Journal of Physiotherapy 71 (2025) 48–56

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s

Research

Clinician experiences in providing reassurance for patients with low back pain in
primary care: a qualitative study
Anika Young a, Simon D French a, Adrian C Traeger b, Julie Ayre c, Mark Hancock d, Hazel J Jenkins a
a
Department of Chiropractic, Faculty of Medicine, Health and Health Science, Macquarie University, Sydney, Australia; b Institute for Musculoskeletal Health, Sydney School of
Public Health, Faculty of Medicine, Sydney, Australia; c Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; d Department of
Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia

K E Y W O R D S A B S T R A C T

Low back pain Questions: What reassurance is being delivered by physiotherapists and chiropractors to people with non-
Reassurance specific low back pain? How is it being delivered? What are the barriers and enablers to delivering
Primary healthcare
reassurance to people with non-specific low back pain? Design: A qualitative study. Participants: Thirty-
Qualitative research
two musculoskeletal clinicians (16 physiotherapists and 16 chiropractors) who manage low back pain in
primary care. Method: Semi-structured interviews were conducted about their experiences delivering
reassurance. The interview schedule was developed using the Theoretical Domains Framework and analysed
using framework thematic analysis. Results: Four themes were identified: giving reassurance is a core
clinical skill for delivering high-quality care; it takes practice and experience to confidently deliver reas-
surance; despite feeling capable and motivated, clinicians identified situations that challenge the delivery of
reassurance; and reassurance needs to be contextualised to the individual. Conclusion: Clinicians possess a
strong understanding of reassurance but require clinical experience to confidently deliver it. This study
provides insights into how reassurance is individualised in clinical practice, including suggestions for clini-
cians about how to implement reassurance effectively for people with low back pain. [Young A, French SD,
Traeger AC, Ayre J, Hancock M, Jenkins HJ (2025) Clinician experiences in providing reassurance for
patients with low back pain in primary care: a qualitative study. Journal of Physiotherapy 71:48–56]
© 2024 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction showing empathy. The term ‘cognitive reassurance’ refers to the pro-
vision of reassuring information. A systematic review of observational
Low back pain (LBP) is common and is associated with substantial studies found that cognitive reassurance was associated with better
disability. Worldwide, 619 million people experienced back pain in outcomes but the impact of affective reassurance was uncertain.12
2020,1 and there are significant personal and societal costs related to Reassuring information recommended in clinical practice guidelines
LBP.2,3 In Australia, back pain continues to be the second leading cause for NSLBP relates, where appropriate, to the absence of serious pa-
of disability4 and back pain management cost AU$3.36 billion in thology, the likelihood of a favourable prognosis and the safety of
2020.4 The prevalence of LBP has been projected to increase over the movement.10,13 A systematic review found that providing patient
next 25 years, with associated increases in disability with healthcare reassurance is important because it decreases healthcare utilisation
costs.1 Most LBP is non-specific low back pain (NSLBP), referring to and costs, and leads to improved patient outcomes.12 Despite identified
LBP that does not have a known pathoanatomical cause.5 LBP is a benefits, there is a disparity between guideline recommendations and
complex condition that is multifactorial in nature, where a person’s use in clinical practice. In primary care settings, such as general prac-
pain experience is influenced by biological, psychological and social tice, physiotherapy and chiropractic, clinicians have reported not of-
factors.6 Recovery from an episode of LBP is also complex; approxi- fering reassurance in the form of information about prognosis in
mately 25% of people with LBP experience recurrence within approximately 25% of first-time consultations for LBP.14
12 months7 and 44% of people can still experience pain at 12 months.8 Considering that not all people with LBP receive reassuring infor-
Clinical practice guidelines consistently recommend that people mation, there appear to be complexities when implementing this
with NSLBP of any duration (acute, sub-acute and chronic) receive recommendation into clinical practice. These complexities may be due
reassurance as a component of their care and not in isolation.9,10 to guidelines providing limited detail about how best to deliver reas-
Reassurance is the act of reducing fear, worry or concern.11 In a clin- surance,14 or that there are circumstances that make it more chal-
ical context, reassurance may include a combination of clinician be- lenging for clinicians to engage in this behaviour. To gain a deeper
haviours. The term ‘affective reassurance’ refers to creating rapport and understanding of the factors that influence clinicians in delivering

https://doi.org/10.1016/j.jphys.2024.11.003
1836-9553/© 2024 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
 Research 49

