The effect of health education in patients with chronic low back pain

Abstract

Objective

To assess the value of health education (active management and postural hygiene) over and above exercise alone, in patients with chronic low back pain.

Methods

Adults (aged 18–30 years) with low back pain of ≥3 months’ duration were randomized to undergo a 12-week programme of lumbar strengthening exercise and health education or exercise alone. Pain, disability (Oswestry Disability Index, ODI), static and dynamic muscle endurance, and health-related quality-of-life (short form-36, SF-36) were assessed at baseline and after completion of treatment.

Results

At the end of the 12-week intervention period, pain, disability, SF-36 physical component and SF-36 mental component were significantly better in the health education group (n = 25) than in the control group (n = 24). There were no significant between-group differences in static or dynamic endurance.

Conclusion

Health education provides additional benefits to exercise alone for improving pain, disability and mental and physical health-related quality-of-life.

Introduction

Low back pain is a common musculoskeletal disorder, affecting 80% of people at some point in their lifetime. ¹ In the USA, total direct and indirect costs of low back pain amount to more than $100 billion annually. ² Chronic low back pain is treated with exercise^3–5 or health education (active management and/or postural hygiene). Active management avoids bed rest and those movements that worsen pain, and promotes physical activity. ⁶ The aim of postural hygiene is to train the patient how to perform daily activities in such a way that back muscle tension and spinal load are reduced. ⁷

European guidelines for the management of chronic low back pain recommend educational interventions to reduce disability and sick leave. ⁸ The concurrent use of health education and conventional care can lead to improvements in pain, disability and health-related quality-of-life, ⁹ although some have found no significant differences between control and health education groups in rates of self-reported pain, disability or sick leave. ¹⁰ It is unclear whether health education programmes can benefit patients with chronic low back pain.

The present study assessed the effects of a 12-week health education programme plus lumbar strengthening exercises versus lumbar strengthening exercises alone on pain, disability and health-related quality-of-life in patients with chronic low back pain, in order to determine whether health education was beneficial in these patients.

Patients and methods

Study population

This randomized, controlled study included college students with chronic low back pain who were attending Hohai University, Nanjing, Jiangsu Province, China. Patients were recruited between October 2012 and June 2013, and were required to be aged 18–30 years and have low back pain (with or without radiating pain to the lower extremity) of ≥3 months’ duration. Exclusion criteria were: (i) visual analogue scale (VAS) pain score >8 (0, no pain; 10, worst pain); (ii) previous participation in a health education programme; (iii) previous spinal surgery; (iv) acute infection, progressive neurological deficit, structural anomaly, severe instability, severe cardiovascular or metabolic disease. All patients completed a questionnaire prior to randomization, which collected information including basic demographic data, medical history, exercise habits (frequency and time/session), and past and present job status. Participants were allocated in a 1 : 1 ratio to either the health education group or the control group by computer-generated random number sequence.

The Ethics Committee of Hohai University, Nanjing, Jiangsu Province, China approved the study and all patients provided written informed consent prior to enrolment.

Intervention

All patients performed lumbar strengthening exercises three times a week (40 min each session) for 12 weeks, focusing on trunk flexor and extensor muscles. ⁴ Exercise programmes were led by registered physical therapists. Each session included: (i) 5-min warm-up; (ii) 15-min trunk flexor strength exercises, including straight leg raises and sit-ups with foot fixation; (iii) 15-min trunk extensor strength exercises, including prone trunk extensions; (iv) 5-min cool-down.

Patients in the health education group underwent education sessions once a week for 12 weeks. Sessions included a lecture (30 min) followed by discussion (10 min), and information was delivered by videos, computer presentations and instruction leaflets. Content included active management and postural hygiene, such as avoiding risk factors for back problems, safe lifting practices at home and work, and correct postures for decreasing back muscle tension and spinal load.

Outcome measures

Outcome measures were assessed at baseline and at the end of the 12-week intervention programme by an investigator who was blinded to group allocation (L. W.) Outcome measures included: (i) pain intensity (VAS) ¹¹ ; (ii) Oswestry Disability Index (ODI); higher values indicate more severe disability ¹² ; (iii) static muscle endurance ¹³ (length of time (in s) that the patient could hold their unsupported upper body in the prone [trunk extensors] and supine [trunk flexors] positions); (iv) dynamic muscle endurance ⁴ (number of curl-ups [trunk flexors] and prone trunk extensions [trunk extensors] performed in 1 min, to a maximum of 25); (v) health-related quality-of-life(Short Form-36 [SF-36] Health Survey, ¹⁴ higher scores indicate better quality-of-life).

Statistical analyses

Data were presented as mean ± SD. Between-group comparisons of baseline data were made using χ²-test or independent samples t-test. Treatment effects were evaluated using two-way analysis of variance (group × time). Statistical analyses were performed using Microsoft Office Excel® 2007 software and SPSS® version 17.0 (SPSS Inc., Chicago, IL, USA) for Windows®. P-values <0.05 were considered statistically significant.

