Advice for the management of low back pain: A systematic review of randomised controlled trials

Health and Rehabilitation Sciences Research Institute, University of Ulster at Jordanstown, Shore Road, Newtownabbey Co. Antrim, BT37 OQB, Northern Ireland.
Manual therapy (Impact Factor: 1.71). 11/2007; 12(4):310-27. DOI: 10.1016/j.math.2006.12.009
Source: PubMed


To synthesise the evidence relating to the effectiveness of advice, the relevance of its content and frequency, and to compare the advice being offered to acute, subacute and chronic low back pain (LBP) patients. A systematic review of Randomised Controlled Trials (RCTs) using advice, either alone or with another intervention. The QUOROM guidelines and the Cochrane Collaboration Back Review Group Guidelines for Systematic Reviews were followed throughout: methodological assessment identified RCTs of 'high' or 'medium' methodological quality, based on their inclusion of at least 50% of the specified internal validity criteria. Outcome measures were analysed based on five recommended core outcome domains; pain, work disability, back-specific function, generic health status and satisfaction with care. Relevant RCTs (n=56) were scored for methodological quality; 39 RCTs involving 7347 patients qualified for inclusion, based upon their methodological quality. Advice as an adjunct to exercise was most effective for improving pain, back-specific function and work disability in chronic LBP but, for acute LBP, was no more effective for improving these outcomes than simple advice to stay active. Advice as part of a back school was most effective for improving back-specific function in subacute LBP; these trials generally demonstrated long-term positive results. Advice as an adjunct to exercise was the most common form of treatment for acute and chronic LBP; advice as part of a back school was most commonly used for subacute LBP. Fifteen percent of acute LBP trials had a positive outcome, compared to 86% and 74% of subacute and chronic LBP trials respectively. A wide variety of outcome measures were used, making valid comparisons between treatment outcomes difficult. The advice provided to patients with LBP within RCTs varied considerably depending on symptom duration. The findings of this review have important implications for clinical practice, and for the design of further clinical trials in this area. Advice to stay active is sufficient for acute LBP; however, it appears that RCTs do not commonly reflect these recommendations. No conclusions could be drawn as to the content and frequency of advice that is most effective for subacute LBP, due to the limited number and poor quality of RCTs in this area: this review provides preliminary support for advice as part of a back school approach. Given that the effectiveness of treatment for subacute symptoms will directly influence the development of chronicity, these results would suggest that education and awareness of the causes and consequences of back pain may be a valuable treatment component for this patient subgroup. For chronic LBP there is strong evidence to support the use of advice to remain active in addition to specific advice relating to the most appropriate exercise, and/or functional activities to promote active self-management. More investigation is needed into the role of follow-up advice for chronic LBP patients.

