Low back pain is one of the most debilitating conditions that most people will face at some point in their lives. The pain can take your breath away. It can keep you from spending time with loved ones. It can deprive you of your work. It is a powerful, yet very misunderstood, force.
Diagnosing Back Pain Is Complicated
Diagnosing, describing, and treating back pain is even more complicated. Most cases won’t show up with diagnostic imaging and sometimes when there is something on the image it isn’t even related to the back pain.
Doctors do their best to try and understand this condition and the healthcare industry does its best to try and help people manage this condition but still people are left feeling alone, misunderstood, and frustrated.
The Importance Of Properly Describing Your Pain
A good description of your pain is often the exact information that can help doctors identify the underlying problem. But what happens when the very nature of pain is that it is so subjective?
What if my back sprain takes my breath away and makes me feel nauseous, while yours is more of a dull ache that follows you around all day and all night and makes it impossible to sleep or sit? Are our sprains different? Is mine worse than yours?
Doctors want to manage our pain properly, and the more information that we can give them, the more complete a picture they can form. Once they understand our pain they can suggest treatments like physical therapy, or perhaps surgery.
Inaccurate descriptions can lead to a misdiagnosis which could lead to a lot of unnecessary, and ineffective treatments. That is a lot of responsibility to put on patients being able to accurately convey their concerns and pain levels to physicians.
Cultural Bias and Its Diagnostic Dangers
Unfortunately, many people who live with chronic pain conditions feel the effects of bias and stereotyping. They are often misunderstood, feel unheard, and their pain is dismissed.
Many are accused of only seeking drugs, like opioids, or they are told that the pain is all in their heads. They are shamed. And blamed. And nowhere is this bias more apparent than in the BIPOC communities.
Racial Bias In The Management Of Chronic Pain
Several studies have explored the associations between Black patients’ experiences of bias and discrimination and worse pain outcomes. Research has found that there are still a significant number of physicians that believe things like:
Black patients have a greater pain tolerance than white people
Black people have thicker skin and therefore feel less pain
Studies done on both medical students and lay people have found that both lay people and individuals with at least some medical training “hold and may use false beliefs about biological differences between blacks and whites to inform medical judgements, which may contribute to racial disparities in pain assessment and treatment”.
Research shows that, relative to their white counterparts, black patients are far less likely to be given pain medications. If they are fortunate enough to receive pain medications they receive much lower quantities.
Todd et al. conducted a retrospective study on emergency room treatments and they found that “black patients were significantly less likely than white patients to receive analgesics for extremity fractures in the emergency room (57% vs 74%) despite having similar self-reports of pain”.
The Bleak Side Of Bias
When we consider the effects of cultural bias in pain management two trends emerge. First is the over prescription of medications for white patients and second is the under prescription of medications for BIPOC patients. Many physicians aren’t consciously aware of their bias but failing to address these biases won’t help patients - it will only perpetuate treatment inequalities.
How To Address Cultural Bias In Back Pain Management
There are some things that we can do to overcome the issue of bias in pain management.
Many medical schools have recently committed to address these issues in their curricula. Standard tests have emerged that can help identify issues of bias among individuals and to help make them aware that they subconsciously hold these biases.
When biases exist they will show up in the data. If healthcare settings collect data on pain management according to a patient’s ethnicity and race as well as their other significant characteristics then it will help us to identify how pain is addressed in these populations. Regularly reviewing this data can help the healthcare industry design strategies to combat these biases.
3. Stigma Scales
Scales like the Chronic Pain Stigma Scale (CPSS) measure stigma from the view of the general public, physicians and family. The scale looks at several dimensions of stigma including general negative attitudes, bias against prescribing opioids, and making people think the pain is all in their mind.
4. Pain Scales
Using data-driven and objective ways to measure the pain experience can help to remove opportunities for mis-interpretation and bias. Designing pain scales that are culturally relevant and that more people can relate to can help patients feel more comfortable and confident when describing their pain levels.
The Benefit Of Back Pain Scales
Pain itself is very hard to measure objectively because it is often a collection of physical and psychological factors that tend to be highly subjective. Pain scales offer a way to measure pain intensity in a more objective and standardized way. It is important to understand that pain scales do still have limitations and they are still open to misinterpretation.
Some Common Types Of Pain Scales
There are many different pain scales available for use and healthcare providers should take a personalized approach to using these scales, allowing patients to choose which scale they relate to the most. Some common types of pain scales for low back pain include:
Visual Analogue Scales (VAS)
Numerical Rating Scales (NRS)
Verbal Rating Scales (VRS)
Brief Pain Inventory (BPI)
Other Factors To Consider In Low Back Pain Management
Because pain is so complex there are some additional factors that healthcare providers should consider when trying to help patients manage their low back pain:
Pain severity - how much time the patient is in pain during their day.
Chronicity - how long has the pain been going on for.
Pain experience - how intensely the patient feels the pain (can be over a period of time - not just at that moment)
Measuring and treating pain is a complicated process. We all experience pain differently and deal with it differently. When there isn’t an obvious cause of the pain, like a broken bone or burst appendix, healthcare providers are often forced to rely on their own judgment which has been shown to be influenced by personal feelings and by biases both conscious and unconscious.
Unfortunately, due to the complicated nature of low back pain, this condition is one that often experiences the greatest variations in treatment and may be influenced the most by cultural biases.
The use of more objective standards, such as pain scales, can be a step in helping people find more standardized ways to describe their pain. It is important to keep in mind that a one-size-fits-all approach to pain scales will not work for low back patients.
People relate to these scales differently and while one person may prefer to use numbers to describe their pain, another person might want to use words or pictures to share how they are feeling. The most important thing that healthcare providers can do when trying to understand a patient’s pain? Listen.