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Abstract

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals’ lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals’ pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals’ scope of practice. Employing Actor Network Theorist Mol’s concept multiplicity, our aim in this paper is to explore how a pain service’s practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service’s clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals’ social context was present and manifested during consultations at the pain service (first enactment: ‘the person’), it was often disconnected from care and overlooked in ‘treatment/management’ (second enactment: ‘the patient’). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals’ social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: ‘the patient-person’). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals’ social contexts can be part of a service’s agenda.

Keywords

actor network theory biopsychosocial low back pain multidisciplinary pain management

Introduction

Low back pain (LBP) is multidimensional, with vast majority of people having no or very minimal underlying patho-anatomical contributors to their pain, particularly when it persists or recurs (Maher et al., 2017; Vlaeyen et al., 2018). LBP research from a range of healthcare disciplines has advocated for a ‘biopsychosocial model’ of LBP where non-biological factors such as psychological (e.g. beliefs, expectations) and social dimensions (e.g. work, legislation, socioeconomic status) should be explored (Foster et al., 2018; Vlaeyen et al., 2018). Yet other researchers, particularly those approaching the topic using social theory, go further to say that cultural, spiritual, power, embodied and other factors are also involved (Mescouto et al., 2022a; Stilwell and Harman, 2019). Given its multidimensionality, it is unlikely that a single profession can adequately attend to the complexity of living with persistent LBP. Hence, the International Association for the Study of Pain (n.d.) and the Australian National Pain Strategy for Pain Management (Pain Australia, 2010) argue for integrated multidisciplinary pain management services, including mental health experts (e.g. psychiatrists, psychologists) and at least two allied healthcare professionals (e.g. physiotherapists, nurses, social workers). They have the potential to provide patients with comprehensive multimodal management strategies targeting a range of biomedical and non-biomedical factors (Pain Australia, 2010).

Despite involving multiple disciplines, biomedical and psychological interventions take precedence with social factors of chronic pain rarely attended to in pain services. For example, Harding et al.’s (2010) British interview-based study, suggested clinicians reproduce a mainly psychological approach with little acknowledgement of social factors impacting patients’ treatment. A systematic review of pain programmes corroborates these findings; cognitive behavioural therapy is the most common intervention delivered in pain services (Scascighini et al., 2008). This narrow psychological focus is at odds with the Australian National Strategic Action Plan, asserting that pain management should be under a ‘sociopsychobiomedical prism’ (Australian Government Department of Health, 2019). Exploration of the social dimensions of chronic pain in multidisciplinary pain clinics is rare in the literature, with few studies describing how (and if) such dimensions are attended to in these clinics (Aho et al., 2010; Goodall and Brown, 2022). Therefore, the over-focus on cognition and behaviour to manage individuals’ pain at multidisciplinary pain services may limit exploration of important social dimensions in these settings.

Broader social considerations relevant to people with LBP are many. Individuals referred to multidisciplinary pain services, especially in public settings, face multiple physical and socio-economic challenges influencing their pain (May et al., 2018). These situations may highlight how clinicians are already in ongoing contact with broader social contexts and how the multiple aspects of living with chronic pain are already present. Although clinicians recognise ‘psychosocial’ aspects as important contributors to individuals’ pain experiences (Carr and Bradshaw, 2014; Ng et al., 2021), what can be considered ‘social’ may be under explored in both research and clinical practice. This under exploration might lead to care inequalities (Brady et al., 2016), and contribute to blame and stigma by, for example, labelling patients as poorly motivated and demanding (McKenzie et al., 2020; Synnott et al., 2015) without further reflection on the broader sociocultural and/or political conditions responsible for such behaviours. Extensive research on the intersection and interaction between health and broader social contexts shows how health (and pain) are shaped by these contextual factors (Craig et al., 2020; Guillemin et al., 2014; Karran et al., 2020). However, better attention and action towards what can be considered ‘social’ requires a paradigm shift away from strong biomedical, or behaviourist, assumptions towards consideration of pain as constructed through broader social and material (or sociomaterial) connections.

Sociomateriality is an umbrella term for theoretical perspectives that consider the interconnectedness and relationality between human and non-human elements and how they have material consequences on human health. ‘The social’ (e.g. contextual factors, norms, institutions, discourses) and ‘the material’ (e.g. human bodies, objects, technology) are interconnected in everyday life and responsible for shaping the world (Latour, 2005; Mol, 2002). An example of sociomaterial relations can be found in philosopher and ethnographer Annemarie Mol’s work on atherosclerosis. Mol (2002) identified how everyday practices at a Dutch hospital performed and made atherosclerosis not as a singular condition, but multiple. Relations between words, paperwork, buildings, insurance system, clinician, patient, family, measurement instruments, arteries, plaque, pain, were all responsible for making different versions of atherosclerosis. Atherosclerosis therefore is not only one fixed condition identified in a textbook, but made, produced, or enacted through practice. These different versions ‘hang together’ or are brought together (e.g. in the patient’s file to convey a treatment plan) (Mol, 2002: 55). In the context of providing care for people with LBP, multiplicity may help explore how LBP is enacted in pain services as biological or psychological but also social, relational, economic and how these different dimensions ‘hang together’. Throughout this paper, we will use the term ‘enactment’ to mean that practices perform multiple realities; instead of having one a priori truth about LBP, practices shape and produce LBP in different and multiple ways.

Multiplicity has been used as a theoretical lens to explore practices related to atherosclerosis (Mol, 2002), blood pressure (Moreira, 2006), obstetrics (Akrich and Pasveer, 2000), physiotherapy (Setchell et al., 2018) and gender (Latham, 2017). These studies explored how healthcare practices enact certain aspects of a medical condition (usually related to biomedical dimensions), while oppressing, neglecting or sidelining others. Although Graham and Herndl (2013) used Mol to argue that pain science and medicine practices enact pain beyond disciplinary boundaries, they have not directly explored how this plays out in clinical encounters nor provided a deeper engagement with how clinicians could attend to the social dimensions of living with chronic pain. Therefore, in this paper, we will use Mol’s concept of multiplicity to unpack how practices in a multidisciplinary pain service enact the social dimensions of individuals with LBP and argue what may be considered ‘social’ can be part of a service’s agenda.

