January 31, 2008 — For patients with acute or subacute low back pain (LBP), intensive patient education seems to be effective, according to the results of a systematic review published online in the January 23 issue of the Cochrane Database of Systematic Reviews.

"While many different types of patient education are widely used, the effect of individual patient education for low-back pain (LBP) has not yet been systematically reviewed," write Dr. Arno Engers, from the Centre For Quality of Care Research, Radboud University Nijmegen Medical Centre in the Netherlands, and colleagues. "Providing information is the central focus in educational activities. The information given by a health-care provider is of utmost importance since it can prevent unnecessary use of health care and enhances self-care and the use of active coping strategies."

The goal of this systematic review was to determine whether individual patient education is effective in treating nonspecific LBP and to determine which type is most effective.

The reviewers performed a computerized search of the literature on MEDLINE (1966 - July 2006), EMBASE (1988 - July 2006), CINAHL (1982 - July 2006), PsycINFO (1984 - July 2006), and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2), and they also screened references cited in the retrieved articles.

Inclusion criteria for studies reviewed were randomized controlled design; LBP in the participants; intervention involving individual patient education; and English, German, or Dutch language of publication.

Two review authors independently evaluated methodologic quality and identified high-quality articles as those meeting at least 50% of the quality criteria. Primary endpoints were pain intensity, global measure of improvement, back pain–specific functional status, return to work, and generic functional status. Analysis was qualitative, resulting in classification of evidence as strong, moderate, limited, conflicting, or no evidence.

More than half of the studies included in this review were of high quality (58%; 14/24). Individual patient education was compared with no intervention in 12 studies, with noneducational interventions in 11 studies, and with other individual educational interventions in 8 studies.

For patients with subacute LBP, there was strong evidence that an individual 2.5-hour oral educational session was more effective than no intervention on outcomes of short-term and long-term return to work. Less intensive educational interventions were not more effective than no intervention.

There was strong evidence that individual education for patients with acute or subacute LBP is as effective as noneducational interventions on long-term pain and global improvement. For patients with chronic LBP, individual education was less effective than more intensive interventions for back pain–specific function. No significant differences were detected among different types of individual education.

"For patients with acute or subacute LBP, intensive patient education seems to be effective," the review authors write. "For patients with chronic LBP, the effectiveness of individual education is still unclear."

Limitations of this review include potential sources of bias involving the literature search and selection process, such as language of publication.

"An individual oral educational intervention of 2.5 hours is useful to speed up return-to-work in workers with acute or subacute LBP," the review authors conclude. "Simple patient education sessions of shorter duration or written information do not seem to be effective as a single treatment. However, as they may be considered harmless if they are evidence-based and up-to-date, there is no reason for not using oral and written education to support treatment."

The Ministry of Health; Centre for Quality of Care Research, University Medical Centre Nijmegen; and EMGO Institute, VU University Medical Centre, Amsterdam, all in the Netherlands, supported this study. A study of 1 of the review authors was included in this review, but the quality assessment for this study was done by 2 other authors. Another review author is coordinating editor of the Cochrane Back Review Group. The other review authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online January 23, 2008.

Clinical Context

Study Highlights

• The reviewers did a computerized literature search of MEDLINE (1966 - July 2006), EMBASE (1988 - July 2006), CINAHL (1982 - July 2006), PsycINFO (1984 - July 2006), and the Cochrane Central Register of Controlled Trials, and they also screened references cited in the retrieved articles.
• Inclusion criteria for studies reviewed were randomized controlled design; LBP in the participants; intervention involving individual patient education; and English, German, or Dutch language of publication.
• 2 review authors independently evaluated methodologic quality. High-quality articles were defined as those meeting 50% or more of quality criteria.
• Primary endpoints were pain intensity, global measure of improvement, back pain-specific functional status, return to work, and generic functional status.
• Meta-analysis was not performed; analysis was qualitative. Evidence was classified as strong, moderate, limited, conflicting, or no evidence.
• Of the 28 studies included in this review, 14 (58%) were of high quality.
• 12 studies compared individual patient education vs no intervention, 11 compared individual patient education vs noneducational interventions, and 8 compared individual patient education vs other individual educational interventions.
• Topics covered in patient education included advice to stay active, return to normal activities as soon as possible, and avoid stress, as well as strategies to cope with LBP and to avoid strain and future back injuries.
• Types of patient education included individual discussion with a healthcare professional, participation in a special class, provision of written information, or viewing a video.
• For outcomes of short-term and long-term return to work, there was strong evidence that an individual 2.5-hour oral educational session was more effective than no intervention for patients with subacute LBP.
• Less intensive educational interventions, such as simple patient education sessions of shorter duration than 2.5 hours, or providing only written information, were not more effective than no intervention for patients with subacute LBP.
• There was strong evidence that for outcomes of long-term pain and global improvement, individual education for patients with acute or subacute LBP is as effective as noneducational interventions including chiropractic manipulation and physiotherapy.
• For patients with chronic LBP, individual education was less effective for back pain-specific function vs more intensive interventions (spinal stabilization, physiotherapy, yoga, exercises, or a modified Swedish back school).
• In efficacy, no significant differences were detected among different types of individual education.
• In some studies, written information was just as effective as in-person education. However, the reviewers noted the difficulties in evaluating the effects of oral and written patient education.
• No harmful effects of patient education were detected.
• Based on these findings, the investigators concluded that intensive patient education seems to be effective for patients with acute or subacute LBP, but for patients with chronic LBP, the effectiveness of individual education is still unclear.
• Limitations of this review include potential sources of bias involving the literature search and selection process, such as language of publication. Most of the treatments were only tested by 1 or 2 studies.
• Common limitations of the included studies were care providers not blinded (88%), patients not blinded (88%), and cointerventions not equal (63%).

Pearls for Practice

• For patients with acute or subacute low back pain, intensive patient education seems to be effective. For outcomes of short-term and long-term return-to-work, there was strong evidence that an individual 2.5-hour oral educational session was more effective than no intervention.
• For patients with chronic LBP, the effectiveness of individual education is still unclear. Individual education was less effective for back pain-specific function vs more intensive interventions, such as spinal stabilization, physiotherapy, yoga, exercises, or a modified Swedish back school.

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