http://orcid.org/0000-0001-8024-9049
Figures
Abstract
Background
An improved understanding of patients’ perceived needs for medical services for low back pain (LBP) will enable healthcare providers to better align service provision with patient expectations, thus improving patient and health care system outcomes. Thus, we aimed to identify the existing literature regarding patients’ perceived needs for medical services for LBP.
Methods
A systematic scoping review was performed of publications identified from MEDLINE, EMBASE, CINAHL and PsycINFO (1990–2016). Descriptive data regarding each study, its design and methodology were extracted and risk of bias assessed. Aggregates of patients’ perceived needs for medical services for LBP were categorised.
Results
50 studies (35 qualitative, 14 quantitative and 1 mixed-methods study) from 1829 were relevant. Four areas of perceived need emerged: (1) Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, receive management options, sickness certification and legitimation for their LBP. However, there was dissatisfaction with the cursory and superficial approach of care. (2) Patients had concerns about pharmacotherapy, with few studies reporting on patients’ preferences for medications. (3) Of the few studies which examined the patients’ perceived need of invasive therapies, these found that patients avoided injections and surgeries (4) Patients desired spinal imaging for diagnostic purposes and legitimation of symptoms.
Conclusions
Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of LBP, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy. Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of LBP in order to improve patient outcomes.
Citation: Chou L, Ranger TA, Peiris W, Cicuttini FM, Urquhart DM, Sullivan K, et al. (2018) Patients’ perceived needs for medical services for non-specific low back pain: A systematic scoping review. PLoS ONE 13(11): e0204885. https://doi.org/10.1371/journal.pone.0204885
Editor: M. Barton Laws, Brown University, UNITED STATES
Received: May 18, 2017; Accepted: September 17, 2018; Published: November 8, 2018
Copyright: © 2018 Chou et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This work was performed in partnership with Move: muscle, bone & joint health and was supported by a partnership grant awarded by the organisation. L.C is the recipient of an Australian Postgraduate Award and Arthritis Foundation Scholarship. T.R is the recipient of an Australian Government Research Training Program Scholarship. D.M.U and A.E.W are recipients of NHMRC Career Development Fellowships (Clinical Level 1 #1011975 and Clinical Level 2 #1063574). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Low back pain (LBP) is the leading cause of disability worldwide[1]. It is highly prevalent and is associated with pain, functional impairment, long-term incapacity, work absenteeism and high utilisation of healthcare[1,2]. LBP is costly, amounting to an estimated $88billion in the United States in 2013, with medical services comprising a considerable proportion of the incurred expenditure[3]. Consequently, several guidelines have been developed to guide the different presentations of acute and chronic back pain management, to direct clinical practice and to rationalise health care resource utilisation appropriately[4–10]. These guidelines recommend, as relevant to pain duration, a thorough clinical evaluation to exclude serious spinal pathology, judicious use of radiology, patient education to support optimal self-management, exercise therapy, psychological therapies for some people, short-term use of prescription medications and spinal manipulation for pain relief[6–10]. However, the publication and dissemination of guidelines does not ensure their implementation[11,12] and previous studies have demonstrated poor uptake of guidelines for the management of LBP [13–17]. Instead, there has been a significant rise in opioid prescribing for LBP, with a resultant 660% increase in expenditure in the United States[18] and an increase in complications such as opioid dependence, addiction and mortality associated with overdose[19]. Spinal imaging has also been inappropriately utilised (overuse when not indicated and underuse when indicated) [20], which has further contributed to the growing financial burden of LBP, as well as other ramifications including additional investigations, referrals and potentially invasive procedures, that for most represent low-value care[8]. Furthermore, despite the recommendations for active rehabilitation such as exercise therapy for LBP, less than 50% of patients report being referred for active rehabilitation programs [17,21]. Collectively, these practices have contributed to unhelpful beliefs held by clinicians and the public concerning appropriate management of LBP, with calls for reframing how back pain is understood and managed [22].
