Abstract
BackgroundThere is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking.AimTo develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial.MethodThe intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention.ResultsIn total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians’ communication skills, during the consultation, in reference to listening skills, validation of patients’ pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients’ clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management.ConclusionThe intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients’ perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.
Highlights
Persistent musculoskeletal low back pain (PMLBP) remains the leading cause of disability globally [1] and an urgent global public health concern [2]
Buchbinder and colleagues [6] call for action in moving away from the emphasis of the biomedical approach, and argue that PMLBP is partly iatrogenic and the exposure to health care, especially western biomedical approaches to examination and management of low back pain, can sometimes have harmful consequences in relation to beliefs and reducing resilience to disability, as indicated by studies with Indigenous [7] and assimilated populations in high-income countries [8]
Because surgery is often viewed as a last stop for people with PMLBP, and because spinal surgeons are often viewed as medical authorities by patients, these settings present an opportunity for education and change
Summary
Persistent musculoskeletal low back pain (PMLBP) remains the leading cause of disability globally [1] and an urgent global public health concern [2]. Patients are often subjected to expensive imaging, which frequently does not improve outcomes but may lead to further unnecessary treatment that may be detrimental [9] For those patients who fail to respond to first line conservative interventions (advice, anti-inflammatory medication, exercise and manual therapy), care is sometimes escalated to more invasive, expensive and potentially harmful interventions that hold limited evidence despite carrying substantial risks [10], such as opioids [11], injections [12], and surgery [13]. While many see the focus of the challenge in stopping the use of harmful and wasteful practices [6], this must be done while ensuring access to effective and affordable health care [14] This means that when spinal clinicians, such as spinal surgeons and advanced practice practitioners (APP’s), explain to patients that surgery is not indicated, they need to offer acceptable alternatives, and ensure that patients feel reassured, rather than dismissed [15]. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking
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