How to Give Advice on Management of Low Back Pain

How do clinical trials that test advice for acute LBP compare with practice guidelines in terms of content, method of delivery, and treatment regimens?

An extensive analysis of recently published practice guidelines on low back pain (LPB) found a discrepancy between what the guidelines recommend and what is actually found in clinical trials—especially when it comes to communicating advice about non-medical and surgical options for the treatment of LBP.
Doctor working on a laptop The analysis included a review of all studies that included the words low back pain, randomized controlled trials, education, and advice. Photo Source:“Advice is widely considered an effective treatment for acute LBP. We wanted to see how clinical trials that test advice for acute LBP compared with practice guidelines in terms of content, method of delivery, and treatment regimens,” noted the authors of the study, which was recently published in The Spine Journal. The study, which was led by Matthew L. Stevens, MChiroprac, at Musculoskeletal Health Sydney, part of the School of Public Health at the University of Sydney, found that the recommendations made in guidelines of advice were often not “concordant” with the results of clinical trails.1

The analysis included a review of all studies that included the words low back pain, randomized controlled trials (RCTs), education, and advice. Twenty-one articles were included in the analysis. Of the 21 studies, the details of 29 separate advice interventions were identified.

Advice interventions were broken down into four categories:

  • Advice about mechanism and course of LBP
  • Advice about being physically active
  • Advice on how to self-manage LBP
  • Advice on the medical management of LBP

Although commonly included in guidelines, statements such as “LBP is a benign condition with good prognosis; patients should stay active; and return to work as soon as possible,” were not supported by clinical studies. Only 15% of the RCTs that included “advice to stay active,” had positive results. Clinical guidelines also understated the support for advice on pain management and coping skills, which have been supported by 60% of the RCTs, but endorsed by only 21% of guidelines.

“The Steven’s study provides food for thought,” said Patricia Zheng, MD, Assistant Professor, Department of Orthopaedic Surgery, University of California – San Francisco, in an interview with SpineUniverse. “We should think more about how these guidelines should be formulated, and once they are established, we should pay more attention to how they are being followed.”

Other important findings from the study included that “LBP clinical practice guidelines generally provided an incomplete description of what constitutes advice. The lack of standardization in advice interventions, which vary widely in content, method of delivery, and regimen, makes research difficult,” wrote Dr. Zheng and Matthew Smuck, MD, in a commentary that accompanied the Steven’s article in The Spine Journal.2 “We agree [with the authors] that the potential clinical value of advice intervention for patients with LBP is not yet being realized.”

One way to improve compliance with advice interventions is to improve the method of delivery, Dr. Zheng said. “My personal interest is in adapting mobile technology to become an interface for delivering some of these lifestyle changes. In the future, I hope the guidelines would touch upon the use of these more novel technologies, because they are going to transform the way we practice medicine,” she added.

Traditionally, the means used to communicate advice to patients has included either the generic handout/pamphlet or face-to-face interaction. As Stevens et al found, advice therapy is more effective when delivered over longer durations and over multiple sessions. However, in the US, such face-to-face interventions are difficult given the time constraints put on physicians, Dr. Zheng noted.

Instead, Drs. Zheng and Smuck have suggested that the development of mobile technology, web-based or apps, will be critical in making behavioral changes because they are cost-effective, accessible, and can be easily personalized. For advice interventions about exercises or coping skills, for example, Dr. Zheng noted that these programs are capable of delivering daily check-ins, personalized set of education or exercises, and video access to health coaches and physical therapists, she noted.

But who should develop these websites or apps? Dr. Zheng is not sure. “What I have found in my own research is that there is not a lot of regulation in this area. Currently, there are companies developing apps that are targeting patients with LBP. But some of these commercial sites are making claims that have not been validated,” Dr. Zheng said. “Therefore, clinicians with knowledge of the medical evidence must guide the development and validation of these applications.”

Digital advice interventions also provide an opportunity to conduct clinical research. These interventions allow for the collection of outcome data for a large cohort of patients, Dr. Zheng noted. The large database can be used to find features that predict best outcomes with different aspects of the interventions, making possible tailored treatment strategies.

“After establishing evidence-based guidelines on how best to deliver advice intervention, clinicians need to guide the development and validation of digital ways to deliver these interventions. Only then can we deliver interventions that are more personalized, effective, and accessible to patients with acute LBP,” Dr. Zheng concluded.

Dr. Zheng had no financial information to disclose.

Updated on: 02/18/19
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