Ep 199: What do people with back pain want? with Dr Giovanni Ferreira

[00:00:00] The American Academy of Sports Physical Therapy and JOSPT are joining forces to bring

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[00:01:05] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:01:11] to quality practice.

[00:01:13] I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy.

[00:01:18] It's great to have you listening today.

[00:01:24] If you work in musculoskeletal rehabilitation practice, chances are you see people with low

[00:01:30] back pain.

[00:01:31] If you consult a clinical practice guideline for any musculoskeletal condition, you'll probably

[00:01:36] see advice and education included as part of the recommendations for helping someone manage

[00:01:41] their musculoskeletal pain.

[00:01:43] Dr. Giovanni Ferreira is an Emerging Leader Research Fellow at the University of Sydney,

[00:01:48] where he studies how musculoskeletal pain is managed and how effective common treatments are.

[00:01:55] Today we're discussing what concerns people with back pain and how well the information in

[00:02:00] clinical practice guidelines addresses those concerns.

[00:02:03] Spoiler alert, unfortunately not that well.

[00:02:07] Dr. Giovanni Ferreira, welcome to JOSPT Insights.

[00:02:11] Thanks for having me, Claire.

[00:02:12] Thanks for jumping online, Giovanni.

[00:02:15] It's really great to chat with you about all things back pain today.

[00:02:19] And JOSPT Insights listeners will know the stats about musculoskeletal pain and about back

[00:02:25] pain in particular.

[00:02:26] We know that it's a major driver of the burden of disease across the world.

[00:02:30] The WHO estimates that close to 2 billion, that's billion with a B, people around the

[00:02:37] world live with musculoskeletal pain.

[00:02:39] And that number is only increasing as the population ages.

[00:02:43] People's work life, their social life, their quality of life and their health are all affected

[00:02:48] by musculoskeletal pain.

[00:02:50] And today we're focusing on your work with people with acute low back pain.

[00:02:54] So tell me, what are the main concerns that people with acute low back pain have?

[00:02:59] People have lots of different concerns and everyone who's in practice and who sees patients

[00:03:04] on a daily basis would agree with that.

[00:03:06] People come in with all sorts of different questions.

[00:03:09] But we wanted to take, I guess, a deeper look into what actually concerns people with acute

[00:03:15] back pain.

[00:03:15] So we asked them and we, in the study that we published earlier this year, we found a

[00:03:22] large number of different concerns, about 34 unique concerns that we mapped onto five different

[00:03:29] themes in our study.

[00:03:30] So people are worried about the consequences of back pain in terms of their future, you know,

[00:03:36] what are the psychosocial consequences of back pain in terms of their affected lifestyle?

[00:03:41] Is it going to affect my work?

[00:03:43] Is it going to persist?

[00:03:45] Is it going to make me less mobile?

[00:03:47] How bad is my prognosis?

[00:03:49] Are my activities going to be affected by back pain?

[00:03:52] So there's a whole range of concerns.

[00:03:55] And some of these concerns, which we thought were really interesting, are not really addressed

[00:04:01] by the literature, not really addressed by clinical guidelines, instead to mention certain things

[00:04:09] that clinicians should address with patients in terms of providing reassurance that weren't

[00:04:13] really described as important very commonly by patients in our study.

[00:04:18] And we'll get to what's in the clinical practice guidelines in a moment.

[00:04:22] Before we get there, I'm interested to know why you wanted to speak with people with acute

[00:04:28] back pain and not people with, say, chronic low back pain.

[00:04:32] We were motivated studying acute back pain is, I guess, the lack of research in that population.

[00:04:38] There's a lot of research into chronic low back pain, and we know quite a bit about it.

[00:04:44] We know much less about chronic pain, sorry, about acute pain.

[00:04:49] So that was motivated us to look into what this population had to say about their pain.

[00:04:56] And I guess understanding what people are concerned about earlier on could give us an opportunity

[00:05:02] to perhaps address those concerns.

[00:05:04] And if we think that those concerns might eventually impair their recovery or make them

[00:05:10] more likely to develop chronic pain or not improve.

[00:05:13] So I think it was a good opportunity for us to have a chat and understand what people think

[00:05:19] about the back pain and what concerns them.

[00:05:21] Given the research suggesting that one, that acute pain or one incidence of pain is prognostic

[00:05:29] for developing persistent pain, it seems to me like a really important thing to understand

[00:05:34] what's going on, as you say, in that acute setting, trying to address some of that

[00:05:38] and proactively perhaps preventing some people going on to develop persistent pain.

[00:05:44] Yes, exactly.

[00:05:45] And we don't really know what the mechanism is behind someone having a specific concern

[00:05:50] or someone having certain thoughts about their back pain and how does that drive long-term

[00:05:56] disability and pain.

