Purpose and background

Understanding patients’ expectations of back pain treatment can help improve their experiences, adherence and outcomes. Patients typically expect a diagnosis and exercise-based physiotherapy, but often undervalue the role of psychological factors. This study explored patients’ expectations of outpatient physiotherapy treatment for back pain in primary care.

Purpose: ‘Red flags’ are patient responses and findings on history taking and physical examination that are associated with an increased risk of serious spinal disorders. The purpose of this paper is to identify red flags reported in the low back pain literature, establish consensus on whether (or not) they are considered red flags, and review the evidence for these signs and symptoms.

Methods: The following databases were searched using key words ‘red flag’ and ‘low back pain’:

MEDLINE (1951→)

In addition, national guidelines and key texts were hand-searched. Each red flag identified in the literature was classified using The Guidelines Development Group’s format (where 100% coverage = ‘unanimity’; 75–99% = ‘consensus’; 51–74% = ‘majority view’; and 0–50% = ‘no consensus’), and the findings summarized.

Results: The electronic searches revealed 54 papers, with the resultant ‘red flags’ ranging from ‘no consensus’ to ‘unanimity’. Evidence for these signs and symptoms is variable. Case reports and series justify labelling some features ‘red flags’, whilst others owe their label to clinical experience and expert opinion.

Conclusion: Case reports and series should be reported/ published to help identify those signs and symptoms suggestive of serious spinal disorders and those more likely to be ‘red herrings’. Despite their importance, there is inconsistency within the literature in identifying true red flags and, an ability to identify these signs and symptoms is essential for all who practise spinal assessments.

Background and purpose of study: Communication between clinicians and patients forms an integral part of any treatment session. To promote positive treatment outcomes, this communication must be effective. To date, research into back pain management has tended to focus on the nature of interventions, neglecting the vital communication that co-exists.

This study aimed to measure verbal communication between clinicians and patients and identify trends in non-verbal communication. With a clearer understanding of how clinicians and patients interact, it is anticipated that this knowledge can be used to maximise health gain in subsequent treatments.

Methods: Following an assessment, the first follow-up treatment session was video recorded for 21 patients (aged 17–65 years), attending a hospital outpatient physiotherapy clinic. Patients with serious spinal pathology or those, whose first language was not English, were excluded.

Verbal communication during the interaction was measured using the validated Medical Communication Behaviour System (MCBS). Trends in non-verbal behaviour were analysed at 40-second intervals, using Heintzman’s classification (smiling, forward leaning, affirmative head nodding, touching and eye gaze). A brief semi-structured interview was undertaken with clinicians to determine the perceived effect of the presence of the video camera.

Results: In 21 treatment sessions, 2055 statements were observed, with clinicians spending approximately twice as long talking as patients. Using the MCBS categories, the majority of clinician and patient interaction related to ‘content’ behaviours (52% and 26% respectively). For the clinician, this includes history-taking, advice etc. The highest frequency of clinicians’ non-verbal behaviour was touch (n=352) and for patients, was eye gaze (n=36).

In a secondary analysis, age, gender and experience of the clinician were all shown to influence the communication that occurred.

Conclusion: Validated outcome measures can be used to analyse the complex communication that occurs between clinicians and patients with back pain. Video recording clinical sessions can provide valuable feedback for clinicians and students on their communication skills.