reassurance, this study sought insights from clinicians to assist in available in Appendix 1 on the eAddenda. The TDF describes 14 do-
implementing guideline-recommended reassurance for people with mains that may impact behaviour: knowledge; skills; social or pro-
NSLBP. A qualitative study allows for the gathering of in-depth and fessional role/identity; beliefs about capabilities; optimism; beliefs
context-rich information on reassurance use. The only available quali- about consequences; reinforcement; intentions; goals; memory,
tative study exploring reassurance for managing LBP is from a patient attention and decision processes; environmental context and re-
perspective in UK general practice.15 That study highlighted the sources; social influences; emotion; and behavioural regulation. In
importance of providing information and advice, but the role of affec- this study, the TDF domains were used to describe barriers and en-
tive reassurance (eg, empathy and relationship building) was less clear. ablers impacting a specific behaviour, which in this case was the
It is believed that this study is the first qualitative investigation of provision of reassurance. Interview questions mapped to each of the
the use of reassurance in two other primary contact professional TDF domains, to ensure that all potential barriers to and enablers of
groups, physiotherapists and chiropractors, who commonly manage provision of reassurance were identified.20 The baseline survey and
people with NSLBP.16 This study aimed to explore the experiences of interview guide were piloted with two clinicians (one physiotherapist
physiotherapists and chiropractors in delivering reassurance to peo- and one chiropractor) who did not participate in the study. Feedback
ple with NSLBP in clinical practice. from these pilot interviews was used to refine the interview guide.
Therefore, the research questions for this qualitative study were:

1. What reassurance is being delivered by physiotherapists and chi- Data analysis

ropractors to patients with NSLBP?
2. How is it being delivered? A data-driven (inductive) approach was used and a thematic
3. What are the barriers to and enablers of delivering reassurance to framework approach was applied to data analysis21 through a critical
people with NSLBP? realism lens.22 The framework approach to thematic analysis was
advantageous in this context, as the study was able to look at patterns
across participants while allowing for the integration of perspectives
from a multidisciplinary team. We did not deductively code to the
Method TDF explicitly as there are limitations to using this method that can
lead to a superficial analysis.23 The inductive approach allowed for
Design greater depth in the analysis.21 We followed the six-stage procedure
to analyse the data described by Gale et al21 in 2013: transcription,
This study employed a qualitative research design using the familiarisation, coding, developing a working analytical framework,
framework method of thematic analysis. The reporting of this study applying the analytical framework, and charting data into the
followed recommendations outlined in the COREQ criteria for framework matrix. Three researchers analysed the data (AY, HJ and
reporting qualitative research.17 JA). The lead analyst and interviewer (AY) is a female PhD candidate
and chiropractor with 6 years of experience in clinical practice and
Participants previous experience conducting qualitative interviews with health
professionals and people experiencing LBP.24,25 HJ is a female
The study recruited clinicians who deliver care to people with researcher and chiropractor with experience in clinical practice and
NSLBP of any duration (acute, sub-acute or chronic). Physiotherapists qualitative research. JA is a female public health and behavioural
and chiropractors were considered eligible if they regularly treated science researcher with experience in qualitative methods. The re-
people with LBP of any duration (self-reported, minimum two to searchers familiarised themselves with the data prior to coding. The
three patients with LBP per week), and were registered to practise initial transcript coding of four interviews using NVivo 14c,26 was
with the Australian Health Practitioner Regulation Agency (AHPRA). performed independently by two researchers (AY and either HJ or JA).
Clinicians were approached using: sampling of clinicians via the One researcher (AY) coded an additional two interviews. Investigators
research team’s professional networks; snowball sampling based on met to discuss coding and reflect on differences in perspectives. After
recommendations from other clinicians participating in the study; this initial coding, the researchers developed and agreed upon the
and electronically via email, professional associations and social preliminary analytical framework. The coding framework was applied
media advertisements. The electronic data capture system REDCapa to the remaining interviews by one researcher (AY). The data were
was used to screen clinicians for eligibility and collect consent and then charted into the framework and discussed with the wider
baseline data. Baseline data included: demographic information (age, research team to develop the preliminary themes. After subsequent
gender, years in clinical practice, type of practice and LBP caseload iteration, the research team decided on the final themes. The coding
estimate); beliefs about the importance of reassurance for LBP; and tree can be found in Appendix 2 on the eAddenda.
frequency of reassurance use.
Purposive sampling of eligible participants ensured that a diverse
range of perspectives were captured (eg, profession, years in practice Results
and gender). Participants were invited to participate in a single 30-
minute, semi-structured, one-to-one online interview with a Flow of participants
researcher (AY), which was conducted using commercial videocon-
ferencing softwareb. Interviews were audio recorded and automati- Thirty-seven clinicians expressed interest in the study, with 32 (16
cally transcribed using the software, and then checked for accuracy physiotherapists and 16 chiropractors) invited and consenting to
by a researcher (AY). Transcripts were not returned to participants for participate in the interviews. Interviews were conducted between
review or further comments. The study aimed to continue to recruit September and December 2022.
participants until an acceptable breadth and depth of themes had
been achieved.18 For most participants (28 of 32) there was no
existing relationship with the researcher prior to study commence- Participant characteristics
ment. Four of the participants were colleagues of the interviewer. No
details about the study were discussed between the participants and The population was diverse in age (range 23 to 68 years; median
AY prior to or after the interview. No participants withdrew from the 36 years; IQR 30.5 to 50 years) and years of clinical experience (range
study after providing consent. 0.5 to 47 years; median 10.5 years; IQR 6 to 24.5 years). Males rep-
The interview guide was designed using the Theoretical Domains resented 63% of the sample. Most participants (88%) rated reassur-
Framework (TDF), which is a theory-informed tool to identify key ance as being extremely important with people with NSLBP, and all
determinants of behaviour.19,20 A copy of the interview guide is reported using reassurance frequently (Table 1).
50 Young et al: Reassurance for low back pain

