Self-management for low back pain

I have had an interest in low back pain since the early stages of my career as a physiotherapist. My relatives, friends and patients complained about this condition and its recurrence even after receiving treatment. At that time, I was intent on finding a “cure” for this condition. I often browsed the literature to find the causes and possible effective treatments for low back pain and was guided by “p” statistical values.

Later in my career, I was guided by Dr Paulo Ferreira and Dr Manuela Ferreira who had just finished their PhDs in low back pain. They supervised my early career as a researcher. Guided by their supervision and by results of my own practice, I began to understand how complex this condition is. A lot of money is spent on a prevalent condition that has too many treatments available. If there are too many treatments, it is unlikely that any of them has a powerful effect. I came to understand that “p” value does not mean the treatment effect is clinically important and that what patients consider as being a worthwhile effect is often greater than the effects reported on high quality research supporting treatments for this condition.

With a PhD scholarship in hand I arrived excited in Sydney, Australia, to start my PhD studies. I wanted to find a treatment that had effects that were clinically important for low back pain that could change the scene. However, when I had the first of many meetings to discuss my projects things began to change. I understood that a new treatment for low back pain is unlikely to have an impact on the effects. So, if we are not able to find a “miracle” treatment for this condition, what could we do to optimize primary care for low back pain? Searching the literature, we found that most guidelines for low back pain recommend self-management. There is a growing awareness that low back pain is a long-term condition and that self-management could potentially decrease the burden of this condition. However, evidence of the effectiveness of self-management of low back pain was unclear.

In a recently published paper in Arthritis Care and Research, we systematically reviewed trials that included participants with low back pain in which at least one treatment for low back pain was named as “self-management” or “self-care” (Oliveira et al 2012). We found very few trials that tested self-management for low back pain and in many of the trials we had some concerns about the adequacy of the self-management programs that were tested. Acknowledging those limitations the effects of self-management on pain and disability seemed small; questioning whether or not it is a worthwhile approach.

We were surprised that there was so little research on this as national guidelines for low back pain consistently advocate self-management. We were also surprised by the programs tested because they did not seem optimal. We think that it is possible that better programs may yield larger effects and that is one of the areas of research we are pursuing right now. For instance, clarify the definition of self-management for low back pain and its features. So in the end, I have understood that low back pain is more complex than I first thought and my journey has just started.

About Vinicius C Oliveira

Vinicius Cunha Oliveira 150x150 Self management for low back painVinicius C Oliveira is a doctoral researcher currently supervised by Prof. Kathryn Refshauge, Dr. Paulo Ferreira, Dr. Manuela Ferreira and Prof. Chris Maher at Faculty of Health Sciences, University of Sydney, Australia. His background is Physiotherapy and Sports and Exercise, and his Master’s was in low back pain. His work focuses on: patient-clinician interaction; prognostic factors in low back pain; and self-management for back pain in order to optimize primary care for low back pain. At last, Vinicius is focused on finishing his PhD and pursuing a position in his early career.

References

Oliveira VC, Ferreira PH, Maher CG, Pinto RZ, Refshauge KM, & Ferreira ML (2012). Effectiveness of self-management of low back pain: Systematic review with meta-analysis. Arthritis care & research, 64 (11), 1739-48 PMID: 22623349

 

Comments

  1. 2013 is the year I am hoping more people will opt out of the ongoing chiropractic adjustments or passive physiotherapy and move towards a proper diagnosis by an evidence based Physiotherapist who teaches patients to self manage over a short period of time. Cochrane Network body of research etc etc all show this is the best and most effective approach. Nobody can “cure” your back pain and if they say they will this is false information. JE Sleeth PT and the Ergonomic Prevention team at OPC Inc.

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    Jordan M Chiro Reply:

    Thanks for your comments Jane. I guess your opinion is based on the assumption that no Chiropractors utilize evidence based care or prescribe short term active exercise programs do we? Nor do we read any Cochrane reviews or any research papers at all for that matter, we have no evidnce based education on spinal and peripheral ortho’s or systemic DDx and all we do is crack bones? Ha. Keep up the great work as it is people like yourself that keep our practices (Passive PT’s included!) busy.

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  2. Some really good points here. Certainly clarification is needed upon which self-management strategies are effective. Potentially, each health professional advising patients upon self-management can be suggesting different ideas based on their knowledge base and belief system.

    As a concept, self-management is important as of course the patient must know what action they can take to move forwards including skills in problem solving and goal setting. They can only do this if there is an understanding of their pain & condition that is dependent upon the explanation/education delivered. This bounces back to the messages given by the health professional, especially in the early stages when learning takes place.

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  3. Lesley Singer says:

    I thought the only thing we really know for sure is to keep moving works better than bedrest. What is self management. it is not defined as a treatment. Therefore when stidies use terminology like this it can mean many things. what is being taught to the patient just as it irritates me when treatments are compared to physiotherapy. What does this mean. Is there a standard thing called physiotherapy? The same as education. Education needs to be better defined as do treatments in many of the studies, It is often too vague.

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  4. Vince Gutierrez, PT, cert. MDT says:

    After attending the MDT international conference, health care practitioners and researchers need to do a more thorough job of providing evidence for the theories and methods that are already utilized in the treatment of LBP. Many of the panel speakers said stop the RCT on new methods of treating back pain and find what works with what is already in use. Speaking of self care, there was one study that compared chiropractic care x 16 visits and TYOB and one session of advice. Although the patients that received 16 visits of massage, mobilizations, and modalities were more satisfied with their care (how surprising), there was no difference in functional outcomes.

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  5. Nick Penney says:

    My understanding of the Australian Acute Musculoskeletal Pain Guidelines was that self management was a consensus view of what a large proportion of back pain sufferers (were assumed to) do, not consult, carry on and take OTC pain relief. The question may be what makes this group different to those who seek care; resilience,self efficacy or a generalised lack of ‘threat’ perhaps?
    Either way the guidelines concept was intended to get all providers on the same page so a consistent message was delivered to consumers, something we have obviously yet to see judging by previous comments

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