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- PATIENTS AND METHODS
Low back pain is highly prevalent in the United States: 80–90% of adults experience low back pain during their lifetimes and 50% report symptoms during any given year (1–3). It is the leading cause of visits to orthopedic surgeons, neurosurgeons, occupational medicine physicians, and osteopathic physicians, and is second only to upper respiratory infections as the reason for visits to primary care physicians (PCP) (2). It has been estimated that the direct medical costs of care for low back pain exceeded $24 billion in 1994; if one considers indirect costs (e.g., disability, lost productivity), this estimate may reach between $50 and $100 billion annually (3–4).
Acute low back pain (ALBP), defined as symptoms lasting less than 3 months, accounts for more than 90% of all back pain and nearly half of the costs (1). Current treatment recommendations include patient education, nonsteroidal anti-inflammatory drugs, a gradual return to normal activities (rather than prolonged bed rest), and low-stress aerobic exercise (1). Because ALBP tends to be recurrent, with unpredictable exacerbations and remissions of symptoms, implementation of these recommendations may be facilitated by programs that enhance self efficacy. Self efficacy is the perception of ability to produce a desired outcome (5) and is a strong predictor of health behavior (6–8), including self management (9). Increasing self efficacy requires not only defining specific desired behaviors, but more importantly, enhancing patient's motivation and confidence to implement strategies required to manage their ALBP, thereby improving health-related behaviors and health status (10–12). Emphasizing self efficacy is central to the Arthritis Self-Management Program (ASMP) (13), a program that has consistently demonstrated effectiveness in improving health outcomes and reducing health care utilization among patients with various rheumatic and chronic conditions (13–15), including low back pain (16).
The ASMP has not been evaluated among socioeconomically vulnerable patients with ALBP. This is unfortunate, given that these individuals shoulder a disproportionate burden of disability and morbidity from musculoskeletal conditions and comorbid medical conditions (17–19). Indeed, in a recent assessment of health concerns and needs among randomly selected congregants of 5 urban African American churches, back pain was reported among 41% as a pressing health issue (20). Moreover, data from the National Health Interview Survey indicated that in comparison to whites, African American men and women in the United States reported losing more workdays for greater lengths of time because of low back pain (21).
Despite the prevalence of back pain, there is a dearth of research on strategies to reduce back pain disability in this population. Studies involving other health conditions such as arthritis, asthma, and weight loss have targeted minorities (22–24) and inner city patients (25). These studies incorporated church-based interventions and involved family members. The support system of the church and family may reduce some of the methodologic barriers of conducting interventions among the economically vulnerable. These barriers may include patient relocation without further contact, group class attendance (26), and attrition due to health problems or caregiver responsibilities (27).
A recent qualitative analysis of influences on diabetes self management among southern African American women suggested that church-based and family-centered interventions are the most appropriate to promote disease self management (28). Thus, based on the ASMP, we developed a self-management program for inner city patients with ALBP. Initially, we designed the intervention as a church-based program for primary care patients and their families. After piloting the intervention, patients indicated that they preferred to meet at the local neighborhood primary care health centers. We then evaluated this program among primary care patients using a randomized, controlled trial. We present the short-term (4-month) effects of our program. Our primary outcomes were functional status and patient satisfaction. Secondary outcomes were self efficacy, self-management practices, social support, and fear of movement.
- Top of page
- PATIENTS AND METHODS
This randomized trial evaluated the short-term (i.e., 4-month) effects of a self-management program designed for low income, inner city primary care patients with ALBP. The short-term outcomes indicated that the program was effective among these socioeconomically disadvantaged primary care patients; a group that shoulders a disproportionate burden of low back pain (17–21). Specifically, compared with patients receiving usual care, those in the intervention group reported significantly better emotional functioning (i.e., anxiety, depressive symptoms), back pain symptoms, and low back pain functioning. Moreover, we found significant increases in patients' confidence (i.e., self efficacy) to self manage their back pain symptoms and decreases in fear of movement/activity.
