Dear Editor
Dear Editor:
The myths described in Overcoming Patient Misbeliefs (PT in Motion, December 2015- January 2016) are ubiquitous in the realm of musculoskeletal medicine, and many are reinforced by the clinicians patients seek for help.
Dr. Steven Woolf, MD, MPH speaks also to this issue in an editorial titled The Price of False Beliefs: Unrealistic Expectations as a Contributor to the Health Care Crisis1
Patients often receive mixed messages and mis-information about musculoskeletal problems that are not grounded in science or supported by research. The ability to diagnose or identify an anatomical pain generator for most patients with NSLBP (non specific LBP) is a prime example. When these patients are told by one caregiver, that an MRI may be required it is very difficult to convince them that research shows it will not likely provide any meaningful information and may lead to harms2.
Patients often present with clear misunderstandings about mechanical factors and LBP as quoted from the referenced article:
Mechanical factors have long been thought to have a causal role in low back pain. However, eight systematic reviews with the Bradford-Hill causation criteria concluded that it was unlikely that occupational sitting, awkward postures, standing and walking, manual handling or assisting patients, pushing or pulling, bending and twisting, lifting, or carrying were independently causative of low back pain in the populations of workers studied.3
These myths if not properly addressed can promote illness behavior, described succinctly by Gordon Waddell, MD. Below are some excerpts from a book of his:4
Illness behavior does not happen: it is learned. It is not fixed, but is a dynamic process over time, and health care may play a key role in its development. The information and advice we give may color patients’ beliefs about their illness and what they should do about it. Traditional treatment of back pain was often direct advice to stop or restrict normal activities and to behave in a more ill manner. We may prescribe sick certification……………………………………………………………………………………… …………….. Chronic pain patients often have repeated consultations and examinations and learn what to say and to do for health professionals. They learn what to expect, and what is expected of them, and this modifies how they react and behave. Conflicting opinions and advice, all lead them to press their case more strongly. We teach, and they learn, illness behavior in their clinical presentation. All of this is unconscious, learned behavior. Sadly, traditional health care for back pain may have done more to cause than to prevent illness behavior.
……………………. Illness behavior must not lead to moral judgments or to rejecting these patients. It is our job as health professionals to care for our patients, both their physical disorders and their illness behavior. The aim of recognizing illness behavior is to manage them more appropriately.
These patients may require both physical treatment of their physical problem and more careful management of the psychosocial and behavioral aspects of their illness.
Health care may have a profound influence on illness behavior
It is often far easier for the healthcare giver (and more profitable for the system) to “medicalize” an issue and provide interventions that are not likely to be helpful or promote the ongoing illness behavior. A concerted effort in education of providers, employers and citizens is required to truly promote a healthy lifestyle and control our escalating healthcare costs that are not leading to better outcomes or health.
The Choosing Wisely Campaign cited by Dr. Woolf is very encouraging, and we can thank Howard Brody MD, PhD for setting the tone for that initiative.5 Dr. Woolf states it well in his editorial: “The best way to reduce wasteful spending is to convince the purchaser that the product is not worth buying. It is a straightforward economic argument, but it can also save lives.”
Edward L. Scott PT, DPT, OCS
December 18, 2015
1 Woolf, S. The Price of False Beliefs: Unrealistic Expectations as a Contributor to the Health Care Crisis. Ann Fam Med 2012;10(6).
2 Chou R; Qaseem A; Owens DK; Shekelle P: Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians. Ann Intern Med. 2011;154:181-189
3 Balagué F, Mannion AF, Pellisé F, Cedraschi C Non-specific low back pain. Lancet 2012; 379: 482–91
4Waddell G. The Back Pain Revolution. 2nd ed. Edinburgh: Churchill Livingston;2004:2; p.194-195
5Brody, H. The Top Five List. N Engl J Med. 2010;362(4):283-285