SPECIAL TOPIC SERIES
Effective Reassurance in Primary Care of Low Back Pain What Messages From Clinicians are Most Beneficial at Early Stages? Monika I. Hasenbring, PhD* and Tamar Pincus, PhDw
Objectives: Effective reassurance of patients reporting symptoms, for which no clear etiological origin is available, is one of the most important challenges in the early phases of nonspecific back pain. However, there is a lack of empirical studies on the effects of reassurance and, also, the effects shown were small. Improvements are needed with respect to the process of physician-patient interaction and to the methods used by the physician. Methods: We provide a short narrative review of the literature with special reference to affective and cognitive communication, based on a systematic review of 16 studies. We further consider recent evidence in the prognosis of low back pain, the role of physical activity, and subgroups-based individual differences in pain coping, questioning the information basis of reassurance. Results: A 2-process model of affective and cognitive reassurance was supported. Recovery improved in a combination of communication of empathy with cognitive reassurance, giving concrete information and instructions. In terms of information, recent research indicate that a substantial percentage of patients do not recover within the first year after onset of back pain. Further, very low and high levels of physical activity are associated with pain and disability, associated with cognitive and behavioral pain coping. Discussion: Reassurance of patients in early phases of persistent back pain might improve from affective and cognitive parts of communication and individually tailored information. Subgroup differences with respect to different prognosis, associated patterns of adaptive or maladaptive pain coping, and levels of health-promoting versus harmful physical activity should be considered more carefully. Key Words: primary care, low back pain, reassurance
(Clin J Pain 2015;31:133–136)
P
ain, such as low back pain (LBP) or headache, normally demands attention when interfering with certain ongoing activities in daily life. When people at first glance fear serious disease, they will consult their physician to clarify the cause of pain. As the pain is experienced in the body, patients suppose some organic causes the physician might detect. One of the main goals of patients is release from their pain to return to their normal activities without further disturbance.
Received for publication February 28, 2014; revised April 4, 2014; accepted March 5, 2014. From the *Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Bochum, Germany; and wDepartment of Psychology, Royal Holloway University of London, Egham, UK. The authors declare no conflict of interest. Reprints: Monika I. Hasenbring, PhD, Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Universita¨tsstr. 150, Bochum 44780, Germany (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/AJP.0000000000000097
Clin J Pain
Volume 31, Number 2, February 2015
In most cases of LBP, pain is apparently not caused by any serious pathology, such as fractures, neoplasms, spinal infections, or a serious disk prolapse. More than 80% of the patients report pain of unknown cause labeled as “non-specific LBP.”1,2 Instead, psychosocial factors are shown to predict and maintain chronic LBP, explaining part of the variance. Consequently, research in the recent decades has indicated a change from a purely “organic injury model” to a “biopsychosocial” understanding of the condition. Furthermore, several systematic reviews suggested a good prognosis for acute nonspecific LBP without invasive treatments.3 As a practical consequence, numerous national and international guidelines for the diagnostics and treatment of LBP correspond in their central recommendations: (1) after a clinical examination, which rules out so-called “red flags” (any signs of possible serious diseases), no further diagnostics, such as x-ray or magnetic resonance imaging (MRI) are necessary. (2) The adequate information of the patient includes reassurance about (a) the benign nature of their symptoms, and (b) the good prognosis during the next weeks and months, and (c) that pain will be resolved spontaneously in the majority of patients.3 Patients are encouraged to maintain or return to their normal level of activities and avoid bed rest. Consequently, reassurance techniques are most important in primary care of nonspecific LBP. As Linton et al4 pointed out in their topical review, the term reassurance refers to a process taking place during the interaction between the caregiver and the patient, method referring to the kind of information, instruction, or persuasion, and the outcome referring to whether the patients worries will be reduced and the recommendations will be translated into action in daily life. In the first part of the following review we will show that there is a surprising lack of empirical studies on the effects in consultations in primary care. There is sufficient evidence to suggest that some techniques are important and impact on short-term, and even on long-term, outcomes. However, the effects are mostly small, often transient, and even paradoxical effects are reported. Therefore, there is a need for more effective models of reassurance in pain management. In the second part, we introduce the distinction between cognitive and affective modes of reassurance, and describe the evidence for their unique contribution on patient’ outcomes. Finally, we question the validity of common messages that are recommended and used by clinicians in reference to adequate levels of activity. In synthesis, recent research indicates the need for better tailoring of reassurance interventions to specific subgroups of patients with LBP.
