A most interesting study, which reported that the patients’ illness behaviour (costs of healthcare utilisation and absenteeism from work) was significantly reduced, despite the absence of significant clinical improvement. The reduction of healthcare and absenteeism costs more than covered the costs of the lifestyle modification program. This study goes beyond the traditional clinical outcome assessment and practical guidelines that primarily focus on the reduction of pain and disability. In this randomised controlled study, the intervention group received a one-hour clinical consultation with a physiotherapist and a 6-month telephone-based health coaching intervention in addition to usual care. The telephone coaching consisted of ten five-minute telephone sessions that focused on lifestyle changes, to support the individuals to modify their eating behaviors, increase physical activity, achieve and maintain a healthy weight, and where appropriate included referral to smoking cessation services. The limitation of the study, as in most randomised controlled studies, was that patients with known or suspected serious pathology were excluded. Thus, the findings are limited to the patients with chronic low back pain in which there is no evident physiological cause.
I wish that the authors had explored the reasons for this surprising outcome. I hypothesise that the coaching intervention, which focused on a healthy lifestyle, was perceived by the patient as caring and attention - two important qualities that are not reimbursed by third party payers (such as insurance companies) and tend to be eliminated from treatment because of time constraints or absence of published efficacy studies. When people experience caring and support in changing diet and exercise, they may feel more empowered and hopeful - they have control over what they are doing. The focus is not on discomfort, but lifestyle changes that are within the patients’ control. Thus, they experience less urgency to seek additional health care interventions or to stay home from work even though their discomfort did not change.
This may be an important contributing reason why patients with low back pain report that postural modifications are most useful: because they are taught skills and receive attention that they can continue to do at home.
Take home message: The findings of this study are highly relevant to policy makers, since the study suggests that healthy lifestyle coaching would reduce societal economic costs. It also suggests that therapists working with patients, who have chronic low back pain and are overweight, may want to include lifestyle modification coaching. If therapists continue to remind patients even in follow-up telephone calls to modify their lifestyle, it may help patients reduce absenteeism or unnecessary medical care utilisation.