"I felt uncertain about my whole future"-a qualitative investigation of people's experiences of navigating uncertainty when seeking care for their low back pain

Co-creating a Choosing Wisely leaflet supporting the reduction of imaging usage in low back pain management - A multi-method study

OBJECTIVE

The objective was to co-create an information resource in the form of a leaflet, to be distributed in clinical settings, websites or social media targeting people with low back pain.

METHODS

This multi-method study was conducted in four stages: literature search, input from practice consultants, program theory development, and think-aloud interviews with people experiencing low back pain. Each stage was followed by a consensus meeting in which the steering group refined the leaflet based on the emerging knowledge.

RESULTS

The literature search highlighted patients' need for easy-to-understand information about their back pain diagnosis, management strategies, social activities, work and solutions for supported self-management strategies. Practice consultants emphasized concise, relatable content. The program theory identified potential mechanisms for content creation, development, and implementation of the leaflet, such as addressing patient concerns, reducing diagnostic uncertainty, insights into management options, and validation. Think-aloud interviews with 18 people living with low back pain informed the iteration of the leaflet, enhancing language clarification and content comprehension.

CONCLUSIONS

We co-created a new Choosing Wisely leaflet, created with end-users in mind, specifically focused on reducing unnecessary imaging for low back pain.

PRACTICE IMPLICATIONS

This leaflet may support clinical settings in delivering evidence-based approaches and supporting self-management.

Coping With a Dead End by Relying on Your Own Compass: A Qualitative Study on Illness and Treatment Models in the Context of Fibromyalgia

Fibromyalgia lacks a coherent illness and treatment model, which includes a set of conceptual ideas shaping individuals' perceptions and understandings of pain, its causing and maintaining factors, and management strategies. Developing personalized illness models that can guide treatment plans and alleviate feelings of uncertainty is of crucial importance. This study investigates how individuals with fibromyalgia develop a personal illness and treatment model while navigating the current healthcare system and explore their experiences during this process. Semi-structured interviews were conducted with 15 cis women with fibromyalgia, which were analyzed using reflexive thematic analysis. The analysis produced two themes, each including two subthemes. The first theme encompassed the difficulty of developing a comprehensive illness model due to the biomedical perspective of the healthcare system; the second theme described the importance of participants (re)gaining ownership and agency over their pain management, by constructing their own illness and treatment model. Most women in this study got stuck in the biomedical healthcare web not being provided with a clear illness and treatment model. Consequently, most women gained ownership of this process by developing their personal illness and treatment model (self-empowerment). Conversely, a few women felt powerless and paralyzed. This study underscores the importance of promoting patient empowerment in chronic pain management. Agency is undervalued in the treatment of fibromyalgia and warrants more thorough examination. Increasing knowledge about agency could enhance treatment effectiveness.

Exploring athlete pain assessment experiences and priorities; a two-part qualitative series of athlete and physiotherapist interactions. Part Two. "Forging our future" - Athlete and physiotherapists' priorities for pain assessment and beyond

OBJECTIVES

To explore the priorities and directions of athlete upper and lower limb pain assessment by facilitating shared understandings of athletes and sport physiotherapists.

DESIGN

Qualitative research using a hermeneutic phenomenological approach.

METHODS

We carried out focus groups comprising a deliberate criterion sample using a constructivist perspective. At the end of each focus group, we used the nominal group technique method to generate a list of consensus-based priorities for future pain assessment. Our paper follows the consolidated criteria for reporting qualitative research (COREQ) guidelines.

RESULTS

We completed five focus groups, comprising twelve athletes (female, n = 5, male, n = 7) and four sport physiotherapists (male, n = 4). Two final themes (and six subthemes) were developed; I Enhanced Communication and Pain Descriptions (describing and representing pain, better communication, the role of technology, providing direction and setting the pace), and II Integrating Sport Specific and Multidimensional Assessments (broadening the pain assessment toolkit, the role of technology). We developed a set of thirteen practical priorities for pain assessment that span the subjective, objective, and general aspects of the athlete pain assessment.