Table 1 That’s happened a few times where maybe people when I thought
Participant characteristics. they’re looking for more of that factual base stuff and you can sort of
Characteristic (n = 32) see the eyes glaze over. You know you pivot and come back to that
Profession, n (%) more empathetic reassurance. Reassurance is never hard. You have to
physiotherapist 16 (50) pick that right mix and fact and empathy for that individual there in
chiropractor 16 (50) front of you. (C87, chiropractor, male, 11 years of clinical
Gender, n (%) experience).
female 12 (38)
male 20 (63)
Age (y), median (IQR) 36 (30.5 to 50) Clinicians described being motivated to deliver reassurance to
Clinical experience (y), median (IQR) 10.5 (6 to 24.5) help address patients’ fears related to their back pain. Clinicians
Location of practice, n (%) described that the de-escalation of patients’ fears was a professional
metropolitan 23 (72)
responsibility.
regional 7 (22)
rural 2 (6)
Current workplace, n (%)a .it’s largely part of our role. I think people come to see us because
private practice 31 (97) they want your opinion on the severity of their issue and also they
hospital or outpatient 2 (6) come in worried and they’re looking for either some sort of reas-
How do you value providing reassurance during a
surance or. escalation of urgency around their case (P16, physio-
clinical encounter for low back pain?, n (%)
extremely important 28 (88) therapist, male, 6 years of clinical experience).
important 4 (13)
neutral 0 (0) In addition, clinicians believed ‘that reassurance is a key factor for
unimportant 0 (0)
good outcomes’ (P109, physiotherapist, male, 5 years of clinical
extremely unimportant 0 (0)
How often do provide reassurance for low back pain?, n (%) experience).
frequently 32 (100) Through reassurance, clinicians aimed to validate patients’ con-
sometimes 0 (0) cerns, build trust and, by reducing concerns, avoid unnecessary use of
rarely 0 (0) further healthcare (imaging, medicines and surgeries).
never 0 (0)

Percentages may not sum to 100% due to rounding. I think when you reassure patients, it validates their feelings, it makes
a
Respondents could select more than one response.
them feel more trust in you as a practitioner (C07, chiropractor, fe-
male, 2 years of clinical experience).

Main themes
.the goal of reassurance is to reduce the likelihood of care escalating
to more invasive or non-conservative treatment options that may be
Four main themes were developed: giving reassurance is a core clin-
unwarranted. So, if it stops someone from getting an MRI when it
ical skill for delivering high-quality care; it takes practice and experience
might not be needed and having surgery when it might not be needed
to confidently deliver reassurance; despite feeling capable and motivated,
or having injections or lots of painkillers when it’s not necessarily
clinicians identified situations that challenge the delivery of reassurance;
going to be beneficial (C13, chiropractor, male, 2 years of clinical
and reassurance needs to be contextualised to the individual.
experience).

Theme 1: Giving reassurance is a core clinical skill for delivering Conversely, if reassurance was not delivered in an appropriate
high-quality care way, clinicians felt that this may negatively impact the patient by
making them feel dismissed.
Clinicians described providing reassurance that aligned with cur-
rent guideline recommendations for NSLBP. Clinicians also felt If you haven’t [validated the patient], you’ll just sound dismissive, so
strongly motivated to deliver reassurance, as they believed that you actually won’t be reassuring. A lot of physios, chiros or doctors
reassurance is associated with improved patient outcomes and they can think they’re being reassuring, but in fact, they’re not reassuring
viewed it as their professional responsibility to provide it. the patient at all (P100, physiotherapist, male, 28 years of clinical
Clinicians described that delivering reassurance for people with experience).
NSLBP mainly comprises providing educational messages about
NSLBP (cognitive reassurance), creating a realistic path forward for
the patient, while also engaging in relationship-building components Theme 2: It takes practice and experience to confidently deliver
of care (affective reassurance) that enhance the delivery of reassur- reassurance
ance. The educational messages aimed to reduce low back-related
fears, including: reassurance about the absence of underlying Theme 2 explored the additional learning curve required to
serious pathology as a cause of their pain; providing advice about a translate knowledge into the capabilities needed to confidently deliver
favourable prognosis (where appropriate); and the use of messaging reassurance in clinical practice. While many clinicians spoke with high
that encourages the safety of movement. Table 2 details specific ex- levels of confidence about delivering reassurance, that confidence was
amples given by clinicians. developed through the clinicians’ experiences with managing NSLBP
Clinicians described that the delivery of educational messages and practice delivering it to a range of different people.
alone is not enough. They emphasised the importance of how the Most clinicians felt that they had the interpersonal skills needed
messages were delivered; this included the framing of messages to to deliver reassurance to people with NSLBP, but these skills had
facilitate a positive outlook, where appropriate, and to outline a developed over time through clinical experience. Clinicians felt that
realistic and measurable pathway forward. they possessed knowledge pertaining to LBP diagnosis, prognosis and
management needed to deliver cognitive messages of reassurance
Reassure them that whatever they’re experiencing is real, reassure upon entering the workforce; however, they did not feel confident to
them. about what the pathway forward looks like and giving them immediately implement that knowledge in practice due to a lack of
a very like, a very realistic picture of what the journey looks like with interpersonal skills (eg, communication skills, establishing rapport)
me (P103, physiotherapist, male, 15 years of clinical experience). on how to confidently deliver the information:

How these messages are delivered depends on what the individ- I think you kind of get a kick start at university but certainly not to
ual needs, with one clinician stating: the extent. Look, I certainly had the knowledge, but I didn’t have the
 Research 51

Table 2
Examples of reassurance messages used by clinicians.

