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16 Articles in Volume 19, Issue #2
Analgesics of the Future: Inside the Potential of Glial Cell Modulators
APPs as Leaders in Pain Management
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control (Part 1)
Complex Chronic Pain Disorders
Efficacy of Chiropractic Care for Back Pain: A Clinical Summary
Hydrodissection for the Treatment of Abdominal Pain Caused by Post-Operative Adhesions
Letters: The Word "Catastrophizing;" AIPM Ceases Operations; Patient Questions
Management of Severe Radiculopathy in a Pregnant Patient
Managing Pain in Adults with Intellectual Disabilities
Pain in the Courtroom: An Excerpt
Q&A with Howard L. Fields: How Patients’ Expectations May Control Pain
Special Report: CGRP Monoclonal Antibodies for Chronic Migraine
The Management of Chronic Overlapping Pain Conditions
Vibration for Chronic Pain
What are the dangers of loperamide abuse?
When Patient Education Fails to Improve Outcomes: A Low Back Pain Case

When Patient Education Fails to Improve Outcomes: A Low Back Pain Case

Further investigation into instructional interventions and their impact on pain chronification are necessary.
Pages 15-17

with Adrian C. Traeger, PhD, James H. McAuley, PhD, Gabriel Sella, MD, MPH, and Steven Richeimer, MD

Intensive patient education—involving two hours of detailed information about pain, psychosocial contributors, and self-management techniques, all provided by a trained clinician—failed to improve pain outcomes for patients with acute low back pain when added to first-line care, according to a study1 involving what authors believe to be the first randomized, placebo-controlled clinical trial on the subject.

Low back pain is the world’s leading cause of disability.2 In the US alone, 80% of adults can expect to experience at least one bout of it in their lifetimes.3 Low back pain contributes to higher healthcare costs and missed work, costing the US economy more than $100 billion a year—two-thirds of which is due to lost wages and reduced productivity.4 These costs, along with the significant toll lower back pain takes on an individual’s quality of life, has created a sense of urgency to find treatments that can prevent an acute condition from becoming a chronic one.

The Role of Guidelines and Education

International treatment guidelines for acute low back pain—that is, pain lasting for 6 weeks or less—include advising patients to remain active, giving reassurance, administering simple analgesics when necessary, and providing pain education.5 While this approach works for many, up to 20 to 30% of these patients still go on to develop chronic pain.6

Intensive patient education is widely considered to be an important and effective component of acute low back pain treatment, noted the study’s authors, who are based at Neuroscience Research Australia.7 However, while patient education has been adopted by “every major clinical guideline,”8 it has yet to be rigorously tested in a clinical trial. The researchers set out to address this need.

(Source: 123RF)

Trial Design and Findings

The study included 202 patients, aged 18 to 75 years, with acute low back pain whom researchers concluded were highly likely to develop chronic pain based on the Predicting the Inception of Chronic Pain (PICKUP) prognosis model. In addition to first-line care, which patients received from their regular practitioner, half of the subjects were randomly assigned to receive intensive patient education. In these 2-hour sessions, a trained clinician provided detailed information about the psychosocial aspects of pain, advice about staying active, and instructions on how to use pacing (a means of adapting to limitations by creating a balance between activity and rest). The placebo group received active listening but no advice or information about low back pain.

More than 90% of the participants completed the year-long study. Self-reported data was collected at baseline; one week after the completed sessions; and at 3, 6, and 12 months after the date of pain onset. After analyzing their data, the researchers concluded that, “Adding two hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes,” pointing out that prior recommendations for intensive support to high-risk acute low back pain patients “may have been premature.”

The researchers did find significant differences in secondary outcomes (the probability of having pain recurrence, interference, and the odds of seeking additional healthcare) during the first few months of their trial. However, these differences were not present at 6 or 12 months after pain onset. “It is difficult to comment on usefulness based on those outcomes, given the risk that the differences were just noise,” said Adrian C. Traeger, PhD, early career fellow at Australia’s National Health and Medical Research Council and co-lead researcher of the study. “However, I do think it is worthwhile to continue to test patient education using different outcomes.”

Implications for Care and Communication

Based on their findings, the authors told PPM that physicians may not need to provide intensive patient education to acute low back pain patients. “It seems that more information is not necessarily more effective,” said co-lead researcher James H. McAuley, PhD, associate professor at the University of New South Wales and Neuroscience Research Australia. However, Dr. Traeger said he hasn’t given up on the benefits of patient education entirely. He hopes the research will inspire others to pursue robust trials using outcomes other than pain, such as the effects of educational interventions on health service use and medication use.

In terms of practical application, Gabriel Sella, MD, MPH, a practicing physician at the Ohio Valley Medical Center, said he believes that regardless of how well-intentioned, “Patients with acute symptoms expect relief…not education.” Only when the intense symptomatic period is over, will they be able to benefit from training, he said. For clinicians who do wish to provide education to their patients, Dr. Sella recommends limiting teaching sessions to 20 minutes and using simple, clear language. To determine whether a patient is grasping the material, he advises that instructors ask questions as they go along and provide a summary of the previous session before beginning a new one. Finally, he suggests the education “address the impairment of chronic pain rather than its disability.”

Steven Richeimer, MD, professor of anesthesiology and psychiatry at the University of Southern California, on the other hand, feels the study was too limited in its practical application. Instead of intensive education, he recommends “occupational therapy and pain psychology to provide the kind of ongoing educational intervention that is needed” for patients who are likely to progress to chronic pain.”

Last updated on: April 12, 2019
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