[00:05:57] But I guess if as clinicians, if you can identify what people are concerned about, if you can address

[00:06:03] them with good quality reassurance, you can only benefit the patient, right?

[00:06:08] Having been able to address misconceptions or just concerns and have a, I guess, a frank conversation

[00:06:15] about what's going on and making sure that people are properly reassured about their condition

[00:06:22] and what they're experiencing.

[00:06:24] Definitely.

[00:06:25] How do these concerns that you talked about at the top of the podcast, Giovanni, how do they

[00:06:31] differ among people from different groups or with different experiences of back pain?

[00:06:37] Right.

[00:06:38] So we did some, and I should say in our study, some exploratory analysis to see if there are

[00:06:43] different types of people, I guess, in our study who had more or less concerns or who

[00:06:49] are more likely to be concerned about their back pain.

[00:06:52] And we found some interesting things that I guess the most interesting finding for us was

[00:06:59] that people who had previously received advice for back pain, which I guess you can see it

[00:07:06] as a proxy for having used healthcare for back pain before or having had back pain in the past,

[00:07:12] etc.

[00:07:13] These people who had received previous advice for back pain, they were more likely to have

[00:07:18] a concern about their back.

[00:07:19] Now, obviously our study was a cross-sectional study, so we can't really tell that having

[00:07:25] received previous advice for back pain causes concerns.

[00:07:31] But I guess there's some evidence to suggest that both exposure to healthcare may make people

[00:07:38] more fearful about certain things in terms of their prognosis.

[00:07:42] They might have been misinformed, that they might have had a better experience with healthcare, and

[00:07:47] therefore they are now slightly more concerned.

[00:07:51] And there's also some evidence to the opposite relationship, right?

[00:07:56] People who have concerns, they're more likely to seek healthcare, and therefore, you know, that would have

[00:08:03] been picked up by our analysis as well.

[00:08:06] But it's an interesting finding, and I think it opens some avenues for questioning and for

[00:08:11] future research.

[00:08:12] We also found that people who had more, who are more educated, so people with university

[00:08:17] education were way, were much more likely to have a concern about their back pain.

[00:08:22] And I guess you can also speculate as to why that happened.

[00:08:27] Is it because people who are more educated have more access to information?

[00:08:30] Some of this information may be not necessarily correct.

[00:08:34] People with higher education levels, university level education were more concerned about back pain,

[00:08:38] and maybe that's because they've had more exposure to the crazy amounts of information,

[00:08:44] good and bad on the internet.

[00:08:46] Giovanni, let's come back to the first question a little bit.

[00:08:50] You talked about the different types of concerns and worries that people with acute back pain have,

[00:08:55] and you alluded to the content of clinical practice guidelines.

[00:08:59] So let's jump into CPGs.

[00:09:01] And I should say up front, we're not criticizing CPGs.

[00:09:04] The point here is that CPGs are a generic piece of content,

[00:09:09] and then you as a clinician have to deal with an individual person who's got very different beliefs,

[00:09:15] understanding, presentation, et cetera.

[00:09:17] But I would really like to explore what's in CPGs and perhaps what's missing from CPGs.

[00:09:25] How well are the concerns that you identified addressed in current CPGs for back pain?

[00:09:32] The short answer is not well enough.

[00:09:35] And if you look at CPGs, whenever a clinical guideline talks about reassurance and advice for people with back pain,

[00:09:44] and I should say that's obviously a small part of the clinical practice guideline.

[00:09:50] These documents, they are meant to provide recommendations on a range of treatments and provide levels of evidence and whatnot.

[00:09:57] So it's really a small part, but it's an important one because that initial reassurance, that initial education that's part of the clinical encounter,

[00:10:06] sometimes it's a critical part of providing treatment to those patients.

[00:10:12] So I think we should be talking more about it.

[00:10:14] So what we did find is that none of the most common concerns were mapped to anything that clinical guidelines usually talk about.

[00:10:24] So for example, clinical practice guidelines often recommend clinicians to reassure patients about the presence of serious pathology.

[00:10:32] And yes, that is an important consideration.

[00:10:36] You want people to, you know, you want to make sure that people, when you examine them, you want to rule out serious pathology.

[00:10:43] But people weren't really concerned in our study at least about having serious pathology.

[00:10:49] Is my back pain a cancer?

[00:10:51] Do I have a fracture?

[00:10:52] That came up really, really, in a really small number of people and didn't make it into the top 10 most common concerns, for example.

[00:11:01] People are more worried about day to day things.

[00:11:05] How is their back pain going to affect essentially their lives and what, and how they go about their lives on a daily basis.

[00:11:14] And this obviously, to clinicians, this sounds really intuitive, but I think it's important for us to talk about that and for us to bring research into this discussion so that we can improve,

[00:11:28] for example, our resources for patients and that we can create, I guess, tools and documents that can address some of the most important concerns, which can be simple concerns, but they're not really talked about much in the literature and research.

