Effectiveness of patient education plus motor control exercise versus patient education alone versus motor control exercise alone for rural community-dwelling adults with chronic low back pain: a randomised clinical trial

Abstract

Background Chronic low back pain (CLBP) is a common health problem in rural Nigeria but access to rehabilitation is limited. Current clinical guidelines unanimously recommend patient education (PE) including instruction on self‐management, and exercises as frontline interventions for CLBP. However, the specific content of these interventions and how they are best delivered remain to be well-described, particularly for low-resource communities. This study determined the effectiveness of PE plus motor control exercise (MCE) compared with either therapy alone among rural community-dwelling adults with CLBP. Methods A single-blind, three-arm parallel-group, randomised clinical trial including 120 adult rural dwellers (mean [SD] age, 46.0 [14.7] years) with CLBP assigned to PE plus MCE group (n = 40), PE group (n = 40), and MCE group (n = 40) was conducted. The PE was administered once weekly and the MCE twice weekly. Each group also received stretching and aerobic exercises twice weekly. All interventions were administered for 8 weeks. Blinded assessments for pain intensity and disability level as primary outcomes, and quality of life, global perceived recovery, fear-avoidance beliefs, pain catastrophising, back pain consequences belief and pain medication use as secondary outcomes were conducted at baseline, 8-week (immediately after intervention) and 20-week follow-ups. Results All the groups showed significant improvements in all the primary and secondary outcomes evaluated over time. Compared with PE alone, the PE plus MCE showed a significantly greater reduction in pain intensity by an additional –1.15 (95% confidence interval [CI], –2.04 to –0.25) points at the 8-week follow-up and –1.25 (95% CI, –2.14 to –0.35) points at the 20-week follow-up. For disability level, both PE plus MCE and MCE alone showed a significantly greater improvement compared with PE alone by an additional –5.04% (95% CI, –9.57 to –0.52) and 5.68% (95% CI, 1.15 to 10.2) points, respectively, at the 8-week follow-up, and –5.96% (95% CI, –9.84 to –2.07) and 6.57% (95% CI, 2.69 to 10.4) points, respectively, at the 20-week follow-up. For the secondary outcomes, at the 8-week follow-up, PE plus MCE showed a significantly greater reduction in fear-avoidance beliefs about physical activity compared with either therapy alone, and a significantly greater reduction in pain medication use compared with PE alone. However, compared with PE plus MCE, PE alone showed a significantly greater reduction in pain catastrophising at all follow-up time points, and a significantly greater improvement in back pain consequences belief at the 20-week follow-up. Additionally, PE alone compared with MCE alone showed a significantly greater improvement in back pain consequences belief at all follow-up time points. No significant between-group difference was found for other secondary outcomes. Conclusions Among rural community-dwelling adults with CLBP, PE plus MCE led to greater short-term improvements in pain and disability compared with PE alone, although all intervention strategies were associated with improvements in these outcomes. This trial provides additional support for combining PE with MCE, as recommended in current clinical guidelines, to promote self-management and reduce the burden of CLBP in low-resource rural communities. Trial registration ClinicalTrials.gov (NCT03393104), Registered on 08/01/2018.

The optimal dose of pain neuroscience education added to an exercise programme for patients with chronic spinal pain: A systematic review and dose–response meta-analysis

“…2,23,24,31,34,35,56,62,67,71,73 In the remaining 15 studies, 3,5,6,20,30,32,37,41,48,49,52,61,66,74,77 follow-up ranged from 3 to 12 months. Pain intensity was assessed using the visual analogue scale (VAS) in 10 studies, 2,20,23,24,32,41,52,61,62,74 the Numerical Pain Scale (NPRS) in 11, 3,5,6,30,34,35,48,66,67,71,77 the Neck Pain and Disability Scale (NPDS) in one, 31 and PROMIS in one. 37 Disability was assessed using the RMDQ in 11 studies, 5,…”

“…31 Quality of life was assessed using the SF-36 in 4 studies 20,48,67,73 and the SF-12 in one study. 30 The PPTs were evaluated in 7 trials. 3,5,6,20,48,52,71 3.3.…”

“…3,5,6,20,48,52,71 3.3. Risk of bias Overall, 5 of the studies had a low risk of bias, 30,41,48,49,77 12 had some concerns, 2,3,6,31,32,35,56,61,62,67,71,74 and 9 had a high risk of bias. 5,20,23,24,34,37,52,66,73 For the randomization domain, 19 of the studies had a low risk of bias, and 7 had some concerns; for the domain of deviations from the intention to treat, 12 had a low risk of bias, 10 had some concerns, and 4 had a high risk of bias.…”

“…Finally, a total of 26 studies were included in the systematic review. 2,3,5,6,20,23,24,[30][31][32]34,35,37,41,48,49,52,56,61,62,66,67,71,73,74,77…”

“…7 However, in the past years, new evidence seems to support the effectiveness of PNE in this population. 3,5,23,24,[30][31][32]34,35,37 However, to the best of authors' knowledge, no systematic review has still determined the optimal dose of PNE added to an exercise programme required for achieving clinically relevant improvements in terms of pain intensity and disability in patients with CSP. This information could be useful to guide clinicians' decision-making when using PNE to treat patients with CSP.…”