MasterclassPerson-centred education and advice for people with low back pain: Making the best of what we know
Introduction
Low back pain is common and burdensome. The point prevalence of activity-limiting low back pain lasting more than one day is 7.8%, meaning that approximately 577 million people experience low back pain at any one time across the world.1 Many people with low back pain seek care to manage their problem; a systematic review of 14 studies found that 47 to 67% of people with low back pain seek care annually, and 30% have sought care within the past month.2 Although spending on health services has increased, outcomes for people with low back pain are not improving.3
Clinical practice guidelines aim to assist clinicians in providing high-value care to people presenting with low back pain. High-value care is providing care with the optimal outcome for the person's circumstance delivered at the right price.4 After screening for clinical features of serious pathology and conducting a physical and psychological assessment, regardless of the duration of low back pain, the first-line treatment consistently recommended is patient education and advice.5,6 However, systematic reviews have highlighted a gap between clinical practice guideline recommendations for care and the care that is actually provided in practice.7,8 For example, people presenting for care with low back pain commonly receive unnecessary diagnostic imaging9 or a high number of treatments known to provide little or no benefit and cause harm such as opioids,10 antidepressants,11,12 muscle relaxants,13 and spinal fusion surgery.14 These services provide minimal or no benefit, considering the harms, the costs, alternatives, and the preferences of the patient, and are classified as ‘low-value’ care.15
Clinicians commonly report that a desire to maintain a harmonious relationship with patients and the time constraints of clinical practice are important barriers to providing high-value care, such as education and advice to people presenting with low back pain.16 In this Masterclass, we will introduce new evidence on strategies to help physical therapists overcome these barriers to providing high-value care. First, we highlight the potential value of providing validation to nurture a harmonious relationship. Second, we will describe a tool to open channels of communication to provide education and advice in a patient-centred and efficient way. Finally, we provide options for tailoring patient education and advice to promote self-management of low back pain based on patient attitudes to maximise the time available in clinical consultations.
Section snippets
Shared decision making is at the heart of person-centred care
A cornerstone of modern healthcare is to include people in their care decisions.17 For effective shared decision making, clinicians should share information on treatment options and their potential outcomes including risks and benefits, based on the best research evidence. In turn, the person is encouraged to provide an insight into the personal burden of low back pain and express their treatment preferences and values.18 However, too often, the person's voice is left out of the decision-making
Communication of patient education and advice
Providing patient education and advice relies on effective communication. Effective communication uses a mix of open and closed questions, seeks permission, explains rationales for approaches, uses the persons own narrative and lived experience to reflect back to them, and is at the heart of person-centred care.39 However, effective communication is undervalued by clinicians and perceived as time inefficient.40 A qualitative synthesis of thirty studies reported barriers and facilitators to
Self-management
One objective of patient education and advice is to promote self-management. Self-management is defined by behavioural scientists as a 'practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and wellbeing'.58 Self-management for low back pain is an active process that should involve exercise, supported by clinical education and advice.59,60 From a clinician perspective, self-management is not just about providing information but teaching
Summary
In this Masterclass, we have provided suggestions for a person-centred education and advice that should enable physical therapists to confidently deliver high value care within the time constraints of clinical practice. We outline these suggested steps in Fig. 1.
Conflicts of interest
ETO, AGC, JHM have no conflicts of interest to declare. ACT has received funding from the Australian National Health and Medical Research Council (NHMRC) including an NHMRC Early Career Fellowship (APP1144026) and funds from an NHMRC Program Grant (APP1113532) entitled ‘Using healthcare wisely: reducing inappropriate use of tests and treatments.’
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