Theoretical framework

Actor Network Theory (ANT: Latour, 1996) guides our sociomaterial analysis of LBP care. Using ANT resists individualistic and human-centred understandings of behaviour, instead emphasising social situations as constructed (materially and semiotically) through networked interactions with others: objects, individuals, and ideas (Latour, 2005; Mol, 2010). Thus, ANT scholars cast healthcare practice as situated and contextual with dynamic and shifting relationships between various human and non-human actors. Clinicians and individuals with LBP, as well as furniture, policy, the physical environment and different institutions, contribute to the care enacted within a service. We employ ANT theorist Mol’s (2002) concept of multiplicity to understand the many ways social dimensions of living with LBP are seen, felt and done in practice.

One critique of ANT is its limited acknowledgement of macro socio-political forces (Walsham, 1997) and apolitical inclinations (Star, 1990). Mol’s adaptation of ANT, however, emphasises power in interaction with feminist concepts (Mol, 1999), highlighting – through the concept of multiplicity – how certain practices are prioritised over others (Mol, 2002) and providing ANT with a critical historical backdrop. For example, in her work, Mol highlights that atherosclerosis is enacted as multiple in a Dutch hospital. Atherosclerosis in the pathology laboratory can be enacted by the microscope as a ‘thick vessel wall’, while at the clinic it is enacted by the patient as ‘pain on walking’. Both enactments can coincide, but they can also clash – you can have a ‘thick vessel wall’ without ‘pain on walking’ and vice versa. Decisions about what treatment to provide must be made in clinical practices and depend on which enactment, or version of the condition, is prioritised. As Mol (2002) states, this is political. Acknowledging multiplicity opens space for questioning practices as usual (e.g. who or what gets funded), rethinking ontological assumptions (e.g. which models of care are foregrounded), and a consideration that different care enactments affects patients differently (with implications for equitable outcomes) .

In a recent exploration, Mol argues that ‘If ANT is a theory, then a theory helps to tell cases, draw contrasts, articulate silent layers, turn questions upside down, focus on the unexpected, add to one’s sensitivities, propose new terms and shift stories from one context to another’ (Mol, 2010: 253). A perception of ANT as evolving and open to more critical perspectives is what we propose here. Mol’s use of ANT and her concept of multiplicity have the potential to expose hidden dimensions of practice (e.g. social contexts, emotions, power relations, culture, objects) that are part of providing care for people with LBP. By exposing hidden dimensions of practice, it is possible to open up discussions on how they could be better addressed. Contrary to Mol’s work on atherosclerosis, in this study we are interested in individuals with LBP, not the condition of LBP. We, therefore, build on and evolve her original work. We are interested in how interactional and material practices at a pain service enact the social dimensions of individuals living with LBP and how they might be better addressed. Thus, in this study we ask: How are the social dimensions of an individual’s LBP enacted in practice?

Methods

We conducted an in-depth, collaborative qualitative study, involving direct observations of how a clinical practice carries out complex care and theoretically-driven analysis. This is a sub-study from a larger project investigating various less considered aspects (e.g. interpersonal, cultural, social, material, environmental) of LBP care.

Participants and setting

We selected a publicly funded pain service in a metropolitan area in Australia, as such services are advocated in addressing the multiple elements of pain (Pain Australia, 2010). Participants were clinicians who worked at the clinic and their patients with LBP. Following sampling principles from ethnographic methods (Hayre et al., 2022), all clinicians working at the clinic at the time of the study were asked to participate. As we were interested in the aspects and elements involving clinical practices and not specificities about the condition, the inclusion criteria for patient participants were broad and included being above 18 years with a primary diagnosis of LBP. Site clinicians were invited to participate in an initial meeting where researchers explained the projects’ aims and methods. Clinicians made a list of patients who had a diagnosis of LBP. These patients were then first contacted by site clinicians or service staff to participate in the study before being approached by a researcher. After giving their verbal consent, researchers asked patient participants to provide demographic data (e.g. age, gender, place of birth, pain characteristics), and written consent. After approximately every seven observations, sampling became iteratively more purposive (Greg et al., 2013) in order to recruit a diverse sample of clinician and patient participants in terms of age, gender, pain levels, place of birth and years lived with the condition (for patients) and age, gender, level of experience and speciality (for clinicians). Such diversity allowed us to explore a range of different clinical practices and different approaches to LBP care.

Participants included 25 individuals with LBP and 24 clinicians. Individuals with LBP were between 35 and 85 years old, with an average of 62 years. Sixteen participants described their gender as female, and nine as male. The majority were born in Australia (n = 18), with seven participants born overseas. Regarding their occupation, most participants reported being retired, having no occupation, or receiving a pension; three reported unpaid care work (housewives and carer role), and seven participants described various formal job descriptions (e.g. manager, carpenter, plumber, nurse, nail technician). Nineteen individuals had moderate to severe pain levels at the time of the study. Clinicians had various specialities: general practitioners, pain and addiction specialists, rehabilitation physician, physiotherapists, psychologists, psychiatrists, nurses and occupational therapists. Their age ranged from 30 to 64, with an average of 41 years. Fourteen clinicians described their gender as female and 10 as male. Years in occupation went from 1 to 40, with an average of 13 years.

The relevant Human Research Ethics Committee approved the study (#2019002446).

