Living with low back pain-Stories of hope and despair

Modes of hoping: understanding hope and expectation in the context of a clinical trial of complementary and alternative medicine for chronic pain

This article explores the role of hope in participants' assessments of their expectations, experiences and treatment outcomes. Data analysis focused on semi-structured, open-ended interviews with 44 participants, interviewed 3-5 times each over the course of a study evaluating Traditional Chinese Medicine (TCM) for temporomandibular disorders (TMD), a form of chronic orofacial pain. Transcripts were coded and analyzed using qualitative and ethnographic methods. A "Modes of Hoping" (Webb, 2007)(1) framework informed our analysis. Five modes of hoping emerged from participant narratives: Realistic Hope, Wishful Hope, Utopian Hope, Technoscience Hope, and Transcendent Hope. Using this framework, hope is demonstrated as exerting a profound influence over how participants assess and report their expectations. This suggests that researchers interested in measuring expectations and understanding their role in treatment outcomes should consider hope as exercising a multi-faceted and dynamic influence on participants' reporting of expectations and their experience and evaluation of treatment.

A qualitative study of influences on older women's practitioner choices for back pain care

BACKGROUND

Back pain is an increasingly prevalent health concern amongst Australian women for which a wide range of treatment options are available, offered by biomedical, allied health and complementary and alternative medicine (CAM) providers. Although there is an emerging literature on patterns of provider utilisation, less is known about the reasons why women with back pain select their chosen practitioner. In this paper we explore the influences on back pain sufferers' decision-making about treatment seeking with practitioners for their most recent episode of back pain.

METHODS

Drawing on 50 semi-structured interviews with women aged 60-65 years from the Australian Longitudinal Study on Women's Health (ALSWH) who have chronic back pain, we focus on the factors which influence their choice of practitioner. Analysis followed a framework approach to qualitative content analysis, augmented by NVivo 9 qualitative data analysis software. Key themes were identified and tested for rigour through inter-rater reliability and constant comparison.

RESULTS

The women identified four predominant influences on their choice of practitioner for back pain: familiarity with treatment or experiences with individual practitioners; recommendations from social networks; geographical proximity of practitioners; and, qualifications and credentials of practitioners. The therapeutic approach or evidence-base of the practices being utilised was not reported by the women as central to their back pain treatment decision making.

CONCLUSIONS

Choice of practitioner appears to be unrelated to the therapeutic approaches, treatment practices or the scientific basis of therapeutic practices. Moreover, anecdotal lay reports of effectiveness and the 'treatment experience' may be more influential than formal qualifications in guiding women's choice of practitioner for their back pain. Further work is needed on the interpersonal, collective and subjective underpinnings of practitioner choice, particularly over time, in order to better understand why women utilise certain practitioners for back pain.

A systematic review and meta-synthesis of the impact of low back pain on people's lives

Background

Low back pain (LBP) is a common and costly problem that many interpret within a biopsychosocial model. There is renewed concern that core-sets of outcome measures do not capture what is important. To inform debate about the coverage of back pain outcome measure core-sets, and to suggest areas worthy of exploration within healthcare consultations, we have synthesised the qualitative literature on the impact of low back pain on people’s lives.

Methods

Two reviewers searched CINAHL, Embase, PsycINFO, PEDro, and Medline, identifying qualitative studies of people’s experiences of non-specific LBP. Abstracted data were thematic coded and synthesised using a meta-ethnographic, and a meta-narrative approach.

Results

We included 49 papers describing 42 studies. Patients are concerned with engagement in meaningful activities; but they also want to be believed and have their experiences and identity, as someone ‘doing battle’ with pain, validated. Patients seek diagnosis, treatment, and cure, but also reassurance of the absence of pathology. Some struggle to meet social expectations and obligations. When these are achieved, the credibility of their pain/disability claims can be jeopardised. Others withdraw, fearful of disapproval, or unable or unwilling to accommodate social demands. Patients generally seek to regain their pre-pain levels of health, and physical and emotional stability. After time, this can be perceived to become unrealistic and some adjust their expectations accordingly.

Conclusions

The social component of the biopsychosocial model is not well represented in current core-sets of outcome measures. Clinicians should appreciate that the broader impact of low back pain includes social factors; this may be crucial to improving patients’ experiences of health care. Researchers should consider social factors to help develop a portfolio of more relevant outcome measures.

