Welcome to the first in a series of rheumatology research digest blog pieces that look into recently published papers, dives into what it means for clinical practice and translates research into a more accessible format.

Why was this study needed?

80% of the population will experience persistent lower back pain at some point and this can significantly impact on an individual’s quality of life, ability to work and carry out their daily activities. These individuals frequently present to their GP or physiotherapist seeking help which can be an ongoing process, proving to be costly in both time and resources. 

Until now little research has been carried out to establish patient expectations regarding their physiotherapy assessment and treatment. Their expectations, satisfaction and overall outcome are strongly linked, therefore by meeting their expectations, we may be able to improve their quality of life and decrease their need to seek help. 

What did this study do?

Patients who were referred to physiotherapy from their GP with a diagnosis of non-specific chronic LBP (where chronic was identified as lasting more than 16 weeks), were invited to participate in this study between September 2013 and June 2015.
They were asked to give a pain score on the visual analogue scale, complete the Roland Morris Disability questionnaire and the Consultation and Treatment and Treatment and Outcomes sections of the Questionnaire for Patient Expectations of Health Care, 7 days prior to attending physiotherapy. 

What did it find? 

79 patients participated in the study with 73% being female. VAS = 7/10, Roland Morris Disability Questionnaire = 12/24 indicating that patients were moderately affected by their back pain.  90% of participants expected:

  • Reassurance

  • Advice

  • How to manage their condition

  • Improved quality of life

  • Diagnosis

  • Physical examination

  • Reduction in symptoms

  • Improvement in health

  • Tests/investigations

  • Cause of condition

They were less concerned with discussing other problems in their life (59.1%), onwards referrals (50%) and prescriptions (51.5%). 

Current guidelines 

NICE guidelines (2016) indicate that we should be clearing for serious pathology (metastasis and cancer, spinal injuries and spondyloarthritis), not routinely requesting imaging and providing advice and education, which meets with the patient expectations highlighted in this study. 

Implications to practice

The purpose of this study was to specifically establish expectation around physiotherapy, similar themes may occur with other professions so the findings may be transferable. Although this study was carried out in Sydney, it was in a publicly funded hospital; therefore these findings should be transferable to other settings in similar countries such as the UK. 

This study highlights the fact that patients often expect investigations as part of their assessment and treatment. One of the biggest challenges in health care is educating the patient on the reason why investigations aren’t needed. In many cases (unless a serious condition is suspected) further investigations would not change the treatment plan and clinical diagnosis is sufficient. We need to educate patients further around the fact that these investigations will most likely show normal changes that may not be problematic in part of the population.

Perhaps this is something that all healthcare providers can become better at. Can we provide more information for patients around this for them to read while they are waiting so that these conversations can be started much more easily? How much of a barrier to their progress is their desire for imaging?

The inclination for scans may be compounded further by the desire of patients to find out the cause of their pain. This is something that we are unable to be precise about due to the complexity of pain, but we need to provide our patients with education and reassurance. Such as the fact that in 95% of the population the cause is non-specific and that hurt is not equal to harm. The back is a strong and stable structure that likes movement and exercise. Many patients I see are simply looking for this approval that they are safe to move and do normal activities. 

Half of patients expect to receive an onward referral, presumably to orthopaedics. Once again patients should be educated on the nature of their problem and reassured by our assessment and findings that a referral is not needed and surgery is unlikely to be either needed or effective. 

Perhaps most interestingly was that some patients expected prescriptions. Although there is the increase of non-medical prescribers within services, this is not something that many clinicians can provide. Patients should be redirected to more appropriate services although this may lead to frustration for the patient.

Finally over half of the patients wanted to talk about the problems in their life. It is unsure whether this was relating to their back pain or other issues. What we must not forget is that pain is complex and that other factors have an influence on their perception of pain. Where possible we must take the time to listen to and understand their problems and the impact this is having on their life to ensure we are taking a holistic approach. Merely having someone really listen to their problems may be enough for some to start the treatment process and their journey towards self-management. 


What Do Patients with Chronic Spinal Pain Expect from Their Physiotherapist?

Kamper, S., Haanstra, T., Simmons, K., Kay, M., Ingram, T., Byrne, J., Roddick, J., Setliff, A. & Hall, A. (2018) Physiotherapy Canada, 70 (1), pp. 36-41

This piece was kindly provided by BSR member Vicky Glanville, a chartered physiotherapist and graduate sports therapist. She currently works in the MSK outpatient department at Gloucestershire Hospitals NHS Foundation Trust, having previously completed a Nursing and AHP research internship with Versus Arthritis. When she isn’t busy seeing patients, she can mostly be found on the back of a horse. You can find her on twitter @vicky_glanville

Research digest blogs are independent reviews and commentary and do not necessarily represent the views or position of the society.