For this blog post, I read Patient Expectations of Treatment for Back Pain: A Systematic Review of Qualitative and Quantitative Studies by Verbeek et al (1). This was another one of those studies that I came across for a school assignment but didn’t make the time to critique/read properly. I wanted to know how qualitative research would relate to the conclusions from my research review #2. The purpose of this study was slightly different, as it aimed to identify what patients expect from treatment as opposed to identifying factors that are associated with seeking treatment.
A side note about qualitative research:
I first learned about qualitative research through Brene Brown’s work (see her amazing TED talks The Power of Vulnerability and Listening to Shame) and then I learned a bit more during PT school. I find it a fascinating way of conducting research for questions that are hard to answer through quantitative research. Qualitative research helps to explore the what, how, and why of social interactions and human behaviour, as opposed to the whether or how much (2). I think what is most interesting is that because bias cannot be controlled in qualitative studies, acknowledging your bias and reflecting on how your bias may be influencing your interpretation of the data is an integral part of performing qualitative research (3). It forces you to be very self-reflective!
I first learned about qualitative research through Brene Brown’s work (see her amazing TED talks The Power of Vulnerability and Listening to Shame) and then I learned a bit more during PT school. I find it a fascinating way of conducting research for questions that are hard to answer through quantitative research. Qualitative research helps to explore the what, how, and why of social interactions and human behaviour, as opposed to the whether or how much (2). I think what is most interesting is that because bias cannot be controlled in qualitative studies, acknowledging your bias and reflecting on how your bias may be influencing your interpretation of the data is an integral part of performing qualitative research (3). It forces you to be very self-reflective!
Onto the study!
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Purpose
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To explore what patients with nonspecific LBP expect when seeking care for back pain and what aspects of treatment they were dissatisfied with
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Population
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Adults (>18) with acute or chronic nonspecific LBP (defined as “pain in the back with or without radiation and without specific systemic disease as the underlying cause of symptoms”)
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Methods
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Qualitative and quantitative studies that reported on aspects of treatment dissatisfaction and/or expectations were identified. Studies were not limited to a specific type of provider. Studies were classified as studying those with acute, chronic, or mixed acute/chronic LBP.
A preliminary list of possible aspects of treatment dissatisfaction and expectations was created based on previous research on patient expectations and satisfaction in general (not specific to people with LBP). If a study reported new aspects of treatment, these aspects were added to this list.
How were the results synthesized?
For the qualitative studies:
If the aspects of expectations or dissatisfaction were mentioned by patients and considered important by the authors in a study, that study was considered to contribute support to the identified aspect. Each study could only contribute once to each aspect. Therefore, for this synthesis, the greater number of studies a treatment aspect had supporting it, the more important that treatment aspect was considered for patients.
For the quantitative studies:
The frequency of answers to questions about dissatisfaction or expectations was used to identify important treatment aspects. If more than 10% of the patients were dissatisfied with a particular treatment aspect, it was considered a relevant treatment aspect.
Two reviewers independently read and extracted data. Two reviewers also independently assessed the quality of the studies. The quality was assessed using different scoring lists for qualitative and quantitative studies developed by the authors.
I should note that when reviewing their scoring criteria, it looks more like an assessment of the quality of reporting rather than an assessment of the methodological quality.
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Results
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12 qualitative studies and 8 quantitative studies met the inclusion criteria. 10 of the qualitative studies and 7 of the quantitative studies were considered “high quality” (again, perhaps high quality reporting but not necessarily in methodological quality as their scoring criteria was not sufficient to measure this).
The top 3 treatment aspects that were most frequently mentioned in the 12 qualitative studies were:
1) Diagnoses/finding cause of pain (8 studies)
2) Information/instructions (8 studies)
3) Pain relief (6 studies)
The top 3 treatment aspects that were most frequently mentioned in the 8 quantitative studies were:
1) Information/instructions (5 studies)
2) Pain relief (4 studies)
3) Understanding (4 studies)
The above top 3 treatment aspects were most frequently mentioned out of the following list of treatment aspects for back pain that patients have expectations for:
1. Clinical management: diagnoses/finding cause of pain, technical competence, information/instructions, convenience of treatment, pain relief
2. Facilities: diagnostic test, other therapy, specialty consultations, sickness certification/job
3. Interpersonal management: communication, congruency/confirmation, being included in decision making, listening, respect, confidence-based relationship, time/effort, understanding
4. Continuity of care: waiting time
5. Finances
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Strengths:
- Considered results of multiple studies (12 qualitative, 8 quantitative)
- Results from qualitative studies fairly consistent with quantitative, in that 2 of the 3 top treatment aspects for both types of studies are the same (information/instructions and pain relief)
Limitations:
- I am not sure how different some of the treatment aspects were and how valid it was to separate some of the aspects. If treatment aspects were separated even though they are fairly similar to each other, it could affect the interpretation of how important some aspects are over others. For example, understanding (particularly, “being believed”) can be similar to sickness certification, which was described as “social recognition and a legitimization of social and economic inactivity”. This could explain why “understanding” came up as the 3rd most important treatment aspect for quantitative studies but not qualitative…
- This article was written in 2004 and there was no standard for synthesizing results of multiple qualitative studies at that time (i.e. the equivalent to a meta-analysis for quantitative studies). Even now, I do not think there is a consensus on performing a meta-synthesis but the approaches taken in this meta-synthesis by Froud et al (4) seems to be much more systematic and thorough.
