Highlights

 

• Psychosocial symptoms are important predictors of those that do worse with chronic low back pain.
• Currently the prevailing view is that psychosocial symptoms drive systemic inflammation.
• Psychosocial problems increase inflammation, and inflammation increases psychosocial symptoms.
• Psychosocial treatments decrease inflammation and reducing inflammation improves psychosocial symptoms.
• The relationship is bidirectional and we should remember this when dealing with patients with psychosocial symptoms.
• Explaining this relationship to patients may reduce the stigma associated with psychosocial symptoms.

 

Background

 

Since the turn of the century there has been an increased awareness of psychosocial symptoms in chronic low back pain (CLBP) patients. It’s well established that CLBP patients with psychosocial, psychological and social, risk factors have poorer outcomes and increased management costs (Grimmer-Somers 2006, Nicholas et al. 2011). The term “yellow flags” was originally used to describe psychosocial risk factors that predict disability in LBP patients. Yellow flags are now included in most LBP guidelines although there is wide variation in suggestions in how to assess and manage these patients (Koes et al. 2010). This is discussed elsewhere on this site, see article on Yellow flags and CLBP. These risk factors are predictors of return to work and disability in CLBP patients (Glattacker et al. 2013). They can be identified using a questionnaire or a clinical diagnosis (Watson and Kendall 2000). Questions cover beliefs that are associated with delayed return to work and disability. These include fears about pain, injury, recovery and being despondent or anxious. It is suggested that having a few strongly held negative beliefs or several weaker ones could be used to identify at risk patients (Nicholas et al. 2011). These beliefs can be viewed as “thought viruses” (Butler and Moseley 2013) and increase a patient’s perception of threat and modern neuroscience suggests that pain is the conscious interpretation that tissue is in danger (Moseley 2007).

 

Inflammation and Psychosocial Symptoms

Inflammation and psychosocial symptoms are intimately related. Those with higher levels of systemic inflammation have more psychosocial symptoms (Hänsel et al. 2010) and Miller at al (2014) found that psychosocial treatment reduces levels of inflammation. Generally this relationship has been viewed top down, e.g. the brain affecting our systemic inflammation level. However, systemic inflammatory molecules signal the brain to induce sickness behaviours and negative affect (negative emotions and a negative view of self) (Walker et al. 2014). It’s also well established that anti-inflammatories improve psychosocial symptoms such as depression (Gallagher et al. 2014, Iyengar et al 2013). Thus perhaps we should consider this as a bidirectional relationship.

Peripherally cytokines, proteins of the immune system that communicate with other cells, interact with afferent nerves which send signals to their primary projection area. For example the nucleus of the tractus solitarius for vagal afferents. From here it propagates to secondary projections including the paraventricular nucleus of the hypothalamus and the central nucleus of the amygdala, where it can contribute towards negative affect. This partially occurs, as there is some active transport of cytokines across the blood brain barrier. With increased levels of systemic inflammation, active transport of cytokines across the blood brain barrier is increased further.

Tissue damage in the body is responded to by two main systems, pathogen associated molecular patterns (PAMPs) and damage associated molecular patterns (DAMPs). In a cold it is PAMPs that give rise to the illness behaviour associated with having cold symptoms. We all tend to withdraw from activity, feel a bit ugh, and have a kind of minor low level depression with a cold. With back pain it is DAMPs that give rise to the illness behaviours. Yet with CLBP we treat patients as if they are making conscious decisions to withdraw from activity. Potentially if we understand these underlying mechanisms and view the behaviours that arise secondary to this condition as like that of an infection we might have more empathy towards understanding the CLBP patient.

The association between peripheral inflammation and depression was initially established in patients undergoing cytokine therapy. Immune stimulating therapies such interferon therapy in those with hepatitis C or malignant melanoma produced initial sickness behaviour and then a transition to depression in many patients (Raison et al. 2007). Capuron et al. (2002) established that the anti-depressant paroxetine only reduces sickness behaviours and not the cognitive and affective aspects of depression. It appears that it is prolonged elevated levels of inflammation that are required for the transition of sickness behaviour in to depression. Obviously there are multiple mechanisms interacting here and to focus on one to the exclusion of others would be negligent clinically.

In healthy individuals typhoid vaccination induces negative mood post-vaccination (Wright et al., 2005), stops the normally occurring improvement in mood as the day progresses (Strike et al., 2004), increases brain activity in depression-related regions such as the subgenual cingulate cortex, and decreases its connectivity to the amygdala, medial prefrontal cortex, and nucleus accumbens (Harrison et al., 2009). Similarly, in healthy mice increasing levels of inflammation induce initial sickness behaviours, which subside, and transition to depressive symptoms following prolonged increased inflammatory levels (O’Connor et al. 2009).

Inflamamtion is closely linked to the pain experience. Peripheral inflammation can propogate signals to key brain areas involved in pain such as the central nucleus of the amygdala. Pro-inflammatory cytokines also lower nociceptor thresholds throughout the body decreasing the temperature, pressure or pH stimulus required for nociception. Further low levels of anti-inflammatory cytokines, such as Il-10 may also lower nociceptor thresholds (Uceyler et al. 2006).

Norman et al (2010) investigated the effects of social isolation on depressive symptoms in mice post nerve injury. Only the socially isolated mice developed depression and increased inflammation in the brain seven days later as measured by Interleukin-1β. Mice that underwent social isolation but received oxytocin did not develop increased inflammation or depression. Conversely, mice that were socialising but received an oxytocin antagonist developed depression and elevated brain Interleukin-1β. This, at least in mice, very clearly demonstrates the importance of social interaction, a positive psychosocial input, on inflammation; and points to the central role of oxytocin, at least as a marker, in this process.

