Beliefs about back pain and pain management behaviours, and their associations in the general population: A systematic review

The Swedish version of the back pain attitudes questionnaire - Translation, cross-cultural adaptation and validation

BACKGROUND

Psychosocial factors influence low back pain (LBP) and guidelines recommend assessing unhelpful beliefs. The Back Pain Attitudes Questionnaire (Back-PAQ) is an instrument developed to assess LBP attitudes and beliefs. There is currently no Swedish translation of Back-PAQ.

OBJECTIVES

To translate and culturally adapt the Back-PAQ into Swedish (Back-PAQ-S) and to test its measurement properties.

DESIGN

Study of diagnostic accuracy/assessment scale.

METHODS

The cultural adaptation followed established guidelines and 120 individuals with and without nonspecific LBP (NSLBP) were recruited for the assessment of Back-PAQ-S's internal consistency, test-retest reliability, standard error of measurement (SEM) and smallest detectable change (SDC). Construct validity was assessed by testing hypotheses regarding Back-PAQ-S's relationship to the Back Beliefs Questionnaire (BBQ) and Tampa Scale of Kinesiophobia (TSK).

RESULTS

The Back-PAQ was translated and culturally adapted to Swedish. Expert panelists and informants thought items were relevant, comprehensive, and understandable. Back-PAQ-S of all lengths (34, 20 and 10-items) showed good internal consistency (Cronbach's α 0.95, 0.91 and 0.82) and excellent test-retest reliability (Intraclass correlation coefficient (ICC) 0.97, 0.96 and 0.95). The SEM was found to be 4.28, 3.13 and 1.66, and the SDC to be 11.85, 8.68 and 4.59 respectively. The Back-PAQ-S showed high positive correlations (Spearman's rho (rs) 0.78, 0.76 and 0.72) to the BBQ and moderate negative correlations (rs -0.67, -0.50 and -0.69) to the TSK.

CONCLUSION

The Back-PAQ-S has good validity and excellent reliability. It is viable for clinical and research use to assess LBP attitudes and beliefs in Swedish populations with and without NSLBP.

Association between perception of harm and valence of shoulder movement images with disability levels related to chronic shoulder pain

ABSTRACT

Recent studies highlight an interplay between pain perception and emotional responses. This necessitates a thorough investigation into how beliefs and motivational influences respond to visual stimuli of movements. Such an analysis is crucial for understanding the extent to which these factors contribute to disability levels associated with shoulder pain. We aimed to investigate the relationship between the perception of harm and the valence in images depicting shoulder movements and determine how these perceptions are linked to disability levels associated with shoulder pain. This cross-sectional study recruited 42 individuals with chronic shoulder pain. Participants were presented with 58 shoulder movements images. Each participant evaluated these images for emotional valence and arousal using the self-assessment manikin. For every image, they provided their level of avoidance, fear, and perception of harm in a numerical scale. We measured disability levels and pain catastrophizing using the Shoulder Pain and Disability Index and the Pain Catastrophizing Scale. A direct acyclic graph was used. Multiple linear regression analysis was conducted with shoulder disability as the dependent variable and perception of harm and valence as independent variables, adjusted for the confounders catastrophizing and arousal. This analysis resulted in a significant model (F4,37 = 11.44; adjusted R2 = 0.547; P < 0.01). The perception of harm to shoulder movement (β = 0.11; P < 0.001; 95% confidence interval = 5.6-11.8) was significantly associated with the level of shoulder disability, whereas valence did not show a significant association (β = 0.26; P = 0.15; 95% confidence interval = 1.7-10.8). The perception of harm associated with shoulder movements images during daily activities was associated with disability. Individuals who believe that shoulder movements are harmful have greater disability.

Biomedical Dogmas Still Influence the Delivery of Exercise Therapy in Chronic Low Back Pain Management: Mixed-Methods Study

Purpose

Non-specific, chronic low back pain (NSCLBP) is a leading cause of disability, prompting long-term rehabilitation. Positive patient beliefs and expectations towards lasting exercise engagement play a crucial role for a successful management of this condition. The aim was to investigate beliefs, unmet needs and expectations of NSCLBP patients for exercise-related health behaviour change in the context of rehabilitative care.

