Introduction

Since more attention has been given to empowering patients to self-manage certain musculoskeletal conditions, consultations with healthcare providers are often reduced in frequency. In these consultations, patients are educated about the nature of their complaints and how to efficiently monitor their condition. In many cases, no specific diagnosis can be given, for example; a clear pathoanatomical cause is lacking in more than 90% of low back pain complaints. The exact origin of someone’s complaint can therefore be unknown and this leads to diagnostic uncertainty which has to be taken into account. Safety netting, defined as the process of communicating information to patients on monitoring their condition and what to do if symptoms persist or worsen, is an essential component of musculoskeletal physiotherapy practice to manage diagnostic uncertainty. Further, it reduces the risk of harm associated with delays in seeking care with worsening/persisting symptoms. A lot of research about this is already available in Cauda Equina Syndrome, but specific safety-netting communication in physiotherapy for low back pain, which is one of the most frequent musculoskeletal complaints in our field, is lacking. Therefore, this study examined safety-netting communication in physiotherapy and teaches us what we can do to improve it.

Methods

This study conducted a secondary analysis of audio recordings and transcripts from 79 consultations involving 41 patients and 12 physiotherapists. The consultations, which included both initial and follow-up appointments, took place in outpatient musculoskeletal departments across Southern England. The Safety-Netting Coding Tool (SaNCoT), previously validated in general practice settings, was used to code and quantify safety-netting behaviors during these sessions.

Step-by-Step Analysis Using the SaNCoT

• Diagnostic Uncertainty: The tool analyzed phrases like “I think” or “it could be” to indicate diagnostic uncertainty.
• Time-Course Information: It assessed whether physiotherapists provided any estimated recovery or progression time frames.
• Safety-Netting Advice: Specific guidance on symptom monitoring, advice on actions if symptoms worsened, and follow-up instructions were examined, and whether the advice given was specific or generic.
• Missed Opportunities: Instances where safety netting could have been applied but wasn’t were also noted, particularly regarding symptoms like leg pain that could signal more serious conditions.

Results

Of the patients presenting, an equal distribution had low back pain without associated leg symptoms and low back pain without associated leg symptoms.

Diagnostic uncertainty was communicated in most of the appointments. Most of the diagnostic uncertainty was expressed during new patient consultations (80.5%). Around half (52.6%) of follow-up consultations included expressions of diagnostic uncertainty.

No specific Time-Course Information was shared with the patients. Some information regarding prognosis was communicated, but no specific timeframes were presented.

Eight patients received safety-netting information on how to monitor their signs and symptoms and which actions to take in case of worsening. This information was communicated 19 times over 12 consultations. This safety-netting information was mostly provided in follow-up consultations.

Most safety-netting communication was advice on what sort of signs and symptoms to monitor closely. For example, in the presence of pins and needles in a patient with low back pain with leg-related symptoms, advice to monitor the strength of the foot and big toe was expressed. Unfortunately, this information was communicated in a relatively non-specific manner.

The safety-netting communication was mostly directed at explaining why and how to seek further help but lacked information about what actions to take in case of worsening of the condition.

The authors concluded that there were several missed opportunities for safety-netting communication in physiotherapy consultations.

Questions and thoughts

What should we remember about safety-netting communication in physiotherapy? Communicating about the nature of someone’s pain can certainly include diagnostic uncertainty. Especially since the high proportion of low back pain arising without a specific underlying pathoanatomical cause. Many physiotherapists fear that not knowing where the complaints come from is seen as a lack of knowledge in the eyes of the patient. Instead of fearing this, I think that by expressing that a lot of low back pain problems are driven without specific “damage” and thus trivial and not at all dangerous, and completing this information with your reasoning why you think this person should not be fearful of having a serious condition is much more valuable and reassuring. Then the next step would be to provide detailed safety-netting information. Especially when someone has symptoms that might fit in a specific back pain diagnosis, he or she should know about the what, why, when, and how and this should be communicated in a direct and specific way. If you want someone to understand more about their condition and how this person should keep an eye out for worsening symptoms, you should indicate

• What specific symptoms to look out for: for example a diminished ability to dorsiflex the foot or big toe in someone with low back pain and irradiating leg pain
• Why it is important to monitor those symptoms so that patients understand the need to report them right away and avoid delays.
• When action should be taken
• How and what specific actions to take: for example, consult the general practitioner, come back to the physiotherapy department, go to the emergency room

Furthermore, it emerged that the use of prognostic information is very important but often lacking. It can be partly explained by the great deal of information that is available on low back pain prognosis, but the high heterogeneity in the outcomes used. Here we can also give specific advice on different outcomes.

Safety-netting communication in physiotherapy practice is part of the recommended pathway for low back pain care. (Finucane et al., 2020)

Talk nerdy to me

We should take into account that the data from this study was collected more than 10 years ago and that since then a lot has changed in the field of physiotherapy. The data are not generalizable to today’s care and were conducted in the United Kingdom, which may also limit generalizability to other healthcare systems. However, the current study sheds light on aspects that we might not always be aware of in our communication. We should look out for not missing opportunities to integrate safety netting information throughout physiotherapy consultations.

When the current study compared the amount of safety-netting communication in physiotherapy versus in general practitioners, it was found that general practitioners use much more safety netting. Yet, it should be noted that a follow-up physiotherapy consultation can also be viewed as a form of safety netting. Yet, as communication on safety netting is regarded as a patient-centered approach to manage uncertainty, it is important to not forget it in your consultations.

Take-home messages

This study creates awareness of the lack of safety-netting communication in physiotherapy. Although the data were collected a long time ago and contemporary communication has potentially evolved, it is insightful to learn how professionals in the field communicate diagnostic uncertainty. Discussing realistic prognostic timeframes can help patients to better understand their condition and learn when they should act if symptoms persist or worsen. Sharing specific instructions on which symptoms to monitor (for example: paresthesia, loss of strength or changes in pain) and setting clear return points could prevent delays in addressing complications.

Reference

Horler C, Leydon G, Roberts L. Communicating safety-netting information in primary care physiotherapy consultations for people with low back pain. Musculoskelet Sci Pract. 2024 Sep 19;74:103192. doi: 10.1016/j.msksp.2024.103192. Epub ahead of print. PMID: 39307044.

Learn more

Cauda Equina Syndrome

Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM, Leech RL, Selfe J. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020 Jul;50(7):350-372. doi: 10.2519/jospt.2020.9971. Epub 2020 May 21. PMID: 32438853.