Introduction

Many who are affected are reluctant to increase activity despite back pain and still this is the most consistent recommendation for people experiencing it. Many healthcare professionals are already doing their absolute best to educate people about the benefits and safety of moving irrespective of the presence of pain. This contrasts with the widespread belief that low back pain is dangerous and a serious concern. In the community, this narrative can be reinforced by inaccurate information that can be found on “health websites”. As such, many naive people still believe that low back pain requires diagnostic imaging and medical care. This perception could stop people from following the advice of staying active. To counter this, the authors of the current study proposed a video explaining more about low back pain to challenge community beliefs about the need for medical care. They proposed a neutral video and a humorous one since it was shown that humorous messages have the potential to lessen health-related anxiety and promote positive action. Further, they hoped that the humorous messages would “go viral”, hoping that the positive narrative would be spread across as many individuals as possible.

Methods

This randomized controlled trial included adults over 18 years with and without low back pain. They were recruited online through Facebook and were sent a survey. Those without low back pain were asked to imagine having it for the study’s purpose. A total of 3 groups were formed:

• People received a humorous video explaining a reassuring message about back pain and the safety of remaining active
• People receive a neutral video with the same message
• People in the control group did not receive any video

The included participants were randomly assigned to one of those groups after filling out demographic data. After watching the video, they completed the primary and secondary outcomes.

In the video, the narrative explained that low back pain is a common condition in which it is safe to move and stay active. The purpose was to examine whether people increase activity despite back pain after watching the video.

Self-efficacy measured using the Pain Self-Efficacy Questionnaire (PSEQ) was the primary outcome. Only the 10th question was considered. This item 10 questions participants to rate how confident they would feel to gradually become more active despite the pain. Responses ranged from 0 (not at all confident) to 6 (completely confident).

As a secondary outcome, participants were asked about their attitudes towards staying active. This was questioned using Factor 1 of the AxEL-Q Questionnaire, a validated questionnaire designed to assess attitudes toward first-line care for low back pain. Factor 1 comprises 9 items and evaluates attitude toward staying active; the score range is 0 to 54, with higher scores indicating a more positive attitude toward messages about staying active.

Results

1933 people were randomly assigned to one of both video groups or to the control group. They were on average 58.9 years old and the majority were female (75%). Seventy percent of the included participants experienced low back pain and in 87% of them, this had been lasting longer than 3 months.

The primary outcome revealed that the participants who watched a humorous or neutral educational video reported a higher level of confidence in becoming active despite their low back pain compared to those in the control group who didn’t watch a video. The mean difference of the humorous video versus no video was 0.3 (95% CI 0.1 – 0.6) and the mean difference of the neutral video versus no video was also 0.3 (95% CI 0.1 – 0.5). No difference was observed between the participants who viewed a neutral or a humorous video (mean difference = 0 (95% CI (-0.2 – 0.3)).

As a secondary outcome, the results showed that those who viewed a video had a more positive attitude toward staying active than those who did not watch a video. Also here, no significant difference was observed between the humorous and neutral video.

Questions and thoughts

Should we now all record videos to help people increase activity despite back pain? Of course not. However, when such a video with detailed and correct information regarding back pain and activity would be the first thing patients would find when searching the internet, it would for sure help tackle common misbeliefs.

But was that difference meaningful? Participants who watched either video reported a mean confidence level of 0.3 points higher on the PSEQ compared to the control group. Both video groups reported more positive attitudes towards staying active compared to the control group, with a mean difference of 2.8 points for the humorous video and 2.7 points for the neutral video. It appears that these differences are really small.

What we can take away from this study however, is that with a short but positive message, we can already inform and educate (naive) people with (and without) low back pain and reassure them that staying active is one of the best ways to recover from low back pain.

In the subgroup analysis, no associations were found between group allocation and confidence about becoming more active due to having or not having low back pain and pain intensity. Similarly, no association emerged for the attitude toward staying active according to whether the participant had current low back pain.

Talk nerdy to me

Outcomes were assessed only after the intervention (watching the video). This refrains us from analyzing the changes that an individual experienced from baseline to after watching the video.

An important aspect to note from this study was the high retention rate, as 88% of participants completed the primary outcome. Furthermore, the trial was held on a large scale and included many participants. Reporting was according to the CONSORT statement and the trial was prospectively registered.

People who enrolled were naive to the study’s purpose since they were only told that they were invited to participate in back pain-related research. As such, the hypothesis remained undisclosed. Further, the control group did not know about the existence of an intervention group. Since everything was registered using an online survey, participants, assessors, and analyzers were blinded to group allocation.

The findings suggest that physiotherapists can consider using brief educational videos as part of their strategy to improve patients’ confidence to increase activity despite back pain. Given the small effect size, these videos should be part of a comprehensive approach that includes other educational and motivational interventions.

Take-home messages

The study demonstrated that a brief video intervention could slightly improve confidence to increase activity despite back pain. However, the effect size was small, and the clinical relevance might be limited. The humorous video did not show a significant advantage over the neutral video in enhancing confidence.

Reference

O’Hagan ET, Traeger AC, Schabrun SM, O’Neill S, Wand BM, Cashin AG, Williams CM, Harris IA, McAuley JH. It’s OK to Move! Effect of a Brief Video on Community Confidence in Activity Despite Back Pain: A Randomized Trial. J Orthop Sports Phys Ther. 2024 Jun;54(6):1-8. doi: 10.2519/jospt.2024.12412. PMID: 38635937.