar and pelvic flexibility
In Gp A, the MacRae Schöber index increased (but not significantly) to M6 and then stabilized up to one year. However, in Gp B, the MacRae Schöber index decreased gradually after t4 so that the value after one year was similar to that at t0.
The FTF distance and TL angle decreased significantly ( p < 0.05) in both groups – between t0 and M3 for the FTF distance and between t0 and M6 for the TL angle, after which times the magnitude of the improvement decreased.
There was a significant intergroup difference in favour of Gp A for the change in FTF distance between t0 and M6 and for the change in TL angle between t0 and one year ( Table 4 ).
1.4.3.3
Muscle endurance
The Shirado and Sorensen test values increased significantly ( p < 0.01) in both groups between t0 and M3, with respectively 36.2 and 31.9 s for Gp A and 22.7 and 20.3 s for Gp B. In contrast, this improvement decreased in both from M6 and up to one year. A statistically significant difference between the two groups was noted for the Shirado test score over the duration of the 1-year study ( Table 4 ).
1.4.3.4
Disability
In Gp A, the Quebec functional index decreased progressively and significantly ( p < 0.01) up to one year ( Table 5 ). In contrast, the Quebec score in Gp B decreased significantly up to M6 but then increased between M6 and one year (+3.9, p = 0.007). An intergroup comparison revealed a statistically significant difference in the change over time in the Quebec functional index between M6 and one year (−0.5 for Gp A; 3.9 for Gp B, p = 0.018).
1.4.3.5
Psychological impact
During the study, the HAD score decreased to varying extents in both groups. Between t0 and t4, the HAD anxiety score decreased by 2.6 points ( p < 0.001) in Gp A and 0.8 ( p = 0.068) points in Gp B. The difference between the two groups was significant ( p < 0.001). In Gp A, the HAD depression score showed a similar change over time to that of the anxiety score. On the other hand, in Gp B, the HAD depression score decreased between t0 and M6, then the trend was reversed between M6 and M12 (+0.9; p = 0.011) ( Table 5 ).
1.4.3.6
Handicap
In Gp A, we observed a variable decrease of handicap experienced during the years of study with a maximum between t0 and M12 (−25.9; p < 0.0001). On the other hand, in Gp B, handicap experienced decrease to a not significant level between t0 and M3 (−2.3; p = 0.0171) then the trend reversed from M6 ( Table 5 ).
1.4.4
Compliance and satisfaction with home based programme
Few study participants were lost to follow-up. In Gp A, one patient was eliminated in the third month (due to an operation for sciatica), four were lost at M6 and seven patients were lost at one year of follow-up. Compliance with the home-based exercise programme was good: 87.8% at the end of the supervised programme (t4) and 88.6% at the M3 consultation ( Table 6 ), showing that the great majority of the patients continued to exercise beyond the first month. In terms of patient satisfaction, 75.4% of the subjects seen at three months stated that they had found the programme useful (with 66% at 6 months and 59.5% at 1 year). Non positive appraisals (useless or indifferent) were given by 24.4% of patients consulted at three months, 34% of the patients at six months and 40.5% of patients at one year.
| t4 | M3 | M6 | M12 | |
|---|---|---|---|---|
| Number of patients | 54 | 53 | 50 | 47 |
| Rates of compliance | 47 (87.8) | 47 (88.6%) | ||
| Satisfactory for program | ||||
| Useful | 35 (64.8%) | 40 (75.4%) | 33(66%) | 28 (59.5%) |
| Needless | 4 (7.4%) | 4 (7.5%) | 6 (12%) | 8 (17.1%) |
| Indifferent | 15 (27.8%) | 9 (16.9%) | 11 (22%) | 11 (23.4%) |
1.5
Discussion
The primary objective of this study was to assess the efficacy and feasibility of a home-based rehabilitation programme (Gp A), (Gp B). For ethical reasons, we were unable to use a placebo group as a comparator and we so decided to compare the evaluating physical, functional and psychological parameters measured in Gp A with those from a group undergoing a standard rehabilitation programme (Gp B), the efficacy of which has been reported . The results of this study show that the home-based programme improved the following parameters: pain, trunk flexibility, muscle endurance and psychological & functional impact. After one year of follow-up, all the parameters measured were better in Gp A than in Gp B. On the basis of the minimum detectable difference that can be clinically validated by international experts , we found that Gp A significantly reduced pain levels and disability at one year of follow-up. However, Gp B only improved the disability status. Furthermore, if we apply the Patient-Acceptable Symptomatic State (PASS: VAS < 40) concept , 63.8% of Gp A patients had a pain level below the PASS, versus 30.4% in Gp B. This difference in the change over time may be due the content of the home-based rehabilitation programme, since the latter lacks analgesic or passive methods of physical treatment and could help play down the pain. In fact, pain is not considered as a factor that limits performance of the exercises, which might thus reduce the perception of pain. Furthermore, group dynamism helps patients to accept and comply with the proposed rehabilitation programme . In contrast, the standard rehabilitation programme improves the physical parameters and disability but not pain. Indeed, some “standard” programmes probably aggravate the situation .
