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FOTO Rehab Outcomes Blog

Education: Placebo vs Intensive Pain Education Appear Equal

Last month this study rumbled around in my brain.  I wonder if this study teaches us how not to do what something that does have supportive evidence.

biopsychosocial-education-placebo-low-back-painThe patients in this study were all identified as being at risk for persistent pain. The patients were experiencing low back pain with an onset within the previous 6 weeks. If I were to guess (because I cannot acquire full text access), these patients probably had higher levels of fear or anxiety or depression as part of their presentation.

What's interesting is the fact that there is plenty of research substantiating the value of spending time educating about pain. This study compared basically pain education with what appears to be active listening.

What I am unable to determine is how the education occurred or who provided the education. The one thing that I do know is that the experimental group underwent two sessions of one hour duration of education about their pain. Apparently the other group underwent two sessions of one hour duration of active listening. I don't know about the rest of you, but a few things immediately pop into my head.

  • The patients had to have felt uncomfortable. Think about it: most patients who have a recent onset of low back pain do not appreciate being in a single position like sitting or standing for one hour at a time. 
  • When I am at conferences, I wonder why the planners like to have long sessions. We already know from neuroscience that our attention spans are not likely to be able to pay attention for 50-minutes.
  • How much interaction did the patients actually have during the educational process in the experimental group? What I mean is, was the education individualized for the specific patient or was the educational aspect a formalized situation where each patient was educated in the same manner with the same information? 
  • Was the educational component one-on-one or a group situation?
  • Why was the study oversimplified and focused only on education? When someone has an acute musculoskeletal condition, I am not aware of education being the go-to answer to solve the situation.

This study obviously points to the lack of value educating patients who are at risk for having persistent pain. I honestly cannot take that particular stance. What this study really indicates is that spending 2 sessions of an hour duration educating about pain is not an adequate plan. This is great news, because I highly doubt that any of us in rehabilitation would even think of spending an hour of a chunk of time solely focused on pain education. The study really wasn't based on reality. The dosage of the education was definitely too high. We also know that telling someone to "stay active" may be really, really vague for the person experiencing pain. We know that we use our assessment and evaluation to prescribe targeted activities for the patient to perform. We use our education and our activity prescriptions to be highly specific to the individual sitting in front of us.

You'll find the abstract to the recent study below.

Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial.




Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care.


To determine the effectiveness of intensive patient education for patients with acute low back pain.


This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks' duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education.


All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice).


The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months.


Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, -0.3 [95% CI, -1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, -1.6 points on a 24-point scale [95% CI, -3.1 to -0.1]) and 3 months (mean difference, -1.7 points, [95% CI, -3.2 to -0.2]) but not at 6 or 12 months.


Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature.

 2018 Nov 5. doi: 10.1001/jamaneurol.2018.3376. [Epub ahead of print]

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