Clinical practice guidelines face multiple impediments to implementation. Barriers to execution include environmental factors, such as resource allocation and costs, as well as clinician-related barriers, including a lack of agreement with clinical practice guidelines, lack of awareness and familiarity with recommendations[16,23]. Patient factors are also critical to the successful uptake and adherence to guidelines[16,17]. Clinicians have reported that patients’ preferences are an important cause of non-adherence to guidelines[17]. Patients’ non-adherence may be related to the high level of patient dissatisfaction with LBP management from medical practitioners[24,25], which has historically focused on a biomedical model of care. This biomedical approach is typically based on the scientific academic literature conducted by healthcare professionals. However this approach may be flawed as it neither adequately takes into account the patient perspective, nor satisfactorily consider the psychological and social drivers to the pain experience[26]. Although there are previous reviews summarising the evidence regarding patient expectations and experiences of healthcare for LBP, none of these have focussed on the patients’ perceived needs for medical services[26,27]. Therefore, we aimed to review the existing literature regarding patients’ perceived needs for medical services for LBP.
Methods
A systematic scoping review, based on the framework proposed by Arksey and O’Malley, was performed to enable a comprehensive exploration of the patients’ perspective[28]. Systematic scoping reviews are aimed at mapping key concepts, identifying gaps in the evidence, and reviewing different types of evidence[29,30]. This review was conducted within a larger project examining the patients’ perceived needs relating to musculoskeletal health[31]. The study methodology is similar to a previously published review examining patients’ perceived needs of health services for osteoarthritis[32].
Search strategy and study selection
The literature search was performed by electronically searching relevant databases (MEDLINE, EMBASE, CINAHL and PsycINFO) between January 1990 and June 2016. This time period was chosen to include relevant studies examining the current patient perspective. The search strategy (see S1 File for full OVID Medline search strategy) was developed by one of the study investigators (MS), with input from clinician researchers (Rheumatologists, FC and AW and Physiotherapist, AB), a patient representative and an academic librarian (KL). The strategy combined both MeSH terms and text words to capture information regarding patients’ perceived needs for medical services for LBP (S3 Supplementary Appendix). We have used the term “medical services” to include any service provided by medical practitioners, including general practitioners, specialist physicians and surgeons. A broad definition was used for “patient perceived needs”, which referred to patients’ perception of services that provided them with the capacity to benefit, including their expectations of satisfaction and preferences for medical services[33]. LBP was defined as non-specific LBP, with or without leg pain, excluding back pain from fractures, malignancy, infection and inflammatory spinal disorders.
Two reviewers, including LC and one of LC, TR and WP independently assessed the titles and abstracts of all studies identified by the initial search for relevance. Discrepancies in the inclusion of studies were reviewed by a third investigator (AW) to reach consensus. The initial screening was set to be open-ended to retain as many relevant studies as possible, with no restriction on the study methods. Studies were included if they met the following criteria: (1) included patients older than 18 years, (2) recruited patients with non-specific LBP and (3) reported on patients’ perceived needs for medical services for LBP. Studies were limited to human studies in the English language and full-text articles. No restrictions were applied to the prevalence of LBP and studies concerning acute, subacute and chronic LBP were included. Those that appeared to meet inclusion criteria were retrieved and the full text was assessed for relevance (LC). The reference lists of identified studies and review articles were searched to find possible further studies for inclusion.
Data extraction and analysis
The following data were systematically extracted by one investigator (LC) using a data extraction form specifically developed for this review: (1) primary study aim, (2) study population (patient age and gender, population source, population size and definition of LBP), (3) description of the study methods and (4) year of publication. Included studies were reviewed to identify aspects of medical services that patients had a preference for, expected, or were satisfied with using principles of meta-ethnography to synthesise qualitative data[34]. One author (LC) developed a framework of concepts and underlying themes, based on primary data in the included studies. Reciprocal translational analysis[34] was then undertaken to identify key concepts from individual studies and then translating and comparing these concepts to other studies to gradually explore and map the overarching themes. Data was extracted based on a customised data collection form. The framework of concepts and underlying themes were independently reviewed by three senior authors (FC and AW with over 15 years of clinical rheumatology consultant-level experience and a senior physiotherapist, AMB) to ensure accuracy of the extracted data and clinical meaningfulness.
