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SPINE Volume 29, Number 20, pp 2309–2318
©2004, Lippincott Williams & Wilkins, Inc.
Patient Expectations of Treatment for Back Pain
A Systematic Review of Qualitative and Quantitative Studies
Jos Verbeek MD, PhD,* Marie-Jose´ Sengers, MSc,* Linda Riemens,† and
Joke Haafkens, PhD*
Study Design. A systematic review of qualitative and
quantitative studies.
Objectives. To summarize evidence from studies
among patients with low back pain on their expectations
and satisfaction with treatment as part of practice guide-
line development.
Summary of Background Data. Patients are often dis-
satisfied with treatment for acute or chronic back pain.
Methods. We searched the literature for studies on
patient expectations and satisfaction with treatment for
low back pain. Treatment aspects related to expectations
or satisfaction were identified in qualitative studies. Per-
centages of dissatisfied patients were calculated from
quantitative studies.
Results. Twelve qualitative and eight quantitative
studies were found. Qualitative studies revealed the fol-
lowing aspects that patient expectation from treatment
for back pain or with which they are dissatisfied. Patients
want a clear diagnosis of the cause of their pain, informa-
tion and instructions, pain relief, and a physical examina-
tion. Next, expectations are that there are more diagnos-
tic tests, other therapy or referrals to specialists, and
sickness certification. They expect confirmation from the
healthcare provider that their pain is real. Like other pa-
tients, they want a confidence-based association that in-
cludes understanding, listening, respect, and being in-
cluded in decision-making. The results from qualitative
studies are confirmed by quantitative studies.
Conclusions. Patients have explicit expectations on di-
agnosis, instructions, and interpersonal management.
New strategies need to be developed in order to meet
patients’ expectations better. Practice guidelines should
pay more attention to the best way of discussing the
causes and diagnosis with the patient and should involve
them in the decision-making process.
Key words: back pain treatment, patient satisfaction,
patient expectations, quality of health care, systematic
review, qualitative research, practice guidelines. Spine
2004;29:2309 –2318
Low back pain is one of the most common health prob-
lems for which people consult their physician.
1
It is not
surprising that many practice guidelines have been pub-
lished in recent years to support physicians in their man-
agement of back pain.
2,3
Two of the authors (J.V. and
L.R.) were also involved in the development of such a
guideline. This was a multidisciplinary clinical practice
guideline for back pain that was intended to be comple-
mentary to existing guidelines for specific disciplines
such as general practitioners and occupational physi-
cians.
4
The focus was to be on the patients’ views. The
clinical parts of the guideline are typically based on sys-
tematic reviews of the literature. In line with this ap-
proach, we decided to apply the same method to find out
about patients’ perceptions.
For a practice guideline, patient satisfaction with
treatment is a relevant outcome measure. It is known
that when patients are satisfied with the encounter with
the physician they are more likely to comply and coop-
erate with treatment, thus promoting treatment effec-
tiveness.
5
There are many studies from other fields of
medicine that support this relation between patient-
with-provider-satisfaction and compliance-with-drug-
treatment.
6–9
The same has not been shown for back
pain, although more positive patient expectations were
related to a better outcome in back pain treatment in one
study.
10
The study also showed that being optimistic
regarding a specific treatment was not the same as being
optimistic in general. However, in back pain treatment,
it is not too difficult to imagine that a patient who is
dissatisfied about the encounter with the physician,
would not be willing to comply with the advice “to stay
active” as it is generally recommended in practice guide-
lines.
The theoretical framework on which patient satisfac-
tion and patient expectations are based is not very well
elaborated yet. Intuitively, we all have ideas about causes
and meanings of satisfaction of patients with contacts
with healthcare providers. Satisfaction with health care
can best be defined as a positive feeling of the patient
toward an aspect of the process or outcome of health
care.
11
Some researchers have named those factors in
health care that are related to satisfaction “dimensions”
of satisfaction.
12
The strongest dimension of satisfaction
is usually to be treated with respect or in a humane way
by the provider of care. The outcome can be less impor-
tant. Apparently, this positive feeling of satisfaction is
due to expectations that we have about the care to be
provided. There is a close link between these expecta-
tions and the dimensions of satisfaction. Usually, pa-
tients are dissatisfied because the treatment did not meet
their expectations.
