I’m not a primary care clinician. The people I see with pain have long-term, chronic, persistent pain that has been around for ages. I think the shortest time someone might have had pain before I see them is 4 months! The average is something like more than 4 years.
But I AM interested in who is likely to ask for treatment for their pain because while the people I see may be ‘experienced’ in the ways of being a patient, not everyone who has a back pain looks for treatment. And I wonder whether people who seek treatment at one point in time might carry on seeking treatment each time they have trouble with their pain.
When I came across this paper by Ferreira, Machado, Latimer and colleagues, I was really interested in what they found out from their review of papers dating from 1966 on treatment seeking in people with low back pain. Strangely enough, although there are a good number of studies looking at treatment seeking in general, it hasn’t been extensively studied in people with low back pain. For some reason I had an idea that there had been some studies on it, and I’ve always associated treatment seeking with high levels of distress and disability, and not so much with pain intensity itself.
Anyway, these researchers identified 3721 hits from the various health databases, of which 3390 titles were excluded mainly due to inappropriate methodology or inappropriate
population groups for this project. That left about 300 studies – and out of that only 11 articles reporting on 10 population based surveys met the quality criteria (makes you think about research quality, doesn’t it?!). A very small number of studies out of a very large pool of papers – but still, the experiences of 13,486 subjects with non-specific low back pain, divided into two groups of care seekers and non-care seekers.
Now one of the problems with this type of study is the definition of low back pain, and the duration of the pain, also the definition of care seeking – scanning the table that is included in this paper shows that the duration of pain was mainly for around 6 months, low back pain being pain from roughly the waist to the buttocks, and treatment ranged from GP care to ‘any type of care’ – but we’re not told whether it included so-called ‘alternative’ health care such as Reiki or colour therapy. The methodology assessment made by the authors of this study ranged from 30 – 80, based on a standardised item list including sampling, response rate, data reproducibility, power calculation and external validity.
One unspoken limitation of any piece of research is the type of factor being studied – interesting to see that in this group of studies, the factors being explored as potential determinants of care didn’t include my preferred candidate of distress – although disability was certainly included. And the findings?
The main determinants of care seeking were:
previous history of back pain
degree of disability (more so than pain intensity)
externalized beliefs regarding pain management (‘you fix me doctor’)
fear of future job impairment (please don’t tell this group of patients to change jobs)
limited social functioning
having a specific diagnosis for the back pain
those engaged in sports activities
Those less likely to seek care?
patients with disabling co-morbidities
pain of less than two weeks duration
those using passive forms of coping
Some very interesting bits of information came out of this study – firstly, despite this being an area of research priority, and a huge number of studies being published – as we so often hear, the quality of the studies meant that only 11 were able to be included. Next, less than 60% of people suffering from LBP opt to seek health care for it. That is really, really interesting. How do these people manage? And it’s not necessarily about their pain intensity being lower, because pain intensity wasn’t associated with care seeking – at least, not as much as disability from pain.
Health care use models have been proposed to explain who looks for treatment and who does not. The most recent models suggest that “individuals seek care based on an interaction that includes their predisposition to use health care, the available resources and their recognition for the need of care”. This paper found “the importance of age as a factor in determining who seeks care for back pain, as well as, factors associated with a patient’s recognition of need for care, such as having a previous history of back pain, poor general health and high levels of pain and disability.”
As I’ve been pondering on here recently, the ‘social’ part of the biopsychosocial model sometimes feels quite lonely and forgotten. When I look at the factors these authors identified, I think of these as having quite social characteristics. After all, the person’s need for care is about a social construct or belief that they’ve developed on the basis of, perhaps, having had back pain before or after having been required to seek medical treatment to satisfy a work accident claim, or having had an interaction with a health care provider that reinforced the behaviour of seeking care in some way.
Disability is about the impact of pain on function - disability can so often be reinforced by social structures in our communities such as our collective beliefs about low back pain (get treatment, rest, possible horrid consequences); the way families interact with an individual to either support the person to do little, or to abandon or isolate the individual to cope alone; the funding of home help and other supports that enable a person to remain inactive and therefore disabled; and even the provision of treatments for back pain that mean the person can return for treatment periodically without needing to demonstrate any change in activity level.
Finally, I’m curious about the way diagnosis was associated with care seeking. People with a specific diagnosis for their back pain (from their previous episode) were more likely to look for treatment than those who didn’t have a label. Yet having a diagnosis can be so important for people who have pain – it validates their pain, it helps them look up things on the internet, it strongly influences their beliefs about ‘what is going on’ – so I suppose I shouldn’t be so surprised. But it does make me think: what if we stuck to the old label of ‘low back pain’?
The purpose of identifying who looks for treatment and who doesn’t is about trying to influence inappropriate health care use and to minimise disability. This is one step along the way to work out how to help people look at back pain in a more positive and self managing light – and I suspect it’s going to be social factors that influence treatment-seeking behaviour in the end.
Ferreira, M., Machado, G., Latimer, J., Maher, C., Ferreira, P., & Smeets, R. (2009). Factors defining care-seeking in low back pain – A meta-analysis of population based surveys European Journal of Pain DOI: 10.1016/j.ejpain.2009.11.005