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Direct and mediated effects of treatment context on low back pain outcome: a prospective cohort study

Direct and mediated effects of treatment context on low back pain outcome: a prospective cohort study
Direct and mediated effects of treatment context on low back pain outcome: a prospective cohort study

Objectives Contextual components of treatment previously associated with patient outcomes include the environment, therapeutic relationship and expectancies. Questions remain about which components are most important, how they influence outcomes and comparative effects across treatment approaches. We aimed to identify significant and strong contextual predictors of patient outcomes, test for psychological mediators and compare effects across three treatment approaches. Design Prospective cohort study with patient-reported and practitioner-reported questionnaire data (online or paper) collected at first consultation, 2 weeks and 3 months. Setting Physiotherapy, osteopathy and acupuncture clinics throughout the UK. Participants 166 practitioners (65 physiotherapists, 46 osteopaths, 55 acupuncturists) were recruited via their professional organisations. Practitioners recruited 960 adult patients seeking treatment for low back pain (LBP). Primary and secondary outcomes The primary outcome was back-related disability. Secondary outcomes were pain and well-being. Contextual components measured were: therapeutic alliance; patient satisfaction with appointment systems, access, facilities; patients' treatment beliefs including outcome expectancies; practitioners' attitudes to LBP and practitioners' patient-specific outcome expectancies. The hypothesised mediators measured were: patient self-efficacy for pain management; patient perceptions of LBP and psychosocial distress. Results After controlling for baseline and potential confounders, statistically significant predictors of reduced back-related disability were: all three dimensions of stronger therapeutic alliance (goal, task and bond); higher patient satisfaction with appointment systems; reduced patient-perceived treatment credibility and increased practitioner-rated outcome expectancies. Therapeutic alliance over task ( • p 2 =0.10, 95% CI 0.07 to 0.14) and practitioner-rated outcome expectancies ( • p 2 =0.08, 95% CI 0.05 to 0.11) demonstrated the largest effect sizes. Patients' self-efficacy, LBP perceptions and psychosocial distress partially mediated these relationships. There were no interactions with treatment approach. Conclusions Enhancing contextual components in musculoskeletal healthcare could improve patient outcomes. Interventions should focus on helping practitioners and patients forge effective therapeutic alliances with strong affective bonds and agreement on treatment goals and how to achieve them.

back pain, complementary medicine, primary care, rehabilitation medicine
2044-6055
Bishop, Felicity
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Al-Abbadey, Miznah
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Roberts, Lisa
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MacPherson, Hugh
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Stuart, Beth
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Carnes, Dawn
bd9800b7-b0aa-46f0-b7f0-bcff5f8f0326
Fawkes, Carol
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Yardley, Lucy
64be42c4-511d-484d-abaa-f8813452a22e
Bradbury, Katherine
e24820a8-5b71-4c81-a53a-45841f52ece7
Bishop, Felicity
1f5429c5-325f-4ac4-aae3-6ba85d079928
Al-Abbadey, Miznah
dca88133-5d37-479e-a0c2-6d2aa19c7da7
Roberts, Lisa
0a937943-5246-4877-bd6b-4dcd172b5cd0
MacPherson, Hugh
6485cd22-1dc3-4600-9e00-d3187e981663
Stuart, Beth
626862fc-892b-4f6d-9cbb-7a8d7172b209
Carnes, Dawn
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Fawkes, Carol
cecfdb9d-8d21-470e-8c7c-975053b1be4a
Yardley, Lucy
64be42c4-511d-484d-abaa-f8813452a22e
Bradbury, Katherine
e24820a8-5b71-4c81-a53a-45841f52ece7

Bishop, Felicity, Al-Abbadey, Miznah, Roberts, Lisa, MacPherson, Hugh, Stuart, Beth, Carnes, Dawn, Fawkes, Carol, Yardley, Lucy and Bradbury, Katherine (2021) Direct and mediated effects of treatment context on low back pain outcome: a prospective cohort study. BMJ Open, 11 (5), [e044831]. (doi:10.1136/bmjopen-2020-044831).