13,14
Therefore, aspects of care about
From the *Coronel Institute for Work, Environment and Health, Am-
sterdam, The Netherlands; and †Stichting Patie¨ntenbelangen Orthope-
die, Westervoort, The Netherlands. Drs. Verbeek and Sengers contrib-
uted equally in the development of the manuscript.
Acknowledgment date: January 15, 2003. First revision date: Septem-
ber 18, 2003. Second revision date: November 3, 2003. Acceptance
date: November 17, 2003.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Institutional funds were received in support of this work. No benefits in
any form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Jos H.A.M. Verbeek,
MD, PhD, Coronel Institute for Work, Environment and Health,
Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands; E-mail:
j.h.verbeek@amc.uva.nl
2309
which patients have specific expectations or with which
they express satisfaction or dissatisfaction are of impor-
tance to providers of care who wish to improve patient
satisfaction. To find out about these aspects, both qual-
itative and quantitative studies that report on patient
satisfaction or on expectations of treatment can be
used.
15,16
A synthesis of these studies could indicate a
more complete picture of what patients expect from their
healthcare providers, than that acquired through single
studies. The results of this synthesis could lead to specific
recommendations as part of practice guidelines in addi-
tion to evidence about the effectiveness of interventions.
We wish to report here the results of our study on what
patients with nonspecific low back pain expect from
treatment for back pain, and with which aspects of their
treatment they are dissatisfied.
Materials and Methods
Search Strategy and Study Selection. MEDLINE, Psy-
cINFO, Embase dating from years 1966 to 2001 were searched
electronically using the keywords (MeSH terms) “backache” or
“back pain” combined with the terms “patient satisfaction,”
“physician-patient relationship,” “doctor-patient relation-
ship,” “patient expectation,” or “patient preferences.” In ad-
dition, the reference lists of retrieved reviews and articles were
screened for relevant titles. To find out if we had missed arti-
cles, we searched the Spine journal separately. These searches
yielded 330 articles. The titles and abstracts of the articles were
screened to determine their relevancy. The articles were subse-
quently read to determine whether they met the following in-
clusion criteria: the publication had to be a report of an empir-
ical study; studies had to concern patients older than 18 with
acute or chronic nonspecific low back pain; studies had to re-
port on aspects of the treatment with which dissatisfaction was
expressed or that were part of the expectation of the patients.
Nonspecific back pain was defined as pain in the back with or
without radiation and without specific systemic disease as the
underlying cause of the symptoms.
17
Back pain lasting longer
than 3 months was defined as chronic.
18
Study Categories. We classified studies into qualitative and
quantitative studies following the authors description. If it was
not clear from that description, we categorized a study by
means of the sort of questions that were asked. If the research-
ers asked the same closed questions among all the patients and
included figures indicating the percentage of patients that were
dissatisfied or that had specific expectations, a study was clas-
sified as quantitative, regardless of the means of gathering the
data. We categorized a study as qualitative if satisfaction or
expectations were ascertained by means of interviews or open-
ended questions. In addition, studies were categorized into
those about acute patients, chronic patients, or a mixture of
these. The studies were also grouped according to the provider
of the treatment.
Treatment Aspects. To collect data about expectations or
dissatisfaction, we used a list with all possible aspects of treat-
ment or themes that were reported to be related to patients’
expectations and satisfaction in general (Table 1).
12,13,19
The
observation list was the same for both quantitative and quali-
tative studies. If a study contained new aspects of treatment
they were subsequently added to the list in line with the ap-
proach of grounded theory.
20
The main aspects were divided
into subcategories if necessary. Aspects of treatment that re-
lated to dissatisfaction and those that related to expectations
were both processed in the same way as aspects that determined
patient satisfaction. All articles were read and data extracted by
two reviewers independently. If there was initial disagreement,
the results were discussed until consensus was reached.
Expectations and Satisfaction. In qualitative studies, as-
pects of expectations or dissatisfaction that were mentioned by
patients and considered important by the authors, were in-
cluded in the results of this review. For example, if a study
reported that patients wanted to know the cause of the pain,
the main item “clinical management” and the subitem “diag-
nosis/finding cause of pain” were scored as an expectation. For
qualitative studies, satisfaction was defined as a patient’s eval-
uation of aspects of treatment by means of a positive feeling or
attitude toward these aspects of treatment.
11
A study could only contribute once to an item. The number of
studies in which a treatment aspect was mentioned was used to
synthesize study results and is therefore an indicator of the
importance patients ascribe to a certain aspect of treatment. To
illustrate these numbers, the actual words used by patients are
quoted from the qualitative articles that scored on the corre-
sponding treatment aspect (Table 1).
