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Are treating practitioners overly cautious with people with back pain?

At a glance:
While most health care practitioners' beliefs about back pain reflect the evidence, some have unfounded fears. If general practitioners believe that patients should avoid pain they are more likely to advise sick leave as a treatment for back pain and not provide good information about the benefit of activity, while also being uncertain about the risks of developing a long term disability.
Treating practitioners care about what happens to their patients. For many years the accepted form of treatment for back pain was rest. Over the last 20 years there have been many research studies that show that rest is not appropriate. Nowadays rest is rarely prescribed for management of back problems.

However there are lingering concerns among doctors about activity and back problems. Many practitioners continue to tell people to be careful, to avoid heavy lifting, or to avoid certain activities such as bending. While people with back problems may wish to avoid certain tasks because they cause soreness, the advice to restrict activity often leads people to become overly cautious. People then avoid returning to day-to-day tasks, which in the long-term can slow down improvement in the back problem.

This study shows that some treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 remain cautious in their advice. Being overly cautious is intended to look after you as the patient. However studies now show that being cautious can worsen the outlook for back problems. Ask your treater to clarify the evidence on activity, and what you should and shouldn't be doing in terms of returning to everyday function.
Treating practitioners can be overcautious in their endeavours to care for people with back pain.

This doesn't mean that people with back problems are able to do all activities. When doctors advise patients to return to normal activities, it doesn't mean that full functionality is possible. But it does mean that patients shouldn't be fearful about doing activities. They should choose what they wish do.

For example, someone who has substantial back pain and muscle spasm may have difficulty digging in the garden. The fact that they have difficulty does not mean that if they did so they would do harm or damage. If people know they are able to do an activity then they can make a choice about whether they wish to proceed putting up with the soreness.

In the home people have a lot of control over what they can and can't do. Giving people flexibility and control creates a relationship of trust and partnership and this makes a huge difference in return to work.

The best outcomes result where people are given productive duties, and they have the confidence to say if a task is causing soreness. Encourage them to communicate regularly and be active.
Health professionals have progressed from prescribing six weeks of bed rest for people with back pain. A return to activity has now become an everyday part of management of back pain. Whilst rest is rarely prescribed, practitioners will often recommend an avoidance of certain tasks such as lifting, overreaching or bending.

While it is appropriate to provide some guidance on what tasks people with back pain may cope with at work, it is important to understand that this advice is given so the patient doesn't experience excessive pain. In many situations patients take this advice to mean that they may harm their back, or delay the recovery process if they do something which results in pain.

What is known is that people who return to everyday tasks do better in the long term.

Other studies show that doctors with back pain return to work very quickly. In a study of spinal surgeons who had back operations themselves, a return to work occurred significantly faster than surgeons usually prescribe for patients. However, the surgeons had flexibility in control over their working day, and they are a highly motivated group of individuals with a determined outlook.

When treating practitioners are overcautious regarding back pain they tend to limit people's return to function. In turn this can worsen the individual's prognosis and can contribute to long term unnecessary disability.
It can take a long time for research to get into practice. Treaters have been through major changes in the management of back pain, from prescribing bed rest and analgesics
A drug used to relieve pain
 to encouraging people to return to activity.

Some treating practitioners remain cautious in the advice they give people with back pain. This can cause a slower return to work and a slower return to normal duties. Occasionally people stay off work for long periods because they become overcautious. Sometimes people remain on long-term modified duties and can ultimately lose their job, because they have not returned to the pre-injury tasks.

Encourage people with back pain and their treating practitioners to base advice and the level of function on the best evidence available.
Original Article, Authors & Publication Details:
S. J. Linton1, J. Vlaeyen2 and R. Ostelo2 (2002).

The back pain beliefs of health care providers: Are we fear-avoidant? Journal of Occupational Rehabilitation; 12(4):223-232

1Department of Occupational and Environmental Medicine, Örebro Medical Center, 701 85 Örebro, Sweden.
2Department of Medical, Clinical, and Experimental Psychology, University of Maastrict, The Netherlands.
Background, Study Objectives, How It Was Done:
Patients' beliefs about back pain have been studied extensively, but we don't know much about the beliefs of heath care providers. Patients' beliefs about their back pain, such as “fear-avoidance', are linked to future pain and disability.
A condition or function that leaves a person unable to do tasks that most other people can do.
 Fear-avoidance describes when patients' fears make them avoid certain movements or activity, which in turn makes them perceive their pain as more severe. Research suggests that the belief an activity or movement is harmful, can cause disability. Fear-avoidance questionnaires have been developed to measure the extent of a patient's fear-avoidance beliefs.

