Masterclass
Beliefs about back pain: The confluence of client, clinician and community

https://doi.org/10.1016/j.ijosm.2016.01.005Get rights and content

Abstract

Patient beliefs play an important role in the development of back pain and disability, as well as subsequent recovery. Community beliefs about the back and back pain which are inconsistent with current research evidence have been found in a number of developed countries. These beliefs negatively influence people's back-related behaviour in general, and these effects may be amplified when someone experiences an episode of back pain.

In-depth qualitative research has helped to shed light on why people hold the beliefs which they do about the back, and how these have been influenced. Clinicians appear to have a strong influence on patients' beliefs. These data may be used by clinicians to inform exploration of unhelpful beliefs which patients hold, mitigate potential negative influences as a result of receiving health care, and subsequently influence beliefs in a positive manner.

Introduction

Psychosocial factors play an important role in the development of back pain and disability, as well as subsequent recovery (or lack thereof).1, 2 Low confidence in the ability to function despite pain (pain self-efficacy), poor expectation of recovery, avoiding movement or activity due to fear of pain and injury (fear avoidance), negative thoughts about the causes or consequences of back pain (catastrophisation), psychological distress (anxiety, depression, and stress), and reliance on passive coping strategies have all been found to be independently associated with poor outcomes including delayed return to work, activity limitation, and pain persistence.3, 4, 5, 6, 7

Many psychosocial factors appear to be inter-related and overlapping, for example, beliefs about the cause of back pain and the expected outcome may contribute to pain-related emotional distress.8 The relative strengths of associations observed between these factors and patient outcomes vary across studies, but key constructs appear to be self-efficacy, fear, expectation, and psychological distress.8, 9, 10 These can be conceptualised as resulting from, or contributing to, the threat associated with back pain.11

Psychosocial factors are relevant during all stages of back pain.12, 13, 14, 15, 16 These do not just influence back pain related behaviour and recovery, but also shape the perceptual experience of pain itself. Neurophysiological research has demonstrated the influence of central nervous system processes on pain perception.17 Context (pain beliefs, experience, expectation), cognition (appraisal, attention, vigilance), and mood (depression, anxiety) alter the pain experienced for a given nociceptive input or level of tissue stimulation.17 Psychosocial factors associated with poor recovery have also been found in those who do not have back pain and these may increase the risk that someone will develop back pain.18, 19

In order for clinicians to positively influence psychosocial factors, it is important to understand the beliefs which underlie these factors and how these beliefs have been formed. Beliefs about the back and back pain have been explored amongst the general population, people who have back pain, and clinicians by way of surveys, prospective studies, intervention studies, and qualitative studies. This Masterclass will discuss back pain beliefs amongst these groups, with a particular focus on recent qualitative interview research which has helped to explain how these beliefs are developed and influenced. This aims to assist clinicians to identify and positively influence patient beliefs which may increase the threat associated with back pain. Individual psychological traits or co-morbidities may also be important to consider in individual patients, but consideration of these is beyond the scope of this Masterclass.

Section snippets

The client

People with back pain appear to view their back as being a fragile or vulnerable structure which is easy to injure.11, 20, 21 As a result, back pain is usually seen as representing tissue damage or dysfunction within the back.11, 20, 21, 22 People who relate their back pain to a structural or pathoanatomic cause are more likely to have higher levels of disability,23 and poor recovery expectations.20 Believing that the pain is due to something which is not alterable (such as past injury or

The clinician

Nearly half of those experiencing back pain do not seek health care,29 but many of those who do seek care see more than one provider.30, 31 Perceived need has the strongest influence on the decision to seek care,30 with those experiencing high levels of disability being almost eight times as likely to seek care, and those with high pain intensity being almost twice as likely to seek care.29 Those who have more maladaptive beliefs, particularly higher levels of fear or more catastrophic beliefs,

The community

Surveys of the general population in a number of developed countries have explored beliefs about what causes back pain and how it should be best managed.19, 44, 48 Collectively these studies indicate that many people believe the back is easy to injure and that back pain represents underlying tissue damage, that back pain has a negative impact on life, that back pain requires professional care and imaging, and that it is necessary to identify the cause of back pain to get effective care.19, 44,

Implications for clinical practice

Beliefs about back pain are dynamic and have multiple interacting influences, however, clinicians appear to play a key role. Each interaction with a patient provides an opportunity to positively influence the beliefs of the person, but also the potential to influence beliefs in an unhelpful way.

In any individual it is likely that different psychosocial factors will have different levels of severity and importance.9 Constructs such as pain self-efficacy, fear avoidance, or catastrophisation

Summary

Patient beliefs are important in back pain development and recovery. These beliefs are shaped by multiple interacting influences but clinicians have a powerful impact which may be positive or negative. Structural or pathoanatomical explanations, management advice which is interpreted as meaning the back requires protection, or poor prognostic expectations can all negatively influence patient beliefs. In contrast meaningful reassurance and clear empowering activity messages can positively

Conflicts of interest

None declared.

