Medical knowledge and the intractable patient: the case of chronic low back pain

I’m Not Ill, it’s Just This Back: Osteopathic Treatment, Responsibility and Back Problems

Personal responsibility has become a central focus for British health policy, professional ideologies and lay ideas around health. This article focuses upon the issue of personal responsibility and long-standing back problems. It uses material from interviews with osteopathic patients to illustrate the ways that patients’ ideas about responsibility for and control over their symptoms are often moulded by their interactions with health care practitioners. Such interactions often lead to contradictions in patients’ attitudes to their health: passive acceptance of treatment on the one hand and desperate attempts to re-establish some control through self-blame on the other (Taussig, 1992). The article ends by arguing that the osteopathic profession needs to critically evaluate its role in encouraging such contradiction and confusion in patients’ understandings of their health states.

A Bitter Pill

Taking a discourse analytic approach, this article explores how a biomedical understanding is drawn on and mobilized in women's accounts of their depressive experiences. Through talk of diagnosis, and by drawing comparisons between depression and physical illnesses, participants constructed depression as a medical condition with the effect of validating their pain and legitimizing their identities. However, participants' accounts also indicated an uneasy fit between the objective discipline of biomedicine and their subjective experiences of depression. Without tangible evidence to validate the ‘reality’ of their condition, speakers were on precarious ground for talking of themselves and their distress within a biomedical frame. The social construction of biomedicine and stigma for marginalized forms of distress are discussed.

Biopsychosocial care and the physiotherapy encounter: physiotherapists' accounts of back pain consultations

BACKGROUND

The physiotherapy profession has undergone a paradigmatic shift in recent years, where a 'biopsychosocial' model of care has acquired popularity in response to mounting research evidence indicating better patient outcomes when used alongside traditional physiotherapy. However, research has not examined how this new dimension to traditional physical therapy is implemented within the therapeutic consultation.

METHODS

The study aimed to investigate physiotherapists' reported approaches to back pain care in the context of increasing pressure to address patients' psychosocial concerns. A secondary analysis of semi-structured qualitative interviews with 12 UK physiotherapists was conducted. Respondents were sampled from a national survey, to include a broad mix of physiotherapists. Data were analysed thematically, adopting the constant comparative methodology.

RESULTS

The combination of traditional physical therapy with a broader biopsychosocial approach presented significant challenges. Physiotherapists responded by attempting to navigate patients' biopsychosocial problems through use of various strategies, such as setting boundaries around their clinical role and addressing lay health beliefs of patients through the provision of reassurance and lifestyle advice.

CONCLUSIONS

As psychosocial issues, alongside biomechanical factors, command a prominent place within the back pain consultation, physiotherapists may benefit from further specific training and mentoring support in identifying specific strategies for combining the best of traditional physiotherapy approaches with greater focus on patients' beliefs, fears and social context.

The experience of chronic back pain: Accounts of loss in those seeking help from pain clinics

BACKGROUND

This study responded to the need for greater understanding of the experiences that help to shape the worldviews of chronic back patients as they seek help from pain clinics.

AIM

To elaborate on the lived experience of chronic back pain in those actively seeking help from pain clinics.

METHODS

This was a qualitative study, based on an interpretative phenomenological approach. As part of in-depth interviews, participants were invited to 'tell their story' from the time their pain began. Participants were twelve male and eight female patients, all of whom were diagnosed as having chronic benign back pain and had recently attended one of two pain clinics as new referrals. The data were analysed thematically.

FINDINGS

Loss was one of five major themes to emerge. The narrative accounts revealed a catalogue of socio-economic and other material losses including loss of physical and mental abilities, occupational and social activities, job or role. In those of working age, these led to financial hardship and changes in interpersonal relationships, culminating in loss of self-worth, future and hope.

CONCLUSIONS

The findings suggest that material losses, as well as perceptions of loss, are prominent issues for those of working age seeking help from pain clinics for chronic back pain, and may need to be acknowledged and addressed as part of therapeutic interventions. The possibility of age-related differences in pain-related loss may be worthy of further investigation.

