Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review

Abstract

Background and objective Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient’s and practitioner’s beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient’s pain and physical functioning. Databases and data treatment Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion–exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach. Results Twenty-one primary studies (N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance. Conclusion This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients’ clinical outcomes, although these findings require judicious interpretation.

An International Consensus Definition for Contextual Factors: Findings from a Nominal Group Technique

“…Discussion during stage three highlighted the inconsistent domains involved in the role of cultural versus political versus power imbalances, whether contextual factors were a measurable mechanism, whether placebo/nocebo effects were a necessity within the definition, if a contextual factor was a "nonspecific" finding, and its role as a prognostic mediator/moderator. Thus, the emerging findings mirror the heterogeneity of conceptual definition and the variability of dimensions associated with contextual factors reported in the literature [14][15][16][17][18][19][20][21]. Our work acknowledged and established an initial synthesis of these complex and important domains, which may in turn be fruitful to consider in future work.…”

“…The ecological landscape in which the clinical encounter occurs, sometimes referred to as therapeutic context, constituting a range of factors increasingly referred to as contextual factors, can also markedly moderate or mediate outcomes [14]. Although increasingly well studied, contextual factors/effects are defined differently across a majority of studies [10,[15][16][17][18][19][20][21].…”

“…Definitions vary and have included sociodemographic variables [15], person-related factors (race, age, patient beliefs and characteristics) [15], and physical and social environments [16]. At a micro-level, contextual factors have been defined by seemingly disparate terms such as therapeutic alliance [10], one's role in the environment [17], treatment characteristics [18], healthcare processes [19], placebo or nocebo effects [20], government agencies [17], and cultural . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.…”

Impact of audible pops associated with spinal manipulation on perceived pain: a systematic review

“…Increasingly, research that acknowledges the importance of such elements including the characteristics of the treatment on clinical outcomes is emerging [ 40 ]. Indeed, recent reviews suggests that these factors are very likely important modulators of outcomes in manual therapeutic approaches to pain [ 41 , 42 ]. In this regard, none of the studies included in this review discussed the potential meaning to the patient of hearing APs during SMT.…”

Musculoskeletal practitioners’ perceptions of contextual factors that may influence chronic low back pain outcomes: a modified Delphi study

“…Preliminary Delphi statements were extracted from various researchers’ recommendations for potentially harnessing placebo effects during clinical practice and relevant reviews [ 1 , 12 – 15 , 48 – 54 ]. The first-round survey was initially developed and piloted with two independent/non-participating Physiotherapists and a Chiropractor providing input concerning: time taken to complete; overall clarity, language, terminology/phrasing; ease of completion (e.g., layout, instructions); general comments and functionality.…”