Utilisation of pain counselling in osteopathic practice: secondary analysis of a nationally representative sample of Australian osteopaths

Introduction

Pain is a multifactorial experience that affects an individuals’ quality of life, and cost the health system in Australia more than $AUD12 billion in 2018 [1]. Chronic pain is defined as pain that recurs or persists longer than three months [2], and is a leading global cause of disability that affects one-third to one-half of the population [3], [4], [5], [6]. The International Classification of Diseases (ICD-11) recently developed a new coding system that recognises chronic pain conditions (CPC) as a centrally important condition requiring individualised treatment in primary care [2]. In all CPCs, the individual experiences pain with substantial contribution (in some cases primary contribution) from biopsychosocial factors in addition to the actual or perceived site of tissue damage or impairment [7].

System-level guidelines [8], [9], policy recommendations [10] and calls-to-action [11] highlight the increasing trend of disability that is associated with musculoskeletal pain, and the increased likelihood of developing non-communicable diseases [12]. Appropriate assessment and management of CPCs is important to reduce negative impacts on individuals and health systems [13].

Pain educational interventions aim to reduce the severity of perceived pain by explaining the biological processes of underlying pain mechanisms [14]. This pain education approach aims to improve function and reduce pain intensity and related disability by encouraging graded activity and exercise as part of multimodal pain management.

Osteopaths are government registered primary contact allied health professionals in the Australian healthcare system. Adams [15] reported that the most common presenting conditions to Australian osteopaths are low back pain (98.7), neck pain (98.0), and thoracic pain (91.7%). This is corroborated by other Australian data that suggests the most common presenting complaint regions were the cervical, lumbar and pelvic regions, with 36.4% of clinical encounters identified as chronic (greater than 12 weeks duration) [16]. As such, osteopaths in Australia would likely be expected to incorporate pain education aligned with clinical practice guidelines into their management plans. For example, when managing non-specific low back pain (NSLBP), patient education and advice to remain active are recommended as first line strategies for both acute and chronic NSLBP [11]. Pain counselling is a term referenced in several Australian allied health practice characteristics publications from the practice-based research network ORION (Osteopathy Research and Innovation Network) [15], [17], [18], [19]. In this context, “pain counselling” refers to cognitive and affective reassurance [20], advice to maintain activity and avoid bed rest, and pain education [11], [21].

No studies appear to have investigated the proportion of osteopaths who engage in pain counselling as part of patient care, or the practice characteristics of these osteopaths. Such data would enable improved understanding of the contemporary practice of osteopaths and inform targeted practitioner professional development with the potential to improve patient outcomes. Therefore, the primary aim of this study was to determine the number of Australian osteopaths who do and do not engage in pain counselling. The secondary aim was to investigate the practice characteristics of those osteopaths who do and do not engage in pain counselling.

Methods

This work is a secondary analysis of data from the Osteopathy Research and Innovation Network (ORION) Project (http://www.orion-arccim.com/). ORION is a practice-based research network (PBRN) established for the Australian osteopathy profession and hosted by the University of Technology Sydney. PBRN’s refer to a collaboration of practitioners, practices and academic institutions to facilitate research projects designed to answer clinical questions and support translation of research into practice [22]. ORION was established to provide a research framework to explore the contribution of osteopathy to the Australian healthcare system. Ethics approval was granted through the University of Technology Sydney (# 2014000759) and osteopaths who chose to participate in the PBRN provided informed consent.

Results

Data were available from 991 participants as 1 participant did not respond to the item about frequency of engaging in pain counselling. Responses to the item are presented in Figure 1.

Figure 1:

Frequency of pain counselling by reported Australian osteopaths.

Discussion

This is the first study that has investigated the proportion of Australian osteopaths who utilise advice, reassurance and education (pain counselling) in their clinical practice, and determined the characteristics associated with the frequency of using pain counselling.

The most prominent outcome of this exploratory study is that only 27% of Australian osteopaths reported utilising pain counselling often in their clinical management. This is an unexpectedly low proportion, given that pain counselling is recommended by best practice guidelines and Australian osteopaths are frequently involved in the care of people with pain conditions.

The results of this study suggest a significant proportion of the Australian osteopathy profession is not frequently engaging with research to inform their practice. As such, clinicians may not be accessing or applying current practice guidelines for these common clinical presentations. Although the impact of these practices on the health outcomes of the Australian public is unclear, our findings suggest that targeted education and training is required to upskill Australian osteopaths. Thus, further research into the potential reasons for these observations appears justified.

