Public health

Intensive education ineffective for averting chronic low back pain


Despite being widely recommended in guidelines for acute low back pain, intensive patient education has been found to be ineffective in an Australian randomised controlled trial.

With 20-30% of patients with acute low back pain going on to develop chronic  pain, guideline recommendations for first line treatment have included the provision of intensive education to explain the biological basis of pain, reframe unhelpful beliefs and encourage patients to adopt self-management techniques to promote recovery such as physical activity.

But when implemented in primary care settings in the form of referrals to two one-hour education sessions, this approach is no more effective than usual care in terms of back pain outcomes at three months and one year, a study from Sydney University and Neuroscience Research Australia has found.

In a randomised controlled trial, 202 primary care patients with acute low back pain of recent onset (< six weeks) were assigned to intensive education delivered by trained clinicians, or ‘placebo’ education (active listening) in addition to usual care. The patients had been identified as at high risk of chronic back pain by the Predicting Inception of Chronic Pain (PICKUP) Tool.

The active intervention was based on recommended educational techniques for low back pain, focusing on aspects such as biopsychosocial contributors and self-management techniques.

There was no difference between the intensive education and the control groups in the primary outcome of back pain intensity at three months. There was a modest effect on back pain disability at one week and three months, though this was judged to be of minimal clinical relevance. There was no effect on disability at six and twelve months follow up.

Writing in JAMA Neurology, the investigators in the Preventing Chronic Low Back Pain Trial [PREVENT] say their findings are instructive, given that recommendations for intensive education in acute low back pain have never been tested in placebo-controlled trials.

“Our results challenge a widespread belief that patient education is an effective strategy for treatment of acute low back pain. For example, every clinical guideline recommends patient education to manage acute low back pain,” they write.

They say that while education can reduce pain-related distress (eg, catastrophisation) this may not have as much influence on the transition to chronic pain as previously thought.

“Adding complex, time-consuming treatments to primary-care based advice and reassurance is likely to be unnecessary for most patients with acute low back pain.

“Intensive patient education should not be offered to patients with acute low back pain who are receiving first-line care,” they conclude.

Speaking to the limbic, co-author Dr James McCauley said the findings were disappointing as they were the latest in a string of negative results for early interventions such as manual therapy and or preventing the transition from acute to chronic low back pain.

However he stressed that this did not mean education of patients should be seen as ineffective, only that intensive interventions added little to current ‘usual care’ of providing reassurance and advice on the importance of staying active .

“What we can say is to practitioners is that they are already doing the best they can. Unfortunately there is a group of patients [with acute low back pain] who despite these efforts will still be in pain at three months,” he said,.

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