Hansel et al. suggested that the variable efficacy of exercise programmes reported for CLPB is due to the fact that the condition is a multifactorial and has multiple aetiologies. The authors also suggested that the prescription of exercises must take into account age, gender and aetiology. The advantages of our treatment protocol are mainly related to choice of the exercises, which were adapted to fit the patients’ clinicals parameters and were perfect well mastered by the patient following four supervised learning sessions (3 sessions for learning the exercises and 1 session for revision of the exercises).
The self-rehabilitation protocols proposed in the literature vary in terms of content and performance procedures. Some programmes offer exercise teaching sessions , whereas others directly deliver a programme noted in a booklet .
According to the literature, the efficacy of self-education seems to depend on the content, monitoring procedures and patient compliance with the treatment protocol .
In a meta-analysis, Hayden et al. concluded that the most effective strategy for CLBP was protocol treatment with therapist-supervised self-rehabilitation exercises and regular follow-up visits . Several authors have reported that programmes with stretching and strength-training exercises are most effective in reducing pain severity and improving functional outcomes .
Our focus on these types of exercises may explain the improvements in flexibility, muscle endurance and functional capacity. However, we noted a greater improvement in the trunk flexor endurance than trunk extensor endurance; this was probably due to the difficulties in performing trunk extensor strengthening exercises and thus neglect of this part of the programme by several of our patients.
A study involving subjects with sub-acute and chronic LBP compared standard care with a programme combining education exercises learned during group sessions and then performed at home. The authors reported a significant improvement in clinical parameters and a decrease in direct and indirect costs during follow-up in the intervention group.
In a study comparing three rehabilitation protocols (aerobic exercises + home-based exercises, standard rehabilitation exercises + home-based exercises and home-based exercises alone), Koldas Dogan et al. found a similar reduction in pain severity in all three groups at the end of treatment (6 weeks) and one month afterwards . The improvements in functional and psychological parameters were statistically significant in group 2 (standard rehabilitation exercises + home programme exercises) at the end of treatment and also one month later .
In our study, pain reduction was greater in the home-based rehabilitation programme (Gp A) at the end of the treatment period. The continued improvement in pain severity and physical and functional parameters in Gp A explains the statistically significant reduction in psychological and disability parameters. These were best in Gp A from the third month onward and up to one year of follow-up.
Our results are similar to those found by Genet et al., who also observed a decrease in the efficacy of a home-based programme after the third month and a return to the baseline state within one year . However, Kuukkanen et al. reported the persistence of an improvement in pain severity and functional parameters four years after a home-based rehabilitation exercise programme .
In the present study, follow-up was performed over one year, with a clustered series of evaluations (t0, t4, M3 and M6) and then a final evaluation (M6, M12). This arrangement may influence compliance with the home-based programme and could explain the decrease in efficacy from M6 to M12, the low number of patients leaving the study and the high compliance rate with the home-based programme. Kolt et al. found similar rates of compliance with home-based exercises to ours (87.7%) . The authors argued that gender does not influence the compliance rate; only the patient’s perception of the programme’s utility appears to influence its compliance .
Although the duration of our study seems to be sufficient with respect to literature data, a longer-term evaluation could enable firmer conclusions to be drawn.
1.6
Conclusion
The results of the present study suggest that a home-based rehabilitation programme including exercises that match each individual patient’s clinical profile can reduce chronic pain intensity and perceived disability, improve functional capacity and limit the psychological impact of LBP. However, this type of programme requires high levels of motivation and regular supervision and patient evaluation.
