Contextual Factors in Low Back Pain Consultations

Lower back pain (LBP) is not perceived as a measure of local tissue pathology or damage alone. It is a multidimensional disorder, which is influenced by physical, psychological, and social factors, which are interrelated, rather than mutually exclusive [1]. LBP can vary from low to high levels of complexity, resulting in different levels of pain and disability in patients [1]. The various approaches to diagnose and manage LBP lead to higher health care costs. Worldwide, the necessity to address this burden on the healthcare system is considered priority [2].

A large prospective cohort study demonstrated that chiropractic care is a complementary and alternative treatment, which should be considered when general medical practitioners make decisions concerning referral routes and pain pathways for patients with musculoskeletal (MSC) conditions [3]. In the United Kingdom (UK), both private and NHS-referred patient groups can benefit from chiropractic care. On one hand, evidence shows statistically significant improvements in patient-reported outcomes of patients with acute and chronic back pain undergoing chiropractic treatment [4]. On the other hand, a systematic review of interventions and economic evaluations suggests that the decision to seek or to refer patients for chiropractic care should be based on patient preference and values [5]. Healthcare professions require a sustainable research culture to underpin evidence-based practice and ensure effective integration of care within the wider healthcare system [6].

Clinical improvement during chiropractic care may be largely understood considering contextual factors [7]. Such contextual components can trigger a powerful contextual effect. A new descriptive model called Contextually Aided Recovery (CARe) explains how the effect can both enhance pain (nocebo) and attenuate pain (placebo) depending on the meaning to the patient of the contextual factors present within the clinical encounter [8]. Contextual effects are considered embodied psycho-neurobiological responses capable of modulating MSC pain and producing changes at different neurobiological, perceptual and cognitive levels [9].

A large prospective questionnaire study in physiotherapy, osteopathy, and acupuncture revealed that contextual factors predict the outcome of low back pain therapies [10]. The first goal of the current project is to conduct a major prospective questionnaire-based study, using advanced statistical techniques to explore the impact of the therapeutic relationship, the healthcare environment, incidental treatment characteristics, patients' beliefs, and practitioners' beliefs on the efficacy of chiropractic care.

The second aim of the current PhD is investigating in more depth the therapeutic relationship between a patient and clinician in chiropractic care. The patient-chiropractor relationship is a fundamental part of treatment and can make a significant difference in the patients' experience. Evidence suggests that patient-centred approach characterised by demonstrating care and empathy can positively enhance patients' experience within the clinical environment and activate psychosociobiological adaptations associated with the placebo effect [11].