Occupational overuse syndrome: moral ambiguities of New Zealand health professionals

In this article we examine the moral ambiguities expressed by New Zealand health professionals regarding their clients and patients who have occupational overuse syndrome (OOS). Workers with OOS were described as being hard working and dedicated, but also undisciplined in their work and personal lives. The goal of rehabilitation in such cases is a return to full work duties and to this end, health professionals represent the disciplinary and normalizing technologies of the neoliberal state which, in New Zealand, provides financial support and treatment for injured workers. According to the health professionals in this study, the disciplinary technologies exercised through rehabilitation require that clients and patients internalize key values associated with the rhetoric of healthism; primarily self-discipline, self-control, self-denial, and willpower. These underpin successful rehabilitation and ongoing management of OOS, and at the same time represent the central values of the neoliberal capitalist workplace.

Patients' own accounts of sciatica: a qualitative study

STUDY DESIGN.: Longitudinal qualitative interview study, nested within a back pain cohort study. OBJECTIVE.: Enhance the understanding of patients' own perspectives on living with sciatica to inform improvements in care and treatment outcomes. SUMMARY OF BACKGROUND DATA.: Reports of patients' own accounts of sciatica and its impact on daily life are still scarce. Research on back pain has shown that it is important to understand how people live with pain and how they perceive interactions with health care professionals and interpret interventions. These types of insights help to improve treatments and their acceptability to patients. METHODS.: In-depth qualitative interviews with 37 people at baseline and 6 and 12 months' follow-up. The interviews covered topics that were derived from the Illness Perceptions Questionnaire and allowed open-ended talk about people's experiences of pain. All interviews were tape-recorded, fully transcribed, and thematically analyzed. RESULTS.: People needed to make sense of sciatica through identifying a cause and having it clinically diagnosed. The impact of sciatic pain was seen to be constant, intense, and all-encompassing. Appreciation of this by clinicians was considered important, as well as the provision of clear information about treatment and prognosis. Expectations about treatment options varied between patients, and people balanced pain relief with adverse effects. CONCLUSION.: Our study highlights patients' own accounts of the distinctiveness, impact, and intrusiveness of their sciatic symptoms. Our findings emphasize the importance of leg pain in identifying a subgroup of back-pain patients more likely to have severe symptoms, be at risk of poor outcome, and who should be considered a priority for early diagnosis and management. Future management of sciatica needs to include listening to patients' stories, offering a credible physical assessment, explanation, and diagnosis of the condition. Explaining the limits to treatment is seen as positively contributing to the partnership between patients and clinicians.

Review of occupational therapy for people with chronic pain

BACKGROUND/AIM

Chronic pain is a significant health-care problem. This review aims to critically analyse occupational therapy services for people with chronic pain and identify significant factors influencing the future development of occupational therapy services for people with chronic pain.

METHODS

A broad range of literature is reviewed and analysed using causal layered analysis, a post-structural critical futures methodology. This layered analysis moves through four layers of analysis; the litany layer, the social causes layer, the worldview analysis layer and the grand myth and metaphor layer.

RESULTS

This layered analysis revealed three significant factors shaping the future development of occupational therapy services for people with chronic pain: the influence of the biopsycho-social model within health-care services for people with chronic pain, occupational therapy philosophy and the social construction of people with chronic pain. Recommendations for future research and practice derived from this analysis include the need to research the effectiveness of occupation-based interventions for people with chronic pain, the significance of client-centred occupational therapy and valuing of clients' narratives to avoid pervasive negative social constructions of people with chronic pain influencing occupational therapy practice.

CONCLUSIONS

This critical analysis has made occupational therapy services for people with chronic pain problematic in order to generate reflection, discussion and new insights. This analysis deconstructs contemporary occupational therapy philosophy and practice and therefore provides a new perspective on occupational therapy for people with chronic pain.

Listening to the body and talking to myself - the impact of chronic lower back pain: a qualitative study

AIMS

The aim was to investigate peoples' experiences of the impact of chronic low back pain.

BACKGROUND

Chronic low back pain is a complex disorder with wide-ranging adverse consequences that can impact on people's lifestyles and self-image. It is also a condition that can sometimes be treated with some scepticism by health care providers and other people in the person's life. It has been suggested that further research into the subjective experience of chronic blow back pain is needed to develop a better understanding of its impact.