Methodological quality assessment
To assess the methodological quality of the included studies, two from a panel of three (LC, TR, WP) independently assessed the methodological quality of all included studies.
Qualitative studies were assessed using the Critical Appraisal Skills Programme (CASP) tool[35]. The CASP is commonly used to assess qualitative research studies[35]. This tool has 10 questions that assists readers appraise articles based on appropriate research design (CASP questions 2–3), sampling (CASP question 4), data collection (CASP question 5), bias (CASP question 6), ethical issues (CASP question 7), data analysis (CASP question 8), research findings (CASP question 9) and the value of the research (CASP question 10). Each question is scored ‘yes’, ‘no’ or ‘cannot tell’ regarding the study quality and potential for bias. This is no overall score for the level of bias.
Hoy’s risk of bias tool was utilised to assess the external and internal validity of quantitative studies. This tool was developed to examine study quality and risk of bias in prevalence studies. This tool is comprised of 10 questions that assess the external validity (questions 1–4) and internal validity (questions 5–10) of a study. Each question is scored either ‘yes’ (low risk of bias) or ‘no’ (high risk of bias). Thus for a study to be determined to be at a low risk of bias it was defined as scoring 8 or more “yes” answers, moderate risk of bias was defined as 6 to 7 “yes” answers and high risk of bias was defined as 5 or fewer “yes” answers[36]. Disagreements were resolved initially through consensus, with remaining conflicts reviewed by the senior author (AW).
Results
Overview of articles
The search returned 1829 articles, of which 50 studies explored LBP patients’ perceived needs for medical services (Table 1). A PRISMA flow diagram detailing the study selection is shown in Fig 1. The descriptive characteristics of the included studies are shown in Table 1. Of these, 19 were from the United Kingdom[24,25,37–54], 13 from the United States of America[55–66], 9 from Europe[67–75], 8 from Australasia[76–83] and one from the Middle-East[84].
The duration of back pain was either undefined or mixed in 39 (78%) studies[24,25,37–43,45–47,50,51,55–65,67–69,72–77,79–81,83,84] . While 11 (22%) studies reported on chronic back pain (>12 weeks duration)[44,48,49,52–54,66,70,71,78,82].there were no studies on acute back pain alone (<6 weeks duration).
There were 35 qualitative studies[25,37,38,40–46,48–54,59–61,65–69,71,74,75,77–79,81–84] with participant numbers ranging from 7 to 110, with a median of 23. There were 14 quantitative studies[24,39,47,55–58,62–64,70,72,73,76,80], with a median participant number of 628 (range 124–1555). Mixed methods were utilised in 1 study[70], which had 348 participants. A total of 10976 participants were included in this review. Of the 32 studies that presented summary statistics, the median age of the participants was 50 years with a female predominance (58% female).
Quality of studies
Quality assessments of the included studies are presented in the Figs 2 and 3. The overall quality of qualitative studies was poor (Fig 2), especially for CASP criteria 4 to 6, indicating potential biases with data sampling and collection. The quantitative studies were of low quality: 10 studies were at high risk of bias, 4 studies were at moderate risk of bias and only 2 studies were at low risk of bias (Fig 3). The quality scores for both qualitative and quantitative studies largely reflected potential biases with recruitment strategy and data collection.
1CASP 1: Was there a clear statement of the aims of the research 2CASP 2: Is a qualitative methodology appropriate? 3CASP 3:Was the research design appropriate to address the aims of the research? 4CASP 4: Was the recruitment strategy appropriate to the aims of the research? 5CASP 5: Was the data collected in a way that addressed the research issue? 6CASP 6: Has the relationship between researcher and participants been adequately considered? 7CASP 7: Have ethical issues been taken into consideration? 8CASP 8: Was the data analysis sufficiently rigorous? 9CASP 9: Is there a clear statement of findings? 10CASP 10: How valuable is the research?
