Reassurance for low back pain

Background: Low back pain causes more years lived with disability than any other health condition. The majority of low back pain is ‘non-specific,’ meaning it cannot be attributed to a pathological cause. Clinical guidelines therefore recommend non-specific treatments such as patient education and reassurance in primary care settings. However, there are few high-quality data on how to reassure patients effectively. Instead, patients with low back pain are receiving high numbers of inappropriate tests and treatments.Methods and Main Findings: This thesis is presented as a series of publications. In total there are seven pieces of original research on the topic of reassurance: one clinical commentary, one aetiological study, one prognostic model development and validation study, one systematic review, two study protocols, and one randomised trial. Three studies on the prognosis of low back pain led to the development of a clinical tool for predicting the onset of chronic low back pain. Based on the results in a large primary care cohort (n=1619) using such a clinical tool has the potential to reduce inappropriate care for low back pain by 40%. A systematic review found high-quality evidence (14 trials, n=4872) that patient education can reduce emotional distress and subsequent health services use. A randomised trial in patients attending primary care for low back pain (n=128) found evidence that professional attire does not influence the credibility of reassurance. The final randomised clinical trial of reassurance targeted to patients with a poor prognosis (n=202) has completed recruitment. Follow-up rates to 6-months in this trial have exceeded 95%.Conclusions: High distress causes patients to consult more often for low back pain. To reduce distress, clinicians should provide structured education, which is effective in the short- and long-term. Dressing formally (in suit/tie) is not likely to improve the effects of reassurance. A new online tool developed out of the work in this thesis has the potential to improve the quality of reassurance and reduce the number of inappropriate interventions provided for low back pain. Targeted reassurance, including enhanced, prognosis-specific education, has the potential to optimise reassurance and possibly prevent chronic pain