Patients with back pain want information and advice about their problem. Indeed, once we exclude serious disease, that may be their main need. Deyo & Diehl (1986) showed that good communication and explanation lead to greater patient satisfaction with care.

All clinical guidelines recommend that we should give adequate information and after all serious medical pathology has been ruled out, you need to be reassured.

The Swiss guidelines add that reassurance depends on providing adequate information. It can be hard to get the message right. For example, simply saying that “I can’t find anything wrong” may imply that you are not sure and that can make you worry more! The European guidelines (www.backpaineurope.org) suggest that reassurance depends on:
  • Doctors need to acknowledge that your pain is real
  • We need to provide you with empathy and support
  • Doctors need to provide as much explanation as you need, in terms you can understand
  • We need to provide positive messages; avoiding negative messages.

Core items of adequate information should be:
  • There is no underlying serious pathology.
  • You do not need X-rays or other special investigations.
  • The prognosis is good.
  • You can and should stay active and get on with your life, despite the pain.

POSITIVE MESSAGES: “THE GOOD NEWS”
Patients get information from many sources, but health professionals are the most authoritative and potentially one of the most important. Doctors must always remember that our impact can be positive or negative. We need to think carefully about what we say to patients and how we say it.

Certain key issues need further consideration.

Diagnostic labels
What’s in a name? Labels are important ( Cedraschi et al 1998 , Bogduk 2000 , Hamonet et al 2000 ). Diagnosis is “the process of determining the nature of a disorder.” A good label shows that the doctor is taking the patient seriously and accepts the complaints are real. But names are also a kind of shorthand that encapsulate a set of ideas and beliefs. So the diagnoses we attach to back pain help to determine how we think about it and what we do about it. That is true for patients, for health professionals, and for society.

The dynasty of the disk was built on the diagnosis of “disk injury.” It was so popular because the idea is so simple. “Arthritis,” “degenerative disk disease,” and “wear and tear” are equally seductive. These labels offer a simple, mechanical explanation that patients can understand. They can even see it on their own X-ray or scan, so that proves it! These beliefs may then become fixed and difficult to change. The fact that these diagnoses are irrelevant in most patients with non-specific back pain is a minor inconvenience. More important, they carry very negative messages ( Abenhaim et al 1995, Deyo & Phillips 1996, Hamonet et al 2000 ) about permanent damage, fear of re-injury, and the need to rest or get fixed. They create beliefs and expectations about treatment that can be quite unrealistic. So the very diagnosis may become an obstacle to someone’s recovery.

We need an equally simple, plausible, and acceptable diagnosis that fits modern understanding of back pain and supports modern ideas of management. It should carry the messages that this is ordinary backache, it is not any serious disease, the outlook is good, and it is not disabling. We want a name that is medically accurate, but at the same time understandable and satisfactory to patients. It must “legitimize” the pain (Borkan et al 1995 , Stone et al 2002 ).

Non-specific or idiopathic low back pain are probably most honest and accurate. They certainly serve to remind health professionals of the limits to our knowledge. But they are really only diagnoses of exclusion.

And these terms are meaningless and unsatisfactory to patients. Deyo & Phillips (1996) described it as “uncomplicated back pain” but that is not really much better. It only gives the negative side, and does not carry any positive messages. It is also somehow just a lay description rather than a medical diagnosis. We previously called it “simple” backache to reassure patients there was no damage to the nerves or any more serious spinal pathology. However, some critics felt that was too dismissive. They argued that it failed to acknowledge that backache can be very painful and disabling, and is not always “simple” to treat. It can be described it as “ordinary backache” or “the kind of back pain that everyone gets.” We mean that to include both everyday aches and pains and acute attacks or spells. Most people seem to understand that. Others have described it as “common” back pain.

We may try to dodge these difficulties by talking about “sprains and strains.” This sounds medical. We mean, rather vaguely, that it is a simple soft-tissue problem and there is no serious damage. We realize that we cannot identify any precise anatomic damage, but we really do not face up to the common lack of evidence of any injury. If we redefine “strain” in terms of dysfunction, this may be reasonably accurate.

