Explaining the “problem” to patients with LBP

[AJ Lievre]

You may be experiencing difficulties explaining your findings to a patient with LBP following the exam. 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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[Farisshd]

This topic is certainly one that I have come across many times already. As you have seen from my recent posts, I have recently been working with a patient who has been fed some very “unhelpful” information about her imaging results, which seemed to heighten her anxiety and with that her symptoms.

These articles both touch on some helpful information regarding patient needs and desires, as well as how they interpret the diagnosis they may hear from their clinician. At first glance, these two seemed slightly contradictory due to one saying patients desire to have a specific confirmatory diagnosis, even though current evidence suggests against imaging, and the next saying that these diagnoses confirmed on x-ray like disc bulge, degenerative disc, arthritic changes lead to negative interpretations with lower expectations and the sense that more drastic measures may be necessary to recover. However, the ideas can be useful in formulating a method of communication that is likely to lead to a more positive expectation. Some patients may respond well to the education that the imaging results are less helpful, and that PT can effectively diagnose and treat their pain as effectively, and with less expense and risk, than surgery or medication.

I do find it challenging to attempt to reshape the patient’s mindset when the doctor or another clinician has already used unhelpful language and told them they have terrible degenerating discs, advanced arthritis, or disc bulges at various sites. In these cases, the patients like a breakdown of what that means and what our actions in physical therapy do to improve it. They also often ask, “does this mean it will just keep coming back?”, and “if it’s degenerating, is it going to get worse and worse”. Those encounters seem to take a bit more time for patient education to get buy-in. In other cases, the patient may not be able to get an MRI unless they have had PT first due to insurance, and I have found it less challenging to elicit positive expectations in the first few encounters in these cases.

I wish we had a successful campaign in this country about the benefits of staying active with low back pain, and I am surprised we haven’t had a large-scale advertisement or campaign to educate the public. There are many resources on the topic, but when I google “back pain relief” the first thing I see is a Web MD article with 14 ways to relieve low back pain, where PT is #6 and the leading remedies are drugs, postural correction, and sleeping better. While some of these are beneficial in many cases, most of them do not fix the problem and several don’t even promote blood flow or healing.

As for a personalized approach. I think patients are correct to desire this, and this can be accomplished based on subjective history taking and examination results. Putting the pieces together, for those without imaging results, careful education on the role of PT in diagnosing and treating their impairments, effectiveness of PT in treating back pain compared to other treatments, reasons why imaging may not be necessary or beneficial in addressing impairments, how we can make a tailored treatment plan based on their specific situation and symptoms, and that we are able to progress the plan or make changes along the way as needed seems to be key in getting the ball rolling on course. For those who already have imaging/and or already have negative expectations, the work is a bit harder, but the biggest difference would be addressing the imaging results, teaching them that they may have had these changes years before having any sensitization in the area, and elaborating further on the prevalence of the same imaging findings in the general population coupled with education on tissue sensitization and potentially more pain neuroscience education may be beneficial.

[zcanova]

These two articles both do a great job of identifying the challenges we face with patients suffering from all forms of low back pain and provide us with great ways to change the way we go about improving patient perspectives. I am hoping that this is something that all healthcare professions are seeing as more research is developed because we need consistency across all professions. I have seen numerous patients who have been hopping between healthcare providers and have received numerous diagnoses and treatments that have failed them. I can see how this becomes very frustrating as it leaves the patient hopeless and misunderstood. These are the patients that I find the most difficulty with because they have this misconception from hearing all these different problems that are poorly understood by the patient and the healthcare provider. I hope that this information is making its way into other areas of the health care system because we are typically seeing these patients after they have seen a physician. If this first interaction is a negative experience for the patient, then it sets them back immediately. I find it interesting how much the patient’s perspective on the problem can affect their prognosis. We discussed a study in a previous course that looked at patients’ perceptions of pain before and after an initial evaluation. It was interesting to see how much of a difference we could make by using positive language, allowing the patient to have their concerns heard, and giving them a sense of understanding. Another study that we discussed that has helped me provide objective information to the patient is a study that looked into imaging findings in patients without back pain. This specific study provides a great chart showing common findings on radiographs at different age ranges. It is a great resource to help patients understand age related changes and how pain does not necessarily correlate to findings on imaging.

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