Identifying patients' beliefs about treatments for chronic low back pain in primary care: a focus group study

BACKGROUND

Current evidence-based guidelines for low back pain (LBP) recommend multiple diverse approaches to treatment and suggest considering patient preferences when formulating a treatment plan.

AIM

To explore patient preferences and to identify patients' beliefs about LBP treatments.

DESIGN AND SETTING

Qualitative study using focus groups in primary care in South-West England.

METHOD

Thirteen focus groups were organised with a purposive sample of 75 adults with LBP. Group discussions of LBP treatments were facilitated, audiorecorded, and the verbatim transcripts thematically analysed.

RESULTS

Eight themes were identified, four related to treatment beliefs and four to seeking treatment. Treatment beliefs comprised participants' expectations and appraisals of specific treatments, which were underpinned by four distinct dimensions: credibility, effectiveness, concerns and individual fit. Treatment beliefs were expressed in the broader context of treatment seeking: participants' primary concern was to obtain a clear explanation of their LBP which went beyond a diagnostic label and provided an understanding of the cause(s) of their LBP. They described engaging in self-management activities and claimed they were willing to try anything if it might help them. Participants wanted an empathic and expert practitioner who could deliver a suitable treatment (or refer them on to someone else) and help them to negotiate the challenges of the healthcare system.

CONCLUSION

These findings highlight the importance of helping patients develop coherent illness representations about their LBP before trying to engage them in treatment-decisions, uptake, or adherence. Addressing patients' illness and treatment perceptions in clinical practice could improve shared decision making and patient outcomes.

Living with chronic low back pain: a metasynthesis of qualitative research

OBJECTIVES The purpose of this qualitative metasynthesis is to articulate the knowledge gained from a review of qualitative studies of patients' experiences of chronic low back pain. METHODS Meta-ethnographic methodology guided the review of 33 articles representing 28 studies published in English in peer-reviewed journals between 2000 and 2012. A systematic comparison of the main themes from each study was conducted and 'synthesised' to create superordinate themes. RESULTS Three overarching interrelated themes were identified: the impact of chronic low back pain on self; relationships with significant others that incorporated two streams - health professionals and the organisation of care and relationships with family and friends; coping with chronic low back pain. Coping strategies were predominantly physical therapies, medication and avoidance behaviours with very few successful strategies reported. Professional and family support, self-efficacy, motivation, work conditions and exercise opportunities influenced pain experiences. Review authors' recommendations included psychological therapies, education, the facilitation of self-management strategies and support groups. DISCUSSION The review substantiates chronic low back pain as complex, dynamic and multidimensional, underpinned by experiences of persistent distressing pain, loss, and lowered self-worth, stigma, depression, premature aging, fear of the future. Future research should address the paucity of longitudinal studies, loss and issues of ethnicity, gender, ageing.

A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

Background

The alleviation of pain is a key aim of health care yet pain can often remain a puzzle as it is not always explained by a specific pathology. Musculoskeletal (MSK) pain is one of the most predominant kinds of chronic pain and its prevalence is increasing. One of the aims of qualitative research in health care is to understand the experience of illness, and make sense of the complex processes involved. However, the proliferation of qualitative studies can make it difficult to use this knowledge. There has been no attempt to systematically review and integrate the findings of qualitative research in order to increase our understanding of chronic MSK pain. A synthesis of qualitative research would help us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples' experience of health care with the aim of improving it.

Aim

The aim of this study was to increase our understanding of patients’ experience of chronic non-malignant MSK pain; utilise existing research knowledge to improve understanding and, thus, best practice in patient care; and contribute to the development of methods for qualitative research synthesis.

Methods

We used the methods of meta-ethnography, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings. We searched six electronic bibliographic databases (including MEDLINE, EMBASE and PsycINFO) and included studies up until the final search in February 2012. We also hand-searched particular journals known to report qualitative studies and searched reference lists of all relevant qualitative studies for further potential studies. We appraised each study to decide whether or not to include it. The full texts of 321 potentially relevant studies were screened, of which 77 qualitative studies that explored adults’ experience of chronic non-malignant MSK pain were included. Twenty-eight of these studies explored the experience of fibromyalgia.

