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Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies



A systematic review of qualitative and quantitative studies. To summarize evidence from studies among patients with low back pain on their expectations and satisfaction with treatment as part of practice guideline development. Patients are often dissatisfied with treatment for acute or chronic back pain. 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. Percentages of dissatisfied patients were calculated from quantitative studies. Twelve qualitative and eight quantitative studies were found. Qualitative studies revealed the following 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, information and instructions, pain relief, and a physical examination. Next, expectations are that there are more diagnostic tests, other therapy or referrals to specialists, and sickness certification. They expect confirmation from the healthcare provider that their pain is real. Like other patients, they want a confidence-based association that includes understanding, listening, respect, and being included in decision-making. The results from qualitative studies are confirmed by quantitative studies. Patients have explicit expectations on diagnosis, 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.
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.
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.
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-
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-
There are many studies from other fields of
medicine that support this relation between patient-
with-provider-satisfaction and compliance-with-drug-
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
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-
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
Some researchers have named those factors in
health care that are related to satisfaction “dimensions”
of satisfaction.
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.
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
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:
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
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.
Back pain lasting longer
than 3 months was defined as chronic.
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).
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.
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.
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%.
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.
For quantitative studies, the
scoring list consisted of six items.
If a study scored more
than four points, it was considered to be of high quality (Ap-
pendix A).
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
Volume 29
Number 20
Table 1. Aspects of Treatment for Back Pain About Which Patients Have Expectations or Express Satisfaction in
Qualitative Studies (N 12) and Quantitative Studies (N 8) According to Type of Back Pain*
Treatment Aspect
Qualitative Studies: Expectations or Satisfaction Quantitative Studies: Dissatisfaction
(N 1)
Mixed Acute
and Chronic
(N 5)
(N 6)
(N 1)
Mixed Acute
and Chronic
(N 6)
(N 1)
Clinical management
Diagnoses/finding cause of
(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)
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) “ 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
(36) (35) “I need to makeѧinformed choices
about what I am going to doѧit is
up to me to make those kinds of
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
(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)
*References are in parentheses.
2311Patient Expectations
Verbeek et al
article described satisfaction levels at the beginning of
and a second article reported on satisfaction
after a 1-year follow-up of participants in the same
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.
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
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-
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.
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.
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.
Two studies
also reported dissatisfaction with superficiality of exam-
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 12) and Quantitative (n 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
General care by chiropractor/
Skelton 1996 (34) Acute and chronic (52) UK In-depth interview GP care High
Chew 1997 (38) Chronic (20) UK Semi-structured
GP care High
McPhillips-Tangum 1998 (29) Chronic (54) USA In-depth interview General primary care from
medical doctors
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
GP care Low
Rhodes 1999 (28) Chronic (54) USA In-depth, semi-structured
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,
House staff physicians Low
Cherkin 1989 (41) Acute and chronic (457) USA Observational,
Chiropractic/GP care High
Carey 1995 (42) Acute (1,633) USA Observational,
Primary care practitioners/
Carey 1996 (44) Acute and chronic (180) USA Observational, telephone
Chiropractor/physicians High
Curtis 2000 (43) Acute and chronic (311) USA Observational and RCT,
GP/chiropractic physicians/
orthopaedic surgeons
Nyiendo 2000 (26) Acute and chronic (139) USA Observational,
Chiropractic/GP care High
Pincus 2000 (40) Chronic (60) UK Observational,
GP/osteopaths High
Nyiendo 2001 (27) Acute and chronic (835) USA Observational,
Chiropractic/GP care High
RCT randomized controlled trial; GP general practitioner.
2312 Spine
Volume 29
Number 20
and for patients with a longer experience in the
healthcare system.
Moreover, patients wanted a com
prehensive approach to management.
That might be
the reason why patients often had the feeling that many
questions remained unanswered
and that information
and recommendations were not given to them.
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-
Patients want an effective treatment,
to decrease difficulties with normal activities.
patients who had gone through many experiences with
the healthcare system did not expect anymore that med-
ical interventions would alleviate their symptoms
opposed to patients who were more inexperienced with
the healthcare system and still expected pain relief.
However, in one study, chronic patients wanted to im-
prove their health and still hoped that the physician
would discover the right remedy,
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-
Patients have the feeling that their condition
deteriorates as a result of continued treatment.
