Explaining the “problem” to patients with LBP

[AJ Lievre]

You may be experiencing that explaining your findings to a patient with LBP following the exam can be complicated. Some patients are looking for a specific answer to why they hurt.They may get frustrated with you when you try to provide a vague or non-specific explanation even if you view this as the best explanation. You may also be trying to avoid nocebic language.

Check out these 2 articles that discuss what patients with LBP may be looking for and also how you might address these needs. I have also provided a link to Peter O’Sullinan’s videos on helpful and unhelpful approaches to communicating diagnosis and prognosis to patients with LBP.

Comment on your experiences and thoughts after reading and watching.

https://lowbackpaincommunication.com/quiz

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[ebusch19]

I really like this week’s discussion topic and do find it challenging explaining findings to patients with LBP and answering some of the questions they ask as demonstrated in Peter O’Sullivan’s videos. One topic I find easier to discuss with patient’s is on posture, more so static posture with sitting. I can think back to a lot of patients I have worked with, not just patients with LBP, that come in and say they think part of their pain is due to their posture. Fortunately, in school we were introduced and were provided evidence that there is no perfect posture. During my first clinical, my CI also shared some research articles with me on this topic. So many patients are surprised when I tell them that there is no perfect posture, and they don’t need to sit upright constantly throughout the day. I also like Peter’s way of using a clenched fist to describe this to patients.

One topic that Peter brought up that I still struggle with though is posture or form with lifting. I remember being mind blown in school when we were presented research that stated that lifting form does not matter with LBP. At the time I felt like that went against everything I had learned previously. I had two internships at gyms where form was everything which shaped my thoughts with how people in general should lift, especially with workers lifting heavier objects as part of their daily job. Even at the military clinic, one of my CIs also harped on this. I still struggle with this in clinic, knowing when to take a step back and not be so strict on form. If you know Adam Meakins, you know he is not afraid to express his thoughts on form and how it doesn’t matter. Then there is Aaron Horschig or “Squat University” on the opposite end of the spectrum. I don’t want to get too off topic, but it’s conflicting with the research, what I hear from other professionals and from my previous experiences. I can definitely see from Peter’s perspective of the patient who constantly feels like they need to contract their core with every movement and the example of the clenched fist. I had a patient who was 2 months post lumbar surgery and told me she needs to protect her back and was literally keeping her back straight 24/7 to the point she was starting to develop neck pain. She even told me she has to “plank” to brush her teeth and actually did plank to prevent bending over in her back. We were even performing the slump test and she asked me if she needed to keep her core activated. With this patient, with simple movements like that, it makes more sense to educate her that it’s okay to relax her muscles and move, and to not constantly have to contract her core. However, I admit it’s still difficult for me to accept that form does not matter when it comes to lifting.

I know I probably took this a different route than expected but would be curious to hear what others thoughts are on this, if you had similar challenges, and how you go about this with patients.

[iwhitney]

Despite knowing the high prevalence of LBP, I found it surprising to hear the statistic from the O’Keefe et al. article that as of 2019, the US spends more money on spinal fusion surgery each year than any other surgery. When reading through both of the articles listed, I found myself thinking back and reflecting on the many patients I’ve evaluated and/or treated who present with low back pain. I can even think of a few patients I’ve seen who’ve had spinal fusion surgery, only to have their symptoms return shortly after rehab, or get worse. I know this isn’t the case with every patient who receives some form of spinal fusion surgery, but I think it highlights the lack of appropriate clinical decision making that is present when determining management strategies for patients with LBP.
I can admit I’ve found myself using language such as degeneration with patients and realizing in subsequent visits how much they held onto that word and the impact it made on the perception they have on their condition. I definitely realize the impact labels can have on how a patient feels towards their condition and how this can often lead to them taking unnecessary steps towards improving their symptoms, such as imaging and surgery. At UVA, we are often seeing patients via referral who have already had imaging done so more often than not, I find myself trying to educate patients more on what their imaging findings really mean rather than describing the purpose and use of imaging. I have to admit that sometimes explaining to patients the prevalence of various imaging findings in asymptomatic populations doesn’t always work, especially in the older population who place a lot more salience in the words of an older, experienced surgeon. The reality is that many healthcare providers aren’t taking the time to explain the imaging to their patients and aren’t giving them reassurance for the prevalence of the image findings and what conservative management options can do for them. Or perhaps it is an instance where the healthcare provider is relying on a biomedical approach to explain to their patients what is contributing to their pain. I really liked the reassurance line used in the O’Keefe et al. article for patients presenting with NSLBP: “I’m not worried that there is anything serious going on here. I think overall your outlook is good. Movement will help. The sooner we can get you back to your normal activity and work, the more likely your back pain is to get better.” Although there can definitely be more added to a statement like that and more patient education provided, I think it’s a nice statement to give the patient confidence that their presentation is not something to feel worried about and may even improve their trust in you as they see your own level of confidence.
The article by Lim et al. discusses the strong desire that patients with LBP express to have a ‘definitive diagnosis’ and explanation for their pain, which they often feel requires imaging. As I mentioned before, I am often not seeing patients who haven’t already been told what is likely contributing to their LBP based on imaging, or some other form of a biomedical approach. I do find that these patients who have a ‘definitive diagnosis’ to be challenging as they have started to develop firmly held beliefs that can be hard to break (cue AJ’s sandstone analogy). I certainly think I could improve my management of these patients by shifting their focus away from the label they’ve been given, and more towards what PT can do for them. In the LBP communication quiz, one video shows Peter O’Sullivan discussing the lack of need for specific lifting techniques and the importance of increasing confidence to bend, lift, and twist in many different ways in order to perform regular daily work and functional activities. Perhaps this could allow me to manage those patients who have firmly held pathoanatomical beliefs with more effectiveness and shift towards a biopsychosocial approach as I utilize the requirements of their daily life to individualize and tailor my treatment to their particular needs.
Overall, I find this to be a very interesting topic and improving my management of patients with NSLBP will likely be a skill I work to improve for many years to come. I think there is a lot of useful information provided in these articles/videos on how we can meet our patients where they want/need to be met in order to improve their outcomes, decrease healthcare utilization, and limit unnecessary procedures such as imaging and surgery. The more I learn on this topic, the more I realize the importance of appropriate communication in the profession of physical therapy and the significant impact we can have on our patients if we are simply able to communicate with them in an effective, educative, and empowering way.