Results

Our findings revealed the new concept of an adversarial struggle that explains the experience of people with chronic MSK pain. This included the struggle to affirm self and construct self over time; find an explanation for pain; negotiate the health-care system while feeling compelled to stay in it; be valued and believed; and find the right balance between sick/well and hiding/showing pain. In spite of this struggle, our model showed that some people were able to move forward alongside their pain by listening to their body rather than fighting it; letting go of the old self and finding a new self; becoming part of a community and not feeling like the only one; telling others about pain and redefining relationships; realising that pain is here to stay rather than focusing on diagnosis and cure; and becoming the expert and making choices. We offer unique methodological innovations for meta-ethnography, which allowed us to develop a conceptual model that is grounded in 77 original studies. In particular, we describe a collaborative approach to interpreting the primary studies.

Conclusion

Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Obstacles to and facilitators of return to work after work-disabling back pain: the workers' perspective

INTRODUCTION

Back pain entails considerable costs, particularly because many injured workers are absent from work for long periods. Factors that influence return to work among workers with back pain are still, however, not well understood. This qualitative study aimed at documenting affected workers' perspective on the: 1--difficulties caused by back pain, and 2--most important obstacles to and facilitators of return to work.

METHODS

Two focus groups composed of workers having suffered from work-disabling back pain were held: a group of participants who had returned to work (n = 9) and a group of participants who had not returned or had recently returned to work (n = 10). The verbatim accounts of the discussions were transcribed and a content analysis was carried out that included a ranking of items.

RESULTS

Difficulties caused by back pain were related to: (1) personal, (2) family, (3) social, (4) occupational, and (5) financial factors, and (6) health services. Obstacles to and facilitators of return to work were of 4 different types: (1) occupational factors, (2) factors associated with the utilization of health services, (3) clinical, and (4) personal factors. Persistent pain, lack of access to information or support groups, and lack of collaboration and understanding from employer were the most important obstacles identified, whereas knowledge of one's limits and physical training were perceived to be the most important facilitators of return to work, ahead of work-related factors. Differences between groups' perceptions were attributed mainly to control beliefs.

CONCLUSIONS

Personal, clinical, occupational and health services factors are perceived by workers with back pain to play a crucial role in determining whether they return to work or not.

'Talk to us like we're people, not an X-ray': the experience of receiving care for chronic pain

Chronic pain is a commonly reported problem in primary care, and is Australia’s third most costly health problem. Despite advances in the understanding and treatment of pain, many people with chronic pain do not receive the best available care. This paper examines the health care experiences of people with chronic pain and focuses discussion on the impact that institutional and cultural factors can have on individual experience. Unstructured narrative interviews were conducted with a convenience sample of 20 people with chronic pain. Participants’ experiences pointed to several factors that can affect the outcome of the health care they receive, including: the belief that all pain is due to identifiable injury or disease; a commitment to finding a diagnosis and cure; problematic patient−provider communication; and poor integration of health services. Comprehensively addressing these factors cannot be achieved by focusing interventions at the individual level. A multifaceted response, which includes public health and systemic initiatives, is required.

No room for reflexivity? Critical reflections following a systematic review of qualitative research

We conducted a systematic search of qualitative research into the individual's experience of chronic low back pain. Two reviewers independently read through 740 unique abstracts. Inter-rater reliability was fair. The final sample comprised 19 articles which we critiqued using the Critical Appraisal Skills Programme checklist. This article focuses on the critical appraisal. Limitations include a lack of an adequate rationale for the theoretical framework, a lack of an account for the decisions made across recruitment and data collection, and a lack of reflexivity. Finally we discuss and offer recommendations for reflexivity and the explication of qualitative methodology in research articles.

Patients' interpretations of a counselling intervention for low back pain: a narrative analysis

BACKGROUND

Low back pain often becomes a chronic condition and causes physical, psychological, social, and occupational impairment. Despite huge allocations of resources into the healthcare system and the labour market for treating and preventing low back pain, problems related to low back pain persist. A Danish randomised controlled trial identified an effective counselling intervention on low back pain patients' physical function, bodily pain and sick leave. Counselling addressed experienced workplace barriers and physical activity.

OBJECTIVE

The objective of the present study was to achieve a deeper understanding of how the patients interpreted the explanatory resources that were made available to them during the intervention, and how they integrated these resources into their personal biographies.

DESIGN

The present study was a qualitative analysis of a purposive sample of transcripts of status interviews performed during the randomised controlled trial's intervention.