Perhaps the old term lumbago met the need best. It was medically accurate, if only because of its lack of precision. It offered a respectable medical label, even if it really only translated as pain in the lower back. Everyone found it satisfactory and thought they knew what it meant, even if they all understood it differently and not always accurately. We need a modern equivalent of lumbago.

People seem to accept the term “muscular” back pain. We agree there is rarely evidence of muscular injury, but musculoskeletal dysfunction appears the most likely explanation of non-specific back pain. So “muscular” back pain may be reasonably accurate, even if it is an oversimplification. For those who wish a more technical term, we may use musculoskeletal dysfunction. For those who wish more detail, we may launch into the description of the cause and mechanism of back pain. This certainly carries the messages we want. It means there is no serious disease or damage, and reassures that this is a common problem that should resolve. It is simple and understandable. It leads nicely into management by getting active and restoring function.

Stone et al (2002) provided support for this approach from a neurology clinic in Edinburgh. They asked patients how they understood various explanations for leg weakness with negative tests. These patients rejected labels that sounded “psychological.” One of the most acceptable was “functional weakness.” Doctors and therapists often use functional as a code-word for psychological or psychosomatic problems, but patients do not understand it that way. Patients do seem to understand the idea of disturbed function and dysfunction. The “number needed to offend” in this study was nine: eight out of nine patients found “functional” an acceptable label.

Along with red and yellow flags, perhaps we also need a “green flag” to reassure patients that it is safe to resume normal activities. Or perhaps we already have it. Nothing could convey the message more dramatically than the complete reversal of how we manage back pain. Traditional rest, bed rest, and even hospitalization carried very negative messages about a serious, disabling condition. Advice to stay active and continue ordinary activities as normally as possible because that is the way to get better, faster, carries a very different set of messages about the problem.

“The challenge remains to find a new term: one that is palatable to doctors, satisfying to patients, and which not only means there is nothing seriously wrong, but also conveys the message that the patient has no grounds for fear, and can expect recovery with straightforward, even minimal, management” (Bogduk 2000 ). That is still true today. We do not have a good, agreed label for back pain.

Moreover, words and usage vary in different places and settings. At the end of the day, I must use clinical judgment. I need to give you an explanation that you are comfortable with. I have to judge what you can understand and accept, and adapt the message to suit you as an individual.

The cause of non-specific back pain
You want to understand your back pain, because that forms the basis for how you deal with it. This is more than just a diagnosis. Modern patients want to know something about the cause(s) and mechanism(s).
  • What is causing my pain?
  • Why is it not getting better? (Or, what is prolonging my pain?)
  • (And the implication is – What can I do about it?)

Once again, we need an explanation that is simple, plausible, and acceptable. It should fit modern understanding of the physical basis of back pain, and support modern ideas of management.

An explanation for patients
1. Back pain is a physical problem. (If required: psychosocial factors may influence how we react to pain and how it affects us, but they do not cause the pain. Back pain is not a psychological problem.) Back pain starts with a physical problem in the back.

2. Back pain is a mechanical problem. It is a movement disorder or an activity-related disorder of the musculoskeletal system. (It is a disturbance of function rather than structural damage or disease. It generally affects the back as a whole rather than one anatomic site.)

3. Back pain is a common bodily symptom, like headache. We all get back aches and pains, and most of us get some more acute attacks or spells at some time in our lives. Back pain is not a disease. Most back pain is not a signal of any serious disease or damage to the back.

4. Most back pain is simply a symptom of physical dysfunction or malfunction. Pain and (dys)function are intimately related to each other. Your back is “not working properly” or as it should. It is “out of condition,” like a car engine that is out of tune. Your posture may be poor. Your back is not moving as it should, but may be stiff or “seized up.” Your muscles are not working as they should, but may be weak and wasted and tire easily. There may be loss of strength and endurance and coordination. This leads to fear and guarded movements. The small joints and other working parts “seize up.” Changes in the nervous system and psychological changes can lead to increased sensitivity to pain. Loss of fitness makes it harder to rehabilitate. This all leads to a vicious circle. The whole pattern of painful dysfunction is the core of the problem and becomes self-perpetuating. It is much more important than any original, long-gone, trigger for the pain.