Our short-term results are similar to another evaluation of a back pain self-management program that was implemented among a sample of well-educated, employed, and predominantly white members of a health maintenance organization in the Pacific Northwest (16). Their self-management intervention group showed short-term (6 months) improvement in low back pain-specific functioning using the exact instrument (Roland disability) from our study. Again, as our study showed, the between-group difference was not statistically significant because the usual care group also improved (16). It is important to note that this study reported statistically significant improvements in low back pain-specific functioning at 6 months among self- management group members compared with the usual care group, and these differences were marginally significant at 12 months. Thus, low back pain improvements may result only after the patient has practiced self management over a longer period. Another study that offered structured exercise classes along with brief education also reported significant improvements in low back pain-specific functioning using the same instrument, Roland disability, at 6 and 12 months (44).
Our self-management program not only targeted increased physical functioning, but also improved emotional functioning by alleviating anxiety and depressive symptoms. Specifically, patients in the intervention group significantly improved their emotional functioning compared with the usual care group. Thus, exposure to a program that provides information on the basic understanding of the back pain (i.e., sources of back pain, red flag symptoms) and its natural history, and addresses the negative emotions associated with pain appears to effectively reduce patient emotional symptoms that may further exacerbate low back pain. In contrast, participants in the Von Korff et al study (16) had significantly reduced specific fears pertaining to low back pain, but did not significantly improve emotional functioning. The difference in our observations may be a result of different instruments (disease-specific versus generic) used to assess emotional functioning.
In addition to functional status, intervention patients increased self-management processes, i.e., time spent in strengthening activities and their self efficacy to manage future back pain episodes. Thus, it appears that the acute low back pain self-management format was sufficient for implementing the self-management process among inner city patients. However, the penetration of our program was limited. Nevertheless, initially 52% of eligible patients indicated a willingness to participate and less than 10% of those randomized to the treatment group received no form of the intervention. That is, the remaining 90% of the treatment group received a dose of the intervention.
In the dose-effect analyses, we found that higher levels of staff/participant interaction through classes resulted in more desirable outcomes for the functional status (i.e., low back pain specific function) items and fear and avoidance of activity items; however, staff/participant interaction through telephone calls was associated with less desirable outcomes for 1 self management outcome (i.e., stretching time per week). It is possible that this negative association may be a result of patients' health status. That is, those who were home long enough to complete telephone calls may have been in poorer health and less likely to have commitments outside of the home and less likely to attend any classes.
Our promising short-term results are limited by several factors. First, one-third of the self-management intervention group attended the group meetings. More than half of the intervention group received the intervention by an alternative mode (i.e., audiotapes, mail materials, telephone calls). For those who received followup calls, we verified that the participant received the materials and listened to the tapes. Interventions delivered by mail or telephone have shown to be efficacious (45, 46). Second, the data is self reported. However, all measures were validated instruments. Finally, those who dropped out of the study were significantly more likely to be younger and in the intervention group. This is not surprising given that the intervention group required active participation and placed more demands on the participants' time. Younger participants may have other time commitments, such as employment or family responsibilities. Furthermore, these patients were more likely to have visited the emergency department as their place for enrollment, reported worse physical functioning and specific low back pain functioning at baseline, and reported less self efficacy to manage back pain symptoms than those who remained in the study. These data suggest that patients presenting with severe back pain in the emergency department have less confidence to manage their symptoms and are less likely to remain in a self-management program. However, it is worth noting that we found no evidence that subjects first presenting in the emergency department who remained in the program responded differently to the intervention than those not first presenting in the emergency department.
Despite these limitations, the results of this study are encouraging and suggest that the self management model is robust in establishing patient self-management, particularly among urban and economically disadvantaged populations. Screening patients within primary care and obtaining physician consent using our computerized medical record system operated fairly smoothly in this study. With 50% of eligible patients interested in the study, further qualitative studies are needed to develop a more attractive program to this population. Given that one-third of the treatment group attended group classes, alternative methods of program delivery are needed to penetrate a greater proportion of the population. In addition, methods to track inner city patient relocation are necessary because patients frequently relocate without any forwarding information. Obtaining contact information from only 1 family member or friend of the patient is often insufficient. Perhaps patients can be rewarded or earn incentives for checking in with staff monthly.
We plan to analyze long-term outcomes of our acute low back pain self-management program to determine if self- management practices produce further changes in functional status and were cost effective.