Categories of reassurance for NSLBP Examples from clinicians

Absence of pathology .there’s unlikely to be anything broken, any muscle tears or anything that is unstable. in up to 95% of cases there isn’t
anything specific or structural going on and it’s a non-specific type of pain. It is unlikely anything is seriously wrong (C13,
chiropractor, male, 2 years of clinical experience).
Prognostic reassurance .their outcomes are more than likely going to be pretty good. And that things regress to the mean relatively well and that
even though they’re uncomfortable immediately, good outcomes are common and quite possible (P06, physiotherapist,
male, 7 years of clinical experience).
Activity reassurance .getting moving again and getting active again. You know, reassurance that movement is OK. Reassurance that they’re
sore, but they’re safe (P113, physiotherapist, female, 15 years of clinical experience).

NSLBP = non-specific low back pain.

skills of being able to do it (P105, physiotherapist, female, 7 years of clinical features (such as psychological distress, pain duration . 12
clinical experience). weeks and previous episodes of LBP) that indicated a higher risk of
poor outcomes.
One clinician spoke about a course in motivational interviewing,
equipping them with communication skills, which assisted with I feel uncomfortable if I’m reassuring someone, but I don’t know if
delivering reassurance: you’re actually going to get better. because you should get better,
but there’s going to be other factors, maybe that delay your recovery.
We had a 10-day [motivational interview] training and, wow, that I don’t want to break someone’s trust by reassuring them. But I also
made me much more confident in talking because all we did was don’t want to then flag you might have a delayed recovery because
practise how to talk. So motivational interviewing was really helpful that’s the opposite of reassurance (P106, physiotherapist, female, 9
and also having seniors watching me deliver some of this stuff gave years of clinical experience).
me more confidence (P102, physiotherapist, male, 15 years of
clinical experience). In addition, these challenges with delivering reassuring prognostic
messages were amplified if patients did not demonstrate expected
Confidence levels in delivering reassurance are shaped by clini- improvements in subsequent treatment sessions, or recovery took
cians’ experiences and knowledge of the evidence base for NSLBP. longer than anticipated. This created uncertainty, introducing doubt
Although all clinicians reported high levels of confidence in delivering about the appropriateness of the prognostic reassurance provided in
reassurance at the time of the interview, they reflected that on-the- the first instance:
job practice and frequently managing people with NSLBP were
responsible for building that confidence. But once it passes a certain time frame and if the pain is still quite severe,
it definitely becomes a lot harder, because people start to doubt whether
I’m pretty confident in delivering reassurance. that I think reflects it is ever going to go away or if this is going to be a. rest of their life
my knowledge level on some conditions. With typical non-specific type thing (C13, chiropractor, male, 2 years of clinical experience).
low back pain, that’s relatively acute on chronic, I’m pretty confident
in explaining that because you get a lot better at it because you see it Patients who felt that the diagnosis implied a poor prognosis were
consistently and then you’re more confident in delivering to the seen by clinicians to be less receptive to reassurance:
patient. So the more you actively try to reassure and because that’s
the thing I typically do like to do, I think you get better at it. So I’m .cases that have their pre-existing thoughts on low back pain are
pretty confident in it (C07, chiropractor, female, 2 years of clinical the challenging patients. if a patient has a pre-existing idea on that
experience). diagnosis. They’ll have a tendency to maybe be less receptive to your
advice and your reassurance as a clinician (C94, chiropractor, male,
One chiropractor with 11 years of clinical experience identified 8 years of clinical experience).
their current confidence level by reflecting on the way they had
delivered reassurance previously, and that further gains in confidence Clinicians described circumstances where it was difficult to
levels are likely to continue to occur into the future: establish rapport and highlighted the importance of developing
rapport with an individual before providing reassurance. Clinicians
.I feel very confident. I probably felt very confident two years ago and described that where rapport was easily established or pre-existing,
probably felt very confident five years ago. But I’m a lot better at it now their ability to deliver reassurance was enhanced.
than I used to be, so I’ll probably say I was not very good at it in five
years’ time, but I feel confident now I’m a lot more confident than I Building rapport allows the patient to feel safe enough that they can
used to be (C87, chiropractor, male, 11 years of clinical experience). be heard and understood and showed some empathy. To show that
the practitioner has some understanding of the issue. When you have
the rapport with the patient. they will trust your opinion and what
Theme 3: Despite feeling capable and motivated, clinicians you’re saying when it comes to reassurance (P16, physiotherapist,
identified situations that challenge the delivery of reassurance male, 6 years of clinical experience).

