[ literature review ]

LEONARDO PIANO, PT, MSc, OMPT1,2 • VALENTINA RITORTO, PT2 • IRENE VIGNA, PT2

MARCO TRUCCO, PT, MSc2,3 • HOPIN LEE, PT, PhD4,5 • ALESSANDRO CHIAROTTO, PT, PhD6,7,8

Individual Patient Education for Managing

Acute and/or Subacute Low Back Pain:
Little Additional Benefit for Pain and
Function Compared to Placebo. A
Systematic Review With Meta-analysis of
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Randomized Controlled Trials

A
t least 8 in every 10 people in the world will experience low as indirect costs from work compensa-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

back pain (LBP) at some time in their lives.53 LBP imposes tion and absence.20,54 Acute LBP refers to
high direct costs due to medical consultations, examinations symptoms lasting up to 4 weeks, subacute
LBP refers to symptoms lasting 4 to 12
(ie, x-rays, magnetic resonance imaging), and drugs as well
weeks, and chronic LBP refers to symp-
U OBJECTIVE: To evaluate the effects of individual
toms lasting more than 3 months.26 While
-0.07) and physical function at short term (stan-
patient education for managing acute and/or dardized mean difference [SMD], −0.25; 95% CI: approximately 40% of patients with an
subacute low back pain (LBP), compared to no −0.47, −0.02) and medium term (SMD, −0.26; 95% acute LBP episode recover within 2 to 4
intervention/placebo education, noneducational CI: −0.48, −0.04), but with no clinically relevant ef- weeks, the rest tend to develop a chronic
interventions, or other type of education. fects. There was low-to-moderate certainty evidence
disorder with long-lasting symptoms.33
U DESIGN: Systematic review with meta-analysis
Journal of Orthopaedic & Sports Physical Therapy®

that individual patient education was superior to

of randomized trials.
U LITERATURE SEARCH: PubMed, CINAHL,
PEDro, Embase, Scopus, and CENTRAL (up to
September 30, 2020); reference lists of previous
systematic reviews.
U STUDY SELECTION CRITERIA: Randomized
controlled trials (RCTs) evaluating individual edu-
cation for patients with acute and/or subacute LBP.
U DATA SYNTHESIS: Random-effects meta-anal-
ysis for clinically homogeneous RCTs. Certainty
of evidence was assessed using the Grading of
Recommendations Assessment, Development and
Evaluation approach.
U RESULTS: We included 13 RCTs. There was
moderate certainty evidence that individual patient
education was more effective than placebo educa-
tion for pain at medium term (mean difference
[MD], −0.79; 95% confidence interval [CI]: -1.52,
noneducational interventions on short-term quality
of life (MD, −12.00; 95% CI: −20.05, −3.95) and
medium-term sick leave (odds ratio = 0.32; 95% CI:
0.11, 0.88). We found no clinically relevant between-
group effects for any other comparison (low-to-high
certainty of evidence) at any follow-up.
U CONCLUSION: One or 2 hours of individual
patient education probably makes little to no dif-
ference in pain and functional outcomes compared
with placebo for patients with acute and/or subacute
LBP. Considering its effects on other outcomes (eg,
reassurance) and patients’ desire for information
about their condition, it is reasonable to retain patient
education as part of a first-line approach when
managing acute and subacute LBP. J Orthop Sports
Phys Ther 2022;52(7):432-445. Epub: 18 May 2022.
doi:10.2519/jospt.2022.10698
U KEY WORDS: low back/lumbar spine, pain,
systematic review/meta-analysis
Physical and psychosocial factors such as
anxiety, depression, and coping strategies
are associated with poor prognosis.2
Patient information and education are
often recommended in treatment guide-
lines to improve self-efficacy and coping
strategies.8,38 Individual patient educa-
tion emphasizes a structured approach
drawing on providing information and
behavior change techniques to influence
the way patients experience and under-
stand their pain.51 Many studies have
focused on providing individual patient
education for patients with chronic LBP,
as misguided beliefs and attitudes about
prognosis and tissue-damage theory may
influence whether LBP symptoms and

1
Unit of Rehabilitation and Functional Recovery, Fondazione dei Santi Lorenzo e Teobaldo, Rodello, Italy. 2School of Physiotherapy, University of Turin School of Medicine, Turin,
Italy. 3Presidio Sanitario San Camillo di Torino, Turin, Italy. 4Centre for Statistics in Medicine (CSM) and Centre for Rehabilitation Research in Oxford (RRIO), Nuffield Department
of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom. 5School of Medicine and Public Health, The University
of Newcastle, Newcastle, Australia. 6Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands. 7Department of Health Sciences, Faculty of
Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands. 8Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands. This review was
registered with PROSPERO (registration number CRD42020136461). The authors declare no financial affiliation (including research funding) or involvement with any commercial
organization that has a direct financial interest in any matter included in this manuscript. Address correspondence to Leonardo Piano, Unit of Rehabilitation and Functional
Recovery, Fondazione dei Santi Lorenzo e Teobaldo, Via Roma 1, 12050 Rodello, Italy. E-mail: leonardo.piano@fondazionesanlorenzo.it t Copyright ©2022 JOSPT®, Inc

