Clinicians’ Views About the Experience of Disability Due to Low Back Pain. Results From a Focus Group Study

Cedraschi C2, Campello M3, Salmi LR4,5 , Côté P1,6 1CanadianMemorialChiropracticCollege,2UniversityHospitals,GenevaUniversity, 3NewYorkUniversity(NYU), 4ISPED, Centre INSERM U1219BordeauxPopulationHealth, 5CentreHospitalierUniversitaire(CHU)deBordeaux, 6OntarioTechUniversity

Abstract

Purpose: For clinicians, treating the cause of nonpathological low back pain (LBP) is central. For patients, it is how LBP limits their activities of daily living. Little is known about clinicians’ understanding of disability and the patient’s perspective. We conducted a qualitative study to examine how clinicians involved in the care of patients with BP describe and define disability, its associated changes, and rehabilitation.

Methods: Two focus groups (FGs) were conducted with spine specialists including eleven confirmed orthopedic surgeons and neurosurgeons, ten advanced residents, and five other clinicians. Participants were questioned about their views on disability, what it means to them and to the patients. Responses were collected by two independent observers using Metaplan techniques. Large stickers were used to collect participants’ responses/ideas; the stickers were posted on billboards so the FGs could check them during the discussion. Metaplan was used to aggregate responses.

Results: Disability was viewed as a major source of physical limitations, difficulties in performing daily activities, associated with emotional distress, and raising legitimacy issues. Changes in roles engaged the social component. Considered from the patients’ perspective, negative emotions and social issues were emphasized, along with the patients’ resources. For rehabilitation, the participants emphasized patient-centered care, teamwork, and objectives for care.

Conclusion: The participants pointed to disability as an umbrella term for impairments, activity limitations, and participation restrictions. They underlined the necessity for clinicians to help patients define their level of optimal functioning when faced with BP, utilizing adaptation and teamwork within the therapeutic relationship.

Keywords

Low back pain, Qualitative methods, Focus groups, Disability, Rehabilitation

Background

The global burden of disease study shows that low back pain (LBP) is the leading cause of disability worldwide [1] which undergoes large increases [2]. The description of the global burden of LBP points to initial pain intensity, psychological distress, and accompanying pain at multiple body sites as increasing the risk of persistent disabling LBP [3].

Providing comprehensive care and addressing disability issues requires the understanding of the complex relationship between pain, function, and participation; thus, the various aspects of the International Classification of Functioning, Disability and Health (ICF) framework need to be considered [4]. Furthermore, within a biopsychosocial model of pain and disability, a dynamic interaction is assumed between somatic, psychological, and social factors, with a multicausal perspective rather than a linear model of causality [5].

Considering both the ICF and the biopsychosocial model emphasizes the need for a patient-centered approach to pain and disability. Indeed, patients present with highly different abilities to regulate emotions but also beliefs regarding the seriousness of pain, expectations of assistance, sense of control and mastery over pain.

For clinicians, diagnosis of signs and symptoms is an essential tool, but from the patient’s perspective what matters is what he or she can/cannot do in daily life [6]. Clinicians have therefore to consider individual differences at various levels (occupational demands, social support, health habits, etc.) as these differences can have a major impact on the patients’ goals, expectations for treatment, and ultimately outcomes [6, 7].

Within this context, it is important to explore the clinicians’ definitions of disability, their views about what it means to experience disability due to LBP, and their perceptions of the domains of life that are affected by persistent LBP. Such descriptions should help finding better ways to address the importance of a comprehensive assessment within a patient-centered approach. The objectives of our investigation included the development of a framework for a patient-centered assessment of disability-related issues allowing for an in-depth description of disability and associated changes and in further steps the development of a specific questionnaire. As a first step, a qualitative exploratory study was performed as this approach offers an insight into social, emotional, and experiential phenomena and may help identifying potentially important variables or concepts and generate coherent theories and hypotheses [8–11].

We conducted a qualitative study to explore how care providers involved in the treatment of patients suffering from LBP describe and define disability, its associated changes, and rehabilitation.

Methods Study Design

Semi-structured interviews using focus groups (FGs) were used [12–14]. FGs are semi-structured discussions with small groups that aim to explore a specific set of issues. These groups start with broad questions from the researcher before asking focal questions; participants are also encouraged to interact with each other. This technique is built on the notion that group interaction encourages respondents to explore and clarify individual and shared perspectives [15–17].

Setting and sampling

Two FGs were performed. Participants were spine specialists involved in the patients’ clinical care. These participants attended a five-day course on the design of clinical research on spinal problems. The format included lectures and small team workshops to encourage interaction in each group. These characteristics are of note as it has been described as advisable for members of FG to be homogeneous in status (e.g., occupation, age, and education): People are more likely to share information with others whom they see as similar (lower status members may not feel warranted to contribute fully) [14].

Data collection and analysis

The next-to-last day of the research course, a FG was conducted lasting 90 min (followed by a 60-min discussion). We used an interview topic guide to question the participants about their views on disability, what it means to them and to the patients (Table 1). The conversation was flexible and responsive to the issues raised by the participants, to offer them an unhurried chance to talk and to allow for the collection of diverse opinions/issues [13, 15].

Because of the particularities of the setting, discussion was not audio-recorded. We used large stickers where the participants wrote their responses/ideas. The stickers were posted on billboards so the whole group could check over the progress of the discussion, as the aim was to use the creativity and group dynamics to dig for ideas from the group, that single members might not have been aware of before the brainstorming [18]. We selected this Metaplan technique [19] as the FG method for this study because it is a group facilitation process that allows participants to voice their opinions on a targeted topic [20]. The effectiveness of this participatory technique has been acknowledged in the education area when interdisciplinary research is conducted [21–23]. The discussion of each question was addressed through a continuum of steps. It started by writing down the issues/opinions each group member saw as important on stickers. Then, all these notes were put on billboards and organized as different dimensions of the question at stake via a group discussion. Finally, the possible connections between these dimensions were discussed. Thus, the individual viewpoints as well as the group consensus were considered [18, 20]. Group discussion, consensus, and a mind mapping software (Freemind; available at: https://freemind.fr.softo nic.com/) were used in parallel to aggregate responses. The session was moderated by two independent researchers trained in FG methods. A third independent observer, trained in synthesis techniques, attended the FG to contribute to data collection and aggregation. All subjects were informed of the goals and design of the study and assured of confidentiality before they gave their consent to allow the use of their anonymized responses. This study was carried out in accordance with the Helsinki Declaration.

Results

Participants

Participants in the two FGs were spine specialists, including eleven confirmed orthopedic surgeons and