Tryptophan is required for the production of the “happy” neurotransmitter serotonin. Decreases in tryptophan have been theorised to cause depressive symptoms and there is some support for this (Dell’Osso et al. 2016). Under increased levels of systemic inflammation there is increased activity of indoleamine 2,3-dioxygenase, an enzyme that converts tryptophan in to kynurenine, Thus there is less available for serotonin production. In animal studies the induction of inflammation has been shown to produce increase indoleamine 2,3-dioxygenase activity, decreased circulating tryptophan and a progression from sickness behaviour to depression (O’Connor et al. 2009).

Increased activity of indoleamine 2,3-dioxygenase ultimately leads to an increase in the NMDA receptor agonist quinolinic acid. Increased glutamate and its receptor subtypes including NMDA have been implicated in the development of both chronic pain and depression (Mitani et al 2006). Glutamate is primary neurotransmitter in nociceptor afferents.

This evidence clearly indicates the role of peripheral inflammation to directly impact our behaviour. This needs to be viewed within a broad context and the central process contributing to illness behaviours must also be considered. Nonetheless this information can be powerful for patients in taking the pressure off themselves to change these behaviours under the illusion that they are 100% under our control. This can be quite empowering in a perverse way and allows for a more open and honest discussion of these behaviours with patients as the pressure for responsibility and feelings of being judged are decreased.

 

What does this mean for treatment?

Psychosocial interventions such as CBT, pain neurophysiology education and mindfulness are still useful when viewing this relationship as bidirectional. In my clinical experience when they are offered these treatments patients often feel like they are being judged, it’s in their head, they should think positively and pull themselves together. Explaining this relationship to patients removes some of the stigma associated with psychosocial symptoms and pain. When patients view these changes in mood as similar to when you have a cold it is easier for us to discuss these symptoms and patients often feel like it becomes more manageable.

 

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References

Butler, D.S., Moseley, G.L. (2013) Explain Pain. London: Noigroup Publications.

Capuron, L., Ravaud, A., Neveu, P.J., Miller, A.H., Maes, M. and Dantzer, R., 2002. Association between decreased serum tryptophan concentrations and depressive symptoms in cancer patients undergoing cytokine therapy. Molecular psychiatry, 7(5), 468.

Dell’Osso, L., Carmassi, C., Mucci, F. and Marazziti, D., 2016. Depression, Serotonin and Tryptophan. Current pharmaceutical design, 22(8), 949-954.

Gallagher, P.J., Castro, V., Fava, M., Weilburg, J.B., Murphy, S.N., Gainer, V.S., Churchill, S.E., Kohane, I.S., Iosifescu, D.V., Smoller, J.W. and Perlis, R.H., 2012. Antidepressant response in patients with major depression exposed to NSAIDs: a pharmacovigilance study. American Journal of Psychiatry, 169(10), 1065-1072.

Glattacker, M., Heyduck, K., Meffert, C. (2013) Illness beliefs and treatment beliefs as predictors of short-term and medium-term outcome in chronic back pain. Rehabilitation Medicine, 45(3): 268-76.

Grimmer-Somers, K., Prior, M., Robertson, J. (2008) Yellow flag scores in a compensable New Zealand cohort suffering acute low back pain. Journal of pain Research, 1:15-25.

Hänsel, A., Hong, S., Cámara, R.J. and Von Kaenel, R., 2010. Inflammation as a psychophysiological biomarker in chronic psychosocial stress. Neuroscience & Biobehavioral Reviews, 35(1), 115-121.

Harrison, N.A., Brydon, L., Walker, C., Gray, M.A., Steptoe, A. and Critchley, H.D., 2009. Inflammation causes mood changes through alterations in subgenual cingulate activity and mesolimbic connectivity. Biological psychiatry, 66(5), 407-414.

Iyengar, R.L., Gandhi, S., Aneja, A., Thorpe, K., Razzouk, L., Greenberg, J., Mosovich, S. and Farkouh, M.E., 2013. NSAIDs are associated with lower depression scores in patients with osteoarthritis. The American journal of medicine, 126(11), 1017-e11.

Koes, B.W., van Tulder, M., Lin, C.W.C., Macedo, L.G., McAuley, J., Maher, C. (2010) An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal, 19(12): 2075-2094.

Miller, G.E., Brody, G.H., Yu, T. and Chen, E., 2014. A family-oriented psychosocial intervention reduces inflammation in low-SES African American youth. Proceedings of the National Academy of Sciences, 111(31), 11287-11292.

Mitani, H., Shirayama, Y., Yamada, T., Maeda, K., Ashby, C. R., & Kawahara, R. (2006). Correlation between plasma levels of glutamate, alanine and serine with severity of depression. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30(6), 1155-1158.

 

Moseley, G.L. (2007) Reconceptualising pain according to modern pain science. Physical Therapy Reviews, 12(3): 169-178.

Norman, G. J., Karelina, K., Morris, J. S., Zhang, N., Cochran, M., & DeVries, A. C. (2010). Social interaction prevents the development of depressive-like behavior post nerve injury in mice: a potential role for oxytocin. Psychosomatic medicine, 72(6), 519-526.

Nicholas, M. K., Linton, S. J., Watson, P. J., Main, C. J. (2011) Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Physical Therapy, 91 (5): 737-753.

O’Connor JC, André C, Wang Y, Lawson MA, Szegedi SS, Lestage J, Castanon N, Kelley KW, and Dantzer R

(2009) Interferon-γ and tumor necrosis factor-α mediate the upregulation of indoleamine 2,3-dioxygenase and the induction of depressive-like behavior in mice in response to bacillus Calmette-Guerin. J Neurosci 29:4200–4209.

