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Who looks for treatment when they have back pain?


ResearchBlogging.org
I’m not a primary care clinician. The people I see with pain have long-term, chronic, persistent pain that has been around for ages. I think the shortest time someone might have had pain before I see them is 4 months! The average is something like more than 4 years.
But I AM interested in who is likely to ask for treatment for their pain because while the people I see may be ‘experienced’ in the ways of being a patient, not everyone who has a back pain looks for treatment.  And I wonder whether people who seek treatment at one point in time might carry on seeking treatment each time they have trouble with their pain.

When I came across this paper by Ferreira, Machado, Latimer and colleagues, I was really interested in what they found out from their review of papers dating from 1966 on treatment seeking in people with low back pain.  Strangely enough, although there are a good number of studies looking at treatment seeking in general, it hasn’t been extensively studied in people with low back pain.  For some reason I had an idea that there had been some studies on it, and I’ve always associated treatment seeking with high levels of distress and disability, and not so much with pain intensity itself.

Anyway, these researchers identified 3721 hits from the various health databases, of which 3390 titles were excluded mainly due to inappropriate methodology or inappropriate
population groups for this project.  That left about 300 studies – and out of that only 11 articles reporting on 10 population based surveys met the quality criteria (makes you think about research quality, doesn’t it?!).  A very small number of studies out of a very large pool of papers – but still, the experiences of 13,486 subjects with non-specific low back pain, divided into two groups of care seekers and non-care seekers.

Now one of the problems with this type of study is the definition of low back pain, and the duration of the pain, also the definition of care seeking – scanning the table that is included in this paper shows that the duration of pain was mainly for around 6 months, low back pain being pain from roughly the waist to the buttocks, and treatment ranged from GP care to ‘any type of care’ – but we’re not told whether it included so-called ‘alternative’ health care such as Reiki or colour therapy.  The methodology assessment made by the authors of this study ranged from 30 – 80, based on a standardised item list including sampling, response rate, data reproducibility, power calculation and external validity.

One unspoken limitation of any piece of research is the type of factor being studied – interesting to see that in this group of studies, the factors being explored as potential determinants of care didn’t include my preferred candidate of distress – although disability was certainly included.  And the findings?

The main determinants of care seeking were:

  • female gender
  • previous history of back pain
  • degree of disability (more so than pain intensity)
  • externalized beliefs regarding pain management (‘you fix me doctor’)
  • fear of future job impairment (please don’t tell this group of patients to change jobs)
  • limited social functioning
  • having a specific diagnosis for the back pain
  • those engaged in sports activities

Those less likely to seek care?

  • patients with disabling co-morbidities
  • pain of less than two weeks duration
  • those using passive forms of coping
  • leg pain

Curious?!

Some very interesting bits of information came out of this study – firstly, despite this being an area of research priority, and a huge number of studies being published – as we so often hear, the quality of the studies meant that only 11 were able to be included.  Next, less than 60% of people suffering from LBP opt to seek health care for it. That is really, really interesting.  How do these people manage? And it’s not necessarily about their pain intensity being lower, because pain intensity wasn’t associated with care seeking – at least, not as much as disability from pain.

Health care use models have been proposed to explain who looks for treatment and who does not.  The most recent models suggest that “individuals seek care based on an interaction that includes their predisposition to use health care, the available resources and their recognition for the need of care”. This paper found “the importance of age as a factor in  determining who seeks care for back pain, as well as, factors associated with a patient’s recognition of need for care, such as having a previous history of back pain, poor general health and high levels of pain and disability.”

As I’ve been pondering on here recently, the ‘social’ part of the biopsychosocial model sometimes feels quite lonely and forgotten.  When I look at the factors these authors identified, I think of these as having quite social characteristics.  After all, the person’s need for care is about a social construct or belief that they’ve developed on the basis of, perhaps, having had back pain before or after having been required to seek medical treatment to satisfy a work accident claim, or having had an interaction with a health care provider that reinforced the behaviour of seeking care in some way.

