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Low back pain - what do patients think about it? What do they need from their doctor?

At a glance:
  • Patients' views about low back pain are diverse
  • Patients are often dissatisfied with explanations they receive about their back pain
  • Good management of low back pain needs to take patients' complex views of the condition into account.
Like the common cold there is no recognised medical cure for non specific low back pain. For 80% of people instances of low back pain occur from time to time and are a normal part of life. It is not a life threatening condition and in the overwhelming majority of cases low back pain does not lead to permanent disability.

The best response to low back pain is to maintain your normal activity as far as possible. Seek a clear explanation from your treating health professional regarding the condition and get advice on a program of exercise that includes stretching.

Understanding the condition as clearly as possible is the best way to alleviate worry and create confidence in your management of the problem. Discuss the problem with your employer and organise your personal life so that you can change posture and activity that has a negative impact on your back, and gain some control over your symptoms.
The majority of people (80%) suffer non specific low back pain from time to time. The people who best manage the problem with minimal disruption to their lives have confidence in their ability to do so.

Those people who do not understand the condition, or lack confidence, are often worried and fearful of its consequences. These people need reassurance and a clear explanation of the condition from an appropriate health professional.

A program of exercise including stretching to assist them in maintaining normal activity as far as possible is the best course. Support from you regarding adapting work practices and/or the work environment to give the person control over their condition will best enable them to manage it.
This paper explores what patients want from doctors when they attend a consultation about their back problems.

A key point of the article is that patients want information about their condition. This study shows people with back pain have a variable level of understanding about their condition and their longer term outlook. In an everyday consultation it is challenging to find sufficient time to cover the various aspects of a work related back condition. By the time a history and examination is completed, a diagnosis
The process of identifying a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of various diagnostic procedures.
 conveyed, perhaps a prescription and / or certificate given, and the employer consulted there is little or no remaining time for a longer discussion with the patient within a standard consultation. Doctors can make double appointments or longer consultations, and this paper suggests a longer consultation is required for patients with back pain at some stage.

Spending time with the patient to provide correct, evidence based information is an important aspect of clinical management. Patients are keen to have a good explanation about their condition. They will benefit from a thorough understanding of the problem, what they can do to help themselves, how to minimise future problems and their longer term outlook. Doctors need to have an understanding of lower back injury in order to provide the relevant advice, and are encouraged to consult other papers on the natural history of back problems and treatment.
Back problems can be frustrating to deal with. However people do better when they are given a good understanding of their condition.

It is of value to support them getting advice about their back condition.

Encourage them to talk to their treating practitioner
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 if you have a sense that they are not confident in their understanding of their condition.
Original Article, Authors & Publication Details:
A. M. Skelton1, E. A. Murphy2, R. J. L. Murphy1 and T. C. O'Dowd3 (1996).

Patients' views of low back pain and its management in general practice. British Journal of General Practice; 46(404): 153-156

1 School of Education, University of Nottingham.
2 School of Social Studies, University of Nottingham.
3 Department of General Practice, University of Nottingham.
Background, Study Objectives, How It Was Done:
The aim of this study was to explore the views of patients about low back pain and its management in general practice.

Low back pain is a major health problem, with 15-20% of people having such pain at any one time. The condition mainly effects the working population and, in the UK, it results in the loss of 33 million working days each year. Although most low back pain is self-managed by patients, one in four chooses to visit their general practitioners, resulting in over two million consultations annually.

Traditional management of the condition has included rest, restriction of activity and analgesia (medication to suppress pain). This approach has been criticised not only on the grounds of ineffectiveness, but also because it may be harmful and costly. Research suggests that adapting management programmes to take account of patients' prior understanding, beliefs and experiences may be important.

Studies of patients' experiences of the management of low back pain in general practice suggest that patients do not accept the general practitioner's opinion of whether the back pain as short of long term, and can be dissatisfied with the medical approach. Many patients indicate that they do not receive an adequate explanation for their problem and are less satisfied with the care that they receive for low back pain than for other conditions.

The study was based on the information obtained through a series of semi-structured interviews, lasting 60-90 minutes. Patients with recurrent low back pain in selected general practices in Nottinghamshire were interviewed between July 1992 and December 1993. The group of adult patients (18-75 years of age) met the study criteria of
  • More than one general practice consultation for back pain
  • No spread of the pain into the leg
  • No history of spinal surgery.
Study Findings:

61 patients were recruited into the study, 85% of these were able to be contacted and interviewed. The average age of those in the study was 41, with the youngest aged 18 and the oldest aged 66.There were seven areas explored in the interviews and study:
  • Impact of low back pain on quality of life
  • Expectations about recovery
  • Commitment to preventing symptoms
  • Readiness to consult a general practitioner
  • Satisfaction with explanation for their pain
  • Satisfaction with general practitioner management
  • Willingness to consult complementary therapists (e.g. chiropractor or osteopath).
After putting together the information from the 52 people who completed the interview, the researchers collated the information on the following seven areas:

Impact of low back pain on quality of life

Just under half the group indicated they had to adapt their lifestyle after back pain occurred e.g. reducing the length of time they spent on certain activities. A further 18 patients claimed that low back pain had led to a major reduction in their quality of life, and that they had to give up or stop activities. They were not confident of the ability of their bodies to withstand physical exercise.

