Is education reassuring?

Acute low back pain is inherently worrying; often there is no clear cause, no effective treatment, and a widely variable time frame in which you can expect to recover. Happily for many, the prognosis is good – they can expect to be a lot better within a matter of weeks. Sadly, for the others, we know all too well where that road can lead.

One of the biggest challenges in back pain today is to figure out how to keep people from heading down that road. So when faced with a worried patient with acute low back pain and a disappointing array of available treatments, what is the clinician to do? Guidelines specify that patients be advised on their favorable prognosis, on staying active, and on simple analgesics (or perhaps not?).[1] They also emphasise that patients should be provided with reassurance.

It certainly is a logical recommendation – that patients be reassured – and it got us to thinking about the best way to achieve this in primary care. When we looked at the literature on reassurance, we found surprisingly little in low back pain. In fact, there was very little literature on reassurance at all. This seemed to fly in the face of the widespread recommendations contained not just in guidelines for back pain, but in several other guidelines for non-specific conditions like irritable bowel syndrome and non-specific chest pain. Of course, not all guideline recommendations can be based on high quality evidence, but they should be logical and unlikely to cause much harm. And surely no harm can be done from providing a little bit of thoughtful reassurance, right?

Wrong. There is now compelling evidence that attempts at reassurance can be harmful. This is not an unfamiliar story: doctor provides advice, “there’s nothing seriously wrong with you”, and hands over a sheet of paper stating that your test result is negative. Meanwhile, your symptoms have not changed. In their hallmark paper, [2] Lucock et al observed patients after consultations just like this. Although patients left the consultation feeling slightly better, their worries returned with a vengeance, to levels higher than before they saw the doctor! Steve Vogel et al have provided further insight into this phenomenon in their systematic review[3] discussed here on BiM. They showed that emotional reassurance, e.g. “everything is going to be ok” can lead to more worried patients who have worse clinical outcomes.

When you think about it, this is something we see all the time in back pain. A perfect example is the provision of diagnostic imaging results. We now have evidence that imaging for low back pain is not reassuring, [4] is costly,[5] doesn’t improve outcome [6] and is probably harmful. [7] So imaging is out, if you are looking to reassure your patient. The next most obvious method to reassure patients is to sit them down and educate them about the problem. Explain what back pain is, and what you should do about it.

But is educating patients about acute low back pain actually reassuring, or does it backfire? To answer this question we performed a systematic review and meta-analysis [8] that combined the results of randomised studies that tested one-to-one education sessions in patients with acute low back pain and also measured reassurance after intervention. Reassurance was defined as any measure of fear or concern.

We included 14 randomised trials on a total of 4872 patients. Education sessions ranged from a GP-endorsed booklet through to 6 sessions of fairly intensive education that included some cognitive behavioral principles. We found that formal patient education is more reassuring than usual care (standardized mean difference [SMD] 0.21, 95% CI, -0.35 to -0.06) and this effect was maintained for 12 months. Patient education also reduced healthcare use. The effect was small but likely to be clinically worthwhile considering the cost (cheap) and duration (brief) of the intervention.

We also did some pre-planned subgroup analyses, the results of which some of you will cringe at. Doctors were significantly more reassuring than physios or nurses (SMD 0.38 for docs vs SMD 0.00 for physios) Really? We can only speculate on the reason behind this effect – perhaps credibility plays an important role in whether patients really take the educational messages on board. Maybe us physios need to think of ways to bump up the credibility. A white coat perhaps?[9] Or maybe a slightly different approach to education [10] is needed. Or both. Another interesting finding was there was no additional benefit from longer format education sessions. Brief and clear might be best.

Our results provide high quality evidence on what we think is a fundamental aspect of clinical practice – the ability to reassure patients. Future work to explore other potentially effective methods, e.g. structured exercise programs, and to examine the relationship between reassurance and clinical outcomes like pain and disability, would be very interesting indeed. Until then, patient education gets the thumbs up for acute back problems.

Adrian Traeger

Adrian Traeger Body In Mind

Adrian is right in the thick of his PhD research at NeuRA looking at the prediction and prevention of chronic back pain. He is particularly interested in the effects of the clinical consultation. Like most physios, Adrian likes talking to patients and, thanks to Carl Rogers, is getting better at listening.

