Alhowimel, Ahmed
(2019)
Psychosocial factors associated with an MRI diagnosis of chronic non-specific low back pain in Saudi Arabia.
PhD thesis, University of Nottingham.
Abstract
Introduction
In patients with chronic low back pain, psychosocial factors have a considerable influence on pain perceptions. These factors also affect treatment and rehabilitation responses, as well as increasing the probability of disability associated to back pain. It is postulated in various studies that in low back pain (LBP) patients, there could be a relationship between psychosocial factors, including catastrophising and fear avoidance, and treatment responses. However, at this time, the research exploring this relationship of psychosocial factors as predictors of pain and disability outcomes in chronic low back pain (CLBP) is insufficient.
Although there is consensus in clinical guidelines that MRI is impractical for diagnosing CLBP, healthcare professionals continue to request further investigations to explain the symptoms radiologically. Despite evidence that MRI for CLBP does not change how the condition is managed, it is nevertheless associated with an increase in pain medication and doctors’ visits. However, the psychological impact of being given the results of an MRI on people with CLBP has not been reported in the literature.
Several publications recommend that to avoid unnecessary medical procedures and keep medical costs down, alternative options be made available to patients. Physiotherapy is one such alternative to MRI that increases beneficial outcomes for LBP patients, as well as reducing medical expenditure.
This project aims I) to identify the psychosocial factors associated with change in pain and disability in CLBP patients treated by a physiotherapist. II) to explores the psychosocial factors associated with MRI diagnosis, and finally, III) determine the feasibility of conducting a definitive randomised control trial to answer the question, does MRI diagnosis negatively influence psychosocial and disability outcomes in patients with CLBP treated by physiotherapy in Saudi Arabia.
Methods
This project has adopted the Medical Research Council framework for complex intervention. Firstly, the association between psychosocial factors and changes in pain and disability outcomes was determined by conducting a systematic review.
Secondly, the psychosocial factors associated with receiving an MRI diagnosis were explored using in-depth qualitative interviews with three different groups (doctors, patients and physiotherapists).
Finally, a feasibility trial with process evaluation was conducted to test the feasibility of a definitive trial to determine the impact of MRI diagnosis on psychosocial, pain and disability outcomes in people with CLBP treated with physiotherapy. People presenting to spine clinics were randomised to receive an MRI diagnosis (intervention) plus physiotherapy rehabilitation or physiotherapy alone (Non-MRI/control group). The acceptability of randomisation to the non-MRI or MRI group was tested during recruitment and by qualitatively interviewing study participants and referring physicians.
Results
Regardless of the form of physiotherapy, the psychosocial factors of catastrophising, depression, fear of movement and self-efficacy can predict disability outcomes following physiotherapy intervention. However, the influence of these factors on predicting pain severity after physiotherapy intervention is less likely.
The qualitative data from 11 patients, six physiotherapists and six doctors highlighted that fear of movement and anxiety were the main psychosocial consequences following MRI diagnosis. Furthermore, the study identified a need for national clinical guidelines for CLBP management in Saudi Arabia.
The feasibility study failed to reach the recruitment target: 16/24 participants were recruited in 4 months (12.4% of those screened); 33% declined. The process evaluation identified a number of factors that may affect the success of a definitive RCT in Saudi Arabia. These were research resources, including limited availability of physicians’ time for research, lack of research infrastructure e.g. to support recruitment to trials and limited research capacity in terms of the knowledge and skills of the healthcare team and limited funding. Interviews with five participants from both groups and physicians raised concerns about the acceptability and feasibility of randomly allocating patients to non-MRI group.
Conclusion
The results of studies revealed that disability outcomes could be predicted reliably by measures of psychosocial factors including catastrophising, depression, fear of movement and self-efficacy regardless of the physiotherapy intervention. This indicates that future physiotherapy screening of CLBP patients ought to include an evaluation of these factors.
The interview study indicated a lack of local clinical guidelines of CLBP management in Saudi Arabia and a mismatch in priorities between primary care and secondary care levels that might explain the long waiting time in secondary care doctors’ appointments. The study also highlighted a possible association between fear and anxiety in patients with CLBP following diagnostic MRI and an over-reliance on biomedical education from the healthcare practitioners.
Various barriers limit the feasibility of conducting a definitive RCT to test the influence of MRI diagnosis on psychosocial and disability outcomes in people with CLBP treated with physiotherapy in Saudi Arabia. A large trial would require multiple recruitment centres, a lengthy recruitment period and research staff trained in good clinical practice. Moreover, physician and participant concerns surrounding the acceptability of randomising patients not to receive an-MRI may limit success and suggest that progressing to large scale RCT would be impractical at the present time.
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