ANALYSIS

Between two individual counselling sessions, all 110 participants were interviewed about their perspectives on adhering to their individual plans for reaching specific goals for adjustments at their workplace and for enhancing physical activity. These plans were developed and agreed upon by the participants and the counsellor. A sample (n=20) of these interviews was analysed in the present study using the three steps in Ricoeur's method for text analysis. Bury's concept of chronic illness as a biographical disruption was used as a theoretical framework for further interpretations of the dataset.

RESULTS

The participants valued the counsellor's open inquiry into the problems they had with their back. The participants' active engagement in creating new explanatory systems was crucial for their benefits from the intervention. If participants managed to change their health behaviour, it assisted them in transforming from being passive victims of pain into becoming active and in control. Participants who did not feel that they were sufficiently able to adhere to the treatment plan felt increasingly stigmatised, because they understood themselves to be in a position of disgrace in their own eyes and in the eyes of the system that offered them help.

CONCLUSION

The counsellor's assistance in crafting the first possible and manageable steps towards returning to work and enhancing exercising supported the participants' commitment to the treatment plan.

'I can't see any reason for stopping doing anything, but I might have to do it differently'--restoring hope to patients with persistent non-specific low back pain--a qualitative study

PURPOSE

To explore the differences in narrative between patients with persistent non-specific low back pain (PLBP) who benefited from a pain management programme, and those who did not benefit.

METHOD

We conducted interviews with 20 patients attending a pain management programme; prior to attending the programme, immediately following the programme and at one year. Our analysis focused on a theoretical sample of patients who either described dramatic life improvements at one year, and who described themselves as much worse. We used the methods of grounded theory.

RESULTS

We found that finding hope was central to good outcome. Patients restored hope by making certain changes; (a) deconstructing specific fears, (b) constructing an acceptable explanatory model (c) reconstructing self identity by making acceptable changes. Those who had not restored hope retained fears of loss of self, remained committed to the biomedical model and were unable to make acceptable changes.

CONCLUSIONS

Our findings may help to operationalise the restoration of hope in patients with PLBP. Firstly, health care professionals need to identify and resolve any specific fears of movement. Secondly, patients need an acceptable explanatory model that fits their experience and personal narrative. Finally our study confirms the centrality of self concept to recovery.

Finally heard, believed and accepted--peer support in the narratives of women with fibromyalgia

OBJECTIVE

The aim of the present study was to analyse how experiences of peer support were described and reflected upon several years after a group rehabilitation intervention. Moreover, we wanted to learn more about what meanings were ascribed to peer support in the narratives of women with a long history of fibromyalgia.

METHOD

This was a qualitative study in which narrative life story interviews of 20 women with fibromyalgia were collected and analysed to elicit the impact of peer support in their lives.

RESULTS

We identified four main domains of experienced peer support; permission to talk, need of information, reciprocity and self-evaluation through comparison. The meanings ascribed to peer support were mainly positive, although the participants also expressed thoughts about fear of future, hopelessness and mental health issues.

CONCLUSIONS

Long-term fibromyalgia patients saw peer support as an impetus to an ongoing process of reconstruction of identity, illness acceptance and coping with fibromyalgia.

PRACTICE IMPLICATIONS

In addition to up-dating their knowledge about fibromyalgia and its treatment, long term patients may need arenas where they can share and compare their experiences to those of other patients with a long history of fibromyalgia.

Patients' own accounts of sciatica: a qualitative study

STUDY DESIGN.: Longitudinal qualitative interview study, nested within a back pain cohort study. OBJECTIVE.: Enhance the understanding of patients' own perspectives on living with sciatica to inform improvements in care and treatment outcomes. SUMMARY OF BACKGROUND DATA.: Reports of patients' own accounts of sciatica and its impact on daily life are still scarce. Research on back pain has shown that it is important to understand how people live with pain and how they perceive interactions with health care professionals and interpret interventions. These types of insights help to improve treatments and their acceptability to patients. METHODS.: In-depth qualitative interviews with 37 people at baseline and 6 and 12 months' follow-up. The interviews covered topics that were derived from the Illness Perceptions Questionnaire and allowed open-ended talk about people's experiences of pain. All interviews were tape-recorded, fully transcribed, and thematically analyzed. RESULTS.: People needed to make sense of sciatica through identifying a cause and having it clinically diagnosed. The impact of sciatic pain was seen to be constant, intense, and all-encompassing. Appreciation of this by clinicians was considered important, as well as the provision of clear information about treatment and prognosis. Expectations about treatment options varied between patients, and people balanced pain relief with adverse effects. CONCLUSION.: Our study highlights patients' own accounts of the distinctiveness, impact, and intrusiveness of their sciatic symptoms. Our findings emphasize the importance of leg pain in identifying a subgroup of back-pain patients more likely to have severe symptoms, be at risk of poor outcome, and who should be considered a priority for early diagnosis and management. Future management of sciatica needs to include listening to patients' stories, offering a credible physical assessment, explanation, and diagnosis of the condition. Explaining the limits to treatment is seen as positively contributing to the partnership between patients and clinicians.

