Education should be provided for all patients with acute non-specific low back pain. ‘How much education?’ was a key question investigated by a recent Australian study.
It found that more is not better. Basic education provided during the usual primary care consultation for patients was just as good as intensive education that involved two 1-hour individual, face-to-face sessions, according to the study.
Why was this study done?
Education is recommended as part of first-line care for patients with acute non-specific low back pain, together with reassurance, advice to stay active and self-management.1-3
The aim of the study was to assess the effectiveness of intensive education (of at least 2 hours) as additional treatment to first-line care.
The authors believed this was the first randomised controlled trial (RCT) to assess any education (basic or intensive) compared with placebo for patients with acute non-specific low back pain.4 The most recent review of research on education found that previous studies had assessed education against other non-invasive treatments.5
Non-specific low back pain
Where a clear cause of low back pain can’t be found, although it’s known not to be caused by a serious spinal or neurological pathology (such as cancer, infection, cauda equina syndrome, spinal stenosis, radiculopathy, vertebral compression fracture or ankylosing spondylitis).6 It affects around 90% of patients who present with acute low back pain.7
Acute low back pain
Pain present for less than 4 weeks, sometimes grouped with sub-acute low back pain as pain present for less than 3 months.6
Chronic low back pain
Pain present for more than 3 months.6
What the researchers did
Patients (n = 202) were recruited from general practices, physiotherapy clinics and a research centre in Sydney, and had experienced low back pain for < 6 weeks. They were all assessed as having a high risk of developing chronic low back pain according to the risk stratification tool Predicting the Inception of Chronic Pain (PICKUP).4
All patients received the recommended first-line care from their usual practitioner. Each participant also received two 1-hour individual, face-to-face sessions of either intensive education or placebo education. Intensive education involved information on pain and biopsychosocial contributors plus self-management techniques. The placebo education was active listening, without information or advice.4
What were the findings?
Intensive education was not more effective than placebo education for the primary outcome of ‘reducing pain intensity during the past week’ (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, –0.3 [95% CI, –1.0 to 0.3]).4
For some secondary outcomes, such as disability at 1 week and 3 months, pain interference at 3 months, pain recurrence at 12 months and odds of seeking health care at 3 months, intensive education was found to be significantly more effective. However, the authors noted that due to the statistical methods used, some of these findings had an increased risk of false positives.4
How the media reported the study
Just one word is all it takes to provide misleading information.
While many media reports were accurate about a new study that found ‘intensive education’ was ineffective for patients with low back pain, others stated ‘GP-led back pain education of no benefit’,8 and ‘Pain education doesn't help those with acute low back pain’.9
By not including the word ‘intensive’, these outlets unfortunately conflated the lack of effectiveness of intensive education into one message that all patient education for low back pain is ineffective. It reinforces the importance of correctly interpreting research.
What you need to know
- The study only assessed intensive education for patients with acute low back pain. Basic education provided during a usual primary care consultation is effective, according to the evidence, and still recommended by guidelines as part of first-line care.1-3
- Guidelines also recommend:1-3
- assessing all patients with acute non-specific low back pain for risk of developing chronic, disabling pain
- providing treatments based on the patient’s risk of developing chronic, disabling pain, where all patients receive first-line care, and higher risk patients receive first-line care and additional treatments. (See Clinical resources and tools)
The additional treatments recommended for patients at high risk of developing chronic, disabling pain include:
- exercise (structured and regular physical activity)
- manual therapies such as massage
- cognitive behavioural approach for targeted pain management of psychosocial factors
- treating specific mental health comorbidities (eg, depression or anxiety), if present.
- Rheumatology Expert Group. Therapeutic guidelines: Low back pain. West Melbourne: Therapeutic Guidelines Ltd, 2017 (accessed 23 July 2018).
- NSW Agency for Clinical Innovation. Management of people with acute low back pain: model of care. Chatswood: NSW Health, 2016 (accessed 1 March 2018).
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. London, UK: NICE, 2016 (accessed 1 March 2018).
- Traeger AC, Lee H, Hubscher M, et al. Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: a randomized clinical trial. JAMA Neurol 2018.
- Van Wambeke P, Desomer A, Ailliet L, et al. Low back pain and radicular pain: Assessment and management. Brussels: Belgian Health Care Knowledge Centre (KCE), 2017 (accessed 30 May 2018).
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-91.
- Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust 2017;206:268-73.
- 6 minutes. GP-led back pain education of no benefit: study. Sydney: Australian Doctor Group, 2018 (accessed 14 November 2018).
- Swan N. Health report. Pain education doesn't help those with acute low back pain. Sydney: ABC, 2018 (accessed 14 November 2018).