Chronic Low Back Pain Patients' Expectations Toward Physiotherapy
Condition: Chronic Low Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Observational

Summary: 
      Non-specific chronic low back pain guidelines recommend rehabilitation along with a
      biopsychosocial approach. However, though psychological and social issues address important
      needs of professionals and patients, they have been scarcely developed in this area so far.
      Noteworthy, little is known about patients' expectations relative to physiotherapy for
      chronic low back pain (CLBP), while professional recommendations advocate taking them into
      consideration.

      A study about patients' experience will provide knowledge about the ill person's perspective
      and how the physiotherapists are perceived as well as the role attributed to them. The aim of
      this study is, thus, to explore the experience of the patients suffering from CLBP in order
      to highlight their expectations toward physiotherapy services and physiotherapists.

      The investigators will apply a critically interpretive socio-anthropological approach based
      on patients' interviews and observations in an intensive CLBP rehabilitation program. The
      results will help improve the care patients receive by facilitating the integration of
      biopsychosocial issues related to patient's expectations into the treatment.
    

Detailed description: 
      INTRODUCTION

      Chronic low back pain (CLBP) is defined as "pain and discomfort, localised below the costal
      margin and above the inferior gluteal folds, with or without referred leg pain" persisting
      for at least 12 weeks. It is classified as non-specific when "not attributable to a
      recognisable, known specific pathology, disorder, radicular syndrome or cauda equina
      syndrome". It is a very frequent condition, one year prevalence being around 25% for men and
      35% for women. It can greatly alter functional capacity and quality of life. Including care,
      sick leave and work loss, it accounts for most of the back pain related costs.

      Recommended management of CLBP is multidisciplinary due to the biopsychosocial impact of this
      condition. Most guidelines include the patient's education, advice to stay active,
      anti-inflammatory and analgesic medication, exercise therapy, and spinal manipulation.
      Multidisciplinary rehabilitation, adjunctive analgesics, and cognitive behavioural therapy
      are recommended if the initial approach is not efficient. Self-management strategies,
      self-monitoring of status, and decision-making are also promoted.

      Physiotherapy plays a role in CLBP management, in collaboration with other health and social
      professions. As defined by the World Confederation for Physical Therapy, "Physiotherapy
      provides services to individuals and populations to develop, maintain and restore maximum
      movement and functional ability throughout the lifespan. (…) Functional movement is central
      to what it means to be healthy (…).This encompasses physical, psychological, emotional, and
      social wellbeing

      Local and international standards of physiotherapy practice advocate taking patients'
      expectations into consideration. Physiotherapists are also advised to take patients
      preferences into account, when applying evidence-based practice (EBP) guidelines. However,
      knowledge about the expectations of patients toward physiotherapy is limited.

      This research is conducted with an interdisciplinary approach. Indeed, it takes into account
      both the physiotherapy and the anthropological discipline. Physiotherapists want to deepen
      their comprehension of the patients' needs in order to take better care of them whereas
      anthropologists are interested in the broader experience of chronic illness and in
      understanding the relationship between cares and patients. With their concepts and
      qualitative methods, the latter have relevant tools to answer the research question.

      Expectations issues within the CLBP rehabilitation process

      Commonly, expectations are understood as "a belief that someone will or should achieve
      something". In the health field literature, the notion of expectation is often used, although
      it is seldom defined. Nevertheless, three dimensions emerge from the literature on CLBP
      patients' expectations: effectiveness of care (diagnosis, effective treatment, pain relief),
      relational issues (understanding, partnership, be believed, be treated as a person), and
      empowerment (self-management, exercise, advice, explanation, etc). In addition, expectations
      appear to be influenced by the course, the prognosis and the outcome of the rehabilitation.

      CLBP patients are often dissatisfied with back pain rehabilitation. As pain relief is slight,
      disappointment with outcome is frequent. Having a clear diagnosis is clearly expected. Thus,
      additional medical investigations are frequently requested to find a cause to the disease.
      The patients also have expectations with regard to the outcome. Health professionals are
      expected to demonstrate communication skills, understand emotional and physical impact, spend
      time with the patient, show respect and build a partnership. They are also expected to
      understand the personal situation, demonstrate empowering skills, and adapt their language.

      The nature of CLBP thus puts health professionals in an uncomfortable position. The
      diagnostic uncertainty and the limited effect of therapy challenge their competencies. The
      professional recommendations advise to avoid complex investigations and to stay active
      despite the pain. This position may be difficult to have when the patient wishes to obtain a
      clear diagnosis or to be prescribed time to rest for example. Thus, unrecommended approaches
      are sometimes implemented to maintain the relationship with the patient.

      Patients' expectations of a diagnosis and a cure are in line with a biomedical approach,
      while a biopsychosocial model applies to CLBP treatment. It requires subtle interaction to
      bring the patient to consider that psychosocial issues influence pain and disability without
      giving the impression that pain is "in the mind" or exaggerated. This is especially difficult
      in a context where the person feels delegitimized. Indeed, disbelief and delegitimization by
      health professionals are motives for dissatisfaction.

