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It is well understood that chronic low-back pain (LBP) has enormous costs and an extensive impact on individuals and their families. In addition to the well-documented effects in terms of levels of disability, incapacity and psychological well-being, social and economic aspects are also significant features of the pain experience, with absence from work and resultant welfare benefit costs contributing to the overall impact of pain.
In Ireland, it has been estimated that over one-third of individuals experience ongoing pain, with chronic pain patients accounting for over €5 billion in healthcare and social expenditure per year (€5.34 billion in 2008).
It is well established in the research literature that prognostic factors related to an acute episode of pain tend to be related to not how bad the injury is, but to how that injury is perceived by the individual patient. Indeed, patients often harbour beliefs related to fears of hurting and harming themselves, for example, “I need to avoid moving as it is the safest way to prevent my back pain from deteriorating”, which negatively influences behaviours engaged in following an episode of pain, eg, significant restriction of activities, thus potentially affecting prognosis.
As such, European guidelines for the management of pain patients suggest appropriate consideration of psychological factors in the assessment of the patient. Unfortunately, evidence suggests that guidelines may not be consistently followed. This inconsistent adherence to the published clinical management guidelines is all the more surprising, given that back pain is considered one of the most challenging and difficult conditions that GPs have to manage.
GPs describe pain consultations as problematic, taking up a significant amount of time, and report deficits in their training in relation to pain management. Despite these difficulties, GPs are in an optimal position to positively influence how the individual manages with their condition and the beliefs they hold around it. The GP’s prime position is reinforced by the knowledge that most acute LBP patients will only consult with a GP on a single occasion in relation to their pain, even though their symptoms may persist. Thus, the potential for positive collaboration between GP and patient is a significant strength of the GP role in this context.
This article will briefly provide an overview of some of the potential issues facing GPs when managing individuals presenting with back pain. It will provide tips for identifying psychosocial issues that may influence the development of chronicity and incapacity and will provide some straightforward and practical management strategies GPs might utilise in supporting the patient to engage in more productive self-management approaches.
The role of the GP in managing the pain patient
The good news is that acute LBP has a largely positive prognosis. However, despite this generally positive prognosis, evidence suggests that GPs consistently report finding the pain consultation problematic and less than satisfactory. Johnson and colleagues’ recent pan-European survey of 1,309 primary care physicians (including 101 from Ireland) focusing on the challenges in managing primary care patients in general practice found most of those surveyed (84 per cent) reported chronic, non-malignant pain to be one of the most challenging conditions to manage. Eighty-nine per cent of those surveyed felt more education was needed in the area. Studies suggest that only around one-third of GPs feel comfortable in managing pain patients.
Indeed, a number of studies have indicated difficulties arising within the patient-health professional consultation, which has the potential to negatively influence the outcome for both the patient and practitioner. A simple example of this is the finding that psychosocial aspects of patients’ LBP are rarely mentioned in pain consultations.
Given the importance of the psychosocial risk factors (outlined in more detail on the right) for the development of chronicity, it is clear that GPs have an important role in making sure that accurate messages about pain are provided to patients. While beliefs about a condition can be influenced by a range of sources, including family, friends, the media, past experience and healthcare professionals, studies have illustrated that beliefs about LBP can be negatively influenced by healthcare professionals. One qualitative study reported a number of key findings, including that patients interpreted many messages as meaning the need to ‘look after’ or ‘protect the back’. The authors reported that healthcare professionals tended to present information regarding the symptoms in what the authors term a “biomedical” or “pathoanatomic” way, meaning that simple messages were therefore interpreted as supporting the belief that the spine was vulnerable and the need to ‘protect the back’. Further qualitative work has supported the view that GPs themselves approached the LBP consultation from a primarily biomedical perspective, and that often mixed messages are provided to patients regarding the need to stay active but also be “careful” with the back.
It is of note that there are extensive clinical practice guidelines available, based on a biopsychosocial model, in relation to the management of the pain patient. Further, a number of reviews of clinical practice guidelines have been conducted in relation to the management of the patient presenting with pain. While evidence-based guidelines for different nations may differ somewhat in terms of emphasis and detail, a consistent recommendation that emerges concerns the need to recognise psychosocial factors as a risk for development of chronicity. Koes and colleagues found that more recent guidelines are much stronger in their recommendations with respect to the assessment of psychosocial risk factors, than guidelines in effect around 10 years previously, reflecting the current state of the science regarding key factors in the development of chronicity and disability.
So how do the guidelines translate into clinical practice? Despite the existence of clear European guidelines for the management of acute LBP, relatively few studies have examined whether these guidelines are actually adhered to.
Of those studies in existence, data suggests around 50 per cent of GPs will follow some aspects of the guidelines, while 50 per cent will not follow any element of the guidelines. Indeed, it has been stated that practitioners’ approaches are not particularly effective in screening patients at risk and consequent management of them. A number of reasons have been provided for this, including patients’ expectations of the consultation and the wish of the GP to circumvent conflict in the patient-doctor relationship and clinicians’ own beliefs about back pain and education. It would appear therefore that if one is to follow these guidelines, greater understanding of these psychosocial issues is imperative.
