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GP management of back pain – challenges and opportunities

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Low back pain is a very common reason to visit the doctor but previous studies have indicated that GP management of back pain is often inconsistent with evidence-based guidelines. We wanted to explore the beliefs of New Zealand GPs about back pain and how these influenced their management of patients with back pain.

We found that GPs who participated in this research tended to look at acute back pain as being directly related to acute injury of tissues in the back. This contrasted with chronic back pain, which participants viewed as being a multifactorial problem influenced by a range of physical, psychological, and social factors. Our finding that psychosocial factors were not considered to be relevant to acute back pain may help to explain why GPs are less likely to adhere to guideline recommendations to explore these factors. GP consultations are very time limited, and GPs are not likely to prioritise activities which they perceive as being inconsequential.

Guideline recommendations for people with acute back pain to be active also appeared to conflict with a perceived need to protect damaged tissues. As a result, a number of GPs reported advising patients to be active and careful at the same time. Some GPs were concerned that if patients perceived they had gotten worse by following GP advice, they would blame the GP, and this resulted in a more cautious approach to activity. We think that these messages to be cautious may contribute to patient uncertainty about the safety of activity.

Although GPs were aware of limitations in their ability to make structural diagnoses, or the ability of such diagnoses to inform management, many still reported providing diagnostic labels to their patients. They considered that these were necessary to meet patient expectations, and that simple musculoskeletal diagnoses were helpful to reassure (themselves as much as their patients) that pathology was not present.

Our research also suggests that GPs may share many of their patients’ beliefs about the back being a vulnerable structure which needs to be protected, and that certain activities are dangerous for the back. As a result they may not be in an ideal position to provide their patients with updated information which empowers an active and confident recovery.

We speculate that by focusing on tissue injury aspects during acute care, and providing a diagnostic label, GPs may lay the foundations for their patients to look at their back pain in this way. This may contribute to doctor-patient relationship difficulties, and patients’ feeling like they are being blamed for not getting better, when clinicians start discussing the influence of psychosocial factors. We think that demonstrating the relevance of the biopsychosocial model to acute back pain may improve GPs alignment with guidelines, improve their confidence to manage patients with back pain, and ultimately improve outcomes.

Other areas in which we have recently published work include: patient beliefs about the back (Easy to harm, hard to heal: patient views about the back. Spine 2015); and how these beliefs have been influenced, particularly by health professionals (The enduring impact of what we say to people who have back pain. Annals of Family Medicine 2013.).

About Ben Darlow

Ben Darlow reducedBen spends his time interacting with patients as a Senior Physiotherapist at Wellington Sports Medicine, and conducting research and teaching medical students as a Research Fellow in the Department of Primary Health Care and General Practice at the University of Otago, Wellington. Ben’s main research interest is related to back pain, particularly understanding beliefs about backs and back pain amongst clinicians, people with back pain, and the general public, and how these all influence each other. He is also interested in strengthening health care teams and improving patient care through interprofessional education. More information about his research and publications can be found here.

References

Darlow, Ben PhD; Dean, Sarah PhD; Perry, Meredith PhD; Mathieson, Fiona MA (Clin Psych); Baxter, G. David DPhil; Dowell, Anthony MBChB (2015) Easy to Harm, Hard to Heal: Patient Views About the Back. Spine 40 (11) 842 – 850

Ben Darlow, Anthony Dowell, G. David Baxter, Fiona Mathieson, Meredith Perry, and Sarah Dean (2013) The Enduring Impact of What Clinicians Say to People With Low Back Pain. Ann Fam Med 11 (6) 527-534

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