Back Pain Education

Introduction

Patient education, reassurance and self-care advice is the first-line care for patients with back and musculoskeletal pain and is recommended by clinical guidelines [1, 2]. Educational interventions for back pain may take many forms and can consist of information about the condition and its management, reassurance, and advice to stay active. Due to the wide variety and options regarding patient education, Engers et al [3] defined patient education as the process of providing information to the patient using pre-planned and structured techniques. Additionally, Bellamy [4] emphasises that patient education aims to facilitate behaviour change and therefore patient education is “a process of enabling individuals to make informed decisions about their personal health-related behaviour”. 

Back pain, consisting of spinal pain in the cervical, thoracic, lumbar and/or sacral regions, can be a recurrent condition and it has a variable course. While many episodes of low back pain (LBP) improve substantially within six weeks and 33% of patients recover in the first three months, 65% still report some pain at 12 months [5-7].  Furthermore, up to 33% of people will have a recurrence within a year of recovering from a previous episode [5, 8]. It is therefore important that persons presenting with LBP are informed about the clinical course of the condition.

The following are top tips for LBP education:

• Reassure persons about the non-life-threatening but recurrent nature of LBP.
• Encourage persons to avoid prolonged rest, stay active and resume activities despite pain, as soon as possible.
• Assess and address misconceptions about LBP.
• Explain why imaging may not be needed.
• Inform persons about evidence-based options for back pain management [1, 9, 10]. 

Table 1 summarises the key education messages for back pain as used in mass media educational campaigns and educational interventions. Media campaigns are used to deliver health messages with the aim to influence population attitudes, beliefs, and health-risk behaviours [11]. The outcomes regarding back pain media campaigns were mixed, and include positively influencing back health beliefs, reduction in sick leave and health care utilisation and user satisfaction [12]. 

Table 1: Key education messages for back pain

Topics for patient education [1, 13-19]

Media campaign messages about back pain [11, 12, 20-23]

Stay active.  Return to normal/usual activities.  Education about the nature of the disorder and prognosis. Reassurance and information and about the course of recovery.  Reassurance that the condition is not a serious disease. Reassurance that symptoms will improve. Patient education about coping strategies.  Patient education about self-management/self care strategies. Patient education about pain and its mechanisms. Education about body mechanics and ergonomics.

Stay active/continue exercising. Continue with usual activities.  Continue and/or return to work.  Do not rest for prolonged periods. The prognosis is usually good. Back pain is rarely caused by a dangerous illness. X-rays may not be able to reveal the cause of back pain.  Surgery may not be the answer/ Only a few people with back pain need surgery.  Try simple pain relief.  Obtain advice. There is a lot you can do to help yourself. Positive attitudes towards back pain are important.

Misconceptions about back pain

There are widespread misconceptions about the causes and prognosis of back pain [24-27] such as:

• the necessity of imaging to diagnose cause of back pain and direct a treatment plan,
• pain being an accurate indicator of tissue damage, 
• that structural displacements cause back pain (e.g. slipped discs), 
• that loading is bad for the lumbar spine, 
• that activities should be avoided when in pain,
• that the spine is vulnerable, and
• that the spine should be protected.

Clinicians are therefore encouraged to explore patients’ concerns, fears, and beliefs about back pain.  In this way, the clinician will be able to address any myths about back pain which the patient may hold. Listening to the patient’s concerns, goals and expectations about management and outcomes, may assist in tailoring back pain education and assist collaborative decision making [28-30]. 

Box 1 elaborates on messages to dispel common myths about back pain. 

Box 1: Dispelling common myths about back pain [25] 

Persistent back pain can be scary, but it is rarely dangerous. Getting older is not a cause of back pain. Persistent back pain is rarely associated with serious tissue damage. Scans rarely show the cause of back pain. Pain with exercise and movement does not mean you are doing harm. Back pain is not caused by poor posture. Back pain is not caused by “a weak core”. Backs do not wear out with everyday loading and bending. Pain flare-ups do not mean you are damaging yourself. Injections, surgery and strong drugs usually aren’t a cure.

Benefits of back pain education

Patient education plays an important role in the empowerment of patients to become successful self-managers of their condition. The benefits of education are that the patient can better understand their condition and is equipped with essential skills to manage their condition and know when to seek help. Therefore, patient education should be a core part of the healthcare professional’s approach to providing care for a patient with back pain.

