Monday, February 11, 2019

Next Time You Treat Low Back Pain, Be Sure To Provide Reassurance


When the patient came into the treatment room, I sat down and welcomed them to do the same.

They refused, preferring to stand, as sitting hurt their lower back too much. When asked how long this pain had been going on, it was an astonishing two years.

Unfortunately, they had been run through the medical system for the previous two years, had seen every kind of practitioner and been given competing advice from all of these medical professionals. When asked what has worked well in the past, getting massage seemed to be the most beneficial. While this sounded great, there was still a lot of work to be done, which had nothing to do with what technique I could use to help ease the pain.

There was now an education and confidence building process that had to take place.

This person was so scared of their pain, they were afraid to sit (even though they had just comfortably driven their vehicle to the clinic).

How could I help this person? What kind of education would help? Would I be able to help?

Clinical Guidelines For Low Back Pain

Looking at the studies on the clinical guidelines for low back pain,  they revolve around primary care settings, which can be described as the “first point of contact regarding patient care”, so generally thought of as doctors in medical clinics or hospitals.

Fortunately, there is a lot of good advice about managing both acute and chronic low back pain.

Unfortunately, when we look at the European guidelines it says “they cannot recommend massage therapy” for the management of low back pain. But when we dig a little deeper when it refers to treatments they cannot recommend “it is owing to lack of/conflicting evidence of effectiveness” and while many of these treatments may be effective, they require the use of more studies to prove their effect (which is a big reason we need more research on massage therapy to be done, we know it’s effective).

But, massage isn’t alone in these studies as the modalities that “aren’t recommended”, there is quite a long list of things they would not recommend which we see used quite regularly:

  • Radiographic imaging for chronic non-specific low back pain.
  • MRI, CT, or facet blocks for diagnosis of facet joint pain, or discographies for discogenic pain.
  • EMG as a diagnostic procedure.
  • Wearing lumbar support.
  • Ultrasound.
  • Laser Therapy.
  • Traction.
  • TENS machines.
  • Acupuncture.
  • Nerve blockers, or corticosteroids.
  • Injections

However, it does recommend:

  • Looking at: work-related factors, psychosocial distress, and patient expectations.
  • Supervised exercise therapy.
  • Exercise programs that do not require expensive training machines.
  • Group exercise.
  • A short course of spinal manipulation for chronic low back pain.
  • Brief educational interventions.
  • Mulitdisiplinary biopsychosocial rehabilitation.

What the article doesn’t really mention is the interaction between the massage therapist and the patient.

While the above information is from the European guidelines when we look at the updated overview of international clinical guidelines they are consistent in recommending a focus on the identification of red flags (which we have written about HERE) and ruling out specific diseases. The only time medical imaging is recommended is when a serious pathology is suspected.

However, consistently across all of the recommendations is that patients should be reassured they don’t have a serious issue, and they should remain active.

Beliefs Regarding Pain

Sometimes it can be difficult to convince a patient they need to remain active, as they become fearful of moving because they associate it with pain.

In fact, there is a hypothesis where those experiencing low back pain fall into two different classifications: confrontation or avoidance, and this is determined by a persons fear of pain.

Those who confront their pain view it as a nuisance and are quite motivated to get back to normal activities. Whereas those who fall into an avoidance response tend to reduce physical and social activities, have a more prolonged disability and have adverse physical and psychological consequences. There is actually a correlation between avoiding activities because of the expectation of pain rather than actual experience or feeling of pain during activities.

There is even speculation that fear avoidance during an acute episode of low back pain can be a prognostic tool in identifying those who are more prone to developing chronic pain and may be the most important factor in determining the transition from acute to chronic low back pain. 

These fear-avoidance beliefs are even consistent for patients with work-related low back pain and the time it takes for them to get back on the job. Most return within one to two months after injury, but those who take longer are less likely to return to work.

Before I became an RMT, I was an industrial first aid attendant in a sawmill and I can remember having discussions with WCB (workman’s compensation) rep about employees returning to work. He told me their studies had shown if someone went 18 months without returning to work post-injury, they were likely never to return to work (I’m citing this from memory, I have no data to back it up other than remembering a conversation). So, looking back, this conversation makes a lot more sense to me now as many people returning to work were worried they would get reinjured on the job again.

Part of what contributes to fear avoidance beliefs is well…us.

All too often it is the messages patients get from health care providers who still rely strictly on explanations around pain being the result of tissue damage along with structural, anatomical, or biomechanical problems (yes these still play a role but there are other factors to consider as well). This is further reinforced by practitioners who confidently express their methods and services are the only way to relieve pain. 

So, we then have to consider how we can better help our patients with this increasingly common issue. The first step is; reassurance.

Providing Reassurance

As we have been discussing, peoples perception of pain has a massive effect on how they deal with pain.

One study shows that reduced feelings like helplessness, catastrophizing, pain being harmful and disabling, along with increased belief in control over pain can predict positive treatment outcomes.

Unfortunately, a lot of these feelings are due to things people have been told in the past (often by practitioners) that their back is ‘weak from a past injury’ or their pain is a result of genetics, lifestyle, or some other physical trait. These beliefs also bring about concerns they will reinjure or damage their back even more with activity.

There is strong evidence that these views are directly related to interactions with clinicians who also have high levels of fear-avoidance beliefs. Part of the difficulty with this is when patients go see multiple practitioners and are getting a different story from each one, this results in more frustration and an increase in those negative beliefs.

However, if we start to use language and descriptions that reassure and empower the patient, we can start to positively influence their pain beliefs. 

Once red flags are ruled out we can reassure the patient how things should get better over the next few weeks because the symptoms are benign in nature and this issue quite often resolves itself. Along with this, we should endeavor to offer some level of education to the patient about their pain and how to self manage, otherwise, a dependence on the therapist could develop, where the patient always needs to be taken care of.

We need to start changing the narrative patients are given. 

When someone comes in who has had an x-ray or MRI and is stressed about the results I like to say something to the effect of:

“Don’t let that freak you out too much, if they took an x-ray of me right now it would probably look similar, yet I’m not experiencing any pain, your back is just sensitized right now and we just need to calm it down”.

Or when someone with chronic pain comes in I’ll say something like:

“Since we know pain is a safety and protection mechanism, your tissues have been protected for a long time now, which puts them in a safe place, your chances of re-injury is minimal”.

Now, this isn’t always going to be easy because they could be getting different messages from different practitioners. So, it may take a while to get your message across. But, for that patient who is afraid to sit down because they fear re-injuring their back, this is a good start.

While these are just a couple of examples I have used with people, they are just examples and won’t necessarily work for everyone. We need to tailor our message for each individual according to their beliefs and relationship with pain. We also need to build up our therapeutic relationship with them and provide appropriate homecare to decrease their dependence on us while reinforcing self-efficacy. These patients are wanting to be heard, have a better rapport with their practitioner, be given reassurance and education, so they know they are going to be okay. These are things rarely given by ‘primary care’ practitioners because they are given such a small amount of time with them, so this creates a valuable opportunity for those of us fortunate enough who get to spend on average an hour with each patient. Even though the clinical guidelines on low back pain could not recommend massage therapy, when we look at what they do recommend, Massage Therapist should be at the top of the list.

Leave a comment below with the language you use, or things you say to reassure your patients, we’d love to hear from you.

from Beauty Salon, Spa, Massage

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