Part 1 Should patient education be part of my treatment?
Patient education gets physiotherapists so worked up! I am often surprised at how virulent discussions of patient education can become. “Nocebo language”—language that worsens pain– seems to be a major concern. “Words can harm!” Did you just use a pathoanatomic label for non-specific low back pain on social media? Prepare for a blood bath. Sure, a clinician diagnosing low back pain as a “disc” or “a facet” or “SIJ” may not realise the (in)ability of current tests to reliably diagnose a nociceptive source.[1] They are probably also unaware of the potential for overdiagnosis.** But the reaction among physiotherapists on social media to biomedical language is a curious one. It raises important questions. For example, how good is the evidence that biomedical information is harmful to patients with low back pain? What are the harms and how long do they last? If words can harm, then the opposite may be true: which are the words, then, that can help a sore back?
That the meaning of pain can impact on pain itself is well accepted among pain researchers, and supported by a strong biologic rationale and laboratory evidence. Many clinicians will have observed patients who improve rapidly after receiving a reassuring explanation for their pain. When I worked clinically, I felt that my explanations were the most important part of my job–more important than any other treatment technique at my disposal. I completed a PhD on the topic. During my PhD I provided around 120 hours of patient education to people with acute low back pain in the PREVENT randomised trial.[2] That trial was published recently in JAMA Neurology, and received quite a bit of attention (and is the subject of another blog post so I won’t focus on it here). The results of the trial made me rethink the role of education in patient care. Below I discuss what I see as the promises and pitfalls of patient education for low back pain.
Should I provide patient education for low back pain?
The short answer is yes. A recent review of international clinical guidelines for non-specific low back pain found 12/14 (85%) recommended patient education.[3] This suggests that there is consensus on the benefits of providing it. Surprisingly, however, the evidence base for patient education is not as strong as one might expect to achieve this level of consensus. For patients with acute low back pain, a systematic review found moderate quality evidence that patient education is reassuring (14 RCTs, n=4872)–that is, it reduces fear and worries about the problem in the long-term–and high quality evidence that it leads to small reductions in healthcare utilisation.[4] However, there is little evidence that patient education can reduce pain or disability for people with acute low back pain (<3 months duration).
The story may be different for chronic low back pain (>3 months duration). There is evidence that patient education can reduce pain and disability in these patients. The latest review of pain neurophysiology education–biopsychosocial education centred on the brain’s involvement in the pain experience–included 7 randomised trials (n=313)[5] in patients with chronic low back pain and concluded there was “moderate quality” evidence that this intervention could reduce pain in the immediate and short term compared to usual care despite 6 of the 7 of the included trials having a high risk of bias. This means that future high-quality placebo-controlled trials could change the conclusion that patient education is an effective treatment for chronic low back pain.
Does it matter that patient education alone may not improve pain or disability, compared with a placebo? I would argue no. We can be moderately confident that patient education has important benefits for people with low back pain. For example, it appears to be reassuring, regardless of the content.[4] Perhaps most importantly, patient education can promote informed choice about healthcare. Informed patients can better navigate the multitude of ineffective and harmful tests and treatments (namely imaging, injections, opioids and surgery) that continue to be funded by insurance schemes in many industrialised countries and promoted by those who profit from providing them. There is even emerging evidence of poor care in low and middle-income countries.[6] Trials have begun to investigate the feasibility of patient education interventions as an alternative to costly and ineffective care in low-income countries such as Nepal.[7] These studies will be a valuable addition to the literature. But if we do it what should it look like? We’ll pick up on that issue in my next blog–watch this space.
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**Overdiagnosis occurs when a person is given a diagnostic label that ultimately brings them no benefit, or causes harm. There is a body of evidence from various health areas suggesting that a diagnostic label can i) negatively impact on psychosocial factors and ii) drive healthcare behaviour. Data on overdiagnosis of low back pain are limited.
An adapted version of this article appeared in the November 2018 issue of the Australian Physiotherapy Association InTouch Magazine.
About Adrian Traeger
Adrian is a physiotherapist and NHMRC Early Career Fellow. Adrian has a special interest in evidence-based patient communication. Adrian worked in primary care for 10 years before completing a PhD in Medicine from the University of New South Wales. He has published 37 scientific papers relating to low back pain and patient communication in leading journals such as BMJ, JAMA Internal Medicine, CMAJ, and PLOS Medicine. Adrian is currently investigating strategies to reduce overdiagnosis of low back pain. He holds a research-focused position at Sydney School of Public Health, The University of Sydney and teaches at Sydney Medical School.
References
[1] Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16(10):1539-50. doi: 10.1007/s00586-007-0391-1 [published Online First: 2007/06/15]
[2] 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 neurology 2018 doi: 10.1001/jamaneurol.2018.3376 [published Online First: 2018/11/07]
[3] Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J 2018 doi: 10.1007/s00586-018-5673-2 [published Online First: 2018/07/05]
[4] Traeger AC, Hubscher M, Henschke N, et al. Effect of Primary Care-Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA Intern Med 2015;175(5):733-43. doi: 10.1001/jamainternmed.2015.0217 [published Online First: 2015/03/24]
[5] Tegner H, Frederiksen P, Esbensen BA, et al. Neurophysiological Pain Education for Patients With Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Clin J Pain 2018;34(8):778-86. doi: 10.1097/ajp.0000000000000594 [published Online First: 2018/02/15]
[6] Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018;391(10137):2368-83. doi: 10.1016/s0140-6736(18)30489-6 [published Online First: 2018/03/27]
[7] Sharma S, Jensen MP, Moseley GL, et al. Pain education for patients with non-specific low back pain in Nepal: protocol of a feasibility randomised clinical trial (PEN-LBP Trial). BMJ open 2018;8(8):e022423. doi: 10.1136/bmjopen-2018-022423 [published Online First: 2018/08/14]