432 | july 2022 | volume 52 | number 7 | journal of orthopaedic & sports physical therapy

 disability persist. Although most clinical
practice guidelines recommend advice
and education for managing acute LBP,
few studies are available on the acute and
subacute stages of LBP.9,10
A Cochrane systematic review pub-
lished in 2008 explored the role of indi-
vidual patient education for patients with
LBP, classifying patients into acute, sub-
acute, or chronic LBP. There was strong
evidence of the effectiveness of an inten-
sive individual patient education program
(at least 2.5 hours) on return to work at
the short and long term compared to no
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intervention for acute and/or subacute
LBP.11 Since 2008, 4 other systematic re-
views published on this topic have focused
on different outcomes and/or populations:
Traeger et al49 focused on reassurance as
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
an outcome; Ainpradub et al1 focused on
the treatment of multiple stages of LBP;
Zahari et al57 focused on an older popula-
tion with LBP; and Jones et al27 focused on
mixed population (neck/back pain) as well
as on pain, disability, and adverse events
as outcomes. As new trials on individual
patient education for patients with acute
and/or subacute LBP have been published
Journal of Orthopaedic & Sports Physical Therapy®
since the 2008 Cochrane review, an up-
dated synthesis was warranted.15
We aimed to review the effects of in-
dividual patient education compared to
no intervention, placebo, other inter-
ventions (eg, exercise, manual therapy),
or other modes of patient education (ie,
group-based education) for adults with
acute and/or subacute LBP.
METHODS
W
e registered a protocol for
this systematic review on PROS-
PERO (https://www.crd.york.
ac.uk/prospero/display_record.php?ID=
CRD42020136461). This manuscript is
reported according to the Preferred Re-
porting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement.34
Identification and Selection of Studies
We searched PubMed, CINAHL, PEDro,
Embase, Scopus, and Cochrane Central
journal of orthopaedic & sports physical therapy | volume 52 | number 7 | july 2022 | 433
Register of Controlled Trials (CENTRAL)
databases from inception to September
30, 2020 (search strategies available in
APPENDIX A). References of previous sys-
tematic reviews on individual patient ed-
ucation for LBP were screened to identify
additional trials.1,11,49
Two reviewers (V.R. and I.V.) inde-
pendently screened titles and abstracts
to find all potentially relevant studies
using the Rayyan platform.39 Full texts
were screened by the same 2 review-
ers to determine inclusion or exclusion.
Discrepancies were discussed among
the research group. If there was lack of
information to determine inclusion, we
contacted authors for more information.
Selection Criteria
Population  We included randomized
controlled trials (RCTs) recruiting adult
patients with acute and/or subacute non-
specific LBP with or without referred
pain—defined as “pain below the 12th rib
and above the gluteus.”3 Acute LBP was
defined as back pain lasting less than 6
weeks, whereas subacute LBP was de-
fined as back pain lasting between 6
and 12 weeks.16 For studies with mixed
populations (eg, lumbar radiculopathy
or chronic pain in other body areas), we
only included studies where 75% or more
of the sample had acute or subacute LBP,
to have a more homogeneous population;
if results were presented separately for the
LBP group, the trial was included even if
less than 75% of patients had LBP.28
RCTs including participants who were
suffering from LBP with a serious specific
cause (eg, infection, cancer, rheumatoid
arthritis, fracture, cauda equina syn-
drome) were excluded. Only studies in
English or Italian were included.
Intervention  Individual patient educa-
tion was defined as a structured approach
drawing on providing information and
behavior change techniques to influence
the way patients experience and under-
stand their pain.51 Education for patients
with LBP was operationalized as any ad-
vice or information (verbal, written, or
audiovisual) provided by a health care
professional with the aim of improv-
ing the patients’ understanding of their
back problem and what they should do
about it. Any form of individual patient
education was accepted: “on-site” or re-
mote interventions. We included trials of
advice to stay active and excluded trials
of instructions on how to perform spe-
cific exercises. We included trials with
combined interventions (eg, education
plus exercise) if they compared the same
intervention program without the indi-
vidual patient education component.
Comparator  We focused on the follow-
ing comparators: (1) no intervention (eg,
waiting list) or placebo education, (2)
noneducational interventions (eg, exer-
cise, manual therapy, usual care), and
(3) other type of patient education (eg,
group-based patient education).
Outcomes  We included RCTs if they re-
ported at least 1 of the following outcomes:
• pain intensity (eg, visual analog scale,
numeric rating scale, McGill Pain
Questionnaire)
• physical function (eg, Oswestry Dis-
ability Index, Roland-Morris Disabil-
ity Questionnaire [RMDQ], Aberdeen
Low Back Pain Scale)
• return to work (eg, number of sick days,
percentage of patients on sick leave)
• health-related quality of life (HRQoL)
(eg, 36-Item Short-Form Health Sur-
vey, Euro Quality of Life, activities of
daily living)
We collected outcomes at the following
time points:
• short term (ST) – (2-6 weeks after
randomization)
• medium term (MT) – (6 weeks to 6
months)
• long term (LT) – (6-12 months)
Assessing Risk of Bias
Two authors (V.R. and I.V.) indepen-
dently assessed risk of bias (RoB) using
the 13-item RoB checklist included in
the guidelines of the Cochrane Back and
Neck Group.16 Biases were divided into
5 domains: selection bias (criteria 1, 2,
and 9), performance bias (criteria 3, 4,
10, and 11), attrition bias (criteria 6 and
 [ literature review
7), detection bias (criteria 5 and 12), and
publication bias (criterion 8). Consensus
was reached by discussion between the
2 review authors (V.R. and I.V.). A third
review author (L.P.) was consulted if dis-
agreement persisted.
Data Extraction and Analysis
We used a data-extraction form to col-
lect data on trial population and types
of interventions as well as quantitative
data from the outcome measures. We
extracted the following information: first
author, year of publication, type of popu-
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lation (ie, acute and/or subacute LBP),
number of participants allocated to each
group, and patient characteristics (eg,
age, sex, education, baseline pain inten-
sity, and duration of symptoms).
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Two independent reviewers (V.R. and
I.V.) independently extracted mean scores
and standard deviations (SDs) for contin-
uous outcomes as well as odds ratio (OR)
or relative risk for dichotomous outcomes.
When necessary, data from graphs were
extracted through the WebPlotDigitizer
software.56
If variance in outcomes was reported
Journal of Orthopaedic & Sports Physical Therapy®
as confidence intervals (CIs), interquar-
tile ranges, or standard errors, we con-
verted them into SDs using the formulas
in the Cochrane Handbook for Systematic
Reviews of Interventions.23 When data
were not fully available, corresponding
authors were contacted to obtain miss-
ing data. If SDs were not reported in the
original RCT, its imputation was done
through the pooled weighted mean of SD
available for that specific meta-analysis.17
Consistent with previous work on this
topic, aggregated results were presented
by pooling data from acute and subacute
LBP populations.11,41,49
Data Synthesis
We used inverse variance and random-
effects meta-analyses to combine results
from trials that we considered clinically
homogeneous with respect to the popula-
tion, intervention, types of comparators,
and outcomes (eg, pain, functioning,
HRQoL). We used the Review Manager
434 | july 2022 | volume 52 | number 7 | journal of orthopaedic & sports physical therapy
]
Version 5.3 software to calculate the
pooled mean difference (MD), standard-
ized mean difference (SMD), or pooled
OR, each reported with 95% CIs.42 We
calculated the MD if the same measure-
ment instruments were used for the same
outcome and the SMD if different instru-
ments were used for the same outcome
(eg, RMDQ and Oswestry Disability In-
dex for physical function).
We calculated the SMD as the differ-
ence between the mean in the interven-
tion and control groups divided by the
pooled SD. To aid clinical interpretation
of results, the SMD was back-trans-
formed into MD by multiplying it by the
pooled SD of the most used and recom-
mended instruments for the core out-
comes for LBP (ie, 2 for the 0- to 10-point
pain numeric rating scale and 5 for the
Identification
Records idenfied through
database searching,
n = 2204
Records aer duplicates removed,
n = 1462
Screening
Records screened,
n = 1462
Eligibility
Full-text arcles assessed
for eligibility,
n = 33
Studies included in the
review,
Included
n = 13
FIGURE 1. Flow of trials through the review. Abbreviation: LBP, low back pain.
24-item RMDQ).6 We then transformed
this value into a percentage by calculat-
ing the proportion of improvement from
the pooled baseline values of the most
used and recommended instruments. We
considered a between-group MD greater
than or equal to 20% as a clinically rel-
evant effect.7,14 We reported dichotomous
outcomes as ORs with 95% CIs.
Heterogeneity was examined as be-
tween-study variation and calculated as
the I2 statistic measuring the proportion
of variation in the combined estimates
due to between-study variance. An I2
value of 0% indicates that none of the
variance in the pooled estimate can be
attributed to between-study variance,
and an I2 value of 100% indicates that all
of the variance in the pooled estimates is
attributable to between-study variance.
Records excluded,
n = 1429
Full-text arcles excluded, n = 21
Wrong populaon, n = 11
- No LBP, n = 1
- Chronic LBP >25% of trial
parcipants, n = 5
- Sciaca >25% of trial
parcipants, n = 5
Wrong intervenon, n = 9
- No education, n = 1
- Group-based educaon, n = 5
- Educaon in both groups, n = 2
Wrong design, n =1
 TABLE 1 Characteristics of the Included Studies