Adrian’s musical taste has changed recently – from moody indie rock to “Giggle and Hoot’s Giggleicious Favourites”.

References

1. Williams CM, Hancock MJ, Maher CG, McAuley JH, Lin CW, & Latimer J (2014). Predicting rapid recovery from acute low back pain based on the intensity, duration and history of pain: a validation study. Eur J Pain, 18 (8), 1182-9 PMID: 24648103

2. Lucock MP, Morley S, White C, & Peake MD (1997). Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey. BMJ, 315 (7108), 572-5 PMID: 9302953

3. Pincus T, Holt N, Vogel S, Underwood M, Savage R, Walsh DA, & Taylor SJ (2013). Cognitive and affective reassurance and patient outcomes in primary care: a systematic review. Pain, 154 (11), 2407-16 PMID: 23872104

4. Rolfe A, & Burton C (2013). Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA internal medicine, 173 (6), 407-16 PMID: 23440131

5. Jarvik JG, Hollingworth W, Martin B, Emerson SS, Gray DT, Overman S, Robinson D, Staiger T, Wessbecher F, Sullivan SD, Kreuter W, & Deyo RA (2003). Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA, 289 (21), 2810-8 PMID: 12783911

6. Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW, Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, & Deyo RA (2015). Association of early imaging for back pain with clinical outcomes in older adults. JAMA, 313 (11), 1143-53 PMID: 25781443

7. Chou R, Fu R, Carrino JA, & Deyo RA (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet, 373 (9662), 463-72 PMID: 19200918

8. Traeger AC, Hübscher M, Henschke N, Moseley GL, Lee H, & McAuley JH (2015). Effect of Primary Care-Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA internal medicine PMID: 25799308

9. Rehman SU, Nietert PJ, Cope DW, & Kilpatrick AO (2005). What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med, 118 (11), 1279-86 PMID: 16271913

10. Traeger AC, Moseley GL, Hübscher M, Lee H, Skinner IW, Nicholas MK, Henschke N, Refshauge KM, Blyth FM, Main CJ, Hush JM, Pearce G, & McAuley JH (2014). Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial. BMJ open, 4 (6) PMID: 24889854

Comments

  1. Emma Scott-Smith says

    Hi,
    My physio recommened this site which has proved interesting. I have been in chrnoic back/spine pain for 25 yrs since childhood and have been on opiates for 22 yrs. I utilise physio, a pain specialist, psychology and pharmacology for management. Funnily enough I am a psychologist/researcher and work within a university. I wanted to cut down my opiotes which I have but my GP has taken over my initial plan. I now cannot work as much and find daily life exhausting tyring to cope with my increadsed awarness of the pain. The pressure that is put upon pain patients I find worrys as now going to the GP is a stressful event where I know I’ll be acussed of not coping as well as I should. I would welcome any advice as feel at a loss to know what I can do next to help my pain?
    Many thanks, Emma

  2. More support for the Rogers-Gloria video here. Very skillful.

    Regarding time consuming adequate physical assessments, I rarely do much at all with my assessments. It’s liberating to know you don’t need to ask 20 questions and perform a barrage of active/passive ROM assessments. All that’s needed is a few questions and maybe one or two movements for most people.

    “Sore knee huh? When did that start up? Does it swell? Show me the spot. Can you bend it? Good, now hop up on the bench and let’s see what happens… because something always happens… something good (suggestion)”. 2 minutes. Of course if I get a feeling that something is unusual, then I might start asking 20 questions, but not otherwise.

    Regards

  3. It’s not ‘non-specific’ at all. It’s just pain with varying degrees of nociceptive input and centrally processed output expression. The trouble is whether we like it or not in reality we are pretty awful at accurately figuring out the nociceptive part beyond the acute phase, yet the vast majority of investigations and interventions are directed to this component. Patient responses are then dismissed if ineffective (or patients simply go elsewhere) or claimed as a ‘success’ and a vindication of the ‘diagnosis’ based on ‘expert’ opinion if effective. Placebo responses abound yet are curiously rarely considered in everyday msk / orth / surgical practice.
    We are essentially playing a ‘numbers’ game and it is a tribute to the adaptability of the human condition that many / possibly even most survive the current ‘diagnosis’ and management pathways. The problem is the ones who don’t are those who are biopsychosocially susceptible to the serious amount of nocebo / fear inducing speculative diagnoses and management pathways available that worsen the centrally processed pain. These form the ever growing persistent pain group.
    So, while I agree that excluding the nasties is always important, it’s time to cut the other bs and understand that what is needed is a true paradigm shift – one part of which is reassurance / assurance / whatever unless we really need to scare our patients (which is incredibly rare). Another part is pain education at all levels.