In quantitative studies, the frequency of answers to ques-
tions about dissatisfaction or expectations was used to discover
relevant treatment aspects. For questions about satisfaction,
percentages were recalculated into percentages of dissatisfac-
tion or negative answers. Next, 95% confidence intervals were
calculated to account for differences in population size that
would lead to a low power of the study. If more than a statis-
tically significant 10% of the patients were dissatisfied with an
aspect of care, it was scored as an aspect of care that patients
were dissatisfied with. We chose to search for aspects of treat-
ment with which patients were dissatisfied because it is known
that patients are inclined to give an ingratiating response about
questions related to treatment, which leads to less informative
high levels of satisfaction. We further inferred that aspects that
patients would be willing to report on as dissatisfying would be
the most important. For the same reasons, we selected the low
criterion of 10%.
13
If more than one question in a study fitted
into the same item of care, the average of the percentages for
those questions was used.
We wanted to take the methodologic quality of the individ-
ual studies into account in the synthesis since low quality stud-
ies will provide less evidence than high quality studies. There-
fore, two reviewers assessed independently the quality of the
qualitative and quantitative studies. If there was initial dis-
agreement, the item was discussed until consensus was reached.
For qualitative articles, a scoring list of seven items from vari-
ous authors was adapted.
21–24
For quantitative studies, the
scoring list consisted of six items.
17,25
If a study scored more
than four points, it was considered to be of high quality (Ap-
pendix A).
Results
Twelve qualitative and eight quantitative articles, origi-
nating from several countries, met the inclusion criteria
(Table 2). Authors reported on the same population in
two articles on two different occasions. In one case, an
2310 Spine
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Volume 29
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2004
Table 1. Aspects of Treatment for Back Pain About Which Patients Have Expectations or Express Satisfaction in
Qualitative Studies (N ⴝ 12) and Quantitative Studies (N ⴝ 8) According to Type of Back Pain*
Treatment Aspect
Qualitative Studies: Expectations or Satisfaction Quantitative Studies: Dissatisfaction
Quotations
Acute
(N ⫽ 1)
Mixed Acute
and Chronic
(N ⫽ 5)
Chronic
(N ⫽ 6)
Acute
(N ⫽ 1)
Mixed Acute
and Chronic
(N ⫽ 6)
Chronic
(N ⫽ 1)
Clinical management
Diagnoses/finding cause of
pain
(30) (31) (34) (28) (29) (39) (33) (32) (43) (45) “The initial diagnosis was just-well you
know, there really wasn’t one. I had
some x-rays and they said they
weren’t really certain what was
going on.” (29)
Technical competence (34) (28) (29) (42) (26) (43) “My back was hurting. I tell the
doctor what’s up. And he still
won’t examine me to see if I’m
telling the truth or notѧyou can’t
fix a car just by looking at it.” (28)
Information/instructions (36) (31) (34) (35) (37) (29) (33) (32) (42) (26) (27) (41) (43) “I need more knowledge or directions
from somebody. I need to know
what to do.” (29)
Convenience of treatment (29) About TENS:“I use it when pain is
severe, but batteries only last for 1
day and that gets expensive.⬘(29)
Pain relief (36) (30) (28) (29) (39) (33) (42) (26) (44) (43) “I am not getting anywhere. I’ve had
all these different things, the TENS
machine and the physio and I’m
still back at square one.” (39)
Facilities
Diagnostic test (31) (28) (29) “With an x-ray you know more, you
know your body better.” (31)
Other therapy (31) (34) (29) (32) “I came to be referred (to
physiotherapist). . . it is already 7
years ago.” (31)
Specialty consultations (29) “..it just hurt too much. So I started my
little quest of trying to find another
doctor to help me.”(29)
Sickness certification/job (34) (35) (37) (38) (43) ⬘My GP told me: When I have back
pain myself, I have to keep
working⬘ (37)
Interpersonal management
Communication (30) (34) (39) (32) “They treat you as if you don’t
understand what they’re talking
about. I’d like to be spoken to on
my own level.” (39)
Congruency/confirmation (33) (26) (41) Congruent patients had expectations
centered on pain that could be
fulfilled by the therapist. (33)
Being included in decision
making
(36) (35) “I need to makeѧinformed choices
about what I am going to doѧit is
up to me to make those kinds of
decisions.”(35)
Listening (34) (28) (32) “..people have a problem talking to
their doctorsѧThey don’t listen to
what you say.” (28)
Respect (39) “It is as if he (physician) is saying to
me: Well I’ve been to college and
university and you are just a lowly
person.” (39)
Confidence based
relationship
(36) (37) (28) (39) (32) (26) (27) (41) “I don’t have any faith really, what I
want to find out is what is causing
the pain all through my body and I
seem to meet a blank wall.” (39)
Time/effort (34) (28) (32) (27) (41) ⬘She might be a good doctor, but I
don’t think she’s got time for
patients.⬘ (34)
Understanding (39) (32) (26) (27) (41) (45) ⬘Being believed is the most
important.⬘ (32)
Continuity of care
Waiting time (39) She was kept waiting for an hour and
a half andѧwithout apology. (39)
Finances
*References are in parentheses.