Overall, there is evidence that patient education can provide long-term reassurance, reduce pain-related distress, and reduce healthcare use in patients with acute or subacute LBP [31, 32]. Educational interventions for back pain as short as five minutes can benefit people for up to 12 months [31-33]. Additional benefits of back pain education [3, 13, 34, 35] may include: 

• decreases dependency on health care providers. 
• alleviates concern about the condition and its consequences.
• may lead to patients’ increased understanding of their back problems. 
• may enhance healthcare literacy. 
• may enhance self-care. 
• may enhance patients’ use of active coping strategies.
• may facilitate behaviour change. 
• may facilitate adherence to prescribed treatment.
• may empower patients to take actions that facilitate return to usual activities. 
• may reduce the risk of chronicity and recurrence.
• may develop confidence for self-management.

Delivery of back pain education

Modes of delivering back pain education

Different modes of delivering back pain education [3, 15, 24, 36, 37] include: 

• Verbal (e.g., discussion)
• Written (e.g., booklet, pamphlet)
• Audio visual (e.g., video)
• Virtual (e.g., tele-health education)
• Online or with a blended learning approach
• Individual or in-group 
• Media campaigns

No one method of delivering back pain education is clearly more beneficial than the other [15, 37].  However, there are indications that combining different methods of delivery of education may be more effective [37]. Verbal education options offer the benefit of tailoring the educational message to be patient specific and condition specific [38]. Good quality websites may offer the opportunity to complement other modes of delivery and support. However, there is currently limited high quality information for back pain available online [39] and there is limited evidence for the efficacy of website support for persistent pain [40]. 

Various factors may influence the effectiveness of back pain educational interventions [31, 38, 41] namely the duration of intervention, the practitioner beliefs, patient expectations, content covered, the use of a theory informed approach [4, 42] and provider training. Effective communication skills are a prerequisite for delivering educational interventions [43] (whether it be written, verbal or audiovisual).

Practical tips for providing back pain education

• Format: Provide information clearly and succinctly. Avoid information overload. Written material should have a clear font. Avoid technical jargon [41, 43].
• Consider the patient’s preferred learning style [43]. 
• Metaphors and analogies could reduce catastrophizing [44], particularly if the patient can identify with the metaphor. One example of a metaphor used by Louw et al. [45] is the nervous system being compared to an alarm system and how an “extra-sensitive alarm system” can be linked to a sensitised nervous system. 
• Consider patient preferences about education: Individuals with LBP preferred education that was clear, consistent, and personalised to their specific presentation that addressed prognosis, management, and self-management approaches, to improve their symptoms and occupational issues [41]. 
• Use tailored/contextualized education strategies: back pain education is not a “one size fits all” approach.  The type and mode of education has to be tailored and built to suit the individual patient preference, the patient context, health care system context, resources available, the stage of the condition and response to treatment [14, 19, 46-48]. For example, back pain education regarding staying active needs to be tailored to individual circumstances [49]. 
• Advice and education regarding return to work is important since the 1-month not back at work timeframe is a crucial point for intervention to prevent long term work absence as a result of back pain [50]. Additionally, advice about returning to work was listed as a patient preference for education about back pain [41]. 
• Practitioner training to deliver back pain education may influence outcomes [31]. The practitioner should be comfortable discussing and assessing psychosocial factors that may influence back pain.

Conclusion

Patient education forms a cornerstone of back pain management and may be delivered in many forms. Education should be tailored to be person-centered and context relevant. Despite the growing body of evidence for the benefits of patient education for low back pain, more research is required regarding the effect of patient education on neck pain and thoracic pain [46, 51]. 

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AUTHORS

Dawn Ernstzen, PhD, MPhil, BScPhysio
Senior lecturer
Division of Physiotherapy, Department of Rehabilitation and Health Sciences
Stellenbosch University
South Africa

Jessica Stander, PhD, MMT, BScPhysio
Department of Physiotherapy, Melbourne School of Health Sciences
University of Melbourne
Australia

Loveness A. Nkhata, PhD, MScMed ClinEpi, MPH, BSc PT
Department of Physiotherapy
School of Health Sciences
University of Zambia
Zambia

REVIEWERS

Adrian Traeger, PhD
School of Public Health
Faculty of Medicine and Health
The University of Sydney
Australia

Mary O’Keefe, PhD
Institute for Musculoskeletal Health
New South Wales
Australia