Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 10 , Pages 1734-1739, October 2009

Self-Management of Chronic Neck and Low Back Pain and Relevance of Information Provided During Clinical Encounters: An Observational Study

  • Pilar Escolar-Reina, PT, PhD

      Affiliations

    • Department of Physical Therapy, University of Murcia, Murcia, Spain
    • Corresponding Author InformationReprint requests to Pilar Escolar-Reina, PT, PhD, Departamento de Fisioterapia, Facultad de Medicina, Universidad de Murcia, 30100, Campus de Espinardo, Murcia, Spain
    • ,
  • Francesc Medina-Mirapeix, PT, PhD

      Affiliations

    • Department of Physical Therapy, University of Murcia, Murcia, Spain
    • ,
  • Juan J. Gascón-Cánovas, MD, PhD

      Affiliations

    • Department of Public Health and Preventive Medicine, University of Murcia, Murcia, Spain
    • ,
  • Joaquina Montilla-Herrador, PT, PhD

      Affiliations

    • Department of Physical Therapy, University of Murcia, Murcia, Spain
    • ,
  • J. Fermín Valera-Garrido, PT, PhD

      Affiliations

    • Department of Physical Therapy, Hospital FREMAP, Madrid, Spain
    • ,
  • Sean M. Collins, PT, ScD

      Affiliations

    • Department of Physical Therapy, University of Massachusetts, Lowell, MA

Article Outline

Abstract 

Escolar-Reina P, Medina-Mirapeix F, Gascón-Cánovas JJ, Montilla-Herrador J, Valera-Garrido JF, Collins SM. Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study.

Objective

To assess the relative influence of information provided during physical therapy on a patient's adherence to self-management strategies in relation to other predictors of adherence (patient and pain characteristics, use of self-management strategies before intervention).

Design

A longitudinal observational study of the relationship between the information provided during physical therapy and adherence to self-management strategies.

Setting

Data came from a clinical-based population in 8 primary health care centers.

Participants

Patients (N=184) with chronic neck or low back pain (77% under the age of 59y) were surveyed at the beginning and 1 month after completion of physical therapy.

Interventions

Not applicable.

Main Outcome Measures

Specific and overall adherence to 2 types of strategies: (1) nonpharmacologic pain management strategies, and (2) neck/back care in activities of daily life.

Results

Adherence to strategies of nonpharmacologic self-management of pain was more probable when patients received information explaining the effectiveness of the self-management strategies (adjusted odds ratio [AOR]=10.1; P<.05) and information about their illness (AOR=3.4; P<.05) during clinical encounters. Information provided by the physical therapist did not have any influence on the adherence to neck/back care in activity of daily life (P>.05).

Conclusions

Information provided during clinical encounters is associated with adherence to different kinds of self-management strategies. While further study is required, it is suggested that more attention be given to clinical practice strategies for improving adherence to self-management of chronic pain.

Key Words: Back pain, Neck pain, Patient compliance, Rehabilitation

List of Abbreviations: ADLs, activities of daily living, CI, confidence interval, LBP, low back pain, OR, odds ratio

 

THE IMPORTANCE OF self-management of chronic illness is increasingly recognized in light of the large and mounting burden of chronic illness in our society.1 Some governments are promoting self-management for common conditions through health service policy and special programs,2 including for patients with back pain.3

Neck and LBP are prevalent, are major causes of work disability, and are responsible for huge societal costs.4, 5 Recurrences are usual and their course is variable,6, 7, 8 with 10% to 15% leading to chronic pain.9, 10 Because of this typically recurrent character, it has been suggested that adherence to self-management strategies learned while actively participating in physical therapy and/or pain clinics may avoid many recurrent cases11 and have a profound influence on long-term care.12

Research on self-management strategies for neck and LBP has tended to focus on community populations.13 Findings suggest that almost everyone who has chronic pain adopts at least 1 form of self-management, and most subjects adopt several.14

Understanding the nature and extent of self-management strategies for chronic pain in the community is important14 for the management of chronic pain in clinical practice. It is also important for health professionals to know how their interventions (particularly information provided) during clinical encounters influence adherence to self-management strategies. However, population-based studies usually exclude reference to information provided by the health care provider,15 and studies based on clinical populations are few that offer insights into adherence to effective self-management strategies learned in health care centers and determinants of that adherence.16

The aim of this study was to assess the relative influence of information provided during intervention by a physical therapist on adherence to effective self-management strategies in relation to other predictors of adherence. An additional aim was to identify rates of adherence to self-management strategies learned during physical therapy intervention in health care centers. Our focus was on physical therapy intervention because physical therapists are typically involved with treating patients with neck and LBP,17 and they often offer information regarding pain self-management strategies.18 This information often includes nonpharmacologic pain management strategies and neck/back care in ADLs.18

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Methods 

Design 

A cohort of subjects with chronic neck and LBP were recruited prior to, and measured prospectively prior to and 1 month after, physical therapy intervention to determine their adherence to chronic pain self-management strategies. Independent variables were information provided during physical therapy and other potential predictors of adherence (patient and pain characteristics, use of self-management strategies before intervention).