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.
Apart from the outcome of treatment, one study
showed that patients were also dissatisfied with the pro-
cess because the treatment was too inconvenient.
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,
which was described as so
cial recognition and a legitimization of social and eco-
nomic inactivity.
Even when patients were confident
of their own body, a formal validation was often de-
Two studies reported that to get a diagnosis or sick-
ness certification patients wanted diagnostic tests.
Therefore, some patients made efforts to convince their
healthcare provider that tests were needed.
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.
In addition to sickness certification, patients consider
a consultation as an opportunity to explore possibilities
of alternative management
or referral to medi
cal or surgical specialist treatment.
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-
Reasons why a confidence-based
relationship could not be established were healthcare
providers failed to diagnose and treat the pain
or pa
tients felt that the healthcare provider did not believe
they were in pain.
In addition to confidence, patients also expect a
healthcare provider to communicate well.
patients were dissatisfied about poor communication
and understanding.
Patients expected to be
treated with respect
and wanted to be listened to rather
than be given a nonexistent “magical cure.”
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.
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.
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.
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.
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.
Next in rank was lack of pain
relief as the most dissatisfying aspect of the treat-
Patients of general practitioners wanted in
formation about diagnostics and specialist consulta-
tions, whereas chiropractors’ patients wanted more
diverse information.
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.
Especially acute patients had little trust in the provid-
ers’ technical competence. They noticed the absence of a
detailed back history and physical examination.
According to the patients, physical ability did not im-
prove after treatment, and there was a lack of help with
their job situation.
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
stated a lack of confidence in provider or treat-
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
or felt that the provider was not confi
dent of the diagnosis or treatment.
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.
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.
Some advocate the use of ethno
graphic methods to synthesize qualitative studies
others use the term metasynthesis to this end.
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.
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.
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
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.
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-
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.
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
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.
However, most guidelines only provide
recommendations on technical skills for physicians such
as diagnostic criteria and effective interventions.
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.
Results of research in both ar
eas are promising.
Moreover, practice guidelines
should pay more attention to the best way of discussing
2314 Spine
Volume 29
Number 20
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’
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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2316 Spine
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Appendix A. Quality Assessment
Qualitative Studies
(39) (30) (34) (33) (36) (35) (38) (28) (29) (32) (37) (31)
1. Description of inclusion, exclusion
criteria and selection of study
population is described.
2. Description of the subjects in
detail (age, gender, social
position, acute or chronic back
3. Someone other than their care
provider recruited the patients.
Data collection/procedure
4. Method of data collection is
described in detail (recruitment,
condition in which data were
collected and listed).
5. The treatment is described and
when more than one treatment is
studied, these are analyzed in
separate categories.
Theoretical framework
6. There is a clear connection to a
wider theoretical
framework/existing body of
Analysis & conclusions
7. Two researchers have
independently analysed the data.
Total score () 735453467566
Conclusion quality H L H H H L HHHHHH
High quality: number of 4
Low quality: number of 3
Quantitative Studies
(45) (42) (26) (27) (41) (43) (40) (44)
1. Description of inclusion, exclusion
criteria and selection of study
population is described.
2. Description of the subjects in
detail (age, gender, social
position, acute or chronic back
3. Someone other than their care
provider recruited the patients.
Data collection/procedure
4. Method of data collection is
described in detail (recruitment,
condition in which data were
collected and listed).
5. The treatment is described and
when more than one treatment is
studied, these are analyzed in
separate categories.
Analysis & conclusions
6. Procedure of statistical analysis is
described detailed (reproducible
Total score () 24466646
Conclusion quality L HHHHHHH
High quality: number of 4
Low quality: number of 3
2317Patient Expectations
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 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)
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
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
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
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 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
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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... Several studies suggest that patients want a specific diagnosis that explains their LBP. (Lim et al., 2019;Sharma et al., 2020;Verbeek et al., 2004) More research will be required to explore how clinicians can best communicate a symptom in a way that is devoid as possible of words reflecting structural disruption, while also meeting patient needs. Broader civic, consumer and clinician involvement in research will be required to examine desire for updating diagnostic labels and how labels associated with good recovery can be communicated across various contexts. ...