THE EFFECTS OF CURRENT REASSURANCE INTERVENTIONS A recent systematic review of reassurance in primary care5 identified 16 studies that measured what clinicians did www.clinicalpain.com |
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in the consultations and analyzed these interactions in reference to patients’ outcomes. The review was limited to symptoms for which there is no clear etiological pathway and prognosis and treatment response are variable. Symptoms that require frequent testing, monitoring, and management by clinicians were excluded, thus making the evidence relevant to LBP, although only one study was found that focused exclusively on this group. Of importance, the analysis was based on a published model6 of persuasive reassurance, that splits clinicians’ reassuring behaviors into 2 groups: affective reassurance, which includes the sets of messages and communications that aim to increase rapport, communicate empathy, and give patients a generic message that they are heard, cared for, and things will turn out right. Cognitive reassurance, in contrast, is an educational neutral type of communication, in which explanations are given, possible prognosis and treatment are discussed, and clarifications are offered. The authors of the original model maintain that patients engage with one or the other but cannot process both types of reassurance simultaneously. This, they argue, is because when affective reassurance is offered, patients respond by reduced anxiety and the sense that the clinician will “take care of them.” This will impact their willingness and ability to work to take on the information offered through cognitive reassurance, which is slower to process and demands more effort. Thus, Coia and Morley6 argue that when the patient is subsequently away from the consultation and the problem rises again, they have no new tools to deal with it, and they are left in a cycle of dependency and helplessness. Pincus et al5 set out to examine the model in primary care by including only prospective studies that measures consultation components in a way that enabled their categorization into cognitive or affective reassurance. The review’s findings are intriguing. Although there is a plethora of narrative publications on patient-centered consultations, the review found only 16 empirical-eligible studies, of which 8 were considered to be of good methodology. Affective reassurance was inconsistently associated with patients’ satisfaction and sense of enablement at consultation exit, but 3 high-methodology studies found an association with higher symptom burden and less improvement at follow-up. Cognitive reassurance, in contrast, was associated not only with higher satisfaction and enablement and reduced concerns directly after the consultations in 8 studies, but also with improvement in symptoms at follow-up in 7 studies and with reduced health care utilization in 3 studies.
OPTIMIZING THE PROCESS: THE IMPACT OF AFFECTIVE REASSURANCE Jumping to the conclusion that affective reassurance is bad for patients would be ill-advised. The review authors caution that early stages of the consultation in which patients’ concerns need to be elicited through sensitive questioning and listening will require empathy and rapport to create trust. They go on to state that it is not known whether cognitive reassurance can be provided without affective reassurance and highlight the possibility that the findings for affective reassurance may be a result of a third variable, some risk factor for poor outcomes that practitioners respond to by providing more affective reassurance. Although more research on affective reassurance is needed, the clear message from the review concerns the positive impact of giving clear information that is acceptable to
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patients. How to do so in the context of uncertainty about etiology, prognosis and treatment that best matches the individual patients’ needs remains a mystery and should form priority for research. What is clear, although, is that a uniform message to all patients is inadequate, and for subgroups with high risk for the development of chronic pain problems, generic messages about expected recovery will constitute false reassurance.
OPTIMIZING THE METHOD: INDIVIDUALLY TARGETING PATIENT REASSURANCE On the basis of recent evidence, we question the validity of current information on prognosis and physical activity and we discuss in more detail whether providing all patients with the same information will be still appropriate. We furthermore suggest integrating information on the biopsychosocial nature of nonspecific LBP into the process of reassurance.
Good Prognosis: Only Valid for Patients Without “Yellow Flags”? The kind of information, primary care physicians are suggested to consider by current guidelines, concerns primarily negotiations: there is “no” serious disease, “no” MRI is necessary, and “no” bed rest is indicated. Consequently, patients are encouraged to keep their level of activity and wait, because the prognosis would be good in terms of reduction of pain in most patients. Thus, although the patient experiences pain, which can be severe, they leave the practice without valid information or adequate tools to deal with their pain and its consequences. Cases in which the pain will diminish within a few days might not be a major problem. However, in cases in which pain persists, the patient might feel let down by their clinician and starts distrusting their clinical decision. This in turn may lead to further health care utilization and searching for a justification for the pain, often through requests for tests such as MRI. The question arises whether the latter case is so seldom that it may be neglected. Current rates of disability and costs for LBP suggest that this scenario is not rare.7 In fact, although current guidelines suggest that acute LBP will resolve spontaneously within a few days or weeks in >90% of the patients,3 more recent prospective studies indicate a significantly higher rate of pain problems during the year after onset of acute pain. For example, Hestbaek et al8 published a systematic review including 36 prospective studies in primary and secondary care indicating persistent or recurrent LBP at 1 year follow-up in 42% to 75% of the cases. More recently, Itz et al9 reported data from a review of 11 studies in primary care. Considering recovery as total absence of pain, 71% of the patients still reported pain at 12-month follow-up. Using less stringent criteria, 57% were evaluated as not recovered. The authors argue that the difference between these reviews and guideline recommendations is based on differences in outcomes and study samples. The evidence of a good prognosis was primarily based on studies in occupational medicine using outcome criteria such as “return to work,” “pain-related disability,” or combined criteria. Thus, patients who returned to work despite pain, even despite severe pain, were assigned as recovered. Given the high rate of recurrent or persistent pain during the first year after onset of acute LBP, adequate reassurance should address the problem of ongoing pain in