Participants 

Over 6 months, all patients with neck and LBP evaluated by a physical therapist in 8 primary care centers of the Health Service of Murcia (Spain) were recruited consecutively into the study. Exclusion criteria were as follows: younger than 18 or older than 70 years, unable to read or write, cognitive deficit (eg, Alzheimer disease, senile dementia), or unable to attend all sessions of the physical therapy program. Informed consent was required to all included patients by their physical therapist.

Data Collection 

At baseline (before physical therapy intervention) we collected, from subjects and by a structured interview, data on subject and pain characteristics, and use of pain self-management strategies. Subjects were blind to the research questions. Data on strategies provided each patient during the physical therapy intervention were obtained from physical therapists using a form adapted from Kerssens et al18 on the last day of physical therapy (4 weeks after baseline). Physical therapists were not blind to the research questions. One month later subjects were asked, via a postal questionnaire, for data regarding the relevant information of the patient-therapist interaction during the treatment program, and their adherence to self-management strategies during the last week.

Measurements 

Information provided by physical therapist 
Physical therapist strategies for self-management 

We asked the physical therapists which self-management strategies were provided to each patient during intervention. We used a checklist (yes/no) that included 7 prioritized strategies with foreseeable use for patient education on neck and LBP.14 All strategies fell into 2 categories: nonpharmacologic pain management strategies and neck/back care in ADLs.18 The former included strategies such as rest, application of local heat/cold, and analgesic exercises. The latter group included postural strategies such as sleeping face down, using correct sitting posture, alternating body position, and using correct lifting technique. We provided training to therapists in advance of the study to use this checklist by a specific meeting with each one.

Information provided at clinical encounters 

We asked patients which therapists' behaviors happened during clinical encounters using 3 items (clarifying doubts of the patient, giving information about illness, justifying therapeutic strategies), scored as yes or no. These items were identified as relevant issues of the patient-therapist interaction by reviewing the scientific literature and clinical practice guidelines pertaining to clinical encounter techniques.17, 19, 20

Potential Factors Associated With Adherence 

Patient characteristics 

Subjects reported their age (y), sex (male/female), education level (without studies/elementary or middle school/high school/university), work participation (yes/no), sick leave (yes/no), and use of physical therapy in previous episodes of pain (yes/no). Age was stratified into 3 age ranges as shown in table 1.

Table 1. Characteristics of the Study Population
VariablesGroupsDifference Between Groups
Respondents (N=184) Percent or meanNonrespondents (n=83) Percent or meanRespondents Minus Nonrespondents (95% CI)
Patient characteristics
Sex
Male19.69.99.7(−0.5to19.6)
Age (y)
18–3930.448.7−18.3(−31.2to−5.3)
40–5946.244.91.3(−11.8to14.5)
>5923.46.417.0(8.8to25.1)
Education level
Without studies20.314.55.8(−4.0to15.8)
Primary studies51.763.2−11.5(−24.5to1.8)
Secondary and university27.922.45.5(−5.9to17.1)
Work participation
Yes60.266.2−6.0(−19.0to7.0)
Sick leave
Yes40.037.03.0(−13.9to19.9)
Pain characteristics
Localization
Neck pain63.166.2−3.1(−15.9to9.6)
Pain-disability
High level61.865.8−4.0(−16.8to8.9)
Pain intensity (0–10), mean ± SD7.2±1.87.2±2.20.0(−0.5to0.5)
Pain characteristics 

Three components of pain were assessed: site (neck or low back), intensity (by an 11-point scale: 0=nothing, 10=intense pain), and disability related to pain (by a 5-point scale: 5=extremely, 4=quite a bit, 3=moderately, 2=slightly, 1=not at all). Disability was then was codified into 2 groups (high/low disability) as shown in table 1 (disability scores 4 and 5 were considered high disability).

