We have spoken before about the pitfalls of clinical guidelines in the management of acute low back pain.  Whilst not being one to conform to political correctness, I have no beef with the need to recognise when research dictates that we alter our clinical practice.  What is sometimes less clear in the stark reality of scientific papers is the practical methodology to restructure the clinical management process to integrate these new concepts. A number of issues arise which we will now discuss  together with the practicalities of their adoption.

Managing Patient Expectations

This is a critical baseline to establish or at least ascertain if the patient and therapist are in the same ball park.  The aspects to consider here are:

The timescales for recovery

Milestones to be achieved

The prognosis

The identification of likely non-responsive symptom components

The recognition of need for multi-disciplinary input.

Radiological Investigation

The issue of inappropriate X-ray’s and the potential harmful side effects have been well addressed in many of the guideline papers over the last decade. From what we know regarding the usefulness of radiology it would appear that diagnostic tests offer little in the way of reassuring patients (unless clear cut surgical cases). Clinical experience has shown that the results of X-Rays, MRI scans seem to strike fear into the hearts of patients and act as obstacles to resuming normal behavior.

However some more startling findings have recently emerged regarding the timing of investigations for MRI and the implications on treatment outcomes. Here are some selected segments from Neil O’Connell’s post.

“A recent study analysed a large workers compensation database for back pain claims in the USA. They looked at the relationship between the early use of MRI imaging in people with work-related back pain and clinical outcomes. They then analysed the effect that having an MRI versus not having it had on outcomes in each of these groups while statistically controlling for things like symptom severity, age etc

The statistically adjusted results indicate that folk in the MRI group came off of disability 200% slower (from a raw average of 134 days with MRI to 23 days without!) than those who did not have an MRI scan. Perhaps more worryingly while those in the no-MRI groups had a surgery rate of less than 10%, the MRI groups had surgery rates of 80-100%.

To be clear in the group who had clinical characteristics that made them less likely to be offered an MRI, but who still received one, 100% underwent spinal surgery. In fairness to the technology it’s not really the scans that are the problem, it’s the way that they are utilised by clinicians. Powerful images of bulging discs, degenerating joints, partial dislocations or instability are evoked to help explain the patient’s symptoms, with the result that patients might be left with the idea that their spine is structurally compromised.

What the study does tell us is that as well as not being very informative, spinal imaging in this group was related to important differences in the treatment paths of these patients and also to a large and unhelpful change in clinical outcome. It’s time to listen to those clinical guidelines and be careful which spines we take pictures of.”

This places the physiotherapist in the position of being forced to decide what the potential implications of seeking investigations are and more importantly how they are likely to influence the management plan.  We have written about this in previous posts on patient satisfaction.

Patient Education

Studies have also shown that the type of patient education information has an influence on outcome.  Studies which compared detailed anatomical / biomechanical information about low back pain having more negative impact than a more general discussion about maintaining activity, minimising the effects of social disengagement and  challenging fear avoidance behaviours. Butler & Moseley’s work “Explain Pain” has also been an excellent contribution in this area.

Therapist’s Attitudes

Prof Mike Sullivan has studied attitudes of clinicians in terms of their personal belief systems and how it influences the information they provide patients.  As clinicians – we need to be very cautious about using phrases such as “take it easy”, “these things take time”, “be careful”, “we’ll see how it goes”, as these may transpire to be re-enforcers of disability behaviour.

So what does all this mean in practice?

Do we have to watch our “P’s” and “Q’s” so much that we can’t express an opinion?  As therapists do we have to seek refuge in vague generic guidelines and avoid uncomfortable conversations or challenging spurious beliefs?

I do not think it is a case of preoccupation with political correctness but more a case of prudence and credibility.  As we have no way of knowing what a patient’s belief system is on our first encounter then the onus is on the therapist to mix their subjective interaction with a combination of open and closed questions and a choice of language which provides less opportunity for misinterpretation i.e. “how can I help you?” “how have you been?” how are your symptoms?” etc are phrases which can be used as conversation openers without predisposing interpretation’s such as “where is your pain”.

Therapists’ attitudes and beliefs about progressive loading on tissues is frequently too conservative. “be careful bending, bend from the knees whilst conveniently ignoring the biomechanical reality of getting out of bed, dressing and activities of daily living. Think about that credibility gap?

This is a situation where the therapist can easily lose credibility by being over protective based on fear of pathology rather than on the actual physical tolerance of the patient.  Although no clinician wants to push a patient up to the point of breakdown it is almost inevitable that this will happen at some point in a clinician’s career.

This is the difference between being on the edge of physiological boundaries for the purposes of enhancing function as quickly as possible and simply hiding behind fear of pathology and allowing the patients to make spontaneous decisions regarding their own management.  As we have discussed before this is not an issue of negligence or “gung ho” behaviour but simply a reflection of the reality of manipulating multiple physiological variables as part of our  clinical intervention.

Let us know any additional strategies you find helpful in clinical practice.

Enjoy the clinical challenge

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2011. | Permalink | No comment | Add to del.icio.us
Post tags: clinical relevance, credibility, negative test results, Patient attitude towards collaboration between the care providers, Patient expectations, psychosocial flags, radiological investigation, therapist credibility

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© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2008. | Permalink | No comment | Add to del.icio.us
Post tags: biomechanics, clinical relevance, impingement, pathology, primary impingement, primary impingemetn, rotator cuff tear, secondary impingement, treatment outcomes

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