Despite reporting having the knowledge, skills and confidence to Clinicians reported that rapport was more difficult to establish
deliver reassurance, in general, clinicians described specific situations with certain individuals. This phenomenon related to a mismatch in
when they were in fact not very confident delivering reassurance either personality or communication style between the patient and
to individual patients. These situations included the presence of the clinician.
clinical features associated with poorer recovery and patient
factors impacting the reception of reassurance, including previous I think sometimes, you know, we’re always going to come across a
patient experiences that reduce their trust in clinician patient that it is a little bit harder for us to build rapport with. So if
recommendations. you haven’t done a great job of building that rapport early on, that’s
Clinicians often felt conflicted when deciding how to offer prog- going to be harder for them to buy into what you’re talking about
nostic reassurance in clinical settings. This conflict primarily arose with reassurance (P113, physiotherapist, female, 15 years of clinical
when there was uncertainty about the patient’s prognosis due to experience).
52 Young et al: Reassurance for low back pain

Table 3
Suggestions for clinicians for implementing guideline recommendations for reassurance for non-specific low back pain.

Guideline-based Purpose Components to Suggested questions or messages

reassurance address/deliver
recommendations10,33

Data gathering

Address Assess individual Identify beliefs/experiences ‘Tell me what you know about your back pain?’
understanding understanding of NSLBP that may be a barrier ‘What do you think might be contributing to your back pain?’
of back pain (beliefs and previous to providing reassurance or be ‘What have you been previously told, if anything, about your back pain?’
experiences) a target for education. ‘You’ve had this kind of back pain before. What was it like then?’
‘What have others (doctors/physiotherapists/chiropractors) said about your pain?’
‘What have you been told about the images of your back?’
‘Do you think your back pain will get better or worse?’

Understand Assess individual Identify specific targets for ‘What concerns you the most about this pain?’
person-specific NSLBP-related reassurance while ‘What are your worries about the future with respect to your back pain?’
concern concerns (current simultaneously enhancing/ ‘How much is your back pain impacting the things you enjoy doing?’
and future) building rapport.

Providing individualised reassurance

Address concerns To de-escalate the  Provide education on the ‘Serious causes of back pain are very uncommon and present in less than 1%
about pathology threat of pathology likelihood of serious of people with back pain’
as a cause of their pathology ‘You told me you have concerns about having [insert pathology here]. Based on
LBP  Provide evidence for my examination, I can assure you that [pathology] is very unlikely and that your
exclusion of serious back is healthy and strong despite being very sore at the moment’
pathology as a possible cause

Explain prognosis To de-escalate  Provide accurate prognostic Acute LBP

concerns that back advice, including the ‘Most people experience a rapid reduction in pain and resolution in symptoms
pain may persist expectation that pain will in 6 to 8 weeks. Based on my assessment, you should recover from this episode
indefinitely reduce where appropriate within that timeframe.’
 Use objective measures to Fluctuating/episodic LBP
inform prognostic advice ‘As you have seen from your previous experiences, your pain tends to come and
(eg, OMPQ) go. Even though you’re uncomfortable now, I expect this episode to recover
 Address concerns related to quickly similar to your previous episodes.’
delayed recovery or previous Persistent LBP or high-risk of poor outcome
history of long ‘We have identified some factors such as [insert factors here] that are contributing
-lasting LBP to your pain and I am confident that if we can address those factors together then
 Address fears and worries I am confident you will start to improve.’
related to personal Personal relationship to someone with a poor recovery
relationships with people ‘I understand you have fears that your back pain is going to follow a similar course
who have experienced to your friend who had [insert pathology here]. Here are the reasons why your LBP
poor recovery is different: Y, and Z’ [Provide targeted information about lack of the feared
pathology that their friend/family member has, or de-threaten that pathology]

Encourage To de-escalate concerns  Provide education on the ‘Movement is safe, and beneficial for recovery.’
activity that movement/ benefits of activity/ ‘You have said that you are hesitant to bend your back, as you have fears about
activity will make the movement these structures being damaged. I understand that when you bend this sometimes
problem worse and  Identify specific movements or triggers your pain. However, these tissues are very sensitive now and your spine is
to encourage activity activities that are of concern for actually very strong. The good thing is that sensitivity can be improved by starting
To build confidence in the individual and reasons for with easy movements that are similar to bending and gradually doing more as
returning to normal activities concern you get used to it.’
 Provide individualised activity [Already physically active]
advice considering current ‘You have said that you enjoy [X activity], and you usually do X amount of this
activity level and preferred activity. I would encourage you to still do X activity as it will assist your recovery,
activities let’s just do a little less to begin with and we can then build up to your previous
 Demonstrate the safety activity levels over the next X weeks.’
of movement through [Less physically active]
experiential reassurancea ‘We know that movement can help recovery, I suggest finding a form of movement
that you like doing and that should help your recovery.’
‘Are you open to starting to do a little bit of [X activity] even though you get some
pain and have concerns? I am expecting that your pain will start to reduce as you
gradually do more, and this will then build your confidence and enjoyment of
doing X’
Reassurance during in-session active care
‘You are sore, but you are safe.’
‘You’re OK, this isn’t going to physically hurt you.’

