Burton, A. Kim, Waddell, Gordon, Tillotson, Malcolm and Summerton, Nick (1999) Information and Advice to Patients With Back Pain Can Have a Positive Effect: A Randomized Controlled Trial of a Novel Educational Booklet in Primary Care. Spine, 24 (23). pp. 2484-2491. ISSN 0362-2436

Study Design. A double-blind, randomized controlled trial of a novel educational booklet compared with a traditional booklet for patients seeking treatment in primary care for acute or recurrent low back pain.

Objective. To test the impact of a novel educational booklet on patients' beliefs about back pain and functional outcome.

Summary of Background Data. The information and advice that health professionals give to patients may be important in health care intervention, but there is little scientific evidence of their effectiveness. A novel patient educational booklet, The Back Book, has been developed to provide evidence-based information and advice consistent with current clinical guidelines.

Methods. One hundred sixty-two patients were given either the experimental booklet or a traditional booklet. The main outcomes studied were fear-avoidance beliefs about physical activity, beliefs about the inevitable consequences of back trouble, the Roland Disability Questionnaire, and visual analogue pain scales. Postal follow-up response at 1 year after initial treatment was 78%.

Results. Patients receiving the experimental booklet showed a statistically significant greater early improvement in beliefs which was maintained at 1 year. A greater proportion of patients with an initially high fear-avoidance beliefs score who received the experimental booklet had clinically important improvement in fear-avoidance beliefs about physical activity at 2 weeks, followed by a clinically important improvement in the Roland Disability Questionnaire score at 3 months. There was no effect on pain.

Conclusion. This trial shows that carefully selected and presented information and advice about back pain can have a positive effect on patients' beliefs and clinical outcomes, and suggests that a study of clinically important effects in individual patients may provide further insights into the management of low back pain.

Nonspecific low back pain is a common and recurring symptom that most people usually deal with themselves and for which there is no effective cure. Hence, the information and advice that health professionals give to patients may be a potent element of the health care intervention. Von Korff and Saunders 36 and Bush et al 12 found that one of the main reasons patients consult physicians is to seek information and reassurance. Bush et al 12 suggested that these patients have practical and realistic desires to learn about their low back pain, what to expect, and what they can do about it. There is some evidence that greater congruence among the patient's and clinician's perception of the problem, the prognosis for the disorder, and its long-term management is associated with higher patient satisfaction and better short-term outcomes. 14

Qualitative studies 8,33 have demonstrated the complexity and heterogeneity of patients' perceptions of back pain, which may raise questions about how easily these can be modified by simple information and advice. Deyo and Diehl 18 and Bush et al 12 found that, for patients in the United States, the most frequent reason for dissatisfaction with medical care was failure to receive an adequate explanation of their back pain. Patients who believed that the physician's explanation was inadequate wanted more diagnostic tests, did not cooperate as well with treatment, and had poorer clinical outcomes at 3 weeks. Skelton et al 33 found that patients in the United Kingdom were skeptical of medical explanations for their back pain either because they doubted its validity or because it did not fit their own understanding of the problem. Borkan et al 8 found that Israeli patients also were quite critical of the medical system and more interested in what works.

The first U.S. and U.K. clinical guidelines for acute low back pain 3,16 recommended that patients should be given accurate and up-to-date information and advice about back pain and its management; however, that recommendation was based on theoretical considerations and general clinical consensus rather than on any firm scientific evidence that such information improves outcomes. These guidelines gave few practical details on precisely what the content of that information and advice should be, apart from general reassurance about the absence of serious disease and that most back pain improves quickly with simple symptomatic measures and activity modification. There has been a progressive shift in subsequent international guidelines. 10 Based on additional evidence that is now available, 40 the more recent U.K. 31 and New Zealand 2 guidelines suggest that the physician provide more positive advice to stay active and continue ordinary activities as normally as possible. The New Zealand guidelines also provide a detailed assessment of psychosocial yellow flags (risk factors for chronic pain and disability) and suggest general behavioral principles for how patients with these features should be managed. 23

Discussion at the Second International Forum for Primary Care Research on Low Back Pain 9 identified the continuing need for a simple and convincing explanation of back pain that is acceptable to patients and that would form a logical basis for active management. Most guidelines recommend that printed educational material should be made available, though this recommendation is based on limited evidence. 10 There are hundreds of leaflets and booklets about back pain, but remarkably few have been submitted to any sort of scientific evaluation. 11 Roland and Dixon 28 reported on the only randomized controlled trial (RCT) of a traditional clinical booklet that showed any significant impact on patients: those receiving the booklet consulted less frequently and had fewer specialist referrals for back pain over the next year. Cherkin et al 15 reported on an RCT that compared a 15-minute session with an educational nurse with a booklet that was similar to the material accompanying the Agency for Health Care Policy and Research (AHCPR) guidelines. 3 The nurse intervention yielded higher patient satisfaction, perceived knowledge, and exercise participation in the short term. The booklet showed similar trends, but they did not reach statistical significance compared with the outcomes of usual care. Neither of these trials showed any effect of a booklet on pain or functional status.

The aim of the current study was to determine the impact of a novel educational booklet on the beliefs and functional outcome of patients seeking treatment in primary care for an acute or recurrent episode of low back pain.

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