EBQ:Good Back Consultation

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Study: Laerum E, et al. What is "the good back-consultation"? A combined qualitative and quantitative study of chronic low back pain patients' interaction with and perceptions of consultations with specialists. J Rehabil Med. 2006 Jul;38(4):255-62. DOI. PMID. Full Text

This page summarises the "Good Back Consultation" article by Laerum et al, and other related literature for patients with chronic low back pain. [1]

Important features of a “good back consultation”

In Laerum et al's study, 35 consultations observed, patients subsequently interviewed. 3 of the specialists had participated in 3 RCTs that had positive outcomes (combined cognitive/mobilisation) – including the famous 1995 study by Indahl et al.[2] Important features of a “good back consultation”:

  • Take them seriously
  • Examination: explanation during the exam (what was being done and what was found)
  • Education: Understandable information on the causes of pain
  • Reassurance: cognitive reassurance not emotional
  • Psychosocial discussion
  • Treatment: Discussing what can be done

Take them seriously

  • Be seen
  • Be heard
  • Be believed
  • a patient’s need to be taken seriously is linked to a feeling that the care provider believes that the pain is real, i.e. that the patient is not regarded as being a hypochondriac suffering from bad nerves
  • reflects a general attitude of the care provider.

Examination

  • explanation during the exam (what was being done and what was found)
  • ‘‘Do you know why I am testing your reflexes? If the flux of signals goes from a stretched tendon via the nerve into the spinal cord and back again without any blockage, then the nerve is functioning normally. You have fine reflexes so there are no signs here of trapped nerves’’.
  • ‘‘Your back seems to be strong and have good muscles even if it hurts’’
  • ‘‘The way you move your spine is just fine’’.

Education

  • Understandable information on the causes of pain
  • Understandable explanation or a diagnosis if possible
  • adapted to their knowledge– “Have you previously received an explanation of why it hurts or have you had any thoughts yourself regarding the cause of the pain?’’
  • simple explanations and metaphors: ‘‘Some of your back muscles are working all the time, like having a cramp in the leg, and your intervertebral disc has probably got ‘wears and tears’what I call wrinkles. That is quite normal, but may hurt if nerves are getting irritated. You have probably got a prolapse. But the prolapse will shrink over time like a grape shrinks to a raisin’’.
  • Plastic models of the spine, posters or scans for explaining the pain mechanism.
  • Exact medical diagnosis not essential (patho-anatomical or taxonomy based) ‘‘This is what I think is the most likely explanation’’. A majority of the specialists included tension, tenderness and cramps of the back muscles as important elements of the pain genesis
  • Greater confidence in explanations supported by clinical findings, such as tenderness, or based on scan findings.
  • Debunk myths

Traeger et al published an RCT on intensive education in patients with acute low back pain, and found that it did not improve outcomes.[3]

  • RCT 202 patients, 2018
  • Intervention: 2 x 1 hour sessions of patient education (pain education, biopsychosocial model, self-management techniques, staying active, pacing strategies
  • Control: Active listening, without patient information or advice.
  • Results: At 3 months no difference in pain, weak improvement in disability (1.6 points on a 24 point scale) but not at 6 months

Reassurance

  • Patients often worry about sinister causes (cancer, brittle bones/fractures, chronic rheumatic disorder, trapped nerves with the risk of muscle weakness, and ending up in a wheelchair)
  • Give clear information that sinister causes can be ruled out with high certainty: ‘‘I can’t find any evidence that anything dangerous is behind your back pain... and I think your prognosis is good. In a couple of months you’ll be much better or even pain-free.’’
  • Many doctors mentioned that the pain could reappear in the future, and that this was fairly normal
  • The most effective type of reassurance turned out to be the type of communication that allowed the patient to draw a conclusion from the explanation given: ‘‘OK, now I do understand. It’s nothing dangerous, and I will not end up disabled’’
  • Avoid major inconsistencies in explanations by various providers.
  • Tell them that pain does not necessarily mean harm, and that some increase of pain when moving or doing exercises may be a sign of stimulating repair processes.

Reassurance can be categorised into emotional/affective and cognitive. [4]

  • Emotional reassurance
    • Immediate heuristic response to concerns and worry
    • Transient effect
    • Illness returns after direct emotional reassurance has ended after the consultation
  • Cognitive reassurance
    • Change disease cognition - shift in a patient’s cognitive appraisal of their health problem
    • Preserved effect on self-management
    • Emotional and cognitive reassurance may be mutually exclusive

Traeger et al published a metaanalysis in 2015 evaluating the effect of cognitive reassurance [5]

  • Cognitive education as short as 5 minutes has positive effects on reassurance for up to 12 months.
  • NNT = 17 to prevent one visit
  • Didn’t assess disability and pain, but reducing health-care utilisation is important.
  • Patients find reassurance from a doctor more reassuring than a nurse or physiotherapist
  • Message must be delivered with conviction and confidence.

Psychosocial discussion

  • Deal with possible correlation (in both directions) between daily life, job, family, coping, quality of life aspects, role function and the LBP
  • ‘‘The doctor was not interested in how my back problem affected my life, it is so important that the doctor also recognizes the connection between back and mind’’
  • Four patients expressed their concerns/frustrations that their back problem during the consultation was labelled as ‘‘just’’ being psychological or psychosomatic

Treatment

  • Discussing what can be done
  • Patients interest in two issues: how to improve the LBP, and where to get help
  • Advise them what kind of activity to do and what they should avoid
  • Give enabling information/explanations : ‘‘If you resume your normal daily activity, including work, as soon as you possibly can, there is substantial evidence to suggest that this will contribute to the healing process. Bones, joints and muscles will have improved function, become stronger and more flexible and therefore less painful; try to obtain a relaxed motion pattern for your body, and stretching is often good for you’’
  • ‘‘Do practice what you like and feel is good for you... diversion from pain by doing or thinking about something else may be an effective painkiller’’.
  • Patients appreciate being asked what advice others had given. It worked as reinforcement if the same explanation or terms were used.
  • Approximately two-thirds wanted to know whether surgery was a solution
  • Meet the patients expectations and preferences – ‘‘The doctor prescribed physiotherapy, but didn’t ask at all about what I thought about that. I have tried such treatment several times without any effect at all. It only provoked more pain’’.

Resources

References

  1. Laerum E, Indahl A, Skouen JS. What is "the good back-consultation"? A combined qualitative and quantitative study of chronic low back pain patients' interaction with and perceptions of consultations with specialists. J Rehabil Med. 2006;38(4):255-262. doi:10.1080/16501970600613461
  2. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine (Phila Pa 1976). 1995;20(4):473-477. doi:10.1097/00007632-199502001-00011
  3. Traeger AC, Lee H, Hübscher M, et al. Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial. JAMA Neurol. 2019;76(2):161-169. doi:10.1001/jamaneurol.2018.3376
  4. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Cognitive and affective reassurance and patient outcomes in primary care: a systematic review. 2013. Available from: https://www.ncbi.nlm.nih.gov/books/NBK154305
  5. Traeger AC, Hübscher M, Henschke N, Moseley GL, Lee H, McAuley JH. Effect of Primary Care-Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(5):733-743. doi:10.1001/jamainternmed.2015.0217