This project was designed to ultimately improve the healthcare of a common and burdensome condition – low back pain (LBP). This condition is the leading cause of disability worldwide. It places a huge burden on Australian individuals and the economy, with over $9 billion spent on direct and indirect costs for LBP each year. For many individuals LBP is persistent, recurrent and bothersome, impacting on workforce participation and quality of life. With this project we sought to contribute to addressing knowledge gaps regarding approaches to treatment. Commonly used treatment approaches are known to be ineffective or have minimal positive effects. Research now widely advocates a shift from a biomedical approach to a multimodal biopsychosocial approach. However, there have been difficulties applying this complex approach in practice, with disappointing results of existing attempts to change systems to align with the biopsychosocial approach. This may in part be due to the high possibility that, in addition to traditional psychological and social elements, there are numerous other elements to LBP care that may need to be considered, such as clinician-patient relationships, chronic pain stigma/marginalization, and broader socio-political factors and chronic pain.
We examined if and how these factors are missing or overlooked in clinical LBP care and how these issues might be resolved. Our principally qualitative project used established methods of 1) direct observation of patient-clinician interactions (based on ethnographic principles), 2) iterative analysis sessions with consumers, clinicians and researchers (analysed qualitatively, and evaluated with an established framework – the Realist Evaluation Framework) to develop new strategies. Close collaboration between researchers, clinicians and consumers with LBP is embedded in the project.
Our findings highlighted how non-biological aspects of care such as power dynamics (i.e., in both clinician-patient and clinician-clinician relationships), interprofessional practices, the physical layout of the clinic, and routine daily practices (e.g., the use of computers to gather patients’ information and clinicians’ body language) were usually under-explored at the multidisciplinary pain service. This affected interactions with patients and likely their outcomes. Through our closer collaboration with clinicians and consumers with LBP we were able to develop recommendations to attend to these broader aspects of care. Recommendations included:
- Clinicians adopting an open body language and limiting their use of computers or changing the way they gathered information during consultations with patients;
- Clinicians attending to patients’ physical and emotional comfort throughout the sessions
- An increase in time for the daily multidisciplinary team meeting to address more complex cases and discuss broader aspects of care
- A better attention to interprofessional practices such as addition of discussion about the clinic’s identity and power dynamics between the team members as part of the clinic’s agenda
- Setting up a transition plan for discharging patients from the pain service, with referrals to services and activities at the community level
These elements go beyond the usual use of the biopsychosocial approach to enhance further aspect of care. Through our in-depth exploration of actual practices and collaboration with clinicians and consumers, we were able to develop and support clinicians to implement feasible and practical recommendations to better attend to broader aspects of LBP care. This had direct positive effects on the clinic involved and has had broader impact through the dissemination strategies we have already implemented and will have further impact as we finalise a number of academic publications and other outputs.
The research aims were to:
- to investigate how the psychosocial+ aspects of care do/do not manifest in the clinical management of individuals with chronic LBP at a major public tertiary hospital’s multi-disciplinary pain clinic;
- to develop, implement and evaluate feasible site-specific recommendations at the study site, using an established evaluation framework; and
- to develop and disseminate broad, industry-wide principles to reduce the burden of LBP on individuals, families, communities and the economy – using cross-comparison of implementation outcomes with those from a previously studied private clinic.
Studying these factors is important as it is already having have significant local and distributed impact on Australian and international LBP rehabilitation for three key reasons. The project is: 1) inherently translational: it tested a knowledge translation strategy and this has direct translational effects by enhancing the clinical care in the study site clinic and develops the strategy for wider roll-out across sites (national grants submitted for this). 2) addresses a major health issue: LBP is the leading global musculoskeletal problem, which contributes significantly to personal and community health burden. Enhancing the psychosocial+ aspects of care is likely to reduce the personal, community and economic burden of LBP. 3) contributes to a paradigm shift: this project extends existing research to enhance the delivery of the biopsychosocial model in LBP healthcare, responding to the now considerable transdisciplinary research findings that highlight a need for such a shift but has found it difficult to facilitate.
Although multidisciplinary pain services are considered an optimal setting to pain management, our findings suggest that certain social and broader dimensions of care (psychosocial+) were little attended to in practice. Biomedical and certain psychological dimensions were prioritised. In collaboration with clinicians and people with lived experience with chronic pain we developed and implemented recommendations to address these gaps between desirable and actual multidimensional practices. For example, collaboratively setting up goals with patients, attention to non-verbal communication and usage of computer screen, longer discussions of psychosocial+ aspects of care in team meetings, arrangement of transition plan to the community, and time to develop the service’s team dynamics, were some of the recommendations developed. Recommendations were flexible and took into consideration the service’s specific context in order to enhance the possibility of implementation. The flexible, specific, and collaborative nature of this study is likely to lead to long-term changes to service’s staff and patients and contribute to better attention to social and broader dimensions of care. The project was designed to qualitatively evaluate the changes. During the project there were significant changes to clinic structure, identity, processes and procedures. These multiple changes were reported to enhance patient care and the efficiency of the clinic. The clinicians report that people living with persistent pain are receiving more targeted services and that wait lists have been reduced due to care being more appropriately directed.
The multidisciplinary pain service has already implemented some changes in their clinical and administrative routine, as better explained in the sections above. Clinicians have already implemented changes in their consultation and team dynamic that directly enhance attention to psychosocial+ aspects of patients with musculoskeletal pain including advancing social prescribing. Other administrative changes (e.g., setting up transition/discharge plans) are in the initial stages of implementation, but are likely to benefit people who are referred to the pain service more broadly due to an enhanced efficiency. Our findings will help inform further research in multidisciplinary pain services (and other settings) to go beyond a biopsychosocial approach and consider broader aspects that impact the lives of people with musculoskeletal pain. Our research design provides an example of a productive co-design process which indicates how it is possible to collaborate with clinicians and people with lived experience to develop recommendations that are feasible and targeted to each services’ needs and context. The process might be replicated in a variety of settings when designing, enhancing or redesigning services.
We have agreement with another 2-3 sites to expand the project to other persistent pain clinics and have submitted a grant for funding for a project commencing in 2022. This will also expand the project beyond low back pain to all forms of non-cancer persistent musculoskeletal pain. We have also secured support to conduct a similar methodology in specialised outpatient spinal clinics (OPSCs) which provide non-surgical options to appropriate patients who were referred for spinal surgery. These projects (amongst other potential avenues) will expand our understandings across more contexts and broaden the potential impact of the work.