Considering patient preferences when treating chronic NSLBP

In a past life I worked as an auto-electrician in a local car dealer. I was kept busy, as Australian build-quality ensures a steady flow of cars in need of repair. The process was relatively simple. A car would come in to the workshop, I would diagnose the problem, replace the faulty part and send it on its way. For the most part, it wouldn’t come back – for that problem anyway. Explanation to customers was easy too. This is what was wrong and this is how I fixed it. They didn’t have to do anything (except pay the exorbitant fee charged by my employer).

Unfortunately, in my transition from auto-electrician to physiotherapist I discovered ‘fixing’ patients wasn’t as straight forward as fixing cars. ‘Faults’ can remain elusive, management strategies do not always work and explanations to patients seeking to know exactly what is wrong with them are much harder. Take non-specific low back pain (NSLBP) for example. By definition, it is a case of ‘I am not quite sure what is wrong with you’ and thus ‘I am not entirely sure of how to fix you’.

Chronic NSLBP is renowned for being difficult to treat and despite a plethora of management options, it appears no one treatment works for every patient. In the latest issue of the Lancet, Balagué and colleagues[1] reviewed the recent literature to see what advances we have made in treating this condition. They noted that many of the treatments commonly used to manage chronic NSLBP, including acupuncture, behavioural therapy, exercise therapy and drugs, had only modest effects at best[3,4].

That no one treatment appeared more effective than any other appears somewhat disheartening. However, Balagué and colleagues suggest it can be turned into a positive. Reflecting on the work of two of our regular bloggers, Ben Wand and Neil O’Connell[5], they reasoned that the similarities in effectiveness between the treatments may occur because they all work through the same mechanism – affecting cortical function. For example, a treatment such as back strengthening exercises may show effectiveness due to changes in beliefs, attitudes and coping mechanisms rather than changes in muscular strength. They suggest that the absence of a notable difference between many evidence-based treatments is an advantage because it allows us to consider patient preferences, access to facilities and the budget of our patients. We know that patient expectations can influence the outcome of treatment[2] and that they are less likely to adhere to treatment plans if their preferences are ignored. We should therefore tailor our therapy to incorporate the patient’s preference whilst delivering it in a manner that encourages changes in pain attitudes and beliefs. Not every chronic pain patient is willing to sit through sessions of pain education, nor will all of them read the material we provide them. As long as we treat using a paradigm that recognises the cortical changes that are contributing to their pain, it is likely we will improve the effects of the chosen therapy.

Balagué’s team finally reiterates the pressing need for our education message to be consistent. That is, we cannot afford the good of one therapist to be undone by another in the multidisciplinary team. They alluded that the chances of altering a patient’s beliefs are greater when the message is consistent, thus all healthcare workers are encouraged to keep up-to-date with current scientific knowledge regarding chronic pain. We also need to ensure we are consistent in our explanations such that our ‘story’ doesn’t appear to blatantly change from peripheral driven mechanisms to centrally driven mechanisms as a patient transitions from acute to chronic.

Unlike fixing a car, it is unlikely one management technique will not work for every chronic NSLBP patient. We need to be flexible and adapt to the individual needs of our patients yet work to foster change in faulty pain beliefs.

Mark Catley

Mark Catley2 150x150 Considering patient preferences when treating chronic NSLBPMark Catley is a PhD candidate in the Body in Mind Research Group (at University of South Australia) in Adelaide. When he is not busy researching, Mark works as a physiotherapist in a rehabilitation hospital. He is interested in the brain’s involvement in the transition from acute pain to chronic pain, and is currently investigating the relationship between cognitive variables,  mood and sensory function in people with back pain.

He also has a very particular approach to cooking rice.  For perfectly cooked rice: 2/3 cup rice, double that in COLD water, and then 8mins in microwave uncovered. Actually, he has a particular approach to many things – including windows.  He is the only BiM team member you should ever get to clean a window.

References

1. Balagué F, Mannion AF, Pellisé F, Cedraschi C: Non-specific low back pain. Lancet 379:482-91.

2. George SZ, Robinson ME: Preference, Expectation, and Satisfaction in a Clinical Trial of Behavioral Interventions for Acute and Sub-Acute Low Back Pain. Journal of Pain 11:1074-82.

3. Keller A, Hayden J, Bombardier C, & van Tulder M (2007). Effect sizes of non-surgical treatments of non-specific low-back pain. European spine journal, 16 (11), 1776-88 PMID: 17619914

4. Machado LA, Kamper SJ, Herbert RD, Maher CG, & McAuley JH (2009). Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology , 48 (5), 520-7 PMID: 19109315

5. Wand BM, & O’Connell NE (2008). Chronic non-specific low back pain – sub-groups or a single mechanism? BMC musculoskeletal disorders, 9 PMID: 18221521

Comments

  1. Chris Barnett says:

    Good work Mark, novice physios are sometimes like budding auto electricians ( they just want to diagnose and fix). this patient preference approach helps . If the diagnosis is aberrant cortical function then why not use a personal preference to ” change the mind ”
    Cheers Chris

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  2. Thanks for this thought provoking post.

    While I agree with the premise, I think the idea of “patient-preference” in chosing a treatment paradigm is wrought with sink holes and in fact…may help explain the mess we are in today.

    This notion of allowing patients to choose any treatment that “works” seems somewhat short sighted when we consider some of the emerging literature on the consequences of nocebo. In my 15 years of practice, it’s quite clear we have a population sunk into the abyss of magical thinking when it comes to pain, and I witness the consequences of this almost daily. Are we not perpetuating this problem by placating patients in this manner? Afterall, if a patient believed ultrasound cured their back pain last time…and I do it again, I would think this then makes my efforts to “foster change in faulty pain beliefs” twofold or threefold more difficult.

