Public and patient perceptions of diagnostic labels for non-specific low back pain: a content analysis

People With Acute Low Back Pain Have Concerns That May Not Be Addressed by Guideline-Recommended Advice: A Mixed-Methods Study

OBJECTIVE: To investigate what concerns people with acute low back pain (LBP) and explore whether demographic and clinical factors were associated with having concerns about LBP. DESIGN: Mixed-methods study. METHODS: We included participants aged ≥18 years with acute LBP (LBP≤6 weeks). We collected demographic and clinical characteristics via an online survey and asked one open-ended question to elicit participants' concerns about their LBP. We investigated concerns about LBP using inductive content analysis. Using multivariable logistic regression, we explored associations between demographic and clinical characteristics and having concerns about LBP. RESULTS: We included 2025 participants, a majority of whom (n = 1200, 59.3%) reported having at least 1 concern about their LBP. There were 34 unique concerns, which mapped to 5 themes: causes of LBP (n = 393, 19.4%), future consequences of LBP (n = 390, 19.3%), psychosocial consequences of LBP (n = 287, 14.2%), physical consequences of LBP (n = 210, 10.4%), and health consequences of LBP (n = 84, 4.2%). Demographic and clinical characteristics were associated with having concerns about LBP: participants with university education, having previously received advice for LBP, with higher LBP intensity, interference, and higher anxiety symptoms were more likely to have concerns about their LBP. CONCLUSION: Most people with acute LBP had at least 1 concern about their LBP, more commonly centered around the causes of and the future consequences of LBP. J Orthop Sports Phys Ther 2024;54(9):1-9. Epub 7 August 2024. doi:10.2519/jospt.2024.12571.

Perceptions of advice for acute low back pain: a content analysis of qualitative data collected in a randomised experiment

OBJECTIVES

To explore how people perceive three different forms of advice for acute low back pain (LBP).

DESIGN

Content analysis of qualitative data collected in a three-arm randomised experiment.

PARTICIPANTS

2200 participants with acute LBP (ie, pain duration for ≤6 weeks) were randomly assigned to receive three types of advice: guideline advice and guideline advice with the addition of either brief pain science or ergonomics messages.

PRIMARY AND SECONDARY OUTCOMES

After receiving the advice, participants answered two questions: 'If your health professional gave you this advice, how would it make you feel?' and 'If your health professional gave you this advice, what treatments (if any) do you think you would need?' Two researchers coded responses using deductive content analysis.

RESULTS

We analysed 4400 free-text responses from 2200 participants. There were little to no differences in participants' feelings, thoughts and expectations after receiving three types of advice for acute LBP. Participants most commonly expressed feeling positive about the advice (38%-35%), reassured (23%-22%) and empowered (10%-8%). Some expressed being unhappy or being frustrated with the advice (4%-3%). Participants most commonly thought they needed no treatment apart from staying active, followed by exercise and medication.

CONCLUSIONS

Guideline advice with or without the addition of brief pain science or ergonomics messages generated positive feelings, reassurance or a sense of empowerment in many people with acute LBP, with no difference between types of advice.

TRIAL REGISTRATION NUMBER

ACTRN12623000364673.

[Does patient communication influence kinesiophobia? A systematic review]

The aim of the present systematic review was to determine the effect of communication in the health care setting on kinesiophobia. To this end, a literature search was conducted in seven databases between November 2022 and February 2023. The review was carried out following the PRISMA statement and for the analysis of methodological quality we used: PEDro Scale, Van Tulder criteria and risk of bias analysis of the Cochrane Collaboration. A total of 13 articles were included with a mean methodological quality of 7.1 out of 10. Significant results were obtained for at least one variable (kinesiophobia, disability or level of physical activity) in 12 articles. There is strong evidence that communication can influence a subject's kinesiophobia. This influence is most likely to be in a negative or disabling sense, but it can also act in a positive sense by decreasing it.

Acceptability, values, and preferences of older people for chronic low back pain management; a qualitative evidence synthesis

BACKGROUND

Chronic primary low back pain (CPLBP) and other musculoskeletal conditions represent a sizable attribution to the global burden of disability, with rates greatest in older age. There are multiple and varied interventions for CPLBP, delivered by a wide range of health and care workers. However, it is not known if these are acceptable to or align with the values and preferences of care recipients. The objective of this synthesis was to understand the key factors influencing the acceptability of, and values and preferences for, interventions/care for CPLBP from the perspective of people over 60 and their caregivers.