Background: Diagnostic labels may influence treatment intentions. We examined the effect of labelling low back pain (LBP) on beliefs about imaging, second opinion, surgery, seriousness, recovery, work, and physical activities. Methods: Six-arm online randomised experiment with blinded participants with and without LBP. Participants received one of six labels: "disc bulge", "degeneration", "arthritis", "lumbar sprain", "non-specific LBP", "episode of back pain". The primary outcome was belief about need for imaging. Results: 1375 participants (mean [SD] age, 41.7 years [18.4 years]; 748 women [54.4%]) were included. Need for imaging was rated lower with the labels "episode of back pain" (4.2 [2.9]), "lumbar sprain" (4.2 [2.9]), and "non-specific LBP" (4.4 [3.0]) compared to the labels "arthritis" (6.0 [2.9]), "degeneration" (5.7 [3.2]), and "disc bulge" (5.7 [3.1]). The same labels led to higher recovery expectations and lower ratings of need for a second opinion, surgery, and perceived seriousness compared to "disc bulge", "degeneration", and "arthritis". Differences were larger among participants with current LBP who had a history of seeking care. No differences were found in beliefs about physical activity and work between the six labels. Conclusions: "Episode of back pain", "lumbar sprain" and "non-specific LBP" reduced need for imaging, surgery and second opinion compared to "arthritis", "degeneration" and "disc bulge" among public and patients with LBP as well as reducing the perceived seriousness of LBP and enhancing recovery expectations. The impact of labels appears most relevant among those at risk of poor outcome (participants with current LBP who had a history of seeking care).
... Most participants had high expectations regarding a manipulative approach for their management. This is similar with other studies describing the expectations of patients with neck and low back pain [42][43][44]. Our participants appeared to present with specific expectations. ...
Full-text available
Background In October 2017, a partnership was established between the University Hospital of Toulouse and the French Chiropractic College, “Institut Franco-Européen de Chiropraxie” (IFEC). Before 2017, chiropractors did not practice in hospitals in France. Chiropractic students and chiropractors are now integrated in an interdisciplinary medical team at University Hospital. Our study aimed to describe the characteristics of patients who received chiropractic care at the University Hospital of Toulouse, their expectations, experiences of care, and satisfaction. Method A prospective case study was conducted. Patients referred for chiropractic care in the French University Hospital of Toulouse from January to December 2020 were eligible to participate. Participants provided the following data: demographics, previous chiropractic care treatments, pain location, intensity (NRS) and duration, disability (NDI, ODI), health-related quality of life (SF-12) and depressive symptomatology (PHQ-9). We conducted semi-structured interviews to explore their expectations, barriers and facilitators impacting their experience of care, and satisfaction. Results Seventeen participants were recruited and seven were interviewed. All participants had chronic pain with a median pain intensity of 05/10 (IQR 04–06) on the NRS scale. Nine of 17 participants presented with multiple pain locations. Thirteen of seventeen participants presented with low back pain and eight with neck pain. The median SF-12 health-related quality of life score was 50/100 (IQR 28.5–60.5) for physical health, and 52/100 (IQR 43–62) for mental health. The PHQ-9 median score of depressive symptomatology was 7.7/27 (IQR 2.0–12.5). Overall, participants were satisfied with their care and the collaboration between chiropractors and physicians. Participants expected a caring communication with the chiropractic team. Their experience was facilitated by their trust in their physician. Patients perceived the turnover of chiropractic students as a barrier to their satisfaction. Conclusion Our participants presented with chronic musculoskeletal pain and depressive symptoms. Our study identified facilitators and barriers for patient expectation and satisfaction with chiropractic care in a hospital setting. This study provides the first data describing the collaboration between chiropractors and physicians in France in the management of musculoskeletal disorders. These findings will inform the quality improvement of our partnership, student’s training and the development of future hospital-based collaborations integrating chiropractic care in a multidisciplinary team in France.
... Ağrının biyopsikososyal modelini klinikte kullanmak, hastayla biraz zaman harcamayı gerektirir. Bu da, hastalar tarafından her zaman çok önem verilmiş kapsamlı bir ilk görüşme ve fiziksel temas ile mümkün olabilir (Robinson & King, 2012;Verbeek, Sengers, Riemens, & Haafkens, 2004). ...
