Background & Aims
During clinical interactions, both explicit messaging (verbal communication, e.g., treatment and prognostic explanations) and implicit messaging (messages that are not explicitly verbalised but a patient infers meaning, e.g., type of treatment provided) may influence a patient’s bodily perception. Clinical messaging may be particularly relevant for low back pain (LBP) where it is common for people to believe that pain is caused by structural pathology and, therefore, that their back is fragile/vulnerable.[1,2] Here, we aimed to determine whether, during a hypothetical experience of LBP, the type of treatment received (passive versus non-passive; implicit messaging), and the treatment explanation provided (biomedical versus biopsychosocial; explicit messaging) influenced perceptions of back fragility and future healthcare utilisation.
Methods
A randomised, three-arm design of online patient vignettes was used. Participants were asked to imagine themselves as the patient experiencing LBP described in the vignette. Vignettes included practitioner videos providing explanations for pain and the treatment selection. All vignettes provided guideline care (education, reassurance, activity advice), after which participants were randomised to:1) Manual therapy with a biomedical explanation (MT Biomed; explicit and implicit biomedical messaging); 2) Manual therapy with a biopsychosocial explanation (MT Pain Ed; implicit biomedical messaging); or 3) A biopsychosocial pain explanation to remain active, and no manual therapy (No MT; explicit and implicit biopsychosocial messaging). The primary outcome was perceived back fragility (FreDIM; range 19-95; higher score, less perceived fragility). Secondary outcomes were future healthcare utilisation when back pain returned and endorsement of physical activity as a recovery strategy.
Results
The MT Biomed group had significantly greater perceived fragility than the MT Pain Ed group (d=-0.37, 95%CI: -0.528, -0.208) and No MT group (d=-0.38; 95%CI: -0.543, -0.222). The MT Biomed group also had greater odds of future healthcare utilisation than the MT Pain Ed group (OR= 1.647, 95%CI: 1.244, 2.18) and no MT group (OR= 2.14 95%CI: 1.612, 2.85), and yet were more likely to endorse higher levels of physical activity than the MT Pain Ed group (OR= 1.354 95%CI: 1.021, 1.80) and No MT group (OR= 1.48 95%CI: 1.111, 1.97), with no difference between the MT Pain Ed and no MT groups. Participants experiencing back pain when completing the vignette reported greater perceived fragility than those not experiencing pain (d=0.50, 95%CI: 0.37, 0.64), were more likely to seek healthcare if back pain returned (OR=1.41, 95%CI: 1.11, 1.79) and, less likely to endorse physical activity (OR=0.749, 95%CI: 0.585, 0.958).
Conclusions
Explicit messaging consistent with biomedical explanations for pain paired with MT, increased perceptions of back fragility and the likelihood of future healthcare use, yet resulted in participants endorsing higher physical activity levels after injury. Providing a biopsychosocial explanation for MT mitigated negative effects on perceived fragility. Experiencing back pain when completing the study influenced how participants responded to the vignette. Pain-informed educational approaches, whether paired with MT or not, lead to lower perceptions of back fragility, supporting the importance of explicit, biopsychosocial explanations for LBP during treatment encounters.
References
1.Nishigami T, Wand BM, Newport R, et al. Embodying the illusion of a strong, fit back in people with chronic low back pain. A pilot proof-of-concept study. Musculoskeletal Science and Practice. 2019;39:178-183.
2.Stewart M, Loftus S. Sticks and stones: the impact of language in musculoskeletal rehabilitation. journal of orthopaedic & sports physical therapy. 2018;48(7):519-522.
Presenting Author
Felicity Braithwaite
Poster Authors
Brendan Mouatt
MSc, PhD Candidate
University of South Australia
Lead Author
Topics
- Specific Pain Conditions/Pain in Specific Populations: Low Back Pain