Patients and Methods

In a mono-centric mixed-methods study, we conducted semi-structured interviews with NSCLBP patients and care providers. We recruited in a rehabilitation clinic which is specialized in orthopaedics and internal medicine. Interviews were analysed deductively by combining health behaviour change theories with Donabedian's quality model of care. In a patient survey, disability (RMDQ), exercise behaviours, fear avoidance beliefs (FABQ), self-efficacy in chronic disease management (SES6G), process- and outcome-expectations (OEE-2) were queried and analysed descriptively.

Results

Twenty-two interviews were conducted and 40 questionnaires completed. Qualitative results revealed that NSCLBP patients had persistent biomedical perspectives on their health condition, marked by strong preferences for biomedical diagnostics and beliefs in the superiority of specific exercise regimes. Based on met expectations and positive movement experiences, patients' motivation was successfully fostered in the motivational phase of health behavior change. In the volitional phase, the postulated desire to receive self-management strategies was largely unmet. Psychosocial aspects of care were not widely accepted. The survey study sample showed a disability score (RMDQ) of M = 6.8 (±4.6). Mean scores of validated scales reflecting on attitudes, beliefs and expectations of chronic NSCLBP management were at FABQ-pa M = 15.4 (±6.0), FABQ-w M = 24.0 (±12.1), SES6G M = 6.4 (±2.3), and OEE-2 M = 2.7 (±0.5).

Conclusion

In this sample, patients' understanding of NSCLBP was still dominated by biomedical dogmas and perspectives. Inpatient rehabilitation predominantly addressed expectations towards the motivational phase of exercise-related health behaviour change.

Related factors to illness perception of individuals with diabetic foot ulcers: A structural equation modelling test

BACKGROUND

Diabetic foot is a common and severe complication of diabetes with limited movement, emotional distress, and poor quality of life. Illness perception was introduced to improve patients' psychological status and quality of life with diabetic foot ulcers. The aim of the study is to explore the related factors of illness perception, and to structure an illness perception model of patients with diabetic foot ulcers.

METHODS

We recruited 208 patients with diabetic foot ulcers from six hospitals from April 2021 to February 2022. A multicentered cross-sectional study was conducted to collect the data. Questionnaires included illness perception, coping behavior, emotional status, and quality of life. We performed multiple linear regression analysis with illness perception as the dependent variable, and evaluated the goodness of fit of the resulting structural equations models based on covariance structural analysis.

RESULTS

Illness perception was negatively related to coping behavior and quality of life, and it was positively correlated with yield-coping behavior, anxiety, and depression. The pain, diabetes duration, quality of life, yield-coping strategy, and sex were the factors that affected illness perception in patients with DFUs (P＜0.05). The resulting model was found to exhibit goodness of fit.

CONCLUSION

Illness perception had an especially strong and direct impact on quality of life, depression, and anxiety. Therefore, it is significant to improve illness perception in patients with DFUs, and provide positive support based on cognitive behavioral therapy to improve illness perception, quality of life, and emotional status.

Societal beliefs about pain may be more balanced than previously thought. Results of the Guernsey pain survey

BACKGROUND

Musculoskeletal pain is multidimensional and associated with significant societal impact. Persistent or chronic pain is a public health priority. A step towards high-value care is a contemporary understanding of pain. While pain-related knowledge has been examined in specific conditions (e.g. neck pain) knowledge of the public's broader understanding regarding musculoskeletal pain per se, warrants investigation. This study examined the public's knowledge and beliefs regarding musculoskeletal pain and pain management.

METHODS

This observational cohort study was conducted in Guernsey (January 2019-February 2020). Participants (n = 1656; 76.0% female) completed an online questionnaire capturing: demographics, pain experience, work absenteeism, understanding of pain and pain management, multidimensional influences, physical activity, pain catastrophising and healthcare decision-making. Statements were deemed true/false/equivocal and mapped to biopsychosocial/biomedical/neutral perspectives based upon contemporary literature. Descriptive statistics were analysed for each statement. Participants' responses were examined for alignment to a contemporary viewpoint and themes within responses derived using a semi-quantitative approach modelled on direct content analysis. Comparisons between participants with/without pain were examined (χ2-squared/Wilcoxon Rank Sum test).

RESULTS

Within the cohort 83.6% reported currently experiencing pain. The overarching theme was perspectives that reflected both biomedical and contemporary, multidimensional understandings of pain. Sub-themes included uncertainty about pain persistence and evidence-based means to reduce recurrence, and reliance upon healthcare professionals for guiding decision-making. Compared to those with pain, those without had a greater belief that psychological interventions may help and lower pain catastrophising.