Raison, C.L., Woolwine, B.J., Demetrashvili, M.F., Borisov, A.S., Weinreib, R., Staab, J.P., Zajecka, J.M., Bruno, C.J., Henderson, M.A., Reinus, J.F. and Evans, D.L., 2007. Paroxetine for prevention of depressive symptoms induced by interferon‐alpha and ribavirin for hepatitis C. Alimentary pharmacology & therapeutics, 25(10), 1163-1174.

Strike, P.C., Wardle, J. and Steptoe, A., 2004. Mild acute inflammatory stimulation induces transient negative mood. Journal of psychosomatic research, 57(2), 189-194.

Üçeyler, N., Valenza, R., Stock, M., Schedel, R., Sprotte, G., & Sommer, C. (2006). Reduced levels of antiinflammatory cytokines in patients with chronic widespread pain. Arthritis & Rheumatology, 54(8), 2656-2664.

Walker, A.K., Kavelaars, A., Heijnen, C.J. and Dantzer, R., 2014. Neuroinflammation and comorbidity of pain and depression. Pharmacological reviews, 66(1), 80-101.

 

Watson, P., Kendall, N. (2000) Assessing psychosocial yellow flags. Topical issues in pain, 2: 111-129.

Wright, C.E., Strike, P.C., Brydon, L. and Steptoe, A., 2005. Acute inflammation and negative mood: mediation by cytokine activation. Brain, behavior, and immunity, 19(4), 345-350.

Mindfulness is basically the western term for meditation. The practice has moved from weird hippies only, to being used by CEOs and professional sport, and is now being studied fairly extensively. This blog will focus on the relevance of mindfulness to chronic low back pain. Outlining the benefits and how to start a mindfulness practice.

Psychological stress can directly influence the musculoskeletal, endocrine, immune and nervous systems through the limbic system modifying chronic pain (Macphail 2014). Psychosocial risk factors for low back pain (LBP) chronicity are well known to lead to worse outcomes (Grimmer-Sommer 2008). Indeed the assessment of psychosocial factors is included in most guidelines for the management of LBP worldwide (Koes et al. 2010). Childhood abuse is associated with an increase in peripheralising of low back pain later in life (Leisner et al. 2014) suggesting psychological processes can modify the pain experience even later in life.

Cherkin et al. (2017) conducted an interviewer blinded, randomized controlled trial comparing mindfulness based stress reduction (MBSR), cognitive behavioural therapy (CBT) and usual care in 342 chronic low back pain (CLBP) patients aged 20-70. MBSR and CBT were both delivered as eight weekly two hour group sessions. Treatment effects were seen at 26 months and 2 year follow up. At 1 year and 2 years, Roland Morris Disability Questionnaire (RMDQ) scores were similar between groups. At 2 year follow 55.4% of the mindfulness group had clinically significant improvements in RMDQ and 41.2% in pain bothersomeness. In contrast usual care produced 42% and 31.1% of patients with clinicially significant improvements respectively, and CBT 62% and 39.6%. Follow-up rates were 78% for MBSR, 75% for CBT, and 89% for usual care. This may reflect lack of adherence to MBSR and CBT compared with usual care, but among those who did respond it appears the MBSR produced the greatest percentage of people with improvements in pain bothersomeness and it outperformed usual care on RMDQ. These results are startling given the limitations of the intervention, only eight two-hour sessions over eight weeks. The 8-week MBSR programme has also been shown to outperform the 10-steps to health aging programme in 282 community dwelling adults with CLBP (Morone et al. 2016). Thus there clearly seems to be benefit for mindfulness in patients with CLBP. So how do you or your patients get started with mindfulness?

Whilst the evidence discussed above strongly suggests some benefit from mindfulness interventions they can be very difficult to deliver. Therapists need to be confident in their value to be able to “sell” it to patients. Personal experience of the benefit is particularly valuable. In addition there will likely be personal benefit to the therapist.

The sequence of progression below is based on the mindfulness based stress reduction courses, with this authors own tweaks to make it easier to fit in to everyday life. In my experience its much easier to start with what personal development speaker Tony Robbins calls NET time, no extra time, activities. For example the first stage is doing one task each day mindfully.

 

1. One task daily done mindfully

e.g. brushing your teeth

2. Add one meal a day eaten mindfully

3. 5-10 minutes walking meditation

e.g. as part of your walk in to or out of work

4. 10-30 minutes mindful stretching

5. 10-30 minutes body scan done each day mindfully

6. 10-30 minutes seated meditation

 

From the very limited research we have in this area it appears seated meditation for about 30 minutes five times a week should be our goal with patients. This is very generic and non-specific. In reality we should look to help our patients develop a mindfulness practice that works for them, their personality and their schedule.

Establish if the patient has any experience of meditating. If not explain to them that mindfulness is being in the moment, the present. Often this is considered being in a “flow” state or in the zone. Flow occurs when our perceived ability meets the perceived demands of an activity. Much more on this can be gleaned by reading Flow by Mihaly Csikszentmihalyi who popularised this concept. Very simply anxiety occurs when we focus on the future and depression when focus on the past. Positive emotions like gratitude occur when looking in the past, and excitement when looking to the future. So the purpose is not to forgo looking forward or back but to develop an ability to be in the moment and to take ourselves back to the present when we find ourselves in a negative state.

With all these tasks its important to try. Some days will be tougher, the mind will be all over the place and concentration will be poorer. Other days a lot of negative thoughts may arise. There are real benefits though to being able to become aware of the fact that you cannot find the time to meditate, or you were so busy you got distracted and forgot or just could not fit it in. Becoming aware of this is the first step and then you can work improving the factors that lead you to miss sessions.