DESIGN

This study is a qualitative analysis of semi-structured interviews with 64 participants identified as having chronic low back pain who were interviewed about the impact of the condition on their lives. The data were analysed using a method of inductive thematic analysis.

FINDINGS

Four main themes were identified: the unpredictability of the pain, the need for vigilance, the externalization/objectification of the body and the alteration to sense of self.

CONCLUSION

Nurses have an important role to play in working with patients experiencing chronic low back pain to identify any patterns associated with exacerbations of the condition, validating their experiences of chronic low back pain and facilitating the accommodation of chronic low back pain into a more satisfying sense of self.

Illness experience in fibromyalgia syndrome: a metasynthesis of qualitative studies

There is growing interest in synthesizing qualitative research. Despite certain philosophical and methodological difficulties, such syntheses are potentially useful in enriching the insights of empirical qualitative work in a particular area. This paper reports an interpretive review of research into the subjective experience of fibromyalgia syndrome (FMS), utilizing principles of metasynthesis. Twenty-three separate studies were identified. Each study was evaluated using methodological criteria to provide a context for interpretation of substantive findings. Principal findings were extracted and synthesized under four broad categories: experience of symptoms, search for diagnosis, legitimacy, and coping. Our findings re-emphasised the point that pain in FMS is ambiguous and invisible, raising questions of credibility and legitimacy. People with a diagnosis of FMS appear to frame the experience of symptoms within the biomedical model, where FMS is viewed as an organic entity potentially identifiable through biomedical tests. The subjective meaning and perceived legitimacy of the diagnostic label appear to be important factors in the subjective experience of FMS. Coping strategies adopted can be subsumed under Mannerkorpi, K., Kroksmark, T., Ekdahl, C. [1999. How patients with fibromyalgia experience their symptoms in everyday life. Physiotherapy Research International, 4(2), 110-122.] notions of 'struggling', 'adapting', 'in despair' and 'giving up'. Most studies had at least one identified methodological shortcoming, though it is not straightforward to identify the significance of such shortcomings. We conclude that there is scope for further research into the subjective experience of FMS, and into the methodology of metasynthesis, especially in relation to methodological appraisal.

'No one agrees except for those of us who have it': endometriosis patients as an epistemological community

This paper contributes to the literature on patients' claims-making work by analysing the epistemological strategies and standards used by members of an endometriosis patient community. It draws upon focus group research with members of a support group for endometriosis sufferers, and an open-ended survey of an e-mail list for women with the disease. Lynn Hankinson Nelson's (1993) concept of epistemological community is used to examine standards and practices for developing and evaluating knowledge used by women with endometriosis. Particular attention is paid to the use and centrality of the notion of experience within this community.

"Disturbing phenomenology" in the pain and engagement narratives of Cambodian American survivors of the Killing Fields

In the clinical literature on trauma, the atrocity survivor's attempt to engage others around the experience of chronic, intractable pain is often viewed as an instance of "help-seeking," logotherapeutic "coherence-making," or-more darkly-"patient malingering." In this article, I challenge the utility of these rubrics through a close examination of the pain and engagement narratives of two survivors of the Cambodian Killing Fields. I demonstrate that survivor narratives can obtain a strategic multivocality, oscillating between phenomenological account and political critique, between clinical description and moral exhortation. This discursive oscillation, speaking "on and to several different levels of experience at the same time" [Levin DM (1998) Int J Philos Stud 6(3):345-392], radically disturbs the audience's conventional sensibilities and distancing-making moves (for example, crafting totalizing accounts of the meaning of suffering or counterfactually speculating about the survivor's experiences of pain). This disturbance allows the survivor's narrative to function hermeneutically, enabling the audience to glimpse the moral significance of strategic multivocality for the survivor's efforts to engage others while tracing its performative responsibilities and possibilities for ourselves. Reading pain and engagement narratives this way forces us into a place of equivocation and ambiguity that makes possible new configurations of sense, meaning, and response. It is, thus, as disturbing phenomenology that the women's narratives derive their greatest practical power and urgency.

