Review article
Self-management program for chronic low back pain: A systematic review and meta-analysis

https://doi.org/10.1016/j.pec.2016.07.029Get rights and content

Highlights

  • Trials are searched on self-management program for chronic low back pain.

  • Thirteen randomized controlled trials with fair quality are included.

  • Self-management program is effective in chronic low back pain management.

  • No adverse events are reported.

Abstract

Objective

To determine the effectiveness of self-management programs (SMPs) on chronic low back pain (CLBP).

Methods

A search of randomized controlled trials (RCTs) was performed in Pubmed, Cochrane Library, Web of Science, Elsevier, and CINAHL through June, 2015. Two reviewers selected trials, conducted critical appraisal, and extracted data. Meta analyses were performed.

Results

Thirteen moderate-quality RCTs were included. There were 9 RCTs for immediate post intervention on pain intensity and disability, 5 RCTs for short term, 3 RCTs for intermediate and 4 RCTs for long term. Specifically, the effect sizes (ESs) of SMP on pain intensity were −0.29, −0.20, −0.23, and −0.25 at immediate post-intervention, short-term, intermediate-term, and long-term follow-ups, respectively. The ESs on disability were −0.28, −0.23, −0.19, and −0.19 at immediate post-intervention, short-term, intermediate-term, and long-term follow-ups, respectively.

Conclusion

For CLBP patients, there is moderate-quality evidence that SMP has a moderate effect on pain intensity, and small to moderate effect on disability.

Practice implications

SMP can be regarded as an effective approach for CLBP management. In addition to face-to-face mode, internet-based strategy can also be considered as a useful option to deliver SMP. Theoretically driven programs are preferred.

Introduction

Chronic low back pain (CLBP) is considered as a world-wide concern, and many strategies have been explored. Low back pain (LBP) is defined as “pain occurring in the lumbosacral region with radiation limited to above the knee, without signs of nerve root compromise” [1]. A systematic review has showed that the global prevalence of LBP was 31.0%, and one-year prevalence was 38.0% [2].

Specifically, LBP can be classified by duration as acute (pain lasting less than 6 weeks), sub-chronic (6–12 weeks), or chronic (more than 12 weeks) [3]. A global systematic review has reported that the prevalence of CLBP was linearly correlated with age between 30 and 60, and women generally have a higher prevalence compared with men. Specifically, the individuals aged between 20 and 59 have a CLBP prevalence of 19.6%, and the prevalence of older people is 25.4% [4]. The primary complaints of patients with CLBP are pain and disability, and further consequences, including reduced productivity and high medical cost, are also serious [5], [6]. Institute of Medicine estimated that the direct annual loss due to CLBP was 34 billion dollars in USA [7]. Global Burden of Disease Study 2013 showed that CLBP was one of the leading specific causes of years lived with disability [8].

According to International Association for the Study of Pain [9], “at the chronic level, musculoskeletal pain is typically managed, but not cured.” As one category of musculoskeletal pain conditions, CLBP should be managed with effective, safe and low-cost approaches [10]. What’s more, advances have been achieved in neuroimaging, molecular, and submolecular techniques to treat CLBP, and etiology, mechanism, as well as treatment paradigm of the condition have been reconceptualized [11]. Based on this paradigm change, self-management model has been considered as a promising “treatment package” to treat CLBP [11], [12].

Self-management (SM) has been defined as “the individuals ability to manage the symptoms, treatment, physical and psychological consequences and lifestyle changes inherent in living with a chronic condition” [13]. Specifically, SM model emphasizes the importance of interactive, collaborative care between patient and health care professional rather than one-way, passive care from expert to patient, allowing for patient empowerment [13]. In the model, personal responsibility is encouraged for one’s day-to-day management over the duration of disease [14]. As a collective term for a group of interventions or “education package”, SM model consists of six essential skills, which has been presented in Table 1 [12], [13], [14], [15], [16], [17], [18], [19], [20]. All the six elements emphasize on individual’s responsibility for his/her health management, which is core to self-management.

