Intensive education ineffective for averting chronic low back pain

Intensive patient education is ineffective for helping acute low back pain despite being widely recommended in international guidelines, finds new research by University of Sydney and collaborators, published in JAMA Neurology.

In the first randomized, placebo-controlled trial for testing the effectiveness of early, specialised patient education for acute low back pain, the researchers found that recommendations to include intensive early management in treatment may be premature as it does nothing to help a patient’s recovery.

Back pain is the leading cause of disability worldwide, and second only to the common cold as a reason for visiting a general practitioner.

“Globally, major clinical guidelines recommend that health practitioners provide patient education to manage acute low back pain. This is the treatment for back pain that is currently the most accepted and recommended,” said lead author Dr Adrian Traeger from the University of Sydney's School of Public Health.

“However, the results of this study challenge the widespread belief that patient education is an effective strategy for treatment, so we are calling for a review of clinical guidelines.

“While education can reduce pain-related distress (e.g. catastrophisation) this may not have as much influence on the transition to chronic pain as previously thought.”

The study followed 202 participants who had experienced low back pain for less than six weeks and showed a high risk of developing chronic low back pain. All participants also saw their regular health practitioner during this study.

Participants in the intervention group received early, specialised care involving patient education over two one-hour sessions. The education focused on pain and contributing factors, and self-management techniques.

Participants in the control group received placebo patient education – active listening, but without information or advice.

The results showed that adding two one-hour sessions of specialised patient education to usual care of patients did not reduce pain intensity or lead to a meaningful reduction in the development of disability.

“Most people recover from acute low back pain without medical intervention. In our study, we were interested in treating those who were at risk of not recovering,” said senior author Associate Professor James McAuley from Neuroscience Research Australia (NeuRA).

“The international guidelines state that rather than give minimal care such as advice and reassurance, health practitioners should refer some patients for early specialised care over multiple sessions if they identify a patient as being at ‘high-risk’ of developing chronic pain.

“Our study shows that adding specialised, time-consuming treatment to primary-care is 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.”

Dr Traeger added: “This study has the potential to fundamentally change the way acute low back pain is managed in primary care.

“Ideally we don’t want people to develop chronic pain. We want to have a strong and robust methodology for GPs to manage low back pain at the grass-root level.

“Key outcomes of this research suggest a basic approach to acute low back pain treatment should include simple advice on how to remain calm and be reassured that your pain will get better; keep active and remain at work; avoid strong medications and to avoid imaging tests.”

The study was a collaboration between University of Sydney, Neuroscience Research Australia (NeuRA), University of Oxford, University of Technology, University of South Australia, Keele University, Macquarie University, University of Dammam and University of New South Wales.