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
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Volume 31, Number 2, February 2015
subgroups of patients. As there is convincing evidence from several systematic reviews that10,11 psychosocial risk factors, such as emotional distress and maladaptive coping with pain, have a significant impact on the maintenance of acute/subacute nonspecific LBP, both eliciting and giving information should include known maladaptive pain responses. Ideally, clinicians should also offer adequate models of the possible development of chronic pain.12–15 For example, there is evidence that cognitive pain responses, such as catastrophizing and helplessness/hopelessness, ongoing with high pain anxiety and fear of (re)injury will increase the probability of future pain and pain-related disability.16,17 In contrast, cognitions such as thought suppression and distraction from pain are also described as high risk factors in sciatic pain18,19 as well as in nonspecific LBP.20–22 On a behavioral level, there is evidence not only for the role of avoidance behavior leading to chronic pain and disability, probably mediated by physical disuse, but also for the role of marked endurance behavior, which is maintained despite severe pain.19,21,23 The avoidance-endurance model (AEM) conceptualizes both extremes, fear avoidance versus endurance as maladaptive pathways leading to ongoing pain in long term by physical underuse or overuse/overload.12 Using a short AEM-based screening method,24 Hasenbring et al21 investigated 174 primary care patients with subacute LBP at the start of their outpatient treatment and 6 months later. Subgroups with marked fear avoidance or endurance pain responses revealed significantly more pain than an adaptive subgroup. In summary, current recommended reassurance messages, which focus on offering information on a good prognosis of LBP, seems to be adequate only for patients showing low levels of distress and an adaptive pain response pattern but may be inadequate or even counterproductive for several other patient groups.
Return to Normal Activity: What is Normal to Whom? Current reassurance interventions in acute LBP involve encouragement of the patients to maintain or increase their level of physical activity in daily life. These recommendations are mainly based on results of randomized controlled trials comparing the prescription of bed rest with the encouragement to stay active.3 In most studies, outcomes indicate better results for activity maintenance, although the level of activity patients had actually engaged in was not measured. As the prescription of bed rest is pretty consistent, but levels of activity differ vastly between people, it is safer to interpret the findings as indicating that bed rest is bad for patients, rather than that maintaining activity at prepain levels is beneficial. This latter interpretation is also in contradiction with findings from studies showing physical activity as positively related to LBP, especially when accompanied with high spinal load.25–28 In 2000, the International Paris Task Force on Back Pain provided some evidence on high versus low levels of physical activity, both linked with LBP, suggesting a U-shaped relation between activity and LBP.29 Analyzing cross-sectional data from a Dutch population-based sample of >3000 patients with chronic LBP, Heneweer et al30 supported this hypothesis at least for female patients. Sedentary behavior and an overall low physical activity level assessed by self-reported data revealed an increase in LBP similar to a very high level of activity, whereas a moderate level was associated with less pain. Copyright
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Effective Reassurance in Primary Care of Back Pain
Furthermore, there is a recent line of research investigating the relationship between pain-coping responses, the level of physical activity, and pain outcomes.31–33 Using objective accelerometer-based measurement of physical activity, there is preliminary evidence that patients showing marked fear-avoidance behavior display high pain and disability and a low level of general physical activity, as well as a low level of static load positions such as forward bent sitting or standing. In contrast, patients showing marked endurance pain response pattern revealed highest levels of pain intensity accompanied with significant higher levels of general activity and static postures compared with fear-avoidance patients and, also compared with an adaptive group.31,34 The adaptive group has shown moderate levels of self-reported avoidance and endurance and the lowest levels of pain intensity and disability besides moderate physical activity.21 Taken together, there is growing evidence that some subgroups of patients with LBP run the risk of developing persistent pain, related not only to low levels of activity but also in relation to very high level of physical activity. Until now, there have been difficulties in the definition of a level of overactivity and/or underactivity in general and to recommend strategies of pacing activities in daily life.35 One solution might be the assessment of adaptive or maladaptive pain responses encouraging fear-avoidance patients to increase their level of activity while recommending pacing strategies, including short breaks for rest and relaxation to endurance patients. Maintaining their normal level of physical activity might be adequate solely for an adaptive subgroup as discussed above.34 In sum, inflexible recommendation of high levels of exercise and activity do not appear to benefit patients. Indeed, there is emerging evidence that many practitioners endorse short breaks from normal activity (including work) to allow for healing and sufficient time to engage with rehabilitation.36
The Role of Individual Targeted Reassurance in LBP Screening for psychosocial risk factors in patients with acute/subacute LBP and the development of individual targeted interventions is realized within several concepts of cognitive-behavioral education and treatment (see review21). The question arises whether the process of reassurance provided by the primary care physician may be improved when based on a yellow-flag screening and using individually targeted recommendations. To our knowledge, there is preliminary evidence that providing patients with subacute LBP with their individual AEM-based risk pattern and discussing possible ways out of these response patterns within a short session of 15 minutes duration leads to significant reduction of pain and disability with moderate effect sizes, even 12 months after the first consultation.37 These results fit well with new evidence on the role of cognitive reassurance for patients described above.5 As these results are rather promising, further research in large patient samples needed to improve reassurance interventions based on individual patterns of pain cognition, affect, and behavior.