Ethics statement

None declared.

Funding

None declared

Acknowledgements

Much of the work presented here was developed as part of the author's doctoral thesis. His PhD supervisors were Prof. Anthony Dowell, Prof. G David Baxter, and Ms Fiona Mathieson. He received additional advice and support from Dr Sarah Dean, Dr James Stanley, and Dr Meredith Perry. This work was supported by funding from Lotteries Health Research, the Physiotherapy New Zealand Scholarship Trust and Wellington Branch Searchwell Trust, and a University of Otago Postgraduate Scholarship.

References (81)

  • T. Pincus et al.

    Attitudes to back pain amongst musculoskeletal practitioners: a comparison of professional groups and practice settings using the ABS-mp

    Man Ther

    (2007)
  • T. Pincus et al.

    Advising people with back pain to take time off work: a survey examining the role of private musculoskeletal practitioners in the UK

    Pain

    (2011)
  • A. Cano et al.

    Spouse beliefs about partner chronic pain

    J Pain

    (2009)
  • H. Flor et al.

    The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients

    J Psychosom Res

    (1987)
  • J.M. Romano et al.

    Chronic pain patient-spouse behavioral interactions predict patient disability

    Pain

    (1995)
  • C.J. Main et al.

    Addressing patient beliefs and expectations in the consultation

    Best Pract Res Clin Rheumatol

    (2010)
  • S.J. Bigos et al.

    High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults

    Spine J

    (2009)
  • D.M. Roffey et al.

    Causal assessment of occupational sitting and low back pain: results of a systematic review

    Spine J

    (2010)
  • E.K. Wai et al.

    Causal assessment of occupational lifting and low back pain: results of a systematic review

    Spine J

    (2010)
  • E.K. Wai et al.

    Causal assessment of occupational bending or twisting and low back pain: results of a systematic review

    Spine J

    (2010)
  • A. Delitto et al.

    Low back pain

    J Orthop Sports Phys Ther

    (2012)
  • S.J. Linton

    A review of psychological risk factors in back and neck pain

    Spine

    (2000)
  • M.M. Wertli et al.

    The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review

    Spine

    (2014)
  • R.A. Iles et al.

    Systematic review of the ability of recovery expectations to predict outcomes in non-chronic non-specific low back pain

    J Occup Rehabil

    (2009)
  • A. Ramond et al.

    Psychosocial risk factors for chronic low back pain in primary care – a systematic review

    Fam Pract

    (2011)
  • A. Ramond-Roquin et al.

    Psychosocial risk factors, interventions, and comorbidity in patients with non-specific low back pain in primary care: need for comprehensive and patient-centered care

    Front Med (Lausanne)

    (2015)
  • H. Lee et al.

    How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain

    Pain

    (2015)
  • B. Darlow et al.

    Easy to harm, hard to heal: patient views about the back

    Spine

    (2015)
  • A.K. Burton et al.

    Psychosocial predictors of outcome in acute and subchronic low back trouble

    Spine

    (1995)
  • S.Z. George et al.

    Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain

    Clin J Pain

    (2006)
  • L. Klenerman et al.

    The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting

    Spine

    (1995)
  • M. Melloh et al.

    Predicting the transition from acute to persistent low back pain

    Occup Med (Lond)

    (2011)
  • S.J. Linton et al.

    Are fear-avoidance beliefs related to the inception of an episode of back pain? A prospective study

    Psychol Health

    (2000)
  • I.B. Lin et al.

    Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians

    BMJ Open

    (2013)
  • G. Stenberg et al.

    ‘I am afraid to make the damage worse’–fear of engaging in physical activity among patients with neck or back pain–a gender perspective

    Scand J Caring Sci

    (2014)
  • S. Bunzli et al.

    What do people who score highly on the Tampa Scale of Kinesiophobia really believe? A mixed methods investigation in people with chronic non specific low back pain

    Clin J Pain

    (2015)
  • T.J. Sloan et al.

    Explanatory and diagnostic labels and perceived prognosis in chronic low back pain

    Spine

    (2010)
  • I.B. Lin et al.

    ‘I am absolutely shattered’: the impact of chronic low back pain on Australian Aboriginal people

    Eur J Pain

    (2012)
  • S. Bunzli et al.

    Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain

    Clin J Pain

    (2013)
  • B. Darlow et al.

    Putting physical activity whilst experiencing low back pain in context: balancing the risks and benefits

    Arch Phys Med Rehabil

    (2016)
  • Cited by (0)

    View full text