Struggling to be seen and understood as a person - Chronic back pain patients' experiences of encounters in health care: An interview study

Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain

BACKGROUND

Low back pain (LBP) clinical practice guidelines recommend referral for patients with persistent LBP however discordance persists between recommended care and implementation in practice. Understanding patient experiences of referral practices and physiotherapy care could be important for optimizing LBP management in primary care settings.

PURPOSE

This study explored referral experiences of people with nonspecific LBP in Australian primary care and their knowledge and experience of physiotherapy.

METHODS

An interpretive descriptive qualitative framework was used with 17 participants interviewed from community-based physiotherapy practices.

RESULTS

Four themes described the participants' experiences of referrals in primary care settings: 1) Referral practices ranged from formal to informal to non-existent; 2) Fragmented inter-and intra-professional LBP care management; 3) Patient perceived differences in the roles of physiotherapists and specialist physiotherapists; and 4) Patient nominated barriers and facilitators to optimal referral practices.

CONCLUSION

Physiotherapists support people with LBP to improve strength and function, whereas the specialist physiotherapist's role was seen as more holistic. Referral pathways that align to clinical guideline recommendations for non-surgical management and treatment remain underdeveloped. Improved referral pathways to clinicians such as physiotherapists with additional credentialed skills and competence in musculoskeletal care could improve people's experiences of care and health outcomes.

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.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

Content of clinicians' communication with patients suffering from spinal pain in assessment situations in a specialized spine center: A qualitative study evaluating psychologically informed pain assessments before and after clinicians' participation in an Acceptance and Commitment Therapy course

INTRODUCTION

Assessment is an important part of chronic pain rehabilitation and should be conducted in line with the current biopsychosocial conceptualization of pain to capture the subjectivity and context of pain. However, pain assessment is commonly conducted from a biomedical framework. A course in Acceptance and Commitment Therapy (ACT) was provided to spinal pain clinicians as a framework to promote more person-centered and psychosocially focused assessments and related psychologically informed practices. The purpose of this qualitative study was to explore the verbal content of clinicians' communication with patients experiencing spinal pain in assessment situations before and after clinicians participated in an ACT course.

METHODS

Pain assessments of patients with chronic low back pain conducted by six spinal pain clinicians from different professions were audio-recorded and transcribed. This was done before and after participation in an eight-day ACT course with four following supervisions. A thematic analysis was carried out by two authors across all material, and a comparison of the applied number of codes pre-course and post-course was carried out as an indicator of change.

RESULTS

Data consisted of transcripts from the six clinicians across 23 different patients (12 before course participation). Through analysis, 11 codes were developed, which were clustered in three overarching themes: Psychological domains, Communication Techniques, and Intervention Elements. Overall, there was an increase in the application of many of the codes in the transcripts from pre-course to post-course, however with large differences across codes. Increases were primary related to the discussion of life values and value-based action and quality of life as well as the employment of mirroring, challenging beliefs and assumptions, and addressing coping and pacing.

CONCLUSIONS

While not the case for all factors, the present findings indicate an increase in including psychological factors and employing interpersonal communication skills after a course in ACT. However, it remains unknown due to the design if the changes reported in this study reflect a clinically valuable change and whether they are due to the ACT training itself. Future research will improve our understanding of the effectiveness of this type of intervention in assessment practices.

Stratification of Spine Patients based on Self-Reported Clinical Symptom Classes: Evaluation of Long-Term Outcomes and Subsequent Interventions

Background

Prior work by our group developed a stratification tool based on four PROMIS domains for patients with low back pain (LBP). Our study aimed to evaluate the ability of our previously developed symptom classes to predict long-term outcomes, and determine whether there were differential treatment effects by intervention.

Methods

This was a retrospective cohort study of adult patients with LBP seen in spine clinics in a large health system between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes as part of routine care at baseline and again at 12-months follow-up. Latent class analysis identified symptom classes based on PROMIS domain scores (physical function, pain interference, social role satisfaction, and fatigue) that were ≥1 standard deviation worse (meaningfully worse) than the general population. The ability of the profiles to predict long-term outcomes at 12-months was evaluated through multivariable models. Differences in outcomes by subsequent treatments (physical therapy, specialist visits, injections, and surgery) were investigated.