The authors of this study investigated health care professional's beliefs about back pain, and whether these beliefs affect how they treat patients with back pain. If doctors are fear-avoidant they may avoid providing clear information about activities, pain and return to work and may therefore harm the patient's prospects for recovery.

Physicians' views about back pain vary and don't always reflect the research evidence. The evidence suggests that patients typically need reassurance and clear advice about how to continue their daily activities. If doctors recommend bed rest, pain relief patients are more likely to become disabled.

General practitioners and physical therapists working in a region in Sweden were invited to attend an education program and those that did were asked to participate in the study. 80 general practitioners attended the education course and 60 completed the study questionnaire (75%). 71 of the 105 physical therapists (68%) that attended the course completed the study questionnaire. 56% of the participants were men and 23% were women.

The questionnaire asked the participants their beliefs about the relationship between activity, pain and injury for non-specific back pain. The questions were modified from the fear-avoidance questionnaires used for patients. They were also asked their gender and type of work (GP or physical therapist). The participants were asked to rate four statements about how they treat low back pain:

Sick leave is a good treatment for back pain.
I always provide advice and instructions about pain management.
I always provide my patients with clear instructions about activities, e.g. what they should and should not do.
I can predict the patients who will develop chronic
continuing a long time or recurring frequently
 pain problems.

Participants were told that all questions related to “common' back pain, not back pain from specific diseases or injuries.
Study Findings:
Beliefs about back pain:

Health care professionals' beliefs about back pain vary. Health care professionals agreed that psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.
 and stress factors can cause non-specific low back pain. Neither doctors nor physical therapists believe that pain means there is something “seriously wrong' with the patient.

20% of doctors and 11% or physical therapists agreed that pain intensity relates to degree of injury.
3% of doctors and 3% of physical therapists agreed that pain indicates serious injury.
31% doctors and 46% of physical therapists agreed that a decrease in pain was necessary for a return to work.
17% of doctors and 23% of physical therapists said they worried if a patient reported exercise was painful.
17% of doctors and 32% of physical therapists said they would not advise a patient to continue an activity that hurt.
5% of doctors and 7% of physical therapists disagreed that mental stress can cause pain in the absence of injury.
2% of doctors and 4% of physical therapists disagreed that psychosocial can cause pain.
58% of doctors and 51% of physical therapists believed that back pain patients should not do heavy or repetitive work.
67% or doctors and 69% of physical therapists agreed that patients should avoid painful movements.
37% of doctors and 52% of physical therapists didn't believe that they could predict if a patient was likely to develop a long-term disability.

Self-reported treatment:

Physical therapists felt more strongly that they provided information about activities and pain management than did doctors.

27% of doctors and 29% of physical therapists believed sick leave is a good treatment for back pain.
43% of doctors and 24% physical therapists said they did not give clear information about activities.
10% of doctors and 4% of physical therapists said they did not give advice about pain management.

Relationship between beliefs and self-reported practice:

Health professionals were grouped into three groups on the basis of their beliefs about back pain:

High concern/fear-avoidance
Low concern/fear-avoidance
Moderate concern/fear avoidance

Health professionals with “high concern':

Were more than twice as likely to report sick leave as a good treatment for low back pain.
Were less likely to give clear advice about activities.
Were less likely to give advice about pain management.
Were less confident that they could identify patients at risk of developing a long-term disability.
This study shows that health care professionals have a range of beliefs about back pain, some of which do not reflect the research evidence.

Research evidence suggests that for back pain:

Normal activity, including work is not harmful.
Patients should continue doing activities and movements even if it hurts.
Sick leave is not a treatment and should not be used as one.

In contrast to these guidelines, nearly a third of health care professionals said that they believed sick leave is a good treatment for back pain. Some said they believed it was necessary to reduce pain before a patient returned to work and some said that they did not always provide advice about the activities the patient could perform during their recovery. Therefore there is potential for improvement in treatment practice.

Health care professionals can hold fear-avoidance beliefs, such as worrying if a patient reports pain during exercise and advising a patient to avoid painful movement. Health care professionals with high fear-avoidance beliefs were more likely to have treatment practices that contrast with research guidelines.

However, despite a minority holding unhelpful beliefs, overall health care professionals hold beliefs consistent with modern research on back pain.
PubMed Abstract
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