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    • "La modification durable des peurs et croyances irrationnelles peut suggérer que la séance d'information a eu une efficacité propre, d'autant plus que des stratégies d'interventions e ´ducatives isolées ont prouvé leur efficacité dans la littérature [19]. Cependant, le programme PRESLO associe a ` cette composante e ´ducative une composante d'activité physique ce qui ne permet pas de distinguer le rôle que chacune des deux composantes a pu jouer sur la modification des représenta- tions. "
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    ABSTRACT: Aim of the study. The objective of this study was to assess the methods of implementation of the PRESLO program from the point of view of users (healthcare workers with a history of low back pain [LBP]) in order to identify potential improvements to the program. Methods. A qualitative study approach was adopted. Twenty-one participants were selected intentionally in different categories of workers. All volunteered to take part in a semi-structured individual interview exploring representations of LBP, expectations, experience of supervised sessions and adherence to the home-based exercises. All interviews were transcribed and analysed using the qualitative analysis software Atlas.ti. Results. Participation in the program was motivated by prior episodes of LBP, relief expectations and the desire to gain autonomy. The impact at 12 months of the education session showed a change in LBP representations among participants. Collective exercise sessions were highly appreciated due to the emulation generated by the group. The attendance to exercise sessions was facilitated by the proximity and accessibility (during working hours in the workplace) and by the information about the program provided in the institution. The autonomy of the participants at the end of the group sessions varied among individuals. The information materials were poorly used. Long-term compliance to the home-based exercises also varied among individuals. The impact of the program was positively evaluated by the participants in terms of empowerment, physical and psychological well-being and pain reduction. The main shortcomings were the lack of booster sessions to maintain autonomy in the practice of exercises and the motivation generated by the group. The suggestions included the need for booster sessions and follow-up in the long term. Conclusion. The results allowed a qualitative assessment of the program's impact and participants' satisfaction in several dimensions. Areas for improvement of the program have been identified. Booster sessions and long-term follow-up seem important to improve exercise compliance over time.
    Archives des Maladies Professionnelles et de l Environnement 09/2014; 75(4):371-381. DOI:10.1016/j.admp.2013.10.006 · 0.09 Impact Factor
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    • "Randomised controlled trials, reviews and meta-analysis have also shown that self-management courses can be clinically effective in terms of improving pain (including low back pain), compared to control groups (controls include usual care, inpatient or outpatient non-multidisciplinary treatments, wait-list controls or alternative treatments) [16-19]. Systematic reviews have shown that providing chronic low back pain patients with advice and information can improve pain and functionality [20,21], but more studies are needed in this area [20,22]. In addition, providing patients with information regarding the effectiveness of self-management and their pain may support patient self-management [23]. "
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    ABSTRACT: Supported self-management, acupuncture and information can help reduce the symptoms of low back pain. These approaches are currently recommended by NICE guidance as treatment options for patients with persistent low back pain. However, there has been no previous evaluation of a service providing them together for this common problem. The purpose of this service evaluation was to report patient outcomes and experiences of the Beating Back Pain Service (BBPS), a pilot service based in a primary and community care setting, delivering acupuncture, self-management and information to patients with chronic low back pain. Patients completed a questionnaire at three time points: pre-BBPS, immediately post-BBPS and three months post-BBPS. Outcome measures included the Bournemouth Questionnaire (measuring musculoskeletal, MSK, problems), EuroQoL-5D (measuring quality of life), Pain and Self-efficacy Questionnaire, and additional questions on medication use, physical activity, understanding of pain and positive well-being. Additionally, the STarT Back (measuring risk of developing chronic pain) was collected at BBPS information sessions. Non-parametric tests were used to evaluate pre- and post- variables. Questionnaires also collected qualitative data (open-text responses) regarding patient views and experiences of the BBPS, which were analysed using thematic analysis. 80 (out of 108) patients who attended the initial BBPS information session agreed to participate in the service evaluation (mean age 47 years, 65% female). 65 patients attended subsequent BBPS acupuncture and/or self-management sessions and were asked to complete post-treatment questionnaires; complete datasets were available for 61 patients.There were statistically significant improvements over time for pain (p <0.0001), quality of life (p = 0.006), understanding of pain (p <0.001), physical activity (p = 0.047) and relaxation (p = 0.012). Post-hoc analysis revealed that scores improved between baseline and post-treatment, these improvements were maintained at 3-month follow-up (except relaxation). Patients receiving a combination of acupuncture and self-management sessions produced the most positive results. Patient satisfaction with the BBPS was high. The BBPS provided a MSK pain management service that many patients found effective and valuable. Combining self-management with acupuncture was found to be particularly effective, although further consideration is required regarding how best to engage patients in self-management.
    BMC Complementary and Alternative Medicine 11/2013; 13(1):300. DOI:10.1186/1472-6882-13-300 · 2.02 Impact Factor
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    • "Two relevant key messages were (i) that plain x-rays of the lumbar spine are not routinely recommended for people with acute non-specific LBP as they are of limited diagnostic value and provide no benefits in pain, function or quality of life, and (ii) advising these patients to stay active produces a beneficial effect on pain, rate of recovery and function [4]. Although the guideline was released in 2004, more recent systematic reviews of randomised trials still support these two recommendations [5,6], and a review of LBP guidelines showed that more recent guidelines made similar recommendations [7]. "
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    ABSTRACT: Chiropractors commonly provide care to people with acute low-back pain (LBP). The aim of this survey was to determine how chiropractors intend to support and manage people with acute LBP and if this management is in accordance with two recommendations from an Australian evidence-based acute LBP guideline. The two recommendations were directed at minimising the use of plain x-ray and encouraging the patient to stay active. This is a cross sectional survey of chiropractors in Australia. This paper is part of the ALIGN study in which a targeted implementation strategy was developed to improve the management of acute LBP in a chiropractic setting. This implementation strategy was subsequently tested in a cluster randomised controlled trial. In this survey phase of the ALIGN study we approached a random sample of 880 chiropractors in three States of Australia. The mailed questionnaire consisted of five patient vignettes designed to represent people who would typically present to chiropractors with acute LBP. Four vignettes represented people who, according to the guideline, would not require a plain lumbar x-ray, and one vignette represented a person with a suspected vertebral fracture. Respondents were asked, for each vignette, to indicate which investigation(s) they would order, and which intervention(s) they would recommend or undertake. Of the 880 chiropractors approached, 137 were deemed ineligible to participate, mostly because they were not currently practising, or mail was returned to sender. We received completed questionnaires from 274 chiropractors (response rate of 37%). Male chiropractors made up 66% of respondents, 75% practised in an urban location and their mean number of years in practice was 15. Across the four vignettes where an x-ray was not indicated 68% (95% Confidence Intervals (CI): 64%, 71%) of chiropractors responded that they would order or take an x-ray. In addition 51% (95%CI: 47%, 56%) indicated they would give advice to stay active when it was indicated. For the vignette where a fracture was suspected, 95% (95% CI: 91%, 97%) of chiropractors would order an x-ray. The intention of chiropractors surveyed in this study shows low adherence to two recommendations from an evidence-based guideline for acute LBP. Quality of care for these patients could be improved through effective implementation of evidence-based guidelines. Further research to find cost-effective methods to increase implementation is warranted.
    Chiropractic and Manual Therapies 12/2011; 19(1):29. DOI:10.1186/2045-709X-19-29
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