CONCLUSIONS Patients experiencing nonspecific LBP who consult primary care health providers need effective reassurance about the benign nature of their disease. Furthermore, they need valid information about the prognosis of their symptoms and
2014 Wolters Kluwer Health, Inc. All rights reserved.
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adequate tools to deal with their pain and its consequences. This topical review has shown that reassurance consists of both cognitive and affective components. However, further research is needed to determine the coordination of both parts to increase symptom release, well-being, and lowering health care costs. We further demonstrated that information based on current guidelines should be updated regularly to create valid recommendations for patients. Specifically, information on prognosis and on adequate levels of physical activity should address recent research indicating the necessity of a practice of individually tailored reassurance. Too low but also too high levels of physical activity mediated by maladaptive individual pain-coping behaviors may afford a differential concept of reassurance instead of generic messages. There is a need to investigate whether individually targeted measures of reassurance lead to better patient outcomes than generic information.
REFERENCES 1. Carragee EJ, Deyo RA, Kovacs MPH, et al. Is the spine field a mine field? Spine. 2009;34:423–430. 2. Deyo RA, Rainville J, Kent DL. What can history and physical examination tell us about low back pain? JAMA. 1992;268:760–765. 3. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(suppl 2): S169–S191. 4. Linton SJ, McCracken LM, Vlaeyen JWS. Reassurance: help or hinder in the treatment of pain. Pain. 2008;134:5–8. 5. Pincus T, Holt N, Vogel S, et al. Cognitive and affective reassurance and patient outcomes in primary care: a systematic review. Pain. 2013;154:2407–2416. 6. Coia P, Morley S. Medical reassurance and patients’ responses. J Psychosom Res. 1998;45:377–386. 7. Wenig CM, Schmidt CO, Kohlmann T, et al. Costs of back pain in Germany. Eur J Pain. 2009;13:280–286. 8. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 2003;12:149–165. 9. Itz CJ, Geurts JW, van Kleef M, et al. Clinical course of nonspecific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain. 2013;17:5–8. 10. Linton SJ. A review of psychological risk factors in back and neck pain. Spine. 2000;25:1148–1156. 11. Pincus T, Burton AK, Vogel S, et al. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27:E109–E120. 12. Hasenbring MI, Verbunt JA. Fear-avoidance and endurancerelated responses to pain: new models of behavior and their consequences for clinical practice. Clin J Pain. 2010;26:747–753. 13. Asmundson GJG, Parkerson HA, Petter M, et al. What ist he role of fear and escape/avoidance in chronic pain? Models, structural analysis and future directions. Pain Manage. 2012; 2:295–303. 14. Sullivan MJL. The communal coping model of pain catastrophising: clinical and research implications. Canad Psychol. 2012;53:32–41. 15. Wideman TH, Asmundson GGJ, Smeets RJ, et al. Rethinking the fear avoidance model: toward a multidimensional framework of pain-related disability. Pain. 2013;154:2262–2264. 16. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;Vol. 9: 745–758. 17. Melloh M, Elfering A, Presland CE, et al. Predicting the transition from acute to persistent low back pain. Occ Med. 2011;61:127–131.
