Acute low back pain is extremely common, most adults will experience at least one episode in their lifetime. Back pain is the leading cause of disability worldwide. Various psychosocial risk factors have been identified to help predict who may develop chronic back pain following an initial acute episode. These can include workplace and general stress and anxiety, as well as catastrophisation. Pain education involves explanation about the neurophysiology of pain and potential sensitisation of the nervous system, and suggests strategies to reduce the sensitisation process through self-management techniques. Current clinical guidelines advise early intensive pain education provided by trained professionals for those identified as high risk for chronicity could prevent development of chronic back pain.
The Preventing Chronic Low Back Pain (PREVENT) trial recruited 202 participants from primary care identified as having acute low back pain as well as a high risk of chronicity using the Predicting the Inception of Chronic Pain (PICKUP) tool. PREVENT compared Pain Education (early specialised care for 2×1 hour sessions) to a Placebo Control (active listening, but without information or advice, for 2×1 hour sessions). Participants also had their ‘usual care’ from their regular health practitioners. Pain intensity during the last week measured using an 11-point numerical rating scale, the primary outcome, was evaluated at 1 week and at 3 (primary time point), 6 and 12 months.
At 3 months, there was no difference in pain intensity between the two groups (mean difference -0.3; 95% CI -1.0 to 0.3). Compared to the Placebo Control, the Pain Education group sought less healthcare at 3-months (odds ratio 0.43; 95% CI 0.19 to 0.93) and had lower recurrence of low back pain at 12 months (odds ratio 0.44; 95% CI 0.24 to 0.82). These secondary outcomes could have important health economic implications. This trial highlights the need for judicious use of clinical resources. Further work is needed to develop methods to change beliefs and attitudes about pain and disability in this high-risk cohort. If pain education alone does not make a significant difference, what other strategies can reduce risk of chronicity? Perhaps the ‘placebo’ active listening, a feeling of ‘being heard,’ is in fact therapeutic?
Listen to Norman Swan interview Adrian Traeger (postdoctoral research fellow from the Institute for Musculoskeletal Health, University of Sydney who is the lead author of the PREVENT trial) for ABC Radio National’s Health Report.
Traeger AC, et al. Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain — a randomized clinical trial. JAMA Neurol 2019;76(2):161-9