 

One task done mindfully daily

To start with pick a simple task that is done every day. The task I recommend is brushing teeth as we do this twice a day, it last about two minutes, and is very low concentration. It’s handy to pick a task you do multiple times a day so that if you miss it once you still have another opportunity. Other tasks, like ironing, washing up or even showering can be used. The key is that the patient will try to do this task mindfully. Instruct them just to focus on sensory cues in the moment. Breathing, tastes, smells, the feeling of the tooth brush on the teeth, their feet on the floor, any cues that bring them in to present and take them away from “monkey mind” thoughts in the past or present.

 

Eat one meal mindfully daily

The next progression is to eat a meal mindfully each day. The great thing with this task is you likely have three opportunities so if you miss one, then you’ve still got two opportunities. You can do this while eating with other people but it’s much tougher as it’s very easy to get in to conversation and being mindful in conversation is tricky. So to start focus on doing this activity during meals you are eating alone, even a snack if necessary.

Just focus on your breathing, the food, the tastes the smells. You will get distracted, just bring your mind back to a cue in the present each time, e.g. the smell, the tastes of the food, the feeling of your feet on the floor.

 

Walking meditation

This is another task that takes no extra time and is usually quite easy to get buy in from clients. As with the others the application is challenging but clients usually report acute benefit. Discuss the patient’s typical schedule with them and find a walk of around ten minutes they do most days. Often this is best to do on the way to work so they turn up to work in a good mindful state. If they don’t have an obvious way to fit this in to their schedule currently they can be encouraged to park 10 minutes further away from work or to go out for a short walk.

During the walk the client should focus on the steps and the sensory experience. Go through it once with them if possible and see which cues they prefer. Focusing on breathing in for four steps, pause for one, out for four. This can be adjusted to 3-1-3 if this suits the patient better. Just feeling the sensations in the feet and keep the walk as even as possible, maintaining a steady flow to the walk.

 

Mindful stretching

Mindful stretches is the first time we ask a patient to set aside extra time for their mindfulness practice. Many patients may never reach this point. The key here is that for a task to be done mindfully it needs to be very easy, unlike a true flow state, when mindful we are doing something very easy for us and being completely present. Thus it’s important the client is very comfortable with all stretches chosen and that none carry an injury risk.

Thus positions like sitting cross-legged, hands and knees, quad stretching in side lying, hamstring stretching in sitting and gentle trunk rotation may be useful. The stretches need to be tailored to the individual so that they are comfortable with them and for optimum efficiency they should also help mechanically.

 

Body scan

A body scan is a good transition from stretching to relaxation before fully transitioning towards a traditional meditative practice.

To start a body scan the patient should find a comfortable position. Common positions are lying down with a pillow for the head, or seated in a chair, on the floor or bed cross-legged with pillows under the hips and knees as needed.

The patient should start by focusing on their breath and settling in to relaxed diaphragmatic breathing. After a minute of settling in to this, the patient should begin getting an overall feel for the tension throughout the body. Then sequentially work down from the head, down the arms, the shoulders trunk and down the legs. In each area 3-5 breaths can be used to get an awareness of the tension in that area specifically and become aware of any sensations or emotions attached. Then 3-5 breaths can be used to relax to let go of the tension in the area.

The patient should be made aware that some areas will be easier than others. Thoughts will come in to the mind, just return to the breath and focus on becoming aware of the tension and feelings in an area and then letting it go.

 

Seated meditation

Seated meditation is our goal for most patients. With the aim of 30 minutes five times a week appearing to have significant anti-inflammatory effects.

By this stage patients should be comfortable at this point with the basics of mindfulness practice. Patients can be encouraged to;

• Listen to guided meditations
• Use various apps. My experience is that patients adhere to headspace for a few weeks and a few have stuck with it long term.
• Progress through a sequence of focusing on the body, then the breath, then sounds and then thoughts.
• Listening to meditative music, such as Anugama.
• Using mantras, such as breathing in with a “yang” phrase such as strength or discipline and then a “yin” word on the exhalation such as humility or grace.
• Progress from focusing on the breath, to areas of discomfort and then trying to focus on these areas on the inhalation and let go of the discomfort on the exhalation.

By the time the patient reaches this stage they will likely have their own thoughts on how they want to develop their practice. Walking meditation, mindfulness during a meal and a couple of daily tasks may be a really useful practice for one. Whilst another may do well with a daily mindful stretching programme. The practice should not be a means to an end in and of itself but should give the patient tangible benefits and if they are not seeing this it should be modified.

 

 

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Abstract

 

CLBP is the leading cause of disability worldwide and patients with yellow flags have the worst outcomes and contribute significantly to the societal cost. Clinicians are aware of the importance of yellow flags but feel undertrained to deal with them. Furthermore there is a lack of clarity for clinicians looking at how to specifically manage these patients from guidelines and an incredibly varied set of approaches available to clinicians. The objective of this review was to establish the effectiveness of physiotherapy interventions for chronic low back pain patients with yellow flags. Three approaches were used for retrieving literature. Searches were conducted initially using the terms “physiotherapy”, “chronic low back pain”, psychosocial and “management or treatment”, using the databases PubMed, Embase, PEDro and CINHAL from January 1987 up to February 2017. In addition content experts were consulted to ensure no additional papers were missed and citation tracking was implemented. 39 studies were identified with 20 meeting the selection criteria. Interestingly the term yellow flags is not used in the treatment literature and specific psychosocial terms are used. This review suggests specific exercise and passive interventions are more beneficial for reducing measures of pain, whilst psychological input and general exercise are more targeted towards psychosocial measures.