Design and data collection

Between January 2020 and February 2021, we employed two methods of data collection: ethnographic observations and participatory consultations (dialogues) with clinicians. We conducted 32 ethnographic observations and four clinician dialogues. In response to intermittent COVID-19 restrictions, at times we recorded and observed phone and telehealth consultations (n = 5) and conducted dialogues (n = 2) via videoconferencing. Although ethnographic fieldwork has traditionally been based in in-person observations, the COVID-19 pandemic has opened discussions about how to reconceptualise the ‘field’ and online interactions in an increasingly digitised world (see e.g. Howlett, 2022; Rahman et al., 2021). Similar to Rahman et al. (2021), our adaptation did not decrease the quality of the data collected nor interfere with our study’s aim.

Our first data collection method was ethnographic observations. Ethnographic observations allowed in-depth exploration of healthcare practices (Becker et al., 1961), fostering attention to ‘sayings, doings, and relations with objects that make up what people do in their everyday lives’ (MacLeod et al., 2019: 180). Five ethnographers (including authors KM, NC) attended the service approximately weekly to conduct observations of clinical appointments (ranging from 0.5 to 3 hours, with most sessions being 1-hour long – the 3-hour appointment involved one patient seeing three different health professionals), the service’s physical space, non-verbal and verbal communication and team meetings. Four ethnographers were healthcare professionals (three physiotherapists, one osteopath); one had a background in education. All were trained in ethnographic methods and wrote field notes comprising the main dataset.

The second data collection method was dialogues with clinicians. Following principles from participatory research (Andersson, 2018), dialogues were collaborative exchanges between researchers and site clinicians to foster critical reflexivity and explore hidden assumptions of clinical practices to transform them (Setchell and Dalziel, 2019; Thille et al., 2018). Thus, dialogues differ from traditional qualitative methods such as interviews or focus groups. JS and KM facilitated the four 2-hour dialogues, inviting clinicians to critically reflect on excerpts of ethnographic fieldnotes and preliminary findings from the larger project. We worked to create a respectful and confidential environment in the dialogues including using pseudonyms when discussing data excerpts and reassuring clinicians that our focus was not on their individual approaches or behaviours but on developing broader principles grounded in the realities of clinical practices. All dialogues were scheduled during the clinic’s regular team meeting time. Due to time constraints and different employment arrangements, not all observed clinicians participated in the dialogues: participation ranged from 8 to 11 clinicians in each dialogue. Dialogues were recorded and transcribed, providing insight into clinicians’ thinking and practices. Facilitated clinician dialogues, guided by Mol’s concept of multiplicity, prompted preliminary and collaborative analyses of observational data.

Data analysis

Data analysis was initially performed inductively in three distinct collaborative spaces: clinician dialogues (see above), consumer advisory panels and research team analysis meetings. The consumer panels (3 × 2-hour panels) consisted of three people with lived experience of LBP providing expertise, analysis and feedback on the study (Mescouto and Setchell, 2020). Research team analysis involved eleven 2-hour meetings over a 1-year period. Here the team inductively and reflexively analysed observations and dialogues, identifying patterns in how the study site managed (or not) aspects of care beyond the dominant biological and behavioural aspects when working with individuals with LBP. Analytic summary notes were produced for each meeting by the core research team including five researchers (physiotherapists, a sociologist and a neuroscientist), two clinicians from the study site (one physiotherapist and one psychologist) and one clinical educator and researcher at a large allied health organisation. Drawing together analytic contributions from these three collaborative spaces, KM conducted an initial analysis by returning to the entire dataset, using NVivo 12 to manage the data. The analysis then became more theory-driven using the work of Mol (2002). Findings were subsequently refined by JS and KM with iterative input from the listed authors. Disagreements and divergences are included in the findings.

Findings

Using Mol (2002), our collaborative analysis of ethnographic observations and clinician dialogues suggests that particular practices, encounters and material environments (buildings, furniture, institutions) enacted ‘individuals with LBP’ differently during pain service consultations. Using pseudonyms to distinguish participants, we first depict the enactment of ‘the person’ when multiple social aspects of a person’s life with pain are brought to light in practice, such as through personal context and relationships and interactions with institutions and healthcare providers. Second, we show how individuals with LBP are enacted as ‘the patient’¹ through expectations of compliance with rules and habits and individualistic approaches to care. These practices contravene the social dimensions of living with LBP. We consider ‘the person’ individuals within their social context, while ‘the patient’ is an identity/role produced at the pain service. Finally, the enactment of ‘the patient-person’ provides examples and opportunities where connection between ‘the person’ and ‘the patient’ was possible by connecting beyond patient-clinician usual roles, shifting power in interactions, through adaptation of rules and habits, and assistance outside the pain service. ‘The patient-person’ enactment offers an opening into revised practices for caring for individuals with LBP.

First enactment: The person

‘The person’ is enacted through individuals with LBP’s efforts to bring social tensions into the pain service: tensions they usually manage alone. Mol and Law (2004: 57) critique the concept of a ‘whole person’ and argue ‘the assumption that we have a coherent body or are a whole hides a lot of work. This is work someone has to do. You do not have, you are not, a body-that-hangs-together, naturally, all by itself’. ‘The person’ is an exploration of how, even with various tensions, individuals with LBP enact their ‘body-that-hangs-together’.

Personal context and relationships

During consultations individuals with LBP did considerable work to enact a ‘body-that-hangs-together’. For example, many individuals with LBP used statements such as ‘pain is there all the time’ to carry the complexity and omnipresence of pain into the pain service. This work is also visible, for example, in Karen’s discussion of her life with Omar (clinician):

I’m just tired. I have tried everything. You know I work for myself because of this crap. I have to work for myself because I cannot just sit in an office like everybody else. . .I need to be able to lie down, change the position of my computer and stuff. My personal relationships also suffered a lot over this. My family is up here so I got a full-time job and moved up here. But then after working 6 weeks in this new full-time job my body decided to not walk – my brain said, ‘we are not using this leg anymore’. My mum had to call the ambulance. They were giving me the triple of the drugs at the hospital – lyrica, endep, endone – but then they all had lactose in it so I couldn’t breathe and felt really sick. I’m on all these drugs but I am still in pain. They stuff my face up, I get groggy, every day is a struggle. I don’t know what is going on and I have no idea how I can fix it. I just want to live a life [Karen starts crying]. I can’t date anyone. . .I can’t go to the shops, I put on 5kg! I’m so sick of this shit!