LBP = low back pain, NSLBP = non-specific low back pain, OMPQ = Örebro Musculoskeletal Pain Questionnaire.
a
Experiential reassurance is reassurance that is achieved through doing.

Some clinicians described that difficulty in establishing rapport sure that the patient gets care whether that’s with another practi-
usually meant that reassurance would not be as effectively delivered. tioner or through you (C07, chiropractor, female, 2 years of clinical
A strategy detailed by two clinicians, both with  2 years in clinical experience).
practice, in this situation was to refer the patient to another health-
care provider. Patients’ previous experiences were thought to influence their
ability to trust the reassurance being delivered by clinicians, primarily
If I don’t feel the patient is clicking with me as a practitioner, I always when the patients’ previous experiences were negative or conflicted
provide them with the opportunity to see another practitioner. they with current clinician advice. The patients’ trust of clinician advice
already have a rapport with, or I could refer them to someone that was impacted by previous non-reassuring encounters within the
they might be more comfortable seeing. If they don’t feel reassured healthcare system. Non-reassuring encounters included experiences
by you, then there’s only so much you can do and you should make (consultations or imaging) that may have had the opposite effect of
 Research 53

reassurance by enhancing concerns. In addition, clinicians reported Clinicians detailed strategies used to identify individual targets for
that patients who felt that their concerns had previously been dis- reassurance. These relate to data gathering by specifically asking
missed might have less trust when they sought a subsequent opinion. about patients’ concerns and their understanding of their pain.
Simultaneously, this is also a strategy employed to help establish
I think there’s sort of no secret in this field that you know will often rapport and build trust with the patient.
come across patients that are distressed or concerned by imaging
findings that they may have had that don’t necessarily correlate well You’ve got to keep asking the probing questions to really get to
with symptoms that they might present with (P98, physiotherapist, the rub of what their main concern is. Otherwise it just becomes
male, 7 years of clinical experience). a throwaway line that they’ve heard 50 million times before
and still not addressing their main concern. So, it’s not reassuring
A lot of clients have reported feeling a bit dismissed by the GP and not at all (P112, physiotherapist, female, 28 years of clinical
having time with the initial practitioner to go through things really experience).
thoroughly (P109, physiotherapist, male, 5 years of clinical
experience). In addition to the identification of specific patient concerns, cli-
nicians must understand a patient’s context and how their concerns
Conversely, clinicians reported that it was easier for patients to may be shaped by personal experiences. Subsequent reassurance
trust their recommendations when they had previously experienced must be delivered with consideration of the patient context in mind.
reassuring consultations and there was consistency in the informa-
tion provided between consultations. They might have a family member who hasn’t gotten better or has
had surgery or a family or a friend of the family who hasn’t done well
I think it’s easier when the client has a good understanding of. pain with back pain. So those we do provide that just a bit more guidance
and how pain works and if they’ve had education from someone and reassurance. (C92, chiropractor, male, 29 years of clinical
previously and they’ve been reassured previously (P06, physiother- experience).
apist, male, 7 years of clinical experience).
After specific patient concerns have been identified, clinicians
Patients who had past experiences with NSLBP that did not detailed the strategies they used to provide reassurance around those
resolve well or were managed inappropriately could also be more specific concerns. Strategies included providing educational messages
challenging to reassure and establish trust with, as guideline- (cognitive reassurance) and a safe environment for them to experi-
recommended reassurance might be incongruent with their own or ence movement (experiential reassurance).
others’ lived experiences. Poor previous experiences encompassed Clinicians detailed how they contextualised cognitive reassurance
either personal experience or the experience of other important to the individual. Clinicians described providing reassurance on the
people in their lives. exclusion of serious pathology by providing evidence after a thorough
history and physical examination, using individual examples perti-
I would say the longer that they’ve had the lower back pain or the nent to their case.
more. severe the back pain episodes have been [more challenging to
reassure] (P106, physiotherapist, female, 9 years of clinical .this is what I got from the assessment, and this is how I know that
experience). there’s no serious pathology in your case. So, I didn’t just say that
this person didn’t have it. I told them why I knew they didn’t have it
their personal experiences. one client who’s in her early 40s has a or why I thought that they didn’t have it and then explained what I
disc bulge at sort of L1/L2. has dermatomal pattern of symptoms thought was going on with the reasons why as well. It is a lot of
that match that. One of the things that she reported was her sister education, not just ‘this is what’s happening’ (P104, physiotherapist,
has had disc bulges and herniations and she can’t sit down on a plane female, 0.5 years of clinical experience).
for an hour. I think in terms of trying to reassure her, it’s kind of again
difficult. Because I haven’t necessarily got the history of the other Clinicians also described contextualising imaging findings to their
family member, but she also will have this preconception that that’s clinical history and their physical examination findings, for example:
what she’s going to end up like (P109, physiotherapist, male, 5 years de-escalation of disc bulge as a concern when there is no radicul-
of clinical experience). opathy present.

