Theme 1: Perceived obstacles to recovery
a)
The importance of psychosocial factors
LBP was thought to give rise to negative emotional responses in sufferers, such as panic, fear and anxiety. For this reason physiotherapists sought to ‘resolve’ some of these emotional reactions in patients. Although they considered such responses to be common amongst people consulting with LBP, they also thought that they should be properly addressed and patients offered reassurance about their symptoms.
B5332: Just through experience, you know, is that there are some joints that physios would call emotional joints… there’s a lot of panic with patients as well and you know and fear. They don’t know what’s going on. “Could it be serious? Could it not be?” and I think what they’re looking for is for you to say “look, this isn’t serious, it’s mechanical, we can help you.”
The management of physical symptoms was thought to be closely connected with patients’ lay beliefs about the causes and manifestations of LBP. While physiotherapists recognised the psychosocial aspects of the LBP experience and the associated link with these factors and chronicity, they claimed to lack sufficient training to effectively address these concerns with patients.
5960: But I’m not claiming that I can help all those patients. I mean there is a limitation to what I can achieve with regard to my, say, counselling skills and my skills of helping them with modifying their pain behaviour and helping them with their cognitive, you know, construct if you like, regarding low back pain. So, and in those cases if it’s outside my area of outside my boundaries if you like, I tend to involve other professionals as well.
This therapist recognised the importance of addressing patients’ psychosocial concerns. However, physiotherapists struggled to find strategies to integrate the clinical explanations within a broader biopsychosocial framework that made sense to patients.
b)
Legitimacy of LBP
LBP is often associated with work absence. Thus it may be unsurprising that wider cultural connotations influenced the beliefs of our respondents towards some patients, and perhaps reinforced the view that they could not always be helped by physiotherapy management alone. Some physiotherapists suggested that they felt certain patients were financially dependent on having LBP. The following respondent alluded to the possibility that patients in receipt of financial support for their back pain or disability could be less likely to follow treatment advice from physiotherapists.
B5332: I suppose, I mean, if you really went down to it, you could talk about those people who are, or you know, poverty in patients, little money, sometimes, is quite, you know, they’re quite willing to be ill, if you understand me?
Interviewer: Yeah, yeah, and the reasons for that?
B5332: Maybe their own benefits, they will be earning more through that way rather than going back to work.
Interviewer: Right, right. So then that makes it, yeah, quite.
B5332: Yeah, but although I’m saying that, it’s very hard to prove anything. You only have your suspicions. There’s nothing you can actually, you can’t turn round and accuse patients of being like that.
These factors clearly impacted on the way physiotherapists viewed patients, and how far they were prepared to persist with those who perhaps were not making progress as expected or who were unwilling to follow clinical recommendations. Lack of progress was sometimes construed as refusal by the patient to follow the physiotherapist’s clinical recommendations. These responses may reflect a wider perception of LBP as attracting largely negative stereotypes of sufferers, and which potentially detract from a person-orientated approach to management. Such views could lead to the marginalisation of patients’ concerns, with greater clinical attention invested in those who appear to want to follow clinical advice. In such circumstances, physiotherapists may find it helpful to open up discussion with patients about these sensitive topics, in order to fully understand patients’ motivation to follow the clinical recommendations.
Theme 2: Responding to psychosocial ‘obstacles’
a)
Negotiating psychosocial problems
Physiotherapists found patients’ unrealistic expectations about the likely success of treatment difficult to manage during consultations. Although they recognised the importance of discussing psychosocial obstacles to recovery with patients, they also stressed that patients had a duty to follow the physiotherapy advice and acknowledge responsibility for their own LBP rehabilitation.
B5997: You certainly get a gut feel of the ones that you’re wasting your time on…They perhaps think they’re coming to me for a massage or something to be done to them to make them feel better, and I won’t go along that line. So they are difficult and there are times when I’ve had to say “well, look if you don’t want to follow what I’m saying I’m afraid I can’t help you.”