2
Version française
2.1
Introduction
La lombalgie représente un problème de santé publique dans le monde en raison de son retentissement socioéconomique et psychologique et des limites des très nombreuses thérapeutiques préventives ou curatives préconisées . La lombalgie affecte 50 à 80 % des adultes durant leur vie . En Tunisie, sa prévalence annuelle était de 50,1 % et son incidence de 57 % . Pourtant, seuls 6 à 8 % des patients passeront au stade de chronicité invalidante et seront responsables de plus de 70 % des coûts médicaux directs ou indirects et poseront des difficultés pour les modalités de prise en charge . Des nombreux traitements médicamenteux et non médicamenteux sont utilisés dans la lombalgie. Faces aux techniques « classiques » de rééducation à visée antalgique, de gain de mobilité et de gain de force et fonctionnelle, il est proposé des programmes dynamiques au cours desquelles le sujet est actif. Il s’agit des programmes de type « école de dos » dont leurs programmes comportent la réalisation des exercices physiques, « réentrainement à l’effort » et interventions multidisciplinaires . L’efficacité, sur la douleur et les déficiences, des approches thérapeutiques actives basées sur l’exercice physique a été démontrée dans plusieurs études . Une revue récente de la littérature conclue que l’exercice physique peut aider le lombalgique chronique à reprendre ses activités habituelles et son travail . En conséquence, les programmes de restauration fonctionnelle ont été développés et leur philosophie est de restaurer la situation physique, psychosociale et socioéconomique des patients en utilisant une démarche active de ceux-ci. Ces programmes entraînent une amélioration significative des indices de qualité de vie et un effet positif sur la réinsertion socioprofessionnelle des patients . Toutefois, les programmes de restauration fonctionnelle sont lourds et ont un coût élevé et incitent à choisir des protocoles thérapeutiques simples, efficaces, peu couteux mais dynamiques et impliquant de façon active le patient.
Le but de cette étude est d’évaluer l’efficacité et l’observance à un programme supervisé d’exercices d’autorééducation chez des patients lombalgiques chroniques.
2.2
Patients et méthodes
2.2.1
Population d’étude
Il s’agit d’une étude prospective ouverte ayant concerné tous les patients adressés au service de médecine physique et réadaptation de CHU Monastir-Tunisie, entre janvier 2006 et décembre 2007, qui présentaient une lombalgie chronique et ayant donné leur consentement pour participer à l’étude.
Les patients étaient exclus de l’étude s’ils avaient un âge supérieur à 60 ans ou inférieur à 20 ans, une lombalgie symptomatique (traumatique, infectieuse, tumorale, inflammatoire), une sciatique et des troubles psychiatriques et/ou comportementaux incompatibles avec une dynamique de groupe ou rendant l’évaluation aléatoire.
2.2.2
Protocole d’étude
2.2.2.1
Procédure
La population d’étude était randomisée en deux groupes A et B :
- •
groupe A (Gp A) ont suivi un programme supervisé d’autorééducation ;
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groupe B (Gp B) ont bénéficié d’un programme de rééducation classique.
2.2.2.2
Contenu du programme
2.2.2.2.1
Programme d’autorééducation
Les patients ont été inclus par groupe de cinq ou de six et ont bénéficié de quatre séances d’enseignement pratique et supervisé des exercices d’autorééducation. Les séances ont été animées par le même kinésithérapeute (AH) à raison d’une séance par semaine d’une durée de deux heures. Les séances se déroulaient en ambulatoire au service de médecine physique et réadaptation de CHU Monastir. Le programme a comporté initialement 18 exercices : quatre exercices d’autopostures (deux en extension et deux en flexion), huit exercices d’étirement musculaire (ischiojambiers et triceps suraux, fessiers et rachis lombaire, quadriceps, psoas et adducteurs de hanche) et quatre autres exercices de renforcement musculaires (abdominaux et spinaux). Les trois premières séances ont comporté l’apprentissage des exercices à raison de six exercices par séance. Il a été demandé aux patients de réaliser ces exercices quotidiennement. Pour une meilleure mémorisation, les exercices ont été schématisés et commentés sur un fascicule donné au patient. La quatrième séance a comporté la révision des exercices appris et l’établissement du programme définitif d’autorééducation comportant neuf exercices adaptés à chaque patient et qui doit les réaliser quotidiennement pendant 30 minutes et durant un mois.
