MasterclassBeliefs about back pain: The confluence of client, clinician and community
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.
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