CONCLUSIONS

We have presented stakeholder-generated perspectives, direction and priorities for athlete pain assessment. Athletes and physiotherapists must continue to work together to achieve a comprehensive sport-specific multidimensional pain assessment experience alongside their wider support networks to ensure optimal representation and communication. We have highlighted some available pain assessment tools and strategies and outlined how novel tools may address certain gaps. Researchers, clinicians, and athletes can consider the practical guidance we have provided to address these priorities.

Addressing the "Black Hole" of Low Back Pain Care With Clinical Decision Support: User-Centered Design and Initial Usability Study

Background

Low back pain (LBP) is a highly prevalent problem causing substantial personal and societal burden. Although there are specific types of LBP, each with evidence-based treatment recommendations, most patients receive a nonspecific diagnosis that does not facilitate evidence-based and individualized care.

objectives

We designed, developed, and initially tested the usability of a LBP diagnosis and treatment decision support tool based on the available evidence for use by clinicians who treat LBP, with an initial focus on chiropractic care.

Methods

Our 3-step user-centered design approach consisted of identifying clinical requirements through the analysis of evidence reviews, iteratively identifying task-based user requirements and developing a working web-based prototype, and evaluating usability through scenario-based interviews and the System Usability Scale.

Results

The 5 participating users had an average of 18.5 years of practicing chiropractic medicine. Clinical requirements included 44 patient interview and examination items. Of these, 13 interview items were enabled for all patients and 13 were enabled conditional on other input items. One examination item was enabled for all patients and 16 were enabled conditional on other items. One item was a synthesis of interview and examination items. These items provided evidence of 12 possible working diagnoses of which 3 were macrodiagnoses and 9 were microdiagnoses. Each diagnosis had relevant treatment recommendations and corresponding patient educational materials. User requirements focused on tasks related to inputting data, and reviewing and selecting working diagnoses, treatments, and patient education. User input led to key refinements in the design, such as organizing the input questions by microdiagnosis, adding a patient summary screen that persists during data input and when reviewing output, adding more information buttons and graphics to input questions, and providing traceability by highlighting the input items used by the clinical logic to suggest a working diagnosis. Users believed that it would be important to have the tool accessible from within an electronic health record for adoption within their workflows. The System Usability Scale score for the prototype was 84.75 (range: 67.5-95), considered as the top 10th percentile. Users believed that the tool was easy to use although it would require training and practice on the clinical content to use it effectively. With such training and practice, users believed that it would improve care and shed light on the "black hole" of LBP diagnosis and treatment.

Conclusions

Our systematic process of defining clinical requirements and eliciting user requirements to inform a clinician-facing decision support tool produced a prototype application that was viewed positively and with enthusiasm by clinical users. With further planned development, this tool has the potential to guide clinical evaluation, inform more specific diagnosis, and encourage patient education and individualized treatment planning for patients with LBP through the application of evidence at the point of care.

Clinician experiences in providing reassurance for patients with low back pain in primary care: a qualitative study

QUESTIONS

What reassurance is being delivered by physiotherapists and chiropractors to people with non-specific low back pain? How is it being delivered? What are the barriers and enablers to delivering reassurance to people with non-specific low back pain?

DESIGN

A qualitative study.

PARTICIPANTS

Thirty-two musculoskeletal clinicians (16 physiotherapists and 16 chiropractors) who manage low back pain in primary care.

METHOD

Semi-structured interviews were conducted about their experiences delivering reassurance. The interview schedule was developed using the Theoretical Domains Framework and analysed using framework thematic analysis.

RESULTS

Four themes were identified: giving reassurance is a core clinical skill for delivering high-quality care; it takes practice and experience to confidently deliver reassurance; despite feeling capable and motivated, clinicians identified situations that challenge the delivery of reassurance; and reassurance needs to be contextualised to the individual.

CONCLUSION

Clinicians possess a strong understanding of reassurance but require clinical experience to confidently deliver it. This study provides insights into how reassurance is individualised in clinical practice, including suggestions for clinicians about how to implement reassurance effectively for people with low back pain.

They paid attention to the whole of me in some way, both physically, mentally, and everything in between: a qualitative study of patients' experiences of interdisciplinary rehabilitation (PREVSAM) in primary care for musculoskeletal disorders

PURPOSE

To explore and describe patients' experiences and perceptions of rehabilitation according to the rehabilitation model 'Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain' (PREVSAM).