METHODS

We searched MEDLINE, CINAHL and OpenAlex, for eligible studies from inception until April 2022. We included studies that used qualitative methods for data collection and analysis; explored the perceptions and experiences of older people and their caregivers about interventions to treat CPLBP; from any setting globally. We conducted a best fit framework synthesis using a framework developed specifically for this review. We assessed our certainty in the findings using GRADE-CERQual.

RESULTS

All 22 included studies represented older people's experiences and had representation across a range of geographies and economic contexts. No studies were identified on caregivers. Older people living with CPLBP express values and preferences for their care that relate to therapeutic encounters and the importance of therapeutic alliance, irrespective of the type of treatment, choice of intervention, and intervention delivery modalities. Older people with CPLBP value therapeutic encounters that validate, legitimise, and respect their pain experience, consider their context holistically, prioritise their needs and preferences, adopt a person-centred and tailored approach to care, and are supported by interprofessional communication. Older people valued care that provided benefit to them, included interventions beyond analgesic medicines alone and was financially and geographically accessible.

CONCLUSIONS

These findings provide critical context to the implementation of clinical guidelines into practice, particularly related to how care providers interact with older people and how components of care are delivered, their location and their cost. Further research is needed focusing on low- and middle-income settings, vulnerable populations, and caregivers.

Patient experiences of rotator cuff-related shoulder pain and their views on diagnostic shoulder imaging: a qualitative study

PURPOSE

To explore patient experiences of rotator cuff-related shoulder pain, and their views on the role and value of diagnostic shoulder imaging.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 20 patients with shoulder pain exploring the impact and management of their shoulder condition, reasons for and experiences of diagnostic imaging, and feelings about and responses to diagnostic imaging findings. Framework analysis was used to analyse the dataset.

RESULTS

Five themes were identified [1]: Lived experience and beliefs about pain and movement [2]; Contextualisation of imaging findings by health professionals is more important than the imaging report [3]; Factors influencing whether and when to have imaging [4]; Imaging can identify the actual problem and guide treatment; and [5] Treatment responses and treatment decision making.

CONCLUSION

Patients commonly believe imaging is needed to formulate a diagnosis. There was minimal concern about potential indirect harms that could arise (e.g., inappropriate diagnosis leading to unnecessary treatments). The context of the diagnostic imaging reports (i.e., what needed to be done) was perceived as more important than the exact meaning of the imaging findings. Patients felt that the diagnostic imaging confirmed their existing biomedical beliefs, and these beliefs were not challenged by their healthcare professionals.IMPLICATIONS FOR REHABILITATIONPatients with shoulder pain may believe imaging is necessary for diagnosis and defining treatment yet do not consider potential indirect harms (e.g., unnecessary treatment for findings that are not relevant).Health professionals should ensure patients are aware of imaging limitations and harms and facilitate shared decision-making about whether to have imaging.Health professionals also have an important role in the appropriate contextualisation of imaging findings (i.e., they do not necessarily relate to pain nor guide treatment).

Effects of Hip Pain Diagnostic Labels and Their Explanations on Beliefs About Hip Pain and How to Manage It: An Online Randomized Controlled Trial

