Part 2 What should patient education involve?
Clinical guidelines provide little detail on the what, where, and how long of patient education. There are common features on what should be included: advice to stay active, reassuring of a good prognosis, nothing seriously wrong. Unfortunately, there isn’t much more than that. We don’t, for example, know whether patients with acute low back pain would benefit more from a biopsychosocial explanation (“…your back pain is affected by things going on in your back, but also your thoughts and feelings”) a neurophysiological explanation (“…back pain means your brain has detected danger and is protecting you”), a biomedical explanation (“…you’ve strained your L4/5 facet joint” ”you have an injured disc”) or a spiritual explanation (“…you’ve been kicked by a witch”). Because the final two options are arguably outdated and difficult to reliably determine, it would be reasonable for a clinician to avoid these. While there is some evidence that neurophysiological explanations may be superior to biomedical ones for patients with chronic low back pain,[1] those data are based on a small number of participants.
Can words influence clinical pain? There is empirical evidence that contextual factors including language can increase pain in a laboratory.[2] A “nocebo” is a term used for when contextual factors increase pain intensity from a given nociceptive stimulus. Judging from Twitter conversations I have observed, these findings have been generalised to the clinic, perhaps prematurely. Certainly, we know words have the capacity to both provoke or reduce fear about pain, and both have behavioural implications. We also know that people with low back pain who receive their imaging findings have worse disability outcomes than those who don’t receive their imaging findings.[3] I would suggest that these effects are likely to be moderated by how the clinician frames the results, and the subsequent care provided. Is there strong scientific evidence that using “nocebic” language per se has robust effects on patient outcomes? I am not so sure. However, I do acknowledge that an outdated biomedical model continues to dominate public discourse about pain. Improvements in management of low back pain are also unlikely until all health practitioners, consumers and policy-makers understand the biopsychosocial nature of pain. Ways of achieving this is an area that continues to be ripe for scientific enquiry.
Who should give it?
Physiotherapists are well placed to provide high quality patient education. They have the knowledge, the expertise, and the time. Unfortunately, there is evidence that we are less effective patient educators than medical doctors.[4] It is unclear why this might be. This discrepancy may become particularly problematic when patients receive different messages from different practitioners. One solution to this could be for future trials of patient education to report their intervention according to the TIDIER checklist (ensures that study authors give the what, where, when, how of complex interventions). This would be a step toward documenting the content that should be provided in an evidence-based patient education intervention. Of course, it may not be as simple as dishing out information: patient education may be fruitless without first listening to understand a patient’s story. Bill Fordyce, an eminent psychologist and pain researcher, likened passive information for patients in pain to throwing spaghetti at a brick wall, and I’d tend to agree. In some cases it may be better to let the patient do most of the talking.
Online health information for back pain is readily available but is often inaccurate and can suffer from the influence of vested interests. It also omits the patient-practitioner interaction, which many believe to be an important moderator of the effects of patient education. Nevertheless, online information is an important resource for those who cannot access face-to-face care. Unfortunately, even patient education sheets from reputable government organisations can include misinformation. It is incumbent on governments to ensure their health information is accurate. Patients would benefit from a central, trusted, peer-reviewed online resource where they could access evidence-based information about low back pain. There are some high quality, peer-reviewed patient education websites including PAINHealth, MyBack, and APA Choose Physio.
How much should be given?
In summary, brief (<10min), clear patient education could be adequate for most patients with acute low back pain.[4] Based on the interventions in our systematic review, if consultations are brief, clinicians would communicate the following elements: i) the high likelihood that the problem is not serious or one that requires intensive therapy, ii) the importance of remaining active and at work as much as possible and techniques to achieve these. Current management guidelines also recommend discussing the likely outcome (using prognostic tool might be better than a blind guess, e.g. STarT Back,[5] OMPSQ,[6] or PICKUP[7]) and providing a list of evidence-based treatment options. However, I should note that the estimates from these tools aren’t perfect, and there is almost no data on the impact of providing prognostic estimates to patients with low back pain. This is an important area for future research. Complex patients with persistent pain and multiple co-morbidities are likely to require longer consultations.
Conclusion
Patient education is an invaluable tool for physiotherapists. It is essential for empowering patients to make informed decisions about their healthcare. It can influence psychological distress and health service utilisation. Although patient education alone may not directly reduce pain and disability, that is immaterial given its potential for other health benefits. It is also rarely given in isolation. Patient education should be complemented with evidence-based treatments known to reduce pain and disability and that are decided upon with the patient. I urge all clinicians to continue to reflect on why they give patient education, what they say, and how much time they dedicate to providing it. They should also consider the amount of time they spend listening. It may not be the panacea for back pain, but patient education is more than an exercise in public relations: better informed patients could revolutionise health care for low back pain.
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] Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain 2004;20(5):324-30. doi: 00002508-200409000-00007 [published Online First: 2004/08/24]
[2] Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain 2004;109(1-2):20-5. doi: 10.1016/j.pain.2003.12.030 [published Online First: 2004/04/15]
[3] Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 2001;322(7283):400-5. [published Online First: 2001/02/17]
[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] Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632-41. doi: 10.1002/art.23563 [published Online First: 2008/04/29]
[6] Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Orebro Musculoskeletal Pain Questionnaire. Clin J Pain 2003;19(2):80-6. [published Online First: 2003/03/05]
[7] Traeger AC, Henschke N, Hubscher M, et al. Estimating the risk of chronic pain: development and validation of a prognostic model (PICKUP) for patients with acute low back pain. PLOS Med 2016;13(5):e1002019. doi: 10.1371/journal.pmed.1002019 [published Online First: 2016/05/18]