Here Karen expresses her feelings, her job and relationships affected by pain and how it is to live with a body in pain. Karen explains how living with pain is done in practice. ‘The person’ is enacted through explaining individuals’ personal context, situating them inside specific social arrangements commonly affected by pain. The enactment of ‘pain [that] is there all the time’ affects jobs, relationships and stops individuals from walking. Here we see ‘the person’ – individuals’ social and work life is brought to the fore.

Interactions with institutions and healthcare providers

Various institutions and healthcare providers were implicated in the enactment of ‘the person’. During consultations, individuals and clinicians situated themselves as part of broader contexts related to economic and healthcare systems. For example, it was common for clinicians to prescribe physiotherapy or physical exercise, requiring a financial commitment from individuals with LBP. ‘The person’ is being enacted through practices of prescribing treatments that place individuals inside an economic system. Living with LBP requires resources. Some individuals discussed depending on government support (through Medicare) that is exemplified in one observer’s notes about Mary’s consultation about her LBP with Bree (clinician):

Bree asked about physiotherapy sessions that Mary had in the past. Mary used to see a physio, and felt very good afterwards. “My granddaughter even told me ‘grandma you seem taller’” she said and laughed. They discussed the possibility of Mary coming back to physiotherapy, and they mentioned that Medicare only permits 5 sessions per year. There seemed to be a little tension in the air. “Has been a while since I last felt tall again” Mary mentioned and laughed.

Mary had experienced considerable financial problems (e.g. bankruptcy, moving states); paying for physiotherapy was not possible. ‘The person’ is enacted; government financial support and private physiotherapy interact. When such supports are not available due to financial constraints, ‘the person’ cannot seek management for their pain.

Healthcare institutions and providers outside the pain service (other clinics, pain programmes, hospitals, general practitioners) were also implicated in the enactment of ‘the person’. Individuals described contradictory messages from external healthcare professionals: saying that nothing could be done for their pain. Although rarely, interactions also signalled how individuals had gone through questionable or unnecessary treatments and procedures. One isolated example occurred in Omar’s (clinician) consultation with Devya, an Indian woman of colour who did not speak English. Devya had gone through one nerve ablation instead of two. Omar sounded and looked frustrated when he disclosed to Devya: ‘You get extra money when you do this procedure separately’. He emphasised it was a ‘medical system fault’ and the hospital could get more money if they did the procedure in this way.

The practice of receiving a questionable procedure in Devya’s case enacted ‘the person’ by placing the individual with LBP in specific social arrangements within the healthcare system. Devya’s and Omar’s interaction, together with contradictory messages, created tensions that could decrease an individuals’ trust in healthcare providers and institutions. In an extreme case, Devya could refuse to go through another procedure that may be beneficial to her pain. Different institutions and healthcare providers, and the tensions that eventuated from them, were all part of ‘the person’.

Individuals’ life situations, experiences with healthcare providers and institutions enacted ‘the person’ by bringing the social contexts of an individual with LBP into the consultation. Mol (2002) proposes that, instead of a hierarchical relationship between peoples’ illnesses and their social reality, in practice the focus is constantly changing. Here, care shifts from individuals’ pain to personal life context, institutions and healthcare providers that were (or are) part of their care. The enactment of ‘the person’ brought tensions that surfaced in workplaces, health systems, and government institutions: tensions not always dealt with in the pain service. Such tensions are highlighted by individuals with LBP who have to manage a ‘body-that-hangs-together’. ‘The person’ foregrounds the multiple ways and actors of individuals’ social context.

Second enactment: The patient

The multiple contexts of individuals with LBP sometimes went unrecognised in practice. Such under-recognition enacted ‘the patient’. As patients, individuals were under regular observation through service rules, habits and individualistic approaches to care. When these practices were enacted, there was a greater disconnection with individuals’ social context. According to Mol (2002), it is normal to encounter clashes in practice. However, these clashes ‘are pacified (and often hardly visible)’ (p. 88). Although there is a clash and disconnection between ‘the person’ and ‘the patient’, they are smoothed and barely visible in the daily routine of the pain service.

Compliance with service rules and habits

Many service rules and habits undermined attention to ‘the person’ and enacted ‘the patient’. For example, using standardised assessment forms (or checklists) to screen for psychosocial aspects of individuals’ pain suggested that they would comply with service’s rules and habits. Using computers to access and record answers to checklists sometimes posed a physical barrier between clinicians and individuals with LBP. The computer stole the clinicians’ gaze, suggesting an agenda, or rule, to be followed; practices of using checklists, especially electronic checklists, underpinned ‘the patient’.

Checklists could be considered beneficial since they incorporate questions about individuals’ psychosocial context, but they were used in the same way for everyone. This approach was enacted, for example, by Tom (clinician) in his consultation with Megan who was attending the clinic for the first time. The observer wrote: ‘“I ask all patients that. . .” Tom started saying and asked Megan if she thought about self-harming. He had a serious look on his face when asking this. “No” Megan replied’.

Checklists held sensitive elements such as suicidality, sexual assault and trauma that clinicians asked, ‘all patients’. Such sensitive elements were rarely followed up and may have been a cause of discomfort for some clinicians, with observers noting their closed body language or speed in going through questions. In a possible attempt to normalise their sensitive effects, clinicians told patients that questions were routine. Such practices enacted ‘the patient’. Individuals went through the same questions with different clinicians, revisiting past trauma with each checklist. Although ‘the patient’ could refrain from answering questions, none of the individuals we observed declined to answer. The enacted ‘patient’ was expected to be compliant and answer clinicians’ questions regardless of the effect. Using checklists, amongst other standardised procedures, disconnected ‘the patient’ from ‘the person’ with LBP.

