Monday, November 18, 2013

What we say to patients with low back pain matters

- Jennifer Middleton, MD, MPH

I have recommendations for patients with benign low back pain (LBP) that I have repeated many times already in my career:

"It appears to just be a problem with the muscles. I don't think that it's anything more serious than that."
"Lift with your kness, not with your back."
"The abs and low back should work together to keep you upright.  A lot of people have weak abs, so getting the abs stronger can help back pain."

I always thought that I was giving good advice, but a study from the current issue of Annals of Family Medicine suggests otherwise.  This excellent qualitative study, titled "The Enduring Impact of What Clinicians Say to People With Low Back Pain," examined how patients interpret the phrases we physicians tell them about their LBP.

The researchers and participants of this entirely qualitative study were in New Zealand.  They included patients with both chronic and acute LBP that were at least 18 years old, had never had back surgery, and spoke English.  Almost all participants had seen a family doctor for their symptoms. The researchers conducted individual face-to-face interviews, and they continued recruiting participants until the findings from these interviews reached saturation, meaning that they were hearing no new themes or information.

Physicians hear "back" and think of all of the muscles, bones, and spinal cord, but this study found that when patients hear "back," they often only think "spine."  Physician advice to protect the back by lifting with the knees or strengthening the abs gave many of this study's participants the impression that their spine was vulnerable.  Because of this perceived vulnerability, several patients limited their activities, which likely worsened their symptoms since inactivity worsens most benign LBP.  Additionally, these back protection recommendations "may result in increased vigilance, worry, frustration, and guilt" for patients.

Happily, most participants responded positively when their physicians recommended that they stay active while recovering.  Physicians' "reassurance about prognosis or safety of movement could be very powerful," stated the researchers, as long as the participants had confidence in their physician; a history and exam perceived to be perfunctory and/or continued symptoms despite following the physician's advice both underminded this confidence.

This article will change my practice.  I'll make sure, in the future, to reinforce to patients that their spinal bones and cord are okay and not at risk from damage or injury.  I'll emphasize that back protection measures are not because I think their spine is at risk but instead to help reduce occurences.

I highly recommend reading this article in its entirety, as there are several more fascinating insights that space doesn't permit me to delve into further here.  AFP also published a helpful review of evaluation and treament of acute LBP last year, and there is also an AFP By Topic on Musculoskeletal Care if you'd like further reading.