Record type: Article

Abstract

Objectives Contextual components of treatment previously associated with patient outcomes include the environment, therapeutic relationship and expectancies. Questions remain about which components are most important, how they influence outcomes and comparative effects across treatment approaches. We aimed to identify significant and strong contextual predictors of patient outcomes, test for psychological mediators and compare effects across three treatment approaches. Design Prospective cohort study with patient-reported and practitioner-reported questionnaire data (online or paper) collected at first consultation, 2 weeks and 3 months. Setting Physiotherapy, osteopathy and acupuncture clinics throughout the UK. Participants 166 practitioners (65 physiotherapists, 46 osteopaths, 55 acupuncturists) were recruited via their professional organisations. Practitioners recruited 960 adult patients seeking treatment for low back pain (LBP). Primary and secondary outcomes The primary outcome was back-related disability. Secondary outcomes were pain and well-being. Contextual components measured were: therapeutic alliance; patient satisfaction with appointment systems, access, facilities; patients' treatment beliefs including outcome expectancies; practitioners' attitudes to LBP and practitioners' patient-specific outcome expectancies. The hypothesised mediators measured were: patient self-efficacy for pain management; patient perceptions of LBP and psychosocial distress. Results After controlling for baseline and potential confounders, statistically significant predictors of reduced back-related disability were: all three dimensions of stronger therapeutic alliance (goal, task and bond); higher patient satisfaction with appointment systems; reduced patient-perceived treatment credibility and increased practitioner-rated outcome expectancies. Therapeutic alliance over task ( • p 2 =0.10, 95% CI 0.07 to 0.14) and practitioner-rated outcome expectancies ( • p 2 =0.08, 95% CI 0.05 to 0.11) demonstrated the largest effect sizes. Patients' self-efficacy, LBP perceptions and psychosocial distress partially mediated these relationships. There were no interactions with treatment approach. Conclusions Enhancing contextual components in musculoskeletal healthcare could improve patient outcomes. Interventions should focus on helping practitioners and patients forge effective therapeutic alliances with strong affective bonds and agreement on treatment goals and how to achieve them.

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More information

Accepted/In Press date: 1 March 2021
e-pub ahead of print date: 18 May 2021
Published date: 18 May 2021
Additional Information: Funding Information: Funding This work was supported by Arthritis Research UK Special Strategic Award grant number 20552. Publisher Copyright: © 2021 BMJ Publishing Group. All rights reserved. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.
Keywords: back pain, complementary medicine, primary care, rehabilitation medicine

Identifiers

Local EPrints ID: 449620
URI: http://eprints.soton.ac.uk/id/eprint/449620
ISSN: 2044-6055
PURE UUID: 51017563-ccab-4149-ba5c-a8c29ad7195f
ORCID for Felicity Bishop: ORCID iD orcid.org/0000-0002-8737-6662
ORCID for Miznah Al-Abbadey: ORCID iD orcid.org/0000-0002-6307-9196
ORCID for Lisa Roberts: ORCID iD orcid.org/0000-0003-2662-6696
ORCID for Beth Stuart: ORCID iD orcid.org/0000-0001-5432-7437
ORCID for Lucy Yardley: ORCID iD orcid.org/0000-0002-3853-883X

Catalogue record

Date deposited: 09 Jun 2021 16:30
Last modified: 17 Mar 2024 03:06

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Contributors

Author: Felicity Bishop ORCID iD
Author: Miznah Al-Abbadey ORCID iD
Author: Lisa Roberts ORCID iD
Author: Hugh MacPherson
Author: Beth Stuart ORCID iD
Author: Dawn Carnes
Author: Carol Fawkes
Author: Lucy Yardley ORCID iD
Author: Katherine Bradbury

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