Expectations about recovery

Patients' attitudes to their likelihood of recovery varied. Ten were optimistic about returning to 'normal health'. At the other extreme 11 patients expressed a much more pessimistic
Tends to stress the negative or unfavorable or to take the gloomiest possible view.
 view. They thought their low back pain was getting worse and feared a loss of mobility and reduced quality of life.

'I know that it sounds stupid, but sometimes I think to myself, "I could end up in a wheelchair"... that's how worried I am sometimes.' (man, aged 34 years)

Between these extremes were two other groups. Six were long-term sufferers who believed that their pain would probably stay with them for the rest of their lives, but not worsen. Twelve were unsure what the future held.

'Is it something that with time can be healed, or is it something that you have to adapt your life around? I don't understand it enough to know what is going to happen.' (woman, aged 31 years)

Commitment to preventing symptoms

Twenty-nine patients claimed to be actively working on their problem and organising parts of their lives (work, leisure or home life) around their back pain. Most were trying to prevent pain in more than one way, including: body posture when bending, sitting and lifting; taking light exercise; rest; and using back and stomach strengthening exercises.

In contrast 16 patients used few or no prevention practices. Most appeared to have some knowledge of prevention practices yet continued to behave inappropriately, and disregard advice.

In between these extremes was a small group of four patients who reported that they were in the process of recognising they had a problem and needed to do something about it. These patients appeared to be on the way to adopting a management strategy for their back pain.

Readiness to consult a general practitioner

Of 44 patients who expressed a strong view, only 15 believed that it was appropriate to visit their general practitioner routinely for episodes of low back pain. Of these, four were mainly concerned with having their sickness certified. The others saw such consultations as an opportunity to challenge misdiagnosis or inappropriate management (six patients), or to explore alternative ways to manage their back pain with the general practitioner (five).

The remaining 29 patients were reluctant to consult their GP. Reasons included trying to ignore the pain, fear of wasting the doctor's time (17 patients), scepticism about the doctor's ability to help (10) and concern about jeopardising their employment prospects (2).

Satisfaction with explanation for their pain

Only 20 interview participants recalled being given a satisfactory medical explanation for their low back pain by a health professional.

Eleven patients thought they had been given a clear explanation, but doubted its validity, because it conflicted with their own prior understanding, or they believed that it was based on inadequate investigations.

Eight patients believed that they were uncertain about the reason for their pain because their doctor was uncertain, there was disagreement among health professionals or medical research was inconclusive.

Five patients discussed a wider range of tentative explanations for lacking a satisfactory explanation for their pain, but were unable to choose between them, and three patients claimed to have no understanding of low back pain and said they had never discussed the reason for their pain with a doctor.

Satisfaction with general practitioner management

Twenty-two patients were satisfied with the way their back pain was being managed. The qualities they valued included the general practitioner's communication skills. In particular patients appreciated being given an opportunity to discuss their problem with a good listener.

Patients also valued thoroughness in diagnosis. They praised general practitioners who took careful histories, carried out detailed examinations and ordered diagnostic
Used to identify a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of X-rays, scans, or other tests.
 investigations, and they appreciated being offered explanations of the rationale behind such investigations.

Of 21 patients who expressed dissatisfaction, only nine blamed the general practitioner for what they saw as the inadequate management of their problem. These patients criticised their general practitioner's inability to explain the condition adequately, the superficiality of examinations, or the doctor's lack of interest in the problem and poor communication skills.

The other 12 dissatisfied patients were more understanding of the problems faced by their general practitioners.

Willingness to consult complementary therapists

Only 10 patients had consulted complementary therapists (mainly osteopaths and chiropractors) in relation to their low back pain. Most of these patients said such consultation was experimental (four) or used as a desperate measure when their pain became intolerable and an immediate general practitioner consultation was unavailable or likely to be ineffective (five). Only one patient had elected to use a complementary therapist because she believed that she would receive better quality care overall.

Of 37 patients who had never used complementary therapy, 13 were largely satisfied with the care they were receiving and had not considered an alternative. Six patients appeared never to have heard of any form of complementary therapy and eight questioned its legitimacy and feared 'being ripped off by quacks.' Ten patients felt unable to pursue complementary therapy through lack of information or lack of money.
This study found diversity in patients' perceptions of low back pain. Patients held complex views on a common problem. Individuals, with what could be regarded as a similar condition, perceived the problem very differently and responded in quite dissimilar ways.

Clinically, low back pain does not usually arouse interest or innovation among the medical profession. Growth in complementary therapies is largely welcomed since it offers possibilities for a multi-professional approach to care. However, this study demonstrated patient suspicion of, and a reluctance to consult, complementary therapists. It also revealed significant levels of dissatisfaction with medical explanations, management and treatment.

Patients valued good communication together with detailed clinical and radiological tests. Some of the study participants were sympathetic to the constraints of general practice and their effect on the diagnosis and management of low back pain. In some cases, it seemed clear that depersonalised management and rapid, processed care were at least partly responsible for the patient's poor response to care, and a different management approach may have led to a more positive doctor-patient relationship.

Most patients in this study were engaged in self help for their backs and did not routinely consult the general practitioner for episodes of low back pain. It appears that patients do not want a 'magical cure' for low back pain as one does not exist, but rather they would like their general practitioners to listen to them and to offer a comprehensive approach to management.
PubMed abstract
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