Living with low back pain-Stories of hope and despair

Previous qualitative research has illustrated a range of issues about the daily life of people living with low back pain (LBP). In this paper, we consider the struggle between hope and despair through consideration of six people's narratives about their experiences of chronic LBP. The six cases were selected from a larger qualitative study of 37 patients in the UK, sampled from a prospective cohort of people consulting their general practitioner. These six cases were selected for particular focus as they exemplify the fluctuating emotions of hope and despair. A number of linked themes emerged which influenced the extent to which people oscillate between hope and despair, the most salient of which were 'uncertainty', 'impact on self', 'social context of living with pain', and 'worry and fear of the future'. It is clear from the narrative accounts that it is not only just physical pain that the back pain sufferer must endure, but also that the psychosocial implications pose an added and often complicated challenge. Health care practitioners should consider these fluctuating emotions of hope and despair in order to facilitate more patient-centred strategies for treatment.

Illness action rediscovered: a case study of upper limb pain

Theoretical frameworks provide generalised accounts of illness action although empirical studies of the process are still in short supply. This study of upper limb pain provided a case study of illness action; as it is a common condition, there is uncertainty about its treatment and management, orthodox and non-orthodox care are seen as legitimate sources of help and it is linked with a range of causes. Face-to-face informal interviews were carried out with 47 informants with upper limb pain and their practitioners (n= 19). The data were analysed in two different ways. The general stages of the illness action process were identified through a descriptive analysis of the upper limb pain sufferers' accounts and the policies and practices reported by their practitioners. Then, case studies were constructed to depict individual pathways through healthcare and consequences for sufferers. The illness action process was characterised by the normalisation and accommodation of pain informed by a discourse that predominantly invoked ageing and the wear and tear of the body. Practitioners also preferred to adopt a biomechanical approach and were reluctant to attribute psychosocial labels. The case studies illustrated the divergent, negotiated and opportunistic nature of the process and showed that the use of both orthodox and non-orthodox care formed only part of strategies used to manage upper limb pain. Sufferers evaluated the care they received in terms of pain alleviation, and were resigned to searching for the best way of living with their pain.

The Influence of Patients' and Primary Care Practitioners' Beliefs and Expectations About Chronic Musculoskeletal Pain on the Process of Care

OBJECTIVES

To review qualitative, empirical studies exploring the influence of patients' and primary care practitioners' beliefs and expectations on the process of care for chronic musculoskeletal pain.

METHODS

A multidisciplinary review group searched 9 bibliographic databases. The group worked in pairs to screen titles and abstracts for relevance, to quality appraise relevant studies, to extract data from high-quality studies and to undertake a thematic analysis of this data.

RESULTS

We identified 12,994 abstracts from our searches, of which we obtained 113 full-text articles as their abstracts contained insufficient information for us to decide on their eligibility. We appraised 22 qualitative studies, 15 of which were included in the analysis. Themes identified included; (1) beliefs about pain, (2) expectations of treatment, (3) trust, and (4) patient education. Both patients and practitioners wanted clear communication within the consultation and to be respected, but conflicts existed on nearly all other aspects of the consultation, some of which at present may seem insurmountable and may lead to difficulties in achieving positive outcomes.

DISCUSSION

To tackle the challenges and conflicts identified within the review, change may have to occur, not just in individual patient and practitioner beliefs and behavior, but also at an organizational and system level, for example, changes in undergraduate and postgraduate education and changes in the organization and availability of health services.

Clinical and social predictors of application for social security disability insurance by workers' compensation claimants with low back pain

OBJECTIVE

The objective of this study was to identify clinical and social predictors of application for Social Security Disability Insurance (SSDI) in workers' compensation claimants with low back pain.

METHODS

Archival and interview data were analyzed for 1372 Missouri claimants who were, on average, nearly 42 months postinjury.

RESULTS

Two hundred sixty-five (19.3%) claimants were receiving SSDI (8.0%) or had applied for SSDI (11.3%). Logistic regression indicated that black race, older age, herniated disc diagnosis, surgery, and longer time since injury were associated with increased odds of SSDI. Higher preinjury wage, more education, and higher satisfaction with medical treatment and/or treatment by employer were associated with decreased odds of SSDI.

CONCLUSIONS

Application for SSDI among claimants with occupational low back pain is associated with social factors like race, satisfaction, and socioeconomics as well as clinical factors like diagnosis and surgery.