Experimental Control
Stage Sample Sample
Study of LBP Characteristicsa Type of Intervention Characteristicsa Type of Intervention Outcomes Follow-up
Burton Mixed n = 83 Biopsychosocial education n = 79 Usual education booklet • Pain = NRS (0-100) Short term = 1
1999 Age = 42.6 (10.9) booklet (how to cope with Age = 44.7 (12.2) (traditional biomedical • Function = RMDQ week
M/F = 42/41 LBP, patient empowerment) M/F = 31/48 information) (0-24) Medium term = 3
n sessions = NR n sessions = NR months
Duration = NR Duration = NR Long term = 12
months
Cherkin Mixed n = 66 Educational booklet (biopsy- Control 1 • Pain = bothersome- Short term = 1-4
1998 Age = 40.1 (11.2) chosocial information about n = 122 Chiropractic manipulation ness of symptoms weeks
M/F = 38/28 prevention and management Age = 39.7 (9.4) n sessions = 6-9 (0-10) Medium term = 3
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of LBP, role of diagnostic M/F = 57/65 Duration = 145’/s • Function = RMDQ months
imaging) (0-24) Long term = 12-24
n sessions = NR
Control 2
• Return to work months
Duration = NR
n = 133 McKenzie Therapy + Treat Your
Age = 41.8 (11.5) Own Back book + lumbar-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