Conversely, clinicians reported that it was easier to reassure and If I’ve got someone who has already shown me that they’re really
build trust with patients who have had a more favourable experience caught up on what the scan says. So you tell me your pain is in the
with NSLBP, such as low pain intensity and quick resolution of pre- L4/5 disc. OK, I’m going to have to look at the scan and actually look
vious episodes. at that L4/5 disc, and then I’m going have to do something in my
physical examination to demonstrate that in fact, the L4/5 disc is
I think it’s definitely easier to provide reassurance to someone who actually OK, et cetera. You don’t need surgery. (P100, physiother-
has had an episode similar to it before, and they normally know their apist, male, 28 years of clinical experience).
body quite well and they know that if something like this happens, it
will go away over a certain period of time (C13, chiropractor, male, 2 Rather than purely relying on didactic means, clinicians may ask
years of clinical experience). patients to actively perform or be exposed to an exercise as a tool to
allow patients to experience the safety of movement. Clinicians re-
ported gradually exposing patients to elements of feared movements,
Theme 4: Reassurance needs to be contextualised to the individual thus building the patient’s tolerance and de-escalating the threat and
fear associated with the movement.
Clinicians felt that a one-size-fits-all model was not appropriate
for clinical practice. Clinicians emphasised the importance of You can give them as much education and advice and reassurance as
considering the individual and adapting reassurance accordingly, as you as you like, but sometimes, you just have to show the patient that
‘without it [individualisation] you are taking a stab in the dark and they can do it. As a physical therapist that you physically get the
you may or may not be reassuring’ (P100, physiotherapist, male, 28 patient to do something or move towards doing something that they
years of clinical experience). This theme addresses the way that cli- didn’t think they might be able to do. You know a particular
nicians have identified targets to individualise reassurance, and how functional goal that they have that you’re exposing them to it (P98,
reassurance is individualised and delivered. physiotherapist, male, 7 years of clinical experience).
54 Young et al: Reassurance for low back pain

Discussion reassured, a patient needs to feel that their practitioner understands

