Research Review #2: Why do patients come to see us?

Someone challenged me with this question in the past. I think this is a great question because our treatment should be tailored towards what the patient wants. I think the most common belief among therapists and patients themselves is that patients come to see us because of pain. If that’s true, then our treatment should be geared towards pain relief, no matter what the means are.

My Bias:
Here is where my bias steps in. I recall reading the abstract of a meta-analysis by Ferreira et al (1) a few months ago (yes, I admit it, I didn’t read the whole thing!) which claimed that “Pain intensity was only slightly associated with care-seeking, whereas patients with high levels of disability were nearly eight times more likely to seek care than patients with lower levels of disability.” This stuck in my head and since then I have assumed that patients come to see us because they are having difficulty doing what they want to do (high disability) rather than high pain intensity. In other words, if someone has high pain intensity but low disability, they probably wouldn’t be coming to see us. If this is true, this means that treatment should be geared towards reducing disability than pain itself. How does this change treatment, if at all? Assuming this is what the research points towards, I will explore this in my next blog post.

Let’s Actually Read the Study
For this blog post, however, I would like to review the meta-analysis and make sure I’m not inappropriately jumping to conclusions based solely on the abstract. Also, if anyone has come across research that has different conclusions than what was found in this meta-analysis, please send it to me because I want to challenge my beliefs.

AMSTAR score (my rating) = 5/11, medium quality as per the Canadian Agency for Drugs and Technologies in Health
(a-priori design = no; duplicate study selection and data extraction = yes; comprehensive lit search = yes; search for grey/unpublished lit = no; list of included and excluded studies = no; characteristics of included studies = yes; scientific quality of included studies assessed and documented = yes; scientific quality of included studies used appropriately to formulate conclusions = no; methods used to combine findings of studies appropriate = yes; likelihood of publication bias assessed = no; conflict of interest included = no)

To determine what factors differentiate those who have non-specific LBP and seek care vs those who do not seek care
People with non-specific LBP
Inclusion criteria for studies:
  • cross-sectional, population-based surveys that reported characteristics of care-seekers vs non-careseekers with non-specific LBP
  • clear definitions of care-seeking and non-specific LBP
  • surveys could be done by phone, internet, and/or mail
  • no age or gender limits
Exclusion criteria:
  • studies on people with specific spinal pathologies or pregnant women
Methodological quality of the studies evaluated on a-priori criteria including quality of sampling, response rate, data reproducibility, power calculation, definition of LBP, and definition of care-seeking.

Associations expressed as odds ratios. For factors that are on a continuous scale (e.g. pain intensity), odds ratios were calculated from standardized mean difference & 95% CI between the care-seeking and non-seeking groups.

Results of studies were pooled if appropriate based on heterogeneity analysis.
11 articles reporting on 10 population-based surveys were included, with data from 7 different countries = 13,846 people with non-specific LBP, pooled prevalence of care-seeking was 51% (95% CI: 44% – 58%)

Care-seeking determinant (# studies), Pooled OR [95% CI] – average methodological quality of pooled studies
Female gender (3), 1.67 [1.51,1.92]* – 60%
Age (2), 1.31 [0.73,2.35] – 65%
Previous hx of back pain (2), 1.45 [1.12,1.86]* – 55%
Job satisfaction (3), 0.95 [0.88,1.04] – 57%
Good general health (2), 0.64 [0.48,0.85]* – 65%
Pain intensity (4), 1.92 [1.33, 2.78]* – 50%
Disability intensity (2), 3.87 [2.86, 5.23]* – 60%
High levels of disability, (3), 7.66 [4.67, 12.57]* – 57%

*statistically significant
Disability intensity measured using RMDQ.
Levels of disability defined using the Chronic Pain Questionnaire where grade III = high disability & moderately limiting, grade IV = high disability & severely limiting (vs grade I or II = lower levels of disability)

Plain language interpretation. The odds of seeking care are:
– 1.67x more if you are female vs male
– 1.45x more if you have a previous hx of back pain vs no hx of back pain
– 1.92x more if you have higher pain intensity
– 3.87x more if you have higher disability intensity (as measured by RMDQ)
– 7.66x more if you have high levels of disability vs lower levels of disability (as measured by Chronic Pain Questionnaire)
– 0.64x lower if you have good general health than those with bad self-reported general health
Job satisfaction and age are not associated with increased odds of seeking care.

  • Despite the different disability measures that were used, the results consistently showed that higher disability was more strongly associated than with care-seeking than pain intensity
  • The results described above are based on pooled data from multiple studies so we can have more confidence in the estimates
  • Data based on cross-sectional studies so we can’t say that high disability is more likely to cause people to seek care than high pain intensity. Hopefully seeking care doesn’t cause higher disability! Though some researchers have discussed the iatrogenic nature of disabling back pain (2)
  • Due to the observational nature of these studies, we also don’t know if there is a confounder masking the relationship (e.g. does high fear lead to high disability and make someone more likely to seek care?)
  • No grey literature was searched, which means unpublished studies finding no association between disability and care-seeking could have been missed
  • Variable definitions of non-specific LBP and care-seeking between the individual studies that can make it difficult to compare. For example:
    • Non-specific LBP: “self-reported back pain for at least 6 months” vs “pain from the 12th rib to lower gluteal folds in the past month for at least 1 day interfering with regular activity”
    • Care-seeking: self-reported health care in the “past 4 weeks” vs “past 6 months”
  • The quality of the individual studies were assessed but it didn’t really come into play when making conclusions or in the meta-analysis, for example by giving a heavier weighting to higher quality studies
  • Speaking of quality, the methodological quality of the included studies were not great either – most common issues were failure to report power calculation, failure to describe reasons for non-response, and failure to validate the questionnaire used to identify care-seekers
While we cannot say from this study that people seek care because of high disability or that care-seeking causes high disability, this study does seem to show that high disability is more strongly associated with care-seeking than high pain intensity. However, the quality of the individual studies is not great so I am less confident in the accuracy of this conclusion. To be honest, my bias still is leaning towards that and until there is some evidence disconfirming my bias I will probably keep believing that (perhaps with less gusto though ;)).

In practice, we often focus on treating pain, assuming that if we get rid of pain, we get rid of disability as per the medical model of disability.
  • Instead of treating pain, should we be addressing disability since they are likely to have high disability levels? Disability seems to be easier to measure anyway (think SMART goals).
  • If we focus on reducing disability, will their pain eventually go away?
  • How does treating disability vs treating pain differ?
  • Instead of having the person focus on their pain, should we communicate with them in a way to have them focus more on their function?
Other Questions:
What factors cause one person to be more disabled than the other? Are there people who have high pain intensity but low disability? How are they different from those who have high pain intensity (or low) but high disability?

If you know of any research suggesting answers to these questions, please let me know as I would love to hear about it :).

    1. Ferreira ML, Machado G, Latimer J, Maher C, Ferreira PH, Smeets RJ. Factors defining care-seeking in low back pain–a meta-analysis of population based surveys. Eur J Pain. 2010 Aug;14(7):747.e1–7.
    2. Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open. 2013;3(4)
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