Use of pain self-management strategies 

Subjects were asked whether they attempted to use daily the 4 neck/back care in ADLs described and whether they attempted to use the 3 nonpharmacologic self-management strategies when in pain. Given that we used a different frequency frame (daily or when in pain) for each type of strategy, we used a nominal scale (yes/no) for nonpharmacologic strategies and an ordinal scale (by a 5-point scale: 5=always, 4=very often, 3=sometimes, 2=rarely, 1=never) for neck/back care in ADLs.

Outcomes 

Adherence 

According to Sackett and Haynes,21 adherence has been defined as the extent to which a person's behavior coincides with the professional advice. One month after physical therapy intervention, subjects who received instruction in the strategies described were asked about their adherence. For nonpharmacologic pain management items (measured as yes/no), adherence was defined as using the strategy when pain became worse, and for neck/back care items (measured by a 5-point scale: 5=always, 4=very often, 3=sometimes, 2=rarely, 1=never), adherence was defined as using the recommended strategy (correct posture/movement during ADLs) frequently (always and very often) or frequently avoiding bad postures/movements.

Furthermore, we defined overall adherence for each category of strategy: nonpharmacologic management of pain and neck/back care in ADLs. We considered good overall adherence when subjects adhered to greater than or equal to half of the strategies provided. We considered this operative definition because the use of all strategies might not be useful in every context.14

Statistical Analysis 

Respondents and nonrespondents were compared by sex, age, education level, working, sick leave, localization of pain, pain-disability, and pain using descriptive statistics. Proportions and 95% CIs were calculated to determine the prevalence of adherence.

We first examined the association of 3 sets of predictors—subject, pain characteristics, and use of self-management strategies before physical therapy intervention—with overall adherence to nonpharmacologic pain management and neck/back care strategies using multivariate logistic regression analyses. Using the recommendation of 10 subjects a variable, we accepted that 180 subjects were sample size enough. Three sets of predictors were entered simultaneously, and the procedure was implemented using a process of backward elimination of independent variables. At each stage, the effect of dropping an independent variable was assessed using the likelihood ratio test at a 2-sided significance level of P greater than .05.

In a second stage, 6 multivariate logistic regression analyses were used to determine the influence of each kind of information provided by the physical therapist (independent variables) on overall adherence to nonpharmacologic pain management and neck/back care strategies (dependent variables). Potential confounder variables (characteristics of subject, characteristics of pain, use of nonpharmacologic self-management of pain and neck/back care in ADLs before intervention) were also introduced as independent variables into the models if their level of significance with the respective type of adherence was significant in the previous analysis (P≤.05).

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Results 

Participants 

During the 6-month recruitment period, we identified 267 eligible people: 104 and 163 subjects with neck or LBP, respectively. Of them, 250 (93.6%) were included and participated in the baseline interview. Reasons for excluding 17 patients were the following: older than 70 years (8) and unable to attend all sessions (9). One hundred eighty-four patients (68.9%) returned the questionnaire after treatment. Nonrespondents did not differ significantly from respondents when compared by sex, education level, working participation, sick leave, localization of pain, pain-disability, and pain intensity. However, the proportion of subjects above 59 years was higher among respondents (see table 1).

Adherence Rates 

All participants received at least 1 of the 7 physical therapist strategies for self-management of chronic neck or back pain. However, the most frequent physical therapist practice was to provide all 7 strategies (75.0; 95% CI, 68.7–81.3).

The prevalence of adherence to individual strategies had a wide range. It was very low for alternating body position (12.9; 95% CI, 7.4–18.4), while the maximum was for rest (86.4; 95% CI, 80.9–91.9) (table 2). Most of the strategies (6 out of 7) had a prevalence of adherence below 80%. Overall adherence showed important differences between strategies aimed to control pain and those for neck/back care in ADLs (see table 2). The prevalence of overall adherence was higher for nonpharmacologic pain management (75.1; 95% CI, 68.6–81.6) than for neck/back care strategies (18.7; 95% CI, 12.7–24.7).

Table 2. Prevalence of Adherence to Specific and Overall Self-Management Strategies Advised by the Physical Therapist
Self-Management StrategiesNo. of Subjects With Recommended StrategyMean percent (95% CI)
Nonpharmacologic pain management
Overall adherence⁎16975.1(68.6–81.6)
Taking rest14786.4(80.9–91.9)
Application of local heat16774.3(67.7–80.9)
Analgesic exercises14564.8(57.0–72.6)
Neck/back care in activities of daily living
Overall adherence⁎16018.7(12.7–24.7)
Sleeping face down13768.6(60.8–76.4)
Correct sitting posture13643.4(35.1–51.7)
Correct lifting technique12436.3(27.9–44.7)
Alternating body position14012.9(7.4–18.4)

⁎Adherence to ≥50% of recommended strategies.

