Why Do Patients Think We Are Good at Managing Low Back Pain?

A recent tweet from a research colleague in The Netherlands gave me new appreciation for a paper titled: “What does the patient with back pain want? A comparison of patient preferences and physician assumptions” (Smuck M, Barrette K, Martinez-Ith A et al. The Spine Journal, 2022; https://doi.org/10.1016/j.spinee.2021.09.007 ).

Dr. Carmichael

The results of this research are eye-opening and invite we clinicians to reflect on what matters most to our patients. The paper also offers keen insights into patient satisfaction and, perhaps, an explanation why chiropractors tend to score higher than other back pain providers in this category.

This prospective survey study was conducted by investigators at three university spine centers: Stanford University, University of California San Francisco, and the University of Michigan. The purpose was to evaluate the expectations of patients with low back pain. The relative importance of eight treatment variables were compared between 419 consecutive patients with back pain at initial presentation to a spine clinic and 198 physicians. Both patients and physicians ranked their survey responses between 0 (“not important”) to 4 (“extremely important”). The eight treatment variables rated by both patients and spine physicians were as follows:

  1. Explanation of what is causing the back pain
  2. Improvement in the level of pain
  3. Improvement in the ability to perform daily tasks
  4. Thorough physical examination
  5. Physical therapy
  6. Diagnostic testing
  7. Medications
  8. Surgery

You quickly realize that chiropractic care is not a variable. This study was designed for patients at spine clinics associated with two orthopedic departments and one physical medicine and rehabilitation department at three academic research universities.

TEST YOURSELF: Rate the eight variables above in the order of importance you think your patients would report. Feel free to substitute “chiropractic care” for “physical therapy.”

As you might expect, the patients valued improvement in pain and improvement in function as the number one and number two most important expectations, respectively. Physicians surveyed in this study closely mirrored the patient mean responses for these top two variables. However, physicians significantly underestimated the patients’ third most important value: the explanation of what is causing their back pain.

Additionally, the providers significantly overestimated patient expectations regarding diagnostic testing (including imaging), the use of medications, and surgery. Patients ranked physical therapy as the sixth most important of the eight variables listed, behind the top three above, thorough examination, and diagnostic testing. If knowing what is wrong is highly important to patients, it makes sense that examination and diagnostics would rank higher than the availability of any treatment offered.

The importance of this paper lies in the fact that it puts the understanding of patients – the primary stakeholders in the back pain spectrum – at the center of the study. It identifies disparities between what patients and their doctors think is most important. Alignment of values and expectations between patients and providers may have a significant impact on the quality of care perceived by patients.

Patient expectations are powerful. You might have x-rayed a patient because you thought they expected it rather than from clinical necessity, dictated by a thorough examination. You may have felt bound to a particular adjusting technique because the chiropractor before you only used that technique – even when your experience and training suggested the patient would benefit from a different approach. Based on the rankings of variables in the study, all of us might be off the hook. After a careful history and thorough examination, most patients are receiving what they’d hoped for – maybe more. After that, a careful explanation of what is wrong and how our recommended treatment will address the problem is key.

We can’t pretend to be all things to all patients, nor should we. The current paper gives us valuable guidance that will help us serve our patients according to their highest priorities, not ours. Patients simply want to feel better and function better. As our evidence-informed treatments measurably improve these priorities, the proof is “in the pudding.”

In the overall management of back pain chiropractors consistently produce superior satisfaction scores. This may relate to better alignment with patient values and, as our paper suggests, better explanations of what is causing the pain. Today’s reference article leaves this unproven, but to possibility. Moreover, thorough examinations and procedures that confirm the diagnosis are welcomed by the patient.

Our challenge is to make sure our explanations align with evidence where evidence exists. If we are honest we’ll admit we can always do better. Something that sounds true isn’t necessarily true. At the very least we must ensure that our explanations to patients do not flatly contradict what is known. Knowledge is imperfect, and often sorely lacking much of the time. This gives more urgency, not less, to know our knowledge gaps and fill them with regularity. We do this by allowing published evidence to serve us, and help us update the explanations we provide to our patients.

Joel Carmichael, DC, PhD practices at The Center for Spine, Sport & Physical Medicine in Colorado. He teaches at Universidad Central del Caribe in Puerto Rico and maintains volunteer clinical faculty status at the University of Colorado School of Medicine. His research seeks to improve the practice habits of sport and spine professionals. Dr. Carmichael loves teaching, latté art, C.S. Lewis, and an occasional morsel of chocolate. He and his wife enjoy morning strolls with their golden retrievers, Stella and Noli.