M/F = 70/63 support cushion

n sessions = 4-6
Duration = 145’/s
Hay 2005 Mixed n = 201 Brief pain management (expla- n = 201 Manual therapy • Pain = VAS (0-100) Medium term = 3
Age = 40.4 (12.0) nation of pain mechanisms, Age = 40.9 (11.6) n sessions = up to 7 • Function = RMDQ months
M/F = 101/100 role of psychosocial factors, M/F = 91/110 Duration = 20-40’ (0-24) Long term = 12
self-management of LBP) • Return to work = months
n sessions = up to 7 patients (%)
Duration = 20-40’
Hazard Acute n = 244 “Good News About Back Pain” n = 245 No intervention • Return to work = Medium term = 3
2000 Age = 38.3 (9.2) booklet (self-management, Age = 39.7 (9.4) n sessions = NR participants not months
Journal of Orthopaedic & Sports Physical Therapy®

M/F = 133/96 return to work, and physical M/F = 141/80 Duration = NR working (%), Long term = 6
activity) days of work lost (n) months
n sessions = NR
Duration = NR
Jellema Mixed n = 143 Educational booklet (psy- n = 171 Usual care • Pain = NRS (0-10) Short term = 6
2005 Age = 43.4 (11.1) chosocial factors) + GP Age = 42.0 (12.0) n sessions = NR • Function = RMDQ weeks
M/F = 65/68 consultation M/F = 90/81 Duration = NR (0-24) Medium term = 3
n sessions = >1 • Return to work = months
Duration = 20’ patients (%) Long term = 26
• Quality of life = weeks
SF-36 (0-100)
Linton Mixed Experimental 1 n = 107 Group-based cognitive-behavior- • Pain = average pain Long term = 12
2000 n = 70 “Back Pain – Don’t Suffer Need- Age = 44 al intervention + usual care (0-10), worst pain months
Age = 45 lessly” booklet (biopsychoso- M/F = 37/75 n sessions = 6 (0-10)
M/F = 20/50 cial information, “stay active” Duration = 2 h • Function = ADL
advice, avoid fear-avoidance (0-60)
behavior) • Return to work =
n sessions = 6 days of work lost
Duration = NR (0-184)
Experimental 2
n = 66 Information based on “The Back
Age = 44 Book” booklet (postural and
M/F = 16/50 ergonomic advice)
n sessions = 6
Duration = NR
Table continues on next page.

journal of orthopaedic & sports physical therapy | volume 52 | number 7 | july 2022 | 435

 [ literature review ]
TABLE 1 Characteristics of the Included Studies (continued)

Experimental Control
Stage Sample Sample
Study of LBP Characteristicsa Type of Intervention Characteristicsa Type of Intervention Outcomes Follow-up
Mayer Mixed n = 26 “Acute Low Back Problems in Control 1 • Pain = NRS (0-5) Short term = 1
2005 Age = 31.3 (10.9) Adults, Patient Guide” booklet n = 25 Heat wrap • Function = RMDQ week
M/F = 2/24 n sessions = NR Age = 29.3 (9.9) n sessions = 5 (0-24)
Duration = NR M/F = 8/17 Duration = 8 h
Control 2
n = 25 Exercise
Age = 32.6 (10.3) n sessions = NR
M/F = 10/15 Duration = NR
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Control 3
n = 24 Heat wrap + exercise
Age = 31.8 (11.8) n sessions = NR
M/F = 9/15 Duration = NR
Newcomer Mixed n = 110 Cognitive-behavioral videotape n = 110 Standard instructional videotape • Function = ODI Long term = 12
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

2008 Age = 40,4 (10,9) (focus on physical activity Age = 37,9 (11,8) (postural advice during ADL) (0-100) months
M/F = 24/46 and its role on LBP manage- M/F = 23/45 n sessions = 1
ment) Duration = 20’
n sessions = 1
Duration = 20’
Pengel Subacute n = 63 Education (how to cope with n = 68 Placebo education + placebo • Pain = NRS (0-10) Short term = 6
2007 Age = 50.1 (15.4) LBP, information about prog- Age = 50.0 (15.6) exercise • Function = RMDQ weeks
M/F = 34/29 nosis and self-management) M/F = 31/37 n sessions = 2.5 (0-24) Medium term = 3
+ placebo exercise Duration = 19’ months
n sessions = 2.9 Long term = 12
Duration = 20’ months
Journal of Orthopaedic & Sports Physical Therapy®

