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

  1. Abrams D, Davidson M, Harrick J,Harcourt P, Zylinski M, Clancy J(2006).’Monitoring the change: Current trends in outcome measure usage in physiotherapy’, Manual Therapy 11:46–53
  2. Hush JM, Kamper SJ, Stanton TR, Ostelo R, Refshauge KM (2012) ‘ Standardized measurement of recovery from nonspecific back pain.’ Arch Phys Med Rehabil; 93: 849-55
  3. Smith L, Bosnic-Anticevich SZ, Mitchell B, Saini B, Ines Krass I, Armour C. Treating asthma with a self-management model of illness behaviour in an Australian community pharmacy setting. Social Science & Medicine, 2007; 64:1501–11
  4. Williams GC, McGregor HA, Zeldman A, et al. Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychology,2004;23(1): 58-66.
  5. Bosworth HB, Powers BJ, Oddone EZ. Patient self-management support: novel strategies in hypertension and heart disease. Cardiol Clin,2010; 28: 655–663
  6. Gardner T, Refshauge K, McAuley J, Goodall S, Hübscher M, Smith L. Patient led goal setting in chronic low back pain—What goals are important to the patient and are they aligned to what we measure? Patient Education and Counselling, 2015; 98 (8):1035–1038
  7. Deci EL and Ryan RM. The “What” and “Why” of Goal Pursuits: Human Needs and the Self-Determination of Behavior. Psychological Inquiry 2000;11:4, 227–268
  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

 

Comments

  1. John Quintner, Rheumatologist says:

    Courtesy!!!

  2. John Quintner, Rheumatologist says:
  3. Thanks John.

    Would be good to read thwe whole thing when it gets published. Consider posting it!

  4. John Quintner, Rheumatologist says:

    @EG.

    In Chapter 19 (Pain concepts: chronic pain) of the recently published 2nd edition of the Oxford Textbook of Musculoskeletal Medicine, Milton Cohen and I have attempted to delineate the large gap in our obviously “monological” clinical discourse of which you are well aware. As I said above, there is still much work to be done!

    Here is a precis of our Chapter that we prepared for the newsletter of the Australian Pain Society:

    ‘Chronic pain has long been acknowledged to be a major public health problem. However, although it has been redefined in “biopsychosocial” frameworks, the biomedical imperative (clinical power and dollars) has held sway in our society, at the expense of sufficient consideration of the psychological and social dimensions. The “chronic pain as a disease” debate has highlighted the problems of language and flaws in reasoning by its proponents. The authors suggest that achieving change in the clinic will require a new language and nomenclature as well as a “level playing-field” approach, all of which can be encapsulated by the concept of integrated intersubjectivity.’

  5. John Quintner, Rheumatologist says:

    Yes, it is the third option (“the middle path”?) that needs to be pursued as a matter of some urgency. But having said that, I must admit that our Western health care systems would seem to preclude such an approach (through the Buddhist tradition) being adopted on a large scale.

    EG Reply:

    Yes, it does preclude it.

    As you know, using such an approach requires the therapist to understand what it means to surrender. Everything that was so hard-won has to be dropped. The ‘healer status’, the role play (expert/therapist), the accrued knowledge (most of it is useless), and so on.

    Just as the dry needler resists an honest look at the research, so the modern BPS practitioner resists looking inwards.

    When I first started looking inwards, I realized “oh hell, I first have to clear my own bullshit before I pretend to help others”. It’s not a pretty process, but necessary.

    Cheers

    John Quintner, Rheumatologist Reply:

    “Just as the dry needler resists an honest look at the research, so the modern BPS practitioner resists looking inwards.”

    EG, in my opinion the practice of “dry needling” of innocent muscles is a blight on the profession of physiotherapy. Yes, those who continue to teach it are guilty of intellectual dishonesty.

    BPS is being supplanted by “sociopsychobiological,” if only for the compelling reasons that are well outlined in the paper by Carr and Bradshaw (2014).

    There is still much work to be done!

    Reference: Carr DB, Bradshaw YS. Time to flip the pain curriculum? Anesthesiology 2014; 120 (1): 12-14.

    Andrew Reply:

    EG a fair bit a vague mr miyagi style generalizations ( which I actually enjoy ) Although I am not sure I follow your confident assertions that this third option has all the answers. Is there evidence ..?Can we even measure it ..?If not what does that mean for evidence based medicine (and dry needling ..) Care to expand a bit ?

    EG Reply:

    Hi Andrew,

    I posted a lengthy reply yesterday, but it was deleted. In fact I posted it twice.