Disability is about the impact of pain on function – disability can so often be reinforced by social structures in our communities such as our collective beliefs about low back pain (get treatment, rest, possible horrid consequences); the way families interact with an individual to either support the person to do little, or to abandon or isolate the individual to cope alone; the funding of home help and other supports that enable a person to remain inactive and therefore disabled; and even the provision of treatments for back pain that mean the person can return for treatment periodically without needing to demonstrate any change in activity level.

Finally, I’m curious about the way diagnosis was associated with care seeking.  People with a specific diagnosis for their back pain (from their previous episode) were more likely to look for treatment than those who didn’t have a label. Yet having a diagnosis can be so important for people who have pain – it validates their pain, it helps them look up things on the internet, it strongly influences their beliefs about ‘what is going on’ – so I suppose I shouldn’t be so surprised.  But it does make me think: what if we stuck to the old label of  ‘low back pain’?

The purpose of identifying who looks for treatment and who doesn’t is about trying to influence inappropriate health care use and to minimise disability.  This is one step along the way to work out how to help people look at back pain in a more positive and self managing light – and I suspect it’s going to be social factors that influence treatment-seeking behaviour in the end.

Ferreira, M., Machado, G., Latimer, J., Maher, C., Ferreira, P., & Smeets, R. (2009). Factors defining care-seeking in low back pain – A meta-analysis of population based surveys European Journal of Pain DOI: 10.1016/j.ejpain.2009.11.005

8 comments

  1. i’ve had low back pain for years. a good reason not to go to a doctor is that it is a waste of time. all i ever hear is, oh, there’s nothing we can do for low back pain (i have degenerative disc). I can always get oxycontin if i ask. other than that, they just tell me there’s nothing i can do and just expect it to get worse. maybe the reason so few people go for helop is that they no that none is available.

    1. I’m sorry to hear of your bad experience with health providers. I guess what doctors might be saying is that they don’t have a medical solution to low back pain – if you read through my blog you’ll see there are lots of things that help pain not get in the way as much. I think the two best questions any health provider can ask themselves is ‘What can I do to reduce distress and disability for this person?’ and ‘How is it that this person has arrived to see me today?’ If they can ask these questions they’ll probably at least be able to respond sensitively – provided they are aware of the range of things that nonmedical people can do!

  2. The problem with the generic LBP label is that it may be too ambiguous. My mother has chronic LBP and so do I. She does not seek care at all, and is much less disabled than I am. But our symptoms differ drastically. She has periodic attacks of pain which are very intense why they last. But her pain reaches its highest intensity quickly, and then gradually recedes over days or weeks. After initial days or two of more intense pain, she is not going to feel any pain when she is sitting or lying down, and pain only happens when she does specific movements. She uses over-the-counter pain relievers, heat and a supportive corset to deal with with the worst it, and then can gradually increase her activity level until she is back to normal. As a result, this is just a periodic inconvenience which never felt like a threat to either her job or her social life.

    Then I have another friend with LBP diagnosis. Her pain is daily, brought on by standing in biology lab for long periods of time. But she found that exercise, in particular walking and swimming, really loosens her joints and reduces pain levels. She manages with regular trips to a local pool, and does not attempt to seek care beyond that. Again, neither her work nor her social life are significantly affected by the pain.

    I have pain in multiple places in my back, including shoulders and thoracic spine. But for lack of a better diagnosis, and because LBP was my first symptom, it is all labelled LBP. With two such clear examples of self-management in front of me, I would love to find an equally effective way! But my experience is very different. My pain comes slowly and gradually builds up, to the point when it is constant even if I am lying down, and will severely interfere with sleep and concentration. I would guess that my actual pain intensity is lower than what my mother experiences during her flares, but because my pain during flares is unremitting, it appears to affect me worse than it does my mother and my friend. Also, while I am going to a gym or exercise classes 3 times a week, the “typical” things recommended for LBP, especially swimming, make me extremely unwell, beyond any reasonable bounds of muscle soreness due to a new activity. I gave up on them after repeated tries resulted in major flare-ups with no benefits. I do manage with pacing, carefully controlled physical activity, regular painkillers and a bunch of CBT strategies. But more than once my limitations affected my job (which requires less potentially problematic physical activity then my mothers), and I feel I have to work very hard and manage my life very carefully to stay in employment.