Roberts Acute n = 35 “Back Home” leaflet (biopsy- n = 28 Usual care provided by GP • Disability = ALBPS Short term = 2
2002 Age = 39.2 (10.9) chosocial information) + GP Age = 39.3 (9.7) (0-100) weeks
M/F = 22/13 advice M/F = 19/9 Medium term = 3
months
Long term = 6-12
months
Storheim Subacute n = 34 “Cognitive intervention” (pain Control 1 • Pain = VAS (0-100) Medium term =
2003 Age = 41.3 (9.4) mechanism, ergonomic ad- n = 30 Group-based aerobic exercise • Function = RMDQ 18 weeks
M/F = 18/16 vice to perform, stay active) Age = 42.3 (9.2) n sessions = 45 (0-24)
n sessions = 2 M/F = 14/16 Duration = 1 h • Quality of life =
Duration = 30-60’ SF-36 (0-100)
Control 2
n = 29 Usual care
Age = 38.9 (11.9) n sessions = NR
M/F = 13/16 Duration = NR
Traeger Acute n = 101 Intensive patient education n = 101 Placebo education • Pain = NRS (0-10) Short term = 1
2019 Age = 46.5 (14.7) (biopsychosocial education Age = 43.8 (14.1) n sessions = 2 • Function = RMDQ week
M/F = 48/53 aimed to improve wrong M/F = 51/50 Duration = 1 h (0-24) Medium term = 3
beliefs) months
n sessions = 2 Long term = 6
Duration = 1 h months
Table continues on next page.

436 | july 2022 | volume 52 | number 7 | journal of orthopaedic & sports physical therapy

 TABLE 1 Characteristics of the Included Studies (continued)

Experimental Control
Stage Sample Sample
Study of LBP Characteristicsa Type of Intervention Characteristicsa Type of Intervention Outcomes Follow-up
Wand Acute n = 51 “Assess-advise-wait” interven- n = 43 “Assess-advise-treat” interven- • Pain = VAS (0-100) Short term = 6
2004 Age = 35 (7.9) tion based on “The Back Age = 34 (9.0) tion based on “The Back • Function = RMDQ weeks
M/F = 23/28 Book” (education on LBP, M/F = 19/24 Book” + manual therapy (0-24) Medium term = 3
“stay active” advice, relation- n sessions = NR • Quality of life = months
ship between symptoms and Duration = NR SF-36 (0-100), Euro Long term = 6
imaging findings) QoL months
n sessions = NR
Duration = NR
Abbreviations: ADL, activities of daily living; ALBPS, Aberdeen Low Back Pain Scale; GP, general practitioner; LBP, low back pain; M/F, male/female; n,
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number of participants randomized (number of participants completing the study); NR, not reported; NRS, numeric rating scale; ODI, Oswestry Disability
Index; QoL, quality of life; RMDQ, Roland-Morris Disability Questionnaire; SF-36, Short Form 36; VAS, visual analog scale.
a
Mean age is presented with standard deviation within round brackets.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

The overall certainty of evidence was
evaluated according to the Grading of
Recommendations Assessment, Develop-
ment and Evaluation (GRADE) guidelines
(and GRADEpro software18), judging the
evidence based on the following domains:
RoB, inconsistency, imprecision, indirect-
ness, and publication bias.45 Certainty was
downgraded by 1 level if we identified a se-
Journal of Orthopaedic & Sports Physical Therapy®
Thirteen trials were included, and
their characteristics are summarized in
TABLE 1. Four trials focused only on pa-
tients with acute LBP,22,44,50,55 7 trials
focused on mixed conditions (ie, acute
or subacute LBP),4,5,21,25,30,36,37 and 2 tri-
als focused on subacute LBP.41,47 Indi-
vidual patient education varied among
trials, ranging from a booklet to a face-
due to differences between groups at
baseline.5,31,44,47 Five trials were at high
risk of attrition bias due to dropout
rate.4,21,37,47,55 “Summary of findings” tables
are presented in APPENDIX C.
Effect of Individual Education Versus No
Intervention or Placebo Education
Individual patient education was superior