Psychosocial risk factors associated with pain
Given that it is now well established that psychosocial factors are important in the development of chronic LBP and disability, what psychosocial risk factors are important in the management of the presenting pain patient? Some 20 years ago, the concept of ‘yellow flags’ was developed to provide a means of creating a shared understanding among clinicians of potentially modifiable risk factors for the development of chronicity. These have been further distinguished, highlighting ‘clinical’ yellow flags, which focus on pain and function (eg, mistaken beliefs about pain and function; illness behaviour; family reinforcement; distress, including anger and depression; willingness to change; and unhelpful pain-coping strategies); occupational blue flags, which concentrated on beliefs about work (eg, beliefs about the impact of pain on work expectations and concerns about return to work, unhelpful dependence on sick certification, litigation); and black flags concerning more objective, organisational aspects of work (eg, employer attitudes to the ‘sick’ worker, financial reliance on disability benefits, etc).
Of these, Main and Williams have highlighted a number of critical psychological factors that would appear to contribute to chronicity and highlight these as vital considerations in the assessment process. These include the belief that back pain is due to progressive pathology; is damaging or very disabling; will be helped by avoidance of activity; will be best managed through passive means, rather than active self-management approaches; and a propensity on the part of the patient towards social avoidance and low mood. Given the interdigitation of these kind of beliefs (the person’s psychological model of pain) with the somatic experience of pain, and the ability of the social environment to contextualise, maintain or reinforce aspects of the pain experience, it would therefore seem critical that such factors require identification and intervention if we are to prevent the acute back pain presentation evolving into chronicity. A biopsychosocial model of LBP in terms of its presentation, assessment and disability is presented in Figure 1.
Strategies for GPs to manage psychosocial issues arising in the consultation and to empower patients
There would appear to be a number of strategies that could be employed by the GP from a psychological perspective to help set the patient on ‘the right path’ in terms of their recovery. Many of these are simple and may be considered unimportant, however, it is essential that they are utilised in order for the patient to start to ‘own’ the recovery process and identify early issues that may form a barrier to recovery. Strategies for supporting GPs in the pain consultation are summarised in Table 1.
Expectations of the consultation
It has been suggested that patients’ expectations regarding the back pain consultation can have significant impacts on the outcome of the consultation and the likelihood of them adhering to the advice proffered by their GP. There are many different reasons why a person with back pain might consult and it is important to establish the reason for the consultation, whether that be for reassurance, medication or sick certification. Moreover, agreement between patients and their GP over the diagnosis and treatment plan has been illustrated to be associated with more positive outcomes, including greater satisfaction and perception of improvement. Indeed, it has been suggested that the role of the GP in managing pain is that of “guide or coach rather than a mere mechanic”. Gregory and colleagues’ review of patients and doctors’ expectations regarding the pain consultation found that patients valued information and provision of support regarding their pain more highly than medical intervention.
This is positive and highlights a potential convergence between patients and GPs over the management of pain, but perhaps uncertainty as to the process by which this is best achieved.
Assessment of psychosocial factors
One of the many strengths of GPs is that they are skilled communicators and are generally aware of the role of psychological factors in relation to the presenting difficulties. However, GPs often highlight concerns with respect to confronting psychological issues satisfactorily within the consultation. Time pressure is usually cited as a reason not to explore or address psychological issues, however, research has indicated that not addressing psychological concerns within both the primary and secondary care settings can lead to an increase in the consultation time. Importantly in relation to individuals presenting with LBP and in line with the available guidelines, it is necessary to focus explicitly on the individual’s beliefs about their pain, the impact of pain on their function, on the individual’s ability to work or engage in other everyday responsibilities and their wellbeing. This has the potential to permit the restructuring of unhelpful, incorrect beliefs and incorrect information about their pain.
To provide an opening in relation to the assessment of psychosocial issues, there are a number of brief assessments available of mood. Many of these, for example, the Hospital Anxiety and Depression Scale, offer good specificity and sensitivity in identifying psychological distress and have established ‘cut-off’ scores. The availability of such assessments as a screen to prompt further, more detailed exploration of mental health difficulties, which may be impacting on the pain experience or vice versa, provide a helpful resource to the busy GP. It is of note that there are also a number of tools available for the assessment of pain and identification of patients at risk of their pain problem developing into chronicity. These have been recently reviewed by Mills and colleagues. It is important to recognise that screening tools can be used to identify patients’ evolving concerns, not just at the start, but throughout their rehabilitation from pain.
Providing a clear message
As outlined above, evidence indicates that it is likely that patients will regard information provided by the healthcare professional as being important and that the information provided may stay with the patient for a number of years. It is therefore important that a clear, simple message regarding a likely explanation and prognosis related to the episode of pain be made explicit. It is suggested that this is provided in as straightforward a way as possible and that context be provided, for example in relation to age-related changes.
