The starting block: low back pain education

1. Provide validation

Management of low back pain is shifting. Traditionally, clinicians direct the diagnosis and treatment. However, the contemporary approach is patient-centered, where clinicians empower the patient to be actively involved in a shared-decision making process. Clinicians should share information on treatment options, risks, and benefits based on clinical guidelines for effective shared-decision making. They encourage the patient to provide insight into the personal burden of low back pain and express their treatment preferences and values. However, patients with low back pain often report feeling dismissed and invalidated by healthcare professionals. This perception is not unique to people in this cohort. 

Mental health screening identifies that people randomly assigned to a virtual human operator, whom they perceived to be automated, were willing to disclose more of their clinical history than those assigned to a human⁽²⁾. Similarly, patients prefer to discuss sensitive topics with a computer-generated avatar interviewer rather than human interviewers, as they feel less judged by a computer⁽³⁾.  

Social media is a contemporary forum for computer-based disclosure. Researchers from the University of New South Wales conducted a content analysis of social media posts to understand how people communicate about low back pain independent of healthcare professionals⁽⁴⁾. The results suggest that the information obtained in a clinical consultation may be incomplete. The researchers categorized the data into two main themes; the first was from the status broadcasts: hear my pain. The data interpretation is that people with low back pain use social media to seek validation and share their experiences. The second theme came from the responses: I feel for you. This theme is interpreted as social media being a place where people with low back pain gain support. There were no public responses to over three-quarters of the status broadcasts. It is challenging to infer meaning from such short interactions. Still, one interpretation is that all the people that seek support are not finding that support.

Rather than turning to social media, health professionals are ideally suited to validate and support people presenting with low back pain. For example, clinicians could begin a clinical consultation by allowing patients time to tell their stories and acknowledge the distressing experience and consequences, validating people’s symptoms.

2. Enhance clinical communication

Clinicians report short consultation times and a desire to maintain a harmonious relationship with patients as barriers to educating people with low back pain. Time constraints may manifest as a rushed consultation, which may hinder the uptake of patient education and advice and its effectiveness. Attitude is inherent in behavioral intention; therefore, understanding a patient’s attitude toward certain education messages could give the clinician insight into the aspects of patient education that will positively affect behavior. Researchers set out to develop and evaluate a new questionnaire to measure patient attitudes toward education and advice for people with low back pain. The questionnaire enables clinicians to provide more efficient consultations within the time constraints of clinical practice⁽⁵⁾.

The researchers developed the questionnaire using guidance from the COSMIN consortium. They evaluated it in a sample of people with low back pain of any duration. A panel of expert researchers, clinicians, and consumers with low back pain identified thirty messages related to; staying active, identifying the rare, serious causes of low back pain, reassurance, unnecessary interventions, principles of management, and disease knowledge. Examples of the key messages include “your pain may not necessarily be related to the extent of damage in your back,” “hurt does not necessarily mean harm,” and “take ownership of your own wellbeing.” The researchers added semantic scales to measure attitudes toward these statements, with the final questionnaire consisting of three sections with 17 questions. Each section demonstrated good reliability and validity, suggesting they could be used independently. The questionnaire is the attitude toward education and advice for low back pain questionnaire (AxEL-Q). 

Clinicians can integrate the AxEL-Q into practice in two ways. Firstly, the AxEL-Q provides a starting point to guide clinical consultations. For example, a negative attitude toward a message of education that a serious health problem rarely causes low back pain could lead a clinician to target that message and begin a conversation with questions such as, “why did you answer that way?” or “what does this statement mean to you?” Conversely, a positive attitude toward a message about advice to stay active might suggest that the clinician should not focus on re-enforcing that message.

Secondly, clinicians could use the AxEL-Q as a triage tool to identify people whose pain could be managed remotely using telehealth. The COVID-19 pandemic has seen the rapid adoption of telehealth in working with people with musculoskeletal pain. Current guidance on who to triage to telehealth is based on several clinical judgments⁽⁶⁾. The AxEL-Q could aid clinicians in identifying who is suitable for telehealth management. For example, if a patient has a positive attitude toward all factors, the clinician may consider telehealth management appropriate. A tool that identifies people who benefit equally from remote management could generate significant savings for individuals and health services. Whether the questionnaire leads to improved patient outcomes would need to be tested in future research.

3. Tailor patient education

One objective of patient education and advice is to promote self-management. Some theorists describe self-management for low back pain as an active process that should involve exercise, endorsed by clinical education and advice. But what education and advice most likely promotes self-management? Researchers from the University of New South Wales conducted an observational study to identify what messages about low back pain predict intention to self-manage. They found that for people with a recent onset of pain (<12 weeks), statements about the cause of pain were most predictive of their intention to self-manage. For people with long-standing pain (>12 weeks), messages about severity and imaging were more predictive⁽⁷⁾.

Learning that “pain does not mean my body is damaged” was necessary for the participants to engage in activities that were meaningful to them, such as physical activity. Similarly, people with low back pain presenting for care completed a survey to understand what they perceived as necessary for their care. The researchers compared the patient results to what physicians perceived as necessary for their patients. The authors reported that patients emphasized an “explanation of what is causing the pain” more than physicians. In addition, patients wanted to understand the cause of pain more than surgery, medication, and diagnostic tests. Together all these data highlight that clinicians should focus on tailoring education to provide information on the causes and consequences of low back pain and, in doing so, promote self-management. In contrast, the attitude of people with low back pain toward key messages about physical activity did not predict intention to self-manage (see table 1).

Table 1: Examples of statements that clinicians could use when providing education and advice

Providing education and advice for low back pain is a vital skill for clinicians to perfect. Yet, the potential curriculum is vast, making it difficult for them to know where to begin. Clinicians can immediately implement the framework discussed to initiate and build effective education and advice strategies into their clinical practice.

References

1.    Brazilian J of Physical Therapy 27, 100478 (2023)
2.    Comput Hum Behav; 37:94-100 (2014)
3.    Comput Hum Behav; 65:23-30 (2016)
4.    Musculoskeletal Science and Practice 54, 102402 (2021)
5.    Musculoskeletal care msc.1715 (2022)
6.    Pain 162, 2558–2568 (2021)
7.    PAIN 163, 1489 (2022)