Journal of Physiotherapy 68 (2022) 86–88
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s
Editorial
Advice and education for spinal pain
Joshua R Zadro a, Mark R Elkins b,c
a
Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia;
b
Editor, Journal of Physiotherapy; c Faculty of Medicine and Health, University of Sydney, Sydney, Australia
This Editorial introduces another of Journal of Physiotherapy’s
article collections.1–4 These article collections feature papers in a
specific field of research and that were published in the Journal of
Physiotherapy within the past decade. The featured articles have been
curated to: facilitate access to recent important findings in the field;
highlight trends in the study designs, methodology, populations and
interventions addressed by the research; and provide a scoping
overview of avenues for further research. The studies in this article
collection relate to advice and education as therapeutic interventions
for spinal pain.
Clinical practice guidelines for the management of spinal pain –
the leading cause of years lived with disability globally5 – recommend
advice and education as first-line care.6,7 For low back pain (LBP),
most guidelines recommend advice to maintain normal activities
(86% of guidelines) and avoid bed rest (92%), and reassurance on the
favourable prognosis of LBP (71%).7 For neck pain, most guidelines
state that advice to stay active and avoid rest for . 3 days is beneficial
(73%).6
There has been an exponential accumulation of published evidence
reporting the clinical effects of advice and education. Among this body
of evidence, about half of the records that relate to using advice or
education as an intervention for people with pain are focused spe-
cifically on spinal pain. While that exponential growth shows that
physiotherapy researchers consider this an important topic, it is worth
examining whether advice and education are interventions that pa-
tients would expect to receive from physiotherapists. McRae et al8
surveyed 500 adults and found that most considered the need for
information and education as a quite/extremely important reason to
visit a primary care physiotherapist (68%). This view appeared to be
more common among adults with spinal pain (versus without) and
those without university education (versus with). The most common
reasons to visit a physiotherapist were for pain relief (89%), improved
function (93%) and prevention (90%). Interestingly, less than half of the
participants (38%) considered information and education to be the
most important reason. McRae et al8 suggested that this may be due to
some people believing it is primarily the role of a general pracitioner
(not a physiotherapist) to provide information and education. The
importance of raising awareness of physiotherapists’ roles in
providing first-line information and education was echoed by Teo
et al9 for the management of osteoarthritis. They argued that phys-
iotherapists should be able to educate patients about the potential
benefits and harms of common osteoarthritis medications and surgi-
cal interventions, to ensure that patients make informed choices and
engage in shared decision-making.
Given that most patients expect advice and education when they
visit a physiotherapist,8 let’s consider the content they wish to be
advised and educated about. Lim et al10 conducted a systematic re-
view of the health information needs perceived by adults with LBP
https://doi.org/10.1016/j.jphys.2022.03.006
1836-9553/© 2022 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
and included 41 studies. They found that participants in the included
studies wanted information about the cause of LBP and underlying
pathology, and had a strong desire for a legitimate/definitive diag-
nosis and diagnostic imaging. They also wanted clear, trustworthy
and consistent information on prognosis, treatment options and self-
management strategies that are tailored to their age, lifestyle and
occupation status. They wanted this information delivered in a suit-
able tone, using understandble language.
Past research has suggested that some physiotherapists were
hesitant to provide advice on physical activity because they perceive
that patients do not expect this from them, and prefer physical in-
terventions instead;11 more recent data suggest that this situation has
changed. Kunstler et al12 surveyed 587 adults and found that 65 to
76% thought it likely/extremely likely and important/extremely
important that physiotherapists provide physical activity and general
advice. In contrast to previous data,11 participant’s expectations about
advice were similar or greater than their expectations about specific
physical interventions (eg, massage, manipulation, heat or cryo-
therapy). Physiotherapists should anticipate that patients expect to
receive advice about physical activity and general health, and not
assume that patients expect only passive treatment.
Given that patients want advice and education from their phys-
iotherapists, how effective is it for spinal pain? Jones et al13 con-
ducted a systematic review and meta-analysis of 27 trials and found
low-to-moderate certainty evidence that advice and education for
non-specific spinal pain reduced pain (8 points on a 0-to-100 scale)
and disability (4.5 points) – but only in the short term – compared
with no advice or placebo advice. Small, short-term effects challenge
guideline recommendations that advice and education should be the
sole first-line treatment for spinal pain,14 and suggest that physio-
therapists should also consider providing interventions often rec-
ommended as second-line care (eg, exercise, psychological therapies).