Comparing clinical and lay accounts of the diagnosis and treatment of back pain

This paper builds on the body of knowledge concerning clinician-patient relationships, patient-centred care and concordance. It extends the analysis to directly comparing patient and professional accounts of diagnosis, treatment and outcomes over time. Comparisons will be made between lay and clinical perspectives, but also between different professional approaches and patients' assessment of those differences. The paper is based upon an in-depth qualitative analysis of two case studies: first, one patient who established concordant relationships with the health professionals who treated her back pain; second, one patient who had both concordant and discordant relationships with health professionals. The issues explored centre on the determinants of concordant/discordant therapeutic relationships and whether greater attention given to the meaning of illness leads to improved care.

Why do doctors issue sick notes? An experimental questionnaire study in primary care

BACKGROUND

Issuing sick notes is one of the core tasks of General Practice and yet little research has explored how doctors decide whether or not to offer a sick note.

AIM

To explore what factors influence this decision with a focus on the impact of type of problem (psychological versus physical), adverse family circumstances (present versus absent) and patient demand (asks for note versus does not ask).

DESIGN

Experimental factorial design using questionnaire-based vignettes with eight scenarios which varied in terms of the three core factors.

SETTING

East and West Sussex PCTs.

OUTCOME MEASURES

Doctors' beliefs about the patient and their subsequent behaviour.

PARTICIPANTS

Four hundred and eighty-nine GPs completed a questionnaire asking them to rate one of eight hypothetical patients in terms of their beliefs about the patient and their hypothetical behaviour.

RESULTS

The doctors rated the patient with the psychological problem as more ill, less work-shy, more unfit for work and described feeling more sympathy towards him compared with the patient with the physical problem. The presence of adverse family circumstances generated more sympathy and doctors considered this patient as less work-shy. A patient demand for a sick note had no effect on doctors' beliefs about the patient. In terms of doctors' behaviour, the doctors were more likely to give the patient with the psychological problem a sick note overall and because they felt he needed or deserved one, and more likely to give the patient with the physical problem a sick note in order to maintain a relationship with him. The decision to give a sick note was not influenced by either adverse family circumstances or patient demand.

CONCLUSION

Doctors have more positive beliefs about patients with a psychological problem and are more likely to offer them a sick note. Issuing sick notes is unrelated to the patient's family circumstances or patient demand.

Making sense of aches and pains

BACKGROUND

The uncertainty about the status of upper limb disorders (ULDs), particularly the non-specific conditions, is believed to have consequences for clinical management and patient care.

OBJECTIVE

This paper presents evidence about how sufferers with ULDs respond to their pain, how their pain is managed, when and who they go to for formal help and how sufferers evaluate the care they receive.

METHODS

The data analysis is derived from face-to-face, informal interviews with sufferers with a broad spectrum of upper limb disorders (n = 47). These informants were selected according to strict criteria from a 'screening' postal survey of the working population (25-64 years) in south-west England (n = 2781).

RESULTS

Ideas about causation were crucial to understanding patterns of illness action and help seeking behaviour. The common strategy was to wait and see what happens as the pain was believed to be a natural part of the ageing process. Explanations invoking psychosocial and work related causes were less common and tended to be used when biomechanical explanations were no longer appropriate. Self-management was the preferred strategy but orthodox practitioners were usually the first choice for formal care. Complementary and alternative medicines (CAM) were popular but were used to complement orthodox care. Practitioners were evaluated mainly in terms of their ability to alleviate pain.

CONCLUSION

There is a need for orthodox and non-orthodox care to be closely integrated in primary care and GPs should not depend on orthodox medications alone when caring for patients with upper limb pain.

"It struck me that they didn't understand pain": the specialist pain clinic experience of patients with chronic musculoskeletal pain

OBJECTIVE

To explore the experiences of diagnosis and management among patients who attended a specialist musculoskeletal pain clinic and the factors influencing their interpretation of these experiences.

METHODS

A postal questionnaire was sent to potential participants 6-20 months after their first clinic attendance. Data were collected on pain presence, severity, and location; health-related quality of life; psychological distress; and care-seeking behavior. Questionnaire data were used to inform combined purposive and theoretical sampling. In-depth interviews were conducted that probed participants' understanding of their chronic musculoskeletal pain and its management in a specialist musculoskeletal pain clinic.

