Pain Education for Patients With Low Back Pain in Nepal: A Feasibility Study
Pain Education for Patients With Low Back Pain in Nepal: A Feasibility Study
The primary aim of this study is to evaluate the feasibility of a full randomized clinical
 trial for assessing the effects of pain education as an intervention for patients with LBP in
 a physiotherapy facility in Nepal. The primary objectives of the study are related to
 feasibility of randomized clinical trial including: (1) willingness to participate in a
 clinical trial, (2) acceptability of random allocation to one of the two study groups, (3)
 feasibility of blinding the assessor(s), (4) eligibility and recruitment rates, (5)
 acceptability of screening procedures, (6) possible contamination between the groups, (7)
 credibility of pain education for patients with LBP, (8) adherence to intervention, (9)
 satisfaction of treatment, and (10) difficulty in understanding the content of pain
 education.

 To address the study objectives, an assessor-blinded, two arm randomized feasibility study
 was designed. Forty patients with LBP will be randomly allocated to one of the two study
 arms, (1) pain education in the experimental group, and (2) evidence based care in the
 control group (CG).
This is a feasibility study that is being performed to determine if a full randomized
 controlled trial (RCT) can be successfully conducted and if it should be conducted. The
 definition of a feasibility study highlights the question, "Can this study be done?" The
 SPIRIT statement and the CONSORT statement- extension to pilot and feasibility randomized
 study will be followed in the planning and reporting of the protocol and the manuscript of
 this feasibility study respectively.

 The study will be assessor blind two-arm feasibility clinical trial study. Ethical approval
 was obtained from the Nepal Health Research Council (NHRC) and University of Otago Human
 Ethics Committee. The study will be conducted in the Sahara Rehabilitation Hospital,
 Kathmandu, Nepal which is a private hospital in Kathmandu, Nepal.

 Overview of the study: Advertisement of the study will be made in social media. Interested
 candidates will be screened for eligibility. Eligible patients with LBP will be enrolled in
 the study. Participants will be randomly assigned to one of the two groups. All the
 participants in the experimental group will receive pain education and those in the control
 group will receive usual (evidence based) physiotherapy care. All the participants will be
 assessed at baseline, and follow-up assessment approximately after a week of randomization.

 Participant screening and recruitment: Consecutive participants with non-specific low back
 pain will be invited to participate in this study. Interested candidates will be explained
 the study purpose, benefits and harms of the intervention, time required for the completion
 of the study, follow-up duration, voluntary nature of participation, cost of participation,
 and the rights to withdraw from the study at any point. A participant information sheet will
 be provided to all potential participants. If the potential participants are interested in
 participating, they will be screened for eligibility by a research assistant who is a
 physiotherapist. If the participants are found eligible, informed consent will be obtained.
 For those who cannot sign the consent, a witness will sign on their behalf, or the study
 participant will provide a thumb print on the form for those who cannot write or sign the
 form as per the ethical guidelines provided by NHRC. Patients with no education and who
 cannot sign an informed consent will be included in order to increase the inclusion of
 uneducated or low education group, given that 31% people in Nepal who are five years old or
 more cannot read and write. Additionally, exploration of feasibility of pain education in
 those with no schooling or low educational attainment is important in order to inform
 clinical practice.

 Participants will be informed that they will receive one of the two treatments randomly. It
 will be highlighted that both of the treatment options are thought to be effective for low
 back pain, and that the goal of the main study is to compare the interventions, however the
 current study will more specifically evaluate the feasibility of such a study. There will be
 no restriction on the participants on both the groups in the pharmacological interventions
 they receive, however, participants in the intervention group will be restricted on receiving
 other physiotherapy interventions on day 1 only. All the participants will continue to
 receive the regular interventions provided by the centre from the second visit after
 follow-up assessment in the second week.

 Group Allocation, Randomization and Blinding: Random number sequence will be generated by a
 researcher not involved in data collection or providing treatment using www.random.org.
 Allocation concealment will be performed using opaque, sealed envelopes. The participants
 will be allocated to one of the two groups by a hospital staff who is not the assessor. The
 two groups are: Group 1: Pain education group (PEG); and Group 2: Control group (CG).
Inclusion Criteria:

 -  Nonspecific LBP (LBP other than those excluded, see exclusion criteria below),

 -  any duration with pain,

 -  pain primarily localized between T12 and gluteal folds,

 -  age 18 years or older,

 -  average pain intensity reported as moderate, or severe, or very severe on a PROMIS
 five- point PROMIS Pain Intensity Short-form Scale over the past week,

 -  is a Nepalese and is able to understand and speak Nepali fluently.

 Exclusion Criteria:

 -  Participants with likely specific causes of LBP will be excluded using a triage
 procedure as suggested by Bardin and colleagues,

 -  having history of prolonged use of corticosteroid,

 -  history of malignancy,

 -  recent history of fever or chills,

 -  history of other diseases associated with compromise in immune system,

 -  history of recent spinal surgery or dental procedures,

 -  history of recent history of trauma to spine or a spine fracture,

 -  history of bladder and bowel dysfunction,

 -  history of perineal or saddle anaesthesia,

 -  history of weakness of lower extremity or loss of sensation in lower extremity. -

 -  current pregnancy,

 -  history of diagnosed mental health conditions (e.g., schizophrenia, bipolar disorder,
 major depressive disorder) that would limit successful participation.