Navigating diagnostic uncertainty in children's chronic lower limb pain: A qualitative study of management strategies using vignette-based focus groups.

Abstract

Background: Chronic lower limb pain is common in children and adolescents and is frequently managed by podiatrists. Due to the complexities of understanding the cause of chronic pain, clinicians may experience uncertainty around the diagnosis, which in turn may impact their communication and management approaches. Limited research explores how podiatrists manage chronic lower limb pain in children, especially in the presence of diagnostic uncertainty. This study aimed to explore the management strategies including language that podiatrists report using to address the pain experience of children with chronic lower limb pain and to investigate if and how the reported management strategies used by podiatrists to address the pain experience of children with chronic lower limb pain vary based upon the level of diagnostic uncertainty.

Methods: Eight focus groups were conducted with a total of 48 podiatrists. Participants were presented with three vignettes, each describing a child with chronic lower limb pain. They were then asked to discuss their certainty in the child's diagnosis presented and their approaches to explain and manage the child's pain. Audio data were recorded, transcribed and analysed using thematic analysis. Three key themes were generated: Language strategies, non-verbal communication strategies and treatment strategies.

Results: Podiatrists were overall certain in the diagnosis presented in vignettes 1 (calcaneal apophysitis) and 2 (juvenile idiopathic arthritis); however, they expressed significant uncertainty in vignette 3, which was written to elicit uncertainty presenting a case with generalised lower limb pain. Many groups fixated on the Beighton score of 5/9 and interpreted this to mean hypermobility, which is inconsistent with the current clinical guidance. Podiatrists used similar language strategies across all 3 vignettes and supported their language strategies with non-verbal communication strategies. Podiatrists also discussed activity modification, passive and self-care strategies and building a team as the treatment strategies they would use.

Conclusions: This study highlights the variety of clinical management strategies used by approaches and highlights how their approach may change depending on their certainty in the diagnosis.