Individualistic approach to care

‘The patient’ was enacted when individuals with LBP were positioned (often indirectly) as responsible for coordinating their treatment and managing their pain. For example, one of the participants with LBP attending the service, Thomas, had been regularly joining the service’s pacing group, where clinicians delivered pain education. In a one-on-one session that Thomas had with Sue (clinician), the observer noted their discussion of the group:

Sue: “How is the pacing group going?”, Thomas: “Yeah. . . it is alright [Thomas seemed unimpressed]. They talked about the brain a lot, but I don’t think my brain understands the situation [chuckles]”. (. . .) Sue: “The pain won’t go away just because you are going to the groups, you need to follow things through. . .you have a tendency to just keep going so you need to break your activities down into shorter slots. For instance, rather than doing 3 hours of mowing, break it down into 20-minute intervals”. Thomas promptly replied: “How long would that take? The seeds don’t wait for me. . .neither does the water. . . nature has its own rhythm. . .it won’t wait for me”. Sue tried to respond, “I know that it is inconvenient. . .”, but Thomas interrupted by saying “I gotta do it”. Sue: “Does it make your pain worse?”. Thomas stopped for a moment, reflected and said “Not really. . . I can’t plan my life around my pain, otherwise I don’t accomplish anything. I am happy to feel a little more pain for the sake of accomplishing something”.

In this consultation, it was Thomas’ ‘brain’ and him not following the group’s recommendations that contributed to his pain. The ‘brain’ seemed detached from Thomas, and the recommendations did not consider his particular (farming/landscaping) context. When asked to manage his pain without further exploring how the recommended changes could fit into his life, there was a clash between ‘the person’ and ‘the patient’. Although they find some middle ground towards the end of the observation, at the beginning Thomas and Sue seemed to be working in opposite directions. Thomas was enacting ‘the person’ and Sue, ‘the patient’.

Individuals with LBP were reduced to ‘the patient’ through practices and procedures that expected conformity to rules and expected individuals with LBP to be responsible for their care. Although ‘the patient’ and ‘the person’ are different versions of the same individual with LBP, here they were treated as separate, with the former prioritised over the latter. Such practices were disconnected from individuals’ social contexts.

Third enactment: The patient-person

In enacting ‘the patient-person’, the pain service makes tension explicit between ‘patient’ and ‘person’ and attempts to resolve this tension. Practices supported the work of ‘hanging-the-body-together’ that individuals with LBP enact alone. According to Mol (2002), things in practice have complex relations; an individual with atherosclerosis:

is not the body on the operating table plus something extra (a mind, a social life). Instead, the patient is someone whom, at some other moment, the surgeon may exchange jokes with. It is someone who, elsewhere, may have a wife waiting for a telephone call. The two realities, that of the artery and that of the patient, do not encompass each other: they are, rather, situated side by side. (p. 149)

‘The patient’ who attends a pain service is not separate from ‘the person’ who has to deal with challenges of living with LBP. ‘Patient’ and ‘person’ are situated and coexist side by side, overlapping and intersecting during consultations.

Connecting beyond their usual roles

‘The patient-person’ with LBP was enacted when aspects beyond individuals’ pain were considered as part of the service’s routine, connecting individuals with LBP and clinicians for a different purpose. In these moments, patient and clinician roles overlapped with other roles (e.g. parents, workers). One observer wrote about Georgia’s interaction with her clinician Louisa: ‘Louisa asked what Georgia’s plans were for that week. “I’m taking them [the kids] to Australia Zoo” Georgia said, sounding proud and happy. “Tell me about that” Louisa responded. The two spoke more about the planned zoo trip’. Although Georgia mentioned she would feel pain afterwards, Louisa did not try to convince Georgia to cancel her trip. The clinician recognised the importance of the trip to Georgia, helping Georgia to feel supported and understood. Differing from ‘the patient’ where individuals are held responsible for their pain, here ‘the patient-person’ is enacted through a deeper understanding of individuals’ reasons for engaging in painful activities. Acknowledging Georgia’s effort to go out with her children, even when in pain, fostered connection and recognition of different aspects of individuals’ lives beyond the physicality of pain.

Humour also supported connections between individuals with LBP and clinicians. During one clinician dialogue, Noah (clinician) described humour’s potential to ‘have people engaging with us in a slightly more human level in this sort of sterile clinical environment’. Ruby (clinician) positioned humour as a therapeutic tool, fostering a ‘sense of creativity and openness’ in interactions with patients. Humour aided in reimagining the clinical environment as a more human, creative and open space, simultaneously shifting expected roles of ‘patients’ and ‘clinicians’. Although humour was seen as positive, clinicians agreed that it should be used with care to avoid misinterpretation.

Shifting power

Continual shifts in power between clinicians and individuals with LBP enacted ‘the patient-person’. In contrast to ‘the patient’ who was expected to conform to service norms, here power was fluid. Shifts in power were practiced through (1) the positioning of people, furniture and objects in consultation rooms and (2) opportunities for disagreement regarding clinicians’ suggestions and proposed treatments. The first mode of power transfer is exemplified in one observer’s notes of Bree (clinician) and Mary’s interaction:

Bree introduced herself as soon as we entered the room and asked Mary to sit in front of her. They were very close to each other. . .. the desk was placed against the wall, so Mary and Bree were not across the table from each other, but beside each other. Both chairs were at the same height.

The furniture arrangement and the way objects and bodies were positioned in the room enacted power relations that fostered collaboration instead of hierarchical interactions. Mary and Bree were sitting beside each other, in chairs of the same height. Although Bree used a computer to gather Mary’s information, she maintained eye contact, facing her body towards Mary when not typing. These practices enacted ‘the patient-person’.