Osteopathy-based literature provides some insight into why osteopaths may oppose engagement with, and incorporation of, clinical practice guidelines into practice. In the United Kingdom (UK) a qualitative study of osteopaths revealed a central theme of ‘precedence of osteopathy’ over medicine. The respondents suggested that osteopathic patients did not ‘fit’ into these guidelines and required a unique ‘osteopathic approach’ [27]. Another UK qualitative study explored attitudes and beliefs of both osteopathic educators and students at a British osteopathic education institution [28]. The five educators and seven students all rejected guideline recommendations for managing NSLBP. A central theme was reported as participants detailing a strong professional ‘osteopathic’ identity that may be threatened by imposition of guidelines and research. This data suggests challenges may exist related to the threat to ‘osteopathic identity’ and needs to be considered when attempting to support capability and capacity building towards integrating practice guidelines in practice. The extent to which these beliefs are similar in the Australian osteopathic population requires further investigation. Our data provides a foundational basis for future research, with a focus on professional development to address these perceived challenges to identity.

In the current study, Australian osteopaths who reported not often using pain counselling were also significantly less likely to discuss physical activity with patients. Undertaking physical activity to improve health and well-being is a consistent public health message in Australia [29]. However, our results suggest many Australian osteopaths are not frequently engaging in physical activity discussions with patients in the context of pain counselling. This finding is consistent with Fernandez, Moore [25] exploring the characteristics of Australian chiropractors, albeit that physical activity discussions are often had in Australian osteopathy [15] and chiropractic practice [17].

These outcomes support the need for professional development to ensure that pain counselling includes the resumption of normal activity and exercise, particularly as current guidelines support their inclusion in clinical management for common musculoskeletal pain conditions like NSLPB [11]. Specifically, the professional development should be developed by consulting with a representative group from the osteopathy profession, in consultation with pain curricula experts. The content could be based on the recommendations of the IASP Physical Therapy curriculum [30], adapted for and aligned with the relevant domains of the Capabilities of Osteopathic Practice 2019 [31].

Australian osteopaths who do not often use pain counselling were also significantly less likely to report often treating patients involved in non-compensable traffic accidents, rather than compensable traffic accidents and musculoskeletal wrist pain. One might expect the compensable traffic accident group to also require pain counselling strategies as part of the treatment plan, given compensation has been identified as a biopsychosocial contributor to longer-term complaints [32]. This outcome would be of interest to explore, given that osteopaths play a role in managing compensable traffic patients, and the role of professional development with respect to pain counselling in the patient groups receiving osteopathy care would be of value.

We also observed Australian osteopaths who do not often utilise pain counselling were less likely to report working with ATSI (indigenous) patients. This result may be the result of the low rate indigenous patients that access osteopathic care (0.7% of the time) [15]. The raw data shows the number of ATSI patients seen in osteopathic practice is low, which may be due to under-identification by patients and practitioners or the geographic location and access to osteopaths in Australia. This finding may provide an avenue for future evaluation of the number of ATSI patients in osteopathic practice as musculoskeletal complaints within the population are prevalent [33].

There are several limitations in the current study including the cross-sectional and self-report nature of the ORION practice questionnaire. Such studies are susceptible to response and acquiescence biases that may skew the data. The previous ORION study did not provide definitions for the survey questions (e.g. a definition of pain counselling) in the publications. Therefore, the respondents may have interpreted the meaning within the context of their own understanding of this practice. Differing conceptions may lead to alternative conclusions being possible. Further research would be beneficial to explore and further validate the definition of pain counselling in the context of Australian osteopathy practice. Future work should clarify the terminology in the practice questionnaire to ensure that is it clearly understood by the participants and determine what level of advice, reassurance and education is being utilised in clinical practice for pain assessment and management. Education in pain, including its psychological and neurophysiological basis, also form part of the practice standards for Australian osteopaths [31]. As such, there is the potential for further work to develop an understanding of how osteopaths develop their pain education skills and knowledge and maintain and enhance these competencies through professional development. Given the reported low use of frequent (often) pain education by osteopaths who teach preregistration osteopaths at universities (11%), this may be a starting point to develop pain education skills in osteopathy as a profession in Australia. Inclusion of a nationally representative sample in an Australian context is strength of this study.

In summary, nearly three quarters of the Australian osteopathic profession report not often using pain counselling as a patient management strategy. Future studies would be beneficial to confirm this finding and clarify why those in this sample are not often utilising this guideline recommendation. Chronic musculoskeletal pain conditions are frequent in Australian osteopathic practices and the costs of chronic pain in Australia are high. Therefore, strategies are needed to support the profession in undertaking professional development to build confidence and competence in accessing and using evidence-based care for all pain conditions.