We joke about never being able to escape the topic of back pain. But it is no joke. For many, their back pain comes and goes, resolving itself. For others, the story is longer. Recent evidence suggests close to a third of acute low back pain sufferers transition to chronic pain. This transition brings with it a range of psychological, biophysical, and social changes that can affect a patient’s quality of life.
Clinical practice guidelines support the identification of ‘yellow flags’ when determining treatment and prognosis in cases of chronic low back pain. Yellow flags are psychological risk factors that can negatively affect a patient’s recovery. Believing their condition will worsen, avoiding movement due to pain, or having care preferences that do not coincide with best practices are all examples of yellow flags. There is a strong correlation between a patient’s thoughts and beliefs of their pain or condition, and its chronicity.
If it seems far-fetched that thoughts could influence whether a condition becomes long-term or not, do consider that research is increasingly indicating potentially profound cognitive and emotional impacts on the experience of pain.
Interestingly, these factors are malleable and can be swayed both positively and negatively by healthcare providers. While evidence regarding the effectiveness of interventions addressing these thoughts and beliefs are limited, the existing evidence reports positive results for utilising strategies to target these yellow flags, as compared to not.
A recent case report published in The Journal of the Canadian Chiropractic Association details a case contrasting two experiences of healthcare for the same individual. The authors aimed to provide further support for the influence communication between patient and practitioner can have on outcomes.
The case
A 34-year-old male presented to a Community Based Outpatient Chiropractic Clinic with complaints of low back pain with occasional paresthesia (burning or pricking sensation) at the front of his thighs on both sides. The complaint had arisen 13 years prior, with no identifiable cause. The pain was significantly affecting the patient’s life, including aspects of his work, social, and self-care activities.
When discussing his concerns with the Chiropractor, he disclosed that he understood the condition to be ‘ominous’, based on past interactions with his initial healthcare provider. He described a “collapsed lower lumber” that he said his initial provider deemed would require surgery, and if it were to further decline, would require he was wheelchair-bound. The chiropractor reviewed the initial radiographs which depicted multilevel Schmorl’s type nodes with a plan for referral to physical therapy. It was also noted that a surgical consult was not considered appropriate for the patient’s axial back pain at that time. Years after this initial experience, the patient encountered a community chiropractic provider that “would not touch [him] because [his] back was so bad”.
The patient was able to manage periodic flare-ups until a pai episode following an extended drive home from work caused him to attend Urgent Care. The patient underwent lumbar computed tomography imaging which revealed a right central disc extrusion at L5/S1. During this visit, a provider shared a story of their relative undergoing surgery for a similar imaging finding. This resulted in the patient presenting to his primary care provider requesting a neurosurgical consult.
The reviewing chiropractor identified an electronic consult was placed to neurosurgery who suggested obtaining an MRI and nerve conduction studies. The MRI was significant for mild disc bulge at L4/L5, and moderate left and mild right paracentral disc herniation. The nerves conduction results showed chronic right L5 radiculopathy. The patient’s subjective reports did not correlate with L5 radiculopathy, but the clinical examination findings supported chronic, mild nerve tension without progressive neurological deficits on the right. The neurosurgeon recommended conservative care for pain management.
Following further evaluation, the diagnosis provided by the chiropractic clinic was chronic, non-specific low back pain with EMG evidence of chronic, right L5 radiculopathy without correlative subjective radicular symptoms. The prognosis was poor, when considering the complicating factors such as the chronicity of the predominant complaint and the patient’s report of previous interactions with providers.
What did the chiropractor do?
Initial chiropractic treatment involved reassuring and educating the patient on the aetiology of the low back pain, and active patient-initiated repeated end range loading exercises. Follow-up care involved spinal manipulative therapy and utilisation of cognitive behavioural principles and pain education concerning pacing, graded activity, sleep hygiene, and hurt versus harm concepts. This was targeted towards kinesiophobia and increasing the patient’s exercise tolerance.
The care plan consisted of 6 visits at one-week intervals. Progress was assessed using Visual Analog Scale (VAS), Patient Reported Outcomes Measurement Information System (PROMIS) Pain Interference short form 6b, and subjective report.
Improvements included an increased ability to recreationally hunt without his back pain limiting his activity, ability to put on or take off socks, performance of odd jobs and his job as a mechanic with manageable pain. Over the course of care there was a 42% improvement in VAS, and a 10.3-point improvement in PROMIS Pain Interference (3.5-5.5 point change being clinically significant).
What could have been done differently?
From the initial evaluation, providing additional context regarding Schmorl’s nodes, their high prevalence, commonly asymptomatic nature, and lack of clinical significance may have prevented the patient developing unhelpful ideas. Additionally, informing the patient that asymptomatic disc protrusions have a high prevalence, and often need to correlate with clinical symptoms in order to be considered clinically significant. It may be that previous healthcare providers discussed the various inconsistencies in symptoms and imaging findings, but the author observes that if they had, the patient had not interpreted the information as intended.
This disconnect may have contributed to the generation of harmful ideas and beliefs about his spinal pain. As a part of the clinical examination, psychosocial factors were identified and subsequently addressed throughout care. Graded activity concepts were taught to the patient, encouraging the exposure to activities that he was avoiding out of fear for pain. For this patient, it was the gradual return to recreational hunting. The author notes pacing concepts working in tandem with graded activity, by encouraging intentional breaks during activities to avoid overexertion. The provider also informed the patient that it was normal to experience mild discomfort when returning to his avoided activities, and hurt did not necessarily represent further harm, and active approaches to pain management were emphasised.
The authors highlight not only the functional improvements observed through the course of care, but the enhanced understanding of chronic low back pain, including ways to modify his activities, such as pacing instead of complete discontinuation of the activities he enjoys. It is suspected by the authors that his prognosis would have been improved if these communication strategies had been utilised during the patient’s early interactions with healthcare providers, although it must be acknowledged that there is a possibility that fear-inducing language was not used and there was instead a misinterpretation of information during those early stages.
Nevertheless, a provider’s approach to communication is exceedingly important. Taking time to consider the psychosocial factors, yellow flags, that may be influencing a patient’s health journey, addressing any yellow flags found with appropriate strategies, advocating for continual education, and ensuring a correct interpretation of communicated information can make all the difference. Communication is both implicit in our manner and body language and explicit in what we say. Creating trust, reducing stress, and creating a therapeutic alliance where the person under care knows they are in safe hands and being cared for by someone who is skilled, knowledgeable and has their best interests at heart is an incredible gift to give.
“Although this is a single case report where conclusions cannot be drawn regarding the effectiveness of these treatment methods, it serves to demonstrate the potential impact providers can have to either positively or negatively influence beliefs surrounding CLBP.”
- Pierce K, Troutner A, Rae L, Austin J. Provider-patient communication: an illustrative case report of how provider language can influence patient prognosis. J Can Chiropr Assoc. 2022. 66(1).