Embodying occupational overuse syndrome

This article explores the ways in which embodiedness has become problematic for New Zealand sufferers of occupational overuse syndrome (OOS). While successful rehabilitation could lead back to employment, this was based on the biographical continuity of a bodily hexus that ignored persistent pain. The reality of OOS involved a liminal fragility associated with social isolation, loss of identities, pain and functional disability that was incorporated into re-negotiated identities and biographies with the result that respondents became exquisitely self-absorbed, exercising constant bodily surveillance and discipline in order to manage their symptoms.

Staying active despite pain: pain beliefs and experiences with activity-related pain in patients with chronic musculoskeletal pain

OBJECTIVE

Maintain a level of activity and exercise is advice often given to patients with chronic musculoskeletal pain, but many patients find physical activity painful and consequently hesitate to move. Disability seems to be associated with fear of pain and there is a need to enhance our understanding of patients' beliefs and attitudes about how fear of pain affects physical activity and why some people are active despite their pain. The aim of this research was to understand thoughts and experiences about pain related to activity in patients with musculoskeletal disorders; the situations that promoted pain and if and how fear was expressed.

METHODS

Five women and five men, recruited from a larger survey on fear, pain and physical activity were interviewed. The interviews were analysed by qualitative methods for themes about participants' pain and beliefs about pain.

RESULTS

By interpreting signals from the body, patients calculated and planned their daily life to stay active despite pain and participate in their social lives. Pain was a signal with diverse meanings which, with the influence of time, seemed to change from a sign of danger to a reminder to moderate their level of activity. By experimenting with different activities, patients learned how to gradually remain or become physically active.

CONCLUSION

Patients strived to stay active despite pain. The interpretation of pain changed over time, from a threatening signal to a signal with diverse meanings.

PRACTICE IMPLICATIONS

The findings provide insights that may improve the educational rehabilitation of patients with musculoskeletal pain.

Older Adults’ Ways of Dealing With Daily Life While Living With Long-Term Musculoskeletal Pain at Home

Long-term musculoskeletal pain is a global health problem among older adults. Yet little is known about how these older adults actually deal with daily life. This study’s aim is to describe the ways these older adults dealt with daily life at home. Phenomenography is used to collect and analyze data from semistructured interviews with 19 older adults and to identify the range in which they dealt with daily life. Findings consist of an outcome space that encompassed four categories: ignore, struggle, adjust, and resign. The different ways older adults dealt with daily life when living with long-term pain at home strengthen the importance of individualized plans of care in the home and a holistic perspective. Findings contribute to enhanced understanding of a common health problem among older adults that can be used to promote quality of care and improve the quality of life of older adults.

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

BACKGROUND

Low back pain (LBP) is a major public health problem, often encountered in primary care. Guidelines recommend early identification of psychosocial factors that could prevent recovery from acute LBP.

METHODS

To review the evidence on the prognostic value of psychosocial factors on transition from acute to chronic non-specific LBP in the adult general population. Systematic review is the design of the study. A systematic search was undertaken for prospective studies dealing with psychosocial risk factors for poor outcome of LBP in primary care, screening PubMed, PsychInfo and Cochrane Library databases. The methodological quality of studies was assessed independently by two reviewers using standardized criteria before analysing their main results.

RESULTS

Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.

CONCLUSION

Few independent psychosocial risk factors have been demonstrated to exist. Randomized clinical trials aimed at modifying these factors have shown little impact on patient prognosis. Qualitative research might be valuable to explore further the field of LBP and to define new management strategies.