The Pandemic leads to different changes in the daily life such as eating, smoking behavior. The study mainly focused to comparatively analyze the change of eating and smoking behavior during lockdown among the people of Gujranwala, Mumbai and New York and also highlight what significant changes come in life due to pandemic. The study is cross national study and quantitative in nature. The survey method was used for data collection. The data was collected through Google survey from. The population of this study was people who belong to Gujranwala, Mumbai and New York and sample sized of 450 people were selected by using convenience sampling technique. The study results showed that participants of these three cities recorded changes in their eating and smoking behavior during pandemic. Most of the respondent’s weight were observed increased. They started eating extra food against their normal routine. The study results also noted that people have also changed their smoking behavior. They increased the frequency of smoking per day in confinement. The study also found that people spent more time with their family after the pandemic, because government of these three countries imposed a lockdown. The study concluded that Covid-19 effect on smoking and eating behavior negatively.
... Because the degree of patient medical knowledge and their preoperative expectations might influence the perceived surgical outcome, providing a patient with reliable, informative materials might facilitate a better understanding of the management proposed by a physician. 26,27 According to our findings, the recommendation of supplementary YouTube educational content on ALIF might allow the patient to familiarize themselves primarily with the purpose and the steps of a surgical procedure and the expected treatment results. Contrarily, since most of the videos analyzed in our study did not discuss possible complications, risk factors, and prognosis after ALIF surgery, the patient's need for information on these aspects should be met by a thorough, preoperative consultation customized to each individual case. ...
Objective For the majority of patients, the Internet constitutes the first source of health information influencing their medical decision-making. We aimed to assess the quality of the online videos regarding anterior lumbar interbody fusion (ALIF). Methods YouTube database was searched using three different phrases: "anterior lumbar interbody fusion", "ALIF", and "ALIF surgery". The first 50 videos for each phrase were selected. Video content was evaluated by three independent researchers using DISCERN instrument. Qualitative data, quantitative data, and the source of upload were analyzed. Results A total of 24 videos were included. The mean DISCERN score was 38.21, indicating the poor quality of ALIF videos on YouTube. Video duration was positively correlated with DISCERN score (r=0.71, p <0.001) but not with the video power index (VPI). A negative correlation between time since upload and DISCERN score (r=-0.8 p<0.001) was found. Furthermore, videos containing surgical complications, risk factors, and postoperative prognosis had a significantly higher DISCERN score. Neither DISCERN score nor a VPI correlated with the presence of intraoperative recordings. Videos including the explanation of the spine anatomy had a significantly higher number of likes (p= 0.018). Conclusions Despite the increasing educational value of ALIF videos over time, the overall quality of YouTube videos on ALIF remains poor. However, the majority of them can be recommended to the patient as an informative source of basic knowledge on the surgical details of the ALIF procedure. Longer video duration increases its quality without simultaneous negative influence on its popularity.
... According to Verbeek et al. (2004), the first-order conditions states that each explanatory variable should be orthogonal to the generalized residual (over the whole sample). This is comparable to the OLS first-order conditions, which state that the least-squares residuals are orthogonal to each variable in * . ...
... However, many of these high-risk treatment options are associated with higher patient satisfaction [13,14], further complicating treatment decisions for clinicians. Imaging can reduce anxiety [15] as patients expect a clear and specific diagnosis [16,17], that some feel is not possible without an MRI [6]. However, because of over-reliance on the biomedical paradigm, patients also interpret a decision to forego medical treatment they think important (imaging, procedures, medication) as being associated with low-value care [18] or even as care that physicians for a variety of reasons are trying to ration [19]. ...
Full-text available
Background Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks. Objective Assess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups. Methods This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs. Results Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention. Conclusion Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process. Trial Registration NCT02777983.
... It has been recommended that providers focus as much attention on the patient and their experiences as they do on selecting interventions.62 This appreciation and attention along with collaborative goal setting may improve the patient experience, 24 enhance patient-provider therapeutic alliance,63 facilitate treatment compliance,40 increase patient involvement in the decision-making process,64 and improve the alignment of interventions with common goals. Therefore, patients may be better able to make decisions when intervention options require trade-offs (eg, symptom management vs functional capacity).65 ...
