Having attended my first TherapyExpo earlier this week, I presented this topic to a far from packed-out audience. As I wandered around the endless stalls, I was struck by the emphasis on selling ideas, gadgets and gizmos to help therapists find and fix the perceived/imagined broken bits of peoples’ bodies, which ironically, but conveniently, exemplified the issues I presented in my talk and the following blog post below.
Anatomy and biomechanics- a well-trodden path in manual therapy
As an osteopath about seventy percent of my patients present with low back pain in the clinic, and I have a rich ‘library’ of theories, and models to guide how I conceptualise practice and assist my clinical reasoning and decision making with regards to my examination and treatment. Many of these theories are full to the brim with anatomy, biomechanics and biomedical terminology. Terms such as pelvic torsion, sacral up-slip, scoliosis, pelvic asymmetry, slipped disc, leg length discrepancy, spinal instability were well and truly part of my early clinical and educational discourse. However, not only is there little-to-no evidence supporting either their theoretical plausibility or clinical utility, there is growing evidence that there is a risk of doing ‘more harm than good’ when using these ideas to shape how we communicate to patients the nature and meaning of their pain and disability, and this appears especially important in low back pain (LBP).
Patients with LBP visit primary contact health professionals (e.g. GPs, osteopaths, physiotherapists and chiropractors) to obtain an understanding and explanation of what is causing their pain, and often desire a specific diagnosis. However, people experiencing back pain are more likely to pay attention to particular words and information which they perceive to indicate their LBP is serious or has a poor prognosis, see here. The diagnostic explanations we provide appear to influence patients’ choice of treatment and management approaches. For example, if we tell a patient their LBP is due to damage in the spine or a loss of structural integrity (e.g. wear and tear, degeneration), they’ll be likely to rely mainly on passive treatments and less likely to view exercise and physical activity as options for treatment.
Words give meaning to back pain
Words and language give meaning to our experiences. Patients use words to convey their lived-experience of LBP, and we as clinicians use words to express our experiences during our clinical interaction with patients (e.g. while we visually observing the patients move, or palpating movement and structures of the back) and also following our clinical examinations and case history (e.g. providing a diagnosis), and convey our experiences during treatment (e.g. describing our manual therapy techniques). When communicating with patients and co-constructing descriptions of experiences and meaning its a tricky give-and-take of words, symbols and signs, and often we miss our intended mark. Patients experiencing back pain frequently interpret ‘medical words’ differently to the intended meaning of the healthcare professional, for example here and here. It’s important to get our communication ‘right’, as it appears to be associated with improved health outcomes, possibly as a result of increased trust, increased agency and empowerment, reduced and anxiety and the placebo effect.
Patients believe what we believe
Pain beliefs (e.g. about the cause and meaning of pain, fears of hurting, harming or injuring the back and pain self-efficacy) are strong predictors of ongoing back pain and disability. There is a wealth of qualitative research describing how healthcare practitioners have a strong influence over attitudes and beliefs of patients with LBP. Excellent work by Darlow and colleagues here and here show that our influence on patients’ LBP beliefs is enduring and can be either positive (i.e. helps recovery) or negative (i.e. hinders recovery) and can last for years. Other recent research shows that physiotherapists and patients share common beliefs of the biomechanical triggers for developing LBP (e.g. lifting, bending, sitting). Our work has shown that the words used by student osteopaths when communicating with patients experiencing chronic LBP influences the degree to which they engage with their own care and take part in the decision making process. An exchange of words between clinician and patient begins a co-construction of beliefs. If we believe that our patients’ back pain is due to being fragile, vulnerable or has little green gremlins running around inside it, its likely our patients will too.
What’s the big deal?
A large body of research now supports psychosocial factors as strong predictors of poor outcome (i.e. obstacles to recovery). These include depression, catastrophic cognitions, anxiety, fear and avoidance, and pain perceptions, beliefs and expectations (e.g. about recovery). These factor are likely to interact in a complex way (together with any possible biological/biomedical factors), and our understanding is still developing in this regard. However, as clinicians, we should ask ourselves ‘to what extent might the words and language that I use when communicating with this individual patient influence the these psychosocial processes and phenomena’? In particular, we should ask ourselves, ‘is there a risk of negatively influencing these factors in this particular patient in this particular time in their back pain experience’? Selecting appropriate words and terminology offers us a communication opportunity to positively influence a patient’s pain experience, beliefs and associated behaviour. Lin and O’Sullivan have developed some useful guidance illustrating negative messages and words which can ‘harm’ and positive messages which can help ‘heal’ patients with back pain. While beliefs don’t dictate behaviour, they’re as good an indicator as we have to predict behaviour with back pain. The fear-avoidance model is well described in the literature (i.e. fear of pain/damage leads to avoidance behaviours) and while it is not perfect (e.g. high levels of pain-related fear may not predict actual physical activity), avoidance beliefs are prognostic for a poor outcome in subacute LBP.
Conclusion and advice
- Primum non nocere – “first, do no harm” Why use models that lack theoretical plausibility and which may result in the co-construction of conceptual framework that is unhelpful and risk creating a perception of threat, fear and danger? This requires being honest with ourselves. Many of these theories, concepts and models, which can only really be communicated using pathoanatomical/biomechanical language, are often deeply rooted in manual therapy professions’ development, identity, traditions and culture. For example, see our work on professional identity of osteopaths here and here. These are not ethical reasons to hold on to them.
- Critically reflect on how language may be interpreted by the patient in front of you.
- Explore the beliefs of the patient before providing explanations or advice.
- Check patient understanding/interpretation of what has been said to them during a consultation.
- Validate their pain/disability experience as real. In the past I’ve been too eager to immediately change patients’ beliefs and provide reassurance and evidence based advice in relation to their LBP. In doing so I have inadvertently dismissed their pain experience, lost their trust and missed an opportunity to help them. Change takes time, and we need to learn to be patient, especially as many of these beliefs are deeply culturally engrained and propagated by bad advice online, media and from us as health professionals.
- Cognitive reassurance strategies can help change patients’ perceptions and beliefs through education and appear to be helpful in the longer term for patients with low back pain.
About the Author
Dr Oliver Thomson is an experienced osteopath practicing in Belsize Park, London. He is an Associate Professor at the University College of Osteopathy (UCO), where he leads the teaching of undergraduate and postgraduate students in the areas of evidence-based practice, qualitative research, biopsychosocial model, and clinical reasoning, and he has published extensively in these areas. For more about Dr Oliver Thomson, click here.