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Introduction

Low back pain (LBP) is one of the most common complaints of adults in the Western world. It’s one of the main complaints that doctors see in their offices and clinics, and it contributes to large numbers of lost workdays and lost productivity.

It would seem that with all the people who have LBP, doctors would have come to an agreement as to the best ways to treat it. However, because there are so many variations to back pain, from the people themselves, to what part of their back is injured, how it is injured, and how the injury occurred, there isn’t yet a definite, well-understood set of guidelines to help doctors decide what to do and in what order.

There have been many attempts at developing guidelines. They have been taught, published, presented, and discussed. However, none have been successful. Recently, researchers looked at the previous efforts and came up with a new set of guidelines to diagnose and improve the quality of care for patients who live with low back pain (LBP).

The experts developing the guidelines understood that in order for physicians to change their practice and treatment of patients with LBP effectively with any type of guidelines, they had to get their information across. The traditional way is to just publish and send out the guidelines to all physicians through the mail or to invite them to attend lectures. However, educational practices have found that to be effective, there has to be a combination of factors to get the information across. This means that there have to be at least two parts to the teaching process, such as education outreach to the physicians, reminders of the guidelines, and interactive education sessions, that allow the physicians to participate as they learn.

Guidelines for measuring patient outcomes

Guidelines for patient care should include how to report patient outcomes, the results of the treatments. Otherwise, there is no way of knowing how effective the guidelines actually are. Few guidelines make this possible because although the idea of treatment is to relieve patient’s pain, prevent the development of chronic pain, and improve their ability to function in their every day activities, measuring this success (or failure) isn’t always easy.
One good example of how this follow-up for patient outcome has been successful is in Germany. Specially trained practice nurses follow patients with diabetes or depression. Using a model of care, the nurses are able to assess the patients and their progress. This model of care gave the researchers in this study the basis for their research.

Teaching the new guidelines

In Germany, the researchers worked on a trial that looked at how general practice doctors were taught new guidelines for treating patients with lower back pain. They also wanted to compare these physicians with those who received the same education but were also provided with training for their nurses who would also work with the patients by providing motivational counseling. There was a third group of physicians who were sent the new guidelines by mail, as is often done, but they received no further training and their nurses didn’t either.

Special training groups

The two groups who were receiving the special training were taught the guidelines using basic modules for studying and pocket guides that they could consult when they needed. They were also given detailed flyers to give their patients. This allowed the patients some control, allowing them to learn what was going to be done and what they should be doing. The physicians also went to three seminars where they took part in exercises to learn various techniques.

During the first session, they learned:

• Diagnosing and triage
• Identifying the red flags – important, urgent

During the second session, they learned:

• Early identification of yellow flags or things they should be looking for
• Managing patients with chronic pain

During the third and last session, they learned:

• Informing and advising patients
• Discussion of barriers to treatment and personal experiences
• Information about the local resources for patients with pain, ranging from self-help groups to health insurers, were provided to the physicians so they would have this information to pass on to their patients

Special training group with trained nurses

Physicians should be encouraged to get the extra training for their nurses in motivational counseling and to learn how to increase their skills and motivate patients with LBP. Specially designed brochures on motivation to help patients make necessary changes to their behavior in order to manage their pain are also helpful.

Studying effect of the educational approaches

Patients should be asked to fill out two sets of questionnaires – one at home and one while waiting in the office.
How the patients function both at the beginning and after six months can be measured by a test called the Hannover Functional Ability Questionnaire for Measuring Back Pain-Related Limitations. If a patient is functioning normally, they will usually score between 80 and 100 percent on this test. Patients functioning only moderately score around 70 percent and if a patient scores below 60 percent, their ability to function is severely limited.

Patients should be asked about their activity levels prior to their first appointment as well as how many days they had pain and how much work they've had to miss from the beginning of their problem and at six months follow-up. Physical activity, usually a good indicator of the severity of back pain, should be measured with the Freiburg Questionnaire on Physical Activity. Finally, the patients should also be asked about their quality of life. This can be measured with a test called the Fear Avoidance Beliefs Questionnaire and the Euro-qol questionnaire.

Pain relief results

Research has shown that the trained physicians and nurses reported less back pain at six months. At twelve months, it’s been shown that patients report less back pain. Research also showed that where the physicians were specially trained, patients missed fewer days of work and fewer of the patients complained of permanent pain. When the nurses are trained in motivational counseling, results are better for the patients.

Conclusion

Good guidelines for treating medical problems can improve the long-term outcome for many patients. Extra training for nurses in motivational counseling for patients with LBP has shown to be effective.