Effects of individualised directional preference management versus advice for reducible discogenic pain: A pre-planned secondary analysis of a randomised controlled trial.

BACKGROUND: Low back disorders are prevalent and directional preference management is a common treatment with mixed evidence for effectiveness. OBJECTIVES: To determine the effectiveness of individualised directional preference management plus guideline-based advice versus advice alone in participants with reducible discogenic pain of 6-week to 6-month duration. DESIGN: Pre-planned secondary analysis of a multicentre, parallel group randomised controlled trial. METHODS: Participants were randomly allocated to receive a 10-week physiotherapy program of 10-sessions of individualised directional preference management plus guideline-based advice (n = 40) or 2-sessions of advice alone (n = 38). Primary outcomes were back pain, leg pain and activity limitation. Outcomes were taken at baseline and 5, 10, 26, and 52-weeks. RESULTS: Between-group differences significantly favoured directional preference management compared with advice for back pain at 5-weeks (1.28; 95% CI 0.34-2.23) and 10-weeks (1.45; 95% CI 0.51-2.40), and leg pain at 10-weeks (1.21; 95% CI 0.04-2.39). These short-term differences were not maintained. There were no significant differences between-groups for activity limitation. Secondary outcomes and responder analyses favoured directional preference management suggesting between-group differences were clinically important. CONCLUSIONS: In people with reducible discogenic pain, individualised directional preference management plus guideline-based advice resulted in significant and rapid improvement in short-term back and leg pain compared with advice alone. These effects were not maintained at long-term and there were no differences in activity limitation. Individualised directional preference management could be considered for patients with reducible discogenic pain seeking rapid pain relief however further research is indicated.