METHOD

A qualitative study was conducted, with individual semi-structured interviews analysed using qualitative content analysis. Fifteen patients from three primary care rehabilitation clinics in Sweden who had undergone rehabilitation based on the PREVSAM model participated.

RESULTS

Four categories were identified from the participants' experiences: Gratitude for the holistic view, Challenging but clarifying to create a health plan, Different needs for addressing work-related factors, and Difficulties and negative experiences. From these categories, an overarching theme was conceptualised: Grateful for being seen for who I am and given the care I need.

CONCLUSION

Participants were generally positive towards the PREVSAM model. The addition of occupational therapy and psychological treatment to physiotherapy was seen by many, albeit not all, as enriching the rehabilitation. Collaboration with the workplace was mainly considered 'good in theory'. The wide variation in the need for support underscore the importance of person-centredness.

Patient perspectives on low back pain treatment in primary care: a qualitative study of hopes, expectations, and experiences

BACKGROUND

Patients' hopes and expectations for low back pain treatment influence their consultation experiences and treatment outcomes. These hopes and expectations may evolve over time, potentially leading to a shift in what patients consider important before and after a consultation. Understanding the distinction between hopes and expectations, and how they evolve is important for improving patient care. This study explored patients' hopes and expectations prior to LBP consultations and examined how these were reflected in their post-consultation experiences.

METHODS

We employed a qualitative design consisting of individual semi-structured pre- and post-consultation interviews with patients seeking care for low back pain from general practitioners, physiotherapists, and chiropractors in Denmark. A convenience sample of 18 patients (10 females and 8 males) aged between 28 and 79 years were interviewed about their hopes and expectations before a consultation and their experiences immediately following the consultation. Data were analysed employing Braun and Clarke's thematic analysis.

RESULTS

Two themes with five subthemes were developed: (1) "Something needs to be done," which included subthemes related to life disruption, expectations of clinical assessment, and the clinicians as experts; and (2) "Experiences and emotional responses to the interaction with the clinician", highlighting the importance of trust and the personal attributes of clinicians. Patients initially sought urgent help and clarity regarding their condition but shifted their focus post-consultation to the relational dynamics and emotional engagement experienced during interactions with clinicians.

CONCLUSIONS

This study contributes to the understanding of how patients' hopes and expectations regarding low back pain consultations evolve, shifting from a focus on clinical actions and outcomes to valuing interpersonal relationships and emotional support from clinicians. Recognising these shifts can enhance clinician-patient interactions and improve overall patient satisfaction and treatment outcomes.

CLINICAL TRIAL NUMBER

Not applicable.

Why might fears and worries persist after a pain education-grounded multimodal intervention for chronic back pain? A qualitative study

Introduction

The effect of pain education (PE) on pain intensity and function diminishes after a few months in people with chronic low back pain (CLBP). One possible explanation is the return of underlying fears and worries related to the condition.

Objective

To explore topics related to participants' beliefs and feelings that might explain why fears and worries persist after a PE-grounded intervention for CLBP.

Methods

We conducted a qualitative study involving semistructured interviews with participants from the active arm of a randomised controlled trial who received an individualised PE-grounded intervention for adults with CLBP. We used reflexive thematic analysis with an inductive approach.

Results

Twenty participants were interviewed (9 women and 11 men, median age = 54 years, median pain duration = 4 years, 13 reporting at least 30% pain reduction on the trial primary outcome). Three themes were identified: 1) "Are you implying my pain is not real?": a few participants believed the validity of their pain was being questioned. 2) "You don't understand, my pain is different": most participants considered the influence of an altered nervous system but did not exclude the possibility of having structural and biomechanical influences for the persistence of their back pain. 3) "I am unsure how to fit it into my daily life": fear and worries persisted when participants could not figure out how to apply an alternative way of making sense of pain in their daily lives.

Conclusion

Patients' perceptions about PE should be monitored and might be addressed with communication strategies, educational content that matches patients' characteristics, and reinforcements over time.

