Interviewee

Dr Alan Breen, Director for the Institute for Muscular-Skeletal Research and Clinical Implementation, Dorset, UK

Article

Breen, A., Austin, H., Campion-Smith, C., Carr, E., & Mann, E. (2006) 'You Feel So Hopeless': A Qualitative Study of GP Management of Acute Back Pain. European Journal of Pain , 11(1):21-29.

Summary

Michael Bouwman talked to Dr Alan Breen who has recently completed a study on GP management of acute back pain in the United Kingdom. Michael and Alan discuss the difficulties encountered by GPs managing patient issues relating to acute non-specific back pain and the lack of guiding evidence available in this area.

Transcript

Michael Bouwman: Introducing Dr. Alan Breen, Director of the Institute of Muscular-Skeletal Research and Clinical Implementation in Dorset, in the United Kingdom. We're here to discuss Alan's research and subsequent article, 'You Feel So Hopeless: A Qualitative Study of GP Management of Acute Back Pain.' Alan, may we please begin with a short summary of this article. Alan Breen: Sure, the article was focused on studying GP attitudes to managing acute low back pain in order to identify areas of difficulty they had because there were clearly areas of difficulty thrown up by the literature. So we invited all family doctors in three primary care trusts in the south of England, where we are, to take part in interviews and before asking them, we sent them contextual material about the study and a copy of the Royal College of General Practitioner's Guidelines for the management of acute back pain. We had twenty-two GP's responding then we did fifteen minute telephone interviews individually with each one and each discussed their feelings about dealing with a specific but unidentified back pain patient of their own choosing whose management had involved psycho-social issues. The main themes we got from that were feelings, context, referral, assessment, analgesia and giving information to the patient. Then we took these things back and debated and discussed them within the research group and that led to the development of three, one paragraph vignettes - little stories which were just brief fictitious accounts of patients with non-specific back pain and then the GP's in three groups of seven attended focus groups, one hour focus groups at a local venue in their area. We tape recorded those and transcribed them and that was analyzed by a qualitative researcher with one being analyzed via second researcher to check. Michael Bouwman: This is quite a significant issue and one that's not fully understood in the world at large unless one is a sufferer of acute or chronic back pain. What was your inspiration behind a study on GP management of back pain and what led you to research within this area? Alan Breen: Well, our institute from the beginning was focused on the need to get evidence into practice in the muscular-skeletal area. We started out helping the government commission committee called, 'The Clinical Standards Advisory Group' back in the early nineties to study access and availability of services and standards of care for back pain. And then after that a few years later the publication and development of, 'The Royal College of General Practitioner's Acute Back Pain Guideline' and then after that an audit tool to audit the Back Pain Guideline and then when we found they were not being implemented, studies of why they weren't implemented. That led us on to trying to find solutions and collaboration with the pain group at Bournemouth University's 'Institute for Health and Community Studies'. We started a qualitative study of feasibility of nurse led services in General Practice and then that really focused us more and more towards the issue of GP attitudes and their problems and areas of difficulty as a further way forward. Michael Bouwman: You mention that there's a lack of evidence or research to inform management in this area, but you also mention that GP's are not necessarily adhering to those evidence based guidelines. What evidence are the guidelines based on and what is lacking in the guidelines as regards to evidence? Alan Breen: The RCGP guidelines were based on the first low back pain serious guideline which was developed in America by 'The Agency for Health Care Policy and Research' and the AHCPR guideline needed updating and the RCGP guideline did that on the basis of four systematic reviews on bed rest, advice on staying active, spinal manipulation and exercise. That was then published a few years later and was actually supplanted and replaced in 2005 by the European Commission's Acute Back Pain Guideline. Michael Bouwman: We then sought to clarify the distinction between psycho-social contrasted with psycho-somatic and Dr. Breen indicated he was working from another paradigm which he referred to as the, 'bio-psycho-social'. Alan Breen: Of increasing the importance of the social issues which sometimes practitioners don't think it's their role to engage. Things like rigidity of the rules of employment, 'don't come back here until you're fit', sort of thing and the demands of work and the way in which the certification system works or even the health care system works. These are things that we would like to see the focus on. I think another, just to mention, these things don't come in ones and twos, they come in multiples so multiple bio-psycho-social factors seem to be particularly strong predicators of poor outcome and seem to be quite daunting for practitioners to engage because... Michael Bowman: I suppose it's difficult for a GP in a short consultation to try and tease out what's what. Alan Breen: It seems to be about becoming more familiar with the terms and the parameters. Michael Bouwman: Since the study's been done, have any of these findings been transferred into general practice? Alan Breen: Yes, there is a number of things that happened after the study was done. One aspect of it was really to get it to go on and tried as educational intervention that we were keen on doing. So we tried a project called 'Improving the Management of Low Back Pain in the Community' using something called 'collaborative action learning groups'. This involves PDSA, 'Plan, Do, Study, Act' cycles in which general practitioners set their own educational agenda in a group of learning outreach visits and then evaluate them as they go along. And that was actually very successful and the success of that was followed by a grant application to develop and evaluate this GP educational package for the management of low back pain and we're actually in the middle of that right now. But the actual change that you refer to, the main improvement that we found in what was just a little pilot study, was an improvement in confidence. We gave the GP's a ten point VAS, 'Visual Analogue Scale' to measure what they thought was the confidence to manage back pain before the workshops and after and there was quite a significant improvement from 3.9 up to 7 points on that scale in their confidence. Michael Bouwman: Well thank-you very much for taking the time to speak with us today. Alan Breen: Thank-you very much, thank-you.