Background Consultation‐based reassurance for patients with low back pain (LBP) in primary care has been shown to be associated with patients' outcomes. Little is known about the role of reassurance in people with LBP consulting with orthopaedic spinal care teams. Reassurance may be important, especially in cases where surgery is not indicated and patients are discharged without treatment. Methods Semi‐structured interviews were conducted with 30 patients with chronic disabling musculoskeletal LBP who had recently consulted with spinal orthopaedic care teams. Interviews were audio recorded, transcribed, coded and analysed. Results Most patients reported feeling dismissed and discouraged. Patients perceived that they needed specific behaviours from practitioners in order to feel sufficiently reassured to commit to self‐management. These behaviours group into four domains: “Knowing my whole story” (evidence that practitioners read the case notes; were familiar with the patients' previous health care history; carried out tests and a physical examination and gathered information about the patients' lifestyle), “Seeing the right person” (showing empathy; listening; building rapport and demonstrating that they are qualified and experienced), “Nothing to worry about” (reducing generic reassuring statements but increasing validating statements recognizing suffering) and “Getting to grips with my problem” (providing explanations and a clear management plan). In the absence of these behaviours, patients rejected advice to self‐manage, reported distress, anger and intention to re‐consult. Conclusion Effective communication with patients attending spinal orthopaedic care settings is important, especially when no active treatment is being offered. Significance This study describes narratives from patients discharged without surgery following consultations with orthopaedic professionals for persistent and debilitating lower back pain. Findings suggest that these interactions are distressful to patients, and that patients require comprehensive and specific reassurance to promote self‐management. The findings contribute a unique insight into the special needs of people with complex pain problems and provide guidance to improve consultation‐based reassurance in orthopaedic spinal care settings.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

ObjectiveThis study aimed to explore the perceptions of orthopaedic clinicians about consultations for people with persistent musculoskeletal low back pain (PMLBP) in which surgery is not recommended. Surgery is not recommended for the majority of PMLBP consulting in secondary care settings.SettingSecondary care sector in the UK.ParticipantsSemi-structured qualitative interviews were conducted with 24 orthopaedic team clinicians from 17 different hospitals in the UK and Ireland. Interviews explored clinicians’ perceptions of the challenges in consultations where surgery is not indicated. Interviews were transcribed verbatim and analysed using thematic analysis.ResultsTwo meta-themes, Difficulties and Enablers, each consisting of several subthemes were identified. Difficulties included challenges around the choice of appropriate terminology and labels for PMLBP, managing patients’ expectations, working with mentally vulnerable patients and explaining imaging findings. Enablers included early management of expectations, use of routine imaging, triaging, access to direct referral elsewhere, including other non-surgical practitioners in the team, training to improve communication skills and understanding of psychological issues.ConclusionThe findings highlight clinicians’ perceived need for concordance in messages delivered across the care pathway and training of orthopaedic clinicians to deliver effective reassurance and address patients’ needs in circumstances where surgery is not indicated.

Background There is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking. Aim To develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial. Method The intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention. Results In total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians’ communication skills, during the consultation, in reference to listening skills, validation of patients’ pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients’ clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management. Conclusion The intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients’ perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.