RESULTS

Fifteen patients were interviewed. Four main themes were identified: spoiled identity (pain limited patients' activities so extensively that it affected their sense of self); diminishing faith in medicine (patients were disappointed with aspects of their care-seeking experience); making sense of pain (patients made sense of their pain by locating their pain within the context of their lives); and learning to live with the pain (an issue for all patients was whether or not their pain would stop or whether they had to learn to live with it).

CONCLUSION

Developing, implementing, and evaluating approaches to address patients' spoiled identities might allow us to improve patient-centered outcomes in chronic musculoskeletal pain.

Evaluating health-care: the perspectives of sufferers with upper limb pain

BACKGROUND AND AIMS

There is considerable uncertainty over the diagnosis, treatment and management of upper limb pain, which has implications for patient care. Research into patient experiences and evaluation of health-care has been neglected and the study presented here aims to fill this gap.

METHODS

A two-staged, mixed methodology was adopted. Phase 1 involved a postal survey of a random sample (n = 2781) of the working age population (25-64) of an area in south-west England. Phase 2 consisted of follow-up, informal face-to-face interviews with a purposive sample of 47 informants identified, according to pre-defined criteria, from the survey sample.

RESULTS

Our data showed that concerns about the effectiveness of treatments for alleviating pain were fundamental to users' evaluations of both orthodox and non-orthodox health-care. This took priority over the need for a diagnosis and other information. There was a general recognition that the treatments available were, at least, only partially effective and the pragmatic approach led some to eventually withdraw from both orthodox care and complementary and alternative medicines (CAM).

CONCLUSION

Patients' priorities for health-care, in this context, were perceived to involve the provision of treatments which alleviated pain and were safe and painless. Orthodox and non-orthodox care needed to be more closely integrated into primary care services.

Race and socioeconomic differences in post-settlement outcomes for African American and Caucasian Workers' Compensation claimants with low back injuries

The purpose of this study was to predict post-settlement pain intensity, psychological distress, disability, and financial struggle among African American (n=580) and non-Hispanic Caucasian (n=892) Workers' Compensation claimants with single incident low back injury. The study was a population-based telephone survey conducted in three population centers in Missouri. Post-settlement outcomes were predicted from claimant demographics (race, age, gender); socioeconomic status (SES); diagnosis and legal representation; and Workers' Compensation resolution variables (treatment costs, temporary disability status, disability rating, settlement costs). Simultaneous-entry, hierarchical multiple linear regression analyses indicated that African American race and lower SES predicted higher levels of post-settlement pain intensity, psychological distress (general mental health, pain-related catastrophizing), disability (pain-related role interference), and financial struggle, independent of age, gender, diagnosis, legal representation, and Workers' Compensation resolution variables. The results suggest that African American race and lower SES-relative to Caucasian race and higher SES-are risk factors for poor outcomes after occupational low back injury. Mechanisms to explain these associations are discussed, including patient-level, provider-level, legal, and Workers' Compensation system-level factors.

Disparities in Occupational Low Back Injuries: Predicting Pain-Related Disability from Satisfaction with Case Management in African Americans and Caucasians

OBJECTIVE

To predict post-settlement pain-related disability from claimant race and satisfaction with Workers' Compensation case management.

DESIGN

Population-based survey with telephone interviewing.

SETTING

St. Louis City, St. Louis County, and Jackson County, Missouri.

PARTICIPANTS

African American and Caucasian Workers' Compensation claimants (1,475) with single incident low back injuries whose claims were settled between January 1, 2001 and June 1, 2002.

MEASURES

Workers' Compensation variables were obtained from the State of Missouri comprising treatment cost, temporary disability payment, disability rating, and settlement award. Satisfaction with Workers' Compensation case management was evaluated across five Likert-type rating scales. Pain-related disability was measured using the Pain Disability Index. Injury variables included diagnosis of disc injury or regional backache. Socioeconomic status included education and income. Demographic variables were race, age, and gender.