Many trials have been performed to explore the role of self-management program (SMP) on CLBP; however, the conclusions were inconsistent. Several related systematic reviews have been conducted. By including 21 randomized controlled trials (RCTs), van Tulder et al. found that behavioral treatment, based on the behavioral therapy principle, has a moderate positive effect on pain intensity and small positive effect on generic functional status [21]. In the systematic review of Guzmán et al., intensive multidisciplinary biopsychosocial rehabilitation with functional restoration was reported to have positive effects in alleviating pain and improving function for patients with CLBP [22]. More specifically, Toomey et al. have published a series of reviews to discuss the effectiveness and implementation fidelity of SM interventions to promote SM for people with osteoarthritis and CLBP, with the conclusion that no significant difference of effectiveness was found between SM interventions and usual management, and the overall levels of implementation fidelity were low [23], [24]. Moreover, Keogh et al. [25] concluded that there is insufficient literature on theoretically driven research of SMPs for CLBP. Specifically, the systematic review of Oliveira et al. indicated that SM interventions have small effects on pain and disability for people with LBP [6].

These studies have made important contributions to the clarification of the role of SMP on CLBP. To our knowledge, however, there are four concerns in previous studies. Firstly, some related systematic reviews did not focus on self-management program as a particular intervention. Secondly, none of the published systematic reviews have considered what are primary outcomes and secondary outcomes in each individual trial. It is considered to be inappropriate to compare primary and secondary outcomes in a review because different choice of the primary outcomes may reflect different contents of intervention [26]. Thirdly, the systematic review of Oliveira et al. [6] focused on SM interventions (not SM education package) in patients with LBP, regardless of pain durations. There was no specific conclusion of the role of SMP on CLBP. Fourthly, in a systematic review we have published in 2011, it was found that there was then insufficient evidence to illustrate the effectiveness of SMPs on for CLBP patients on pain intensity and disability [5]. It is essential to integrate subsequently published trials into systematic review to update the conclusion.

Considering these concerns, we sought to quantitatively assess the effect of SMP on CLBP using systematic review and meta analysis. Our research question is “What is the effectiveness of SMP on patients with CLBP in terms of pain intensity and disability?”.

Section snippets

Literature search

A search was performed in five English databases: Pubmed, Cochrane Library, Web of Science, Elsevier (ScienceDirect), and CINAHL (Cumulative Index to Nursing and Allied Health Literature), which have been checked from their inception up to June, 2015. We used following MeSH (medical subject heading) terms and text words: (“back pain” OR “chronic back pain” OR “low back pain” OR “lower back pain” OR “chronic low back pain”) AND (“self-management” OR “self-care” OR “patient education”) AND

Search process

Search process was presented in Fig. 1. The search of databases resulted in 1,300 potential articles. Excluded on duplicates, titles, and abstracts were 1,176 articles, leaving 124 articles requested for full texts. With the full text of one study not found, 123 articles with full texts were available. These retrieved articles were subsequently read and evaluated according to the inclusion criteria, with 111 articles excluded at this stage. Meanwhile, another one article was found based on the

Main findings

This study shows that SMP probably has a beneficial effect in improving pain intensity and disability for CLBP patients. Specifically, the SMP has a moderate, significant effect in reducing pain intensity across the first year. For disability, there is a moderate, significant effect in improving the symptom at immediate post-intervention and short-term follow-up; while intermediate-term and long-term effects (within the first year) are small but significant. Our findings are generally

Conflict of interest

The authors have no conflict of interest.

Ethical approval

Not required.

I confirm that the patient/person(s) have read this manuscript and given their permission for it to be published in PEC.

Funding

This work was supported by grants from Youth Fund of Humanities and Social Science Research Foundation, Ministry of Education, China, 2014 (Grant Name: Study on the self-management model in patients with chronic low back pain based on Self-Efficacy Model; Grant No.14YJCZH024), Directing Program of Philosophy and Social Science Research Projects in Institutions of Higher Education, Jiangsu Province, 2014 (Grant Name: Study on the influencing factors of quality of life of patients with chronic

Acknowledgment

We wish to thank the three anonymous reviewers for their valuable and helpful comments and suggestions.

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