5. This has obvious implications for management. The original cause or site of the pain really does not matter much any more. Whatever the original trigger, pain will continue as long as there is dysfunction. Recovery and relief of pain depend on getting your back working again and restoring normal function. The answer is to get moving and get fit again. This leads to a sports medicine analogy, and sports medicine principles of rehabilitation. It also depends very much on you taking responsibility for what you do, rather than depending on a doctor or therapist to “fix it.”

The outlook is good
Von Korff (1999) asked primary care patients in a US health maintenance organization about their goals when they saw the doctor. He found that patients wanted to understand:

  • the likely course of their back pain and associated activity limitations
  • how to manage their back pain
  • how to return to usual activities quickly
  • how to minimize the frequency and severity of recurrences.

Patients ranked these concerns even higher than seeking a cause for their back pain or a diagnosis.

Here, we need to strike a balance between honesty and optimism. The harsh reality is that back pain is often a recurrent or fluctuating problem over long periods of our lives. And there is no magic answer . It is dishonest to pretend anything else, and false reassurance may come back to haunt you.

But the epidemiology is not all doom and gloom. We should present its bright side. Back pain is very common, and most people manage to cope with it pretty well most of the time. Most acute attacks settle quite quickly, at least enough to get back to most ordinary activities and get on with your life. The risk of chronic, intractable pain and long-term incapacity is very low: a few percent. So your odds are very good. Even if there is no magic cure, I have treatments that can help to relieve or control the pain. And there is a lot you can do to help yourself. So even if you might continue to have some back pain at times, the good news is that you should be able to deal with it, with a little bit of help when you need it.

EDUCATIONAL MATERIAL
One-to-one communication between doctor or therapist and patient is the most important method of providing information and advice. However, we can supplement this with printed material. Leaflets and booklets on their own have a limited effect. They are simply an aid to reinforce information and advice from my office.

There is a profusion of material for patients with back pain: hundreds of leaflets and pamphlets and booklets, and dozens of books. And there is now an enormous range of websites ( Li et al 2001, Butler & Foster 2003 ). Potentially, this could play a useful role in helping you to learn about your condition and how best to manage it. Unfortunately, the content is of very variable quality. It often comes from vested interests, which are not always obvious. A lot of it is blatant or disguised advertising. Even professional society sites are often promotional. Much of the information and advice is not evidence-based and does not conform to current guidelines Some of it is downright wrong and harmful – for example, about bed rest and exercise. You may wish to search the internet yourself to see what is currently available. The National Institutes of Health (NIH) guideline website (www.guide line.gov) now lists about 40 sites about back pain (www.nlm.nih.gov/medlineplus/backpain.html). These have been screened by NIH though they do not say what criteria they used. Yet these sites still offer the same mish-mash of information. If you do use the internet for advice, please let me review any sites that you are basing your advice on. And remember that internet sites and material can change very rapidly. That is why we do not recommend any sites, because they might soon become outdated.

Leaflets and booklets
There are two completely different types of educational material: traditional biomedical education and modern biopsychosocial information and advice ( Burton & Waddell 2002 ). These have very different content and goals. The traditional approach was factual education. It imparted biomedical information and provided instructions about physical activities and treatment. From a psychosocial perspective, it often gave negative messages with damaging effects on patients’ beliefs and behaviors (Deyo & Phillips 1996, Hamonet et al 2000). The modern approach tries to prevent the development of chronic pain and disability by addressing these very issues. Its main focus is on beliefs and behavior. It promotes self-help, builds confidence, and reduces unnecessary worry (Burton & Main 2000 ). Turner (1996) was one of the first to make this distinction. She reviewed earlier studies and suggested that traditional back schools had little long-term effect. However, she suggested that educational and behavioral interventions that activated patients and encouraged active management were more promising.

Traditional biomedical education
The vast majority of the available material is based on traditional ideas about spinal disorders and medical treatment or physical therapy. More recent material usually gives some modern, evidence-based information, e.g., the lack of serious damage; no indication for X-rays; avoid bed rest and stay active; good prognosis. However, that is often buried in the overwhelming biomedical thrust. The possible impact on people’s beliefs or behavior is often ignored.

There is very little evidence on the effectiveness of that kind of material (Turner 1996, Van Tulder et al 2000, Burton & Waddell 2002 ).