rious flaw in any of the domains. The cer-
tainty of evidence was classified as high,
moderate, low, or very low. High certainty
indicates we have a lot of confidence that
the true effect is similar to the estimated
effect. Moderate certainty means we be-
lieve that the true effect is probably close
to the estimated effect. Low certainty
means that the true effect might be mark-
edly different from the estimated effect.
Very low certainty means that the true ef-
fect is probably markedly different from
the estimated effect.19 The results were
presented in “summary of findings” tables.
RESULTS
to-face education session administered
from a general practitioner or a physio-
therapist (TABLE 1): 6 trials used verbal
education,21,25,41,47,50,55 7 trials used written
education resources,4,5,22,25,30,31,44 and 1
trial used an education video.37
Overall, 4 trials were conducted in the
United States5,22,31,37; 4 trials were con-
ducted in the United Kingdom4,21,44,55; 2
trials were conducted in Australia and/or
New Zealand41,50; and 1 trial was conduct-
ed in the Netherlands,25 Norway,47 and
Sweden.30 Short-term follow-up ranged
from 2 days to 6 weeks, medium-term
follow-up ranged from 3 to 18 weeks, and
long-term follow-up ranged from 6 to 24
months. The mean age of participants
to placebo education for pain intensity at
medium-term follow-up (3 months; MD,
−0.79; 95% CI: −1.52, −0.07; 2 trials, n =
314; moderate certainty) (FIGURE 3).41,50 The
effect size was not clinically relevant, cor-
responding to 0.79 points on a 0-10 pain
scale. No effect for individual patient edu-
cation was found at short- and long-term
follow-up, with low certainty of evidence
due to inconsistency and imprecision (FIG-
URE 3). No trials comparing individual edu-
cation to no intervention on pain intensity
were found.
Physical Function  Two trials with acute
LBP50 or subacute LBP41 tested the effect
of individual patient education compared
to placebo education on physical function-

T
he study selection process is il-
lustrated in FIGURE 1. We excluded 2
trials after contacting the corre-
sponding authors.9,48 We detailed rea-
sons for which all potentially relevant
trials were not included in our review in
APPENDIX B.
ranged from 29.3 to 50.1 years (TABLE 1). ing measured with the RMDQ.41,50 Indi-
vidual patient education was superior at
Risk of Bias Assessment short term (6 weeks; SMD, −0.25; 95%
Eleven trials were at high risk of perfor- CI: −0.47, −0.02; 2 trials, n = 308; mod-
mance bias due to the lack of blinded erate certainty) (FIGURE 3) and medium
clinicians (FIGURE 2).5,21,25,30,31,41,44,47,55 Four term (3 months; SMD, −0.26; 95% CI:
trials were at high risk of selection bias −0.48, −0.04; 2 trials, n = 313; moderate

journal of orthopaedic & sports physical therapy | volume 52 | number 7 | july 2022 | 437

 [ literature review
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Journal of Orthopaedic & Sports Physical Therapy®
FIGURE 2. Risk of bias for each trial included in the review.
certainty) (FIGURE 3); the effect was not
clinically relevant as corresponding to ap-
proximately 1 point on the 0- to 24-point
438 | july 2022 | volume 52 | number 7 | journal of orthopaedic & sports physical therapy
RMDQ. No statistically significant effect
was found at long-term follow-up (FIGURE 3).
No trials comparing individual education
]
to no intervention on physical functioning
were found.
Work Status and HRQoL  Individual pa-
tient education was not superior to no
intervention on work domains (% of pa-
tients not working and workdays lost due
to LBP) at the medium and long term,
based on moderate certainty of evidence
(due to high RoB) derived from 1 study
involving 450 subjects.22 No trials evalu-
ated HRQoL outcomes.
Effect of Individual Education Versus
Noneducational Intervention
Pain Intensity  Six trials investigated the
role of individual patient education com-
pared to noneducational intervention on
pain, specifically physiotherapy approach-
es (eg, manual therapy, exercise therapy)
or usual care.5,21,30,31,47,55 Individual patient
education was not superior to noneduca-
tional intervention at any follow-up, based
on moderate certainty of evidence due to
inconsistency or imprecision (FIGURE 4).
Physical Functioning  Eight trials in-
vestigated the role of individual patient
education compared to noneducation-
al intervention on physical function-
ing. 5,21,25,30,31,43,47,55 Individual patient
education was not superior at short-,
medium-, or long-term follow-up, based
on low, moderate, or high certainty of evi-
dence, respectively (FIGURE 4).
HRQoL  Individual patient education was
superior to noneducational intervention at
short term in improving HRQoL domains
(6 weeks; MD, −12.00; 95% CI: −20.05,
−3.95; 1 trial, n = 65; low certainty) (FIG-
URE 5).55 No differences were reported at
medium- or long-term follow-up, based
on low certainty of evidence from 3 tri-
als 25,47,55 and 2 trials, 25,55 respectively
(FIGURE 5).
Work Absence/Sick Leave  Individual
patient education was superior to non-
educational intervention for sick leave
at medium term (3 months; OR = 0.32;
95% CI: 0.11, 0.88; 1 trial, n = 248; mod-
erate certainty).25 No differences were
found at short- or long-term follow-up,
based on moderate certainty of evidence
due to imprecision.5,21,25 One trial (n =
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Journal of Orthopaedic & Sports Physical Therapy®

FIGURE 3. Mean difference (95% confidence interval) of the effect of individual patient education versus placebo education at short-term (n = 308), medium-term (n =
314), or long-term (n = 304) follow-up on pain by pooling data from 2 trials41,50 as well as standardized mean difference (95% confidence interval) at short-term (n = 308),
medium-term (n = 313), or long-term (n = 306) follow-up on physical functioning by pooling data from 2 trials.41,50 Abbreviations: CI, confidence interval; SD, standard
deviation; Std, standardized.