[ebusch19]

Awesome post Ian, I really enjoyed reading your response. The first part of your post reminded me of when I was at the military clinic, for some reason radiofrequency ablations were very common for people with low back pain which would maybe help for the first 6 months and then their pain would come back. One of the guys I saw with my CI was dealing with PTSD and was struggling to find a psychologist that he trusted to talk to about what he’s been through. He had persistent low back pain and had already gone through an RFA which surprisingly did not help the pain long-term. It was really difficult to hear what he is dealing with and what he has gone through. I can’t help but think if his providers initially took a more biopsychosocial approach, his symptoms would have been different.

It was also very common during that clinical that the providers didn’t talk to their patients about their imaging results so they would ask me to explain it to them. At the time reading the results, there were things I didn’t fully understand and would have to look up. It was difficult having to explain the results to the patients and I could definitely tell at times I used words that I should not have that the patients held on to. I also really like that phrase from the O’Keefe et al. article and will use a version of that when I’m talking to patients in clinic.

Managing patients with NSLBP or persistant pain conditions is a hard skill and I’m excited to take the course with Adriaan Louw to learn more about PNE and applying it during treatments with patients.

[cmocarroll]

I found this week’s discussion topic to be very relevant to recent patient encounters – even those not related to LBP. When reading the topic, I could immediately think of multiple patients that I have struggled to explain their pain in a specific manner. I do find that I try to be more vague when explaining my hypotheses to pts. I think that I do this because in my perspective, I would rather the patient have a non-specific answer than believe that they have a “disease” or “condition” that they need to have imaged or go through extensive surgery to fix. I can tell that most patients are not satisfied with my explanations and I often have to reiterate myself over several visits due to the patient’s repetitive questions regarding an explanation for their symptoms. In order to remedy this situation, I think that I could learn a lot from approaching conversations like Peter O’Sullivan exemplifies in the videos. He is able to keep the explanations simple yet informative and evidence based. Clearly, much of our treatment with LBP is breaking stigmas and I couldn’t help but laugh at some of the video examples as I noted that I have definitely given some unhelpful advice to patients without realizing it.

Watching the videos, it seemed so blatantly clear what was helpful and unhelpful so it surprised me to think that I have used the unhelpful language with my patients. As a new clinician, I think that sometimes I am trying to come across as knowledgable and confident and this can lead me to be unaware of how I am phrasing things that may give patients the wrong idea about their symptoms. For example, I think that I tell patients to “let pain be their guide” in a different manner, but while I try to emphasize that just because something is painful, doesn’t mean that they can’t do it, I wonder if my explanation truly comes across that way. While watching the clips, I also noted that sometimes I brush aside unhelpful or untrue comments that the patient brings up themselves. For example, I often have patient’s bring up that the exercises are helping their “posture” or that they “need better posture”. Occasionally I will dive deeper into this and explain to patients that there is not truly one great posture, but other times I just nod and move on. After watching these videos and reading the articles – I wonder if this is a small aspect that I could better address with patients to help break the back pain stigma.

Furthermore, when reading the O’Keefe article, I found the outcomes related to the labeling of the patients symptoms to be fascinating. Recently we have been told not to use the ICD-10 code “low back pain” and instead use extremely similar codes that are “low back pain, unspecified” or “vertebrogenic low back pain”. All of the codes seem exceedingly generic, which as the Lim article explained is a clear mismatch between what patient’s want and what health providers believe is most helpful. With that being said, I think it’s interesting that the O’Keefe study showed that people who were given these generic labels perceived less need for imaging, better prognosis, less need for second opinion, etc than those who received more specific diagnoses. Knowing the results of this study, I think it shows that we should try and find a “happy medium” where we can successfully give patients more generic explanations for their symptoms and load them with evidence/knowledge surrounding LBP, posture, lifting mechanics etc in order to decrease the stigma with low back pain as well as reduce the unnecessary rabbit hole of healthcare appointments/intervention that so many of our patients fall down.

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