their history, has carried out thorough examinations and understands
This study developed four themes about clinicians’ use of reas- how the pain has impacted their lives.15,32 In addition, the Australian
surance for NSLBP. Clinicians in this study possessed comprehensive Clinical Care Standard recommendations for LBP support this approach
knowledge about delivering reassurance and believed that it was an and recommend to ‘assess their [the patients’] understanding of, and
important part of the high-quality care they delivered. They believed concerns about, diagnosis and pain’ and provide ‘targeted advice to
that reassurance helped them to: foster a positive outlook in patients; increase their [the patients’] understanding and address their con-
dispel fears related to underlying pathology; dispel fears related to a cerns’.10 This study builds upon this knowledge by offering insight into
poor prognosis of the NSLBP; and encourage safe activity. While cli- the strategies used to deliver interventions tailored to patient-specific
nicians expressed confidence in their ability to provide reassurance, concerns and worries. These strategies included providing tailored
they acknowledged that this confidence was developed gradually educational messages (cognitive reassurance) and a safe environment
through clinical experience. They reported that delivering reassur- for them to experience movement (experiential reassurance). Based on
ance was more challenging in situations where: patients were less the findings from this research, the expertise of the author team and
likely to experience a favourable prognosis; there were difficulties in available evidence,10,33 a table was created that outlines some sug-
establishing rapport between the clinician and patient; factors were gestions for clinicians to use to assist them in implementing guideline
present that impacted the patient’s ability to trust in the reassurance recommendations for reassurance for NSLBP (Table 3).
provided by the clinician, such as the patient’s previous experiences Clinicians face challenges with delivering prognostic reassurance
with NSLBP and the healthcare system. Participants also stressed the when they are uncertain as to whether the patient will experience a
importance of establishing rapport and trust and tailoring reassur- favourable prognosis or not. Where clinicians faced uncertainty or
ance by addressing individual concerns. identified clinical features making a favourable prognosis less likely,
Consistent with recommendations in clinical practice guidelines, they tended to de-emphasise prognostic discussions in the consul-
clinicians in this study believed that the provision of reassurance was tation. This finding is consistent with existing literature that reported
important for people with LBP. However, quantitative investigations 22% of patients who presented with increased distress did not receive
of the effect of reassurance on patient outcomes have yielded mixed prognostic information.14 In addition, a population of people experi-
results. A systematic review that investigated the effects of reassur- encing LBP generally had beliefs that a poor prognosis was com-
ance on patient outcomes found that affective reassurance demon- mon.34 From a patient’s perspective, there is frustration when they
strated inconsistent results for patient enablement and satisfaction, seek advice about the expected course of their pain and they receive
whereas cognitive reassurance was associated with increased satis- either vague or no information related to this.15 While this can be
faction, patient enablement, and reduced concerns and healthcare frustrating for patients, prognosis for LBP can be challenging to pre-
utilisation.12 A subsequent systematic review found that patient dict.35 An alternative approach in circumstances where complete
education reassures patients with acute LBP, as well as reducing recovery is unlikely could be to provide reassurance that their LBP
subsequent healthcare use.27 In contrast, a mediation analysis of the will not get progressively worse. This messaging may be reassuring,
PREVENT trial28 found that reassurance does not reduce disability or particularly in a population who believes that their prognosis is poor.
healthcare utilisation.29 The PREVENT trial28 explored the effective- It is proposed that the presentation of information alone is insuffi-
ness of patient education on low back pain outcomes. These mixed cient and that clinicians should also approach consultations as a
results may reflect the complexity of the delivery of reassurance and partnership to help patients to navigate this uncertainty.36 These
the need for appropriate individualisation, also highlighted in this findings highlight the need for strategies to improve the delivery of
study. prognostic information in these challenging populations.
These results support and extend existing evidence that rela- This qualitative study with rich data explored the perspectives of
tionship building and individualised data gathering (understanding a both physiotherapists and chiropractors about the delivery of reas-
person’s pain) are essential precursors to delivering effective reas- surance for NSLBP in primary care. This study included clinicians who
surance. A qualitative study of patients consulting with general varied in age, gender, geographical location and years in clinical
medical practitioners found that patients value affective reassurance practice. However, most clinician participants practised in metro-
(including relationship building, being taken seriously, feeling that politan areas, meaning that the study may not be representative of
the doctor listened and understood their story, and when they felt clinicians’ experiences in regional and rural settings. Most clinician
that the doctor was doing everything they could to help).15 Although participants rated reassurance as being important and reported
these behaviours are viewed positively, there is some evidence to frequent use. The findings in this study reflect the perspectives of
suggest that affective reassurance is associated with reduced recovery clinicians who think that reassurance is important; however, this is
and higher symptom burden.12 They concluded that the role of likely to be a common attitude amongst clinicians. This is evidenced
relationship building and empathy remains unclear.15 The current by two qualitative studies that explored general medical practi-
study provides insights from a clinician’s perspective that relation- tioners’ management of LBP and found that reassurance was impor-
ship building and empathy might be necessary for patients to engage tant37 and discussed reassurance being included in some form in the
with cognitive reassurance. These elements of a patient encounter first consultation.38 The interview schedule was developed using the
(relationship building and data gathering) are also part of a validated TDF, which is a framework that was developed systematically and
patient-reported outcome measure, the consultation-based reassur- widely used to explore the implementation behaviours of clinicians.
ance questionnaire, used to ascertain a patient’s level of reassurance Using this framework helped to ensure that this study included a
and includes subscales on relationship building and data gathering, more comprehensive set of questions. Data were coded by more than
further emphasising the known importance of clinicians engaging in one analyst and our team included multidisciplinary perspectives.
these behaviours.30,31 This study is the first to explore whether and Employing a qualitative research design provided deep insights into
how clinicians are actually performing these reassuring behaviours strategies used by clinicians to implement reassurance into practice.
during consultations and the barriers and enablers that they face with Details about clinicians’ experiences in delivering reassurance have
delivering reassurance. The findings demonstrate strategies that were not been explored in previous research.
employed by the clinicians when delivering reassurance to enhance Although clinicians reported having the confidence and skills to
relationship building and individualise data gathering. deliver reassurance, it is unclear to what extent they are delivering
Clinicians detailed the importance of an individualised approach to reassurance within a consultation for NSLBP, and to what extent the
reassurance, which includes tailored data gathering to identify a patient is reassured. The delivery of reassurance is important and the
patient’s concerns and their understanding of LBP, and tailored reception of this reassurance by patients can be varied. If reassurance
delivery to reduce their specific concerns and worries. This approach is is not delivered in the right way, these messages can be perceived as
supported by available qualitative evidence, which found that to be dismissive, as evidenced by ‘.How am I supposed to feel reassured if
 Research 55

I feel there is something wrong with me, and they keep telling eAddenda: Appendices 1 and 2 can be found online at https://doi.
me that everything’s fine?’32 To gain a deeper understanding of org/10.1016/j.jphys.2024.11.003.
reassurance practices, it is necessary to undertake observation of Ethics approval: The Macquarie University Human Research
reassurance practices via ethnographic studies. Furthermore, self- Ethics Committee approved this study (HREC approval Number:
reported patient data should also be collected during these consul- 520221181439566). All participants gave written informed consent
tations to determine the reception of reassurance by patients. Further before data collection began.
investigation of the relationship between clinicians’ self-reported Competing interests: Nil.
reassurance delivery, observed reassurance during a consultation Source(s) of support: This study was not funded by a research
and patient-reported measures of reassurance should be explored. grant. AY received scholarship support from Macquarie University Pro
Clinicians felt that there was scant detail available to them about Vice Chancellor’s scholarship and from the Australia & New Zealand
how to apply guideline recommendations regarding reassurance or to LBP Research Network.
manage more challenging clinical situations and that they relied on Acknowledgements: Nil.
clinical experience to develop the necessary skills. While this study Provenance: Not invited. Peer reviewed.
highlighted patient-specific factors challenging the delivery of reas- Correspondence: Anika Young, Department of Chiropractic, Fac-
surance, clinician and systemic factors may also be important and ulty of Medicine, Health and Health Science, Macquarie University,
may need further investigation to inform strategies to improve the Sydney, Australia. Email: [email protected]
delivery of reassurance.39 To further support clinicians with limited
clinical experience, entry-level clinical training programs for health-
care professionals involved in the management of NSLBP should
incorporate competencies related to the delivery of reassurance, as References
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