Reassuring patients about low back pain.

Lowbackpain is oneof themost commonlyencountered conditions in clinical practice. Despite trends showing increasing use of advanced imaging tests, opioids, and invasive surgical and interventional procedures,with attendant increases in costs, theprevalence andburdens associatedwith lowback pain appear to be on the rise.1 Most acute low back pain improves substantially within the first 4weeks.However, a small proportionofpatientswith acute lowback pain go on to develop chronic disabling symptoms. Suchpatients often are refractory to treatments and account for the majority of the costs associated with low back pain. Preventing the transition fromacute to chronic lowback pain is therefore an important goal of current evaluation and management strategies. Back pain is best understood as a complex biopsychosocial condition. For example, the presence of common degenerative findings on spinal imaging poorly correlates with the presence of and severity of low back pain or the likelihood of developing chronic disabling symptoms. Rather, predictors of chronicity are primarilypsychosocial.2Clinical practice guidelines recommend an approach to low back painmanagement that includes an emphasis on self-care and the identification andmanagement of psychosocial contributors to chronicity,withearly interventions to address such factors when present.3 Reassurance is frequently recommended in patientswith pain conditions but has beendescribed as being supported by “a surprisingly thin evidence base.”4 Reassurance is a complex process involving the dynamic interplay between a caregiver and thepatient. Thegoal of reassurance is to alleviatepatientworriesandfears regarding lowbackpainandtopositively change associated behaviors. Common concerns in patients with back pain are that it signifies a serious underlying problem such as cancer, that the back pain will prevent the ability towork or participate in activities they enjoy, or that the back pain signifies the onset of progressive or permanent damage. Suchworriesmay leadpatients to avoidnormal activities that cause discomfort because of concerns that they will further damage the back (fear avoidance behavior) or to believe that the worst possible outcome (eg, permanent pain and disability) is inevitable (catastrophizing). These types of behaviors, referred to as maladaptive coping strategies, are an important predictor of chronicity.2 Psychological symptoms such as anxiety, which may be associated in part with illness concerns, also predict chronicity. A number of therapies for low back pain—such as advice to remain active, exercise therapy, and cognitive-behavioral therapy—aim in part to address and correct maladaptive coping beliefs and behaviors. Asystematic review in this issueof JAMAInternalMedicine byTraegerandcolleagues5evaluatedtheeffectsofprimarycare– based education on reassurance in patients with acute or subacute lowbackpain.The reviewwasgenerallywell conducted, meetingstandardsfor identificationofstudies,selectionofstudies for inclusion, risk of bias assessment, and data synthesis. It included12 randomizedtrials inwhicheducationwasdelivered through a self-care booklet or verbally. The education content varied but commonly included concepts consistent with evidence-basedclinical practiceguidelines, suchas thebenign nature and generally favorable prognosis of low back pain, advice to stayactivewithgraded return tousual activity, andpromotion of self-management. The review found primary care– based education to be associated with improved measures of reassurance vs usual care or a control intervention through 12 months.Themagnitudeofeffectwas relatively small, basedon pooledstandardizedmeandifferences (−0.15 to−0.21), andwas mainlypresent in trials inwhicheducationwasgivenbyaphysician rather than anurse or physiotherapist.However, educationwasalso associatedwith fewer subsequent lowbackpain– relatedprimarycarevisits(equivalenttoanumberneededtotreat witheducationof17toavoid1lowbackpain–relatedprimarycare visit).Although the reviewestimatedacostof $1700 toprevent 1 furthervisit, this calculationmaybeanoverestimatebecause it appeared to be based on the entire cost of the clinic visit in which education occurred. Patient education is likely to occur in the context of a visit for low back pain that is already taking place; thus, the additional costs with the interventionmay actually bemuch lower. Achallenge in interpreting the findingsof the review is that there is no standardizedmeasure for reassurance. Rather, the review combined results for different constructs conceptually related to reassurance, such asmeasures of fear, catastrophizing,worry, or anxiety.Theuseofdifferentmeasuresmight explainsomeof theobservedstatisticalheterogeneity inpooled analyses because the effectswere largest formeasures of fear, with no clear effects on the other outcome types. Another issue in interpreting the findings is that effective blindingof patients and caregivers is difficult in studies of patient education. Observed effects could therefore be related in part to Related article page 733 Reassurance in Patients With Acute Low Back Pain Original Investigation Research