Advice for the management of low back pain: a systematic review of randomised controlled trials
From: Man Ther. 2007 Nov;12(4):310-27. Epub 2007 Mar 28
The socio-economic burden of low back pain continues to increase due largely to disproportionate rises in low back pain disability. Indeed, in the 3 years from 1992–1995, days of work disability in the UK are reported to have escalated from 27 to 125 million. While it is estimated that about 90% of acute back pain patients return to work within three months, many experience symptom recurrence and functional limitation.
Advice constitutes all the information that the patient receives verbally, in written, audiovisual, or electronic format during the course of treatment. Its value to the physiotherapist is well recognised, and as such is a common component in the management of low back pain; the use of ‘The Back Book’, produced by the Royal College of General Practitioners (RCGP), has been widely endorsed as a means of encouraging low back pain patients to stay active . At present, the provision of advice to promote an understanding of low back pain, and the importance of the patient playing an active role in their recovery, is largely dependent on the individual clinician, their available time and resources. As a result, the most efficacious means of delivering advice, what such advice may comprise, and the frequency with which it is provided, has not been widely investigated in the low back pain literature. While back schools have aimed to maximise the value of group-based advice and education, trials in this area to date have largely been of poor quality; furthermore, variations in the content of back schools have made it difficult to isolate their most beneficial features and, as a result, their cost-effectiveness is debatable. Waddell et al. have indicated that patients need clear and unambiguous advice about low back pain and its management, with individually tailored treatment being purported to improve outcomes. Tailored programmes are thought to promote adherence to treatment, increased patient responsibility, and sustainable behaviour change. Current guidelines are in place to recommend that acute low back pain patients are best to stay active for faster return to work and less chronic disability. Little attention has been directed at the specific type of advice offered to patients with low back pain, whether this advice varies depending on symptom duration, the value of advice used in conjunction with other interventions, and its relevance in terms of low back pain treatment outcomes.
Although acute and chronic pain are recognised as being very different, this review has identified that RCTs most commonly use advice as an adjunct to exercise for both of these phases of low back pain. This occurs in spite of the fact that current guidelines for acute low back pain patients do not recommend the prescription of specific exercise programs, but rather more simple advice to remain active, for acute low back pain patients; the results of this review provide further support for the existing guidelines on acute low back pain, (i.e. advice to stay active is sufficient). The authors do not claim that advice to remain active alone is superior to advice plus specific exercises but the above references relating to the management of acute low back pain, and the findings of this review indicate that simple advice to stay active is sufficient for this patient group. Therefore, the authors suggest that perhaps wider use of ‘The Back book’, an existing resource containing the necessary information on how to stay active and why this is important, may help to reinforce this key message to patients in the early stages of low back pain, and dispel the fears and mistaken illness attributions that can often contribute to symptom chronicity.
In comparison, the back school approach was favoured (over advice as an adjunct to exercise) in subacute low back pain trials, all with a positive outcome. The use of functional restoration, incorporating a cognitive behavioural approach, was also common in both subacute and chronic low back pain phases, again with a predominance of positive results. The highest percentage of positive results was achieved in subacute low back pain trials (86%), along with maintenance of these results at intermediate and long-term follow-up (100%). This result tentatively suggests that a back school or functional restoration approach may have positive long-term effects on the subacute low back pain patient; however, it is unclear whether the frequency of advice affects the maintenance of positive results with this clinically important subgroup of patients. More high quality trials are required within the subacute low back pain phase before any more definitive pronouncements on treatment effectiveness are possible. In this respect it is interesting to note that 10 years have passed since Faas called for more high-quality trials investigating subacute low back pain.
The use of simple advice to stay active (continue normal activities) as the experimental intervention was less likely to be used in trials in which low back pain symptoms had reached the chronic phase; rather advice to stay active combined with specific advice relating to exercise, and/or restoration of functional activities were more commonly used to manage this patient subgroup. This observation reflects the generally accepted view of an increase in the complexity of low back pain with prolonged symptom duration. However, it is unclear why the back school is not more commonly used in chronic low back pain trials: this may be partly explained by the conflicting evidence on the benefits of back schools, and/or reports that individually tailored instructions are more effective with chronic low back pain patients. It may also be explained by the fact that a number of trials using a back school approach were excluded from the review. It would, therefore, appear that more high-quality back school trials are required to allow comparisons with other interventions, such as exercise or functional restoration. As part of this, the use of a standardised back school programme within trials would be useful to improve the reliability and validity of such comparisons.
Follow-up advice was apparently not instrumental in maintaining positive results, in the short or long-term, within subacute low back pain trials. In contrast, for chronic low back pain patients, it has been suggested that the use of refresher programmes at follow-up may help to maintain the positive results of treatment. While only one chronic low back pain trial did not maintain its positive results at all follow-up points, there were wide differences in the lengths of follow-up carried out within chronic low back pain trials having a positive outcome. If a relationship exists between the provision of advice after the completion of treatment and long-term maintenance of results for chronic low back pain patients, this can only be determined from further trials designed specifically to test this hypothesis.
As reported in a recently published review of exercise and chronic low back pain, this review identified an over-emphasis on the use of measures of impairment within RCTs at the expense of outcomes representing the restoration of activity (previously disability) and participation (previously handicap) (WHO, 2000). This is despite the fact that low back pain patients can experience improvements in function with little or no effect on their level of impairment. Roland and Torgerson indicate that the use of ‘physiological surrogates’, not clearly related to health outcomes, must be viewed with caution; outcome measures need to be able to reflect the ‘real world’ concerns of patients, clinicians, and policy-makers.
The main clinical implication of this review centres on the relevance of chronicity to the type of advice that is required to produce effective outcomes with low back pain patients. While the nature of the evidence available makes it difficult to be specific about the content and frequency of advice that should be provided, this review supports the current recommendation that advice to stay active (such as that provided in ‘The Back Book’) is sufficient for acute low back pain patients, and could perhaps be more widely implemented in practice. For the effective management of chronic low back pain, this review provides strong evidence that patients require advice to stay active plus specific advice relating to appropriate exercise(s) and/or restoration of functional activities to promote active self-management; advice on staying active is not sufficient. The research implications centre around the need for more high-quality trials within the subacute low back pain phase, the development and use of a standardised back school program, the putative relevance of follow-up advice for chronic low back pain patients, and a greater emphasis on the appropriate use of clinically relevant outcome measures within RCTs in order to accurately assess the effectiveness of interventions and promote a standardisation of outcome measures within clinical practice.
