Dynamic Disc Designs
Patient Education Dynamic Disc Designs

Patient Education Materials for Non-specific Low Back Pain and Sciatica

Introduction

Being the leading cause of disability worldwide and a common cause of family doctor visits, low back pain (LBP) is a serious health concern. Significant financial expenses are incurred, direct (health care) and indirect (loss of productivity, compensation claims). International recommendations for the therapy of non-specific low back pain (NSLBP) urge against needless imaging and favour patient education, self-care, mild analgesics, and reassurance. Patient education materials (PEMs) aim to dispel myths, encourage self-management, and give factual information on low back pain (LBP). This systematic review and meta-analysis1 investigate the effectiveness of PEMs alone on various outcomes for acute and chronic NSLBP and sciatica.

 

Patient Education Dynamic Disc Designs

Methods

The review protocol was published, and searches were conducted on March 24, 2022, with the adapted search strategies from a previous review. A tailored search strategy was applied to include databases such as MEDLINE, EMBASE, CINAHL, PsycINFO, and SPORTDiscus and alleviate the high degree of heterogeneity. De-duplication and screening of records were conducted with Covidence software, and translations and author clarifications were made as necessary. Data extraction, risk of bias assessments, and publication management were conducted through standardized means. The risk of bias using the PEDro scale was assessed per-study basis, and studies were categorized as high, moderate, and low risk of bias. Analyses included comparative studies and PEMs alone versus no intervention, PEMs alone versus another intervention, and the comparison of PEMs alone versus a combination of two interventions. Moreover, random-effects models assessed outcomes across immediate, short, medium, and long-term follow-up periods.

Results

Study Characteristics

Of 6,435 records, 27 studies were included: 21 RCTs and six cluster RCTs, primarily from the US and Europe. Participants were mainly recruited through primary care. The studies involved acute (12 studies) and chronic (15 studies) LBP populations. PEMs were compared to usual care or other interventions like exercise, yoga, and cognitive-behavioral therapy. PEMs content typically included information on LBP causes, posture, exercises, pain management, and self-care strategies, delivered via booklets, pamphlets, or digital formats.

Risk of Bias

The results indicated ten studies had a high risk of bias, mainly due to a lack of blinding and insufficient follow-up. Eight and nine of the studies had moderate and low risk, respectively. Common biases included a lack of or inadequate reporting of blinding and clustering adjustments among cluster RCTs. Regarding pain intensity, PEMs were effective in the short term compared with usual care, as the SMD was -0.24; 95% CI: -0.42, -0.06; p = 0.01. No significant effects were indicated in the immediate, medium, or long term. 

There was no significant effect on disability in the immediate, short, medium, or long term. PEM studies resulted in modest quality-of-life benefits in the short term. However, no medium—or long-term advantage was observed. PEMs provided insufficient, moderate-quality evidence. The effect was inconsistent at long-term follow-up, but it did substantially increase knowledge at immediate and short-term follow-up. A short-term effect revealed no substantial results on pain self-efficacy in two trials but considerable improvement in one trial for each.

The findings of this review showed that PEM-based interventions had no significant impact on patient fear-avoidance beliefs and catastrophizing at any of the follow-up time points under high-quality evidence. Similarly, moderate-quality evidence also showed no significant effects on anxiety at the immediate follow-up. At the same time, the low-quality evidence showed a substantial reduction in the number of days off in the short term but no significant effects at other time points. There was a long-term decrease in the need for imaging and physician supervision in the case of PEM, with an RR of 0.60 for imaging and an SMD of -0.16 for physician visits using very low-quality evidence. On the other hand, very low-quality evidence also depicted the need for a more significant impact on specialist referrals or costs.

 

Discussion

PEMs may result in small improvements in pain intensity and knowledge and reductions in imaging and physician visits for acute/subacute NSLBP. They demonstrate no effect on disability, long-term pain, fear-avoidance beliefs, or catastrophizing. The quality of evidence concerning outcomes is mixed; for some, it is rated as moderate and high certainty but, at the same time, low to very low for others. Future studies should address methodological limitations regarding blinding and faulty follow-up to minimize biases and better establish the impact of PEMs.

Effectiveness of Patient Education Materials for Chronic LBP

When comparing PEMs alone to usual care or no intervention, five trials were analyzed. These studies did not specify the details of usual care but allowed participants to continue their regular LBP treatments. One study used unguided internet searches for LBP information as a comparator, which was considered similar to usual care. The outcomes measured included pain intensity, disability, quality of life, and fear-avoidance beliefs. Only one study measured global improvement, self-efficacy, stress, and depression, while other potential outcomes like function, knowledge, and cost were not assessed.

In terms of pain intensity, PEMs largely reduced this measure, with moderate quality of evidence supporting a significantly low intensity of pain in the immediate and long term relative to usual care. However, regarding the immediate, short, and medium terms, which had low-quality evidence, the measure of the effect of PEMs was small. Particularly, the standardized mean difference of low-quality evidence was from -0.16 to -0.53 at different periods. Concerning disability, moderate-quality evidence of PEM effectiveness showed a significantly low disability in the medium term but not relative to the immediate, short, and long term. Furthermore, regarding quality of life, moderate quality of evidence of the measure showed a significant improvement relative to PEMs during the immediate and medium terms; thus, the difference between the SMDs was -0.15 and -0.23. However, there was no significant immediate impact in the long term.

One study assessed the effect of PEMs on global improvement ratings and found very low-quality evidence that PEMs led to lower effect sizes at all time points. A similar result was observed with self-efficacy, fear-avoidance beliefs, and mental health, where very low-quality evidence depicted that PEMs had smaller effect sizes than the control groups immediately and in the short, medium and long terms. Notably, fear-avoidance beliefs had a low effect size in the medium term but were insignificant in other terms. Specifically, in the long term, very low-quality evidence reported stress to reduce significantly but do not affect depression. In contrast, fear-avoidance beliefs were reduced with low effects in the medium term. Similarly, ten trials found that PEMs were less effective than other interventions in reducing pain intensity immediately and in the short-term effect size of SMDs 0.30 and 0.54, respectively. The evidence was mixed for medium and long-term effects, insinuating no difference.

Conclusion

PEMs can positively affect pain intensity, disability, and quality of life in chronic LBP patients; however, their efficacy is usually lower compared to other approaches. These outcomes depend on the nature of PEMs and the duration of their efficacy, with the evidence mostly favouring the short-term aspect.

 

 

 

At Dynamic Disc Designs, we create accurate modelling for effective patient education on sciatica. 

 

 

 

  1. Patient education materials for non-specific low back pain and sciatica: A systematic review and meta-analysis