Research Review By Dr. Joshua Plener©


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Date Posted:

August 2022

Study Title:

What does the patient with back pain want? A comparison of patient preferences and physician assumptions


Smuck M, Barette K, Martinez-Ith A et al.

Author's Affiliations:

Physical Medicine and Rehabilitation Division, Department of Orthopedic Surgery, Stanford University, CA; Department of Orthopedic Surgery, University of California San Francisco, CA; Department of Physical Medicine and Rehabilitation, University of Michigan, MI, USA

Publication Information:

The Spine Journal 2022; 22: 207-13.

Background Information:

Low back pain (LBP) is extremely common and remains a leading cause of disability. LBP patients describe frustration and anger as they often feel misunderstood, stigmatized and trapped within the medical system (1). Studies have found that patients with LBP want a diagnosis and an explanation for their pain, while viewing simple descriptions like “age related changes” and “wear and tear” as unacceptable (2).

In addition to patients, physicians can frequently feel frustrated when managing LBP (3, 4). Despite patients wanting a specific diagnosis, a study of family physicians found that most of them feel that appropriate treatments don’t require a precise diagnosis (4). Also, arriving at an accurate diagnosis for most cases of back pain remains challenging.

It is suggested that fostering a positive relationship through alignment of patient expectations and shared decision making improves outcomes. The purpose of this study was to evaluate the expectations of patients with LBP at the time they presented for consultation in an outpatient multispecialty spine clinic and compare these to the assumptions of physicians.

Pertinent Results:

419 consecutive patient surveys were completed at the two sites. The majority of patients reported chronic symptoms lasting more than 6 months. 198 physicians responded to the survey with approximately 60% being Physical Medicine and Rehabilitation specialists, while the remainder were neurosurgeons or orthopedic surgeons, expect for 1 sports medicine physician and 2 chiropractors.

Patients indicated that they placed the greatest importance on improvement in their pain, obtaining an explanation of what is causing their problem, and improvement in ability to perform daily tasks. Patients attributed the least importance to surgery, medications and diagnostic tests.

Physicians placed the greatest importance on improvement in pain, improvement in ability to perform daily tasks, explanation of what is causing their problem, and the least importance for surgery, physical therapy and medications.

Compared to patients, physicians underestimated the importance of an explanation of what is causing their problem and overvalued diagnostic tests, medications and surgery.

For subgroup analyses, there were no differences when comparing patients previously participating in physical therapy compared to those who did not, no difference in those who previously used medication for back pain compared to those who did not, and no significant difference for patients with a history of spine surgery on their perceived importance of surgery. Patients who previously had a spine injection viewed surgery as more important compared to those who didn’t have a previous spine injection and placed less importance on physical therapy. In addition, college educated patients placed less emphasis on the importance of diagnostic testing compared to those without a college education.

Clinical Application & Conclusions:

The results of this study can be used to understand the preferences of low back pain patients, with the hope of optimizing treatment expectations and outcomes. This study demonstrated that physicians and patients assign incongruent importance to different aspects of care (perhaps not surprising?). Patients strongly desire an explanation of what is causing their pain and attributed the least importance to surgery, medications and diagnostic tests. Overall, physicians underestimated the importance of an explanation of what is causing their pain and overestimated the importance of diagnostic tests, medication and surgery. Physicians appear more compelled to do something for their patients by ordering tests and administering treatments, while patients are more interested in gathering a diagnostic opinion from their physician.

Even though patients value an explanation about the cause of their low back pain, this is not an easy thing to do. Up to 80% of back pain seen in primary care lacks a specific, identifiable cause, leading to the frequent use of the term “non-specific low back pain”. Despite this explanation not being satisfactory to all patients, wrongfully labelling their potential pain source (such as age-related degenerative findings found on imaging that may be considered normal), can lead to negative consequences and lead to fear of further damage.

Pain specific education can be helpful, as moderate evidence has been found to support the use of pain education, in addition to exercise therapy to reduce pain and disability in chronic LBP patents. Specific education regarding the etiology of pain may help increase patient involvement in shared decision making, lead to the resumption of normal functional activities, and improve outcomes.

Overall, the results from this study provide valuable information to clinicians regarding the expectations of our patients – we need to close these gaps in communication and care provision! This study provided an understanding of patients attending a physician’s office, in addition to Physical Medicine and Rehabilitation specialists and spine surgeons. Future research assessing patients seeking care in other clinical settings (such as a rehab clinics), as well as other healthcare providers within primary care (such as emergency medicine, chiropractors and physical therapists) would be informative. Capturing the experiences of these different groups may lead to different results.

Study Methods:

A prospective survey study was completed involving both patients and physicians. The patient survey was provided to a consecutive cohort of LBP patients, asking about their demographics, characteristics of pain and experience with back pain treatments. All new patients to the clinic were given the opportunity to participate in the study. The inclusion criteria were a primary complaint of LBP with or without leg symptoms and being 18 years of age and older. Patients were asked to rank the importance of 8 variables related to medical care of back pain using a 5-point Likert scale. These variables consisted of: 1) improvement in the patient’s level of pain; 2) improvement in ability to perform daily tasks; 3) explanation of what is causing their problem; 4) thorough physical examination; 5) diagnostic testing; 6) medication; 7) physical therapy; and 8) surgery.

A second survey was provided to physicians at a different time. They were asked to provide their primary speciality and number of years in practice, in addition to rating the same 8 variables on the same Likert scale regarding their importance to their patients. Physicians were recruited through two forums to gather a multidisciplinary response from clinicians. First, at a rehabilitation conference the survey was placed on every seat asking for participation, and the second forum was an online version of the survey sent to North American Spine Society (NASS) members.

Study Strengths / Weaknesses:

  • This study helps to provide an understanding of the priorities of patients when they seek help for their LBP.
  • The results of this study can help clinicians better manage expectations of patients.
  • The majority of physicians who participated were not involved in the care of patients surveyed.
  • The findings may not be generalizable outside the two academic clinics where the data was collected.

Additional References:

  1. Walker J, Holloway I, Sofaer B. In the system: the lived experience of chronic back pain from the perspectives of those seeking help from pain clinics. Pain 1999; 80(3): 621–8.
  2. Lim YZ, Chou L, Au RTm, Seneviwickrama Kl MD, Cicuttini FM, Briggs AM, et al. People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. J Physiother 2019; 65(3): 124–35.
  3. Cherkin D, Deyo RA, Berg AO, Bergman JJ, Lishner DM. Evaluation of a physician education intervention to improve primary care for low-back pain. I. Impact on physicians. Spine 1991; 16(10): 1168–72.
  4. Cherkin DC, MacCornack FA, Berg AO. Managing low back pain−a comparison of the beliefs and behaviors of family physicians and chiropractors. West J Med 1988; 149(4): 475–80.

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