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Question Can a back pain self management group intervention led by trained lay people increase self care confidence and reduce patient worries, activity limitations, and pain?
Design
Randomised, single blind (outcome assessor), controlled trial with follow up at 3, 6, and 12 months.
Setting
Primary care setting in Puget Sound, Washington state, USA.
Patients
255 patients aged 25−70 years (mean age 50 y, 62% women) who were seen in a primary care setting for back pain or strain, a disc disorder, or sciatica and had been enrolled in a health maintenance organisation for ≥1 year volunteered to participate in the study. Patients who were being considered for surgery or planning to withdraw their enrolment from the health maintenance organisation were excluded. Follow up at 12 months was 85%.
Intervention
129 patients were allocated to the back pain self management group, which included 4 sessions of problem solving techniques and development of an action plan for back pain self management and encouragement for active self care. Group sessions were highly structured, 2 hours in duration, led by 2 trained volunteer lay people who had recurrent or chronic back pain, and supplemented with educational materials (books and videos). 126 patients were allocated to the usual care group and were given a book on back pain care.
Main outcome measures
Attitudes toward back pain self care (Self Care Orientation Scale), back pain worries (global worry rating), limitation of activities because of pain (Roland Disability Questionnaire), pain intensity and interference, and mental health (Short-Form 36 Mental Health Inventory).
Main results
Analysis was by intention to treat. The self management group had greater confidence in back pain self care than the usual care group at 6 months (Self Care Orientation Scale scores 3.22 v 2.96, p=0.03) but not 12 months (3.24 v 3.04, p=0.10); reduced back pain worries at 6 months (global worry ratings 2.97 v 4.28, p=0.01) and 12 months (2.63 v 3.83, p=0.01); and reduced activity limitations at 6 months (Roland Disability Questionnaire scores 5.83 v 7.23, p=0.007) but not 12 months (5.75 v 6.75, p=0.09). At 6 months, more patients in the self management group had a ≥50% reduction in Roland Disability Questionnaire scores compared with patients in the usual care group (48% v 33%, p=0.02). No differences existed between groups for average pain intensity or interference rating, or mental health status at 6 or 12 months.
Conclusion
An educational back pain self management group intervention led by trained lay people reduced patient back pain worries and activity limitations and increased self care confidence at 6 months, but did not reduce pain intensity or interference.
Commentary
Increasingly, research findings are showing the benefits of the resumption of normal activities as a means of improving outcomes for people with acute low back pain.1 Few studies, however, have focused on methods of educating people with back pain about their condition and how to improve functional ability.2
This study by Von Korff et al examined a primary care self management programme delivered by trained lay leaders for people with back pain. Study strengths include the use of interviewers who, to avoid bias, were unaware of the group to which patients had been allocated and the presentation of standardised information to each of the back pain self management groups to ensure uniformity. The positive outcomes shown early in this study are consistent with those shown in other lay leader programmes, such as the Arthritis Self Management Program (ASMP).3 Caution should be used in generalising the results. The sample consisted of volunteers who were predominantly well educated, white, and employed; further studies in different populations are needed to determine whether similar study findings occur. In addition, some of the positive results shown at 6 months had disappeared by 12 months. Although pain reduction was not an aim of the programme, refining the programme to reduce pain intensity (such as in the ASMP) might be considered.
This study suggests that self help programmes initiated by lay leaders for people with back pain could provide a useful alternative to multidisciplinary pain programmes, which are often limited by cost, geographic location, and referral processes. Nurses working in primary healthcare settings would be the ideal health providers to initiate and support the organisation of such programmes in the community.
Footnotes
Sources of funding: National Institutes of Health; The Boeing Company; and The Group Health Foundation.
For correspondence: Michael R Von Korff, Center for Health Studies, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA. Fax +1 206 287 2871.