    That someone believes in acupuncture and thus gleans a positive effect on their pain experience doesn’t make it an appropriate treatment option in my opinion at all. Same for Reikki, craniosacral therapy or any mode of mumbo jumbo whose sole purpose is to supply the unsuspecting patient with fantastical explanations thus ramping up the expecation of a postive outome.

    A stupid patient population that is satisfied with the treatment they chose (chiropractors have high patient satisfaction rates) doesn’t make for a healthy-painfree society. Like I stated, I’m certain this “choice” is what helps explain the epidemic of pain we currently have.

    Good luck getting a Riekki master to change their explanations of effects to better reflect science accurately. In so doing, they remove the bulk of why they might get “outcomes”….the absurd story they tell patients.

    Patient preference may result in short term success I think…with hefty long term consequences. I’m near positive of that.

    Although clinical utopia would see me “meet the patient” where they are as well as foster changes in faulty pain beliefs, I’m not sure that’s feasible within out current healthcare structure.

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    Mark Reply:

    Thanks for your thoughts Glen – you raise an important issue. Considering patient preferences should never mean we advocate for inappropriate treatments. Rather, we should always be upfront and explain the both the benefits and limitations that each treatment provides. A classic example would be the patient that fronts up to the practice every second week like clockwork asking for “that manipulation that fixes them every time”. Clearly ‘that treatment’ isn’t doing the trick or they wouldn’t keep rocking up! Manipulation may, however, provide a window of pain relief in which the patient can commence light exercise, which is more beneficial in the treatment of chronic pain. If this explanation is given within a paradigm that incorporates pain education and thus attitude change, it may be worthwhile. Whilst it is necessary to be flexible and incorporate patient preferences, fostering a patient’s false beliefs will not inevitably help them or the problem of chronic pain in society.

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  3. Mark
    The engineer in me also came to the same conclusion about “fixing ” patients following my transition 25 years ago! Whilst I agree with the thrust of your agrument are we not just replacing “cortical justification” for some of the other failed treatment terminologies?.
    Given we’re in the realm of the cortex onb this forum there may not be too many dissenters but I’ll bet if I replaced the words “cortical” with “clinical” there would be a barrage of response saying this was no longer good enough?
    If it’s a case of same treatment – different story, I’m am sufficiently flexible to adapt but I still wonder if it’s a superior argument – or just one that make us feel more intellectually justified to treat as we see fit?
    Thanks for the post
    David

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  4. Neil O'Connell says:

    Cheers for the post Mark, now this is a discussion!

    I am with Glen on this , though I would replace “stupid” with “misinformed” patients. In terms of back pain to continue to offer failed treatments in an attempt to placate patients into getting better (be it through a hypothetical model of cortical change, or simply placebo and distraction) is potentially dodgy ground.

    The idea of the expert patient is gaining ground in health but in my opinion patients can not easily make decisions regarding what treatment is appropriate as they do not have access to quality information. Many clinicians are ill-informed of the evidence or resistant to the story it tells us. Instead patients wade through a minefield of misionformation and overselling of various marginally or ineffective treatments.

    If a cortical approach to treating patients is to be a way forward (and its a big “if”) then it will need to be novel and focused and validated in good trials. Otherwise we might be in danger of using it as todays pet theory for explaining clinical effects that may themselves be illusory. There is still a good case that less intervention may be more…

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  5. Thanks Neil. I think you’ve touched on David’s point too. Strong evidence in support of interventions targeting pain-related beliefs and attitudes are still lacking in the current literature. That said, it is well established that psychosocial factors are key drivers in chronic pain, hence we should endeavour to target these in our treatment. Clinical practice involves consideration of current research evidence, patient preference and clinical experience. As clinicians we need to weigh up these factors, consider the resources we have at hand, and decide what is best for each individual patient. As you aptly stated, we cannot expect our patients to be experts on what is best for them as they do not have access to the same resources we have. Rather, it is our responsibility as clinicians to be informed and maintain a current understanding of the mechanisms that drive chronic pain. Staying up-to-date with current research should hopefully should steer the astute clinician away from inappropriate treatments.

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  6. David Nolan says:

    I think Glen makes many good points. I often hear “Pilates/ Chiro/ Myofasical releases/ AN other therapy is the only thing that keeps me going” my heart can tend to sink when you probe into their beliefs, behaviours and attitudes to their pain. I cannot help but think we can make and manufacture some of what we see.

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  7. Lower back pain is an ongoing issue with many people. It’s something that can be relieved with the right treatment!

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  8. At a certain point, self-management with education is what you have left. For the susceptible individual, entrenched patterns of relief seeking are all too easy. I used to see a lot of ‘cast-offs’ from chiropractors in which a manipulation ‘just didn’t fix it long enough anymore.’ I know that education had been provided with those patients to some degree but it takes time and if the patient is not interested and wants you to ‘nail the problem quickly’, and you have a hammer, it’s hard to condemn this (lots of physios do though). I find it fascinating that graded exercise is often so hard to ‘sell’ especially with new paradigms of cortical involvement and the fact that graded aerobic exercise has been shown to have significant effects on the brain with mood, arthitis management and LBP. Making access to gyms, indoor walking/pool facilities (with extremes of climate), and accessible public transport is critical but involves a re-think for a lot of city planning. If it ain’t easy for a lot of people, it ain’t happening. If you look at interventions like CIMT that do have amazing results years post insult (for CVAs) it just involves making it easier to do something different for a coupleish weeks (and some shaping – behavioral activation) for cortical changes to occur. Why is it so hard to make things easier for healthier solutions ? If you answer me that, I think we’ll get somewhere… Looking forward to input… Thanks !

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