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Title:  A comparison of two short education programs for improving low back pain-related disability in the elderly: a cluster randomized controlled clinical trial.

Authors and affiliation: Francisco M. Kovacs1, María Teresa Gil del Real1, Víctor Abraira2, Severo Santos3, Elena Díaz2, Mario Gestoso1, Alfonso Muriel2,  Nicole Mufraggi1, Juan Noguera4, and Javier Zamora2 for the Spanish Back Pain Research Network

1: Departamento Científico.Fundación Kovacs, Palma de Mallorca and Madrid, Spain.
2: Unidad de Bioestadística Clínica. Hospital Ramón y Cajal. Madrid, Spain
3: Unidad de Asturias, Fundación KOVACS, Gijón, Spain
4: Residencia Sa Nostra, Palma de Mallorca, Spain

Email address: mtgildelreal@kovacs.org

Introduction. Low back pain disability is influenced by cognitive and behavioral factors, which might improve with education. Education programs emphasizing postural hygiene and active management have been advocated for the elderly, but there is currently no data on their effectiveness in that population.

Objectives. To assess the effectiveness of two short education programs for improving low back pain related disability in the elderly.

Methods. The 129 homes for the elderly in three health areas of Asturias (Spain) were invited to participate in this study. The first 12 to accept had 1,647 residents, and 661 (40.1%) participated in the study. Homes were randomly assigned to three groups. In all groups, the intervention consisted of a booklet to be given to each participant, and a 20 minute group talk to all the participants. Contents of the programs were education on active management, on postural education, and on cardiovascular health (control group). Subjects were assessed just before the intervention and 30 and 180 days later. Generalized mixed linear random effects models were used to estimate the effect of each kind of education on the evolution of disability.

Results. Mean age in the groups ranged between 79.9 and 81.2 years. Subjects had a physical quality of life which was inferior to the general population, and most of them had chronic illnesses which required constant treatment. Disability improved in all the groups with regard to baseline values. Compared with the control group, at the 30 day assessment linear models showed an additional improvement of 1.06 (95% CI: 0.20, 1.92) Roland-Morris points, only in the postural education group. At the 180 day assessment, the additional improvement was 1.99 (95% CI: 0.58, 3.40) points, only in the active education group. When analyzing only those subjects with low back pain when entering the study, postural education had no advantages on the control group at any assessment, while at the 180 day assessment the additional improvement in the active education group was 3.02 (95% CI: 1.51, 4.53) Roland-Morris points. At 30 and 180 days, fear Avoidance Beliefs had improved 11.5% in the active education group, 1.85% and 4.6% in the postural group and –1.4% and 0.6% in the controls.

Conclusions. In the elderly, an intervention focusing on active management education improves disability 6 months later and has an even greater effect on subjects with low back pain. This effect seems to be mediated, at least in part, by reduction of fear avoidance beliefs.