"All of these things interact, that's why it's such a wicked problem": Stakeholders' perspectives of what hinders low back pain care in Australia and how to improve it

BACKGROUND

Low-quality care for low back pain (LBP) is pervasive in Australia. Drivers of low-quality care have been identified elsewhere and include misconceptions about LBP, vested interests and limited funding for evidence-based interventions. Yet, the literature that identified such drivers is not specific to the Australian context, and therefore, it is likely to represent only part of the local problem. This study aimed to determine where the most influential drivers of LBP care are in the Australian healthcare system and what could be done to address them.

METHODS

Clinical leaders from various disciplines, academics, hospital managers, policy-makers, consumers involved in LBP advocacy, board members of relevant health profession boards and private insurers were invited to participate in one-on-one interviews. Interviews were transcribed verbatim. Interview data were analysed using content analysis.

RESULTS

We interviewed 37 stakeholders. Challenges that hinder LBP care in Australia included variability in care and inconsistent messages, funding models that are not supportive of appropriate care for LBP, the community's understanding of LBP, vested interests and commercial forces, difficulties in accessing timely and affordable conservative care, neglect of social determinants and health inequities, short consultations, siloed practices, uncertainties that stem from gaps in evidence and the experience of having LBP, individual and contextual variability, the mismatch between evidence and practice, the Australian healthcare system itself, the lack of political will and acknowledgement of LBP as a public health issue, stigma, the need to improve human aspects and the compensation system. When discussing factors that could improve LBP care, participants raised collaboration, changes in funding, improvement of access to - and affordability of - models of care and care pathways, public health campaigns targeting LBP, enhancement of policy and governance, increasing and better training the workforce, consideration of inequities, making improvements in information sharing and reforming the worker's compensation sector.

CONCLUSIONS

LBP is a wicked problem, influenced by several systemic factors. An agenda for system change in the LBP landscape should be guided by a collaborative, coherent and integrated approach across sectors to enhance quality of care and system efficiency for those who seek and provide care.

Communicating safety-netting information in primary care physiotherapy consultations for people with low back pain

BACKGROUND

Safety-netting involves communicating information to patients about diagnostic uncertainty, the likely time-course of their condition and how to appropriately seek help from a healthcare professional if their condition persists or worsens. Little is known about how physiotherapists communicate safety-netting information to people with low back pain (LBP).

OBJECTIVES

This research aimed to use a Safety-Netting Coding Tool (SaNCoT) to explore how physiotherapists communicate safety-netting information to people with LBP.

METHODS

The SaNCoT was used to conduct a secondary analysis of audio-recordings and transcripts from 79 primary care physiotherapy consultations (41 initial and 38 follow-up) involving 12 physiotherapists and 41 patients with LBP in Southern England. Quantitative data from the SaNCoT were analysed descriptively.

FINDINGS

The study found evidence of diagnostic uncertainty in 53 (67%) appointments and no examples of physiotherapists providing patients with specific information about their condition time-course. Eight patients were given safety-netting advice, but most (57.9%, n = 11) episodes of safety-netting advice did not include specific signs and symptoms for patients to monitor. Potential missed opportunities for safety-netting advice were identified in 19 appointments (24.1%) which tended to relate to the patient's associated leg symptoms but also included possible serious pathology.

CONCLUSION

The SaNCoT was successfully used to measure safety-netting communication within physiotherapy consultations and found missed opportunities for providing clear safety-netting advice. Physiotherapists can use the findings to reflect on how they can provide clear safety-netting information to patients with LBP to effectively support patients to self-manage and help them seek appropriate care if their condition deteriorates.

'Leaving my comfort zone'. A qualitative study of physiotherapists' experiences blending an eHealth psychosocial intervention with face-to-face physiotherapy

BACKGROUND

Many physiotherapists do not feel adequately equipped to address psychosocial risk factors in people with complex pain states. Hence, a biopsychosocial blended intervention (Back2Action) was developed to assist physiotherapists to manage people with persistent spinal pain and coexisting psychosocial risk factors associated with the development or maintenance of persistent pain.

OBJECTIVE

This study aimed to gain insight into the experiences of physiotherapists with this blended psychosocial intervention.