Cherkin et al (1996) compared different methods of giving information to patients with back pain in a US health maintenance organization. Patients received a booklet alone, or a 15-minute session and follow-up phone call from a primary care nurse (plus the booklet), or usual care. They wrote a new booklet for the trial: Back in Action – a guide to understanding your low back pain and learning what you can do about it. It was based on current scientific knowledge and guidelines. It addressed patients’ concerns about the cause, the good prognosis, actions to aid recovery, and the value of return to normal activities as soon as possible. However, the presentation and content still followed a conventional biomedical pattern. The booklet started with two pages of anatomy. Then there was information about pathology, investigation and referral, therapy options, and back exercises. The nurse-led information gave greater short-term patient satisfaction and perceived knowledge. Those who received the booklet alone showed no effect. There was no difference between the three groups in worry, symptoms, physical function, or health care use.

Cherkin et al (1998) used the same booklet for the control group in a randomized controlled trial (RCT) of McKenzie physical therapy and chiropractic. Both physical therapy and chiropractic produced greater improvement in self-reported symptoms and disability, compared with the booklet alone.

Little et al (2001) carried out an RCT in UK patients attending their family doctor with back pain. Four groups received the leaflet alone, verbal advice on exercise from the doctor, both, or neither. All patients got advice to keep as mobile as possible, to minimize bed rest, and take simple painkillers. The leaflet gave rather mixed messages. There was traditional biomedical information on anatomy and the physical causes of back pain. (Though that was not all evidence-based, e.g., sitting was given as “a major cause of back pain.”) Modern messages included the strength of the spine, the limited role of X-rays, and the good prognosis. The major focus was on practical hints about how to perform activities of daily living. There was advice to minimize bed rest, keep mobile, and progressively increase activity. However, there was also advice to take “great care” with bending, sitting, and lifting. There was mild encouragement to return to work even with some symptoms. Roberts et al (2002) showed that patients did learn and use some of the practical hints. Little et al (2001) showed that either the leaflet or advice from the doctor gave modest improvement in self-reported pain and function at 1 week, though that disappeared by 3 weeks. The combination of both verbal advice and the leaflet was less effective. This suggests that verbal and written advice must be closely matched, or patients are likely to become confused.

Biopsychosocial information and advice
As traditional clinical management of back pain failed, it is hardly surprising that traditional educational material was also ineffective. If regular medicine is going to change clinical management, they must also change patient information and advice. It must be in line with modern understanding of back pain and disability. It should be evidence-based and fit modern clinical guidelines. Even more important, it should be directed to psychosocial just as much as biologic issues. The impact on people’s beliefs and behavior is crucial. Indeed, that appears to be more important than any likely therapeutic benefit from the advice given.

Roland & Dixon (1989) wrote the first Back Book. This was arguably the first psychosocial booklet for patients, even if what it tried to do was limited and the approach quite primitive. Not surprising, it could not escape completely from the conventional biomedical format of the time. There was a brief account of the anatomy of back pain, advice to rest, practical advice on daily activities, and back-specific exercises.

However, in some ways it was quite innovative. It presented the information in a very simple and reader-friendly way. It stressed that back pain is rarely due to any serious disease More important, the whole emphasis of the booklet was on self-care, with the subliminal message to stay away from doctors. The conscious intent of the booklet to change patients’ thinking and behavior was quite different from any previous material. Roland & Dixon tested this booklet in a small RCT of primary care patients with acute or chronic low back pain. Patients who received the booklet made fewer visits to the general practitioner during the next year. There was no difference in sickness absence.

Symonds et al (1995) developed the first true psychosocial leaflet: Back Pain – don’t suffer needlessly. It was based on the fear-avoidance model and aimed to shift passive beliefs and attitudes. It used blunt, positive messages written in simple language: “Back pain is not usually a serious problem. Continued back pain is not inevitable. Most people can take care of it themselves.” It gave reassurance that activity and work do not hinder recovery and encouraged early return to ordinary activities. It used a dramatic contrast between the “coper” and the “avoider.” Copers take a positive approach, cope with the pain, and get on with their lives. Avoiders take a negative approach, rest a lot, and wait for the pain to get better or someone to fix it for them. Symonds et al gave this leaflet to workers in one factory, and a traditional biomedical leaflet to those in another factory. Workers who got the new leaflet showed a positive shift in beliefs about the inevitability of consequences from back pain. Those who got the traditional leaflet showed a negative shift. The factory that got the new leaflet had a marked fall in days of sickness absence and spells of extended absence.