- The authors do not indicate what measures were used in the quantitative studies and how comparable they were. Differences in the questions asked or the wording of the questions could influence the results. For example, what if they did not ask about a treatment aspect that would have turned out to be relevant had they asked about it?
- There were no strategies to give greater weighting to treatment aspects that were found to be more important than others within an individual study. For example, let’s say that in an individual study, treatment aspect A and B were both relevant. However, treatment aspect A was found to be much more important than treatment aspect B. In this systematic review, both would have been considered equally important (i.e. each contributing 1 “point” to the respective treatment aspects)
Implications:
Patients who seek care for their back pain want:
- Information/instructions on how to manage their back pain
- Pain relief*
- To find out about the cause of their pain (Oh hey, I think some pain physiology education may be useful here ;))
- To feel understood
So we should strive to offer these things to them! I don’t think any of this is new to clinicians but it’s nice to have our thoughts confirmed! Interesting that effective communication and education underlies each of those aspects.
*How does this relate to the study I discussed in my previous blog post?
- From the previously discussed study: when comparing those with back pain who have sought care and those who have not, they are 7.66x more likely to have high disability levels and 1.92x more likely to have high pain intensity levels. Care-seeking is much more strongly associated with high disability than high pain intensity.
- Therefore, I brought up the question of whether we should be focusing on improving function more than pain relief during rehab (I also questioned how different those two approaches would be or if there would be a lot of overlap, but that’s for another blog post)
- Based on the results of this study however, people with back pain who seek care expect pain relief (among other things) so we should try to provide this to some degree at least.
- I wonder if this is because, based on what I see in the media and what I hear everyday, our society is still very rooted in the medical model. Perhaps people come to us because their pain is interfering greatly in their daily life and believe that if they get rid of the pain, they will be able to return to their daily activities. Indeed, this meta-synthesis by Froud et al (4) of the impact of low back pain on people’s lives found in one study that “participants may focus on the amelioration of pain in the belief that once this is achieved, normal relationships can be resumed”. While the medical model has helped advance healthcare greatly in the past century (e.g. vaccines, antibiotics), I think society needs to learn a broader approach to handle chronic disease. Pain is not a virus, as much as people would like it to be – we can’t just take pain away like killing a virus in the body. Pain is much more complex than that. The best example of this is phantom limb pain. You get rid of the body part that is causing problems and it still hurts even after it is gone.
- Given what we know about pain though, I wonder if (a) providing information/instructions on how to manage their back pain, (b) helping them understand the cause of their pain, (c) ensuring they feel understood would indirectly help to reduce pain? Even better would be to address these treatment aspects in ways that help them feel robust and in ways that reinforce/promote function despite pain.
It would be interesting to see a study that collected quantitative information on care-seekers vs non-careseekers while simultaneously exploring, from a qualitative perspective, why these people chose to seek care or not to seek care. How would the quantitative factors that are associated with care-seeking relate to the lived experiences of people who seek care versus those who do not seek care? I think I am dreaming though as I think this would probably be a very difficult study to do!
References:
- Verbeek J, Sengers M-J, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine; 2004;29(20):2309–18.
- Giacomini MK, Cook DJ. Users’ Guides to the Medical Literature XXIII. Qualitative Research in Health Care A. Are the Results of the Study Valid? JAMA. American Medical Association; 2000 Jul 19;284(3):357.
- Johnson R, Waterfield J. Making words count: the value of qualitative research. Physiother Res Int. 2004 Jan;9(3):121–31.
- Froud R, Patterson S, Eldridge S, Seale C, Pincus T, Rajendran D, et al. A systematic review and meta-synthesis of the impact of low back pain on people’s lives. BMC Musculoskelet Disord. BioMed Central; 2014 Jan;15:50.
