exercise prescription for patients with non-specific chronic low back pain: whose back is it anyway?...
TRANSCRIPT
Exercise prescription for patients with non-specific chronic low back pain:
whose back is it anyway?
Rob Stenner PhD MSc MCSP
Communication is …….
The most important aspect that health professionals have to master’
Weatherall (1998)
80% of patients’ complaints arise from a breakdown in communication
Towles BMJ;1998:301-4
Motive
“They just gave me a sheet of exercises to
do”
“Treatment and care should take into account patients’ needs and preferences. People with non-specific low back pain should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals” (NICE, 2009 p.6).
Process of Decision Making
Prior Preference
Information
Gathering
Options Appraisal
Informed Preference
s
Decision
Shared decision making is a process in which clinicians and patients work together to clarify treatment, management or self-management support goals, sharing information about options and preferred outcomes with the aim of reaching mutual agreement on the best course of action (Coulter and Collins, 2011).
Definition of SDM
Research Literature• The optimal type of exercise for NSCLBP remains unresolved. This
means that there is no consensus on the best evidence for action i.e. a situation of clinical equipoise exists.
• Where both healthcare professionals and patients agree that equipoise exists, situations may be regarded as having ‘dual equipoise’, which is an ideal situation for shared decision making (Elwyn, Frosch and Rollnick, 2009).
• The type of exercise prescribed does not appear to influence levels of engagement. Patient preference should be considered in an attempt to increase motivation to initiate and maintain an exercise programme. (Cochrane review 2010)
RelevanceThis research fits well with the CSP recently identified areas of musculoskeletal physiotherapy practice most requiring evidence, in terms of:
• Patients’ adherence to/concordance with exercise programmes.
• Prescription of exercise for patients with chronic, long term musculoskeletal conditions.
Rankin et al. (2012)
Phase 1
What are the characteristics of, and processes involved in, physiotherapy exercise prescription for patients with NSCLBP?
Method and Methodology• Design: A qualitative study using a
philosophical hermeneutic approach.
• Methods: Eight physiotherapists were each observed on three occasions undertaking their usual clinical activities (total n=24 observations). They undertook brief interviews after each observation and a later in depth semi-structured interview. Iterative hermeneutic strategies were used to interpret the texts and identify the characteristics and processes of exercise prescription for patients with NSCLBP.
Findings
3 main themes were formed from the texts:
1. ‘I want them to exercise’
2. ‘Which exercise? – the tension between evidence and everyday practice’
3. ‘Compliance-orientated more than concordance based’
‘I want them to exercise’
“I have to say I don’t particularly ask the patient what they want. I think giving them so much choice, they can often get confused, it is almost too much for them.” (T5)
“I must admit for every low back pain I have coming in through my door I pretty much will always give them exercise. I don’t think about it too hard it’s just part and parcel of the package that I like to give.” (T1)
“I try and get people to think about it from my point of view. I want them to exercise so they get used to getting their spine moving again.” (T3)
“I’ve tried exercise religiously in the past, it made no difference it was ridiculous.” (Patient)
‘Which exercise? – the tension between evidence and everyday practice’“Evidence tends to imply that any form of exercise is going to be helpful in the long run, it’s just about getting out there and doing it.” (T1)
“People are going to have the best outcomes if enjoy it. Some patients come in with specific ideas or they are already attending yoga or pilates, and I think it is worth taking on board what they bring in with them rather than what you think – if that makes sense.” (T4)
“Overall the objective assessment plays a very large role in the choice of exercises. I will tend to work out what I think is best.” (T4)
“I think a specific exercise programme of what are often particularly boring exercises, a patient is likely to do them in the short term I suspect, but only if they see some improvement in their pain.”(T6)
‘Compliance-orientated more than concordance based’
“I often give them a programme that only consists of 3 exercises that only take 3 to 4 minutes to do 2 to 3 times a day. I say ‘do you have enough time to make a cup of tea or brush your teeth’ and they’ll go ‘yes’ , and I say ‘this is just exactly the same it is something you have got to slot in, in your life that will be part of your lifestyle now and for the foreseeable future.” (T5)
“I just want to make sure that they do something that’s simple and not particularly difficult or challenging and get them on board that way, and then up the intensity.” (T6)
“I want to give them something to take away from the session if only it’s a simple exercise or two.” (T8)
Conclusions• This study supports the suggestion that physiotherapy practice is
not always consistent with models of patient-centred care identified in the physiotherapy literature (Cooper et al., 2008) and frameworks underpinning a shared decision making consultation (Elwyn et al., 1999).