1Criteria 1:Was the study’s target population a close representation of the national population in relation to relevant variables? 2Criteria 2: Was the sampling frame a true or close representation of the target population? 3Criteria 3: Was some form of random selection used to select the sample OR was a census taken? 4Criteria 4: Was the likelihood of nonresponse bias minimal? 5Criteria 5: Were data collected directly from the subjects? 6Criteria 6: Was an acceptable case definition used in the study? 7Criteria 7: Was the study instrument that measured the parameter of interest shown to have validity and reliability? 8Criteria 8: Was the same mode of data collection used for all subjects? 9Criteria 9: Was the length of the shortest prevalence period for the parameter of interest appropriate? 10Criteria 10: Were the numerator(s) and denominator(s) for the parameter of interest appropriate.
Results of review
Four areas of perceived need were identified from the included studies (Tables 2–5).
The perceived need for medical practitioners (Table 2)
Twenty-three papers discussed the patients’ perceived role of the medical practitioner in the management of LBP[25,37,38,40,43,50,52,53,59,61,67,69,73,74,79–85]. A consistent theme that emerged from patients recruited from general practice [69,81,84,86], the community[43,60] and tertiary care was the need to obtain a diagnosis and a cause of the pain[37,38,59,60,67,69,79,81,84]. Other reasons for seeking medical care included a need to obtain medications for pain relief[50,51,61,80], to receive advice and discussion of options for LBP management[38,61,85], to receive sickness certification and legitimation of their back pain[25,51,52]. Patients also considered consultation with primary care medical practitioners as an opportunity to explore alternative medicines[25,61] and to obtain referrals to specialist medical or surgical services[73]. Patients generally viewed medical practitioners to be knowledgeable about their pain[53,79] and could provide individual assessment [83]. Westmoreland found that patients perceived the strengths of the medical practitioner to include continuity of care, listening and counselling skills[40].
Six studies identified factors related to patient preferences regarding the role of medical practitioners in LBP and their satisfaction with them[24,41,49,62,63,74]. Patients described having faith in medical practitioners and a dependence on them and professions allied to medicine[49]. Fifty-one percent of patients thought that specialist referral was valuable[24]. Patients have reported reluctance by the general practitioner to refer patients to a specialist[41]. A single study by Carey found that patients who saw orthopaedic surgeons reported higher satisfaction than those who saw primary health care providers[63].
Patients expressed their reasons for consultation with a medical practitioner in 3 studies[58,59,64]. It has been reported that 98% of patients sought medical care due to difficulty with normal activity and 95% of patients wanted to find the cause of their pain[59]. Patients with greater pain and more severe functional impairment were more likely to seek medical help for their symptoms[58,64].
Eleven studies reported on the patients’ perceived inadequacies of the medical practitioners[37,40,41,45–47,51,53,60,68,84]. Dissatisfaction with medical practitioners was reported from both qualitative[40,45,46,51,53,60,68,84,87,88] and quantitative[47] studies, as well as from all levels of care, including general practice[40,46,51,84,87], community-based[47,60], allied health clinics[45,47] and tertiary centres}[53,88]. Coole and Liddle found that patients felt there was little to be gained by consulting their primary care medical practitioner about their LBP[51,68] as they believed that they lacked specialist knowledge[41,46,47]. Patients felt that their consulting time with their medical practitioner was restricted and that therapeutic options were limited[40,45] and not individually tailored[47]. Furthermore, patients complained that medical practitioners had a cursory and superficial approach to the management of LBP, lacked empathy and had a tendency to be dismissive or delegitimise their symptoms[37,40,45,53,84]. Patients were disappointed that their medical practitioner did not provide a diagnosis[46,60] and they felt that the medical practitioner’s primary focus was on prescribing pain medications[53,68]. Also, patients were displeased with the delays in obtaining referrals to physiotherapy[45]. Patients also felt that once certain pathological causes of LBP were eliminated, medical practitioners appeared to slacken their investigations into the aetiology of pain[84].
