The role of contextual factors during conservative chronic low back pain management.

Abstract

Background: Chronic low back pain (cLBP) is a prevalent condition causing substantial disability globally, but current treatments provide moderate symptom relief. Acknowledging and targeting implicit elements within clinical encounters may enhance the quality and effectiveness of care. Contextual factors (CFs), such as the patient-practitioner relationship, beliefs/characteristics of patients and practitioners, treatment characteristics, and the therapeutic environment may affect long-term recovery, but knowledge of their role during conservative cLBP management is limited. Translational research is needed to explore ways of harnessing CFs, given patients’ and practitioners’ underexplored perspectives. Methods: This research aimed to investigate the role and impact of CFs during conservative cLBP treatment through three consecutive studies: a systematic literature review, a modified Delphi-consensus survey, and semi-structured interviews with patient-practitioner dyads. The systematic review examined interventions modifying CFs and their impact on patients’ clinical outcomes. Findings informed the modified two-round online Delphi-survey which measured panel consensus regarding the perceived acceptability and influence of CFs during LBP rehabilitation. To gain deeper insights into the perceived importance of CFs during LBP consultations, patient-practitioner dyads were interviewed separately. Results: The systematic review included 21 primary studies identifying CFs which may enhance cLBP treatment. Notable CFs included addressing patients' unhelpful illness beliefs; verbal suggestions influencing recovery expectations; visual/physical cues modifying treatment expectations; and positive communication to enrich the therapeutic relationship. The Delphi panel indicated a high degree of consensus regarding CF care approaches to enhance the patient-practitioner relationship, leveraging their own characteristics/beliefs, and modify patients’ beliefs. Through interviews with patient-practitioner dyads, four main themes emerged: the journey with LBP, quality of the relationship, shared recovery journey, and quality of the treatment space. Notably, the practitioner’s beliefs and characteristics shaped the quality of these LBP consultations and influenced the patient’s experiences of care. Conclusions: This research highlights the potential of modifying CFs to augment conservative cLBP treatment. It may have potential implications for clinical practice, education, and theory. These insights can guide the development of targeted interventions which may improve patient outcomes. Providing supplementary training or bespoke interventions that support musculoskeletal practitioners’ confidence and competence in applying contemporary knowledge could improve patients’ recovery. The proposed conceptual framework may have relevance in other clinical settings. The collective findings demonstrate that actively harnessing CFs can be beneficial during cLBP management.