    Perhaps BiM are trying to tell me something. “Don’t critisize out research!!” : (

    Who knows…

    BiM Reply:

    Hi EG. Your comments are set to auto post on BiM (once you have had one comment approved they are automatically approved after that). Can you please try again? We’ll email you as well so that if it doesn’t go through we can investigate.

    EG Reply:

    Hi Andrew,

    In terms of evidence, have a look at Carl Rogers’ extensive body of work. In the third approach, the client’s emotions are neither dismissed nor are they met with cloying sympathy. Distancing is almost akin to rejection. Sympathy is self-focussed, not client-focussed. There’s no help there. Rogers said:

    “Accurate empathic understanding means that the therapist is completely at home in the universe of the patient. It is a moment-to-moment sensitivity that is in the ‘here and now’, the immediate present. it is a sensing of the client’s inner world of private personal meanings ‘as if’ it were the therapist’s own, but without ever losing the ‘as if’ quality”.

    We need to pay very close attention to the client’s emotional world. When we do this with non-judgment, the emotion will be expressed. When it’s expressed, we need to be able to remain unaffected ourselves. “Unaffected” doesn’t mean maintaining a stiff upper lip. “Unaffected” doesn’t mean re-establishing distance, or putting up a wall. It means we are so present, that even powerful emotions are seen for what they truly are – momentary perturbations of ego. At least they should be momentary. Emotions get stuck in the psyche when they are shamed, dismissed, repressed. When we allow them, they are released.

    To be able to do this properly will require of us therapists a very silent and present mind. Personally, I’m not skilled at this, which is why I practise meditation. But if you can do it just a few times, you’ll see its power. Huge chucks of pain simply vanish in this space. The connection between stuck emotions and chronic pain becomes apparent.

    The other thing that happens when we are fully present in the moment is that the desire to fix/help/assist/change/alter disappears. Don’t mistake this as indifference. Taoists would call it ‘non-doing’. Non-doing doesn’t mean you don’t do anything; it means you do a few simple things with such presence that the ego’s desire for change (or fear of failure) is let go. When you experience it, you’ll know. Most therapists reading would have experienced this space. Consistency is hard to achieve (for me).

  6. John Quintner, Rheumatologist says:

    Frederic, I too feel that something of importance is missing from the oft-mentioned so-called “evidence-based” strategies. Here is an extract from Brody [1997] that challenges us to do better, if not only for our patients but also for ourselves:

    “If the professional who seeks to cure the patient is confident that she will remain untouched by the patient’s suffering, then no one is listening to the patient’s story, the suffering remains without meaning, and healing has been rendered impossible.”

    Reference: Brody H. Who gets to tell the story? In: Lindemann-Nelson H, ed. Stories and their Limits: Narrative Approaches to Bioethics,
    Routledge, New York, 1997: 19–30.

    EG Reply:

    This is a very key quote John.

    The most common way to approach healing is to distance oneself from the one who is suffering. Very common and not helpful.

    The other less common method is to open oneself up to the suffering, and come away ‘contaminated’ (can’t think of a better word, but you know what I mean). This approach takes a lot of work and courage, but it is equally ineffective.

    There is in fact a third option which is deeply healing. It’s a very difficult skill to master, therefore requires an enormous amount of practice. Anyone want to know what’s involved?

  7. Frederic Wellens, pht says:

    I think goals that revolve around function are important. But, often, when patients come back to me after going to intensive multidisciplinary pain clinic one of their “complaints” , so to speak, is that : “Well, yeah, I’m back to work, but I’m still in as much pain as I used to be when I was seeing you. They just got me to back to work despite that pain still being there”.

    So really, they seem only half happy.

    Sometimes, I wonder if the focus in therapy is on function instead of pain because we are better at improving the first rather than the latter.

    This becomes even more obvious when a generaly functionnal individual with chronic pain comes in asking simply to have less pain. Improvement in function isn’t a goal for him since it isn’t restricted. I’ve had many LBP patients like that over the years and I’d count myself in that category too. I often feel ill equiped (despite all the knowledge I may have in pain physiology) to really help them achieve their goal in a meaningful and lasting way.

  8. John Barbis says:

    Good work and the focus on the patient needs to be a more important component of our care. We need to be careful, however, as we head in this direction. A recent study has demonstrated that patient satisfaction scores decrease dramatically for general practitioners when they do not prescribe the medications that patients think they need. This can dramatically affect physician evaluation and reimbursement when they work in large facilities in the US. This was particularly true of those patients requesting antibiotics for colds or the flu. There needs to be practitioner sensitivity and improved communication to both hear the patient and yet provide the best of clinical science, even when it is not what the patient wants to hear.