2311Patient Expectations
•
Verbeek et al
article described satisfaction levels at the beginning of
treatment,
26
and a second article reported on satisfaction
after a 1-year follow-up of participants in the same
study.
27
In the other case, two articles described studies
using the same population but reported on different as-
pects of low back pain and its care.
28,29
These articles
were analyzed separately. Ten of the qualitative studies
were of high quality, with two studies scoring the maxi-
mum 7 points (Appendix A). In only four studies, the
data were analyzed by two researchers; and in six stud-
ies, someone else than the healthcare providers recruited
participants.
Only one of the eight quantitative studies scored low
on quality assessment, with four studies achieving the
maximum score. One qualitative and one quantitative
study were restricted to acute patients. Nine studies in-
cluded care by chiropractors or compared care between
different providers.
Qualitative Studies
Within the area of clinical management, two treatment
aspects occurred most frequently: patients want to know
the cause of their pain and patients want information or
instruction (Table 1). They expect an accurate diagno-
sis,
30–32
so that they can prove to others that their pain is
real. Therefore, patients are often dissatisfied either
about not receiving a diagnosis, inadequate diagnoses, or
different diagnoses over time.
29,33
Patients blame their
healthcare provider for the care provider’s inability to
explain the cause of pain and feel that their pain is not
legitimate. The process of delegitimization is described as
an experience of a series of negative consequences, from
not being seen to not being heard, to a sense of deficiency
and shame.
28
Even when an explanation was given, some
patients doubted its validity because it conflicted with
their own prior understanding or because they believed it
was based on inadequate investigation.
28
Two studies
also reported dissatisfaction with superficiality of exam-
inations.
29,34
From eight studies, it can be concluded that patients
also expect instructions or advice regarding their back
pain management. Advice seemed to be especially impor-
tant for patients for whom management of pain was a
Table 2. Qualitative (n ⴝ 12) and Quantitative (n ⴝ 8) Studies on Satisfaction With and Expectations of Treatment of
Patients With Back Pain, Included in the Review
Author and Year (reference) Population (N) Country
Study Design and
Measurement Treatment/Intervention Quality
Qualitative studies
Cedraschi 1996 (33) Chronic (71) Switzerland Semi-structured
interview
General care by chiropractor/
rheumatologist
High
Skelton 1996 (34) Acute and chronic (52) UK In-depth interview GP care High
Chew 1997 (38) Chronic (20) UK Semi-structured
interview
GP care High
McPhillips-Tangum 1998 (29) Chronic (54) USA In-depth interview General primary care from
medical doctors
High
Åbyholm 1999 (32) Chronic (22) Norway In-depth interview Physicians High
Walker 1999 (39) Chronic (20) UK Interpretation of
narrative accounts
Pain clinic High
Grimmer 1999 (36) Acute (45) Australia In-depth interview, focus
groups, questionnaires
Physiotherapeutic care High
Rogers 1999 (35) No information (17) Australia Semi-structured
interview
GP care Low
Rhodes 1999 (28) Chronic (54) USA In-depth, semi-structured
interviews
Diagnostic tests High
Sigrell 2001 (30) Acute and chronic (93) Sweden Questionnaires Chiropractic care Low
Ostlund al 2001 (37) Acute and chronic (20) Sweden In-depth interviews Rehabilitation High
Schers 2001 (31) Acute and chronic (20) The Netherlands In-depth interviews GP care High
Quantitative studies
Deyo 1986 (45) Acute and chronic (140) USA Observational,
questionnaire
House staff physicians Low
Cherkin 1989 (41) Acute and chronic (457) USA Observational,
questionnaire
Chiropractic/GP care High
Carey 1995 (42) Acute (1,633) USA Observational,
questionnaire
Primary care practitioners/
orthopaedic
care/chiropractor
High
Carey 1996 (44) Acute and chronic (180) USA Observational, telephone
interviews
Chiropractor/physicians High
Curtis 2000 (43) Acute and chronic (311) USA Observational and RCT,
questionnaire
GP/chiropractic physicians/
orthopaedic surgeons
High
Nyiendo 2000 (26) Acute and chronic (139) USA Observational,
questionnaire
Chiropractic/GP care High
Pincus 2000 (40) Chronic (60) UK Observational,
questionnaire
GP/osteopaths High
Nyiendo 2001 (27) Acute and chronic (835) USA Observational,
questionnaire
Chiropractic/GP care High
RCT ⫽ randomized controlled trial; GP ⫽ general practitioner.