The perceived need for pharmacological management (Table 3)
Thirteen studies examined the need for medications[24,39,41,43,48,51,57,65,67,69,74,81,82]. Of these, 5 studies reported that patients preferred medications[24,43,57,74,81], and that analgesics enabled them to cope with their social life and activities of daily living[67]. Patients believed that medications would enable relaxation of muscles, reduce inflammation, provide pain relief, enable activity and prevent worsening of LBP[48]. Narcotic use was reported in 1 study to be associated with patient satisfaction[57]. However, Buchbinder found that only 20% of patients presenting to an academic Emergency Department with LBP requested analgesics, and those that did utilised strategies of mitigation, indirection and deference which suggested that they were aware of the intricacies of their requests[65]. Other studies of patients attending either rehabilitation or pain management programs found that the patients were generally dismissive of medication as a treatment[50] and felt that drugs were neither important nor appropriate in the management of LBP[39]. Furthermore, patients have described their general practitioners as being too “keen to dish out drugs” and patients viewed medication use as treating symptoms rather than managing the actual problem[41]. Some patients would only take medications if strictly necessary[69] and were generally resistant to taking medication regularly[82].
Patients recruited from all levels of healthcare (i.e. general practice, the community, specialist referral centres and allied health practitioners) have concerns regarding medications, which were reported in 8 studies[42,44,48,54,65,74]. Patients were apprehensive about the side-effects of medications and the potential for addiction and desensitisation[42–44,48]. Many patients felt trapped in a vicious cycle of increasing pain and consumption of drugs[42,74]. They were also concerned about the impact of medications on their work[51]. Furthermore, patients have reported confusion about medications and a lack of explanation by their healthcare provider[54]. Patients also expressed a reluctance to request analgesics for fear of stigmatisation, and if they did request medications, they were more likely to do so indirectly, particularly opioid-based analgesics[65].
The perceived need for interventional therapies (Table 4)
Five studies explored patients’ preferences for interventional treatment for LBP[44,48,55,70,75]. A single study by Lyons assessed patients’ preferences for injection therapy and found that most patients avoided injections and would “rather live with the pain”[44]. Two studies reported that patients would rather avoid surgery and viewed surgical intervention as a last resort[44,48]. Franz found that half of the patients referred to a neurosurgical clinic were willing to undergo surgery in the absence of pain if they had radiological abnormalities, however, only 33% of patients believed surgery to be more effective than physical therapy[55]. Patients were willing to wait 2 years for the effects of conservative treatment to avoid surgery[70]. In comparison, Lacroix stated that patients felt that “there comes a moment when an operation becomes inevitable”[75]. Patients who preferred surgical intervention were more likely to be male, have higher pain scores and a longer duration of pain[55,70].
The perceived need for imaging (Table 5)
Both qualitative and quantitative studies found that patients wanted imaging of their spine to find a diagnosis of their LBP[24,69,76,77,81]. Hoffman reported that most patients expected their general practitioner to refer them for an x-ray, particularly if they felt that their pain was severe[81]. Amonkar found that more than 60% of participants thought that back x-rays were a positive investigation[24]. Many patients felt that x-rays provided reassurance as well as confirmation of their general practitioner’s diagnosis[38,81]. Furthermore, imaging that showed a physical defect seemed to provide closure[66] and relief[85] for patients and patients sought diagnostic imaging as a means to legitimise their back pain[59,60,77].
Two studies examined the characteristics of patients requesting spinal imaging[56,76]. Wilson found that radiology utilisation was associated with the severity of back pain and a history of osteoporosis[56]. Jenkins reported that increased age, lower education level, non-European cultural background, history of previous spinal imaging and negative beliefs about back pain were associated with a perceived need for imaging[76].
Discussion
This review identified 50 relevant articles that explored patients’ perceived needs for medical services for LBP. Four main areas of perceived need emerged, related to the need for (1) medical practitioners, (2) pharmacotherapy, (3) interventional therapies and (4) diagnostic evaluation. Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, sickness certification and to receive management options. However, patients were dissatisfied with a biomedical approach to care provided by medical practitioners. Patients saw a need for pharmacotherapy in pain management to facilitate function, however, they had concerns about medication side-effects and a fear of stigmatisation. Of the limited studies that examined the patients’ perceived need for invasive therapies, they reported that patients tend to avoid these treatment modalities. Furthermore, patients had misplaced beliefs about the necessity of imaging, and desired spinal imaging for diagnostic purposes and legitimation of symptoms.
