Combined education and patient-led goal setting intervention reduced chronic low back pain disability and intensity at 12 months: a randomized controlled trial.

Gardner T, Refshauge K, McAuley J. et al. Br J Sports Med. 2019.53: 1424-1431.

https://bjsm.bmj.com/content/53/22/1424

Take-Home Message

People with chronic low back pain who decided on treatment goals and actions with help from a clinician had better outcomes than people who received standardized advice to exercise.

Summary

Chronic low back pain is common and challenging to treat. Goal setting is a common component of interventions for people with chronic low back pain. However, few studies explored the effectiveness of patient-led goal setting. Patient-led goal setting, which is supported by the healthcare professional but led by a patient, involves 3 key features:

education about pain identification of important issues/problems establishment of goals and strategies to meet these goals feedback with collaborative discussion on barriers and progress with the strategies

Gardner and colleagues completed a randomized controlled trial to assess if patient-led goal setting led to better outcomes compared to advice to exercise (control intervention). The authors randomly assigned 75 participants to the two groups. Participants in the patient-lead goal-setting group met with the research team for an initial 1-hour session followed by 4 15- to 30-minute sessions conducted every 2 weeks. Participants in the control group could attend 3 face-to-face sessions with a physiotherapist including an hour session to start and then a 30-minute session at 2 and 4 months. Participants in the control group received a standardized exercise program and discussed their history of low back pain. Follow-up questionnaires assessing quality of life (SF-36), depression and anxiety (Depression Anxiety Stress Scale), self-efficacy (Pain Self-Efficacy Questionnaire), and fear of reinjury (Tampa Scale for Kinesiophobia) were collected at 2-, 4-, and 12-month follow-up sessions. Overall, patients in the patient-led goals setting group had more improved pain, fear of reinjury, quality of life, and self-efficacy through all follow-up sessions compared with the control group.

Viewpoints

Overall, the results of this study are congruent with the recommended guidelines for treating chronic low back pain. While this is not surprising, the authors offer new evidence where it was once lacking. Clinicians skeptical of incorporating this patient-centered approach into their treatment protocols should consider its potential benefits compared with the minimal risks. Clinicians should also note that this is one of the initial studies to demonstrate the benefits of this treatment approach. More research regarding best practices for delivering this approach (e.g., the optimal number of sessions) should be conducted before the full benefit of this patient-led approach can be understood. Furthermore, a common critique of this study may be that the control group only received advice to exercise, but we should keep in mind that this is often the only thing many patients with chronic low back pain receive. Hence, we should become more proactive in managing chronic low back pain and engage the patient in the decision-making process.

Questions for Discussion

How do you incorporate patient-led goal setting into your current treatment protocols? If it is not a formal part of your treatment plan, would you consider doing so?

Written by: Kyle Harris

Reviewed by: Jeffrey Driban

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