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18. Hasenbring M. Endurance strategies—a neglected phenomenon in the research and therapy of chronic pain? [in German]. Schmerz. 1993;7:304–313, . 19. Hasenbring M, Marienfeld G, Kuhlendal D, et al. Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome. Spine (Phila Pa 1976). 1994;19:2759–2765. 20. Hasenbring MI, Hallner D, Rusu AC. Fear-avoidance- and endurance-related responses to pain: development and validation of the Avoidance-Endurance Questionnaire (AEQ). Eur J Pain. 2009;13:620–628. 21. Hasenbring MI, Klasen BW, Rusu AC. Risk factor-based cognitive-behavioral therapy for acute and subacute back pain. In: Hasenbring MI, Rusu AC, Turk DC, eds. From Acute to Chronic Pain. Risk Factors, Mechanisms, and Clinical Implications. New York: Oxford University Press; 2012:513–528. 22. Held SM, Rolke R, Treede RD, et al. Pain-related endurance, fearavoidance and somatosensory sensitivity as correlates of clinical status after lumbar disc surgery. Open Pain J. 2013;6:165–175. 23. Andrews NE, Strong J, Meredith PJ. Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93:2109–2121. 24. Hallner D, Hasenbring M. Classification of psychosocial risk factors (yellow flags) for the development of chronic low back and leg pain using artificial neural network. Neurosci Lett. 2004;361:151–154. 25. Hoogendoorn WE, Bongers PM, Vet de HCW, et al. High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study. Occup Environ Med. 2002;59:323–328. 26. Kujala UM, Taimela S, Viljanen T, et al. Physical loading and performance as predictors of back pain in healthy adults: a 5year prospective study. Eur J Appl Physiol. 1996;73:452–458. 27. Bakker EWP, Verhagen AP, van Trijffel E, et al. Spinal mechanical load as a risk factor for low back pain. Spine. 2009;34:E281–E293. 28. Wong KCH, Lee RYW, Yeung SS. The association between back pain and trunk posture of workers in a special school for the severe handicaps. BMC Musculoskelet Disord. 2009;10:43. 29. Abenhaim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic management of back pain. Report of the international Paris task force on back pain. Spine. 2000;25: 1–31. 30. Heneweer H, Vanhees L, Picavet HSJ. Physical activity and low back pain: a U-shaped relation? Pain. 2009;143:21–25. 31. Hasenbring MI, Plaas H, Fischbein B, et al. The relationship between activity and pain in patients 6 months after lumbar disc surgery: do pain-related coping modes act as moderator variables? Eur J Pain. 2006;10:701–709. 32. McCracken LM, Samuel VM. The role of avoidance, pacing, and other activity patterns in chronic pain. Pain. 2007;130:119–125. 33. Huijnen IPJ, Verbunt JA, Peters ML, et al. Differences in activity-related behaviour among patients with chronic low back pain. Eur J Pain. 2011;15:748–755. 34. Plaas H, Sudhaus S, Willburger R, et al. Physical activity and low back pain: the role of subgroups based on the avoidanceendurance model. Dis Rehab. 2013. [Epub ahead of print]. 35. Nielson WR, Jensen MP, Karsdorp PA, et al. Activity pacing in chronic pain: concepts, evidence, and future directions. Clin J Pain. 2013;29:461–468. 36. Pincus T, Greenwood L, McHarg E. Advising people with back pain to take time off work: a survey examining the role of private musculoskeletal practitioners in the UK. Pain. 2011; 152:2813–2818. 37. Hasenbring MI, Hallner D, Klasen BW, et al. Pain riskscreening-based cognitive-behavioral approaches (PARISCBA) for subacute LBP: results from a randomized controlled trial using “Graded Balance”. Poster presented at the 14th World Congress on Pain, Milan, Italy.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Effective Reassurance in Primary Care of Low Back Pain What Messages From Clinicians are Most Beneficial at Early Stages? Monika I. Hasenbring, PhD* and Tamar Pincus, PhDw
Objectives: Effective reassurance of patients reporting symptoms, for which no clear etiological origin is available, is one of the most important challenges in the early phases of nonspecific back pain. However, there is a lack of empirical studies on the effects of reassurance and, also, the effects shown were small. Improvements are needed with respect to the process of physician-patient interaction and to the methods used by the physician. Methods: We provide a short narrative review of the literature with special reference to affective and cognitive communication, based on a systematic review of 16 studies. We further consider recent evidence in the prognosis of low back pain, the role of physical activity, and subgroups-based individual differences in pain coping, questioning the information basis of reassurance. Results: A 2-process model of affective and cognitive reassurance was supported. Recovery improved in a combination of communication of empathy with cognitive reassurance, giving concrete information and instructions. In terms of information, recent research indicate that a substantial percentage of patients do not recover within the first year after onset of back pain. Further, very low and high levels of physical activity are associated with pain and disability, associated with cognitive and behavioral pain coping. Discussion: Reassurance of patients in early phases of persistent back pain might improve from affective and cognitive parts of communication and individually tailored information. Subgroup differences with respect to different prognosis, associated patterns of adaptive or maladaptive pain coping, and levels of health-promoting versus harmful physical activity should be considered more carefully. Key Words: primary care, low back pain, reassurance
(Clin J Pain 2015;31:133–136)
P
ain, such as low back pain (LBP) or headache, normally demands attention when interfering with certain ongoing activities in daily life. When people at first glance fear serious disease, they will consult their physician to clarify the cause of pain. As the pain is experienced in the body, patients suppose some organic causes the physician might detect. One of the main goals of patients is release from their pain to return to their normal activities without further disturbance.
