Communicating and diagnosing non-specific low back pain: A qualitative study of the healthcare practitioners’ perspectives using a social diagnosis framework

Abstract

When presenting with persistent low back pain, more than 9 out of 10 patients cannot be given a structural cause of their symptoms. These individuals receive a diagnosis of non-specific low-back pain, which does little to inform them about the type of problem they have or how it might be remedied. This study used a social diagnosis framework, which considers multiple factors in relation to illness, to explore how physiotherapists, chiropractors and general practitioners might help us to identify a diagnosis (i.e. a label and the meaning we bring to it) alternative to non-specific low back pain. The aim being to enable better communication with patients about their condition. The study found that healthcare practitioners consider multiple biopsychosocial factors relevant to the condition, they consider it important to help patients make sense of their condition, and to engage patients in dealing with individual contributors to pain. Healthcare practitioners did not consider a new diagnostic label for non-specific low back pain to be a priority for their own practice. Background: There is general agreement that nonspecific low back pain is best understood within a biopsychosocial understanding of health. How ever, clinicians and patients seemingly adhere to a biomedical model, which may introduce misperceptions of pain and does not inform treatment or prognosis. Objective: To explore, from the perspective of health care practitioners, how persistent nonspecific low back pain may be communicated in a way that moves beyond a biomedical diagnosis. Design: An explorative qualitative investigation using a constructivist diagnostic framework. Methods: Focus group and individual interviews of 10 purposefully selected chiropractors, physiotherapists and general practitioners were codified and thematically analysed. Results: Four themes emerged: "Clinicians' nuanced understanding of back pain"; "The challenges of shared decision-making"; "Cultural barriers to moving beyond biomedicine"; and "More than a label-individual explanations for pain". Pain and disability were perceived as products of multiple bio-psychosocial factors. Clinicians identified the impact of multiple social actors, an unhealthy work culture, and the organization of the medical system on the notion of pain and suffering. Conclusion: Clinicians perceived a need to communicate the complexity of non-specific low back pain in order to help patients make sense of their condition, rather than applying diagnostic labelling. There are multiple barriers to integrating a constructivistic diagnostic framework into clinical practice that need to be overcome.

The effect of shared decision-making on recovery from non-chronic aspecific low back pain in primary care; a post-hoc analysis from the patient, physician and observer perspectives

“…A possible explanation of the observation that GP’s reflections on their moderate performance of SDM aligns with a higher chance of developing non-chronic complaints might be that GPs adapt their behaviour to the patient’s characteristics associated with recovery rates [ 12 , 37 , 38 ]. Recently, Arnborg Lund described GPs’ views on treating LBP as an act of dialogue rather than a fragmented experience with different explanations and recommendations [ 39 ].).…”

User perspectives on systematic data collection regarding back pain managed in general practice – a qualitative study

“…Being positive that both GPs and patients miss this overview and want an evidence-based instrument to structure the pathway and facilitate collaboration, this approach might include some challenges. First, research suggests that GPs might experience a number of barriers towards using guidelines or evidence-based recommendations to guide their treatment of patients with back pain [ 29 – 32 ]. Second, the assumption that it is possible to describe patients in terms of ‘those doing well and those doing less well over time’ might turn out to be rather difficult to substantiate, let alone illustrate in few words in a guideline.…”

Surgeons Have an Implicit Preference for Specific Disease Over Nonspecific Illness

“…Most specialists know from experience that effective communication strategies do not eliminate disappointing visits for people with nonspecific illness who may feel their only hope is to find the problem and fix it [6,13,14]. Some qualitative evidence suggests that people may not achieve the meaning they desire from applying a diagnostic label [2,14]. Overall, patients receiving upper extremity specialty care have comparable experiences, regardless of whether they receive a specific or nonspecific diagnosis [26].…”

“…However, this approach may not work as well for patients with symptoms and signs that are not characteristic of a specific, common pathophysiology (nonspecific illness). Nonspecific illness is characterized by discomfort and incapability that is not accounted for by objective, measurable impairment and pathophysiology (physical examination findings, imaging results, or laboratory values) [2,21,22,26]. Some examples include fibromyalgia, chronic fatigue syndrome, radial tunnel syndrome, complex regional pain syndrome, and repetitive strain injury [3].…”