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Effectiveness of self-management of low back pain: systematic review with meta-analysis

Heather Gray

This week in Scotland has been designated as self-management week. There is a growing awareness that low back pain (LBP) is a long term condition and that self-management can decrease the burden of this, and many other, conditions. To date, self-management has been described as a model of care where patients use strategies to manage and monitor their own health, retaining a primary role in management, and where they learn skills to be used in the daily management of their health condition.

As part of the redesigned musculoskeletal services in Scotland patients are often directed, via NHS24, to self-management resources online or a through a mobile phone app. But how effective is the self-management of LBP? This was the question asked in a systematic review by Oliveira et al. (2012).

Here’s what they did

Studies were retrieved from searches of the following databases from earliest record to April 2011: MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, PEDro, AMED, SPORTDiscus and Cochrane Register of Clinical Trials. Trials were eligible if they included participants with non-specific LBP of any duration. They included trials in which at least one intervention was indicated by authors as self-management for LBP by naming the intervention using the terms “self-management” or “self-care”. Eligible studies were assessed for methodological quality using the PEDro scale (0-10), and the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to summarise the strength of the recommendation for each outcome:

Here’s what they found

Search strategies identified 2325 titles after removing duplicates. Screening of titles and abstracts identified 154 potentially eligible papers and 13 original trials were included that recruited a total of 3063 participants. Trials used written information, discussion sessions and audiovisual resources (i.e. audiotape, videotape or website) as self-management strategies. The amount of support given by health care providers or lay-trained leaders varied between one and thirteen sessions. The mean score for methodological quality using the PEDro scale was 6.5/10

The authors concluded

signs pointing to change
“There is moderate quality evidence that self-management has small effects on pain and disability in people with LBP.”
Their review provided moderate evidence that the effects of self-management for non-specific LBP (less than 6 points on a 100-point scale) are only small if compared to minimal intervention, posing the question of whether or not this is a worthwhile approach.
However, the authors cation that it would be premature to completely dismiss self-management of LBP. Instead they advocate an increase in research seeking to further understand the limitations of self-management and how its effectiveness may be increased.

The Musculoskeletal Elf’s view

Many primary cThe Musculoskeletal Elfare and LBP management clinical guidelines promote the use of self-management; however, when it comes to LBP, it appears that there is work to be done in defining what a ‘self-management intervention’ is and how it is best introduced to patients and delivered.

Another review conducted by the Health Foundation (de Silva, 2011) concluded that information provision alone is unlikely to be sufficient to motivate behaviour change and improve outcomes, and that interventions such as motivational interviewing, telephone coaching and active group interventions should be used.

What are your experiences of giving or receiving self-management resources/ interventions? What feedback have you had from your patients on their views of self-management resources? How can you improve any current self-management resources that you are delivering?

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community.

Links

Oliveira, V.C., Ferreira, P.H., Maher, C.G., Pinto, R.Z., Refshauge, K.M. & Ferreira, M.L. 2012, “Effectiveness of self-management of low back pain: Systematic review with meta-analysis”, Arthritis Care & Research, online ahead of publication, http://www.ncbi.nlm.nih.gov/pubmed/22623349 [PubMed abstract]

de Silva, D. (2011) Evidence: Helping people help themselves, A review of the evidence considering whether it is worthwhile to support self-management, The Health Foundation, London, [online] http://www.health.org.uk/resource-centre/new-sms/overview/evidence-sms-improves-outcomes/ [accessed 29/9/12]

Arthritis Care (2012) Self management [online] http://www.arthritiscare.org.uk/LivingwithArthritis/Self-management [accessed 29/9/12]

The Health Foundation (2012) Self management support research centre [online] http://www.health.org.uk/resource-centre/new-sms  [accessed 29/9/12]

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Written by

I am currently the Head of Physiotherapy & Paramedicine at Glasgow Caledonian University and Chair of the Chartered Society of Physiotherapy's Professional Committee. I have worked at the University of Glasgow in several research positions. I am on the Editorial Board of the Journal of Physical Therapy Education. Other work in which I have been involved is as an Educational Consultant with NHS Education for Scotland. Prior to moving into academia I worked in the National Health Service (NHS) in Scotland as a physiotherapist for 11 years.

Add a comment
  • Heather Gray

    Heather Gray

    13 years ago
    Hi Paul, Thank you for your comments. It seems to me that you would be in an ideal position to evaluate the effects/ impact of a self-management approach as you will have access to plenty of data from your own professional practice. Perhaps you could collaborate with some friendly researchers from your local university and get a study set up. There is also plenty of scope for some qualitative work to be undertakend to establish patients' views of self-management. Thank you for reading our blog & look forward to your future comments. Heather
    • 1 reply
    • Paul Boxcer
      Paul Boxcer 13 years ago
      Hi there Heather, you are more than welcome re my reply, it is something I am very passionate about. Evaluating the effects to self-management is something I have thought about, although not something I feel I am ready for quite yet, and I would definitely need some friendly researchers to help me set it up that’s for sure :-). Re qualitative patients’ views of self-management, that is something that would be a little more practical for me to take on and something I will definitely bear in mind. In the mean time, thanks for the good work you are doing, I’ve already got my eye on a couple of other articles, but there seems to be so little time… Take care, Paul.
  • Paul Boxcer