Results

The study recruited 60 patients. After exclusions and withdrawals, the final analysis included 49 patients (health education group n = 25, control group n = 24; Figure 1). Baseline demographic and clinical characteristics are shown in Table 1. There were no statistically significant between-group differences in any baseline data.

Figure 1.

Flow of patients through a study to assess the treatment value of health education and exercise versus exercise alone, in patients with chronic low back pain.

Table 1.

Baseline demographic and clinical characteristics of patients with chronic low back pain included in a study to investigate the treatment value of health education and exercise versus exercise alone (control).

Characteristic	Health education group n = 27	Control group n = 27
Male/female	18/9	16/11
Age, years	22.29 ± 2.85	23.04 ± 2.24
Height, cm	171.93 ± 7.29	169.07 ± 7.31
Body weight, kg	61.96 ± 7.57	61.07 ± 5.25
BMI, kg/m2	21.02 ± 2.85	21.41 ± 1.95
Duration of back pain, months	10.93 ± 3.67	11.45 ± 3.47
Pain, VAS	5.59 ± 1.53	5.78 ± 1.19
Disability, ODI 12	42.78 ± 9.32	45.19 ± 11.40
Health-related quality-of-life, SF-36 14
Physical component	57.28 ± 20.62	50.23 ± 22.78
Mental component	83.76 ± 14.11	80.83 ± 15.19
Static endurance, s
Flexion	63.35 ± 45.51	61.39 ± 47.91
Extension	71.07 ± 45.11	68.56 ± 45.95
Dynamic endurance, repetitions
Flexion	39.91 ± 34.88	37.30 ± 28.11
Extension	15.72 ± 7.72	15.91 ± 7.90

Data presented as n or mean ± SD.

BMI, Body Mass Index; VAS, visual analogue scale (0, no pain; 10, worst pain); ODI, Oswestry Disability Index; SF-36, 36-Item Short Form Health Survey.

No statistically significant between-group differences (P ≥ 0.05; χ²-test for sex, independent samples t-test for all other variables).

Table 2 shows data for all outcome measures at the end of the 12-week intervention period. Patients in the health education group had significantly better pain, disability, SF-36 physical component and SF-36 mental component scores than those in the control group (P < 0.001, P = 0.025, P < 0.001 and P = 0.011 respectively, Table 2). There were no statistically significant between-group differences in static or dynamic muscle endurance.

Table 2.

Clinical characteristics of patients with chronic low back pain following a 12-week intervention programme of health education and exercise or exercise alone (control).

Parameter	Health education group n = 25	Control group n = 24	Statistical significance a
Pain, VAS	2.02 ± 1.46	2.71 ± 1.98	P < 0.001
Disability, ODI 12	14.27 ± 7.11	17.84 ± 9.48	P = 0.025
Health-related quality-of-life, SF-36 14
Physical component	90.92 ± 13.02	63.68 ± 23.87	P < 0.001
Mental component	89.84 ± 11.93	82.35 ± 14.11	P = 0.011
Static endurance, s
Flexion	76.65 ± 56.59	74.28 ± 57.96	NS
Extension	85.99 ± 54.59	82.95 ± 55.60	NS
Dynamic endurance, repetitions
Flexion	48.27 ± 42.21	45.13 ± 33.88	NS
Extension	19.25 ± 9.57	19.02 ± 9.34	NS

Data presented as mean ± SD.

VAS, visual analogue scale (0, no pain; 10, worst pain); ODI, Oswestry Disability Index; SF-36, 36-Item Short Form Health Survey; NS, not statistically significant (P ≥ 0.05).

a

Two-way analysis of variance (group × time).

Discussion

This randomized, controlled study compared health education plus exercise with exercise alone for the treatment of chronic low back pain, and found that health education provided additional benefits in terms of pain severity, disability and physical and mental health-related quality-of-life compared with exercise alone.

The added value of health education remains unclear. Some studies found health education can reduce pain ¹⁵ and absence from work, ¹⁶ but a critical review of nine randomized controlled clinical trials found no effect of education on preventing low back pain. ¹⁰ The findings of the present study indicate that health education intervention is effective for improving pain and disability in patients with chronic low back pain. This may be accomplished by the educational goals of reducing anxiety and encouraging patients to self-manage their pain actively. The short duration of the education programme may explain the lack of significant between-group differences in muscle endurance in the present study. It is possible that a longer education programme may result in improved static or dynamic muscle endurance.

The present study had several limitations. First, the study population included only patients aged 18–30 years, and the findings therefore cannot be applied across all age groups. Further studies are required to determine the value of health education in other age groups, such as the elderly. Secondly, it was not possible for patients and physical therapists to be blinded to group allocation. Thirdly, the sample size was small, limiting the value of the findings. Finally, there was no long-term follow-up in our study.

In conclusion, health education provides additional benefits over and above lumbar exercise alone for improving the pain, disability and health-related quality-of-life of young patients (aged 18–30 years) with chronic low back pain. It remains to be seen whether this is the case in other age groups.