What’s in Your Clinical Context? | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

What’s in Your Clinical Context?

What’s in Your Clinical Context? - themanualtherapist.com

Contexual factors and their influence in low back pain care

Contextual factors play a part in the care of low back pain sufferers. These factors are things like: what the doctor is wearing, how he smells, what the office looks like, where the clinic is located, how the front-end customer service is, and what kind of tools the professional uses to convey the clinical findings and proposed treatment could be.

A paper published in Chiropractic and Manual Therapies1 the authors set out to explore the impact these contextual factors had on low back pain outcomes.

Musculoskeletal problems account for the second most cause of disability worldwide, with low back pain being at the top of those conditions. If you are a professional and reading this, what sort of things do you do to set your stage in the care of low back pain?

In this paper, the authors attempted to partition contextual factors into five general components:A patient’s widespread belief about what to expect.

A practitioner’s belief about what to expect and also their reputation and the clothes they wear, for example
  1. The practitioner-patient relationship
  2. The clinic environment
  3. How the treatment is delivered (including the type of patient education tools used)
  4. Partitioning context into these five general categories was a monumental task, as the lines between them are often blurry as one context can bleed into another.

Take the delivery of patient education for low back pain, for example. The patient has often seen a few different practitioner proposals using various tools like video, charts and anatomical models. And patients are often encouraged to see more than one practitioner. In this case, the patient’s beliefs and expectations will build on the previous practitioner encounter if they have witnessed multimodal practitioners for the same condition. The physiotherapist may have enforced that the low back pain was due to a muscle imbalance and was shown a chart of muscles or on video. At the same time, the medical doctor explained the condition as a lack of core muscle strength without using any aids and to muck up the waters further; the chiropractor would explain the low back disorder with a degeneration phase model.

Here, you can see a changing and confusing landscape being created for the patient to understand their condition and what to do about it. How many cooks are in the kitchen for one meal prep?


After a review of the literature looking at four electronic databases (CINAHL, Medline, PschyINFO, and AMed), 170 full text records were included. After drilling down on the pertinent papers, contextual factors played a role in eight studies that helped improve the outcomes.

“Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to
influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance.”
Spine Patient Education, Patient Centered, Education

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