Secondly, shifts in power occurred when individuals could disagree with clinicians’ suggestions and treatment options. For example, in one consultation, Sarah (clinician) wanted to add squats to John’s routine exercises. He responded: ‘This body don’t do squats’. Sarah answers: ‘That’s OK. It’s your body’. Although Sarah likely assessed squats as helpful to John’s treatment aims, she did not insist that he follow her prescription; she supported John’s resistance. Such resistance could also be due to implicit gender norms, where John (a male patient) seemed comfortable disagreeing with Sarah (a female clinician). In discussing this excerpt during one clinician dialogue, Sarah’s reaction was perceived as non-judgemental: the act of ‘not-squatting’ and ‘not-being-judged’ is normalised. Sarah and John’s interaction provides an alternative enactment to ‘the patient’, who is expected to be compliant, opening opportunities for more equal power sharing.

Adaptation of rules and habits

Adapting routine practices, such as those underpinned by electronic standardised assessment forms (checklists), to consider individuals’ physical and psychological comfort enacted ‘the patient-person’. Checklists contain physical and psychosocial components to assess diverse aspects of living with pain, are long and standard for every individual with LBP - as explained in the enactment of ‘the patient’. However, alterations can enact ‘the patient-person’. An example of this alteration can be seen in the observer’s note below:

Piper (clinician) noticed how Mila looked like she was in pain, so she was not going to do the physical assessment she normally did. Piper was sure the doctor had already done everything, and she didn’t want to make Mila go through that again. Mila looked relieved and said, “I was a little bit worried” and they laughed.

Although Piper possibly lost some information related to Mila’s pain, adaptation demonstrated prioritisation of the individuals’ physical comfort. As mentioned before, individuals’ pain was ‘there all the time’ and aggravated by sitting for long periods of time. Some individuals took pain medication prior to their appointments, anticipating the pain they would feel when attending the service. Here, the ‘incomplete’ (or the ‘not-performed’) checklist enacted ‘the patient-person’ by prioritising the individuals’ physical (and psychological) comfort, demonstrating understanding of the burden of having pain ‘all the time’.

Assistance outside the pain service

‘The patient-person’ was also enacted through connecting individuals with LBP to other institutions (e.g. GPs, government and community services). It was common for clinicians to provide letters to GPs and social support services or search for feasible options in the community so individuals could engage with exercise or social activities. For example, in one observation, Beni (who was a person of colour and spoke little English) asked Lara (clinician) to write a letter to the housing department to assist him in moving houses. Because of his pain, Beni was constrained to a wheelchair and his one-bedroom house accommodated nine people. Although Lara initially resisted (perhaps due to implicit racial bias), she soon acknowledged that Beni (‘the patient’) needed better housing to facilitate better rehabilitation (‘the patient-person') and acted to support his request. Clinicians also sometimes assisted patients with exercise and social activities they could continue in their community. In some consultations, clinicians even went through different options that could fit into individuals’ lives and finances. A member of our advisory panel recalled a clinician arranging a more comfortable seating space for her at a concert. The support letters, searches for options in the community and seating modifications, alleviated tensions that individuals with LBP face in ‘hanging-their-body-together’ and enacted ‘the patient-person’.

Both ‘the person’ (within individuals’ social context) and ‘the patient’ (produced at the pain service) are recognised and actively supported in the enactment of ‘the patient-person’.² Here, overlapping versions of the same individual with LBP coexist and interact during consultations.

Discussion

In this paper, we explored how practices performed at a multidisciplinary pain service enacted different versions of individuals living with LBP: ‘person’, ‘patient’ and ‘patient-person’. Although multiple realities are enacted in consultations, we focused on ‘social’ aspects – that are arguably outside of medical attention and practice – due to their ongoing under-recognition in scholarship and practice (Mescouto et al., 2022a). Our analysis demonstrated how individuals’ social contexts are always present, manifesting during consultations (enacting ‘the person’), but sometimes sidelined through expectations to comply with clinic rules and be responsible for one’s own care (enacting ‘the patient’). In contrast, enacting ‘the patient-person’ with LBP was possible when the service centred individuals’ social dimension. To cite Mol (2002), ‘no phenomenon can be ignored on the grounds that it belongs to another discipline’ (p. 158): the multiple aspects of individuals living with LBP are not outside, but part of every clinician’s practice.

The social dimensions of individuals with LBP were made visible in consultations by enacting ‘the person’, showing broader social aspects matter in the pain service and are embedded in all practices. Although medicine and the health sciences have moved beyond the recognition of the body as a machine, biological and some psychological dimensions are still dominant with little exploration of social (and theoretical) considerations of bodies with LBP (Mescouto et al., 2022b). Sociological and philosophical/theoretical considerations of the body have helped explore ‘what a body is’, moving from a mere physiological construct to the consideration of social, cultural, political, economic factors (Newton, 2003; Williams, 2006). But bodies are also shaped and enacted by socio-material practices, where a body is not something we are, but also something we do or enact (Mol, 2002). This discussion moves from an epistemological consideration of the body (through experiences) to an ontological one, where objects/diseases/bodies are enacted by the everyday clinical practices which shape reality. Mol and Law (2004: 51) assert: the ‘body is not a well defined whole: it is not closed off, but has semi-permeable boundaries’ (emphasis in the original). The enactment of ‘the person’ can be considered as one version of a social body, where the social contexts of individuals with LBP are brought to the fore.

Although there is a call for pain services to see pain management under a ‘sociopsychobiomedical’ prism (Australian Government Department of Health, 2019), the enactment of ‘the patient’ sidelines the ‘social’, making attempts to attend to it fragmented and simplistic. Using standardised forms or checklists to assess patients’ ‘social’ risk factors and context, for example, has been critiqued as oversimplistic and inadequate at addressing the social complexity of living with pain (Stewart et al., 2011). Law and Mol (2002), in their theoretical work on complexity, argue that classification systems help to group categories together but are ultimately problematic because they fail to recognise their incompleteness. They argue that lists should be flexible, accommodating for additions. Under recognition of a checklist’s incompleteness and simplicity may constrain care. Even using the well-known term ‘psychosocial’ to assess individuals with chronic pain has been challenged; it glosses over variation in the importance of social factors to individuals with LBP (Blyth et al., 2007). There are many forces that underpin this ‘glossing over’ of social factors, including interprofessional power differentials which have traditionally tended to empower professions with less social focus. This is a point that is beyond the scope of our research, but would be an important consideration for further work.