The Back Book
The Back Book    (Roland et al 1996 ) accompanies the UK RCGP (1996) guidelines. At the time it was written, it was innovative and challenged traditional teaching and advice about how to deal with back pain. The authors had difficulty getting any publisher to produce it, and released it with some trepidation. It is now the established market leader and has been translated into many languages. Building on that success, in the second edition (Roland et al 2002 ) they have been more confident about some of the contentious issues. It spells out the risks of chronic pain and disability, and tries to get the patient to address obstacles to recovery. It also deals with work issues. The authors have recently published an American edition (Bigos et al 2002 ). They have also made a video Get Back Active that has even won a film award! This supplements The Back Book or offers an alternative presentation for those who wish it. It is suitable for use in a class, in occupational health, or in a clinic.

They developed The Back Book from the original Back Book by Roland & Dixon (1989) and the industrial leaflet by Symonds et al (1995). It is strictly evidence-based and in line with current concepts and guidelines. They made a conscious decision to reduce the biomedical content, and to focus on shifting beliefs and behavior. They put a great deal of effort into making it easy to read. The messages are sharply focused and uncompromising: the spine is strong; back pain is not a disease; the natural history is benign; rest is bad, activity is good; self-coping is the answer, and passive treatment from doctors is not. They deliberately tried to “de-medicalize” the problem.

Burton et al (1996) made a pilot study of The Back Book in 124 patients attending an osteopath or a community physical therapy department. Almost all the patients found the booklet very easy to read, interesting, believable, and helpful. They said they would recommend it to family or friends. Despite concern from some health professionals, neither workers nor primary care patients took offense at the idea of copers and avoiders. They got the main messages.

Burton et al (1999) then tested The Back Book in an RCT in primary care. Patients received either The Back Book or a traditional biomedical booklet in a sealed envelope at the end of the consultation. There was no other intervention, and apart from that, all patients received “usual care.” Patients who received The Back Book showed a substantial improvement in beliefs about the inevitability of back problems at 2 weeks, and this was maintained at 1 year. Patients with high fear-avoidance beliefs showed improvement in their beliefs about physical activity at 2 weeks, and this was followed by improvement in self-reported disability at 3 months. There was no effect on pain. There were insufficient patients off work to show any effect on return to work.

Other biopsychosocial material
Several other educational programs have used similar psychosocial messages but presented them in different ways.

Linton & Andersson (2000) in Sweden carried out an RCT of three forms of information. Their aim was to prevent long-term disability in patients with acute or subacute low back pain. The main intervention was a cognitive-behavioral program of six 2-hour group sessions. The goals were to reassure and activate patients, correct dysfunctional beliefs, and promote coping. Patients in the two control groups received either a Swedish translation of the Symonds leaflet, or a package of more conventional biomedical material.

All patients received usual care. All three groups showed improvement in pain, fear avoidance, and catastrophizing. The cognitive-behavioral group had a ninefold reduction in the risk of >30 days’ sickness absence in the next 6 months. They also used less health care. Clearly, the cognitive-behavioral intervention was by far the most effective. However, suitable pamphlets might be a cheap and cost-effective alternative for some patients at lower risk.

There is one other RCT of a biopsychosocial leaflet that is instructive because it had negative results. Hazard et al (2000) wrote and tested a leaflet Good News About Low Back Pain. They included ideas from various recent guidelines and educational materials. The main aim was to encourage self-care, staying active, and early return to work. This was an A4-size leaflet similar in style to Symonds et al (1995), with bullet points and “danger” signs. It was a biopsychosocial leaflet and the advice and messages were to some extent comparable to The Back Book. However, there was less overt attempt to challenge and change dysfunctional beliefs. The leaflet was mailed to workers who filed claims for back injuries: they and the controls otherwise received usual care. Unfortunately, workers perceived this coming from the Workers’ Compensation Authority, and 56% either did not reply or refused to take part in the trial. The pamphlet made no difference to days lost from work over the next 6 months. Most such educational material is designed for use in primary health care. The results of this trial suggest that the presentation and setting are also important.