The above review13 only considered studies involving people with
non-specific spinal pain. But what about sciatica? An invited topical
review concluded that first-line care for people with sciatica (which,
in the literature, often encompasses related diagnoses such as radi-
culopathy and radicular pain) should include information about the
condition and the role of imaging, advice to stay active, and advice to
avoid bed rest.15 Information should cover the nature and prognosis
of sciatica, and that imaging is unnecessary, unless a more serious
condition is suspected (eg, cauda equina syndrome). Despite these
recommendations, there is a lack of high-quality evidence on advice
and education for sciatica. A 2010 Cochrane review16 found no effect
of advice to stay active on pain and function compared with advice to
rest in bed (based on low-certainty evidence from two trials). One
trial found little-to-no difference in outcomes between physio-
therapy, advice to stay active and advice to rest in bed.17 A more
recent review18 of five trials found low-certainty evidence that

Table 1
Pooled median (IQR) percentages of physiotherapy treatment choices involving advice and education that were recommended (green), were not recommended (orange) or had no
recommendation (grey) for different spinal conditions. Data from Zadro et al.26
Spinal condition Method of data Advice to stay active
collection
Acute LBP Surveys of physiotherapists 32% (13 to 55) n = 7
Clinical notes 70% n = 1
Post-acute LBP Surveys of physiotherapists 56% (35 to 76) n = 4
Mixed duration Surveys of physiotherapists 35% n = 1
LBP Clinical notes 50% (30 to 56) n = 3
Advice to stay active
Neck pain Surveys of physiotherapists 93% (89 to 96) n = 2
Acute whiplash Surveys of physiotherapists 81% (44 to 87) n = 3
Chronic whiplash Surveys of physiotherapists 80% (79 to 80) n = 2
IQR = interquartile range, LBP = low back pain; n = number of studies contributing data.
supervised exercise is superior to advice for reducing leg pain in the
short-term (11 points on a 0-to-100 scale, 95% CI 1 to 22), but not for
reducing short-term disability (1 point on a 0-to-100 scale, 95% CI –3
to 5). No effects were observed in the long term (moderate-certainty
evidence). This suggests that advice and education alone may be
insufficient if reducing leg pain is the desired outcome.
Another invited topical review concluded that people with neck
pain need: reassurance that their pain is not due to a serious condi-
tion; information on pain and prognosis; information that imaging is
unnecessary; advice to stay active; and education about self-care,
exercises and stress coping skills.19 These recommendations were
largely based on a 2016 systematic review of six trials.20 The review
found that stuctured patient education provides similar effects to
other conservative interventions for improving the recovery of
whiplash and neck pain, and that stuctured patient education may
have a small, transient effect on whiplash if it is combined with
physiotherapy or emergency room care.
Guidelines for the management of LBP often advise clinicians to
spend time reassuring patients to aid recovery; recent data challenge
this recommendation. In a 2019 randomised controlled trial,21
including 202 participants with acute LBP at high risk of developing
chronic LBP, two 1-hour sessions of pain education were compared
with sham education, where both groups received guideline-based
advice. It found that pain education was not superior to sham edu-
cation for reducing pain intensity (primary outcome), but it did have
small, short-term effects on reducing disability and care-seeking. To
explore potential mechanisms of effect, Cashin et al22 conducted a
mediation analysis on this trial. They found that although pain edu-
cation reassured patients, feeling reassured did not explain improve-
ments in disability and care-seeking. This challenges the idea that
clinicians need to spend a lot of time reassuring patients with LBP.
Instead, clinicians should spend more time on other important aspects
of care (eg, listening to a patient’s story, estimating and discussing
prognosis, and matching preferences with recommended care).
Advice and education combined with a structured exercise pro-
gram can play a role in the prevention of spinal pain;23 however, the
effectiveness of this approach seems to depend on how intensive the
intervention is. De Campos et al24 conducted a randomised controlled
trial including 262 adults who had recovered from an episode of LBP
within the last 6 months. They examined the effect of a 2-week
McKenzie-based self-management exercise and education program
delivered over two 30- to 45-minute sessions compared with one
session of telephone advice. The intervention had no effect on
recurrence of LBP generally or activity-limiting LBP specifically. There
was some indication that patients who received the intervention
were less likely to seek treatment when their pain recurred (344 days
to care-seeking versus 238 days, HR 0.69, 95% CI 0.46 to 1.04);
however, this finding should be viewed with caution, as care-seeking
was a secondary outcome. One possible explanation for the lack of
effect of the intervention was that the education and exercise pro-
gram was not intensive enough. A systematic review of 21 trials23
found that combined education and exercise programs reduced the
Editorial 87
Advice and education Reassurance Other advice (posture, heavy Advice promoting bed
to support lifting, sit/stand habits, rest or time off work
self-management analgesics, avoid painful
movements)
- 3% n = 1 70% (54 to 75) n = 11 9% (2 to 28) n = 8
- - 49% (34 to 62) n = 5 -
- - 68% (57 to 86) n = 9 1% (0 to 6) n = 7
26% (22 to 31) n = 2 16% n = 1 89% (77 to 93) n = 4 26% (6 to 57) n = 4
21% (16 to 27) n = 2 - 68% (33 to 91) n = 9 23% (12 to 33) n = 3
Information on nature, Advice on posture or analgesics Advice promoting bed
management and course rest or time off work
- 96% n = 1 12% n = 1
56% (41 to 70) n = 2 53% (32 to 74) n = 2 11% (5 to 15) n = 2
60% n = 1 95% n = 1 10% (5 to 15) n = 2
risk of future LBP episodes by nearly 50%. Most trials in this review
demonstrated an effect on prevention and it appears that effective
programs were longer and more intensive (eg, 20 sessions over a 13-
week period) than the program tested by de Campos et al.24 However,
a potential problem is that long, intensive education and exercise
programs do not appear to be acceptable to patients.25 Future
research is needed to identify effective prevention programs that are
flexible and low-cost.