Patients perceive a need for medical practitioners to obtain a diagnosis and strategies to cope with LBP and the associated disability[89],[25,37,38,50,51,59–61,67,69,74,79–85]. In particular, patients with greater pain and more severe functional limitation sought medical help[58,59,64], thus highlighting the urgent need for more comprehensive and targeted delivery of effective and tailored pain management and coping strategies. In particular, it reinforces the importance of educating patients that in more than 90% of cases LBP cannot be attributed to a pathoanatomic cause, and is thus termed ‘non-specific’. Here, it is critical to reassure patients about their presentation and prognosis. [90]. The patients’ utilisation of medical services for sickness certification and legitimisation of their back pain has also clearly emanated from this review[25,43,50–52,60,69,79,84]. This mirrors the complexity of LBP and the widespread impact of the condition on social functioning, financial security and workplace satisfaction.
Patients have areas of dissatisfaction with the medical approach to management of LBP. They have expressed a lack of confidence in general practitioners in the management of their LBP[41,46,47], which may reflect the knowledge gap in primary care settings in LBP management[91,92]. This reinforces the need for training medical practitioners and further targeted education campaigns to upskill clinicians[93,94]. Patients were also displeased with the biomedically-focussed and cursory approach of medical practitioners in managing LBP[37,40,41,45–47,51,53,60,84]. This frustration with medical practitioners may stem from the biomedical paradigm used by many healthcare providers, which does not adequately consider the important psychological and social drivers to a pain experience nor address the patients’ need for holistic care[95]. Importantly, reliance on a biomedical approach to diagnosis and care in low back pain presentations is now considered overly reductionist and discordant with contemporary pain science. There is emerging evidence supporting the implementation of tailored therapy, addressing not only the physical aspects but also psychological factors in healthcare delivery for people with chronic LBP: this has been shown to improve health outcomes[96,97]. Despite a body of evidence supporting the biopsychosocial paradigm, practitioners encounter challenges in executing this approach to care[91,98]. In recent years, musculoskeletal Models of Care have been introduced[99–101]. These provide evidence-informed strategies for the delivery of patient-centred healthcare, including multidisciplinary pain management clinics, community-based education groups for patients, self-management group and individual programs for patients and carers, and education programs for primary care physicians. These interventions have been shown to improve health outcomes in terms of service delivery, patient satisfaction and health costs[96]. Further research is required to improve their implementation, assess cost effectiveness and promote the long-term sustainability of these approaches to care.
There is a wide spectrum of patient perceived need for pharmacotherapy in the management of LBP. Their needs are in line with current recommendations, with due consideration of potential side effects which require careful monitoring[102–105]. This review found conflicting beliefs regarding pharmacotherapy amongst patients, with some expecting medications for LBP management[24,43,48,50,57,67,74,81], whereas others were concerned about medication side-effects and the potential for addiction and desensitisation[42–44,48,50,54,65,74]. There is a critical need to rationalise the utilisation of prescription medication for LBP[106] with the recent epidemic of prescription drug misuse, particularly in developed countries[107,108]. The excessive use of opioids is problematic as there is little evidence to support the use of opiates for longer than 12 weeks, there are significant risks of addiction and death[107,109], and substantial costs[110]. This highlights the need for more effective training of medical practitioners in pain management and counselling patients regarding the use of prescription analgesics. Additionally, widespread patient education programs informing patients about the potential risks of pharmacotherapy, particularly opioids, should be provided and may have positive behavioural consequences that can lower the risk of addiction and abuse related to prescription medications[111].
