We probably have to face the fact that most common treatments that we learn such as manual therapy, exercise (yes even exercise) etc are often little more than hugs and kisses for the most costly and burdensome issue in musculoskeletal health today, Lower Back Pain (LBP). Something that is pretty clear however in the murky world of therapy, when it comes to back pain something people suffering from it value one thing highly, INFORMATION!
Before many people even come to see a therapist they search the problem on the internet and consult the medical sage that is DR GOOGLE (and we know how good that often is).
This 2018 paper “What matters most to people in musculoskeletal physiotherapy consultations? A qualitative study” found some clear themes. Firstly that people often have some clear questions they want to ask. Secondly that people required information about their problem and third was the need for collaboration with their therapist.
“In this study the people frequently reported lack of understanding, such that information and an explanation of their condition and a diagnosis was one of the main issues of importance that emerged for all but one participant”
This makes complete sense! People want to know what this is and if it’s a big problem? Is it medically serious? How long might it take to go? Now rather than 'fancy pants' explanations of neurobiology, load capacity and other poorly define buzz words it might just be basic epidemiology delivered in a reassuring and non-threatening way. The current trend of 'simplicity' in rehab probably applies here to! This can take practice and knowledge and like most simple sounding things can be tough to actually do.
Perhaps if we can satisfy the people engaging our services needs then they might be more likely to trust and engage with the messages that we feel are important? Just a thought!
Why is this important info?
We should really see the data around what people want from us as market research for therapists! This makes it worth taking notice of what the end user actually wants without just guessing or assuming, which can happen. Rather than meeting and satisfying the needs of those seeking help some of the current approaches actually probably fuel more uptake of the product (smart from a business sense)!
Education forms a key part of the current LBP treatment guidelines and papers such as the recent Lancet series "Prevention and treatment of low back pain: evidence, challenges, and promising directions" but like another guideline staple, exercise, what exactly does ‘education’ mean? Education about what exactly? This is why guidelines are often not followed, they are just too vague. But low and behold we have a lot of research to guide us here on what people would like to know.
What is treatment anyways?
We also have to ask ourselves what actually IS treatment when it comes to back pain? Is education really seen as treatment? Often not, but it really should be. The therapists role may shift from DOING treatments to people to helping people understand and navigate their painful situation BETTER.
This recent paper looked at examination as treatment “Evaluation is treatment for low back pain” the authors stated.
“Participants showed a significant reduction in pain through just the history taking and physical exam for both the back with an NPRS reduction of 1.23 and the leg showing a 0.95 NPRS reduction”
It is important to note that this was for first time back pain sufferers and also the pain reduction was in a small timeframe with no longer term follow up but interesting none the less!
So we could suggest that information & assessment IS treatment not just things that we add TO or do BEFORE treatment. I have had therapists suggest to me in the past that this is NOT what people want, they want to be ‘treated’ (in a more traditional sense of stuff being done to them) and certainly for some this is the case but interestingly, when we actually ASK them (I know right, madness!), understanding what is happening does actually seem to be what people want!
What do people want?
From looking at the qualitative literature there are theme's that clearly emerge, people want to makes sense of their painful condition, people want to be reassured that its nothing serious and people want to increase their ability to self-manage (we could call this locus of control if we were being fancy)
The nicely titled systematic review “People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies” looked at 41 papers and identified the type of information people are really after.
“Participants were keen to learn about simple and basic information regarding LBP”
“patients wanted clear, trustworthy, consistent information about the nature of LBP, its benign prognosis, and advice on both pharmacological and non- pharmacological management strategies”
One thing that was also apparent in this a paper and others was the need for a patient to get a diagnosis. This obviously is extremely challenging currently, but I believe a way to approach this is not to say we don’t know as this is often unhelpful. Instead tell people what it is NOT (99% of the time serious pathology), potential causes of MSK origin, the prognosis (generally good) and what they can do about it, which kind of fits the title of the paper : )
People also want to legitimise and validate their symptoms. Perhaps this is hard to do in the medical system without a clear diagnosis, this may also drive the clear need for imaging that was identified by patients, paradoxically it can make things worse. I feel it is an important message that we let people know that it is entirely plausible to have high levels of pain without an identifiable structural issue and this is inability to give a clear diagnosis is our fault not theirs. Learning to manage diagnostic uncertainty is a emerging challenge.
Is there an 'information' disconnect here?
A recent paper looked at the information that experts thought were important to inform people about LBP “Essential key messages about diagnosis, imaging, and self-care for people with low back pain: a modified Delphi study of consumer and expert opinions”.
The authors found that messages that he experts felt were important such as “carrying on with normal activities” ranked 2nd (out of 30) by experts. In comparison this was seen as 24th most important message by consumers, quite a disparity I am sure you will agree. So, what did people see as important? The first three messages ranked by consumers all related to red flags and identification of serious pathology. Other things that were important to people were self management and reassurance information and this was ranked much lower in importance by the experts. It does seem there is a bit of a disconnect between the two groups here. Perhaps with a bit of acknowledgment of people’s needs we can make them more receptive to what WE feel is important too.
How do we use this information?
How does this inform us?
Well it certainly means that information on occurrence of serious pathology, screening and a thorough explanation of findings is not an unimportant thing to many people and probably provides a large chunk of reassurance. If we accept that having pain can be a scary scenario for our physical, emotional and functional well being then it’s not so hard to connect the dots. Also helping people answer the question of “what can I do about it myself” seems to be important. Maybe treatment is often seen as something that happens INSIDE the treatment room (it’s even in the name; ) not what happens outside. As life mostly happens outside perhaps this is where 99% of treatment probably really occurs and helping people with this is really important (a future piece me thinks).
This is a great quote from what I feel is a hugely insightful and underrated paper “How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury”
“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis”
This sums up a bunch of what we deal with on a daily basis with so many non specific painful conditions such as low back pain.
“What Do Patients with Chronic Spinal Pain Expect from Their Physiotherapist?” again found that people want DIAGNOSIS and information about their problem and this is pretty consistent with the previous papers that have looked at this subject. Interestingly, a reduction in symptoms actually came BEHIND improving quality of life as being important in the responses. Not by a huge amount, 68% found it important versus 66% for pain reduction but this shows the importance people actually put on life and not just pain. Clinical implications here again are the importance of examination and the information that we give alongside finding out what quality of life means to people.
A 2008 paper "Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain" highlighted the tension that exists between people wanting information but also wanting the opportunity to tell their story and this is an important balancing act. Allowing time and creating a safe space to let someone’s story emerge whilst also providing relevant information is again a tough thing to do, especially in the limited time frame many operate within.
To make sure we can get key informationacross perhaps this is where the use of good open questions come in.
“What is most concerning you that you would like me to answer today?”
“Its important we really address your concerns so what would you really like to know?”
“What is worrying you that you would like to talk about?”
Effective reassurance is much more effective if it actually addresses the things people are worried about.
What better way to find that out than to ask?
Next time - How to go about creating a positive narrative around back pain!
People want simple information about their problem (so you need to know it)
People want a good assessment
They want a clear diagnosis to validate their symptoms
This is REALLY hard!
But we can replace it with a clear and concise NARRATIVE around LBP
The potential causes, prognosis and management options
Effective reassurance targets the problem or worry