Factors Associated With Adherence 

Overall adherence to pain self-management strategies was independent of the site (neck or low back) of pain, as well as pain-disability rating. Results showed that subjects with neck and LBP had similar odds of adherence for nonpharmacologic (OR=1.59; 95% CI, 0.69–3.68, coding as 1 for LBP) and neck/back care strategies (OR=1.61; 95% CI, 0.68–3.78).

On the other hand, use of self-management strategies before physical therapy intervention was strongly and positively associated with adherence to the respective strategies (table 3). Previous physical therapy intervention and some subject and pain characteristics were good predictors of the overall adherence to the neck/back care ADLs self-management strategies (see table 3).

Table 3. Summary of Logistic Regression Analysis for Predictors of Overall Adherence to Pain Self-Management Strategies
PredictorsOverall Adherence on Nonpharmacologic Pain Management Strategies (n=162)Overall Adherence on Neck/Back Care in ADLs (n=146)
βSEOR (95% CI)βSEOR (95% CI)
Patient characteristics
Use of physical therapist in previous episodes 1.070.542.9(1.01–8.6)⁎
Pain characteristics
Intensity (increase of 1 point) 0.290.141.3(1.01–1.8)⁎
Use of self-management before intervention
Application of local heat2.050.437.8(3.4–18.3)⁎
Doing analgesic exercises2.110.668.3(2.3–30.1)⁎
Sleeping face down 1.670.695.3(1.3–20.7)⁎
Correct lifting technique 0.940.482.6(1.01–6.5)⁎
Alternating body position 1.340.533.8(1.4–0.7)⁎
Constant−0.63 −6.36
χ2 1.27 29.91
df 2 6

⁎P<.05.

Information Provided by Professional 

Adherence to strategies of nonpharmacologic self-management of pain was more probable if subjects received information during clinical encounters. In particular, giving information about illness and explaining the effectiveness of the self-management strategies was a very good way to increase the probability that subjects would follow them. Subjects that received information on the usefulness of treatment and the nature of the illness had 10.1 and 3.4 times more adherence, respectively (table 4). On the other hand, information provided by the physical therapist did not seem to have any influence on the adherence to neck/back care ADLs strategies (see table 4).

Table 4. Adjusted OR (95% CI) of Different Types of Information Provided During Clinical Encounters
PredictorsOverall Adherence on Nonpharmacologic Pain Management StrategiesOverall Adherence on Neck/Back Care in ADLs
Adjusted OR† (n=171)Adjusted OR‡ (n=145)
Information provided by the physical therapist
Clarifying doubts and questions2.5(1.01–5.8)⁎1.6(0.5–5.1)
Giving information about illness3.4(1.4–8.1)⁎0.5(0.2–1.1)
Justifying usefulness of strategies10.1(3.7–28)⁎1.3(0.5–3.8)

⁎P<.05.

†By predictors of adherence on nonpharmacologic pain management strategies (see table 3).

‡By predictors of adherence on neck/back care in ADLs strategies (see table 3).

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Discussion 

This study extends several important aspects of previous knowledge about magnitude and determinants of adherence to pain and neck/back care self-management strategies. Similar to other studies, this study documents different rates of adherence between self-management strategies. In particular, others have found variability when several behaviors were analyzed after a pain management self-care program.22 Differences achieved between both areas of pain self-management strategies, nonpharmacologic pain management and neck/back care in ADLs, could be a result of the different nature of the strategies themselves. Nonpharmacologic pain management is curative in nature, and neck/back care in ADLs is preventative in nature.23

Contrary to our expectations, this study revealed that predictors of adherence to nonpharmacologic pain management strategies were different than those associated with adherence to neck/back care self-management strategies.

As might have been expected, the respective previous self-management habits were the only common factors to adherence to each area of self-management strategy. Previous physical therapy, among all subject characteristics, was associated with adherence to neck/back care strategies. A clinical factor such as intensity of pain was also associated with adherence. These findings suggest that for programs interested in promoting neck/back care strategies, knowledge of previous episodes, clinical factors, and habits might be important. However, only specific habits would be important to identify people who are more likely to adhere to nonpharmacologic management strategies.

A high proportion of subjects who attended physical therapy for previous episodes are more adherent, which is consistent with our overall expectations and findings. However, there were some unexpected findings. In contrast with our expectations, information provided during intervention was not associated with both areas of pain management strategies, nonpharmacologic and neck/back care. Information provided during physical therapy intervention to justify usefulness and to clarify the etiology, evolution, and prognosis of neck or LBP increased the odds of adhering to nonpharmacologic pain management strategies, but not to neck/back care.