OBJECTIVES: To compare the effects of diagnostic labels and their explanations on people's beliefs about managing hip pain. DESIGN: Online randomized controlled trial involving 626 participants. METHODS: Participants aged ≥45 years with and without hip pain considered a hypothetical scenario (initial doctor consultation for hip pain). They were randomized to receive a diagnostic label and explanation of (1) hip osteoarthritis, (2) persistent hip pain, or (3) hip degeneration. Primary outcomes were the beliefs (1) exercise would damage the hip and (2) surgery is necessary at some stage (scales, 0 = definitely would not/unnecessary, 10 = definitely would/necessary). Secondary outcomes included beliefs about other treatments and care providers. RESULTS: Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain believed exercise was less damaging (mean difference -1.3 [95% CI: -1.9, -0.7] and -1.8 [-2.3, -1.2], respectively) and surgery less necessary (-1.5 [-2.1, -1.0] and -2.2 [-2.7, -1.6], respectively). Compared to hip osteoarthritis, participants who were allocated to persistent hip pain believed surgery was less necessary (-0.7 [-1.2, -0.1]), but not that exercise was less damaging (-0.5 [-1.1, 0.1]). Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain were less concerned about their hip and believed exercise and care from an exercise and sports physician, rheumatologist, or physiotherapist would be more helpful, and care from an orthopaedic surgeon less helpful. CONCLUSIONS: People who were allocated a diagnostic label and explanation of hip osteoarthritis or persistent hip pain believed exercise was less damaging and surgery less necessary for a hip problem than hip degeneration. J Orthop Sports Phys Ther 2023;53(11):673-684. Epub 5 October 2023. doi:10.2519/jospt.2023.11984.

General practitioners' decision-making process to prescribe pain medicines for low back pain: a qualitative study

BACKGROUND

Pain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines.

OBJECTIVES

The aim of this study was to investigate what influences GPs' decision to prescribe pain medicines for LBP.

DESIGN

Qualitative study with in-depth interviews.

SETTING

Australian primary care.

PARTICIPANTS

We interviewed 25 GPs practising in Australia experienced in managing LBP (mean (SD) age 53.4 (9.1) years, mean (SD) years of experience: 24.6 (9.3), 36% female). GPs were provided three vignettes describing common LBP presentations (acute exacerbation of chronic LBP, subacute sciatica and chronic LBP) and were asked to think aloud how they would manage the cases described in the vignettes.

DATA ANALYSIS

We summarised GP's choices of pain medicines for each vignette using content analysis and used framework analysis to investigate factors that affected GP's decision-making.

RESULTS

GPs more commonly prescribed opioid analgesics. Anticonvulsants and antidepressants were also commonly prescribed depending on the presentation described in the vignette. GP participants made decisions about what pain medicines to prescribe for LBP largely based on previous experiences, including their own personal experiences of LBP, rather than guidelines. The choice of pain medicine was influenced by a range of clinical factors, more commonly the patient's pathoanatomical diagnosis. While many adhered to principles of judicious use of pain medicines, polypharmacy scenarios were also common. Concerns about drug-seeking behaviour, adverse effects, stigma around opioid analgesics and pressure from regulators also shaped their decision-making process.

CONCLUSIONS

We identified several aspects of decision-making that help explain the current profile of pain medicines prescribed for LBP by GPs. Themes identified by our study could inform future implementation strategies to improve the quality use of medicines for LBP.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia

OBJECTIVES

To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions.

DESIGN

We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting.

SETTING

Australian primary care.

PARTICIPANTS

Registered physiotherapists who are members of a practice-based research network (n=31).

RESULTS

The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application.

CONCLUSION

High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment

OBJECTIVES

To explore how people perceive different advice for rotator cuff disease in terms of words/feelings evoked by the advice and treatment needs.

SETTING

We performed a content analysis of qualitative data collected in a randomised experiment.

PARTICIPANTS

2028 people with shoulder pain read a vignette describing someone with rotator cuff disease and were randomised to: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation emphasised that treatment is needed for recovery.

PRIMARY AND SECONDARY OUTCOMES

Participants answered questions about: (1) words/feelings evoked by the advice; (2) treatments they feel are needed. Two researchers developed coding frameworks to analyse responses.

RESULTS

1981 (97% of 2039 randomised) responses for each question were analysed. Guideline-based advice (vs treatment recommendation) more often elicited words/feelings of reassurance, having a minor issue, trust in expertise and feeling dismissed, and treatment needs of rest, activity modification, medication, wait and see, exercise and normal movements. Treatment recommendation (vs guideline-based advice) more often elicited words/feelings of needing treatment/investigation, psychological distress and having a serious issue, and treatment needs of injections, surgery, investigations, and to see a doctor.

CONCLUSIONS

Words/feelings evoked by advice for rotator cuff disease and perceived treatment needs may explain why guideline-based advice reduces perceived need for unnecessary care compared to a treatment recommendation.