Although some patients perceive a need for invasive interventions to manage LBP, there is limited or inconclusive evidence to support its use[112,113]. In addition to rising costs of pharmacotherapy for LBP, the costs of interventional therapies such as epidural and facet joint injections, as well as spinal surgery have also risen substantially[7]. Despite the widespread use of interventional modalities, this review identified only five studies[44,48,55,70,75] that described patients’ perceived needs for these therapies. These found that patients wanted to avoid interventional therapies such as injections and surgery[44,48,70]. Patients who preferred invasive interventions were more likely to be male, have higher pain levels and a longer duration of symptoms[55,70]. The relationship between their preferences and understanding of the risks and benefits of these procedures was not reported. These studies mainly recruited patients from hospitals, general practices or chiropractic clinics, thus representing a population of patients that have actively sought care for the management of their LBP, and potentially may have more disabling or persistent pain and are self-selected for a biomedically-oriented belief system about the aetiology of their pain. Health system interventions may need to be introduced to limit access to these therapies that lack evidence of effectiveness. Patient education and pain multidisciplinary management programs which embrace a biopsychosocial approach to care may also be used to better equip patients with more appropriate coping strategies for pain and address the patients’ perceived needs for interventional therapies in community-based populations[114].
Finally, many studies found that patients with LBP wanted imaging of their spine[24,69,76,77,81], despite the evidence-based recommendations to limit the use of radiological imaging[6–10,115], which is inappropriately overused[8]. Patients reported a preference for imaging to find a diagnosis, and some requested imaging to legitimise their back pain[24,38,59,60,66,76–78,81]. Patients’ preference for imaging suggests the need for additional public education about the inability to link the experience of pain with a structural pathology in the majority of cases[8,116] and appropriate utilisation of radiology and management of LBP. Public education campaigns have been used to reduce unnecessary radiology imaging[117], which may decrease the enormous economic burden of LBP. Addressing patients’ expectations and perceived needs of radiology utilisation may improve the provider-patient relationship, thus, improving health outcomes.
The results of this review need to be interpreted in light of a number of limitations. First, the included studies were heterogeneous in their study aims, study populations, participant sources, study design and methodology, thus the results of this study need to be interpreted in the context of heterogeneity in source data used. A further limitation of the design of the review is that potentially important differences between studies (e.g. population groups, healthcare settings) may be hidden by virtue of the analysis and reporting method used. Moreover, study populations were predominantly female. Participants were recruited mainly from hospital settings or general practices, rather than from the community. Additionally, many studies were from developed, English-speaking countries. These limitations restrict the generalizability of the results. Furthermore, few studies examined the possible effects of demographic variables such as age, gender, ethnicity, socioeconomic status, other co-morbidities and education on the perceived needs of medical services for LBP. Future studies examining specific subgroups defined by key characterising variables would be informative. Many of the included studies were susceptible to bias and had methodological limitations. However, as this was a scoping review, the main concern relates to a failure to capture populations that were not included and the breadth of perceived needs. Another limitation of this review is that there were no studies that specifically examined patients with acute LBP. Patients with acute LBP may have different perceived needs compared to those with chronic LBP, however, these were not differentiated in the primary papers we retrieved for this review. Therefore, the results from this review cannot be extrapolated to those with acute presentations of LBP. Future studies examining patients’ perceived need for medical services for acute LBP are warranted. Despite these limitations, this review incorporates qualitative and quantitative studies and encompassed four complementary databases to capture the breadth of the topic, and found consistent themes regardless of differences in study populations and methodologies. The data from studies was collated to provide an inclusive and in-depth description of the patient perspective of the medical management of LBP.
Patient expectations inform their use of and satisfaction with healthcare, particularly with conditions driven by symptoms, such as LBP. This review has highlighted the patients’ perceived needs and perceptions of the medical management of LBP and outlined gaps in our current knowledge, as well as areas of mismatch between patients’ perceived needs and evidence-based practice. The National Institute of Health and Care Excellence (NICE) guidelines for LBP acknowledge the importance of “tak(ing) into account the person’s expectations and preferences” in the implementation of evidence-based practice[118]. Moving forward, when formulating clinical practice recommendations, clinicians and guideline panels should collaborate with patient groups, to ensure incorporation of the patient perspective[119]. This may be achieved through a combination of consumer-centred Models of Care, public community education campaigns and enhancing clinicians’ communication skills to convey the appropriate messages. A coordinated educational campaign is required to bring medical management and patient expectations in line with evidence-based practice to optimize patient and health service outcomes.
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