‘Social’ in our study is the multiple experiences individuals with LBP face with other healthcare professionals, the institutions/clinics involved in their care, the government support (or lack thereof) and the personal relationships and roles in their lives. Latour (2005) argues that ‘social’ is not a specific domain, but a means of connection (or association) between humans and non-human actors. Places, people, and society are connected, networked and entangled together in world-making practices. Thus, attempts to compartmentalise and reduce ‘the social’ to a checklist or consider it as outside the therapeutic interaction miss the importance of multiple other actors in an individual’s life with pain. People with LBP manage and negotiate aspects of their pain with healthcare professionals, significant others and social systems (Holloway et al., 2000). Unfortunately, they are sometimes treated impersonally by healthcare professionals (Hadi et al., 2017), who have to follow guidelines and routines and miss listening to individual’s wishes and preferences (Allvin et al., 2019). In a study by Allvin et al. (2019), for example, participants with chronic back pain tried to explain their feelings and preferences to their clinicians, but felt obligated to comply and adapt to care requirements. This obligation often made them feel vulnerable, frustrated and not seen nor understood as a person. Similarly, the compliance with service rules and habits in our enactment of ‘the patient’ suggests disconnection: a lack of attention to ‘the person’ with LBP.

Arguments that people with chronic pain want to be treated as people first instead of only patients or numbers are ubiquitous in the literature (Allvin et al., 2019; Hadi et al., 2017; Richards, 2020). Our findings challenge such assertions by suggesting that to consider only ‘the person’ would leave individuals with LBP to ‘hang-their-body-together’ alone. We suggest that what might be required is action and support from pain services to go beyond simplistic acknowledgements of ‘the person’, to enact ‘the patient-person’. In their ethnographic study of people with diabetes, Mol and Law (2004: 58) suggest that medicine does not offer diagnostic and therapeutic interventions in isolated bodies but offers interventions on peoples’ lives ‘beneath and what is beyond the skin’ and it should be appreciated accordingly. ‘The patient-person’ exemplifies how interventions can be tailored to aspects ‘beyond the skin’ (e.g. individuals’ social contexts, engagement with healthcare and economic systems, daily routines of dealing with pain) and still be inherently part of the medical agenda.

The enactment of ‘the patient-person’ offers an alternative interpretation of a patient-centred (or person-centred) care approach, one which appreciates both ‘the patient’ and ‘the person’ as acceptable and coexisting. Much is discussed in the literature regarding patient- or person-centred approaches to the care of people with musculoskeletal conditions (Lin et al., 2020). Although they seem similar, researchers have argued for greater consideration of ‘the person’ (Håkansson Eklund et al., 2019), bringing attention to the importance of multidisciplinary teams in developing a partnership with individuals with LBP (Howarth et al., 2012). According to Pluut (2016), the need for a unified concept of patient-centredness is unproductive and may hinder the recognition of the multiple and diverse ways that a relationship between patients and healthcare professionals can be carried out. The discourse of empowerment in patient-centredness has been criticised as more beneficial for clinicians than patients, since it may allow clinicians to withdraw from responsibilities for patients’ care (Pluut, 2016; Salmon and Hall, 2003). Such research emphasises a need to reflect on ‘when’ and ‘how’ the discourse of patient empowerment should be considered.

Within the different enactments presented in this study it was evident that, depending on individuals’ contexts and conditions, clinicians need to provide different levels of support. ‘The patient-person’ brought broader elements of care to light in interactions. For example, the healthcare system experiences of people of colour who spoke little English (such as Devya and Beni), brings attention to how pain services play a role in these broader aspects of care. Considerable other research has demonstrated in more detail the effects of racial and ethnic discrimination in pain prevalence and pain care in various settings (Green et al., 2003; Hoffman et al., 2016; Morales and Yong, 2021), with a call for chronic pain to be viewed through a social justice lens – not only in clinical encounters, but at organisational and programming levels (Wallace et al., 2021; Webster et al., 2019). Although our findings point to the importance of sharing power between clinicians and patients, we did not explore the details of how power relations are carried out in specific patients’ groups. This topic is worthy of further intersectional analysis (e.g. regarding race, class, gender, immigration status). Because multidisciplinary pain services are considered an optimal approach for people with chronic pain that have higher psychosocial complexities (Kamper et al., 2015), such services must adapt to patients’ and communities’ social contexts and needs (Brady et al., 2019; Craig et al., 2020). To cite one of the clinicians in our study, enacting ‘the patient-person’ indicated how clinicians could engage with individuals with LBP in a ‘slightly more human level’ through an active engagement with individuals’ social contexts. We also want to note that the focus of this paper is on what clinicians can do to better navigate social dimensions of LBP. Although this is an intentional move on our part to focus the gaze on the people who are traditionally in positions of power in clinical research and not the object of research attention, we do realise that this focus may detract from noting patients’ agency to enact their healthcare, which is appropriately discussed as key in literatures on critical health literacy and cultural capital.

To summarise, the enactments of ‘the patient’, ‘the person’ and ‘the patient-person’ suggest how social dimensions of individuals with LBP can be (and are) part of clinical encounters. Individuals with LBP bring their social contexts into the consultation (first enactment: ‘the person’). However, these social dimensions can be taken for granted (second enactment: ‘the patient’) or attended to during clinical interactions in different ways (third enactment: ‘the patient-person’). Although these are just a few of the multiple other versions of individuals with LBP that are enacted in a pain service, fostering practices that attend to ‘the patient-person’ can be meaningful in helping services to adjust, embrace and support individuals’ social contexts. Drawing on Mol (2002: 171), this study does not ‘try to show that the social is larger than we took it to be (. . .) it may be better to stop shifting the boundary between the domains of professionals and patients and instead look for new ways of governing the territory together’. Accordingly, in this study, we highlight a new way of ‘governing the territory together’, offering better and equitable healthcare practices: a pain service that can provide support and assistance to individuals with LBP doing the work of ‘hanging-their-body-together’. Supporting practices that attend to ‘the patient-person’ provides valuable enterprise for other services, not limited to the pain management arena.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Health and Medical Research Council of Australia Fellowships [JS: APP1157199 and PWH: APP1102905], and an Early Career Researcher grant.

