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Patients whose treaters explain their subacute low back pain condition in detail have better outcomes

At a glance:
A short course of treatment or “mini-intervention' by a doctor and physiotherapist can help people with back pain.  In this study information support and simple advice from a specialist:

         Reduced patients' daily symptoms 
         Reduced patients' sick leave 
         Helped patients to adapt to their pain
         Gave them more satisfaction with treatment than usual care. 
Perspectives:
Employee
If you understand your back condition you will have a better outcome.  Seeking advice through an in-depth discussion with your doctor and physiotherapist will assist you.   Test results do not generally help; sometimes labels such as disc bulge
disc bulge
When a disc
disc
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae.  Disks
disk
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disc.
  have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disk.
 has extended out from its normal position. A disc bulge can be normal (30-80% people without back pain have some degree of disc bulge on a back scan). In other cases the disc can press on the nerve and cause sciatica
sciatica
Pain caused by pressure on a branch of the sciatic nerve, which starts in the lower back and runs through the legs. The pain is felt in the leg and foot. There may also be numbness, weakness or difficulty moving the leg.
 or leg pain. Also called a disc prolapse or disc herniation.
 or disc degeneration simply make people worry.  In many cases these changes are simply the ageing process.  

Make sure you get the best advice about returning to activity, and what you can do to improve your situation. Most people with back problems get better fairly quickly.  However up to 25% of people have lingering pain for a year or two.  Learning what you can do to help yourself is worth its weight in gold. 

This study gave people with back pain simple, but clear advice about what they could do.  The patients who received the advice did better than those who did not receive this advice.  The findings of this study are much the same as many other similar research projects.
Employer
People with back pain are often worried.  They may be concerned about their job, or worried their back will get worse over time.  

This study showed that good medial advice and explanation early on helped people with a back problem become more active and return to work earlier. 
Treater
Talking to people takes time.  However this study shows that good advice and explanation for patients with back pain improves outcomes.  Further, patients who receive advice and explanations are more satisfied with their treatment.

We have had a heavy reliance on investigations and diagnostic
diagnostic
Used to identify a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of X-rays, scans, or other tests.
 labels for back pain.  Many studies indicate that tests rarely help people with back pain.  Scan results can provide labels that leave the person worried.

Providing people with good information about back pain is paramount, but it takes time.  Refer the patient to someone who is able to provide good advice if you cannot.  Alternatively, arrange a longer appointment so that there is sufficient time to talk through the range of issues that are common to people with this condition. 
Insurer
Hands-on treatment or medication can help people in the early stages of back pain.  

The longer the back pain has been around the more important advice and explanation becomes.  

Advice and explanation improves outcomes, demedicalises the condition, and alleviates people's concerns.  It helps them return to activity, return to work and get back to pre-injury duties as soon as possible. 
Original Article, Authors & Publication Details:
K. Karjalainen1, A. Malmivaara1, T. Pohjolainen2, H. Hurri3, P. Mutanen4, P. Rissanen6, H. Pahkajarvi1, H. Levon1, H. Karpoff1 and R. Roine5 (2003).

Mini-intervention for subacute low back pain: A randomized controlled trial. Spine; 28(6):533-540

1Department of Occupational Medicine, Finnish Institute of Occupational Health
2Social Insurance Institution
3ORTON Orthopedic Hospital, Invalid Foundation
4Department of Epidemiology
epidemiology
The study of factors affecting the health and illness of populations. Also refers to the study of management and control of health problems.
 and Biostatistics, Finnish Institute of Occupational Health
5Helsinki and Uusimaa Hospital Group, Helsinki, Finland
 6University of Tampere, Tampere School of Public Health, Tampere, Finland.
Background, Study Objectives, How It Was Done:
Low back pain is usually short-term and most patients recover without treatment.  However, some people suffer recurrent episodes of back pain, leading to a long-term condition that effects everyday functioning.  For people with long-term back pain returning to work can be difficult.  Work site visits may help people with low back pain return to work faster. 

The aim of this study was to investigate the effectiveness and cost of a short intervention to help workers with short-term low back pain get back to work.  The authors also wanted to see whether a worksite visit further improved outcomes for patients.     