Von Korff et al (1998) reported an RCT of self-management, group education for US primary care patients with subacute back pain. Each group met for four sessions and was led by a lay person. It applied problem-solving techniques to the self-management of back pain. This was supplemented by a book and video giving similar messages to The Back Book but in much greater detail. The educational program reduced worry and improved confidence. These patients also had more improvement in self-reported disability on the Roland score at 6 and 12 months.

The same group carried out a second RCT of a similar intervention led by a clinical psychologist (Moore et al 2000 ). Patients had two group sessions supplemented by a book and videos. It was designed to provide accurate information about back pain, reduce fears and worries, promote self-care, develop personal action plans, and improve functional outcomes. This reduced back-related worries and fear-avoidance beliefs. It also produced modest but significant improvements in pain and functional outcomes at 3–12 months. Overall, the results were similar to the earlier study but tended to occur faster.

Buchbinder et al (2001a ,b) described the first public education program for back pain in Victoria, Australia. Neighboring New South Wales acted as a control. The Victorian Workcover Authority ran a multimedia public education campaign called Back Pain: Don’t Take it Lying Down. It lasted about 2 years.

It was based on the messages of The Back Book, and promoted the benefits of staying active, avoiding prolonged rest, and staying at work. Prime-time TV adverts featured medical experts, and national sporting and television personalities. Radio and printed advertisements, billboards, posters, seminars, workplace visits, and publicity articles supported the messages. The Back Book was translated into 11 languages and distributed widely. All doctors in Victoria received evidence-based guidelines giving the same messages.

Surveys of doctor and population samples over 2 years measured the impact in Victoria and New South Wales. The education campaign produced a positive shift in population beliefs about back pain. Doctors also showed a shift to more active management. The number of workers’ compensation claims, days lost, and medical costs all fell slightly. There was no change in any of these outcomes in New South Wales over the same period. These effects were relatively modest, but no one had ever managed to produce such a shift at a population level. And in view of the massive impact of back pain, even modest improvements were well worthwhile. The whole campaign was cost-effective.

Working Backs Scotland is a national educational campaign that has been running since October 2000. It is a true national partnership, involving all the health professions who treat back pain, national organizations, employers, unions, and patients. It is led by the Health Education Board for Scotland (HEBS), which is an international leader in the field. It is “badged” to HEBS and the Health and Safety Executive, both of whom enjoy wide public recognition and trust. Its aims are:
• to share new understanding about the management of back pain
• to make sure everyone gets consistent advice
• to get employers, employees, and health practitioners to work together.

They did not try to reinvent the wheel, but built on the RCGP (1999) and the UK occupational health guidelines ( Carter & Birrell 2000 ) and The Back Book. They then devoted their efforts to presenting the main messages in a simple, user-friendly way:
• Stay active.
• Try simple pain relief.
• And, if you need it, get advice.

They developed slogans, single-page leaflets for each user, and posters. They put together an information pack containing all our material and background resources (You can download everything from www.workingbacksscotland.com). The core of the campaign was commercial radio adverts – played 1777 times on 15 stations in the first 4 weeks, and reaching 60% of adults. The got extensive (free!) press and TV news cover. They distributed 35000 packs to every health professional treating back pain in Scotland. They got 120000 hits on their website in the first few months. Since that time they have had periodic “booster” campaigns. And they developed additional resources for family doctors, occupational health, and orthopedic surgeons. They are still struggling to develop material and to get through to small and medium-sized enterprises, but that is a common problem for any such campaign.

CONCLUSIONS
  • Information and advice from doctors and therapists can have a powerful positive or negative impact on a person’s beliefs, behaviors, clinical outcomes, and sickness absence.
  • Carefully selected educational material can produce a positive shift in beliefs and potentially improve clinical outcomes and sickness absence.
  • The material should be evidence-based and in line with modern guidelines.
  • A focus on shifting beliefs and behavior appears to be more effective than attempts to impart biomedical knowledge.
  • The format, presentation, and setting are important.
  • Printed material on its own is likely to have modest impact. It is designed to supplement information and advice from doctors and therapists. All health professionals and any educational material should provide consistent messages. Ideally, this should be integrated into a cohesive educational package.

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