    Paul Boxcer

    13 years ago
    Hi there Heather, I shall begin my reply with an apology for not even knowing that it is Self Management Week in Scotland. OK, so I live in England, but I am a Physiotherapist who strongly advocates the role of self management, and in particular with regard to Low Back Pain & Sciatica and therefore I should be aware of such initiatives. Reading your blog, my heart sank to read that recent research has concluded that there is “moderate evidence that the effects of self-management for non-specific LBP… are only small if compared to minimal intervention” Whilst I appreciate they go on to add that it would be premature to dismiss the self-management of low back pain (phew!) and that there should be an increase in research, it is still very disappointing to read this, if for no other reason than I do not believe it is true. Not only that, but I would say that it should be seen as the first school of thought and treatment approach used when aiming to resolve or manage these conditions. I hope this doesn’t come across as patronising or being too judgemental, but I believe one of the main problems that arises is attempting to change the mind set of those suffering in pain. A culture has been built up where if someone suffers with low back pain or sciatica (or any health condition to a certain extent) then they need to see a health professional for it to be ‘fixed’. It is changing this thought process which needs to be addressed if self management is to be successful. I also believe that, for some reason, a kind of mystique has been built up around low back pain where it is different to any other kind of injury suffered in that it has to be ‘treated’ or ‘fixed’ by a health professional, and in some cases ‘maintained’ by the same health professional for fear of it coming back again. This is simply not true. OK, so the problem may have to be maintained, but it certainly doesn’t need someone else to maintain it. It can (and should) be maintained by the person who is suffering with low back pain or sciatica. Unfortunately, though, this thought process becomes a self fulfilling prophecy in that if the individual concerned does not look after and care for their own back, the likelihood is that they will suffer with low back pain or sciatica again. What are they then going to think? They will think that they need to go and have it ‘fixed’. Once again, if no self management occurs i.e. addressing the cause of the problem, then the pain will likely return and therefore another trip to the health professional is seen as the only option. This cycle will continue with repeated trips to the health professional or alternatively a kind of ‘giving up and living with the pain’ thought process occurs (maybe because the repeated treatments are becoming too expensive!). This leads to the frustrating phrase I often hear that ‘once you have had low back pain, you will always suffer with low back pain’, once again, this is not true. The frustrating part is both are unnecessary, as long as we take responsibility for our own health and look to address why we have developed the low back pain or sciatica in the first place, this vicious cycle of repeated treatment or a giving up attitude can be avoided. My approach to treating low back pain and sciatica is one where I totally put the emphasis on self management. I have had the odd confrontation while working within the NHS, where patients have been adamant about having, for example, traction or ultrasound because “it worked before” (Mmmmmm, maybe it wasn’t the best line of treatment then if you back pain has returned). With these people I explain to them I do not use these modalities and ask if we may still continue with the assessment. More often than not the assessment continues, I explain my approach and treatment plan and they are happy to continue, largely with successful outcomes (although I must admit there has been the odd occasion where I have had to transfer the patient to another physio for traction or the like). By the way, I am not dismissing that phsyio’s or any other health professional should not use these modalities, it is just they do not form a part of my treatment approach. I feel so strongly about the role self management has to play in the treatment of low back pain and sciatica, that I have written a book on how to self treat these conditions (Low back Pain & Sciatica – A Personalised Treatment Approach) and the feedback I am receiving is very good. Now it could be argued that the mind set of those who have actively sought to treat their own low back pain or sciatica is different to those who have been referred to have their back pain ‘fixed’… maybe. Nevertheless, it can be done and far too many people suffer unnecessarily by not adopting a similar mindset. Anyway, I will go on and on and on if I am not careful, so I shall wind up my reply now. As I said at the top, my heart sank when I began reading your blog, but it is fantastic that there are organisations such as Musculoskeletal Elf (which will make my life a little easier!), Alliance Scotland, NHS Inform, NHS 24 and My Condition My Life (apologies to those I have missed out) who are there to help others help themselves. Keep up the good work, I shall follow you on Facebook and Twitter and look out for all the good work being done. Take care for now, Paul Boxcer.
  • Vinicius Cunha Oliveira

    Vinicius Cunha Oliveira

    13 years ago
    Dear Dr Heather Gray Spread evidence is very important in order to improve health care. Congratulations for your blog! Self-management has been considered a potential cost-effective intervention mainly for chronic/recurrent conditions such as low back pain. However, some issues should be further explored such as small effects and lack of consensus on definition of self-management in the literature. Firstly, do patients believe small effects of self-management for low back pain is worthwhile considering direct and indirect costs? Secondly, studies investigating effectiveness of self-management differ in regards to what self-management is. For instance, should we consider mailed information/booklets a self-management approach for low back pain? Moreover, treatments supervised by health care providers are sometimes considered self-management approaches for low back pain. So, is there consensus on the difference between supervised treatment and self-management for low back pain? Further investigation should answer these issues and look for specific features of self-management for low back pain likely to improve its effectiveness.
    • 1 reply
    • Heather Gray
      Heather Gray 13 years ago
      Dear Dr Oliveira, I think you are very right in suggesting that there probably needs to be some consensus work undertaken to try to establish a working definition of what comes under the banner of 'self-management'. Perhaps others out there know of work like this that has been/ is currently being done? Heather