CONCLUSIONS

Participants' understanding of pain demonstrated both biomedical and multidimensional pain understanding consistent with elements of a contemporary understanding of pain.

Use of social media as a source of health information among patients with chronic low back pain

OBJECTIVE

To evaluate the use of social media (SM) as a source of health information among patients with chronic low back pain (LBP) and to evaluate the factors associated with this use.

METHODS

This was a cross-sectional study involving patients with chronic LBP. Information on their sociodemographics, LBP characteristics, and comorbidities was collected. With the use of a questionnaire, we evaluated the use of SM as a source of information, examining the frequency of use, the type of SM used, and degree of confidence and application of information found. Catastrophising, trust in physicians, and concerns regarding medicines were assessed through the Pain Catastrophizing Scale (PCS), Trust in Physician Scale (TPS) and Beliefs about Medicines Questionnaire (BMQ Specific Concerns). A regression analysis was conducted to identify factors associated with the use of SM.

RESULTS

A total of 118 patients were included. The mean age was 53.01 ± 14.09 years. Of the sample, 68.6% sought information regarding their LBP on social networks. The main source was YouTube (30%). Eighteen point six percent of patients trusted the information found through SM, and 16.1% have already acted on some of this information. The majority of patients (82%) would prefer to have healthcare professionals in their virtual spaces to answer their questions. In a multivariate analysis, only the degree of trust in the physician was negatively associated with SM use (OR = 0.95 IC 95% [0.91-0.99]; p = 0.03).

CONCLUSION

This survey showed that a proportion of patients suffering from chronic LBP use SM, YouTube in particular, as a source of health information. The level of trust in physicians was the strongest factor that impelled people to use SM as a source of health information.

Exploring chronic pain related attentional experiences, distress and coping strategies among Arabic-speaking individuals in Jordan and the United Kingdom

Introduction

The lived experiences of chronic pain (CP) among Arabic-speaking populations remain underexplored. A better understanding of these experiences and their associations with attention difficulties, coping mechanisms, and treatment options could lead to improved support for this group.

Methods

This qualitative study utilised a descriptive design and involved one-to-one interviews with 51 participants with CP who had just completed two attention tasks. Interviews were conducted using a semi-structured topic guide, transcribed verbatim and translated from Arabic to English before agreeing on the coding framework. Themes and subthemes were extracted using a framework analysis approach.

Results

The study identified six main themes: Factors contributing towards developing or exacerbating CP, the impact of CP on psychosocial functions, including attention, the perceived role of social support, coping strategies for managing CP, perceptions about available treatments and recommendations for interventions.

Discussion

CP significantly impacts individuals' physical and psychosocial functions, and it is reciprocally associated with attentional difficulties. Despite using various approaches to manage their CP, none of the participants used psychological interventions or counselling. Understanding the diverse impacts of CP and the coping strategies employed to develop culturally sensitive interventions, review current related policies, and improve healthcare services is crucial to managing CP among this population.

Does Preoperative Pain Belief Affect Postoperative Pain and Breastfeeding?

PURPOSE

This research was carried out to determine the relationship between pain belief of women who experienced cesarean section for the first time and their postcesarean pain and breastfeeding self-efficacy levels.

DESIGN

The research is a descriptive study.

METHODS

The study was conducted with 144 patients who had not undergone any surgical operation and had their first cesarean section. Data were collected with an introductory information form, pain beliefs questionnaire (PBQ), visual analog scale (VAS), and breastfeeding self-efficacy scale (BSES).

FINDINGS

The patients' PBQ organic belief score (3.06 ± 0.61) was higher than their PBQ psychological belief score (1.87 ± 0.83), and their pain beliefs were based on an organic cause. The postcesarean section pain of the women was moderate-severe (6.75 ± 1.71), breastfeeding self-efficacy levels were high and sufficient (57.88 ± 4.86), and their pain beliefs were of organic origin. There was no significant relationship between patients' pain beliefs and postcesarean pain and breastfeeding self-efficacy levels.

CONCLUSIONS

The results of our study indicate that working status, income status, and chronic illness were associated with patients' pain beliefs, but we observed no relationship between pain beliefs and postcesarean pain and breastfeeding self-efficacy levels.

Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management

BACKGROUND

The biomedical understanding of chronic musculoskeletal pain endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. Although the biopsychosocial approach is an important advancement, it has a limited theoretical foundation. As such, it tends to be misinterpreted in manners that lead to artificial boundaries between the biological, psychological, and social, with fragmented and polarized clinical applications.

OBJECTIVE

We present an ecological-enactive approach to complement the biopsychosocial model. In this approach, the disabling aspect of chronic pain is characterized as an embodied, embedded, and enactive process of experiencing a closed-off field of affordances (i.e., shutting down of action possibilities). Pain is considered as a multi-dimensional, multicausal, and dynamic process, not locatable in any of the biopsychosocial component domains. Based on a person-centered reasoning approach and a dispositional view of causation, we present tools to reason about complex clinical problems in face of uncertainty and the absence of 'root causes' for pain. Interventions to open up the field of affordances include building ability and confidence, encouraging movement variability, carefully controlling contextual factors, and changing perceptions through action according to each patient's self-identified goals. A clinical case illustrates how reasoning based on an ecological-enactive approach leads to an expanded, multi-pronged, affordance-based intervention.

CONCLUSIONS

The ecological-enactive perspective can provide an overarching conceptual and practical framework for clinical practice, guiding and constraining clinicians to choose, combine, and integrate tools that are consistent with each other and with a true biopsychosocial approach.

How Do Physiotherapists Explain Influencing Factors to Chronic Low Back Pain? A Qualitative Study Using a Fictive Case of Chronic Non-Specific Low Back Pain

BACKGROUND

While pain is influenced by multiple factors including psychosocial factors, previous research has shown that physiotherapists still favour a biomedical approach.

PURPOSE

To evaluate: (1) how physiotherapists explain the patient's chronic non-specific low back pain (LBP); (2) whether physiotherapists use one or multiple influencing factors, and (3) whether these factors are framed in a biopsychosocial or biomedical approach.

MATERIALS AND METHODS

This exploratory qualitative study uses a vignette depicting chronic non-specific LBP and employs a flexible framework analysis. Physiotherapists were asked to mention contributing factors to the pain based on this vignette. Five themes were predefined ("Beliefs", "Previous experiences", "Emotions", "Patients behaviour", "Contextual factors") and explored.

RESULTS

Physiotherapists use very brief explanations when reporting contributing factors to chronic pain (median 13 words). Out of 670 physiotherapists, only 40% mentioned more than two different themes and 2/3rds did not see any link between the patients' misbeliefs and pain. Only a quarter of the participants mentioned the patient's worries about pain and movement, which is considered to be an important influencing factor.

CONCLUSION

The lack of a multifactorial approach and the persistent biomedical beliefs suggest that it remains a challenge for physiotherapists to fully integrate the biopsychosocial framework into their management of chronic LBP.

Back Pain: Pathophysiology, Diagnosis, and Treatment

Although back pain is one of the most common medical conditions [...]

Understanding how patients' pain beliefs influence chronic low back pain management in Ghana: a grounded theory approach

INTRODUCTION

Chronic low back pain (CLBP) is associated with negative consequences in high and low/middle-income countries. Pain beliefs are important psychosocial factors that affect the occurrence and progression of CLBP and may be influenced by the sociocultural context and interactions with healthcare professionals (HCPs). The pain beliefs of Ghanaian patients with CLBP are unknown and the factors influencing pain beliefs in African contexts are unclear.

OBJECTIVES

To explore the pain beliefs of Ghanaian patients with CLBP, how they influence CLBP management/coping and to identify the mechanisms influencing them.

DESIGN

Qualitative study using individual semistructured face-to-face interviews, situated within Straussian grounded theory principles and critical realist philosophy.

PARTICIPANTS

Thirty patients with CLBP accessing physiotherapy at two teaching hospitals in Ghana.

RESULTS

Participants suggested dominant biomedical/mechanical beliefs (related to CLBP causes, posture and activity, and the belief of an endpoint/cure for CLBP). Maladaptive beliefs and practices, in particular fear-avoidance beliefs, and dependence on passive management and coping, were common among participants. These beliefs and practices were mostly influenced by HCPs and sociocultural expectations/norms. Although spirituality, pacing activity and prescribed exercises were commonly mentioned by participants, other active strategies and positive beliefs were expressed by a few participants and influenced by patients' themselves. Limited physiotherapy involvement, knowledge and awareness were also reported by participants, and this appeared to be influenced by the limited physiotherapy visibility in Ghana.

