For a couple of years now, the focus of researchers on factors that identify ‘high risk’ of ongoing disability has turned from patients and onto providers. I’ve written before that health provider’s own beliefs about pain, particularly pain-related anxiety and avoidance, can change the advice they give. This can lead to less ‘reassurance’ about remaining active despite an episode of acute low back pain, and more advice to ‘use pain as a guide’. Occupational therapists with high levels of pain-related anxiety and avoidance beliefs can issue more equipment and advise patients to use compensatory movement patterns than those who don’t.
As a result I was really interested in another paper exploring communication patterns between doctors and patients when the patients demonstrated high levels of ‘yellow flags’, or psychosocial factors that increase the risk of ongoing disability.
Bill Shaw and colleagues obtained consent from nearly 100 patients with work-related low back pain to record their interactions with their health providers. The patients also completed a ‘risk factor’ questionnaire which was analysed to identify people with low, medium and high presence of ‘yellow flags’.
Each interaction was recorded and the ‘utterances’ coded, then these tapes were reviewed against the findings of the risk factor questionnaire.
And guess what they found?
Just amongst people with high risk of ongoing disability, clinicians asked for and obtained much more biomedical information. Patients similarly gave more biomedical information and asked more biomedically-oriented questions. Providers certainly talked more, used more language to engage with patients and facilitate communication – but only elicited more biomedical information.
The psychosocial exchanges didn’t differ between those with high levels of psychosocial risk factor, and those with medium or low levels of risk.
Shaw and colleagues identify that while clinicians may recognise the presence of yellow flags, and understand that this needs more assessment and management, but revert to what they know best, ie biomedical advice and explanation, rather than exploring lifestyle and psychosocial factors.
There have been several studies examining whether treatment ‘guidelines’ help to expand the use of evidence-based approaches to acute low back pain, and like this study, what they find is that health providers do identify those with ‘high risk’ of ongoing disability and those with psychosocial risk factors – but then they just don’t seem to know what to do with this.
Many factors probably influence their reluctance to engage in discussion of psychosocial risk factors. I’ve heard of things like:
- patients don’t like it when I start suggesting there might be something psychological going on
- it’s going to take so much more time than doing a routine appointment
- I don’t get paid for the extra time it takes to talk about psychosocial factors
- I don’t know how to talk about psychosocial issues
- it’s like Pandora’s box, you never know what’s going to come out in the open
- once you start talking about these things, what do you do about them?
- there are so few services for psychosocial factors and it’s going to take so long to get to them, I don’t really want to go there
…and on and on.
I appreciate how little time is available for community and primary care providers, and that starting to talk about psychosocial factors can feel like straying onto enemy territory – and sad to say, there is a pervasive feeling that these factors are messy, difficult to manage, and complex. Well, it’s true – these factors are messy, difficult and complex – but they’ve also been shown to strongly influence progress.
The guidelines and other documents discussing ‘how to’ manage psychosocial risk factors have been an incredible force for change, even if many providers don’t really understand them and don’t feel they can use them. The turn-around in managing acute low back pain from resting to remaining active has been swift and pervasive. It seems timely, though, to review the ‘gap’ in skills that health providers have in delivering effective psychosocial assessment and management.
I’m going to stick my neck out here for a moment: psychosocial risk factors are not always as difficult to manage as we might believe and all health providers can do things to start the process. People with high levels of psychosocial risk don’t ALL need to be referred to see a psychologist.
What can we all do?
The first step is to listen to what the person is saying. Ask them:
‘What problems does having low back pain have for you?’
‘What do you think is going on?’
‘What is bothering you the most about your back pain?’
‘What does having this pain mean to you?’
Then listen. And listen again. And reflect back what you’ve heard.
That’s a start.
Then ask about biomedical factors – most of us will do this readily and easily.
Talk people through your examination – let them know what you haven’t found and why this is good news for them.
Then words of reassurance might actually reassure – empathising that having pain is distressing, back pain is common but does resolve, and that having negative emotions like fear, anger and frustration is normal when something unexpected and uncomfortable happens.
And then prescribe really good pain relief (or if you’re not a prescriber, some really effective self help strategies like diaphragmatic breathing and relaxation), and most importantly ask them to come back in a few days or a week. Emphasise that you won’t leave them stranded.
And when they return, once again talk them through your examination, ask them the same questions as above, and reflect back that you’ve heard their responses. And reassure them that their reaction is normal, and that this kind of back pain settles down over a few weeks, but might flare up again – and start giving them permission to do normal activities even if it’s sore.
Watching our own response to people in distress, and noticing our own tendencies to respond with biomedical and ‘factual’ material rather than empathic responses and eliciting psychosocial factors is going to take some thought and time – but it will reap benefits. Or so the literature shows.
Shaw WS, Pransky G, Winters T, Tveito TH, Larson SM, & Roter DL (2009). Does the presence of psychosocial “yellow flags” alter patient-provider communication for work-related, acute low back pain? Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine, 51 (9), 1032-40 PMID: 19687758