RESULTS

Path analysis indicated direct negative associations between satisfaction and disability. Race had a direct association with disability but was also mediated through other variables: African Americans received less treatment/compensation across the Workers' Compensation variables (relative to Caucasians), which predicted lower satisfaction. This pattern also held true for lower socioeconomic status claimants and those with regional backache.

CONCLUSIONS

For African Americans and lower socioeconomic status persons in the Workers' Compensation system, less treatment/compensation was associated with lower satisfaction with the process, which in turn predicted higher levels of post-settlement disability. Given that the function of Workers' Compensation is to reduce disability from work-related injuries, the current results suggest that the system produces inequitable outcomes for these groups.

Framing the doctor-patient relationship in chronic illness: a comparative study of general practitioners' accounts

How family doctors conceptualise chronic illness in the consultation has important implications for both the delivery of medical care, and its experience by patients. In this paper, we present the results of a re-analysis of qualitative data collected in a series of studies of British family doctors between 1995 and 2001, to explore the ways in which the legitimacy and authority of medical knowledge and practice are organised and worked out in relation to three kinds of chronic illness (menorrhagia; depression; and chronic low back pain/medically unexplained symptoms). We present a comparative analysis of (a). the moral evaluation of the patient (and judgements about the legitimacy of symptom presentation); (b). the possibilities of disposal; and (c). doctors' empathic responses to the patient, in each of these clinical cases. Our analysis defines some of the fundamental conditions through which general practitioners frame their relationships with patients presenting complex but sometimes diffuse combinations of 'social', 'psychological' and 'medical' symptoms. These are fundamental to, yet barely touched by, the increasingly voluminous literature on how doctors should interact with patients. Moving beyond the individual studies from which our data are drawn, we have outlined some of the highly complex and demanding features of what is often seen as routine and unrewarding medical work, and some of the key requirements for the local negotiation of patients' problems and their meanings (for both patients and doctors) in everyday general practice.

Low back pain: an economic assessment in the United States

Although it is clear that LBP imposes a grave economic cost on society, the lack of consensus on causes and appropriate treatments makes it difficult to develop explicit guidelines and best practices. To gain a greater understanding of the economic impact of the condition and to reduce the unnecessary procedures that patients undergo, a series of cost-effectiveness analyses on established treatment options and on proposed integrated programs of prevention, treatment, and counseling, would be not only informative but integral to the progress of LBP disease management.

Exploring the experiences of partners who live with a chronic low back pain sufferer

Chronic low back pain (CLBP) is a condition that causes individuals considerable distress. It also presents a significant challenge to the health service and is often viewed by clinicians as frustrating to manage. The purpose of the present paper is to explore the experiences of individuals in the immediate social sphere of those suffering from CLBP and their role in care-giving for their partner. An approach was taken using two qualitative research methods to gather data: journals and focus groups. Findings from the journals and the focus groups revealed issues for partners of CLBP sufferers in relation to living with their partners' pain, perceptions of healthcare and the dominance of illness over social contacts. Key themes revealed the complex emotions experienced by respondents, and underlined the need for their role as care givers and partners to be acknowledged by healthcare professionals. The data also highlighted respondents' desire to have greater involvement in their partners' healthcare, which includes provision of relevant information and involvement with therapeutic interventions. The findings emphasise the need for healthcare professionals to include and acknowledge partners and others in the immediate social sphere of patients in the management of chronic conditions.

Involving users in low back pain research

OBJECTIVE

To involve users in the design of a research project that aims at describing a 12-month course of low back pain in an adult population sample (epidemiological strand), and to determine how patient and professional perceptions of low back pain and its treatment relate to the use of health-care and to subsequent outcome (qualitative strand).

DESIGN

Three focus groups were organized in the preparatory phase of the project with general practitioners, other health professionals and low back pain sufferers. Issues pertaining to the experience of living with, or treating low back pain were explored and users were asked to identify relevant research questions for consideration within the study.

FINDINGS

The focus groups revealed tensions between involving users as co-researchers for design issues and their role as sufferers and health professionals who want to share their narrative accounts of low back pain. The group discussions produced a wealth of material for analysis, but no explicitly stated research topics. Three key themes and the process of user involvement in the focus groups are discussed.