2312 Spine
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Volume 29
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Number 20
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2004
priority
35
and for patients with a longer experience in the
healthcare system.
36
Moreover, patients wanted a com
-
prehensive approach to management.
34
That might be
the reason why patients often had the feeling that many
questions remained unanswered
29
and that information
and recommendations were not given to them.
31–33,37
This was especially the case with patients whose opin-
ions differed from that of the physicians, the so-called
noncongruent patients.
Pain relief is a treatment aspect that comes up in many
interviews. It can be regarded as the driving force for
seeking treatment or for returning for subsequent treat-
ment.
36
Patients want an effective treatment,
30
designed
to decrease difficulties with normal activities.
28
Chronic
patients who had gone through many experiences with
the healthcare system did not expect anymore that med-
ical interventions would alleviate their symptoms
38
as
opposed to patients who were more inexperienced with
the healthcare system and still expected pain relief.
36
However, in one study, chronic patients wanted to im-
prove their health and still hoped that the physician
would discover the right remedy,
39
which was often not
the case. As a result, dissatisfaction with pain relief is
often mentioned. Patients assessed treatments as ineffec-
tive because these did not alleviate their symp-
toms.
28,29,39
Patients have the feeling that their condition
deteriorates as a result of continued treatment.
39
Con
-
gruency between patient and healthcare provider is prob-
ably related to the effectiveness of the treatment. Con-
gruent patients experienced more pain relief than
noncongruent patients.
33
Apart from the outcome of treatment, one study
showed that patients were also dissatisfied with the pro-
cess because the treatment was too inconvenient.
29
Sickness certification was mentioned as an important
aspect of treatment in four of the 12 qualitative studies.
Some patients seemed even to be primarily concerned
with sickness certification,
34
which was described as so
-
cial recognition and a legitimization of social and eco-
nomic inactivity.
37,38
Even when patients were confident
of their own body, a formal validation was often de-
sired.
35
Two studies reported that to get a diagnosis or sick-
ness certification patients wanted diagnostic tests.
28,29
Therefore, some patients made efforts to convince their
healthcare provider that tests were needed.
31
Dissatisfac
-
tion with diagnostic tests is a major theme in one study
because such tests did not turn out to provide the solu-
tion or diagnoses that patients desired.
28
In addition to sickness certification, patients consider
a consultation as an opportunity to explore possibilities
of alternative management
29,31,32,34
or referral to medi
-
cal or surgical specialist treatment.
29
In none of the studies did the patients mention expec-
tations about or dissatisfaction with medication.
With respect to interactions with healthcare provid-
ers, the dominant expectation of patients, especially ex-
perienced patients, was a confidence-based associa-
tion.
28,32,36,37,39
Reasons why a confidence-based
relationship could not be established were healthcare
providers failed to diagnose and treat the pain
39
or pa
-
tients felt that the healthcare provider did not believe
they were in pain.
28,32
In addition to confidence, patients also expect a
healthcare provider to communicate well.
30
Therefore,
patients were dissatisfied about poor communication
skills
34
and understanding.
32,39
Patients expected to be
treated with respect
39
and wanted to be listened to rather
than be given a nonexistent “magical cure.”
34
Patients
did not feel that the treatment came up to their expecta-
tions because healthcare providers did not listen and did
not spend enough time with them.
28,32,34
Finally, it is
reported that especially experienced patients wish to be
involved in the decision-making process. When this does
not happen they become frustrated. These patients state
that they are the best judges of what is good for them.
