EXPRESSIONS OF FEAR IN BACK PAIN CONSULTATIONS

¹University of Southampton, Faculty of Health Sciences, Southampton, United Kingdom, ²University Hospital Southampton NHS Foundation Trust, Therapy Services, Southampton, United Kingdom

Background: Of all 291 conditions studied in the Global Burden of Disease 2010 Study, low back pain ranked highest in terms of disability. With a lifetime incidence ranging from 60-90%, back pain has been cited as the most common musculoskeletal condition seen by physical therapists. Such prevalence, along with the misery and socio-economic burden caused by back pain, justifies the need for research. To date, much of the research in back pain has focussed on intervention strategies (including manual therapy and exercise) while relatively little is known about the impact of the initial assessment itself and how this may influence both outcome and patient experience.

Purpose: As part of a wider study investigating the communication and clinical decision-making that takes place in consultations between physical therapists and people with back pain, this research specifically addresses how fears are expressed by patients during initial physical therapy consultations.

Methods: This cross-sectional, observational study took place in a physical therapy department in a city hospital in Southern England. Patients were referred to the outpatient service by their primary care doctor and allocated an individual (45-minute) consultation with a clinician, with follow-up (30-minute) appointments as necessary. Twenty-five, initial clinical back pain encounters, involving 9 physical therapists, were observed, audio-recorded and transcribed verbatim. Data were analysed thematically using a Framework approach, and Conversation Analysis was used to explore key aspects of data in detail. From the themes and sub-themes identified, a model of ‘Expressions of fear in back pain consultations’ was developed and interrogated by representatives from both clinical and Conversation Analysis communities.

Results: The data set, totalling 16 hours and 15 minutes, comprised 15,489 turns (7,659 made by patients; 7,647 made by clinicians; and 183 made by others such as the patient’s spouse or a clinical colleague). The mean duration of consultation was 38 minutes and 59 seconds (38:59), ranging from 26:21–53:16. Physical therapists spoke for half of the consultation duration (spending 12.5% of the total time offering advice), while patients spoke for approximately one third of the time. During the consultations, patients expressed fears in 3 main themes: the diagnosis; its impact on others; and fears about the future. These fears were rarely overtly expressed and during the consultations, 13 sub-themes were identified: fear of actual damage; other diseases (including cancer, osteoarthritis); being told the truth; being believed; impact on family; impact on work; future susceptibility to back pain; whether it will always be there; ability to get back to their former life; possible future damage; the likelihood that it will deteriorate; nothing can be done; they will become an invalid.

Conclusion(s): Expressions of fear by patients during back pain consultations were complex and implicit, rather than explicit.

Implications: Communication, arguably the most important aspect of practice that health professionals have to master, impacts upon every clinical encounter. Nowhere are these skills more important than in the initial consultation, as interpersonal relationships develop. In order to maximize outcome and enhance patients’ experience, it is imperative that clinicians overtly identify and address patients’ fears, delivering a tailored and patient-centred consultation.

Funding acknowledgements: The author was funded by clinical academic fellowships from Arthritis Research UK and the National Institute for Health Research.

Topic: Professional issues

Ethics approval: Ethical approval for this study was granted by the Southampton and South West Local Research Ethics Committee, United Kingdom (08/H0502/15).

All authors, affiliations and abstracts have been published as submitted.