Results

There were 3,236 adult patients (average age 61.1 ± 14.2, 55.4% female) included in the study with three distinct classes identified: mild symptoms (n = 986, 30.5%), mixed (n = 798, 24.7%) with poor scores on physical function and pain interference but better scores on other domains, and significant symptoms (n = 1,452, 44.9%). The classes were significantly associated with long-term outcomes, with patients with significant symptoms improving the most across all domains. Utilization differed across classes, with the mixed symptom class receiving more PT and injections and significant symptom class receiving more surgeries and specialist visits.

Conclusions

Patients with LBP have distinct clinical symptom classes which could be utilized to stratify patients into groups based on risk of future disability. These symptom classes can also be used to provide estimates of the effectiveness of different interventions, further increasing the clinical utility of these classes in standard care.

Feasibility and Acceptability of the Pain Profile, a Clinical Questionnaire Aimed at Improving Pain Care

Purpose

Despite being one of the most common medical complaints, chronic pain is difficult to manage due to ineffective communication between providers and patients and time restraints during appointments. Patient-centered questionnaires have the potential to optimize communication by assessing a patient's pain history, prior treatments, and associated comorbidities to develop an effective treatment plan. This study aimed to analyze the feasibility and acceptability of a pre-visit clinical questionnaire aimed at improving communication and pain care.

Patients and Methods

The "Pain Profile" questionnaire was piloted across two specialty pain clinics in a large academic medical center. Patient and provider surveys were conducted with patients who completed the Pain Profile questionnaire and providers who use it in practice. Surveys consisted of multiple-choice and open-ended questions regarding the helpfulness, usability, and implementation of the questionnaire. Descriptive analyses of patient and provider surveys were conducted. Qualitative data were analyzed using matrix framework-based coding.

Results

A total of 171 patients and 32 clinical providers completed the feasibility and acceptability surveys. 77% of patients (N= 131) found the Pain Profile helpful in communicating their pain experiences and 69% of providers (N= 22) found it helpful in guiding clinical decisions. The section that assessed the impact of pain was rated most helpful by patients (4/5) while the open-ended section asking patients to describe their pain history was rated least helpful by patients and providers (3.7/5 and 4.1/5, respectively). Both patients and providers provided suggestions to future iterations of the Pain Profile, including the addition of opioid risk and mental health screening tools.

Conclusion

The Pain Profile questionnaire was feasible and acceptable in a pilot study at a large academic site. Future testing in a large-scale, fully powered trial is needed to assess the effectiveness of the Pain Profile in optimizing communication and pain management.

"No one wants you" - a qualitative study on the experiences of receiving rejection from tertiary care pain centres

Background and aims Four out of 10 referrals to tertiary care pain centres in Norway are not granted pain centre treatment, confirming earlier research on that this group of patients struggle to access the highest standard of care. Still, no study investigating how people with chronic pain experience rejections from pain centres was found. The aim of the study was therefore to investigate how people with chronic pain experience receiving a rejection from tertiary care pain centres after being referred by their general practitioners (GPs). Methods This was a qualitative study with semi-structured individual interviews with 12 persons, seven men and five women, rejected from the four different pain centres in Norway. The data were analysed thematically using systematic text condensation. Results The pain centre rejection created strong reactions, partly because the rejection was perceived as a refusal from the health care system as a whole. This was especially so because the pain centre was regarded as the last remaining treatment option, and given the rejection, they were now declined help by the experts in the field. Even though some informants had received an explanation for why they had not been granted pain centre treatment, a prominent experience was that the informants found it difficult to understand why their referral had been rejected given the severity of their pain. The incomprehensibility of the rejection together with a feeling of lack of future treatment options, increased the hopelessness and frustration of their situation and made it challenging to move on and search for help elsewhere. Conclusions The experiences with the pain centre rejections indicate that the rejection can have grave consequences for each individual in the following months. An improved system for how to handle expectations towards referrals, including prepare for the possibility of rejection and how to follow up a rejection, seems warranted. Implications Because a pain centre rejection most likely is received by persons in a vulnerable position, there should be available health care services to help them understand the rejections. And furthermore, help them to move from disappointment and hopelessness, towards an experience of empowerment and reorientation, by for instance planning further actions and interventions, and thereby, acknowledge their need for help.