When patients are included in the decision-making pro-
cess, there is a greater chance of congruency between
patient and healthcare provider.
35,36
One study reported that patients were dissatisfied
with the continuity of care, which means that patients
were often kept waiting for referrals, investigations or
the results thereof, appointments, surgery, further opin-
ions, or a pain clinic.
39
No study mentioned expectations about or dissatis-
faction with the “location of the treatment,” “access to
care,” or the “costs” involved.
Quantitative Studies
Percentages of dissatisfied patients varied to a large ex-
tent. In one study on chronic patients, there was no dis-
satisfaction beyond our 10% criterion.
40
Variation
seemed to be related to type and formulation of questions.
Large differences in dissatisfaction occurred between differ-
ent types of healthcare providers (Appendix B).
In most studies, patients were dissatisfied with the
amount of information they received from their health-
care provider.
26,27,41–43
Next in rank was lack of pain
relief as the most dissatisfying aspect of the treat-
ment.
26,42–44
Patients of general practitioners wanted in
-
formation about diagnostics and specialist consulta-
tions, whereas chiropractors’ patients wanted more
diverse information.
41
Moreover, high proportions of
patients reported receiving a lack of instruction about
how to take care of their back, such as back exercises,
postures, and lifting.
27,41,43
Especially acute patients had little trust in the provid-
ers’ technical competence. They noticed the absence of a
detailed back history and physical examination.
26,42
According to the patients, physical ability did not im-
prove after treatment, and there was a lack of help with
their job situation.
43
In none of the quantitative studies were questions
asked about facilities such as diagnostic tests, referrals,
or sickness certification.
2313Patient Expectations
•
Verbeek et al
In some studies, up to 80% of the patients complained
about not being understood by their provider
26,41,45
and
stated a lack of confidence in provider or treat-
ment.
26,27,41
Comparisons on this subject between gen
-
eral practitioners and chiropractors were all in favor of
the chiropractors. High proportions of patients had little
confidence in the treatment only a year after starting
treatment
26,27,41
or felt that the provider was not confi
-
dent of the diagnosis or treatment.
27
Communication, listening, and respect were not mea-
sured or mentioned in the quantitative studies as aspects
of dissatisfaction.
In none of the studies was continuity of care or costs
mentioned as causes of dissatisfaction.
Discussion
This review reveals that there is a gap between what is
offered by healthcare providers and what is expected by
patients. It shows that patients with back pain expect an
explanation for their pain (diagnosis), instructions and
advice on back pain management, pain relief, and sick-
ness certification. Like patients with other disorders, they
appreciate a confidence-based relationship with a pro-
vider who communicates well and listens to them. Pa-
tients are dissatisfied with treatment for the same rea-
sons. Therefore, they feel delegitimized and lose their
confidence in the healthcare provider. Results of qualita-
tive studies are confirmed by quantitative studies. Vari-
ations in satisfaction with treatment between different
care providers are explained by the same items.
No established methods for reviews of qualitative re-
search exist as yet.
16
Some advocate the use of ethno
-
graphic methods to synthesize qualitative studies
46
and
others use the term metasynthesis to this end.
47
We used
a combination of techniques in which findings from
qualitative studies were supported by the results from
quantitative research. Because we used a list based on an
extensive review of patient satisfaction and expectations,
we were comprehensive in listing aspects of patient sat-
isfaction. In 10 of the 12 qualitative studies, participant
selection had been described and patients represented a
wide range of patients with low back pain. This guaran-
tees that a wide range of ideas about satisfaction with or
expectations about back pain treatment was included in
our review.
48
In addition, the methodologic quality of
most studies was high, which supports our conclusions.
A weak point in most qualitative studies was that care
providers recruited their own patients, which could re-
sult in selection bias. However, we found no indication
that patients who were recruited by their own care pro-
vider showed higher satisfaction levels. The studies orig-
inated from several countries, which could have resulted
in culturally determined reasons for satisfaction. How-
ever, all studies were from developed Western countries,
and we did not find aspects of satisfaction that were
pertinent to a specific culture. We found few studies that
consisted only of patients with either acute or chronic
back pain. From these studies, we could not conclude
that there were different expectations among acute or
chronic patients. There was a gradual difference between
more and less experienced patients. More experienced
patients expected more information and made higher de-
mands on the interpersonal association with their health-
care provider than new patients. Analysis of the results
according to the methodologic quality of the studies did
not change the results since almost all studies were of
high quality.