155) exhibited no effect of individual pa- Effect of Individual Education Versus types of educational interventions4,30,37: 2
tient education on return to work, based Other Types of Patient Education trials compared individual patient educa-
on low certainty of evidence due to high Three trials explored the effect of individ- tion to providing biomedical information
RoB and imprecision.30 ual patient education compared to other (ie, pain is linked to damage, do not lift

journal of orthopaedic & sports physical therapy | volume 52 | number 7 | july 2022 | 439

 [ literature review ]
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Journal of Orthopaedic & Sports Physical Therapy®

FIGURE 4. Standardized mean difference (95% confidence interval) of the effect of individual patient education versus noneducational intervention at short-term (n = 472),
medium-term (n = 759), or long-term (n = 218) follow-up on pain by pooling data from 6 trials5,21,30,31,47,55 as well as standardized mean difference (95% confidence interval)
at short-term (n = 720), medium-term (n = 1090), or long-term (n = 893) follow-up on physical functioning by pooling data from 8 trials.5,21,25,30,31,44,47,55 Abbreviations: CI,
confidence interval; SD, standard deviation; Std, standardized.

440 | july 2022 | volume 52 | number 7 | journal of orthopaedic & sports physical therapy

Downloaded from www.jospt.org at on July 21, 2022. For personal use only. No other uses without permission.
FIGURE 5. Mean difference (95% confidence interval) of the effect of individual patient education versus noneducational intervention at medium-term (n = 403) or long-term
(n = 349) follow-up on quality of life by pooling data from 3 trials.25,47,55 Abbreviations: CI, confidence interval; SD, standard deviation.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
weight if you have back pain)41,47; 1 trial
compared individual patient education to a
standard video educational intervention.37
Pain Intensity  There was moderate cer-
tainty of evidence of no additional benefit
of individual patient education compared
to standard biomedical information at any
Journal of Orthopaedic & Sports Physical Therapy®
follow-up (2 trials, n = 247) (FIGURE 6).4,30
Physical Function  There was moderate
certainty of evidence of no additional
benefit of individual patient education
when compared to traditional standard
information at any follow-up (3 trials, n
= 358) (FIGURE 6).4,30,37
Work Status  There was no evidence that
individual patient education was superior
to other types of education (1 trial, n =
121; low certainty of evidence due to high
RoB and imprecision).30
DISCUSSION
W
e found moderate-certainty
evidence that individual patient
education was superior to pla-
cebo education for improving pain at
medium term and for improving physi-
cal function at the short and medium
term. However, the between-group ef-
fect did not exceed the 20% smallest
worthwhile effect threshold, and we
journal of orthopaedic & sports physical therapy | volume 52 | number 7 | july 2022 | 441
contend that these results are not clini-
cally relevant.
There were no between-group differ-
ences at short- and long-term follow-up
(low-to-moderate certainty of evidence)
and no differences when education was
compared to noneducational interven-
tions (low-to-high certainty of evidence).
Low-to-moderate certainty of evidence
indicates that individual patient education
was superior to noneducational interven-
tion for improving HRQoL up to 6 weeks
and for reducing sick leave up to 3 months.
These findings question the clinical
relevance of individual patient education
as a stand-alone treatment. However, our
data may suggest a role for patient edu-
cation even if no statistical significance
was achieved; for example, when patient
education is compared to placebo/no
intervention, the uncertainty estimates
around the short-term effects on pain in-
tensity include the threshold for a small-
est worthwhile effect.
Our findings were consistent with a
recent review, which found a short-term
effect of advice or education on pain and
disability for nonspecific spinal pain (ie,
neck and back pain).27 Our results were
more imprecise due to fewer included tri-
als (wider CIs). Our review had a more
specific research question and narrowed
the eligibility criteria to focus on acute
and subacute LBP, individual patient ed-
ucation (vs all types of patient education),
and a core outcome set for LBP.
In a previous Cochrane review,11 2.5
hours of verbal education was an effective
intervention for people with acute and/or
subacute LBP compared to no interven-
tion on short- and long-term return to
work.11,24,35 The Cochrane review included
no meta-analysis and no GRADE ap-
proach, which makes direct comparisons
to our results challenging. We identified 2
new trials37,50: 1 trial comparing education
to placebo49 and 1 trial comparing educa-
tion to another type of education (stan-
dard educational videotape).37 Traeger
et al50 had a low RoB, contributing to an
upgrading of the certainty of evidence on
individual patient education for patients
with acute and/or subacute LBP. We did
not include trials with more than 25% of
people suffering from sciatica, meaning
that 2 trials on individual patient educa-
tion deemed effective on return to work by
Engers et al11 were not included.24,35
Guidelines on back pain management
recommend individual patient education
as a key component of a multimodal ap-
proach.15,38,46 Individual patient education
 [ literature review ]
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FIGURE 6. Standardized mean difference (95% confidence interval) of the effect of individual patient education versus other types of patient education at long-term (n = 247)
follow-up on pain of life by pooling data from 2 trials4,30 as well as standardized mean difference (95% confidence interval) at long-term (n = 358) follow-up on physical functioning
of life by pooling data from 3 trials.4,30,37 Abbreviations: CI, confidence interval; SD, standard deviation; Std, standardized.

