CHAPTER 6 Watchful Waiting and Brief Education

Ben B. Pradhan, Jens Ivar Brox, Aage Indahl

Description

Terminology and Subtypes

Watchful waiting, in the context of this chapter, is defined as minimal care through activity modification, education, and observation of the natural history of low back pain (LBP). It is passive in nature and does not include any interventions delivered by a health care provider to address specific symptoms (e.g., prescription medications, injections, supervised exercises, manual therapies). Watchful waiting does not indicate a complete absence of health care, and does not imply that symptoms are ignored by the patient. The decision to initiate watchful waiting may in fact be made by a health care provider after an initial consultation to rule out the possibility of potentially serious spinal pathology. This decision is often made in conjunction with the patient, and may represent an educated choice by those who have been informed of the relative efficacy, harms, and costs of available treatment options, and nevertheless select watchful waiting.

As a treatment philosophy, watchful waiting is very conservative and relies on giving the patient a chance to heal naturally without relying on external interventions. Watchful waiting can also include various patient-initiated comfort measures such as home heat or ice, postural modifications, lumbar supports (e.g., braces, belts) or over-the-counter topical analgesics. Self-care is encouraged to determine whether a patient can reduce his or her own symptoms through simple tactics before concluding that more invasive, costly, time-consuming, or potentially harmful interventions are warranted. Watchful waiting consists of the following types of approaches: watchfulness, waiting, reassurance, activity modification, and education. Most of these are tried in combination, and may be considered progressive steps in watchful waiting.

Brief education, on the other hand, usually consists of a single discussion with a health care provider. The content of this discussion varies, but typically includes basic education about the etiology of LBP, the expected prognosis of LBP, the treatment options available for LBP, tips for self-managing LBP, and circumstances in which to consider seeking additional care for LBP. Because watchful waiting also requires that clinicians educate their patients about why it may be an appropriate approach to managing LBP, the line between watchful waiting and brief education is often blurry. Advocates of watchful waiting often imply that brief education will be performed as part of this process without considering that brief education itself constitutes an intervention strategy for LBP. Although they are presented separately in this chapter, watchful waiting and brief education may in fact be synonymous depending on how they are implemented.

History and Frequency of Use

The management of LBP has undergone several paradigm shifts in the past century, from being mostly ignored to gradually being considered something of a nuisance. LBP was then attributed to newly discovered pain generators that could be eliminated with surgical interventions. After poor long-term results from those interventions, LBP was eventually deemed a condition whose etiology was complex but could nevertheless be addressed with prevention. When substantial sums were invested in workplace ergonomic modifications without noticeable improvement in LBP outcomes, it was proposed that LBP was a biopsychosocial illness involving physical, behavioral, occupational, and socioeconomic factors that could be addressed through behavioral approaches. That view largely prevails today, and common LBP is now widely considered a benign condition without any obvious anatomic cause that is self-limiting in the short term and is likely to recur, but can be managed with conservative approaches. Such statements are usually made with the caveat that LBP is occasionally associated with potentially serious spinal pathology or results in severe neurologic deficits, both of which may require more invasive interventions.

Given these changes in the broad understanding of LBP, it is not surprising that the advice given to patients by health care providers about LBP has changed markedly over the years, often resulting in contradictory messages, misconception, and confusion. The application of evidence-based medicine (EBM) to the management of LBP attempted to improve and clarify this situation. In the early 1990s, the Agency for Health Care Policy and Research (AHCPR), presently known as the Agency for Healthcare Research and Quality (AHRQ), assembled a multidisciplinary group of expert clinicians and researchers to develop clinical practice guidelines (CPGs) on the management of acute LBP in adults based on the best available scientific evidence.¹ It was proposed at the time that the first step in managing LBP was to conduct a basic diagnostic triage and group patients into one of three categories: (1) potentially serious spinal conditions (e.g., spinal fracture, spinal infection, spinal tumor, or cauda equina syndrome), (2) nerve root compression (e.g., sciatica, radiculopathy), and (3) nonspecific back symptoms. This triage was intended to be sequential and to unfold by process of elimination (e.g., after eliminating potentially serious spinal conditions and nerve root compression, it was assumed that the patient had nonspecific LBP). Although potentially serious spinal conditions required additional diagnostic testing, both nerve root compression and nonspecific LBP were deemed self-limiting in most cases and could improve without medical attention or with only conservative interventions. These recommendations were widely distributed in the United States, and this approach was slowly adopted by health care providers, after which watchful waiting became a more accepted option for LBP.