      Unclear diagnosis and poor social recognition

      In Social sciences, the few studies that have explored the experience of CLBP patients show
      that, since they face long term diagnostic uncertainty, this places them in a liminal state
      being both well and sick, and being neither. Struggling for a diagnosis is an important
      source of strain added to the experience of pain, altered moods and functional limitations.
      Medical validation of pain cannot be performed through medical imagery in non-specific CLBP,
      as the relation between findings and pain is low. Following the anthropological distinction
      between disease, illness and sickness, patients, find themselves with "illness" (their
      subjective experience of suffering), but without "disease" (medical definition of the
      affection) or "sickness" (social construction and recognition). Lack of clear body damage
      explaining pain leads to an absence of social recognition as a sick person needing to be
      supported by the society.

      Living with CLBP: a biographical disruption

      Chronic symptoms can lead to a feeling of hopelessness, depression, anger and a loss of self
      and identity. The loss of social role, status and identity induced by chronic illness is
      documented in medical socio-anthropology. As shown in socio-anthropological studies on
      chronic illness, there is a biographical disruption when the illness appears. The CLBP
      patient has to manage his life accounting for pain. Self-image is altered and a feeling of
      self-discrepancy, i.e. a difference between ideal and perceived self, may be experienced.

      Some patients feel that there are held responsible for their suffering, when physicians
      situate the origin of pain "in the mind" in the absence of identified body damage. Patients
      often consider that physicians don't admit the limitations of medicine. Persons in
      unexplained pain, speak of solving the riddle which they can't resign to consider as
      "imagined pain". They are often convinced of the concreteness of their pain, since "you can't
      hurt this bad and there being nothing wrong". Some complain "having been let down" in this
      quest and explain they had to cope on their own with their situation.

      Although these studies show the importance of taking into account the lived situations and
      trajectory of the ill persons since the beginning of the illness, they make little
      articulation between these trajectories and ill persons' expectations towards caregivers. In
      this study the investigators assume there are strong links between these aspects. For
      instance, the duration of the illness, the level of disability, its impact on the quality of
      life, the previous recourse to other therapists and treatments necessarily produce variations
      in the patients' expectations towards the physiotherapists.

      Research aims

      The main aim of this study is to identify CLBP patients' expectations toward physiotherapy
      and physiotherapists. The investigators will aim at providing a qualitative insight into the
      factors influencing the expectations by relating them to the experience and elements of the
      context in which they appear. The elements accounted for will include the representation of
      CLBP, physiotherapy and its therapists, the illness trajectory, the socio-economic
      characteristics, the techniques and the perceived relationship with the physiotherapists.
      Expectations will be investigated at the beginning and the end of an intensive rehabilitation
      program to seize how this experience answers and/or modifies the patient's expectations.

      Methodology

      Design: individual interviews and observations

      Interviews with patients and observations of the patient-physiotherapist interactions are
      planned.

      Interviews

      Individual comprehensive interviews are a common method to provide accounts of the experience
      of illness.

      The investigators will use semi-structured interviews based on a guide of questions.
      Interviews will be conducted by the anthropologists of the research team. Interviews will
      last around 1 hour. They will take place at the ill person's home if he/she agrees.

      At the beginning of the process, 4 pilot interviews and two individual sessions
      (observations) will be run to refine questions and procedures, as well as adjust to unplanned
      practical issues.

      Two interviews will take place, one at the beginning of the rehabilitation program, and the
      second at the end. Both interviews will be conducted by the same researcher.

      Observations

      With an aim of a triangulation of data, the interviews will be completed with observations of
      the relationship between patients and physiotherapists.

      The observations will take place in the back rehabilitation unit of the university hospital.
      Patients will follow a 3 week intensive CLBP rehabilitation program.

      Focus will be put on individual therapy sessions. More specifically, the first and the last
      session of the program will be observed. The investigators will choose ten patients among the
      twenty participants using the same purposive sampling process.

      These observations will be conducted by the two anthropologists in the research team.
      Following the observations, all members of the research team will meet for debriefing
      sessions, to share visions between anthropologists and physiotherapists about the meaning of
      the events. This will assure taking into account both socio-anthropological concepts and
      physiotherapists' knowledge of the field in an interdisciplinary approach.
    

Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        A purposive sample will be used. The investigators will aim at the recruitment of a
        diversified sample of patients following an intensive chronic low back pain rehabilitation
        program. The sample will include as many men as women, as many young than older
        participants (3 age groups: 18-30, 30-50, 50-65), as much variety in educational level and
        occupation as possible. The type of work (physical demand of employment) and career track
        will also be taken into account, as well as having a representation of migrants (since they
        are overrepresented in the back pain population58). It is estimated that data saturation
        should be reached with 20 participants.
      
Keywords: expectation; chronic illness; trajectory