  4. Adrian Traeger says

    Thank you all for your thoughtful comments on this.

    Ilaria,
    I agree wholeheartedly that word choice is so important when it comes to reassurance. As far as I am aware, content of education/communication has not been widely investigated in clinical trials. In our study, we were surprised to find that content did not moderate the effect of education on reassurance. Those who received a modern “biopsychosocial” explanation were no more reassured than those who received a biomedical/biomechanical explanation. We may have been underpowered, but still found this surprising. I for one am very interested in testing different types of advice/education to see what really works best in acute back pain. Then there is the other issue you raised, which how it is provided. Again, not much done on this but is certainly worthy of more research.

    Graham,
    I’m glad to have a fellow fan of Carl Rogers and the Gloria video set. For those who haven’t seen these videos, they demonstrate the technique of active listening. Because I am so interested in providing useful info to patients, sometimes I forget to stop and listen. I suspect this might be a fatal flaw of many education programs. You will be happy to hear Graham that we are testing this approach in the RCT we are doing. We want to know whether pain education + active listening induces better outcomes that active listening alone. Unfortunately we don’t have “no treatment” arm, because it would be really interesting to know whether just listening, and providing no advice, actually helps people with back pain as well. Although CBT provided by non-psychologists has not shown robust effects in the past, future trials using CBT principles, education & exercise might be more promising.

    John,
    Reassurance is a tricky word. Linton et al have pointed out how it can both refer to a behavior of the therapist (reassuring someone), and an outcome (being reassured). We were interest in the outcome of reassurance ie were people less worried/fearful after received education about back pain.

    I too grapple with the term “non-specific” in clinical practice and don’t tend to use because patients usually run for the hills or to the physio down the road afterwards. I can think of numerous patients that have seen me, furious, after they had been given a diagnosis of non-specific back/neck/shoulder pain. It is an unsatisfying diagnosis for the patient and for the therapists who pride themselves on being professional diagnosticians. BUT what if being told that there problem was non-specific was actually better for the patient despite their initial dissatisfaction? It almost certainly would be bad for business. The problem is that we still don’t know what sort of effect providing a pseudodiagnosis like “facet joint”, “disc sprain”, “up-slip” has on the patient in the long term. If I had to guess, it would be that this is no more helpful than a non-specific diagnosis. But the patient would be statisfied. I think the only way forward is to, like Ilaria highlighted, look into the effects of what we say to people on important long-term outcomes.

    Your point about reassuring people about specific problems is also an important one. Without an adequate clinical assessment, reassurance or “false reassurance” will almost definitely be harmful. If reassurance is used because of laziness or incompetence in detecting important specific causes of symptoms, then something has gone very wrong. I am sure your friend’s story is an unfortunately common one (but happily resolved in her case). A proper assessment and ruling out serious disease is the hallmark of good medicine. Education about symptoms that are very likely to be non-specific should also be a hallmark.

    Jeannie,
    Assurances by clinicians are no doubt important. We would suggest that, based on our results, they should be combined with some form of education about the patient’s presenting symptoms. I agree that in some cases, a scan or test might be the only thing that will reassure the patient. There is evidence that those scoring high on health anxiety measures might get some benefit out of receiving a negative test result. The problem in back pain is that even if the scan is reassuring, there is equal or greater chance that it won’t be, and it is also very likely to worsen their outcome in terms of pain and disability. Our results along with the other studies in back pain would suggest that if you do have a patient that is very concerned and wanting a scan, good education is important and effective. If they are that keen to get a scan, education about the likely findings might be the way to go – I know researchers have done some good work on this in cardiac testing and it seems to help.