Received for publication February 28, 2014; revised April 4, 2014; accepted March 5, 2014. From the *Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Bochum, Germany; and wDepartment of Psychology, Royal Holloway University of London, Egham, UK. The authors declare no conflict of interest. Reprints: Monika I. Hasenbring, PhD, Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Universita¨tsstr. 150, Bochum 44780, Germany (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/AJP.0000000000000097
Clin J Pain
Volume 31, Number 2, February 2015
In most cases of LBP, pain is apparently not caused by any serious pathology, such as fractures, neoplasms, spinal infections, or a serious disk prolapse. More than 80% of the patients report pain of unknown cause labeled as “non-specific LBP.”1,2 Instead, psychosocial factors are shown to predict and maintain chronic LBP, explaining part of the variance. Consequently, research in the recent decades has indicated a change from a purely “organic injury model” to a “biopsychosocial” understanding of the condition. Furthermore, several systematic reviews suggested a good prognosis for acute nonspecific LBP without invasive treatments.3 As a practical consequence, numerous national and international guidelines for the diagnostics and treatment of LBP correspond in their central recommendations: (1) after a clinical examination, which rules out so-called “red flags” (any signs of possible serious diseases), no further diagnostics, such as x-ray or magnetic resonance imaging (MRI) are necessary. (2) The adequate information of the patient includes reassurance about (a) the benign nature of their symptoms, and (b) the good prognosis during the next weeks and months, and (c) that pain will be resolved spontaneously in the majority of patients.3 Patients are encouraged to maintain or return to their normal level of activities and avoid bed rest. Consequently, reassurance techniques are most important in primary care of nonspecific LBP. As Linton et al4 pointed out in their topical review, the term reassurance refers to a process taking place during the interaction between the caregiver and the patient, method referring to the kind of information, instruction, or persuasion, and the outcome referring to whether the patients worries will be reduced and the recommendations will be translated into action in daily life. In the first part of the following review we will show that there is a surprising lack of empirical studies on the effects in consultations in primary care. There is sufficient evidence to suggest that some techniques are important and impact on short-term, and even on long-term, outcomes. However, the effects are mostly small, often transient, and even paradoxical effects are reported. Therefore, there is a need for more effective models of reassurance in pain management. In the second part, we introduce the distinction between cognitive and affective modes of reassurance, and describe the evidence for their unique contribution on patient’ outcomes. Finally, we question the validity of common messages that are recommended and used by clinicians in reference to adequate levels of activity. In synthesis, recent research indicates the need for better tailoring of reassurance interventions to specific subgroups of patients with LBP.
THE EFFECTS OF CURRENT REASSURANCE INTERVENTIONS A recent systematic review of reassurance in primary care5 identified 16 studies that measured what clinicians did www.clinicalpain.com |
133
Clin J Pain
Hasenbring and Pincus
in the consultations and analyzed these interactions in reference to patients’ outcomes. The review was limited to symptoms for which there is no clear etiological pathway and prognosis and treatment response are variable. Symptoms that require frequent testing, monitoring, and management by clinicians were excluded, thus making the evidence relevant to LBP, although only one study was found that focused exclusively on this group. Of importance, the analysis was based on a published model6 of persuasive reassurance, that splits clinicians’ reassuring behaviors into 2 groups: affective reassurance, which includes the sets of messages and communications that aim to increase rapport, communicate empathy, and give patients a generic message that they are heard, cared for, and things will turn out right. Cognitive reassurance, in contrast, is an educational neutral type of communication, in which explanations are given, possible prognosis and treatment are discussed, and clarifications are offered. The authors of the original model maintain that patients engage with one or the other but cannot process both types of reassurance simultaneously. This, they argue, is because when affective reassurance is offered, patients respond by reduced anxiety and the sense that the clinician will “take care of them.” This will impact their willingness and ability to work to take on the information offered through cognitive reassurance, which is slower to process and demands more effort. Thus, Coia and Morley6 argue that when the patient is subsequently away from the consultation and the problem rises again, they have no new tools to deal with it, and they are left in a cycle of dependency and helplessness. Pincus et al5 set out to examine the model in primary care by including only prospective studies that measures consultation components in a way that enabled their categorization into cognitive or affective reassurance. The review’s findings are intriguing. Although there is a plethora of narrative publications on patient-centered consultations, the review found only 16 empirical-eligible studies, of which 8 were considered to be of good methodology. Affective reassurance was inconsistently associated with patients’ satisfaction and sense of enablement at consultation exit, but 3 high-methodology studies found an association with higher symptom burden and less improvement at follow-up. Cognitive reassurance, in contrast, was associated not only with higher satisfaction and enablement and reduced concerns directly after the consultations in 8 studies, but also with improvement in symptoms at follow-up in 7 studies and with reduced health care utilization in 3 studies.