Other studies that used different methods to relate
patient satisfaction to aspects of care support the find-
ings from this review that patients are more satisfied with
technically competent physicians and extensive diagnos-
tics such as radiographs.
49,50
Another study showed that
concordance, defined as concordance between physi-
cians’ recommendations and patients’ adherence to
them, was as low as one third of all cases with back
pain.
51
Hazard et al did not find a relation between out
-
come and satisfaction, which was explained by a differ-
ence in treatment goals of practitioners and patients.
52
It is unclear if, or to what extent, expectations of and
dissatisfaction with the interpersonal relationship with
the care provider are specific for back pain patients. Pa-
tients with other diseases have similar expectations such
as an effective treatment or help with their job situa-
tion.
53,54
Even if this is a factor specific to back pain
treatment, it is of importance to take into account be-
cause there is evidence that better interpersonal manage-
ment leads to better outcomes.
55
It is interesting to note that patients were more satis-
fied with chiropractic care. There is evidence that this is
not related to the provider himself or the content of care
but to the better management of expectations of diagno-
sis, information, clinical skills, and the patient-provider
relationship.
41,56
If the treatment of healthcare providers does not meet
the expectations of back pain patients, practice guide-
lines could be a means to help professionals in improving
the quality of care. It has been suggested that patient
preferences should be taken into account when develop-
ing guidelines.
57
However, most guidelines only provide
recommendations on technical skills for physicians such
as diagnostic criteria and effective interventions.
2
This
places the practitioner in a highly unenviable position.
On the one hand, the practice guideline recommends re-
fraining from diagnostic tests in patients with nonspecific
back pain and stresses that there is no underlying patho-
logic cause known. On the other hand, patients are more
satisfied with extensive diagnostics and wish to know the
cause of their back pain. There is an urgent need to fill
this gap, either through the development and training of
communication skills for physicians or through public
information campaigns.
31
Results of research in both ar
-
eas are promising.
58–60
Moreover, practice guidelines
should pay more attention to the best way of discussing
2314 Spine
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the causes and diagnosis with the patient and should
involve them in the decision-making process.
Key Points
● There is an extensive literature of qualitative
studies on patients’ expectations of treatment for
back pain of generally good methodologic quality.
● The treatment aspects that emerge from the qual-
itative studies are better diagnosis, need for instruc-
tions and pain relief, and confirmation that pain is
real and legitimate.
● Better strategies are needed to meet patients’
expectations.
Acknowledgments
The authors thank Marjolein Godfroij and Nico Sten-
vers for their help in the collecting the data, and Lilian
Åmre, Daphne Lees, and Kumar Jamdagni for help in
translation and editing.
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Appendix A. Quality Assessment
Qualitative Studies
(39) (30) (34) (33) (36) (35) (38) (28) (29) (32) (37) (31)
Subjects
1. Description of inclusion, exclusion
criteria and selection of study
population is described.
101110111111
2. Description of the subjects in
detail (age, gender, social
position, acute or chronic back
pain).
101110011111
3. Someone other than their care
provider recruited the patients.
100000111110
Data collection/procedure
4. Method of data collection is
described in detail (recruitment,
condition in which data were
collected and listed).
111111111111
5. The treatment is described and
when more than one treatment is
studied, these are analyzed in
separate categories.
111011111101
Theoretical framework
6. There is a clear connection to a
wider theoretical
framework/existing body of
knowledge.
111111111011
Analysis & conclusions
7. Two researchers have
independently analysed the data.
100000001011
Total score (⫹) 735453467566
Conclusion quality H L H H H L HHHHHH
High quality: number of ⫹ ⱖ4
Low quality: number of ⫹ ⱕ3
Quantitative Studies
(45) (42) (26) (27) (41) (43) (40) (44)
Subjects
1. Description of inclusion, exclusion
criteria and selection of study
population is described.
01111111
2. Description of the subjects in
detail (age, gender, social
position, acute or chronic back
pain).
01111111
3. Someone other than their care
provider recruited the patients.
00011101
Data collection/procedure
4. Method of data collection is
described in detail (recruitment,
condition in which data were
collected and listed).
11111111
5. The treatment is described and
when more than one treatment is
studied, these are analyzed in
separate categories.
00111111
Analysis & conclusions
6. Procedure of statistical analysis is
described detailed (reproducible
process).
