1.1

Introduction

In industrialised countries, low back pain (LBP) is a high-priority public health issue. Some studies have defined LBP as one of the leading causes of invalidity in the under-45s and even as the prime cause of musculoskeletal disorders, with a prevalence of 26.9% . Even though chronic forms represent less than 10% of all cases of LBP , they generate about 80% of the related expenditure .

LBP is multifactorial and its management varies according to the conceptual model used. The biomedical model (the foundation of the back schools) is evolving into a biopsychosocial model ( Table 1 ) that emphasizes the value of an integrated approach to clinical, psychological and social factors and generates multidisciplinary strategies .

In this frequent, non-severe condition, the objective is to reduce the transition to chronicity (by acting rapidly on “yellow flag” warning signs) rather than reducing the frequency of the initial episodes (since the aetiology and the causes of LBP are usually unknown). The “yellow flags” include clinical factors (such as pain intensity), work-related factors (such as the lack of job satisfaction) and psychobehavioural factors (such as depression, fear, false beliefs or inappropriate coping strategies). Fear of pain is associated with avoidance behaviour, which accentuates anxiety and the long-term negative functional impact . Patients develop a negative interpretation – “catastrophizing” – in which physical activity supposedly causes damage and exacerbates pain . These fear-avoidance beliefs are related to the severity of the LBP (i.e. the intensity of the initial pain) and its repercussions and are predictive of the functional disability in activities of daily living , the time to a return to work and the outcome of rehabilitation programmes . Furthermore, these beliefs are markedly modified by the information given to the patient . As a result, the use of therapeutic patient education (TPE) to help patients to better understand their disease (and thus reduce the influence of fear-avoidance behaviour) appears to be critical.

TPE for the management of LBP is not new; as early as 1969, the first back schools included information sessions (sometimes including postural advice) . Patients were told how to protect their back in activities of daily living on the basis of anatomical, physiological and ergonomic principles (the biomedical model). However, the efficacy of this type of approach has never been demonstrated by methodologically sound studies . The emergence of the biopsychosocial model enables integration of the psychosocial dimensions of LBP. Disease management is moving towards multidisciplinary programmes that include a pro-active, formalized educational approach to the acquisition of therapeutic independence . Several studies have confirmed the patient benefits associated with the latter approaches .

According to the World Health Organization, TPE helps patients to acquire or maintain the skills they need to manage their life with chronic disease in the best possible way . Thus, healthcare professionals can use TPE to help patients to better understand their LBP and acquire appropriate knowledge, including (i) optimal control of their disease, in order to remain active or become active as quickly as possible, (ii) better knowledge of spinal diseases, in order to provide reassurance and limit catastrophizing, (iii) acquisition of positive coping strategies and (iv) the choice of personalized activities to avoid lower back stiffening and deconditioning.

TPE in LBP is a continuous process that can take various forms (a simple discussion, a booklet, a video, etc.) and forms an integral part of medical care. However, TPE is not limited to advice alone. It includes organized activities, such as awareness-raising, information provision, learning and psychosocial support – all of which are related to the disease and its treatment and designed to make the patient aware and informed of his/her health problem. This training process must also enable the patient and his/her family to “collaborate” with carers more effectively. Hence, the objective of TPE in LBP is not simply to give the patient a list of medical facts: he/she must be able to understand and manage LBP (kinesiophobia, pain, recurrence, etc.) to stay active, not depend on the healthcare system and, ultimately, improve his/her quality of life.

1.2

Objective

The objective of this article was to examine the role and efficacy of TPE in the medical and surgical management of common LBP by reviewing studies that have used interventional educational measures alone or in association with other treatments.

1.3

Method

We performed a non-systematic literature review of the period from 1987 to 2010 by searching PubMed, the Cochrane Database of Systematic Reviews, government websites and national, European and international guidelines. The following keywords used were: lower back pain, LBP, prevention, treatment, education, self-care, educational materials, recommendations, guidelines, exercise, training, acute, subacute and chronic. Articles were selected on the basis of their abstracts. We selected articles on randomized controlled studies, reviews and guidelines in French or in English that included at least one educational intervention for LBP in adult subjects. The reference lists of selected articles were also searched for articles meeting our inclusion criteria but not present in the initial search results. The final set of articles enabled us to address the following issues: factors contributing to the educational outcome, the content and impact of TPE programmes for the medical management of acute and chronic LBP and the surgical management of lumbar nerve root disorders. In order to be as exhaustive as possible, primary prevention approaches were considered – even though they are not strictly part of TPE (i.e. secondary prevention). Lastly, we provide a reminder of the current guidelines, whenever available.

1.4

Results

Out of a total of over 200 identified abstracts, we selected only those articles, reviews and guidelines (in French or in English) in which at least one educational intervention had been applied to adult LBP patients. A total of 52 articles, six reviews and the six English-language guidelines were analyzed.