[00:11:45] And I guess one of the challenges is that often in research, people describe quite a generic health education intervention.

[00:11:55] And then when you as a clinician go to implement something around education, you're really stuck to know what is it that I should implement?

[00:12:06] Exactly. That's a really good point. And a lot of the education interventions, they are based on what clinical guidelines recommend, right?

[00:12:14] So important parts of the education intervention in some trials have been about providing information that reassures people that they don't have cancer, that they don't have a fracture, that staying resting in bed isn't necessarily going to be helpful.

[00:12:29] And yes, these are good pieces of information.

[00:12:32] But again, that doesn't necessarily addresses the concerns of the person in front of you.

[00:12:37] So I think making the point that clinicians have to have that flexibility to listen first, to then address whatever concerns the person brings to the clinician, I think that's an important point.

[00:12:49] And also, it opens up the possibility for more flexible interventions to be created around addressing concerns in a more flexible way.

[00:13:01] Definitely. If you were to design a new education intervention based on the results of your study, and I should say we'll put a link to your study in the show notes so people can find it, what would you put into your education intervention?

[00:13:14] I think an education intervention has to be fully pragmatic and that sometimes there is a cost to designing a fully pragmatic intervention, which is sometimes it's hard for it to be replicated.

[00:13:28] So you would leave it up to the clinician to first listen to the patient to then address any issues, any concerns that there may be.

[00:13:38] But I think that's the only way forward.

[00:13:41] Any intervention that's an education intervention that's based on understanding what the person in front of you knows about the condition and wants to know and wants to change, I think there's no other way other than being fully pragmatic.

[00:13:56] And I think we just need to find a way to design a fully pragmatic intervention and make sure that there is a way for us to replicate this or for us to create training materials that will allow clinicians to follow guidelines that would allow them to have a meaningful conversation with the patient and extract the relevant information to enable them to then provide the education, the advice that's needed.

[00:14:24] So it's a bit of a bit of that tension between a clinical practice guideline when it's designed well giving you, I've heard people talk about a CPG or a well-designed CPG giving you guardrails or guidelines around what to do as a clinician but not giving you the specific recipe.

[00:14:40] So I guess it's the tension between how much of the recipe do you provide in the guideline, because we can all understand that the recipe is a fairly generic recipe in itself.

[00:14:53] And you're working with an individual who brings all sorts of experiences and background and presentation to that initial consultation or that ongoing consultation with the clinician.

[00:15:03] Exactly. And I think this is up to us researchers as well to communicate to clinicians that we, I don't think there's an expectation that clinicians will blightly follow a guideline.

[00:15:15] Guidelines, they are guidelines, they're not rules.

[00:15:17] And I think it's important to have that level of flexibility and to understand that navigating the complexity and understanding that there is flexibility is also part of being an evidence-based clinician and having that knowledge to understand where to follow the guidelines exactly and when to have that sort of flexibility.

[00:15:38] I think it's an important feature, an important skill for an evidence-based practitioner.

[00:15:43] For sure. And I think the other side of it is that when you're starting out, it's often challenging and overwhelming to get your head around absolutely everything that you need to know or to feel comfortable interacting with the broad range of patients you're going to see on a daily basis.

[00:16:00] And that's where I can see the tension between people wanting to have the recipe, because then it takes one less piece of cognitive load out of the demands for the day.

[00:16:11] Exactly. Yes. And I think if there's any, I guess, main message from our study is that it's probably best to listen first and then talk about whatever concerns come up instead of just, you know, ticking the boxes of what's mentioned in the guidelines.

[00:16:29] What should I be asking in terms of concerns? Because you might get a whole lot of information that we weren't expecting.

[00:16:36] And, you know, if you try to reassure someone that their back pain isn't caused by cancer, that may obviously create concerns for the person in front of you as well, because they weren't even thinking about having cancer.

[00:16:47] But now this has somehow been, you know, put on the table.

[00:16:51] So should they be concerned about having cancer or not? Should they seek a second opinion or not?

[00:16:56] Why is my physio talking about cancer? I don't understand.

[00:16:59] So I think it's, if anything, is the main message should be listen first and then talk later.

[00:17:07] So Giovanni, what's the best way or maybe ways for people to receive information and support that addresses their concerns about back pain?

[00:17:17] That is a really great question.

[00:17:19] And I guess we live in an era where information is available everywhere for free 24-7.

[00:17:27] It's just crazy the amount of information we have to deal with.

[00:17:30] And we just have to accept that people will come to us and will have information prior to seeing a health professional, right?

[00:17:39] And that we want to know about the condition.

[00:17:41] And I don't think we can expect that people will only rely on the clinician in front of them to be the only source of information that they will get their information from.