aims to reassure, promote self-efficacy cation on outcomes more closely related able to change their level of self-efficacy,
and adequate coping strategies, and pre- to developing self-management strate- and be based on a patient-centred dia-
vent fear avoidance and beliefs that could gies, such as self-efficacy and coping logue.” Nevertheless, individual patient
Journal of Orthopaedic & Sports Physical Therapy®

alter the LBP trajectory.2 Despite the lack
of effect on pain and functioning, indi-
vidual patient education could be an im-
portant intervention within a multimodal
approach for patients with subacute LBP.
Individual patient education is superior
to usual care and other interventions in
reassuring patients with LBP,49 and reas-
surance is 1 of the main clinical goals.
Previous studies emphasized the role
of individual preferences to structure a
tailored treatment approach: people with
LBP want clear and tailored explanations
regarding the whole health care process (ie,
diagnosis, therapy, and prognosis issues).
Information and education are a critical
component of the approach to managing
musculoskeletal disorders,32 as is sharing
information regarding self-management
strategies.29 Involving the patient in the
clinical decision-making process is impor-
tant to prevent recurrence of LBP.12
Future systematic reviews may focus
on the effect of individual patient edu-
behavior.
Implication for Practice
Individual patient education alone is
not superior to other interventions, but
it may form part of a multimodal ap-
proach to improving pain and function.
In the clinical setting, patient education
is seldom provided alone, but rather com-
bined with modalities such as exercise
and manual therapy.40,52 Two main issues
hint at the clinical value of individual
patient education for people with acute
and/or subacute LBP: (1) patients want
information and education about their
condition29; (2) education is effective for
reassuring patients, which is a key com-
ponent of health care.49
Some guidelines recommend patient
education for “selected” people with acute
and/or subacute LBP. Who should receive
individual patient education? Stochkend-
ahl et al46 suggest that education “only be
offered to patients who are motivated, are
education seems to have the same effects
on people with different psychosocial
risk profiles.49 Eventually, individual pa-
tient education may have some tangible
advantages compared to other interven-
tions: it is usually cheap (especially when
delivered through booklets) and may be
safer than other interventions (eg, man-
ual therapy, drugs).
Implication for Research
Our findings are mainly based on low-
to-moderate certainty of evidence. Im-
precision was the principal reason to
downgrade the certainty of evidence. It is
unlikely that the effect sizes will become
clinically relevant in favor of patient
education, the need for new trials not-
withstanding.13 Investigating the effect
of patient education on other outcomes
facilitating self-management strategies
may be the priority from now on. Trials
investigating the role of other variables
may also add valuable information to the

442 | july 2022 | volume 52 | number 7 | journal of orthopaedic & sports physical therapy

 body of evidence. None of the included
trials performed an economic evalua-
tion. Therefore, future research should
aim to investigate cost-effectiveness to
better understand the societal and eco-
nomic benefits of patient education when
implemented in health care systems as a
first-line management strategy for acute
and/or subacute LBP.
Limitations
The main limitations of this review may
be related to the date of publication of
the included trials. All included trials,
Downloaded from www.jospt.org at on July 21, 2022. For personal use only. No other uses without permission.
except Traeger et al,50 were published
more than 10 years ago. We included all
the trials focusing on the comparison
between individual patient education
and other interventions: 2 trials inves-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tigated the clinical effect of individual
patient education combined with other
interventions (ie, usual care and exercise
therapy)30,41; this issue may be question-
able since it introduced a likely clinical
heterogeneity when compared to other
included trials.
CONCLUSION
Journal of Orthopaedic & Sports Physical Therapy®
I
ndividual patient education did
not confer clinically meaningful ef-
fects on pain and function over pla-
cebo education for people with acute
and/or subacute LBP. Individual patient
education was not superior to other in-
terventions for improving HRQoL or
work status. t
KEY POINTS
FINDINGS: Individual patient education
reduced pain and improved physical
function compared to no intervention/
placebo education at 3 months, but the
effect sizes were not clinically relevant.
Individual patient education was not su-
perior to other interventions for health-
related quality of life and work status.
IMPLICATIONS: Patient education should
not be recommended as a stand-alone
strategy for managing acute and/or sub-
acute low back pain (LBP). Clinicians
might consider using patient education
journal of orthopaedic & sports physical therapy | volume 52 | number 7 | july 2022 | 443
as part of a multimodal intervention to
reassure patients and foster coping.
CAUTION: Certainty of evidence varied
from low to moderate for most of the
outcomes, preventing definitive con-
clusions about the effect of patient
education for people with acute and/or
subacute LBP.
STUDY DETAILS
AUTHOR CONTRIBUTIONS: All authors con-
tributed to the review and preparation
of the manuscript. Each of the authors
has read and concurs with the content
of the final manuscript.
DATA SHARING: All relevant data are in-
cluded in the article or are available as
online appendices.
PATIENT AND PUBLIC INVOLVEMENT: Patients
or public partners were not involved in
the design, conduct, or interpretation of
this systematic review.
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journal of orthopaedic & sports physical therapy | volume 52 | number 7 | july 2022 | 445