Traditional approaches based on the medical model of disease were contrasted with a biopsychosocial model of illness to reexamine success and failure in the management of LBP. This shift in thought regarding LBP inspired others to reconsider its management. For example, Indahl and colleagues began telling patients with LBP that light activity would not further injure their discs or other structures.² Following a clinical examination, brief education was given by a physiatrist, physical therapist, or nurse, who instructed patients that the worst thing they could do to their back was to be too careful. Any perceived link between emotions and chronic low back pain (CLBP) was simply attributed to increased tension in the muscles. Brief education has also been managed in the physical therapy setting.^3,⁴ Cherkin and colleagues evaluated the value of an educational booklet in patients with acute LBP, which was not effective in reducing symptoms, disability, or health care use.⁵ Their findings challenged the value of purely educational approaches in reducing symptoms and costs of LBP when delivered solely with a booklet.

Practitioner, Setting, and Availability

A licensed health care provider trained in recognizing signs and symptoms of red flags associated with serious spinal pathology may administer this intervention. This may include a primary care physician, spine specialist, chiropractor, or physical therapist. The qualifications and training required for brief education varies considerably depending on the nature of the advice given. This intervention is widely available in the United States in a variety of private practice, clinic, or hospital settings.

Procedure

Watchful Waiting

Watchfulness

Waiting for symptoms of LBP to resolve does not mean ignoring telltale signs of something more serious, thus the term “watchful” waiting. If a health care provider is recommending watchful waiting for someone with LBP, a detailed medical history is critical. Certain conditions require urgent diagnosis and treatment (e.g., tumors, which usually cause slow, progressive pain, unless there is a pathologic fracture). Acute pain, in the back or leg, may also be caused by disc herniation, whereas paraspinal symptoms are usually muscular in origin. Most LBP is mechanical in nature (worse when loading or moving the back). Nonmechanical back pain, or pain during rest, usually indicates an inflammatory, infectious, or oncologic origin. There are also certain conditions that exhibit red flags, which can be detected with careful screening through history-taking and physical examination and need urgent diagnosis and appropriate treatment.

It has been observed in several reports that the vast majority of acute LBP episodes resolve spontaneously with time (Figure 6-1). A preexisting active lifestyle has been shown to accelerate symptomatic recovery and to reduce chronic disability.⁷ The routine use of passive treatment modalities is not recommended, because it might promote chronic pain behavior. Such interventions may be more appropriate for “subacute” pain. The British Medical Journal reported that increased stress from therapeutic exercises may be harmful in acute LBP based on a randomized clinical trial that was included in the Philadelphia Panel.⁸

Figure 6-1 Watchful waiting requires patience and education.

(Image courtesy of Deluxe for Business, Shoreview, MN.)

Reassurance

Reassurance may help patients, decreasing their stress and anxiety, and thus reducing inappropriate pain behavior and encouraging proactive healthy behavior (Figure 6-2). Reassurance may be the first step of psychological treatment. Some authors recommend that in addition to the traditional examination of neurologic symptoms and signs, psychological factors should be considered at the initial visit for a patient with an episode of LBP. Reassurance usually consists of educating the patient that LBP is a common problem and that 90% of patients recover spontaneously in 4 to 6 weeks.⁹ Patients also need to be reassured that complete pain relief usually occurs after, rather than before, resumption of normal activities and that they may return to work before obtaining complete pain relief; working despite some residual discomfort from LBP poses no threat and will not harm them.¹⁰

Figure 6-2 Reassurance is an important part of watchful waiting.

Activity Modification

Although severe LBP may necessitate rest or activity modification as tolerated by each patient, mandatory bed rest has not been shown to be beneficial in the overall course of acute back pain. If disabled by pain, bed rest may be recommended, but for no more than two days, because longer periods of bed rest can delay recovery.¹⁰^–¹² The Philadelphia Panel found good evidence to encourage continuation of normal activities as an intervention for people with acute LBP.⁸ The Institute for Clinical Systems Improvement (ICSI) also recommends that patients with acute LBP be advised to stay active and continue ordinary daily activities within the limits permitted by the pain. Patients may be advised to carefully introduce activities back into their day as they begin to recover.¹⁰ Gradual stretches and regular walking are good ways to get back into action. Patients also need to be told to relax, because tension will only make their back feel worse. Patients should also be instructed to avoid activities that caused the onset or aggravation of symptoms, especially those that peripheralize (spread outward to the extremities) symptoms.

Education

Educating patients about LBP can help them take steps in their everyday lives that will help maintain back health (Figure 6-3). Although most studies point to the spontaneous resolution of the vast majority of episodes of LBP, there exists controversy in this area. For example, ICSI provides a slightly less optimistic outlook and states that most patients will experience partial improvement in 4 to 6 weeks and will have a recurrence of LBP in 12 months.¹⁰ The long-term course of LBP typically allows for a return to previous activities, although often with some pain. Employers are encouraged to develop and make available patient education materials concerning prevention of LBP and care of the healthy back. Topics that should be included are promotion of physical activity, smoking cessation, and weight control; these interventions are reviewed in Chapter 5. Emphasis should be on patient responsibility and self-care of acute LBP. Employer groups should also make available reasonable accommodations for modified duties or activities to allow early return to work and minimize the risk of prolonged disability. Education of frontline supervisors in occupational strategies to facilitate an early return to work and to prevent prolonged disabilities is recommended.¹⁰

Figure 6-3 Education is an important component to managing low back pain.