• Reliance on exercise may represent a conflict between guideline-
driven care and patient-centred care
• The decision to use exercise, defines the normal routine or customary practice which often results in unequal possibilities for patient participation.
Phase 2
What are the experiences, information and decision support needs of patients with NSCLBP who have been offered exercise as part of their management plan?
Methods and Methodology
Data collection – semi-structured interviews, including use of vignettes (highlighting differing levels of patient involvement in decision making) enabled the participants to discuss and compare their experiences regarding exercise prescription. Data analysis - thematic analysis was guided by the principles of philosophical hermeneutics.
Findings
Four main themes emerged:
1. ‘Patients’ expectations and patients’ needs are not synonymous’
2. ‘Information is necessary but often not sufficient’ 3. ‘Not all decisions need to be shared’ 4. ‘Wanting to be treated as an individual’
‘Patients’ expectations and patients’ needs are not synonymous’
“To be honest I wasn’t quite sure what to expect from the physio appointment other than this vague idea that I would be given exercises only because it’s sort of what I expect a physio to do, and from other people who I have spoken to, that is what their experience has been, a set of exercises that they have to complete regularly”.
“I think I really wanted to know what was going on more than anything else. I wanted to know more about my back and I suppose sometimes you don’t get that, I wanted more understanding”.
“Perhaps a clearer diagnosis of what the problem was as up to that point I hadn’t really been given a clear explanation”.
Expected
BUT WHAT MATTERED MOSTMore understanding
‘Information is necessary but often not sufficient’
“I think I felt the same as when I was prescribed painkillers because I felt that there was a fairly vague explanation of what might be wrong with my back I wasn’t sure whether what was being suggested was targeted enough because it wasn’t made clear what the problem was, so I wasn’t quite sure how people knew how to remedy the problem if they didn’t know or that information wasn’t passed onto me”.
“I was given my management plan which was exercise, but that was just delivered to me. I wasn’t offered any choice, other than exercise. I was told that was what I needed to do.”
“The lady went to the computer and looked at whatever exercises she has got on the programme and chose some for me and printed me off a sheet. I imagine it was to loosen or strengthen the muscles, but I made that assumption myself.”
‘Not all decisions need to be shared’
“It did feel like it was 4 exercises and that’s what they gave to everybody, and I guess I didn’t think to say how about this. If I had been more in tune with what was going on with me I could have been a little bit more challenging……”
“I see it differently, It’s not about what we want to get as we can have misconceptions, I think we need to be told what we need and what we are going to get and be realistic”.
“I think there is a very fine line between the doctor doing what is right and involving the patient, but it all depends on the patient and building a relationship of exactly what they need”.
“I think you ultimately defer to the professional because they know what they are talking about, and exercise is minor stuff .“
‘Wanting to be treated as an individual’
“I can’t put my finger on it but it was just the way I felt she was coming across to me. It was like here we go again someone else with back pain.”
“What it felt like, to put it plain and simply when I went in there I felt like I was simply a number with back pain, and I realise, especially now, there are a lot of people with back pain, but I felt like I was simply a number.”
“It’s all well and good you going to a physio and them saying you have got to do this, if you don’t do this it’s not going to get any better you need to help yourself, and you come out and burst into tears and think I can’t help myself I don’t know how to help myself. You can try and do the exercises but you haven’t got the motivation there.”
Conclusions• Potential exists for the misinterpretation of patients
expectations of care - physiotherapists may overestimate the extent to which patients are concerned with treatment rather than gaining information and support.
• Lack of information and knowledge, the type and level of decision, and trust in the healthcare professional, can all impact on patients’ desired role in decision making regarding exercise.
• Increased understanding, individualisation of care, and a supportive therapeutic relationship may be more important to patients with NSCLBP than involvement in treatment decision making.
Physiotherapy studiesDierckx et al. Implementation of shared decision making in physical therapy: observed level of involvement and patient preference. Physical Therapy, 2013.
SDM was not applied; although patients preferred to share decisions or at least provide their opinion about treatment, therapists did not recognise this and were more likely to make decisions in the best interests of their patients.
Jones et al. Shared decision making in back pain consultations: an illusion or reality? European Spine Journal, 2014
SDM rarely occurred, with main barrier being clinicians strong desire to treat the patient.
‘Whilst healthcare policy has called for a strengthening of patient and public engagement in health care decision making, flexibility in responding to each patient as a unique individual is likely to be the key success factor concerning the use of shared decision making principles.’
‘Delivering a health system that informed patients want, not one
that clinicians think they should have.’
Acknowledgments• Professor Shea Palmer• Dr Theresa Mitchell• Dr Annette Swinkels
• Patients and physiotherapists who kindly gave their time and agreed to participate in this study
