For Patients in Pain, Choose Your Words Carefully

In an ideal world, health care professionals would like patients not only to understand and take to heart what we say to them but also to properly weigh the importance of our words. And, obviously, we would also like patients to receive accurate information from their caregivers.

A new study on highlights the importance of these things for patients with low back pain (LBP).¹ The study, which was performed in New Zealand, involved a semistructured interview of 12 patients with acute low back pain (ALBP), defined as pain of less than 6 weeks' duration, and 11 with chronic low back pain (CLBP) defined as more than 3 months’ duration.

Patients were asked 19 open-ended questions about their pain, including the meaning to them of their pain; concerns they had about the pain; their thoughts about the best way to manage pain; where they had sought information on the pain; and the meaning of terms for LBP commonly used by health care professionals. The length of the interviews, which were recorded, varied from a half hour to 100 minutes and lasted until the interviewer felt that the patients had completed providing the information they wished to convey in their responses. The results were analyzed by a team of researchers.

The patients with ALBP expressed uncertainty about their prognosis and what they should be doing about the pain to reduce it and to prevent it from becoming chronic. They had a desire to learn more about the pain and although they sought information from a range of sources, including the Internet and acquaintances, especially those who also had LBP, they felt that the clinicians they saw were the best source and provided the most certainty.

Those with CLBP, most of whom had been treated by several health care professionals from a variety of disciplines, tended to express more skepticism about the value of the advice provided by clinicians. The major reason for this skepticism was doubt about the clinicians' competence as evidenced by what the patients considered to be inadequate assessment of their condition or their poor response to prescribed treatment. Patients with CLBP also tended to have more faith in their own views of the pain than that of their clinicians if there was a conflict between patient and physician.

Clinicians influence patient expectations

The study found that patients' expectations played a significant role in how they viewed their pain and that expectations were markedly influenced by clinicians-especially during the acute period. When clinicians expressed doubt about the chance for improvement, patients tended to accept this and become more pessimistic about their future course. This appeared to be especially true if there was an abnormality found on objective testing such as an MRI. Virtually all the patients in both groups reported that they received a pathoanatomic explanation for the pain.

Patients with ALBP expressed a willingness to accept clinicians' recommendations that they remain as active as possible and reassurance that the pain could improve if they did so.

Unfortunately, one piece of advice to patients appears to be frequently misinterpreted. Patients with CLBP reported that instruction on proper body mechanics, which is often emphasized and is usually considered of vital importance to successfully manage the pain, was often interpreted to mean that their spines were vulnerable. Therefore, many thought that they had to be more protective of their backs and that they had to be exceedingly careful about what activities they performed. This appeared less likely to occur if the clinicians emphasized what activities the patients could do rather than those that they should avoid.

This is obviously a small study and therefore can not be accepted as the final word on the subject. Furthermore, we have no way to identify whether factors in those with ALBP made it either more or less likely that the pain would become chronic. However, what the results do demonstrate fits with what colleagues and I frequently observe and provide several important messages:

• Couch recommendations to patients with LBP in positive rather than negative terms with an emphasis on what they can do and not what activities should be avoided.

• Make clear to patients that instruction in proper body mechanics does not mean that their spines are in peril or that they must be especially cautious in performing activities.

• Remember that too frequently patients receive pathoanatomic explanations for their pain despite the fact that repeated studies have shown that in the overwhelming majority of patients with LBP we don't have any clear idea of the etiology of the pain.

Patients' trust in their health care providers is not limitless. Unfortunately, I have witnessed far too often patients being told that their pain would end if they underwent a specific treatment, even treatments that in well-performed studies have demonstrated minimal or no benefit. Not surprisingly, patients become increasingly distrustful of caregivers and so when given appropriate advice, may ignore it.       

When dealing with patients with pain, we need to provide a carefully balanced message. On the one hand, if we appear to understate the importance of the pain and recommend that patients go on with their lives in spite of it, they may feel the pain is being dismissed and even that the clinician does not believe the complaint.  

On the other hand, if we are over-solicitous, patients may believe their condition is serious enough to require marked changes in their lives. Based on this, patients may move in a direction opposite to one we wish them to go, which may result in reduced levels of function and even lead them to seek unneeded testing and treatments.

References:

1. Darlow B, Dowell A, Baxter GD, et al. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11:527-534.