11011101
Total score (⫹) 24466646
Conclusion quality L HHHHHHH
High quality: number of ⫹ ⱖ4
Low quality: number of ⫹ ⱕ3
2317Patient Expectations
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Verbeek et al
Appendix B. Questions About Treatment That Provoked Dissatisfied or Negative Answers Among Significantly More
Than 10% of Patients Treated for Back Pain in Quantitative Studies of Satisfaction With Back Pain Treatment (N ⴝ 8)
Aspects of treatment/Questions % Reference Provider
1. Clinical management
Diagnosis/cause of pain
Did not explain cause of back pain 19 (43) Phys ⫹ man
Did not explain cause of back pain 20 (43) Phys
Cause of problem not clearly explained 25 (43) Phys var
Did not give an adequate explanation of my problem 25 (45) Phys hosp
Technical competence
No careful examination of the back performed 20 (42)
Overall treatment result not excellent 25 (43) Phys ⫹ man
No detailed history of back pain taken 32 (42) Phys var
Overall not excellent treatment 34 (43) Phys ⫹ train
Not satisfied with treatment condition/overall 41 (26) GP
Overall not excellent treatment 45 (43) Phys
Not satisfied with treatment of back problem 68 (42)
Information/education
No advice on pain/prevention 20 (43) Phys
Not sufficient information about cause of back pain 21 (26) Chir
Patient not given sufficient information 27 (27) Chir
Not sufficient information about cause of back pain 34 (26) Chir
Not satisfied with information and idea about recovery time 52 (41) Chir
Not satisfied with information given 53 (42) Chir
Patient not given sufficient information 60 (27) GP
Not satisfied with information given 70 (42) Phys var
Not satisfied with information and idea about recovery time 84 (41) GP
Instructions
Patient knew how to care for back 18 (27) Chir
No instructions on exercises, lifting, don’t know what to do 29 (41) Chir
Patient knew how to care for back 49 (27) GP
No advice on sitting/sleeping/back exercise 50 (43) Phys
No instructions on exercises, lifting, don’t know what to do 62 (41) GP
Pain relief
Treatment not helpful 20 (44) Phys
Result of pain relief not excellent/good 32 (43) Phys ⫹ man
No improvement in low back pain after 1 month 44 (26) GP
Result of pain relief not excellent/good 45 (43) Phys ⫹ train
Result of pain relief not excellent/good 56 (43) Phys
Not satisfied with overall results of treatment 58 (42) Chir
Not satisfied with overall results of treatment 73 (42) Phys var
No improvement in low back pain after 1 month 87 (26) GP
Improvement physical ability
Did not improve ability to perform social activities/walk/work 38 (43) Phys ⫹ train
Did not improve ability to perform social activities/walk/work 45 (43) Phys ⫹ man
Did not improve ability to perform social activities/walk/work 52 (43) Phys
2. Facilities for patients
Did not help with job situation 59 (43) Phys ⫹ train
Did not help with job situation 59 (43) Phys ⫹ man
Did not help with job situation 65 (43) Phys
3. Interpersonal management
Confirmation
Doctor did not agree that pain was real 22 (27) GP
Did not believe that my pain was real 29 (41) Chir
Did not believe that my pain was real 62 (41) GP
Confidence
Not confident that treatment was working 26 (27) Chir
Not confident that recommended treatment would work 47 (26) GP
Doctor not confident/comfortable about diagnosis/treatment 35 (27) GP
Provider did not seem confident 40 (41) Chir
Not confident that treatment was working 64 (27) GP
Provider did not seem confident 79 (41) GP
Time/effort
Time spent listening by doctor not adequate 36 (27) GP
Not very satisfied with amount of time spent 47 (41) Chir
Not very satisfied with amount of time spent 72 (41) GP
Understanding
Doctors did not understand what was bothering 19 (45) Phys hosp
Doctor did not understand concerns about pain 25 (26) GP
Doctors did not understand patients’ concerns 40 (27) GP
Did not understand my concerns 45 (41) Chir
Did not understand my concerns 75 (41) GP
Concern care provider
Not concerned about pain 42 (41) Chir
Not concerned about pain 80 (41) GP
Phys ⫽ physicians; phys ⫹ man ⫽ physicians instructed in manual therapy; Phys var ⫽ physicians from various specialties; Phys hosp ⫽ physicians from a hospital
setting; GP ⫽ general practitioner; Chir ⫽ chiropractor.
2318 Spine
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