DESIGN

and methods: This was an interpretative qualitative study with a reflexive thematic analysis of semi-structured interviews with physiotherapists (N = 15) who delivered Back2Action. The interview started with the grand-tour question: "What was your experience in using Back2Action?" Physiotherapist were encouraged to provide examples, and follow-up questions were posed to ensure a deeper understanding could be reached.

RESULTS

Four themes were constructed: Physiotherapists became increasingly aware of (1) their own implicit expectations, biases and skills, and underlying treatment paradigms, and (2) the implicit expectations from their patients towards them. This led to (3) creating a deeper and stronger therapeutic alliance with the patient, but also (4) an understanding that implementation of a true biopsychosocial intervention - even if offered in a blended form - requires more practice, confidence and resources.

CONCLUSIONS

Back2Action is considered a valuable treatment to deliver a biopsychosocial intervention in primary care. Considering the high level of knowledge, skills and competency of the participating physiotherapists, the perceived barriers may be more difficult to overcome for more junior physiotherapists.

A confirmatory factor analysis of an electronic format painDETECT questionnaire for patients with low back pain

BACKGROUND

The substantial burden of low back pain on patients and healthcare systems is exacerbated by unclear pathology and ineffective diagnostic methods, hindering effective management. The painDETECT questionnaire (PD-Q) has been used to facilitate the evaluation and categorization of low back pain. While preliminary validation and translations of the paper-based format of PD-Q into languages such as Spanish and Dutch have been accomplished, the underlying factor model inherent to the electronic format of the PD-Q remains to be established.

OBJECTIVE

The objective of this study was to utilise confirmatory factor analysis (CFA) to investigate the factor structure of an electronic format PD-Q among patients with neuropathic low back pain.

METHODS

This cross-sectional study was conducted at a Spinal Clinic in Sydney between November 2020 and October 2022. Eligible participants were adults over 18 with low back pain and no history of lumbar surgery or systemic co-morbidities. Participants completed the electronic format of the PD-Q, and CFA was employed to assess the validity of the suggested two-factor, nine-item structure. Recommended cut-offs for goodness-of-fit indices were used to evaluate the model fit.

RESULTS

Of the 236 patients that visited the clinic during the data collection period, 142 (71, 50% female, mean age 51.26 ± 15.28 years) participated in the study. Median pain severity was 9/10 over 4 weeks. CFA indicated strong model fit, with goodness-of-fit and comparative fit indices over 0.9, and overall internal consistency was 0.77. Construct validity analysis demonstrated the PD-Q's effectiveness in distinguishing neuropathic, mixed, and nociceptive LBP, aiding neuropathic pain evaluation in low back pain patients.

CONCLUSION

This study confirms the reliability and two-factor structure of the electronic PD-Q for neuropathic pain assessment in low back pain patients. To enhance comprehension of the clinical applicability of the electronic format PD-Q, future research should conduct clinimetric evaluations.

Competences to self-manage low back pain among care-seeking adolescents from general practice - a qualitative study

BACKGROUND

There is limited knowledge about when and how adolescents with low back pain (LBP) interact with health care providers. This limits our understanding of how to best help these young patients. This study aimed to understand when and how care-seeking adolescents with LBP interact with health care providers and which health literacy competencies and strategies do they use to self-managing their LBP.

METHOD

Ten semi-structured interviews (duration 20-40 min) were conducted online among adolescents aged 15-18 with current or recent LBP (pain duration range; 9 months - 5 years). The interview guide was informed by literature on health literacy and self-management in patients. We conducted a semantic and latent thematic data analyses.

RESULTS

Three major themes emerged from the analysis: (1) Self-management, (2) Pain and Function, and (3) Communication. All adolescents were functionally limited by their pain but the main reason to consult a health care provider was an increase in pain intensity. Many were able to navigate the healthcare system, but experienced difficulties in communicating with health care providers, and many felt that they were not being taken seriously. Their first line self-management option was often over-the-counter pain medicine with limited effects. Most adolescents expressed a desire to self-manage their LBP but needed more guidance from health care providers.

CONCLUSION

Adolescents with LBP seek care when pain intensifies, but they lack self-management strategies. Many adolescents want to self-manage their LBP with guidance from health care providers, but insufficient communication is a barrier for collaboration on self-management.