    I can go on with a list of differences, and the point is, does this really help to put all 3 of us in the same LBP category? The origin of pain appears to be different, and so do our body’s reactions. It doesn’t appear productive to “average out” these experiences in studies, either, or in treatment approaches when talking to people.

    I think the current labelling based on X-rays and MRIs is not very helpful – disk herniations which are often asymptomatic is a very good example. I certainly had a couple of doctors route me to the procedures which seemed a poor fit for what I have been dealing with, but which help many LBP people. So I think labels are important, but it would be good if doctors came up with better ones, which are actually correlated with effective treatment for a given subgroup, and validates their pain/experience at the same time.

    1. Hi Mary
      Thanks for your comments – lots to think about! I guess my question is whether ANY diagnosis, which is aimed at grouping symptoms and signs together (and in the process, losing some of those distinctions that you’ve pointed out), is helpful? The name that you give to your ongoing back pain doesn’t really describe what it means to you nor how it affects you, and oftentimes it doesn’t make any difference to the basic steps to manage it. Who is the diagnosis for? Is it for you – in which case what does having a label tell you? Is it for the health provider – in whcih case, does it predict what the outcomes might be? or the treatment approach might be? Is it for the funder?
      My personal preference is for a broad category that can act as ‘diagnosis’ ie ‘low back pain’, then to generate individualised hypotheses that can be tested for each problem that back pain has caused. So if your back pain gets worse in cold weather, a hypothesis might be that you tense up in cold weather – so to test it, learn to relax those muscles and try it out in cold weather. If it works consistently, then that could be one answer to ‘what is going on with my back’. It’s not a diagnosis – it’s more of an explanation about what goes with what and how it might work.
      BTW there was a study some years ago where ‘subgroups’ of low back pain were identified by various treatment providers – and the findings were that there was almost NO agreement between the treatment providers as to which back pain subcategory lead to which treatment! We have a long way to go…

      1. I think you hit the nail on the head – labels make sense when there is a specific use for them. In terms of outcomes, my best results came from the physical therapists who generally relied on the “generate hypotheses and test” approach, just like you described. I think one used a specific label, one didn’t, but both had a “story” for what was going on, and what combination of measures (exercise, heat, fixing ergonomic issues, pacing) will fix the problem. And then it either made sense, or if it didn’t work, generated other possibilities based on what failed.

        The issues with labels happen, I think, when they are either too wide or too narrow. I have certainly seen people given “diagnoses” that focus on one single thing (herniated disk), or otherwise a laundry list of 10 diagnoses at once. I resisted this approach to my problems, because neither seemed productive of anything other than either focusing too narrowly on a single problem, and missing the context, or otherwise treating everything possible in an uncoordinated fashion.

        But with wide labels the issue is that both researchers and medical providers start taking evidence about them more seriously. So when questions like does exercise, massage, CBT, work for LBP, the study may average over a very large number of dissimilar people. Then some providers will take it too seriously, and stick to an evidence-based “protocol”, treating the average. My treatment problems came from doctors who assumed that they knew how to “fix” me just because staying active, or swimming, or core muscle strengthening, or proper ergonomics is known (either statistically or as “common wisdom”) to be effective for LBP. They then assumed that I lied, didn’t do things properly, or was otherwise at fault for not recovering.

        So perhaps LBP is the best achievable label given the medical knowledge that exists, but it sure would be nice if better labels develop with time.

      2. I think you’ve hit the nail on the head – there are really two different things going on here. One is for research and eventually to develop Guidelines or a protocol, and this is the very specific ‘diagnostic label’ thing – but I think for LBP we are a very long way from this… The other is more about working through proposed explanations in a hypothesis testing way – and this is much more about individualising management to suit the individual. Whether the two approaches will meet in the middle is anyone’s guess right now!

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