Capitalising on effective treatment strategies for low back pain – How do we bridge the self-management gap?
Article Outline
Epidemiological evidence confirms that low back pain has a tendency to recur. Over the last decade, insights have increased significantly into diagnostic approaches and the development of effective treatment packages which are often multi-modal in nature. There has been a move into a bio-psychosocial philosophical approach to care, although, contrary to this integrated philosophy there are Instances where some clinicians take a completely hands-off approach to care, whilst others simply ignore the psychosocial dimension. Patients of course are not really in a position of awareness or knowledge to be able to comment or express their views and needs in relation to treatment and therefore, to a large extent, this polarity may go un-noticed.
Many clinicians are well versed in multi-modal treatment approaches and engage with patients in a patient-centred approach to their problems. The treatment usually comprises of passive elements such as mobilisations and manipulation, active elements such as exercise and education and advice. This is the most common multi-modal approach used, particularly in physiotherapy practise. In recent years the concept of patient profiling and syndrome classification has also been explored from a variety of perspectives and standpoints.
The conclusions are that as a professional speciality, physiotherapists are moving closer to finding answers to the many questions that have existed for a large number of years and the gaps in our understanding of the complexities of syndromes such as low back pain are gradually narrowing. However, as the Sokunbi et al. study published in this issue indicates, there is some way to go to close the gap in patient focused outcomes. As clinicians, we read time and time again about the results of randomised controlled trials involving patients with low back pain where patients, in certain treatment groups, appear to do very well compared to their control group at the end of treatment and at three months following discharge, but after this time the differences reduce and, in some cases, the problem re-occurs. The Sokunbi et al. (2010) article, although a small study, perhaps provides a small insight into what our problem might be. The majority of patients clearly engage with treatment when it is occurring. They want, need and enjoy the interaction with the therapist who can provide detailed information about their problem and how to deal with it, they are full of enthusiasm about the treatment which helps them control their problem and brings pain relief, they like the opportunity to have all their questions answered about their particular problem, they adhere well to their treatment programs whilst they are undergoing active treatment, they realise the benefits at the end of the treatment, they feel empowered and they feel clinically improved and very knowledgeable about their problems.
Normally outcomes measured show an improvement compared to the outcome measurement at the commencement of treatment. Discharge sees the majority of patients fully in control of their situation and excited about their empowered position, but then what happens? As the Sokunbi research has shown is that many patients, when asked, said they would probably not continue to carry out the prescribed exercises at home as they felt so much better and didn't feel they would have the time to actually carry out the exercises in such an intensive manner. Few said they would continue with the exercise programme as described.
In normal circumstances patient outcomes in a randomised controlled trial would be measured before treatment, after treatment, at three months, six months, one year, eighteen months and possibly two years following treatment. This model has obviously been in place for some decades as it follows the typical medical/surgical model which may well be appropriate in terms of measuring the outcomes of surgical interventions. However, even after an intensive and highly patient-centred program of low back pain management, patients are indicating that they will probably not continue with their exercise programs and what does this tell us?
Does it mean that clinicians should relinquish responsibility for the patient's outcome and situation following discharge and simply expect re-occurrences? Should new mechanisms be developed for reminding patients about the need for them to continue their self-management programmes, thus enhancing long term adherence to self management? Are new skills in health psychology required to enable clinicians to premeditate patient deviations from suggested self-management packages following discharge from treatment? Perhaps clinicians could also learn how to better prepare patients for their own responsibilities in relation to a likely recurring problem.
Clearly patients have a choice as to whether they engage in a self-management programme or not, but should physiotherapists or other clinicians be held responsible for poor outcomes in the longer term if patients do not adhere, conform or comply with suggested self-management strategies? Should the whole concept of outcome measurement timings be reconsidered?
The issue of long term adherence needs to be debated and researched at an international level. Importantly research into the effect of genuine compliance with self-management strategies on the long term on reduction in recurrence rate needs to be undertaken to fuel a change in patients and clinicians' behaviour.
Reference
PII: S1356-689X(10)00020-2
doi:10.1016/j.math.2010.01.007
© 2010 Published by Elsevier Inc.