Discussion

 

Given the significant nature of the problem of chronic low back pain it is surprising only 20 studies met the inclusion criteria. These studies show a consistent pattern that a variety of interventions are able to decrease psychosocial symptoms, improve function and decrease perceived pain. Disappointingly none of the research on the popular Maitland and McKenzie approaches met the inclusion criteria. Of the studies included the reporting of how interventions were carried out is often not sufficient to allow reproducibility or use in practice, with limited details on sets, repetitions, tempo and progressive overload of exercises across all studies.

Of all the studies those using the CFT approach had the most positive effects as measured by disability and pain. The other particularly effective approach was the walking programme of Hurley and colleagues (2015) which had the same effect as their exercise group and usual physiotherapy interventions for pain, disability and psychosocial measures but the walking programme had greater adherence and lower costs. This fits with some of the emerging research in whiplash pain which suggests a low cost telephone based intervention was equal to a more expensive and time intensive motor control intervention (Michaelef et al. 2014).

A general theme emerging across the studies was the benefits to pain of more specific exercise programmes and the benefits to psychosocial factors through general exercise and psychological input. The admittedly very limited selection of two studies (Weiner et al. 2003, 2008) suggests that whilst passive interventions could positively affect pain, the addition of general conditioning was required to reduce fear avoidance. Similarly, Vincent et al. (2014) found that the lumbar extensor strengthening was sufficient to increase physical function but the total body programme was required to improve perceived disability and psychosocial measures. Supporting this Geisser et al. (2015) found specific exercise and manual therapy reduce pain whilst their general exercise group had reduced disability.

Improvements in fear avoidance beliefs are often associated with improved function (Crombez et al. 1999) nonetheless in these studies it appears that active treatment such as walking or whole body exercise is required to improve psychosocial measures. There were only two education-based studies but the positive results suggest pain acceptance and neurophysiology education in combination should be useful. The results from intensive functional restoration and CBT programmes suggests these kind of multidisciplinary programmes are effective across all measures, with Pfingsten and Hilderbrandt (2001) noting the importance of work hardening in promoting return to work.

The classification based approaches such as Macedo et al. (2014) suggest that there could be future developments allowing clinicians to classify which patients respond best to general exercise and to more general exercise based approaches. In particular patients classified as dysfunctional on the multidimensional pain inventory have been shown to respond best to combined psychosocial and physical input (Riipen et al. 2015).

 

Conclusion

Considering that CLBP is the leading cause of disability worldwide and those with yellow flags are known to suffer the worst and contribute most to societal cost it is surprising how few studies met the selection criteria. This review has shown that whilst the term yellow flags are used in the assessment literature and guidelines, the term psychosocial and the factors that make it up are used in the treatment literature. The studies selected highlight that passive, active; more comprehensive and simple education interventions can all positively impact the pain experience of this patient group. While passive interventions can improve pain, more whole body active approaches such as whole body weight training or walking may be necessary to positively impact the psychosocial aspects. Comprehensive CBT and functional restorations are effective but the inclusion of work hardening may significantly aid in return to work. Pain education approaches involving pain neurophysiology education and pain acceptance were both effective compared with more traditional back school and pain avoidance approaches respectively. A combination of these may be useful clinically. The CFT approach was the most effective in terms of disability and self reported pain. This review suggests specific exercise and passive interventions are more beneficial for reducing measures of pain, whilst psychological input and general exercise are more targeted towards psychosocial measures.

References

On request! kieran@kieranmacphail.com

Start	Current	Aim1
Physical Activity
Aerobic activity		20 minutes (Meng and Yue 2014)
Sleep		8 hours in bed resting- ideally sleeping (Alsaadi et al. 2012)
Nutrition & Biochemistry
Protein		1gram of protein for every kg of body weight (Wood et al. 2006)
Carbohydrate Grams Fibre		<15% of calories (Wood et al. 2006)
Omega 3’s		1g (Lopez-Garcia et al. 2004, Maroon and Bost 2006)
Fruits		2-3 portions of different fruit (Watzl et al. 2005, Bhupathiraju and Tucker 2011)
Vegetables		5-6 portions of different vegetables (Watzl et al. 2005, Bhupathiraju and Tucker 2011)
Multivitamin and mineral		(Wood et al. 2006)
Probiotics		(Shiranian et al. 2014)
Antioxidants		400mg Vit C (Wannamethee et al. 2006)
Liquids and Hydration		Urine clear
Alcohol		Up to 2 units
Coffee		Up to 3 shots of coffee (Kotani et al. 2008)
Stress Management and Behavioural Modification
Relaxation		30 minutes mindfulness 5 days per week (Linger 2014, Morone et al. 2008)
Environment Exposure
Sunlight		1 hour of sunshine or 500IUs of vitamin D (Pitaway et al. 2013)

Discussion

The literature review overviews the various different methods currently used in practice to give an overview of the background to which these decisions are being made.

Why these physiotherapists practice

The literature review showed the breadth of approaches available to clinicians and informed the interview process. This research sheds some light on how and why clinicians choose which of these interventions to use. The central theoretical code identified was the physiotherapists looked to do what was best for the patient from a variety of motivations. This is similar to previous grounded theory work, which found that all physiotherapist expressed a commitment to caring (Resnik and Jensen 2003). One of the key open codes supporting this concept was that of empathy. Interestingly a study of 1111 students found that physiotherapists in training had the highest levels of empathy compared with other allied health professions (Williams et al. 2014). This suggests empathy could have more influence over behaviour in physiotherapists than other professions. Empathy is known to increase helping behaviours and this has both strengths and weaknesses. The pioneering work of Goleman (1996) highlighted the many benefits of empathy such as “success” in multiple professions and more specifically in a healthcare setting treatment outcomes, satisfaction and job performance. Back pain patients report more satisfaction when treated by clinicians with more empathy (May 2001). However this increased desire to help others can lead to more empathetic individuals feeling more pressure and helplessness, leading to negative health outcomes. This is important for physiotherapists to be aware of as it can lead to being taken advantage of, helping colleagues and patients more than is necessary and feeling greater responsibility than those with less empathy. Thus this trait can lead to significant difficulties that can transcend the professional life and affect all areas of a physiotherapist’s life.