ORCID iDs

Karime Mescouto

Rebecca E Olson

Nathalia Costa

Notes

Author biographies

Karime Mescouto is a physiotherapist from Brazil and a PhD student at The University of Queensland, Australia. Her doctoral research is interested in enhancing low back pain healthcare delivery by looking critically at the biopsychosocial model of health. Her research uses a variety of qualitative methodologies and engages with critical social theories to challenge taken for granted aspects in the care of people with low back pain. She holds a master’s degree in Rehabilitation Science from the Federal University of Rio Grande do Norte, Brazil and a Graduate Certificate in Clinical Physiotherapy (Musculoskeletal stream) from Curtin University, Australia.

Rebecca E Olson is a Reader in Sociology, Co-Director of SocioHealthLab and Program Director of the Bachelor of Social Science at The University of Queensland. With expertise in advancing innovative, translational qualitative methods, Olson leads applied interdisciplinary research for healthcare practice and healthcare education improvement, by attending to social-emotional aspects of care. Funded by competitive national grants (NHMRC, Cancer Australia, Arthritis Australia), her contributions to innovative, translational qualitative inquiry have been recognised by invitations to deliver keynotes at national and international symposiums (ACSPRI, British & American Sociological Associations).

Nathalia Costa has expertise in musculoskeletal health, with a focus on low back pain (LBP). She is a Postdoctoral Research Fellow at the University of Queensland (UQ) and a Postdoctoral Research Associate at the University of Sydney (USYD). Dr Costa has received the foremost international award for back pain research – the 2021 ISSLS Prize for Lumbar Spine Research (Clinical Science). At UQ, Costa is investigating how both clinicians and people with LBP navigate uncertainty during clinical encounters. At USYD, Costa is investigating system-level intervention points to promote transfer of outcomes of LBP research into health policy and practice.

Kerrie Evans is a part-time Post-Doctoral Research Fellow at The University of Sydney and a practising Specialist Musculoskeletal Physiotherapist. She has 27 years’ of clinical experience and leads the professional development and research for Healthia Limited, a large publicly listed allied health organisation. Her research and clinical interests are prevention and management of spinal pain, pain and models of care in primary healthcare settings.

Miriam Dillon is a physiotherapist at the Royal Brisbane and Women’s Hospital and PhD candidate at The University of Queensland.

Niamh Jensen is a Clinical Psychologist with the Metro South Health Pain Rehabilitation Centre. She has more than ten years of experience working in multidisciplinary teams in the Queensland public health system. Dr Jensen was awarded a PhD in Clinical Psychology from the University of Queensland in 2011. Her doctoral research focused on quality of life outcomes for people engaging in an outpatient group CBT programme for the treatment of anxiety and depressive disorders. Dr Jensen has an interest in contextual behavioural science and process-based therapies, with a specific focus on the application of functional analysis and psychological flexibility processes in pain rehabilitation.

Kelly Walsh is a Senior Physiotherapist with the Metro South Health Pain Rehabilitation Centre. She also holds a Bachelor (Honours) of Behavioural Science, Psychology. Kelly has worked with people in chronic pain conditions for 14 years.

Megan Weier is a Research Fellow at the Centre for Social Impact. Her research interests are in the influences of progressive faith and politics, anti-racism, feminism and poststructural thought. Her focus is to grapple with fundamental human rights for justice which fuels a conviction to speak out on existing inequalities that exist within Australia. Megan’s personal experiences with mental health challenges, chronic disease and pain, as well as professional engagement with policy making and research on drug and alcohol policy debates have led to complex beliefs about the effects of public policy on personal health and wellbeing.

Kathryn Lonergan is a programme and project manager at a company in Brisbane. She has had chronic pain since she was 12 and has provided expert feedback on the present manuscript.

Paul W Hodges, DSc MedDr PhD BPhty(Hons) FAA FACP APAM(Hon) is an National Health and Medical Research Council (NHMRC) Senior Principal Research Fellow, Professor and Director of the NHMRC Centre for Clinical Research Excellence in Spinal Pain, Injury and Health at The University of Queensland (UQ). He is lead chief investigator on an NHMRC Program Grant that includes colleagues from the Universities of Melbourne and Sydney. Paul has received numerous national and international research awards that span basic and clinical science.

Jenny Setchell, PhD is a Senior Research Fellow in physiotherapy at The University of Queensland, Australia. Their research interests include social and cultural perspectives on healthcare broadly, and physiotherapy specifically. Dr Setchell has produced over 60 publications and has presented over 70 times on their work including prestigious international invited presentations. They have been awarded funding in Canada and Australia including their current NHRMC Fellowship and an NHRMC CRE (as AI). Dr Setchell has 20 years of diverse clinical experience in Australia and internationally across multiple sub-disciplines and contexts. Dr Setchell has also been an acrobat and a human rights worker.

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‘Engaging on a slightly more human level’: A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic

Abstract

Keywords

Introduction

Theoretical framework

Methods

Participants and setting

Design and data collection

Data analysis

Findings

First enactment: The person

Personal context and relationships

Interactions with institutions and healthcare providers

Second enactment: The patient

Compliance with service rules and habits

Individualistic approach to care

Third enactment: The patient-person

Connecting beyond their usual roles

Shifting power

Adaptation of rules and habits

Assistance outside the pain service

Discussion

Footnotes

Declaration of conflicting interests

Funding

ORCID iDs

Notes

Author biographies

References