What concerns workers with low back pain? Findings of a qualitative study of patients referred for rehabilitation

INTRODUCTION

Health and workplace strategies to address work loss and sickness absence due to low back pain are urgently required. A better understanding of the experiences of those struggling to stay at work with back pain may help clinicians and employers with their treatment and management approaches.

METHODS

A qualitative approach using thematic analysis was used. Individual semi-structured interviews were conducted with a convenience sample of 25 low back pain patients who had been referred for multidisciplinary back pain rehabilitation. All were in employment and concerned about their ability to work due to low back pain. Initial codes were identified and refined through constant comparison of the transcribed interview scripts as data collection proceeded. Themes were finally identified and analysed by repeated study of the scripts and discussion with the research team.

FINDINGS

Five main themes were identified: justifying back pain at work; concern about future ability to retain work; coping with flare-ups; reluctance to use medication; concern about sickness records.

CONCLUSIONS

In this study, workers with low back pain remained uncertain of how best to manage their condition in the workplace despite previous healthcare interventions and they were also concerned about the impact back pain might have on their job security and future work capacity. They were concerned about how back pain was viewed by their employers and co-workers and felt the need to justify their condition with a medical diagnosis and evidence. Clinicians and employers may need to address these issues in order to enable people to continue to work more confidently with back pain.

Paired interviews of shared experiences around chronic low back pain: classic mismatch between patients and their doctors

BACKGROUND

current treatments for chronic low back pain (LBP) appear to be inadequate and there are growing calls for new approaches. This study explores the paired interviews of shared experiences among chronic LBP patients and their physicians with the ultimate goal of improving doctor-patient communication and clinical outcomes.

METHODS

in-depth interviews of a purposeful sample of paired chronic LBP patients and their doctors were conducted, transcribed and analysed using a multistep iterative process. Interview pairs were examined for important themes and major areas of convergence and divergence/mismatch.

RESULTS

patients' stories focused on their suffering from severe and disabling LBP while conveying a high level of reliance on their family physicians. Physicians described many challenges in treating this patient population. Patient and doctor stories were convergent regarding the severity/seriousness of illness, the lack of effective treatments and the existence of many barriers to care. Notable areas of mismatch: biomedical/biomechanical versus biopsychosocial (BPS) models of illness, treatment expectations/goals of reducing pain versus improving function and the importance of a definitive diagnosis.

DISCUSSION

patient and physician stories revealed shared themes and convergences, as well as significant discordance and mismatch. Family physicians, trained in and adherent to the BPS model, may have great difficulty when matched with biomechanically oriented patients. Re-conceptualizing doctors and LBP patients as a single teachable dyad may be useful. Clinical application of paired interviews of shared experiences may be useful in bridging communication and paradigmatic gaps, reducing mismatch and developing shared treatment plans.

Maintaining a balance: a focus group study on living and coping with chronic whiplash-associated disorder

Background

There is little qualitative insight into how persons with chronic Whiplash-Associated Disorder cope on a day to day basis. This study seeks to identify the symptoms persons with Whiplash-Associated Disorder describe as dominating and explore their self-initiated coping strategies.

Methods

Qualitative study using focus groups interviews. Fourteen Norwegian men and women with Whiplash-Associated Disorder (I or II) were recruited to participate in two focus groups. Data were analyzed according to a phenomenological approach, and discussed within the model of Cognitive Activation Theory of Stress (CATS).

Results

Participants reported neck and head pain, sensory hypersensitivity, and cognitive dysfunction following their whiplash injury. Based on the intensity of symptoms, participants divided everyday life into good and bad periods. In good periods the symptoms were perceived as manageable. In bad periods the symptoms intensified and took control of the individual. Participants expressed a constant notion of trying to balance their three main coping strategies; rest, exercise, and social withdrawal. In good periods participants experienced coping by expecting good results from the strategies they used. In bad periods they experienced no or negative relationships between their behavioral strategies and their complaints.

Conclusions

Neck and head pain, sensory hypersensitivity, and cognitive dysfunction were reported as participants' main complaints. A constant notion of balancing between their three main coping strategies; rest, exercise, and social withdrawal, was described.