The need to identify key psychosocial obstacles to recovery was stressed by physiotherapists, though they expressed difficulty in fully dealing with and managing these obstacles, perhaps preferring to maintain a level of professional detachment. Some patients sought a quick resolution and did not recognise the non-physical ‘obstacles’ to their LBP recovery. Physiotherapists conceded that pursuing a full recovery from LBP could be futile in these cases.
B5499: It could be things the patient has been told about their problem that makes them feel it’s something more serious than it is and you can’t, no matter how much you explain that, you don’t actually get through to them. So that can mean that the treatment you think is going to work doesn’t.
It was thought that LBP can acquire central prominence in a sufferer’s life, and encouraging deeper discussion and providing a more in depth explanation about what is expected of patients during the consultation was considered important to redress the balance.
B5332: I suppose when I when I first qualified, patients became more dependent on me because of the way I treated them but now it’s trying to get them to say, “look,” well, yeah “you have to help yourself. I can give you the information and I can I can help, maybe, get rid of your acute period at this point, but you’re the one who has to help yourself, here.” You know, so its trying to just reinforce that bit, doing it in a nice way and you know, and being empathetic with them. They have got pain, but they have to realise that they have to then maybe do some pain management as well. That we might not be able to take the pain away fully but you need to get on top of it, break your kind of cycle here.
b)
Addressing lay health beliefs
Illness beliefs can influence decisions to engage or abstain from health enhancing activities [
19‐
21]. Health professionals may be aware of the clinical agendas but may be less familiar with the patient’s agenda. In the current study, this view led physiotherapists to try to ‘reposition’ patients’ health beliefs in line with current understanding of the pathoanatomy and mechanics of LBP.
B5544: If we say “you’ve got a degenerating spine” I think if people think that using it is going to degenerate faster, and unless you actually tell somebody that’s not the case then you can’t blame them for believing that…
This physiotherapist recognised the potentially negative impact of the language used during LBP consultations, and stressed the need to ensure patients were not misinterpreting the clinical message. Several physiotherapists claimed that many people still believe that exercise is ‘harmful’ for LBP, and the most helpful approach during physiotherapy management is one that reinforces the message that exercise and physical activity are actually central to recovery.
B5997: Well, she’s had this for four weeks. The benefit of having time off at this stage is minimal compared to maybe the first week of the back pain, and it would be more important to make sure that her work posture is correct, rather than just to avoid work. I think at this stage four weeks after the initial onset she needs to be mobile, not resting.
Quite to what extent physiotherapists relayed this message to patients during interactions is unclear as we did not conduct observations. Despite recognising the importance of the psychosocial dimension of LBP, physiotherapists questioned the appropriateness of engaging patients in such discussions and anticipated a certain level of resistance. The following quote provides an example of how one physiotherapist did engage with a patient’s ‘unhelpful’ reaction to her LBP, (i.e. anxiety and fear of movement) which is presented as something to be corrected through specific advice.
B5324: With this lady there’s anxiety problems there, she’s demonstrating past coping mechanisms, she’s got a fear of flexion. These are all things that you can address by explaining to her that that’s exactly the wrong way of going about dealing with back-pain, and then its whether they then actually buy into that and accept that and start doing it.
The emphasis was on helping the patient derive a realistic understanding of their back problem to facilitate recovery. This was achieved through presenting ‘hard’ ‘evidence’ such as MRI results to objectively demonstrate the presence or absence of serious spinal pathology.
B5393: With the chronic ones who tend to be imaged to death, so you can be quite sure that we know there’s nothing wrong with you because, you know, you’ve been scanned; you know, you’ve had an MRI, you’ve had a CT (scan), whatever. You know, as far as medicine’s concerned you’ve had blood tests; there’s nothing wrong with you, so, we know what it is and we could get on with it and if you buy into this we’ll get there.
