The missing link - Return to Work Matters

Take Home Messages
When trying to determine the risk of developing long-term disability in low back pain patients, clinicians may need to shift their focus from medical issues to psychosocial issues.

This study shows that most questions asked in examinations are focused on biomedical factors, while more attention should be focused on psychosocial factors. These lifestyle-based queries may be on topics such as:

Patient’s views about functional limitation;
Self-care practices; and
The ability to modify physical demands at home and at work.

In higher-risk patients, while more biomedical questions were asked, more lifestyle questions were not. Therefore, the nonmedical factors commonly associated with the transition to chronic pain were largely unrecognised.

Why the research matter
Low back pain places a significant burden on both the individual and the economy.

Evidence suggests that personal circumstances, pain beliefs, and other nonmedical and psychosocial factors have a greater impact than physical factors on the development of chronic pain and disability. Therefore, effective communication between the patient and the clinician is crucial in identifying these risk factors so that early intervention may be possible.

What the research involved
This study, conducted in the U.S.A, looked at factors which may impact communication between patients with low back pain and their treating clinician. The study recruited 97 patients seeking initial treatment for work-related low back pain from ten different community based occupational medicine clinics.

Participants completed a questionnaire to identify risk factors for developing chronic pain and disability, such as:

Physical health;
Pain beliefs;
Mood;
Expectations for recovery; and
Workplace factors.

Most participants then agreed to have their visits with their treating clinician audiotaped.

The data gathered by the questionnaire was used to classify participants as low, medium or high risk for developing a long-term disability. The information gathered by the audiotapes was analysed to assess the communication between the participant and their treating clinician.

Summary of research findings
The study found that for participants identified as high risk of developing long-term disability:

Clinicians asked more biomedical questions;
Patients provided more biomedical information; and
Clinicians talked more to engage patients and facilitate communication.

The study concluded that clinicians do recognise the need for more detailed assessment of patients at high risk of developing long-term disability. However, increases in communication are focused on medical explanations and treatment plans, while lifestyle and psychosocial factors are neglected.

Original research
Does the presence of psychosocial "yellow flags" alter patient-provider communication for work-related, acute low back pain?

Shaw WS, Pransky G, Winters T, Tveito TH, Larson SM, Roter DL.

J Occup Environ Med. 2009 Sep;51(9):1032-40.

Link to PubMed abstract