1.5

Discussion

Patient education is a pro-active, structured approach that must help the patient gain a better understanding of his/her disease and achieve better treatment compliance . Although the literature results are still contradictory, it appears that TPE in LBP must be based on the biopsychosocial model. This is necessary for covering all the various dimensions of this multifactorial disease, in which the prognosis is usually favourable once a diagnosis of non-specific LBP has been made. The impact of an educational approach can be evaluated on several levels by assessing the patient’s state of knowledge (rare), pain, role function, professional abilities and/or the patient’s level of satisfaction. The diversity of the evaluation criteria partly explains the heterogeneous nature of the literature data and thus the difficulty in identifying clear guidelines for clinical practice.

A “knowledge check” is an essential step in the construction of a personalized, appropriate programme. In the absence of precise guidelines and given the wide range of tools for evaluation of the LBP patient, we suggest use of the BBQ , which has been validated and is quick to apply and interpret – factors which enable its use in routine practice. Few studies mention knowledge checks and the same is true for post-intervention evaluations of knowledge on back ache . On the whole, knowledge is not improved by simple advice or media that are not integrated into more structured programmes. It is possible to sustainably modify fear-avoidance beliefs if therapeutic targets are defined. The longer the time since onset of LBP, the more the patients appear to require a structured programme.

Many educational tools are available ( Table 2 ) but their use in isolation does not have the same value as a structured educational programme . Indeed, it appears that the impact of certain types of information depends on when they are delivered (primary or secondary prevention), where they are delivered (in a professional or institutional setting) and their ultimate purpose (improved function or work capacity, pain reduction, choice of treatment, etc.). Although clinical studies have not been able to define the perfect medium, they have confirmed the fact that enrolled patients benefit from educational protocols when provided with support, guidance and follow-up .

The use of general information that does not address the patient’s needs partly explains the lack of results when TPE is not contextualized ; this justifies approaches that include a prior knowledge check. General information (available on the Internet, for example) does not appear to be any more useful to healthcare professionals . Hence, an educational protocol must break through the above-mentioned barriers (with access to information, personalized explanations, educational follow-up, etc.) in order to optimise the information given individually or collectively . In a primary care setting, the stakeholders in an educational approach are usually general practitioners, nurses, physiotherapists or pharmacists. These healthcare professionals have an important role to play but do not always possess the skills required for this type of patient management. Indeed, some research studies have demonstrated that advice provided by a nurse trained in TPE had more impact than standard care , although the effect was not long-lasting . Pharmacists have satisfactory knowledge and positive behaviour (i.e. appropriate advice) concerning LBP patients and their treatment – other than a certain reluctance to encourage patients to resumption activities as early as possible . Lastly, it has been shown that general practitioners’ fear-avoidance beliefs have a negative influence on the management of LBP patients .

In the absence of practical guidelines on TPE in LBP, it is however possible to fall back on the work by Epstein et al., who have structured the various steps with a view to helping the clinician talk about the scientific evidence with the patient . The clinician understands the patient’s experience and expectations, builds a collaboration, uses examples to explain the lessons provided by the scientific data, gives recommendations and checks the patient’s uptake and commitment. The clinician must retain a certain degree of flexibility and must adapt to the patient’s different approaches to knowledge uptake and processing; this emphasizes the need for judgement criteria that match the educational objectives. This model can be applied to LBP.

Lastly, few studies have evaluated the cost of TPE in LBP, although it does not appear to be high . Lamb et al. evaluated a behavioural therapy programme containing a structured (but non-evaluated) educational component . At 1 year, the cost of the intervention in England was judged to be relatively modest, compared with its efficacy. There are no health economics studies of formalized TPE in LBP. However, Cherkin et al. compared an information booklet (the control intervention) with a physiotherapy and chiropractic protocol. At 2 years, the cost of the information booklet was estimated at $153, with physiotherapy and chiropractic care rated at $437 and $429, respectively – prompting the authors to question the health economics value of the two latter methods . Other researchers have suggested that TPE reduces the number of hospital days . Lastly, the diversity of LBP patients is clearly an obstacle to this type of evaluation. The fact that the combination of a simple, informational, audio message with a brochure gives the same results as a 6-week educational or exercise programme illustrates how difficult it is to analyze this type of data. The objective is thus to find out which type of LBP patient should be targeted by TPE and in which format and under which conditions TPE should be delivered.

1.6

Conclusion

Patient education is recommended in secondary prevention. Information provision and education based on the biopsychosocial model are effective strategies for modifying beliefs about LBP, minimizing its consequences and increasing compliance treatment. The impact of this type of procedure on chronic LBP is still unclear. Assistance with the formalisation of TPE in specialist LBP care centres should be considered.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.