Low back pain management in primary care settings: Usual Care, Purposes, & Patient Perspectives

The overall aim of this PhD project was to gain an understanding of low back pain (LBP) management in a multidisciplinary primary care context by exploring the care provided and potential disparities in the management of LBP, the purposes of the provided care, and patient perspectives on LBP visits.

Studies I and II were cross-sectional based on a multidisciplinary prospective survey registration of LBP visits for adults seeking care from general practitioners (GPs), physiotherapists (PTs) and chiropractors (DCs), and each study is based on more than 3,200 LBP visits.

The objective of Study I was to explore management on the professional and individual clinician level and if subgroups of clinicians could be characterised by the frequency of their combined care provided. This study points to substantial variation within and between clinician groups, although some types of care are common for each clinician group. Some clinicians appear to alter their combinations of care between visits, whereas others rely on few combinations. Further, practice patterns were identified for PTs and DCs, which were mainly differentiated by varying use of information about LBP and advice on self-management. These results challenge usual care as a uniform concept.

Study II presents a novel approach to explore associations between PTs’ and DCs’ purposes and the provided care for patients with LBP, provide a preliminary external validation of purposes, and discuss findings through a small clinician survey of expected associations. Several associations were observed between distinct purposes and care elements. Most associations were consistent between clinician groups and the associations expected from a small clinician survey but with discrepancies and exceptions. An external validation showed meaningful fluctuations in the frequency of purposes without prominent unanticipated peaks. We observed correlations between the number of purposes and number of care elements at visits, and purposes partially explain the choosing of individual care elements. Asking clinicians about the purposes of the care provided appears useful in a research context. Future research on purposes of care provision may help explain otherwise unobserved reasons for variation in care.

Study III was a before-after qualitative design based on interviews with 18 patients seeking care for LBP. Our objectives were to explore patients’ hopes and expectations before and their experiences following LBP visits. Data were analysed using Braun and Clarke’s thematic analysis with an inductive approach. Before visits, patients expressed that something needed to be done, motivated by life disruption. For some patients, previous healthcare experiences with a lack of action led to hopes that something could be done or a diagnosis. Others had strong confidence in clinicians, who were expected to find the cause and alleviate their LBP. After visits, perspectives changed towards appreciation for clinicians’ who made the patients feel comfortable and welcome. Combined with thoroughness and dedication in assessing their bodies and providing explanations and care that made sense, the patients felt validated and acknowledged, but not all felt reassured at once. Overall, pre-visit interviews were focused on action and outcomes, while post-visit were centred around the process and what clinicians made the patients feel, but patients involved their bodies as central both before and after the visits.