Patients with CLBP often find that their symptoms wax and wane over time, and many of them have devised means of minimizing their symptoms. In the event that these methods are no longer effective, symptoms are worsening, physical function is interfering with their ability to conduct normal activities, sleep is deteriorating and is no longer restful, or quality of life has decreased markedly, it is reasonable to seek advice from a health care provider. Even those patients dedicated to watchful waiting may need to consult with a health care provider at some point to receive additional reassurance and advice on other approaches to managing their LBP.

Brief Education

Brief education encompasses many of the elements already described and attempts to achieve the same goals as back schools in a condensed time period. Brief education often consists of a single discussion with a health care professional, including physical therapists, primary care physicians, chiropractors, or behavioral health care providers. Follow-up sessions may also be held to reinforce some of the important messages or monitor changes in clinical presentation (Figure 6-4). Alternatively, brief education may also be delivered by a trained lay person (often someone who has personally experienced CLBP), or supplemented through a brochure or book, or in a moderated online discussion group.¹³ Brief education often summarizes some of the basic information about LBP presented in lengthier back schools. Back schools are not standardized but generally encourage self-management using heat, ice, over-the-counter analgesics, or relaxation techniques, provide advice to remain active despite the pain, and address common misconceptions about LBP (e.g., that diagnostic imaging is always required).

Figure 6-4 Reinforcement may be required to educate patients about low back pain.

Regulatory status

Not applicable.

Theory

Mechanism of Action

The principal mechanism of action involved in watchful waiting is allowing sufficient time for the body’s natural healing mechanisms to repair the injured tissues at the root of CLBP, whatever they may be. Watchful waiting therefore depends on what is currently known about the natural history of LBP. Epidemiologic studies of LBP indicate that it is a common but benign condition of mostly unknown etiology that generally improves within a few weeks and disappears within a few months, although periodic recurrences are expected.¹⁴ Such observations are based on population studies and cannot be extrapolated to every patient with LBP. Watchfulness is therefore necessary to identify rare but potentially serious spinal pathology that may be responsible for symptoms and may require urgent treatment. It is also important to identify rare nonspinal causes of LBP that may need to be addressed if the LBP is to improve.

An essential component of watchful waiting is continual reassurance, which is thought to decrease anxiety related to the LBP, and therefore minimize its negative impact on recovery and quality of life. Although temporary activity modification may occasionally be required for severe acute LBP, patients with CLBP need to be instructed to remain physically active and not attempt to favor their backs by avoiding activities perceived to aggravate symptoms. Educating patients, as stated previously, can help them take steps in their own everyday lives that will help maintain back health.

Nonspecific CLBP may have an association with an imprint of pain that exists in the central nervous system, specifically the spinal cord and the brain. Thus, patients who experience acute LBP – even if it fully resolves—may continue to have residual pain signals in the central nervous system. This makes it important to properly treat acute LBP, avoiding treatments that may unnecessarily aggravate the symptoms, and especially letting self-limiting episodes experience a natural recovery.

Indication

Watchful Waiting

This intervention is indicated for patients with nonspecific CLBP without red flags for serious spinal pathology who do not wish to seek any form of active care and understand the advantages and disadvantages of watchful waiting.

Brief Education

The ideal patient may be a young manual laborer who enjoys his or her job but has been out of work (for the first time) for less than 8 weeks due to LBP. Although these patients have a normal range of motion, they move carefully in an attempt to avoid pain, and their back muscles are tense and painful. Magnetic resonance imaging may have revealed a small disc protrusion, which is not believed to be the cause of pain or functional limitations. They may have tried medications, massage, and acupuncture, but these did not improve their symptoms.

Assessment

Before receiving watchful waiting or brief education, patients should first be assessed for LBP using an evidence-based and goal-oriented approach focused on the patient history and neurologic examination, as discussed in Chapter 3. Additional diagnostic imaging or specific diagnostic testing is generally not required before initiating these interventions for CLBP.

Efficacy

Evidence supporting the efficacy of these interventions for CLBP was summarized from recent CPGs, systematic reviews (SRs), and randomized controlled trials (RCTs). Observational studies (OBSs) were also summarized where appropriate. Findings are summarized by study design for each intervention.