Full-text available
Background and aims Goal attainment scaling (GAS) has been widely applied to chronic conditions; however, only recently has it been used for patients with low back pain (LBP). The objectives of this systematic review were to (a) examine the characteristics and rigor of published studies of GAS in the rehabilitation of patients with LBP, (b) describe how GAS has been applied in patients with LBP, and (c) evaluate the responsiveness and validity of GAS as an outcome measure in patients with LBP. Methods A systematic search of the CINAHL, PubMed, and MEDLINE databases was performed (1968 and 1 September 2020) in addition to hand searching. Studies including GAS procedures in patients with LBP during rehabilitation were included in the review. Two authors independently selected studies for inclusion and determined levels of evidence using the Oxford Levels of Evidence and rated each study for quality using the Newcastle-Ottawa scale and reporting transparency using the STROBE statement checklist. Results Six Level IV and one Level III/IV study were included in this review (search produced 248 studies for review). These studies assessed GAS feasibility, validity, sensitivity, and association with other outcome measures in patients with LBP. Findings suggest that patients with LBP are able to identify and set individualized goals during GAS, while GAS may be more sensitive to change and may measure different aspects of the patient experience as compared with fixed-item patient-reported measures. Additionally, GAS may have a therapeutic effect while improving patient outcomes and may be associated with patient satisfaction. Conclusion Based on this review, GAS shows promise as a feasible patient-centered measure that may be more responsive to change than traditional outcome measures. However, GAS has been inadequately developed and validated for use during rehabilitation in patients with LBP.
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Background Knowledge about patient satisfaction and experience with care they receive can guide practitioners in establishing doctor-patient relationships and improve health outcomes. Although evidence suggests high patient satisfaction with chiropractic care in general, there is limited understanding of the expectations and experiences of athletes receiving sports chiropractic care. Objective To explore the athletes’ expectations and experiences with care received from sports chiropractors, and their perceptions of relevant areas of future research. Methods A qualitative study was conducted through an interpretivist lens exploring the perspectives of elite and competitive athletes receiving care from sports chiropractors in Canada. Participants were purposively recruited and interviewed until saturation was reached. Two research team members independently analyzed the interview transcripts using a conventional approach to content analysis. Content was inductively coded and discussed by the research team to generate categories. Results We interviewed 18 participants between December 2018 and March 2020, 14 were national level athletes participating in sports ranging from paddling to combat sports. Reported reasons for seeking care included acute care, injury prevention, enhancing performance and maintenance care. Generated categories were organized under topics of experience with care, expectations of care, and research agenda. Participants experienced a variety of interventions, reassurance, varying treatment times, and reported positive impact on their athletic performance. They expected musculoskeletal assessment and treatment including at and beyond the injury site, symptom improvement, good communication and expertise from the chiropractor. Some participants suggested interpersonal and interprofessional communication can be improved, in particular the level of collaboration with other members of their health care team. Overall, participants reported a high level of trust and satisfaction with care received from sports chiropractors. From our participants’ perspective, suggested areas of research should focus on injury mechanics and prevention, impact of care on performance, and interprofessional collaboration. Conclusions In general, participants were very satisfied with care. Overall, participants’ expectations and experiences aligned but changed over time. Addressing the findings of this study can be used to enhance the quality of care provided to athletes from sports chiropractors, as well as inform future research agendas. Further work assessing if athletes in other competitive levels have similar experiences and expectations is needed.
