Chronic low back pain – are we really measuring the treatment outcome patients want?

Traditionally health care professionals (HCP) assess and treat according to the biomedical model, where the practitioner takes the leading role with diagnosis and intervention. Treatment goals are set by the HCP and are set against standard biomedical measures1.  But are patients are interested in our goals? How many exercise programs set by the physiotherapist are left in the top drawer of a bedside table or hanging on the fridge by a magnet? Chronic low back pain can result multiple problems for the patient and as such will effect not just the physical but also the psychological and social aspects of the patient’s life2. Chronic pain by its very nature, is long term, and as with other chronic conditions, the patients themselves need to learn how to self-manage. Allowing the patient to set goals has been shown to be effective in self-management in asthma, diabetes and hypertension but the literature in CLBP is quiet3,4,5.

As part of a pilot study investigating the feasibility and efficacy of patient led goal setting, we recorded patient goals, and carried out thematic analysis to identify the domains the goals were set in6. We then compared these goals to current outcome measures used in both clinical and research setting.

From 20 participants, a total of 27 unique goals were identified, the most common goal related to physical activity (49%). 17/20 of the participants set goals in more than one domain. Comparison of participant goals to the most common measures used by physiotherapists found none of the goals could be aligned.

When we looked closer at the exercise goals and strategies, we found that the majority of them were very individual, being related to participants’ individual interests. Only 20% of the exercise goals and strategies matched specific exercises that are routinely prescribed by physiotherapists.

What we can see from this analysis is that the goals that are important to patients with chronic low back pain are varied. With every new participant there was a new problem to discuss and analyse, and new strategies to develop and review. There was no standard intervention implemented, instead very individual and varied strategies were carried out by each participant.

Goals that are important to patients are not homogenous and cannot be categorised into simple groups. They are not simply classified as physical or psychological, the majority of cases, participants had a combination of physical and psycho-social goals.

As primary care practitioners we need to be prepared to investigate the many layers of an individual’s chronic pain experience in order to establish the problems they are encountering and commence to address these in collaboration with the patient. The confusing mix of contributing factors within the individual and between the individual and his or her environment may also be manifestations of pain itself.

If we are to engage our patient into their management of back pain we need to engage in what is important to them. Self regulation theory7 states that a patient will be more motivated to work towards a goal that is intrinsically important to them and not what is necessarily important to the practitioner.

Perhaps this will mean a need to shift towards an approach more open to a biopsychosocial approach. Historically HCPs are trained and practice with a high biomedical focus to CLBP with a heavy dependence on disease and injury models of pain, as well as an overreliance on investigations such as Xrays, CTscans on the never ending search of “pathology”8. Once red flags can be confidently crossed-out, the focus should turn to the patient: an individual, interacting with the environment and circumstances around them.

Patients’ goals did not align themselves to standard clinical outcome measures. There was no mention of “increase in range of motion”, “grade 4 quadriceps”, “activation of transverse abdominis” in the identified goals. Outcome measures are used to aid in clinical decision making and assess the success of an intervention both in the clinical setting as well as in research. Most often outcome measures are based on biomedical parameters ie. range of motion, pain, strength1,9  in the hope that improvement in these measures will be reflected in improvement of pain and patient function.

How do these outcome measures reflect what the patient wants or perceives as a successful outcome?

How should we measure treatment success? What amount of success have we achieved if our patient has reached full range of motion and yet still cannot sleep or be able to sit through a work meeting? Conversely, how can we justify ongoing intervention which has shown improvement in patients’ goals and little change in standard measures?

Our findings also have implications for compensation claims. Reimbursement often depends on meeting outcomes, set in guidelines, controlled by standards set by insurance companies or higher management of larger health organisations. Health care professionals are being asked to produce key performance indicators based on objective measures to ascertain the success and feasibility of our clinics and health programs. How many health care professionals have had to justify treatment for our compensable patients because their clinical pathway has not met the predetermined algorithm set out by the current health guideline?

Several limitations of the study warrant a mention. The participants were highly functioning in terms of employment, social and recreational activity and on low levels of medication. This may not reflect the population from a primary care setting. Due to the small sample size solid inferences about the results cannot be drawn from this pilot study.

Our study has shown that patient goals are varied and do not align with standard outcome measures. We need to re-evaluate the reimbursement system and service priorities to include patient-reported outcome measures.

About Tania Gardner

Tania GardnerTania is a Senior Physiotherapist in the Department of Pain Medicine, St Vincent’s Hospital Sydney, and has over 20 years experience in the treatment of low back pain. She is currently investigating patient led care in chronic low back pain as part of her PhD candidature at the University of Sydney.

References

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  8. Foster NE and Delitto A, (2011), ‘Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice—challenges and opportunities’, Physical Therapy, 91(5):790–803
  9. Swinkel I CS, van den Ende C HM, van den Bosch W, Dekker J, Wimmers RH (2005) ‘Physiotherapy management of low back pain: Does practice match the Dutch guidelines?’ Aus J Physio: 51;35-41