[00:17:52] So people will go on the internet and they will find a lot of ore information.

[00:17:58] And we've done some research on that.

[00:18:01] And there is a lot of bad information out there encouraging people to, you know, take up treatments that are not effective,

[00:18:08] that can even be harmful treatments that are not recommended at all.

[00:18:13] That's one side of the story.

[00:18:15] The other side of the story is that I think there's now a bit more awareness about, you know, the amount of ore information online.

[00:18:23] And there's been some attempts to fix that.

[00:18:26] People are now going to, you know, AI chatbots for information.

[00:18:30] They're asking all sorts of questions.

[00:18:32] And why not ask questions about their health?

[00:18:34] And we actually published a study a couple of weeks ago looking at how accurate these chatbots are in providing recommendations in terms of treatment for back pain.

[00:18:45] Not necessarily providing advice in terms of addressing concerns and things, but how accurate are treatment recommendations.

[00:18:51] And we were really surprised with the findings that, you know, overall about 60 odd percent of the time, these bots, they provided accurate information.

[00:19:02] When you look at stats from clinicians and how accurate treatment recommendations are when provided by clinicians, we're talking about perhaps 70, 60, 70 percent.

[00:19:13] So that's pretty similar.

[00:19:14] And I think there isn't a best way.

[00:19:19] I guess we have to accept the fact that people will seek information everywhere.

[00:19:25] Luckily, I think information may be proven online and we were really impressed by the accuracy of the bots.

[00:19:32] And I think they will only improve over time.

[00:19:35] In a clinical encounter, obviously, there's many ways for us to provide that information that can be in a conversation.

[00:19:42] You can hand out materials to the patient, you know, they are written in a friendly language.

[00:19:49] And I guess picking up on the AI or maybe technology generally in healthcare, there's, of course, people developing apps and all sorts of technology used to deliver information as well.

[00:20:03] So it doesn't necessarily have to look like a face-to-face discussion.

[00:20:07] Although I think my read on the literature is that it's not enough to simply give someone a flyer and expect that they're going to remember stuff or take away the messages that you hope they take away.

[00:20:19] I think for certain types of information, there needs to be that meaningful connection with a person.

[00:20:24] It doesn't necessarily have to be a clinician, but a person.

[00:20:27] And surely, I guess, the simple concerns can be addressed initially, at least, by technologies and by more hands-off approaches.

[00:20:37] But at the end of the day, having that connection with someone, with a person, with a clinician, with a doctor, I think that's a really important part of what we do.

[00:20:48] And we surely have to invest in that and we surely have to get better at communicating with patients and making sure that we are good listeners and that we ask the right questions.

[00:21:00] And your advice earlier to listen and then act, I think, is really important here because there is the tendency to jump in too quickly.

[00:21:09] And then you perhaps lose some of that background information about what the person really understands about what's going on with their body or, as you say, what they particularly are concerned about or want to know more about.

[00:21:21] Now, Giovanni, what's next on the agenda for you and the research team?

[00:21:26] How are you building on the work that you've been doing, both what we've been talking about today in this specific study and then more generally?

[00:21:34] If you look at the education reassurance literature, it's mostly centered around spinal pain, spinal problems.

[00:21:44] There's quite a bit that's been done in back pain and neck pain.

[00:21:49] We're sort of trying to expand what we're doing now to other conditions to understand what people are concerned with.

[00:21:55] Other musculoskeletal conditions are concerned about how education has been delivered for these other conditions.

[00:22:03] We're doing a bit of work at the moment with shoulder pain and clinical practice guidelines for shoulder pain are even, I guess, less complete than back pain guidelines in terms of education reassurance.

[00:22:15] We don't really know what works in terms of education reassurance for these conditions.

[00:22:19] It could be just that people just need the same type of approach, but it could be that they need something different.

[00:22:26] We don't really know.

[00:22:27] And we're looking into that at the moment in terms of this research stream that we develop around education and advice.

[00:22:36] It's quite exciting.

[00:22:37] It sounds great.

[00:22:38] Thank you very much for focusing on this perhaps neglected area of CPGs.

[00:22:44] We've spent a lot of time focusing on the exercise programs and what's the dosage and what's the intensity and which exercises and when and how.

[00:22:52] And we've had the more generic, as we talked about at the top, more generic advice and reassurance and education.

[00:22:59] So fleshing out what that truly looks like and giving people ideas about where to take that in their own practice is really important and will help move our field of musculoskeletal rehabilitation forward.

[00:23:11] So Dr. Giovanni Ferreira, thank you for joining me on JOSPT Insights today and for all of the great work that you and the team are leading.

[00:23:20] Thanks, Claire.

[00:23:20] It's been a pleasure.

[00:23:25] Thanks for listening to this episode of JOSPT Insights.

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