  9. We have always found good results from the COPM – the Canadian Occupational Perfomance Measure – because the patient determines the goal self assesses their current perfomance level — yes we guide towards achievable and realistic goals within the timeframe of our intervention and in so doing guide away from less pain please goals towards functional goals. I also think the Pain Disability Questionaire is sensitive to change in our Chronic pain populations self assessment of their pain related disability.
    Our problem is getting the forms back after the patient has been discharged for three to six months. Any thoughts?

    John Quintner Reply:

    ste5e, what is the time frame of your intervention? Is it a fixed or variable one?

    EG Reply:

    ste5e,

    Why would you force the client to choose a functional goal when his complaint is pain?

    It’s very easy to push a worker back into his job and get him functioning despite ongoing pain. Bosses and compo firms love it.

    What about the client and his pain?

  10. Seamus Barker says:

    Interesting read though, as a physio, I must say that it’s pretty standard in all the departments I’ve worked in to attempt to to elicit meaningful goals from the patient. Many patients struggle to identify goals, other than, as EG says, for the pain to be gone, or, vaguely, to move better. When prompted and encouraged to think about their current activity and participation, compared with how they might like these things to look after successful rehab, many (most) struggled to articulate much. I personally feel that physios and psychologists should work much more closely together, especially in Pain Clinics, particularly to work with the client to arrive at meaningful goals. This allows physio to function more as a behavioural therapy (the B in CBT) than simply as a physical, biomedical modality.

    Tania Reply:

    Totally agree that when working with the chronic pain population an ‘interdisciplinary approach” works best. All therapists need to be ready to examine all facets of a patients experience and be confidant to guide the person to the best evidence based strategies.
    The chronic pain population is a heterogenous population and as expected there is varied ability amongst patients to ascertain and articulate their goals. It is then up to the therapist to have the skills to navigate the narrative and allow the patient to come to their own meaningful goals.

  11. Isn’t it obvious from the interview what the client wants?

    99 out of 100 times he wants the pain +/- stiffness gone.

    The modern therapist: “Pain relief? Haha! Oh no, we don’t serve that here. However, I’m sure our friendly staff can assist you with a core strength program, coloured taping. and pilato-Xfit hybrid rehab. We have some new Taping Technicians (TTs) who perform the most wonderful origami with Kinesiotape (TM). Also, we do a lot of foam rolling here. Ok? Just so you know. LOTS of foam rolling”.

    Tania Reply:

    Interestingly not one of the participants chose a reduction of pain as a goal. It may be that as HCPs we assume this to be the goal of our patients. By working on what is important to the person and/or what the pain is effecting in the persons life resulted in significant improvements in disability, quality of life, pain self efficacy and pain scores.

    EG Reply:

    Alright, thanks.

    Say a person’s car breaks down because it runs out of petrol. A helper comes along and asks “what’s your goal?” the driver might say “I need to get to my destination – that’s my goal”. He’s considering the *end* goal, which is fine. If the helper asks “ok if that’s your goal, how can we make it happen?”. And he replies “I need petrol in the tank – can you fill it up?”. The goal cannot be achieved without focussing on the problem. So the helper makes fixing the problem into *his* goal.

    In this way, the driver and the helper might be said to have different goals. The link between problem and goal is fairly obvious, and therefore implicit most of the time. We just make the jump, but I can see how on rare occasions this might be problematic. So I see value in your study. We need to be more explicit and differentiate 1) the goal from 2) things that prevent the goal happening and 3) ways to address those obstacles (these become goals in themselves).

    If a client said: “My goal is to return to work”, that’s useful, but only up to a point. The therapist could facetiously reply: “well go back to work then”. The underlying cause needs to be aimed at, creating a new goal.

    Tania Reply:

    Hi EG, a nice analogy. I would suggest that getting to the destination is the goal. The barrier to achieving this is the empty tank. The strategy to achieving the goal is filling up the tank. The goal remains getting to the destination.
    Often when discussing goals with chronic pain patients the barriers to achieving their goals is their mood/thoughts related to the pain, fear of movement, postural habits, time/scheduling, sleep, relationships etc etc. By addressing and focussing on these barriers and strategies the patient can work towards their goals and a reduction in pain can often be the secondary gain.
    The skill in listening and facilitating the narrative around goals is an important skill!

  12. John Quintner says:

    Tania, you have raised a number of important issues that have been discussed many times over the years.

    The question that needs to be urgently addressed might well be this one: Is it realistic that therapists of all persuasions be expected to match the goals of their patients with those of third party payers? I suspect the answer will be NO, but others may differ in their opinions.

    Tania Reply:

    As long as our current clinical quantitative and objective measures and goals set by third parties are used to measure success of treatment, patient goals and meaningful success to the patients will be poorly matched with those indicators put forward by third party payers.

    John Quintner, Rheumatologist Reply:

    So who will cut the Gordian knot?