OPTIMIZING THE PROCESS: THE IMPACT OF AFFECTIVE REASSURANCE Jumping to the conclusion that affective reassurance is bad for patients would be ill-advised. The review authors caution that early stages of the consultation in which patients’ concerns need to be elicited through sensitive questioning and listening will require empathy and rapport to create trust. They go on to state that it is not known whether cognitive reassurance can be provided without affective reassurance and highlight the possibility that the findings for affective reassurance may be a result of a third variable, some risk factor for poor outcomes that practitioners respond to by providing more affective reassurance. Although more research on affective reassurance is needed, the clear message from the review concerns the positive impact of giving clear information that is acceptable to
134 | www.clinicalpain.com
Volume 31, Number 2, February 2015
patients. How to do so in the context of uncertainty about etiology, prognosis and treatment that best matches the individual patients’ needs remains a mystery and should form priority for research. What is clear, although, is that a uniform message to all patients is inadequate, and for subgroups with high risk for the development of chronic pain problems, generic messages about expected recovery will constitute false reassurance.
OPTIMIZING THE METHOD: INDIVIDUALLY TARGETING PATIENT REASSURANCE On the basis of recent evidence, we question the validity of current information on prognosis and physical activity and we discuss in more detail whether providing all patients with the same information will be still appropriate. We furthermore suggest integrating information on the biopsychosocial nature of nonspecific LBP into the process of reassurance.
Good Prognosis: Only Valid for Patients Without “Yellow Flags”? The kind of information, primary care physicians are suggested to consider by current guidelines, concerns primarily negotiations: there is “no” serious disease, “no” MRI is necessary, and “no” bed rest is indicated. Consequently, patients are encouraged to keep their level of activity and wait, because the prognosis would be good in terms of reduction of pain in most patients. Thus, although the patient experiences pain, which can be severe, they leave the practice without valid information or adequate tools to deal with their pain and its consequences. Cases in which the pain will diminish within a few days might not be a major problem. However, in cases in which pain persists, the patient might feel let down by their clinician and starts distrusting their clinical decision. This in turn may lead to further health care utilization and searching for a justification for the pain, often through requests for tests such as MRI. The question arises whether the latter case is so seldom that it may be neglected. Current rates of disability and costs for LBP suggest that this scenario is not rare.7 In fact, although current guidelines suggest that acute LBP will resolve spontaneously within a few days or weeks in >90% of the patients,3 more recent prospective studies indicate a significantly higher rate of pain problems during the year after onset of acute pain. For example, Hestbaek et al8 published a systematic review including 36 prospective studies in primary and secondary care indicating persistent or recurrent LBP at 1 year follow-up in 42% to 75% of the cases. More recently, Itz et al9 reported data from a review of 11 studies in primary care. Considering recovery as total absence of pain, 71% of the patients still reported pain at 12-month follow-up. Using less stringent criteria, 57% were evaluated as not recovered. The authors argue that the difference between these reviews and guideline recommendations is based on differences in outcomes and study samples. The evidence of a good prognosis was primarily based on studies in occupational medicine using outcome criteria such as “return to work,” “pain-related disability,” or combined criteria. Thus, patients who returned to work despite pain, even despite severe pain, were assigned as recovered. Given the high rate of recurrent or persistent pain during the first year after onset of acute LBP, adequate reassurance should address the problem of ongoing pain in
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subgroups of patients. As there is convincing evidence from several systematic reviews that10,11 psychosocial risk factors, such as emotional distress and maladaptive coping with pain, have a significant impact on the maintenance of acute/subacute nonspecific LBP, both eliciting and giving information should include known maladaptive pain responses. Ideally, clinicians should also offer adequate models of the possible development of chronic pain.12–15 For example, there is evidence that cognitive pain responses, such as catastrophizing and helplessness/hopelessness, ongoing with high pain anxiety and fear of (re)injury will increase the probability of future pain and pain-related disability.16,17 In contrast, cognitions such as thought suppression and distraction from pain are also described as high risk factors in sciatic pain18,19 as well as in nonspecific LBP.20–22 On a behavioral level, there is evidence not only for the role of avoidance behavior leading to chronic pain and disability, probably mediated by physical disuse, but also for the role of marked endurance behavior, which is maintained despite severe pain.19,21,23 The avoidance-endurance model (AEM) conceptualizes both extremes, fear avoidance versus endurance as maladaptive pathways leading to ongoing pain in long term by physical underuse or overuse/overload.12 Using a short AEM-based screening method,24 Hasenbring et al21 investigated 174 primary care patients with subacute LBP at the start of their outpatient treatment and 6 months later. Subgroups with marked fear avoidance or endurance pain responses revealed significantly more pain than an adaptive subgroup. In summary, current recommended reassurance messages, which focus on offering information on a good prognosis of LBP, seems to be adequate only for patients showing low levels of distress and an adaptive pain response pattern but may be inadequate or even counterproductive for several other patient groups.