Study participants visited general practitioners at 36 medical centres in Helsinki.  They were asked to participate in the study if they were aged between 25 and 60 and had daily back pain that had interfered with their work for more than 4 weeks but less than 3 months.  Patients whose back pain was caused by a specific disease, who needed surgery, or who had psychiatric or other problems that could hinder their rehabilitation were excluded from the study.

Patients completed an initial questionnaire and were then divided randomly into three treatment groups:

1.       Mini-intervention group (56 patients)

This intervention
intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 included light exercise and graded activity.  Patients had three sessions.  Firstly, a specialist doctor discussed the causes of back pain with the patient, explaining the results of their X-rays or other investigations and encouraging them to ask questions.  This session lasted for 45 minutes. 

The doctor then introduced the patient and their case to a physiotherapist, who told the patient that people usually recover fully from back pain and that it is important to avoid bed rest, remain active, and exercise daily.  This session lasted for about 15 minutes.  The aim of these consultations was to reduce the patient's concerns about their back pain by providing accurate information and to encourage physical activity. 

The third session was with the physiotherapist and lasted 1.5 hours.  The physiotherapist taught the patient exercises to strengthen muscles and help them use their back properly, and showed them how to do daily activities and work tasks with minimal back strain.   The specialist doctor and physiotherapist gave the patient's GP recommendations about their continued treatment. 

2.       Work site visit group (51 patients)

This group had the same treatment as the mini-intervention group and also a work site visit.  The specialist doctor, physiotherapist, patient, company nurse and patient's work supervisor were asked to attend the worksite.  The visit was used to ensure the patient was using their back properly at work and to involve the supervisor and company health professionals in the patient's return to work.  The patient was encouraged to co-operate with the company's health care staff.  The visit lasted 75 minutes.  A report on the work site was sent to the patient's company health care professionals and GP.

3.       Usual care group (57 patients)

Patients were given a leaflet about back pain (as did patients in the other treatment groups).  They were treated by their GPs and referred to specialists or physiotherapy when necessary.

All patients completed a questionnaire 3, 6 and 12 months after their treatment.  They were asked about their sick leave from back pain, intensity of pain (on a scale of 1-10), frequency of bouts of pain, level of disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 and quality of life.  They were also asked about their work, exercise routine, use of health care services and expenses from their condition.  98% of the study participants completed the follow-up questionnaires.
Study Findings:
The intervention groups (work site visit group and mini-intervention group):

         Had fewer patients with daily pain (at 3, 6 and 12 months) than the usual care group
         Spent fewer days on sick leave in the 12 months after treatment (average of 19 days compared to 28 days for the usual care group)
         Were more satisfied with their overall medical care (at 3, 6 and 12 months) than the usual care group

For the mini-intervention group:

         pain bothered them less than the usual care group
         pain interfered less with their daily life than the usual care group
         Combined costs of health care and sick leave were reduced (by $3552 U.S.) compared with the usual care group

For the work site group:

         Costs of diagnostic tests were reduced compared to the usual care group
         Combined costs of health care and sick leave were reduced (by $2927 U.S.) compared with the usual care group
Conclusions:
This study shows that a short course of treatment or “mini-intervention' by a doctor and physiotherapist can help people with back pain symptoms.  A knowledge providing consultation early in the course of back pain reduced daily symptoms and sick leave and led to better satisfaction with treatment than usual care.  A visit to the patient's work site by the health care professionals did not make a difference.

Previous studies have shown that fears about pain can be more disabling than pain itself.  In this “mini-intervention,' patients were reassured and their concerns were taken seriously by health professionals.  This may explain the high patient satisfaction and better outcomes. 

Encouraging patients to carry on with their normal life and to work as normally as possible despite their pain helped them to have fewer days on sick leave in the 12 months after treatment.

To estimate costs, visits to health care, medication used, diagnostic examinations, and use of alternative medicines were recorded from the questionnaires.  The mini-intervention used in this study reduced costs from health care and from lost work due to sick leave.  Thus, investing in a short intervention can produce long-term savings.
References:
PubMed Abstract
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