Human beings typically achieve more fulfilment in work than in our social activities (Csikszentmihalyi 1991). This comes as a surprise to many. Nonetheless in this research it seemed that a sense of personal pride in their work was central to reasons for why physiotherapist wanted to help patients. The finding of professional competitiveness was very surprising. KM strove to come from a clear mind as suggested by Descartes (1637) that would be ideal for an inductive piece of research. Despite this an affinity for the physiotherapists who gave up their time to help with the study developed. This made the emergence of the code all the more troubling. Initially there was an eagerness to dismiss this due to this affinity, however it’s repeated emergence meant it needed to be analysed and considered as shown in KM’s theoretical memo.

Memo 1^st October 2015

The disdain for other professionals and repeated allusions to mistakes made by other professionals appears to be part of giving experienced physiotherapists their self-worth in practice. It may be that this comes from an innate competitive drive that shows its self in these statements. Further this may help push therapists to improve and enjoy their practice further.

This finding may be more particular to this group of physiotherapists. Perhaps due to their experience they were all confident. For example all felt comfortable with the patient having yellow flags and described their strategies for managing this. In contrast previous work has suggested physiotherapists may not feel that comfortable or well trained in managing the psychological aspects of patient care (Hemmings and Povey 2002).

This research cannot give direct recommendations for how to assess and potentially change a physiotherapist’s motivation to practice. However, perhaps it can be of value by encouraging the interested reader to reflect on their own motivations to practice and consider how this may affect decisions in practice on a day-to-day basis.

 

What’s technically best for the patient

The results of this study show that “how” physiotherapists try to help patients is by finding what is technically best for them. The model of how and what is interesting when viewed in the context of previous grounded theory work in to physiotherapists’ clinical reasoning. The clinical reasoning of the “what” would fit with Jensen et al.’s (2000) diagnostic reasoning. Jensen et al. describe a narrative reasoning, reasoning and procedure element within diagnosis, which would equate to the understanding, whilst their interactive and collaborative reasoning would equate to the rapport element highlighted in developing adherence. Jensen et al.’s predictive, ethical and teaching reasoning components are not included within the theory here, but are more the underlying processes of deciding how to empower the patient, based on the other elements. Jensen et al. split these elements across diagnosis and treatment; whilst the data gathered here suggested the clinical audit process clinicians used makes such distinctions difficult. Thus the integrative diagram in the previous article can be updated as seen below.

Figure 1 Update cycle of Iterative cycle to help patients do what is best for them

The finding of how clinicians came to their clinical reasoning decisions may be a disappointment to policy makers and proponents of the contemporary descriptions of evidence based medicine. The term evidence based medicine is evolving and whilst all physiotherapists alluded to it or mentioned it directly there was broad variation in what they appeared to mean with the term. The physiotherapists interviewed used a combination of trial based evidence, experience and expert opinion as well as the patient’s wishes. This suggests these physiotherapist are generally practicing somewhere between traditional expert based medicine (Smith and Rennie 2014) and Sackett et al.’s (1996) definition of evidence-based medicine, which discussed the integration of the best evidence with what the patient presents and the clinician’s experience. Current definitions have progressed to focus on using the best available evidence to make decisions (Gray 2014), with an emphasis on a hierarchy of evidence prioritising meta-analyses, systematic reviews and higher quality trials over expert opinion and basic science (Moore and Jull 2006). Greenlagh et al. (2014) argue that the movement has had significant benefit but that there is too much evidence for clinicians to consume, guidelines are too large and rules have become inflexible and mechanical. Greenlagh et al. (2014) argue that clinicians should return to “real evidence-based medicine” using expert analysis of evidence to deliver patient centred care. They argue this should be done using higher levels of analysis and human intuition as described by the Dreyfus brothers (1987). Nonetheless physiotherapists struggle to apply trial based evidence to practice (Jette et al. 2003). In a sample of 488 American Physical Therapy Association members lack of time was seen as the major limiting factor. Similarly, Hannes et al. (2009) highlighted several barriers to the implementation of evidence-based practice by Belgian physiotherapist. They conducted a grounded theory approach analysis of 43 purposively sampled physiotherapists with varied interests and expertise in evidence based medicine. The problem tree they developed highlighted the key obstacles to the implementation of evidence-based practice as a lack of autonomy and authority to decide treatments. Interestingly questions were raised of the quality, applicability and accessibility of evidence. A lack of motivation from physiotherapists to use evidence-based practice was alluded to but not expanded on. However, this returns us to a fundamental human conundrum. Behavioural economics has shown us human intuition is not reliable and following simple algorithms is often more effective (Tversky and Khaneman 1981). Interestingly we prefer human error to computer error and would usually prefer to trust a human rather than an algorithm (Kahneman 2011). Nonetheless at this time reducing the treatment of CLBP patients with yellow flags to an algorithm is out of reach due to it’s complexity but it is not impossible that in the fullness of time we may be able to develop more useful “mechanical” guidelines.