CONCLUSIONS

The focus group format could be restrictive in that it allows for detailed exchange between participants, but is insufficiently geared towards the production of a research agenda. We draw conclusions as to possible approaches for user involvement in health services research design.

The Boeing prospective study and beyond

STUDY DESIGN

The Boeing prospective study was reviewed. The Boeing prospective study, comprising two articles, was a large field study that explored why workers would or would not report occupational back pain problems.

OBJECTIVES

The most immediate objective was to determine the extent to which conclusions drawn from the Boeing prospective study withstand critical examination. The ultimate purpose of this review was to develop guidelines for field studies of back pain in industry.

SUMMARY OF BACKGROUND DATA

For more than a century, researchers have noted great variability among individuals in the reporting of back pain, but the explanations posed for this variability have been inconsistent. Because findings gain credibility roughly to the extent that they bear on the world outside the laboratory, field studies in particular hold great potential for clarifying the underlying explanation for individual variability in back pain reporting. The Boeing prospective study was a large and ambitious field study that examined this issue.

METHODS

The Boeing prospective study was examined through the lens of research conducted since it was published. The review used both the methodological and substantive literature.

RESULTS

The Boeing prospective study, based on a minority of workers originally solicited to participate in it (33-41%), accounted for 7% of the variation in why workers would or would not report a back pain problem. A number of issues that may have biased its results toward the null are examined.

CONCLUSIONS

The highlighting of the Boeing prospective study's limitations may be instructive not so much to criticize this one particular study but, rather, to anticipate problems that in general may be encountered in field studies of back pain in industry. Looking beyond the Boeing prospective study, the following guidelines for the conduct of such studies may be proposed: 1) Study designs should be based on explanations from which testable hypotheses may be derived; 2) Subgroups within the more general category of "back pain" should be delineated; 3) Both occupational exposures and psychosocial factors should be entered into the analysis; 4) Factors not apparent at the workplace should be considered; 5. Abstracts of articles should be carefully crafted.

Chronic spinal disorders and psychopathology. research findings and theoretical considerations

BACKGROUND CONTEXT

Numerous studies have documented a strong association between chronic spinal disorders and psychopathology. However, there have been methodological shortcomings associated with much of this.

PURPOSE

This article reviews the relevant research literature, including methodological refinements that have resulted in improved measurement of psychopathology, in order to provide the most updated conclusions concerning the links between spinal disorders and psychopathology.

STUDY DESIGN

A systematic review of all Medline referenced articles on this subject during the past three decades.

METHODS

Previous research has shown that chronic spinal disorders are most often associated with depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders. In addition to reviewing this research, the relationship between chronic spinal disorders and depressive disorders is examined in more detail.

RESULTS

Although the relationship between spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical model. In this model, diatheses are conceptualized as pre-existing semidormant characteristics of the individual before the onset of chronic spinal disorders, which are then activated by the stress of this chronic condition, eventually resulting in a diagnosable depressive disorder.

CONCLUSIONS

In the present review, a diathesis-stress model was applied specifically to the relationship between chronic spinal disorders and depressive disorders. Such a model may also be applicable to the relationship between chronic spinal disorders and other types of psychopathology, such as anxiety and substance use disorders. However, conclusive empirical support will require a prospective research design, given that these diatheses could be validly assessed only before the onset of the chronic pain condition.

Dealing with doubt. How patients account for non-specific chronic low back pain

OBJECTIVE

To explore the ways that persons with long standing chronic low back pain respond to the problem of medical doubt about the presence of organic pathology.

METHOD

Qualitative analysis of accounts provided by 12 persons attending a back pain rehabilitation clinic in NW England.

RESULTS

Subjects rejected the notion that they were culpable for their pain. They were not culpable for the onset of their pain. They argued that despite their cooperation, no sensible explanation of their pain was forthcoming from health professionals. Finally, they asserted that medical scepticism had been damaging and dispiriting.

CONCLUSION

Patients dealt with clinical doubt by stressing their own expertise. They constituted their beliefs about the cause and trajectory of their pain and disability as accurate accounts of their disability. They resisted the suggestion that there might be psychological factors involved in their ill-health by locating culpability among clinicians, who were confused or uncertain about diagnosis and treatment.