Return to Normal Activity: What is Normal to Whom? Current reassurance interventions in acute LBP involve encouragement of the patients to maintain or increase their level of physical activity in daily life. These recommendations are mainly based on results of randomized controlled trials comparing the prescription of bed rest with the encouragement to stay active.3 In most studies, outcomes indicate better results for activity maintenance, although the level of activity patients had actually engaged in was not measured. As the prescription of bed rest is pretty consistent, but levels of activity differ vastly between people, it is safer to interpret the findings as indicating that bed rest is bad for patients, rather than that maintaining activity at prepain levels is beneficial. This latter interpretation is also in contradiction with findings from studies showing physical activity as positively related to LBP, especially when accompanied with high spinal load.25–28 In 2000, the International Paris Task Force on Back Pain provided some evidence on high versus low levels of physical activity, both linked with LBP, suggesting a U-shaped relation between activity and LBP.29 Analyzing cross-sectional data from a Dutch population-based sample of >3000 patients with chronic LBP, Heneweer et al30 supported this hypothesis at least for female patients. Sedentary behavior and an overall low physical activity level assessed by self-reported data revealed an increase in LBP similar to a very high level of activity, whereas a moderate level was associated with less pain. Copyright
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Furthermore, there is a recent line of research investigating the relationship between pain-coping responses, the level of physical activity, and pain outcomes.31–33 Using objective accelerometer-based measurement of physical activity, there is preliminary evidence that patients showing marked fear-avoidance behavior display high pain and disability and a low level of general physical activity, as well as a low level of static load positions such as forward bent sitting or standing. In contrast, patients showing marked endurance pain response pattern revealed highest levels of pain intensity accompanied with significant higher levels of general activity and static postures compared with fear-avoidance patients and, also compared with an adaptive group.31,34 The adaptive group has shown moderate levels of self-reported avoidance and endurance and the lowest levels of pain intensity and disability besides moderate physical activity.21 Taken together, there is growing evidence that some subgroups of patients with LBP run the risk of developing persistent pain, related not only to low levels of activity but also in relation to very high level of physical activity. Until now, there have been difficulties in the definition of a level of overactivity and/or underactivity in general and to recommend strategies of pacing activities in daily life.35 One solution might be the assessment of adaptive or maladaptive pain responses encouraging fear-avoidance patients to increase their level of activity while recommending pacing strategies, including short breaks for rest and relaxation to endurance patients. Maintaining their normal level of physical activity might be adequate solely for an adaptive subgroup as discussed above.34 In sum, inflexible recommendation of high levels of exercise and activity do not appear to benefit patients. Indeed, there is emerging evidence that many practitioners endorse short breaks from normal activity (including work) to allow for healing and sufficient time to engage with rehabilitation.36
The Role of Individual Targeted Reassurance in LBP Screening for psychosocial risk factors in patients with acute/subacute LBP and the development of individual targeted interventions is realized within several concepts of cognitive-behavioral education and treatment (see review21). The question arises whether the process of reassurance provided by the primary care physician may be improved when based on a yellow-flag screening and using individually targeted recommendations. To our knowledge, there is preliminary evidence that providing patients with subacute LBP with their individual AEM-based risk pattern and discussing possible ways out of these response patterns within a short session of 15 minutes duration leads to significant reduction of pain and disability with moderate effect sizes, even 12 months after the first consultation.37 These results fit well with new evidence on the role of cognitive reassurance for patients described above.5 As these results are rather promising, further research in large patient samples needed to improve reassurance interventions based on individual patterns of pain cognition, affect, and behavior.
CONCLUSIONS Patients experiencing nonspecific LBP who consult primary care health providers need effective reassurance about the benign nature of their disease. Furthermore, they need valid information about the prognosis of their symptoms and
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adequate tools to deal with their pain and its consequences. This topical review has shown that reassurance consists of both cognitive and affective components. However, further research is needed to determine the coordination of both parts to increase symptom release, well-being, and lowering health care costs. We further demonstrated that information based on current guidelines should be updated regularly to create valid recommendations for patients. Specifically, information on prognosis and on adequate levels of physical activity should address recent research indicating the necessity of a practice of individually tailored reassurance. Too low but also too high levels of physical activity mediated by maladaptive individual pain-coping behaviors may afford a differential concept of reassurance instead of generic messages. There is a need to investigate whether individually targeted measures of reassurance lead to better patient outcomes than generic information.
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