Backgroud context: Low back pain can be difficult to diagnose, leaving patients frustrated and confused after medical visits. Purpose: To evaluate the importance of reasons for seeking care in patients with back pain, and to compare this to physicians' assumptions about these patients' reasons. Study design/setting: Prospective survey study carried out at two Academic Spine Centers. Patient sample: 419 patients with back pain upon initial presentation to a spine clinic, and 198 physicians; all volunteered to complete a survey. Outcome measures: Variance in mean values between patient and physician responders with significance determined by non-overlapping 95% confidence intervals. Methods: Patients were asked to "rate each of the following with regard to their importance to you" (answering between 0 "not important" to 4 "extremely important"): improvement in level of pain, improvement in ability to perform daily tasks, explanation of what is causing your problem, thorough physical examination, diagnostic testing, medication, physical therapy, surgery. Physicians were asked to rate each of these "with regard to their importance to your patients." Results: Patients indicated the following items were the most important (mean values): explanation of what is causing your problem (3.27), improvement in level of pain (3.48) and improvement in ability to perform daily tasks (3.31). Patients attributed the least importance and lowest scores to: surgery (1.07) and medication (1.89). Comparing the mean values to each item by patient and physician responders revealed statistically significant differences in certain items. Specifically, physicians underestimated the importance of an explanation of what is causing the problem (2.78 ± 0.119 vs. 3.28 ± 0.098, 95% CI) and overvalued diagnostic tests (2.64 ± 0.120 vs. 2.30 ± 0.147, 95% CI), medications (2.38 ± 0.118 vs. 1.89 ± 0.143, 95% CI) and surgery (1.60 ± 0.126 vs 1.07 ± 0.140, 95% CI). Conclusion: Patients did not place as much importance on diagnostic tests, medications and surgery as the physicians assumed. Physicians understand that back pain patients want improvement in both pain and function, but they underestimate the importance of an explanation for the pain.
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To advance understanding of the lived experience of diabetes as described in published research and theses. Meta-analysis extends the analysis of individual research studies beyond individual experience to incorporate dominant system beliefs and health system ideologies. Curtin and Lubkin's (1990) conceptualization of the experience of chronic illness. Forty-three qualitative interpretive research reports in six computerized data bases 1980-1996 pertaining to the lived experience of diabetes and published in nursing, in the social sciences, and in allied health journals were used. Meta-ethnography in which trustworthiness was achieved by using multiple researchers, identifying negative or disconfirming cases, and testing rival hypotheses Balance is the determinant metaphor of the experience of diabetes. People learn to balance diabetes through their experience and experimentation with strategies for managing their illness. Learning to balance is a developmental process in which one learns to assume control of diabetes management. Support for such development requires that nurses know their clients as individuals and value the expertise they have gained in living with diabetes. Control of blood sugar levels within a prescribed range may be a goal established by professionals, but the goal of healthy balance determines a person's willingness to assume an active role in self-care.
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Background and objectives. Improving the sensitivity of general practice to Patients' needs demands a good understanding of Patients' expectations and priorities in care provision. Insight into differences in expectations of patients in different cultures and health care systems may support decision-making on desirable models for care provision in general practice. An international study was conducted to determine priorities of patients in general practice care: which views do patients in different countries have in common and which views differ? Methods. Written surveys in general practices in the UK, Norway, Sweden, Denmark, The Netherlands, Germany, Portugal and Israel were performed. Samples of patients from at least 12 practices per country, stratified according to area and type of practice, were included. Patients rated the importance of 38 different aspects of general practice care, selected on the basis of literature analysis, qualitative studies and consensus discussions. Rankings between countries were compared. Results. A total number of 3540 patients (response rate on average 55%) completed the questionnaire. Patients in different countries had many opinions in common. Aspects that got the highest ranking were: getting enough time during the consultation; quick services in case of emergencies; confidentiality of information on patients; telling patients all they want to know about their illness; making patients feel free to talk about their problems; GPs going to courses regularly; and offering preventive services. However, differences between opinions of patients in different countries were also found for some of the selected aspects. A confounding effect of Patients' characteristics may have played a role in these differences. Discussion. The study provides information on what patients expect of and value in general practice care. It shows that patients in different cultures and health care systems may have different views on some aspects of care, but most of all that they have many views in common, particularly as far as doctor–patient communication and accessibility of services are concerned.
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Objective: To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care. Design: Randomised unblinded controlled trial. Setting: 73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial. Subjects: 421 patients with low back pain of a median duration of 10 weeks. Intervention: Radiography of the lumbar spine. Main outcome measures: Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation. Results: The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score. Conclusions: Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.
Background: Chronic lower back pain (CLBP), without definable cause, is a symptom commonly presented to GPs, accounting for a significant proportion of their workload; it is also a common reason for sickness absence, and thus of national economic importance. Objectives: This qualitative study aims to explore how sufferers of CLBP describe their pain and its impact on their lives, and how their problem is dealt with in the consultation with their family doctor. Method: Semi-structured interviews were carried out with a sample of attenders at a back pain clinic set up in general practice. Transcription and analysis was carried out using a grounded-theory approach. Results: Sufferers of CLBP describe withdrawal from normal social obligations, including work. They view their GP as being unable to help and, because of this, the doctor becomes a resource through which their social and economic inactivity can be legitimated. Conclusions: Presenting with CLBP permits the patient a good deal of power over the GP: it is difficult for the GP to challenge the patient's ideas without damaging the relationship. GPs are forced to collude with the patient's definition of ill-health, which may not be in the best interests of the patient or society.