2.2.2.2.2
Programme de rééducation classique
Les séances de rééducation classique se sont déroulées en ambulatoire à raison de trois séances hebdomadaires d’une heure et demie durant quatre semaines. Le programme a comporté une physiothérapie antalgique et des exercices d’assouplissement du rachis lombaire et de l’étage sous pelvien, des exercices de prise de conscience de la bascule de bassin, des exercices de renforcement musculaire isotonique et isométrique du tronc et des exercices de proprioception du rachis lombaire. Tous les patients ont bénéficié d’une séance individuelle faite par le même kinésithérapeute (BS).
2.2.3
Paramètres d’évaluation
2.2.3.1
Déficiences
Nous avons réalisé les mesures suivantes :
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une intensité moyenne de la douleur sur la semaine écoulée évaluée par une échelle visuelle analogique ;
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un indice de Schober MacRae pour l’évaluation de la souplesse lombaire ;
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une mesure de la distance doigts-sol (DDS) pour l’évaluation de la souplesse sus et sous pelvienne ;
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une mesure de l’angle jambe cuisse, coxo-fémorale à 90° (AJC) qui évalue l’extensibilité des ischiojambiers. Nous avons tenu compte de la moyenne des valeurs mesurées au niveau de deux membres inférieurs ;
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une endurance des abdominaux par le test de Shirado et des extenseurs du rachis par le test de Sorensen .
2.2.3.2
Incapacités et handicap
Le retentissement fonctionnel de la lombalgie a été évalué à l’aide de l’échelle de Québec . L’évaluation du handicap ressenti a été faite à l’aide d’une échelle visuelle analogique pour le handicap (EVA) en réponse à la question suivante : « Quelle est l’intensité moyenne de votre handicap ressenti durant la semaine précédente en rapport avec votre mal de dos ? »
Le retentissement psychologique de la lombalgie chronique à été analysé à l’aide de « Hospital Anxiety and Depression scale » (HAD) .
2.2.3.3
Satisfaction et observance au programme d’autorééducation
L’évaluation du taux de satisfaction du patient au programme d’autorééducation a été réalisée par une échelle semi-quantitative en trois classes (utile, inutile, indifférent). L’observance du patient a été évaluée par le médecin en calculant le rapport entre les séances réalisées à domicile et le nombre total possible des séances.
L’évaluation des paramètres étudiés a été faite par le même médecin pour chaque groupe et durant toute l’étude : FY pour le groupe autorééducation et BSZ pour le groupe rééducation classique. Le suivi des patients a été réalisé au début de l’étude (j0), à quatre semaines (S4), à trois mois (M3), à six mois (M6) et à un an du protocole thérapeutique.
2.3
Analyse statistique
L’analyse statistique a été réalisée avec le logiciel SPSS ® version 11 pour Windows ® . L’analyse descriptive a utilisé les moyennes, les écarts-types, les extrêmes et les pourcentages. L’étude comparative a utilisé le test de Student pour séries appariées, l’anova et le test de Khi 2 . Le seuil de signification « p » a été fixé à 0,05.
2.4
Résultats
2.4.1
Évaluation à l’entré de l’étude
Cent sept patients ont été recrutés pour cette étude. Il s’agit de 82 femmes et de 25 hommes d’âge moyen de 35,7 ± 0,8 ans.
Le groupe d’autorééducation (Gp A) a comporté 54 patients dont 41 femmes, d’âge moyen 34,7 ± 1,2 ans. Dix pratiquent une activité sportive de loisir et deux ont dans leurs antécédents une chirurgie rachidienne. La durée d’évolution de la lombalgie a été en moyenne de 64,5 ± 8,7 mois.
Le groupe de rééducation classique (Gp B) a comporté 53 patients dont 39 femmes, d’âge moyen 36,9 ± 1,3 ans. Douze pratiquent une activité sportive de loisir et sept ont dans leurs antécédents une chirurgie rachidienne. La durée d’évolution de la lombalgie a été en moyenne de 67,7 ± 10,7 mois.
La comparaison entre les deux groupes en terme de données épidémiologique (âge, sexe, antécédents de chirurgie rachidienne, pratique des activités sportives), examen clinique (extensibilité sus et sous pelvienne, endurance musculaire) et retentissement fonctionnel et psychologique de la lombalgie n’a pas montré de différence significative. Ces données sont rapportées dans les Tableaux 1 et 2 .
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