Welcome back to SpineIQ’s BackBlog! In previous blogs, we have discussed how educational materials can play a key role in delivering information to patients. Not only can these educational materials be used actively throughout a session to lead conversations with patients but they can be used to provide information “passively” as posters in your clinic that patients may read. Educational materials can play a key low-cost, low-time consuming role in care for low back pain.1 Especially as patient education is recommended consistently by clinical practice guidelines for spinal pain regardless of pain duration or intensity.2,3 However, what the best way to present this information has not been studied. The study we summarize in this blog sought to assess whether “fact sheets” or “myths and facts sheets” led to patients remembering the information better and led to a decrease in fear avoidance behavior.4

Aims and methods

Mass media campaigns have been used in public health campaigns for decades. Some of the more famous ones have been advertisements and commercials providing information about the dangers of tobacco. The research on the best way to present educational information has been conflicting. Some studies suggest that presenting “myths” may lead people to mistakenly remember the “myths” as “facts.”5 However, other studies suggest that presenting both “myths and facts” can provide a more persuasive argument than only “facts.”6 This study created two educational materials. One sheet with 6 facts written on it and another sheet with the same 6 myths plus 6 myths related to the facts. Participants were patients seeking care for chronic low back pain, who were randomized to either “facts only” or “myths and facts” sheets. The outcome measures were being able to correctly answer all 6 questions about the facts at their next visit and their score on the FABQ-pa, which measures their fear avoidance beliefs towards physical activity.


151 patients were randomized into one of the two groups and subsequently analyzed. There was no difference in correctly answering 6 questions about the facts between the two groups. An average of 32% correctly answered all 6 questions in each group. The group that received “myths and facts” information sheet had statistically significant better fear avoidance beliefs at follow-up, however the difference was small and unlikely to be clinically meaningful.


These findings present a great opportunity for clinicians to feel comfortable that the educational material that they share with patients, social media, or have in their clinic can be presented in different ways. There appears to be no difference in patient recall, which suggests that presenting “myths” will not lead to patients mistakenly misremembering them as facts. At SpineIQ we provide several  back pain fact sheets on our website. There are also some facts and myths on low back pain sheets that have been used in the published literature, such as the ones used in this study and a study by O’Sullivan et al.7 Finally, this study presented the information as bullet points with no graphics so clinicians that want to create their own but are hesitant due to making them look more artistic should not worry.

  1. Engers A, Jellema P, Wensing M, van der Windt D a. WM, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057. doi:10.1002/14651858.CD004057.pub3
  2. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  3. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
  4. Viana da Silva P, Kamper SJ, Robson E, et al. “Myths and facts” education is comparable to “facts only” for recall of back pain information but may improve fear-avoidance beliefs: an embedded randomized trial. J Orthop Sports Phys Ther. Published online July 8, 2022:1-29. doi:10.2519/jospt.2022.10989
  5. Peter C, Koch T. When Debunking Scientific Myths Fails (and When It Does Not): The Backfire Effect in the Context of Journalistic Coverage and Immediate Judgments as Prevention Strategy. Sci Commun. 2016;38(1):3-25. doi:10.1177/1075547015613523
  6. Cornelis E, Cauberghe V, De Pelsmacker P. Two-Sided Messages for Health Risk Prevention: The Role of Argument Type, Refutation, and Issue Ambivalence. Subst Use Misuse. Published online April 22, 2013. doi:10.3109/10826084.2013.787093
  7. O’Sullivan PB, Caneiro JP, O’Sullivan K, et al. Back to basics: 10 facts every person should know about back pain. Br J Sports Med. 2020;54(12):698-699. doi:10.1136/bjsports-2019-101611