While it has been largely demonstrated that information is a prerequisite for changing behavior, information by itself is insufficient to achieve this change if it is not combined with motivation.24, 25, 26, 27, 28, 29, 30 It is possible that subjects are more motivated to adhere to interventions that have expectations of positive results in a short time, such as self-management behaviors to control pain, than to others that have effect after a long period (postural behavior).

Study Limitations 

This study has limitations. First, the data presented here are based on self-report measures. In an attempt to limit self-report bias caused by subjects responding with what would be assumed to be socially desirable responses in adherence (biased toward increased adherence), we asked for self-report of behaviors without reference to specific physical therapist advice. In addition, the measure of overall adherence might not be the most valid method and should be validated in future studies. However, using this strategy, we highlighted different explanatory factors and levels of adherence to 2 areas of self-management strategies.

Second, because variables related to physical therapists' behaviors were measured together with adherence measures, the direction of causality cannot be determined. However, the literature does show that the physical therapist–subject interactions increase adherence in home physical therapy programs.31 A follow-up investigation that measures physical therapists' behaviors prior to measuring adherence is underway with the aim of providing evidence for the direction of causation.

Third, there are 2 mechanisms by which selection bias (nonparticipants) may have influenced the results of this study. On the one hand, subjects meeting the exclusion criteria (<18y, >70y, unable to read or write, or with cognitive deficit) could bias the results toward increased adherence by creating a sample that is more likely to adhere. However, the converse of this interpretation is there is a necessary reduction in heterogeneity of factors affecting adherence. Rather than considering exclusion criteria as a selection bias, they should be interpreted as a methodologic approach to keeping the control of confounders manageable. The impact is that these results can be generalized only to those between the ages of 18 and 70 years, who can read and write, who do not have a cognitive deficit, and who can commit to a full course of physical therapy intervention.

On the other hand, loss to follow-up as a result of nonrespondents (66 nonrespondents from an initial 250 participants) could bias the results toward increased adherence. An intent-to-treat approach to analysis would reduce the potential impact of this bias; however, it would create a bias toward reduced adherence and would undermine the goal of this study because of the lack of information (both predictors and outcomes) on the nonrespondents. The intent-to-treat approach would be limited to demographic predictors because physical therapy intervention predictors of adherence were collected from the follow-up survey. The proportion of subjects greater than 59 years was lower in the nonrespondent group. It is difficult to ascribe interpretative meaning to the differential response rate by age other than to limit the generalization of the results to older subjects, because it is from this older sample that the associations and coefficients are calculated. Whether the younger nonrespondent subjects were adherent, and whether factors measured in this study were predictive of adherence, are unknown in this group. Therefore, the impact of age on adherence cannot be assessed, and the conclusions are limited to the sample of respondents, which were proportionally older than nonrespondents. Future studies should collect predictor data before potential loss to follow-up and implement additional strategies to assure follow-up with younger subjects.

Fourth, follow-up was relatively short, considering advice for self-management is a long-term recommendation. As such, the results are limited to short-term adherence (∼1mo). While it is unlikely that subjects who are nonadherent after a month of follow-up would become adherent, it is possible that subjects adherent after a month might become nonadherent over longer periods. The hypothesis tested in this study was that information provided by physical therapists was predictive of adherence. We would maintain that such information is more predictive of short-term adherence, and that long-term adherence is associated with short-term adherence plus several other factors that accrue with the passage of time. One such factor could be the subjects' perception of continued success and attributing success to the short-term adherence of the self-management strategies. Clearly, studies with longer follow-up are warranted.

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Conclusions 

The present study provides important information regarding short-term adherence to pain self-management strategies learned during a physical therapy intervention. We have shown in a sample of clinical subjects that self-management habits before a physical therapy program, clinical characteristics, and information provided during intervention are associated with higher levels of adherence to different types of self-management strategies.

We recommend that attention be given to clinical practice strategies that improve adherence to self-management strategies. The results of this study strongly support the attractiveness of subject education by demonstrating that high levels of some kinds of self-management strategies can be achieved. It is encouraging that information provided during physical therapy interventions are associated with adherence to self-management of chronic pain.

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 Supported by the Ministry of Health and Consumers Affairs Spain (grant no. PI030317).

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

PII: S0003-9993(09)00412-2

doi:10.1016/j.apmr.2009.05.012

Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 10 , Pages 1734-1739, October 2009

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