Advice and education can play an important role in the prevention
and treatment of spinal pain, but it needs to be the right advice and
education. A 2019 systematic review of 94 studies summarised
physiotherapists’ use of various treatments for musculoskeletal con-
ditions. Treatments commonly provided by physiotherapists,
including advice and education, were categorised as recommended,
no recommendation (unknown value) and not recommended, based
on guidelines.26 For spinal pain, between 3 and 93% of physiothera-
pists provided recommended advice and education (eg, stay active,
reassurance), 49 to 96% provided advice and education that is of
unknown value (eg, advice on posture), and 1 to 26% provided advice
and education that is not recommended (eg, bed rest, time off work).
It appears that more physiotherapists provided guideline-based
advice for neck pain compared with LBP (Table 1). A systematic re-
view by Gardner et al27 offers possible insight into why some phys-
iotherapists fail to provide guideline-based advice. The review
explored the influence that physiotherapists’ beliefs and attitudes
about chronic LBP have on their management approach. The main
finding was that physiotherapists with a higher biomedical orienta-
tion were more likely to give patients advice to delay return to work
and activity. This suggests that a biomedical orientation may be
preventing some physiotherapists from providing reassurance and
guideline-based advice to stay active.
This article collection highlights several important avenues for
future research. McRae et al8 identified the need to raise public
awareness of physiotherapists’ roles in providing first-line advice and
education. Jones et al13 highlighted the need for future studies on
advice and education to investigate whether their effect is modified
by fidelity to the intervention and baseline knowledge and beliefs
about spinal pain. Cashin et al22 opened a new line of enquiry into
research exploring potential mediators that could explain the effect of
advice and education. de Campos et al24 highlighted the need to find
effective low-cost, scalable and acceptable spinal pain prevention
programs. Gardner et al27 demonstrated the need for better education
and training of physiotherapists, to reduce biomedical management
orientations. In addition to the studies mentioned in this article
collection, Suman et al28 identified several mass media campaigns on
the management of LBP, which appeared to be effective for improving
back pain knowledge and beliefs of the public and clinicians. Unfor-
tunately, these campaigns often only run for a limited time and have
only been evaluated in limited cultural and regulatory contexts.
Future research should aim to explore and overcome the barriers to
re-running effective campaigns and to evaluate campaigns in new
places.
88 Editorial

In summary, this article collection includes a range of important 3. Dennett AM, et al. J Physiother. 2020;66:70–72.
4. Goff AJ, et al. J Physiother. 2021;67:240–241.
developments in research into advice and education for spinal pain. 5. James SL, et al. Lancet. 2018;392:1789–1858.
The study designs addressed patient expectations,8–10,12 treat- 6. Parikh P, et al. BMC Musculoskelet Disord. 2019;20:81.
ment,13,15,19 prevention,24 causation,13,24 mediation,22 and practice 7. Oliveira CB, et al. Eur Spine J. 2018;27:2791–2803.
8. McRae M, et al. J Physiother. 2017;63:250–256.
patterns.27 Importantly, each paper has clear implications for clinical
9. Teo PL, et al. J Physiother. 2020;66:256–265.
physiotherapists, which are identifiable in the paper’s ‘What this 10. Lim YZ, et al. J Physiother. 2019;65:124–135.
study adds’ summary box. 11. Breanne E, et al. AIMS Med Sci. 2018;5:224–237.
Competing interests: Nil. 12. Kunstler B, et al. J Physiother. 2019;65:230–236.
13. Jones CMP, et al. J Physiother. 2021;67:263–270.
Source(s) of support: Nil. 14. Almeida M, et al. Med J Aust. 2018;208:272–275.
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Provenance: Invited. Peer reviewed. 16. Dahm KT, et al. Cochrane Database Syst Rev. 2010;6, CD007612.
17. Hofstee DJ, et al. J Neurosurg. 2002;96(Suppl 1):45–49.
Correspondence: Mark R Elkins, Centre for Education & Workforce 18. Fernandez M, et al. Spine. 2015;40:1457–1466.
Development, Sydney Local Health District, Sydney, Australia. Email: 19. Verhagen AP. J Physiother. 2021;67:5–11.
mark.elkins@sydney.edu.au 20. Yu H, et al. Spine J. 2016;16:1524–1540.
21. Traeger AC, et al. JAMA Neurol. 2019;76:161–169.
22. Cashin AG, et al. J Physiother. 2021;67:197–200.
23. Steffens D, et al. JAMA Int Med. 2016;176:199–208.
24. de Campos TF, et al. J Physiother. 2020;66:166–173.
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