In this document, the framework for carrying out systematic reviews is described in three stages: planning, reviewing and disseminating. The need for a review should be established before commissioning or commencing review work. The methodology of the review should be documented and working arrangements should be put in place to ensure that the methods can be followed. Finally, there should be a strategy for putting together a report of the review and disseminating its findings to relevant audiences, and if possible, updating the review. The stages of a review and the phases within them are described consecutively. However, this chronology may vary during the review. It will not always be possible to complete one phase before another has to be started, and sometimes it will be more efficient to work on several phases simultaneously. It is essential that good communication is maintained between those commissioning or supervising the review and those carrying it out. To aid the process, this framework includes agendas for some joint meetings. These meetings help set a timetable and ensure that the review work receives the required direction and support. The number of meetings and their schedule may have to be tailored to suit the requirements of a given review. The content of this report draws on information from several sources. All the steps necessary to undertake a systematic review have been listed, but it is not possible to provide definitive advice on all of the methods. This is because the science of systematically reviewing the literature is relatively young, and many methodological issues are still being explored. Therefore this guidance is to assist those conducting reviews to reach a minimum standard based on the understanding of the subject at the time of writing. Reviewers wishing to obtain up-to-date information in this area should look at the Cochrane Methodology Database and systematic reviews of empirical methodological research in the Cochrane Library. New advice is incorporated in updates of the Cochrane Reviewers' Handbook (URL: http://www.updatesoftware. com/ccweb/cochrane/hbook.htm) and the ‘Resources available at the CRD’ web site (URL: http://
This paper concerns the concepts and practices currently in use in occupational health for the rehabilitation of workers with back pain. No conclusive evidence exists for an etiologic model for nonspecific back pain. A difference between acute and chronic back pain is backed up by evidence from the literature. Apart from having the patient stay active and return to ordinary activities as early as possible, there are no significant forms of intervention for acute back pain that effectively decrease the time off work. For chronic back pain multidisciplinary treatment in an occupational setting is effective in enhancing return to work. Clinical practice guidelines consist of diagnostic triage, the assessment of "red flags" for medical emergencies, and guidance in the appropriate application of diagnostic facilities. Occupational health guidelines concentrate on gradual return to work, psychosocial issues, and multidisciplinary rehabilitation facilities.
People treated for cancer have reported a variety of problems at work. However, there is little data on work experience after breast cancer, particularly for women treated in recent years. This exploratory qualitative study was conducted among 13 breast cancer survivors who had paid employment at diagnosis, returned to work afterwards, and mentioned work-related problems to a clinic nurse or physician. Unstructured, thematic interviews were undertaken. Qualitative thematic content analysis was conducted to identify and group themes which emerged from participants' discourse. Women in various types of jobs reported experiencing job loss, demotion, unwanted changes in tasks, problems with the employer and co-workers, personal changes in attitudes to work and diminished physical capacity. These work problems also preoccupied people treated for cancer more than two decades ago. New areas of concern also emerged: possible positive and negative effects of learning (implicitly or explicitly) about the diagnosis while at work and lack of discussion with health professionals about work and return-to-work issues, suggesting that health professionals' behaviour may influence women's work experience right from diagnosis. The identification of these new problems and confirmation of previously reported ones underlines the pertinence of determining how important and widespread these problems are in women now being treated for breast cancer.
We compare health maintenance organization enrollees' evaluations of the care they received from family physicians and chiropractors for low back pain. Patients of chiropractors were three times as likely as patients of family physicians to report that they were very satisfied with the care they received for low back pain (66% versus 22%, respectively). Compared with patients of family physicians, patients of chiropractors were much more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem. Although the more positive evaluations of chiropractors may be related to differences in the patient populations served by the two providers or to benefits of spinal manipulation, it is suggested that a potentially more potent force--the therapeutic effect of the patient and provider interaction itself--may explain the observed differences.