    Thanks again for commenting guys…

    Adrian

  5. Jeannie burnett says

    I like this last post , the term assurance fits nicely . Assurance that even with changes on X-ray , that lady will be able to have a functional neck … That on top of scanning for structural changes , the patient can be assured that there is either no functional impairment ir if there is , what can be done to manage these . It is late so hope this makes sense !
    Also I think that in response to the comment that scans are not reassuring – this is a very case by case thing to be determined when we are working in the clinic … Do we think ?
    Cheers. JeannieBurnett

  6. John Barbis says

    I have always found the term “reassurance” strange. Why isn’t “assurance” sufficient? The need to repeatedly assure someone about your opinion means that the basic facts of your argument are not very convincing. To me reassurance is something that used car salesmen do when they are trying to sell you a vehicle that you are not convinced is worth the money or the trouble of ownership. The trouble with the word “reassurance” is not the “re” part. It is the “assurance” part. We, all healthcare professions are included here, make up language for pain (like nonspecific Low back or fill-in-the-blank pain) that would not be used other types of physical ailments (non-specific sore throat, cardiac arrhythmia, blood disorder, bowl disorder, etc.). During the Pain Adelaide Conference there was much made about non-specific low back pain. To this day, as someone who primarily treats spine patients, I cannot force myself to use that term. First of all I have never had someone give me a good definition of what “Specific Low Back Pain” is let alone NSLBP.
    Actually when we talk about NSLBP, we are asking patients to accept our assurance that what is producing their problem is a harmless unknown. I can understand where a patient would have a difficulty with that. It might be good to take a few hints from used car salesman to see how we might get them to buy our diagnosis better
    I do not like to buy new cars. My wife and kids call me cheap. I take that as a badge of pride. I buy used cars from dealers who do not give me reassurance but give me the best assurance that they can provide. I want assurance that the dealer has checked the major working parts of the car. I often take it to another mechanic for their opinion. There may be squeaks, noises from the body, and other entities that may not be pristine that I do not know about. However, I know that certain specific problems have been cleared and I have assurances about what isn’t wrong. Also I get some type of “assurance” in the form of a warranty that puts the dealer’s financial butt on the line. I do not think that we as health professionals can provide warranties, but there is a real tangible benefit to the patient’s knowledge that we have done a thorough clinical evaluation and can say with a high degree of certainty what is not wrong. Hopefully through that process we can give the patient some “assurance” that whatever is going on is not life threatening or dangerous. Doing that good evaluation, however, takes time and providing the explanation takes real practice and clinical expertise. We need to give the NSLBP patient the same clinical considerations that we provide to the cancer patient, not blow them off because “ we do not know”. By the way, I just had a very close and dear friend get the confirmation that she is clear of bowel cancer. She is alive today because she did not accept her GP’s assertion that her bowel dysfunction was due to a non-specific gastric disorder. Let’s not reassure- let’s confidently assure. JohnB

  7. Graham Yates says

    I am an osteopath in the uk who uses the biopsychosocial approach to pain.
    I took a diploma in cognitive behavioural hypnotherapy partly to add to my skill set by using a “Socratic” CBT approach to interviewing patients.
    However I also have found hypnotherapy a great under utilised tool with a strong evidence base for pain treatment.
    I thought a strong therapeutic alliance and giving hope the foundations of CBT.I think the research would probably show much better outcomes,as per CBT,if we as manual therapists studied CBT as part of our undergraduate education.Its the skill of the therapist.
    Personally I prefer Albert Ellis in his style(the Grandfather of CBT) of interview with Gloria and try to watch any Michenbaum you can who I think the master of the guided therapist.
    It comes down to dealing with cognition and behaviour as much of the body and this will not probably be a comfortable initial journey for the patient.Reassurance therefore may not be apt in many persistent pain patients
    I also love “Problem Solving Therapy” as per Nezu, Nezu and D’Zurilla ,which is I believe highly suited to physical therapists and also a strong evidence base.

  8. Hi Adrian, you underlined something that, I think, is strictly connected to communication problems. It is still hard to choose words and tone adapt to friends and family harder and harder to . ….it’s a art, something that I worry and analyse every day. …
    good job!
    Ilaria

  9. Ingrid van der Aa says

    I am a “patient” with a 20 yr history of lower back issues and pain. Like to talk about it.

    Kind regards,
    Ingrid van der Aa

    Sjouke van Rossum Reply:

    Hi Ingrid,

    What would you like to talk about? I’m a psychosomatic physio with a big interest on the subject. Maybe I can help? By the way, are you Dutch?

    Greetings,
    Sjouke van Rossum