Self-management interventions are widely recommended for patients with low back pain (LBP), but a systematic review with meta-analysis by Australian researchers suggests that its effects on pain and disability are likely to be small and are supported by only moderate-quality evidence.
The study, by Vincinius C. Oliveira, a PhD candidate in the Arthritis & Musculoskeletal Research Group at the University of Sydney, Australia, and colleagues was published online October 27 and in the November print issue of Arthritis Care & Research.
"The improvement [in pain and disability] was less than what is generally considered worthwhile by patients," Oliveira told Medscape Medical News. Specifically, the short-term improvement was −3.2 points on a 100-point scale for pain and −2.3 points for disability. According to the authors, effect sizes of 20% to 30% are needed for patients to consider interventions worthwhile.
Dawn Carnes, DO, director of the National Council for Osteopathic Research and senior research fellow at the London School of Medicine and Dentistry in the United Kingdom, was not convinced. "I was surprised by the strength of the conclusion [Oliveira et al.] come to for the following reasons: Small changes in large populations (such as [LBP]) do make a difference at a population level. Small changes are all you ever see in studies of [LBP]," Dr. Carnes told Medscape Medical News.
Dr. Carnes added, "Important outcomes in chronic [LBP] are being able to do things despite the pain; learning that pain does not necessarily mean harm; coping with associated depression, anxiety, and fear; and reactivating and engaging in society overall to improve quality of life. If the authors had presented data on quality of life and or self efficacy, they might have found positive effects for these too. Who are we to say that these are 'trivial' effects for these patients?"
Oliveira and colleagues included randomized controlled trials evaluating self-management for nonspecific LBP and assessing pain and disability in the systematic review. They pooled data when studies were similar enough and divided analyses into short-term (less than 6 months after randomization) and long-term (at least 12 months after randomization) outcomes.
The researchers found 13 original trials that met inclusion criteria. Efficacy of self-management (including shared responsibility for a plan of care, self-monitoring, and management of signs and symptoms) was compared to efficacy of minimal intervention and to other interventions such as massage, acupuncture, yoga, and exercise.
Dr. Carnes was concerned about the inclusion criteria. She said, "[The authors] included all types of [LBP], including chronic. Why would you expect pain to improve in a chronic pain population, where drugs don't even work for these people? Similarly, disability is unlikely to change in chronic patients, especially those with permanent bony or physiological change."
Should Guidelines Be Reconsidered?
Given that self-management is included in guidelines, such as the Australian Government's First National Primary Health Care Strategy, Oliveira said, "We were surprised by lack of definition criteria for self-management. The study raised questions that our group is currently working on such as consensus on what self-management for [LBP] is among experts, including clinicians and researchers."
In comparing self-management with minimal intervention, the authors found "moderate-quality evidence that self-management interventions have small but statistically significant effects, compared to minimal interventions, on pain and disability for LBP." Moderate-quality evidence means that further research is likely to affect confidence in the estimate of the effect and might change the estimate.
In addition, the authors found only low-quality evidence that self-management is not better than massage, acupuncture, yoga, and exercise in reducing pain or disability in LBP. Low-quality evidence means that further research is likely to change the estimate.
From the clinician's viewpoint, Oliveira noted that nothing in this report should be taken as a guide to changing current clinical practice. Experts, including clinicians and researchers, should discuss what self-management for [LBP] is and specific features likely to improve on its effectiveness," he said.
The authors conclude, "Although effective when compared to minimal intervention, we are unsure if self-management provides worthwhile effects in the management of LBP. This result challenges the endorsement of self-management in treatment guidelines."
The study authors and Dr. Carnes have disclosed no relevant financial relationships.
Arthritis Care Res. 2012;64:1739-1748. Abstract
Janis C. Kelly • Medscape Medical News © 2012 WebMD, LLC