"We need to get you focused": general practitioners' representations of chronic low back pain patients

Although subject to considerable research from perspectives including general practitioners, patients, and perspective guidelines, chronic low back pain (CLBP) continues to be a common but contentious condition in primary care. We used medical consultation records, critical incident interviews, and a think-aloud problem-solving task to examine how general practitioners applied professional knowledge of the condition, especially in relation to psychosocial care. Using qualitative content analysis and thematic analysis, we identified a pragmatic, goal-focused approach to patients, a schema based on biomedical knowledge and tacit theories of motivation. The doctors' expectations for CLBP included uncertainty over symptoms and doubts over patient credibility, which helped to explain an autonomous rather than collaborative approach to managing back pain patients. The findings are discussed in light of social representations theory, self-determination, and research on the therapeutic relationship.

Validation of an adaptation of the stress process model for predicting low back pain related long-term disability outcomes: a cohort study

STUDY DESIGN

Twelve-month cohort study.

OBJECTIVE

The aim of the study was to examine the ability of an adaptation of the stress process model to predict different outcomes among low back pain (LBP) sufferers.

SUMMARY OF BACKGROUND DATA

Recently, the stress process model was adapted and was shown to be useful to partially explain long-term disability related to low back pain, an important occupational health problem.

METHODS

French-speaking compensated workers on sick leave because of subacute common LBP (N=439) completed a questionnaire including the adapted stress process model's factors: life events and appraisal, cognitive appraisal of LBP, emotional distress, avoidance coping strategies, and functional disability. Six and 12 months later, participants gave information about their work status, number of days of absence, and functional disability. Regression analyses were performed to identify significant predictive factors of these outcomes. Pain intensity, fear of work, gender, and presence of pain radiating below the knee were used as control variables.

RESULTS

Number of days of absence, functional disability, and absence from work were predicted at 6 and 12 months by cognitive appraisal of LBP and emotional distress. Functional disability was predicted in addition by functional disability at study entry (T1). When the control variables were considered, number of days of absence was predicted at 6 months by cognitive appraisal, fear of work, and being a male, and, in addition, by emotional distress at 12 months. Functional disability was predicted by functional disability t1, emotional distress, cognitive appraisal of LBP, and fear of work at 6 months, and by the same factors and variables at 12 months, except for functional disability t1. Regarding absence from work, it was predicted at 6 months by fear of work and being a male, and at 12 months by cognitive appraisal of LBP and fear of work.

CONCLUSION

In association with fear of work, 2 factors from the adapted stress process model are significantly useful for predicting LBP related long-term disability outcomes and could be targeted by preventive interventions.

Listening to the body and talking to myself - the impact of chronic lower back pain: a qualitative study

AIMS

The aim was to investigate peoples' experiences of the impact of chronic low back pain.

BACKGROUND

Chronic low back pain is a complex disorder with wide-ranging adverse consequences that can impact on people's lifestyles and self-image. It is also a condition that can sometimes be treated with some scepticism by health care providers and other people in the person's life. It has been suggested that further research into the subjective experience of chronic blow back pain is needed to develop a better understanding of its impact.

DESIGN

This study is a qualitative analysis of semi-structured interviews with 64 participants identified as having chronic low back pain who were interviewed about the impact of the condition on their lives. The data were analysed using a method of inductive thematic analysis.

FINDINGS

Four main themes were identified: the unpredictability of the pain, the need for vigilance, the externalization/objectification of the body and the alteration to sense of self.

CONCLUSION

Nurses have an important role to play in working with patients experiencing chronic low back pain to identify any patterns associated with exacerbations of the condition, validating their experiences of chronic low back pain and facilitating the accommodation of chronic low back pain into a more satisfying sense of self.

Qualitative research on pain

PURPOSE OF REVIEW

This review brings together developments over the past year in pain research using qualitative methodologies. In line with the goals of the current biopsychosocial model of pain, such a research framework offers in-depth understanding of the experience of pain within its cultural, familial and socioeconomic environmental context.

RECENT FINDINGS

Using 'qualitative' and 'pain' as title and keyword Medline and CSA database searches, the pain literature revealed four main areas where qualitative studies have contributed significantly to knowledge development. These are: general chronic pain care: perspectives of patients and practitioners; pain experience across the lifespan; psychosocial aspects of back pain; and experience of underresearched conditions.

SUMMARY

The detailed insight into subjective experiences of the pain sufferer or healthcare provider offered by qualitative research can make important contributions to evaluating and improving practice and also in theory development.