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NEWS ITEMS 2015 - The balancing exercise of exercise prescription in chronic pain?

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History taking during the first consultation of patients with low back pain:
What do physiotherapists ask?

Several studies demonstrated the importance of assessing the perceptions of patients regarding their illness (i.e. the illness perceptions) as they are of prognostic value. A study examining nearly 1600 patients with Low Back Pain (LBP) revealed that negative illness perceptions - for example believing that the problem will last long or that many symptoms are related to the person’s back problem, weak beliefs about self-control and low confidence in the person’s own ability to perform activities despite the pain - were better predictors of disability at 6 months than fear avoidance, catastrophizing or depression ( Foster et al. 2008 & Foster et al. 2010). The question arises whether physiotherapists pay attention to the assessment of illness perceptions during their history taking.

We therefore audiotaped the history taking during the first consultation of 34 physiotherapists treating patients with LBP. We aimed at evaluating whether physiotherapists question patients with non-specific LBP regarding the different domains of illness perceptions using a specific observational instrument. After the history taking, patients were asked to fill in the Illness Perception Questionnaire to measure existing illness perceptions which may not have been addressed during history taking.

Given the nature of the study, both patients with non-specific LBP and physiotherapists were included as participants. They were however not aware of the specific research aims. They were told that the recordings would be used to investigate possible cross-national differences in history taking by physiotherapists. The design of this study allowed us to investigate the nature of information elicited by the therapist and given by the patient during the first consultation and to compare it with the results of questionnaires.

From the results, it appears that physiotherapists assessed the illness identity (symptoms associated with the illness). Also perceptions regarding the (physical) cause and controllability (belief the condition is curable or controllable) of LBP were evaluated. However, illness perceptions such as timeline (will the LBP last for a long time), consequences (impact of the illness on patient well-being), coherence (overall patient understanding of the condition) and emotional representation were poorly assessed. The results of the Illness Perception Questionnaire Revised Low Back Pain revealed that LBP-patients report overuse, workload and bad posture as primary cause.

In conclusion, despite the call to use a bio-psycho-social framework when treating patients with LBP, Belgian physiotherapists mainly question bio-medically oriented illness perceptions, e.g. physical symptoms and causes, but do not sufficiently address psychosocially oriented illness perceptions (Roussel et al. 2015) as recommended in low back pain guidelines.

Nathalie Roussel

2015 Pain in Motion

References and further reading

Foster NE, Bishop A, Thomas E, Main C, Horne R, Weinman J, Hay E. Illness perceptions of low back pain patients in primary care: what are they, do they change and are they associated with outcome? Pain. 2008 May;136(1-2):177-87. http://www.ncbi.nlm.nih.gov/pubmed/18313853

Foster NE, Thomas E, Bishop A, Dunn KM, Main CJ. Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care. Pain. 2010 Mar;148(3):398-406. http://www.ncbi.nlm.nih.gov/pubmed/20022697

Leysen M, Nijs J, Meeus M, Paul van Wilgen C, Struyf F, Vermandel A, Kuppens K, Roussel NA. Clinimetric properties of illness perception questionnaire revised (IPQ-R) and brief illness perception questionnaire (Brief IPQ) in patients with musculoskeletal disorders: A systematic review. Man Ther. 2015 Feb;20(1):10-7. http://www.ncbi.nlm.nih.gov/pubmed/25435470

Roussel NA, Neels H, Kuppens K, Leysen M, Kerckhofs E, Nijs J, Beetsma AJ, Van Wilgen CP. History taking by physiotherapists with low back pain patients: are illness perceptions addressed properly? Disabil Rehabil. 2015 Aug 26:1-12. http://www.ncbi.nlm.nih.gov/pubmed/26308888

van Wilgen P, Beetsma A, Neels H, Roussel N, Nijs J. Physical therapists should integrate illness perceptions in their assessment in patients with chronic musculoskeletal pain; a qualitative analysis. Man Ther. 2014 Jun;19(3):229-34. http://www.ncbi.nlm.nih.gov/pubmed/24389339