It has been proposed that the means by which individuals are told what they should not do activity-wise, rather than what they should do, gives the message that recovery is more dependent on avoidance of activities rather than engagement in movement and activity. Furthermore, it has been shown in qualitative studies that reports of professionals encouraging movement are much less frequently mentioned than the protective advice provided, perhaps suggesting a less powerful interpretation of the ‘activity’ message.
However, it is implicitly accepted that patients trust their clinicians so that positive encouragement of activity and the safety of movement has the potential to be very powerful. Moreover, it has been suggested that unambiguous exercise advice can influence both current and subsequent episodes of pain, which may occur years later.
Evidence suggests that the outcomes of consultations as assessed by patients and doctors can often be diverse. Providing written information or a summary of the points covered within the consultation can be very helpful. Although many GPs may be dubious of the effectiveness of written materials, providing patients with a written summary of information regarding their symptoms can be of significant value, and may limit biases in the recall of information commensurate with their fears or concerns.
Check and correct understanding
It is imperative that the patient understands the explanation provided by the clinician for the difficulties they are experiencing (formulation of the various aspects of their pain problem, eg, likely causes, maintaining factors, etc) and advice provided (treatment plan). It is also wise to confirm that the patient understands what has been said during the consultation. This can be done by asking the patient for a very brief summary of the take-home messages or management plan. Such action provides a further opportunity for modifying unhelpful and incorrect beliefs, and assumptions with respect to pain and its management, and serves as another chance to prevent the development to chronicity and unnecessary disability.
Providing appropriate reassurance
It is well accepted that in order for reassurance to work, a patient must feel that their concerns have been adequately heard, taken seriously and have been listened to. Providing brief summaries to the patient throughout the consultation can aid this process. As stated previously, it is important to use simple explanations that do not reinforce existent fears patients may have about their pain and its prognosis. For example, referring to ‘minimal disease’ or ‘early arthritis’ may increase concerns for the patient — ‘if this is early arthritis, what is going to happen in a few years?’ Recognising the impact of pain on various aspects of the patient’s life but emphasising that it may not represent a serious process, ie, the difference between ‘hurt’ and ‘harm’, and that there is a management strategy that will be helpful, is critical.
One of the principal strategies in the management of the pain patient is the facilitation of patient self-management. In essence, the patient needs to leave the consultation feeling at least a shared responsibility for their rehabilitation.
While self-management should have been implicitly encouraged via the use of strategies outlined above in relation to the consultation generally, this can be further encouraged via a number of specific strategies. These include:
Provide clear messages with respect to remaining active despite the pain;
Encourage the patient to set themselves realistic goals regarding their progress;
Support the patient to ‘pace’ their activities, thus gently increasing in stages the activities they are undertaking;
Support the patient to record their activities, eg, time spent walking each day, so that they can see progress;
Highlight distraction techniques they can engage in if the pain is particularly bad, such as taking a short break from an activity or listening to a favourite piece of music;
Encourage the use of simple yet effective progressive muscular and autogenic relaxation techniques (for example, those available on the Internet) as an opportunity to encourage self-management;
Highlight the importance of active relaxation strategies (such as actively maintaining their social network) as opposed to more passive strategies (such as watching the television);
Encourage them to identify when they are thinking in unhelpful ways about their pain, eg, ‘is this ever going to get better?’ and work to support them to change such understandable but ultimately unhelpful thinking into more helpful positive thoughts, eg, ‘it is frustrating but I am making some progress, I am further on than I was two days ago’;
Suggest mindfulness techniques that help with re-focusing of attention in pain, and with broadening a person’s coping repertoire;
If appropriate, provide details of support available online, eg, Chronic Pain Ireland (www.chronicpain.ie) runs self-help meetings and emphasises the role of self-management strategies, or for men who may be socially isolated, suggest Community Men’s Shed (http://menssheds.ie), where men have the opportunity to participate in meaningful activities with other men and engage with the opportunity to improve and maintain their health and wellbeing.
Pain is a multifaceted and challenging condition, which necessitates the appropriate consideration of physical/biological, psychological and social aspects in its assessment and management. In an ideal clinical situation, all patients presenting with pain would be afforded the opportunity of psychological assessment and management if appropriate in the routine management of their pain, given the importance of psychosocial factors in the development of pain chronicity and incapacity. Currently in the Irish healthcare system, resources do not permit this and thus GPs are faced with the key role of appropriately recognising distress and unhelpful thoughts and beliefs related to pain in their patients and subsequently managing these. Relatively simple and straightforward approaches utilising a collaborative biopsychosocial approach to manage the patient’s experience of pain with patients viewed explicitly as partners with their GP in the management of the physical, psychological and social aspects of the pain is most likely to lead to positive outcomes for patients with LBP.
References available on request