Psychosocial issues were perceived central alongside biomedical factors, to managing back pain by our participants. However, the aim was to discourage the behaviours or attitudes of patients that could prevent recovery, through promoting health enhancing practices such as losing weight.
B5332: I think you’ve just got to ‘plug away’ at them; just got to say, “well” you know “you might think you’re right, but evidence is suggesting that if you lose some weight then we can make a difference in your back.”
Physiotherapists encouraged people to live with their pain, rather than attempt to understand the underpinning reasons for their ‘negative’ beliefs. Others encouraged patients to describe their concerns and fears in the hope that they could be redressed through discussion. Again the emphasis seemed to be on putting ‘negative’ beliefs to rest through reassurance. However, reassurance alone may be insufficient to eradicate the intractable psychosocial problems.
B5544: I probably won’t treat you today. I may not even going to look at you today. “I’m going to listen to you” and by letting them talk and letting them tell me absolutely everything, and keeping it as unstructured as possible, hopefully, as I say, we’ll find these little bits of things that have either been missed or have never ever come out in the open, you know and it can be the smallest, smallest little fear that’s niggling away in somebody’s head and you can have dramatic effects just by
putting that to rest.
c)
Setting boundaries
Discussing and negotiating lay health beliefs with patients was one strategy used by physiotherapists to aid recovery. However, such an approach was not always successful because patients either did not appreciate the advice or resorted to old ways of thinking about their back pain and its management. Consequently, a further strategy was for physiotherapists to place boundaries around the management of psychosocial problems, in the realisation that the negotiated approach was not always effective.
B5324: If there’s a relationship issue and things like that, that’s stuff that I won’t add, won’t necessarily address, because I don’t think that’s my area. I mean, I’m not going to start saying to patients, you know, how is your relationship with your husband at the minute, because I don’t think that’s the, it’s certainly relevant, but what am I going to do about it, if you know what I mean? If they start ‘bringing up’ those sorts of issues?
Physiotherapists were reluctant to engage in discussion regarding patients’ personal lives in the absence of the necessary skills with which to offer appropriate advice. Involving other professionals with greater knowledge of psychological problems was one solution.
B5499: looking at why the patient’s anxious, why they’re not doing things. Sleep patterns, all those kind of things that you look at but I think its limited as to how far you go with that. The patient’s presenting with a very chronic pain pattern and I think if that’s the case, they’re better treated with a multi-professional input because I think the outcomes then are much better than just seeing the patients as a sole professional.
Others claimed that in certain circumstances, for example where people received financial benefits as a consequence of their disability, the challenge of assisting patient recovery from their back pain was thought to be too great. This was because patient’s wanted to maintain a ‘back pain identity’ with which to justify the presence of incapacity, and hence demonstrate inability to resume normal activities.
B5544: I’ve got one gentleman, at the minute, all he wants is his benefits and you know, realistically you can find absolutely nothing wrong from an assessment but all he wants “I want my…” you know “I want my benefits, I can’t work because you know I had this injury 15 years ago.”. OK yeah but that was 15 years ago, but he’s now got a full range movement of his spine and he could, quite happily work, but he doesn’t want to. He wants to stay quite disabled and, you know we’re on to a non-winner with that one…
Others claimed that physiotherapists perpetuated a ‘back pain identity’ in patients by reinforcing their physical ‘incapacity’ rather than their ability to adapt to life with pain.
B5317: We keep asking them, “well, how long can you walk for?” or “how many of these can you do before your pain comes on?” and then they go and analyse that and they’re actually looking for the pain constantly. So, I think, sometimes we in breed that in people.
The implication was that physiotherapy practice should be an approach that does not focus on the pain response. In this case, boundary setting was a strategy with a dual purpose for physiotherapists; to help define their scope of practice more explicitly for greater clarity about their clinical role, and to aid patient recovery through a focus on patient self-care by encouraging them to focus less on pain symptoms and limitations and more on function and activities they can achieve. In other words, a greater focus on what they can do rather than what they cannot do.