At the superficial level it is interesting to compare “what” the different physiotherapists wanted to do with the patient in the vignette. The background and literature review highlighted the varying different approaches and emphasised their differences across the spectrum of physiotherapy. The interviews found a similar breadth of approaches likely extenuated by the purposive sampling. This was evident in sub-grouping where physiotherapists would use overt and covert sub-grouping. Sometimes using specific methods and other times interviewees were able to specify specific conditions under which they would give one style of intervention or use a specific questionnaire. Given the effectiveness shown by the classification-based approaches in the literature review it is not surprising most interviewees were using some form of classification. Clinicians often prefer classification-based or more individualised treatment-based approaches. However, Karayannis et al. (2015) showed that across the most prominent forms of classification there is both overlap and discord. Thus whilst there is utility in sub classification there are certainly discrepancies in application. It may be that this is because they allow more autonomy. The social sciences have shown as autonomy in our work decreases so does our motivation and performance (Cerasoli et al. 2014). Thus it makes sense that these approaches are more appealing in comparison to approaches that simplify treatment and perhaps suggest there is less skill involved in the work of physiotherapists. This area has become contentious in the physiotherapy literature as governing bodies push for more physiotherapists to follow guidelines and evidence begins to suggest all exercise has a fairly similar response (Searle et al. 2015). Thus clinicians desire for autonomy which may be central to the desire to continue to practice, appears at loggerheads with policy makers who may acknowledge the need for individual based treatment but focus guidelines and policy around delivering one size fits all programmes.

Whilst there was a dearth of literature that met the selection criteria considering the significance of the problem, those that did highlighted the benefits of passive, active; more comprehensive and simple education interventions. The physiotherapists interviewed all mentioned a process KM used the code “graded exposure” for. This was a process of getting the patient to do what they could from both activities of daily living perspective and an exercise perspective and then gradually increase it. Interviewees used their own paradigms to explain how this approach was having an effect; often using biomechanics based explanations, which may be at least partially accurate. However, it appears this approach can definitely work to reduce pain related fear, catastrophising and pain related disability (Vlaeyen et al. 2001). Macedo et al.’s (2010) systematic review suggested graded exposure was effective for reducing back pain of longer than 6-weeks duration in the short term compared to minimal interventions but no different to other exercise interventions. This is not a fair comparison as many of the different approaches coded as “graded exposure” would fit within the other exercise approaches compared in Macedo et al.’s review. This is a common problem in physiotherapy where semantics and how techniques are labelled leads to disagreements where there is much common ground.

The literature appeared to show that while passive interventions can improve pain, more whole body active approaches such as whole body weight training or walking may be necessary to positively impact the psychosocial aspects. Interviewees appeared conscious of this and almost conflicted about the role of passive approaches, in particular manual therapy. As demonstrated in the memo below:

Memo 27^th September 2015

Physiotherapists appear conflicted over the role of manual therapy. They appear to want to use it and feel it will help, but are fearful patients will become dependent on it, and it will not lead to long-term recovery. All interviewees seem to feel that there may be specific manual restrictions that can significantly benefit from manual therapy and improve symptoms.

This is an interesting concept and when examined the potential for the development of dependency does not appear to have been well examined. Indeed it is not discussed in guidelines for the management of CLBP (Koes et al. 2010). Indeed for acute symptoms manipulation is actively encouraged (Koes et al. 2010), although it’s benefit for CLBP is at best no greater than other interventions and may not be superior to sham (Rubenstein et al. 2011). Furthermore manual therapy has been found to outperform exercise at one year follow up in patients with greater than 8-weeks of low back pain in a 49 patient randomised controlled trial (Aure et al. 2003). Culture was mentioned as one factor to sub-classify patients to receive manual therapy. The implication from the interviewees was that patients from certain culture expect manual therapy and respond favourably at least in part due to their expectations. Interestingly Bishop et al. (2011) investigated the role of patient expectations in manual therapy for CLBP. Their analysis suggested that patients expected active interventions and manual therapy to help their pain and disability more than medication, electrotherapy or rest. However, they found that if patient’s met the clinical prediction rule for a positive prognosis for a manipulative technique this superseded the patient’s beliefs. Thus whilst the use of manual therapy is a broad area the fears of the physiotherapists interviewed do not appear fully warranted.

The literature found good strength evidence demonstrating the benefits of comprehensive CBT and functional restoration programmes. However, whilst all interviewees indirectly mentioned functional restoration, they directly mentioned pain education and specifically “explain pain”. Approaches involving pain neurophysiology education and pain acceptance were both effective compared with more traditional back school and pain avoidance approaches respectively in the literature review. Physiotherapists interviewed described using a combination of these approaches in practice. Neuroscience education for musculoskeletal pain, disability, anxiety and stress has been found to be effective in a systematic review, which retrieved eight papers of good quality (Louw et al. 2011). Importantly whilst not all the papers reviewed were on CLBP some looked at longer term follow ups than the very short terms considered by the two studies included in the literature review. Thus demonstrating longer-term benefits to neuroscience education.

The code “clinical audit” was used to describe a process of assessment and re-assessment to see if a patient’s symptoms could be modified during the session. Liebenson (2010) describes this process as using active techniques to carry out the assessment, whilst some of the interviews used passive techniques, such as the general nociceptive screen outlined by one interviewee. This process coded as the clinical audit, is an interesting example of where a technique is used widely in practice but has not been studied extensively. This is likely due to the flexibility of the technique as any movement that reproduces the mechanical sensitivity can be used for the assessment and any technique that may reduce the mechanical sensitivity can be used for treatment. Thus clinicians are attracted to the flexibility and researchers and policy makers are afraid of the lack of reproducibility. Furthermore, the analysis showed that physiotherapists used this modification of symptoms as a way to get the patient to understand their symptoms could be changed and to see the benefit in the treatment used. In particular they suggested using this to get patient “buy-in”.