Clinical Practice Guidelines

Watchful waiting

None of the recent national CPGs on the management of CLBP have assessed and summarized the evidence to make specific recommendations about the efficacy of watchful waiting as a sole intervention for CLBP. However, many CPGs have included a discussion of related messages, i.e., diagnostic tests are rarely indicated for most patients with CLBP, many interventions have relatively small effects, and education and self-care should be encouraged to improve long-term outcomes.

Brief Education

Four of the recent national CPGs on the management of CLBP have assessed and summarized the evidence to make specific recommendations about the efficacy of brief education.

The CPG from Europe in 2004 found conflicting evidence that brief education delivered through Internet-based discussion groups is more effective than no intervention with respect to improvements in pain and function.¹³ That CPG also found limited evidence that brief education is as effective as massage or acupuncture with respect to improvements in pain and function. That CPG also found moderate evidence that brief education combined with advice to remain active is more effective than usual care with respect to improvements in disability. That CPG also found moderate evidence that brief education encouraging self-care is more effective than usual care with respect to improvements in function, but not pain. That CPG also found strong evidence that brief education, when combined with advice to remain active, is as effective as usual physical therapy or aerobic exercise with respect to improvements in function. That CPG recommended brief education in the management of CLBP.

The CPG from Belgium in 2006 found moderate evidence that brief education is effective with respect to improvements in function and disability.¹⁵ That CPG recommended brief education in the management of CLBP.

The CPG from the United States in 2007 found evidence of a moderate benefit for brief education in the management of CLBP.¹⁶

The CPG from the United Kingdom in 2009 reported that brief education alone is not sufficient for the management of CLBP.¹⁷

Findings from the above CPGs are summarized in Table 6-1.

TABLE 6-1 Clinical Practice Guideline Recommendations About Watchful Waiting and Brief Education for Chronic Low Back Pain *

Reference	Country	Conclusion
Brief Education
¹³	Europe	Recommended for management of CLBP
¹⁵	Belgium	Recommended for management of CLBP
¹⁶	United States	Evidence of moderate benefit
¹⁷	United Kingdom	Brief education alone is not sufficient

CLBP, chronic low back pain.

* No CPGs made recommendations about watchful waiting as an intervention for CLBP.

Systematic Reviews

Watchful Waiting

No recent, high-quality SRs were identified that reported specifically on the efficacy of watchful waiting as an intervention for LBP.

Brief Education

Cochrane Collaboration

An SR was conducted in 2008 by the Cochrane Collaboration on individual patient education for acute, subacute, and chronic nonspecific LBP.¹⁸ A total of 24 RCTs were included. Of those, 14 included acute or subacute LBP patients, 4 included CLBP patients, and 6 included a mixed population.^2,¹⁹^–⁴⁰ This SR concluded that individual education was not effective compared with noneducational interventions for CLBP. In particular, written educational material is less effective than noneducational interventions.

Other

An SR was conducted in 2008 by Brox and colleagues on back schools, brief education, and fear avoidance training for CLBP.⁴¹ A total of 23 RCTs were included, of which 12 pertained to brief education. This SR concluded that there is strong evidence that brief education leads to reduced sick leave and short-term disability versus usual care. However, there was strong evidence that brief education in the clinical setting did not reduce pain compared with usual care and limited evidence that brief education in the clinical setting did not reduce pain compared with back school or exercise. Furthermore, this SR concluded that there is conflicting evidence for certain types of brief education (e.g., back book, Internet discussion) versus comparators such as a waiting list, no intervention, massage, yoga, or exercise.

Findings from the above SRs are summarized in Table 6-2.

TABLE 6-2 Systematic Review Findings on Watchful Waiting and Brief Education for Chronic Low Back Pain*

Randomized Controlled Trials

Watchful Waiting

No RCTs were identified that reported specifically on the efficacy of watchful waiting as an intervention for LBP.

Brief Education

Eleven RCTs and 14 reports related to those studies were identified.^2,^21,^25,^29,^31,^33,^34,^36,⁴²^–⁴⁷ Their methods are summarized in Table 6-3. Their results are briefly described here.

TABLE 6-3 Randomized Controlled Trials of Brief Education for Chronic Low Back Pain

An RCT conducted by Indahl and colleagues ^2,⁴² included LBP patients at a spine clinic in Norway. Participants were patients with subacute or chronic (4 to 12 weeks) LBP who were referred to the clinic; excluded were pregnant women on sick leave for LBP and patients with LBP lasting longer than 12 weeks. The intervention group (initially, n = 463; 5-year follow-up, n = 245) were assigned to treatment consisting of an examination, information about reflex activation of spinal muscles, reassurance to reduce fear and sickness behavior, mini-back school, and encouragement to set their own physical activity goals. The control group (initially, n = 512; 5-year follow-up, 244) consisted of usual care. Pain and disability outcomes were not measured in this study. This study was considered of higher quality.

An RCT conducted by Von Korff and colleagues ⁴³

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