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How to consult with a patient with simple back pain

Issue 34 Synovium (Autumn 2011)

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A study published in International Musculoskeletal Medicine1 reported some really interesting findings that we (humbly) suggest every clinician who consults with patients complaining of back pain will find helpful.

The study asked (by questionnaire) 81 GPs and 427 patients from 12 practices about their views on the utility – or otherwise – of 8 possible components of the consultation. These were: taking a history, physical examination, requesting lumbar spine x-rays, prescribing or advising medication, referring for physiotherapy or osteopathy, advising back exercises, referring to a specialist, and ‘allowing nature to take its course’. Subjects were given 6 possible responses for each component: essential, useful, occasionally useful, not useful, a waste of time/money, or potentially harmful. The patients were also asked to state if they had ever consulted a GP about back pain.

It was interesting to find significant differences in the values placed on some components of the consultation by doctors and patients. Predictably the subject of x-rays revealed most disagreement, with very few doctors (<3%) rating x-rays as valuable, unlike the majority of patients (>60%). Patients valued specialist referral significantly higher than doctors (57% : 1%) but were negatively disposed (43%) to allowing nature to take its course and let the back ‘heal over time’ – a small number of patients thought this potentially harmful, whereas most doctors (83%) valued this approach. Perhaps the most surprising was the relatively low value doctors placed on examination of the back compared with patients (70% : 90%). Interestingly there was no difference in the patients’ responses depending on whether or not they had previously consulted for back pain.

The importance of these findings is that they can guide the clinician towards a more effective consultation, avoiding issues that might lead to patient dissatisfaction. Patients want to be examined. They need an explanation about why an x-ray is not a useful investigation. They need a discussion about the utility of referral for physical therapy and a specialist opinion. They will happily accept back exercises. And if all this is covered they may perhaps accept the advice that back pain is not usually serious, is part of the normal human experience, is usually self-limiting and safe to leave to nature to heal.

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