 

How to get the patient to do what’s technically best for them

The second aspect of “how” identified was how physiotherapists get patients to do what is technically best for them. The individual elements of the iterative flow identified of understanding, rapport, adapting, and empowering the patient have received some investigation in the literature but overall this half of the “how” receives far less attention. For example the clinical guidelines for the management of CLBP focus on the “what” and not how to get patients to do this (Koes et al. 2010). McCrum et al. (2015) highlight the importance of understanding CLBP patient’s perspectives in helping physiotherapists adapt their communication to gain compliance and empower patients to engage in self-management. A Cochrane systematic review of 42 studies looking at improving adherence to exercise in patients with musculoskeletal pain indicated that these interventions had moderate sized effects (Jordan et al 2010). One of the key criticisms of the studies was their lack of a relevant behaviour change theory that might explain the underlying processes. In fact only two were based on a relevant behaviour change theory. Therefore as Lonsdale et al. (2010) state the most effective methods for behaviour change and how they work remains to be ascertained. Work in this area is currently developing with pioneering work looking at the use of a theory based on a self-determination intervention to improve exercise adherence in CLBP currently underway (Lonsdale et al. 2012).

In the realm of adapting the empathy identified as a frequent trait in these physiotherapists and in student physiotherapists by Williams et al. (2014) may help in improving adaptability. Empathy is central to Goleman’s (1996, Goleman 1998a) concept of emotional intelligence (EI) and is theorised to play a central role in all communication. Potentially most important is managing feelings and reactions to others’ communication. This allows an individual to look for the real meaning, which is frequently not what is initially perceived. Individuals that are empathetic are attentive to emotional cues and listen well (Goleman 2000). Further they show sensitivity and understand other’s perspectives. This allows them to communicate in a way, which is effective for each individual and the group as a whole. The key to empathy is actively listening to effective communication. Goleman (1998b) states that the mark of having truly heard someone else is to respond appropriately, even if that means making some change in what you do.

 

Nonetheless until further high quality research is conducted this area of practice will continue to be led by clinicians working in practice. Reflecting on the model outlined here may prove useful for novice clinicians and to hep stimulate and challenge more experienced clinicians to develop improve their own ability to help patients do what is technically best for themselves.

Limitations

This research has several limitations. Most notably that the research was conducted and analysed by a novice researcher. Six interviews were conducted and whilst theoretical saturation was achieved these findings are not generalisable. KM’s lack of experience relative to the more experienced clinicians may have limited the quality of interviews, meaning they were less challenging than they could be. This may have encouraged interviewees to make more comments about other healthcare professionals and increased the likelihood of the findings around egotistic drives. Whilst not invalidating this finding it may have come across differently with a more experienced clinician interviewing. Further the interviewees were all experienced clinicians and thus the results are not applicable to inexperienced clinicians, although they may be useful to stimulate reflection and generate ideas in novice therapists. KM struggled with the dichotomy of being objective in collecting data whilst getting close enough to obtain rich data. The use of a vignette means the “what” the findings are not generalisable around what to do with a patient cannot be generalised and more suitable as idea generators for clinicians and to help challenge current practice and physiotherapists own motivations. Furthermore, the other findings are likely influenced both by the context of the vignette and by KM’s involvement in the interview and analysis process. The interviews focused on the “what” to analyse the why and how, however this meant there was no questioning of how clinicians paradigms were formed. It would have been very informative to probe this area, by asking their own views and getting an overview of their formative physiotherapy experiences. The study relied solely on interviews where Glaser  (1992) stated that to have a proper grounded theory required observation. The implication of this would be that this research is focused more on the lived experiences of the participants rather than the social processes (McCann and Clark 2004). However, the by interviewing participants about the “what” and analysing this to uncover the social processes, the “why” and “how” this potential criticism is less valid.

 

Implications for practice

Given the limitations and methodology of the study it is hard to make any firm recommendations for practice. Nonetheless this research should provide a useful insight in to a framework of what experienced physiotherapists do to manage a typical patient with CLBP and yellow flags. The research may potentially be of more value by aiding clinicians in considering their own “why”, stimulating thought and reflection on their own motivations to practice. Furthermore, the two step “how” process of working out what is technically best for the patient and then how to get the patient to do this may help stimulate physiotherapists to consider their own processes. Additionally, the iterative flow highlighted in this research may provide a framework for therapists to consider how they get patients to do what is technically best for them and whether there are ways they could be better at doing this.

Conclusion

The importance of the researcher in a qualitative study such as this in co-creating the data means the inexperience of KM is a key inherent limitation to this research. The analysis produced the grounded theory; physiotherapists seek to help CLBP patients with yellow flags for altruistic and egotistic reasons, by establishing what they feel is technically best for the patient and working out how to get the patient to do that. What they do with patients relies on “Sackettian” reasoning, paradigm-based approaches, sub-classification, clinical auditing, graded exposure, education, and an uneasy relationships with manual therapy. This theory along with the framework physiotherapists used to decide what do with patients and the updated iterative flow used to help patients do what is best will provide points for reflection to help develop the practice of physiotherapists. This study would benefit from being repeated by another more experienced researcher and further understanding may be gained by repeating the research in novice clinicians. These findings will also be of use to policy makers as it may help them understand how clinicians are choosing treatment approaches and help the target guidelines more effectively. In particular it is hoped it will draw some attention to the need to focus on compliance and how physiotherapists achieve this. It is clearly an important, under researched area and is ignored within guidelines.