CONCLUSION

Participants' narratives suggested the dominant influence of HCPs and the sociocultural environment on their biomedical/mechanical beliefs. These facilitated maladaptive beliefs and adoption of passive coping and management practices. Therefore, incorporation of more positive beliefs and holistic/active strategies by Ghanaian patients and HCPs may be beneficial. Furthermore, patient empowerment and health literacy opportunities to address unhelpful CLBP/sociocultural beliefs and equip patients with management options for CLBP could be beneficial.

Primary Investigation of Low Back Pain among Saudi Arabians: A Cross-Sectional Study

Low back pain (LBP) is a prevalent disease that affects all ages and is a symptom that induces immobility. Patients' beliefs may influence LBP management, and adjusting detrimental beliefs is required to improve treatment outcomes. Our aim was to evaluate the prevalence of LBP within the Saudi population and beliefs regarding LBP, physical activity, rest, imaging, and medication. People with LBP were targeted with a questionnaire containing sections on demographic information and the validated Back Beliefs Questionnaire (BBQ), in addition to questions regarding imaging, physical activity, rest and medication. A total of 651 responses were received, 559 of them (86%) experienced LBP. The most common age group was those aged 18-21 (n = 221), 80% from females. The average BBQ score was 27.8 (SD = 5.58). The majority of the respondents held the following beliefs, which are contrary to the best available evidence: back pain must be rested (77.1%) and X-rays or scans are required to gain the best medical care for LBP (73.2%). The Saudi population holds unhelpful beliefs that may affect their quality of life. Healthcare professionals working with patients with LBP have an important role in changing detrimental beliefs and behaviors about the condition.

What influences graduate medical students' beliefs of lower back pain? A mixed methods cross sectional study

BACKGROUND

Low back pain (LBP) is a common condition with substantial associated disability and costs, best understood using a biopsychosocial approach. Research demonstrates that beliefs about LBP are important, with biomedical beliefs influencing practitioner's management and patient recovery. Beliefs about LBP can be inconsistent amongst healthcare and medical students. The aim of this study was to investigate graduate medical student's beliefs of LBP and what influences them.

METHOD

A cross sectional mixed methods study of Phase 1 (first year) and Phase 3 (third and fourth year) current graduate medical students at the University of Warwick (MBChB) was conducted. Participants were recruited via voluntary response sampling. A survey investigated LBP beliefs, utilising the Back Beliefs Questionnaire (BBQ) and Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS). Qualitative data was collected on what influences beliefs about the causes and management of LBP, which was analysed descriptively using thematic analysis.

RESULTS

Fifty-seven students completed the questionnaire (61% female), with a mean age of 27.2 years. Eighty two percent of participants reported a history of LBP. Median BBQ scores were 31.5 for phase 1 and 31 for phase 3, with median HC-PAIRS scores of 57 and 60 for phase 1 and phase 3 students respectively. Three main themes emerged from the qualitative data: Sources of influence, influence of personal experience and influence of medical education. Participants discussed single or multiple sources influencing their beliefs about the causes and management of LBP. Another main theme was the influence of experiencing LBP personally or through discussions with family, friends and patients. The final main theme described the influence of medical education, including lectures, seminars and clinical placements.

CONCLUSIONS

The HC-PAIRS and BBQ scores suggest graduate medical students in this sample tended to have positive beliefs about the outcome of LBP and functional expectations of chronic LBP patients, consistent with other healthcare students. The findings from qualitative data suggest how medical students form beliefs about the causes and management of LBP is complex.

Reconfiguring the biomedical dominance of pain: time for alternative perspectives from health promotion?

Strategies to reduce the burden of persistent pain in society are rooted in a biomedical paradigm. These strategies are located downstream, managing persistent pain once it has become a problem. Upstream activities that create social conditions to promote health and well-being are likely to help, yet health promotion discourse and research are lacking in pain literature. In this article, we argue that the subjective nature of pain has not sat comfortably with the objective nature of medical practice. We argue that the dominance of the biomedical paradigm, with a simplistic 'bottom-up' model of pain being an inevitable consequence of tissue damage, has been detrimental to the health and well-being of people living with persistent pain. Evidence from neuroscience suggests that bodily pain emerges as a perceptual inference based on a wide variety of contextual inputs to the brain. We argue that this supports community, societal and environmental solutions to facilitate whole-person care. We call for more salutogenic orientations to understand how people living with persistent pain can continue to flourish and function with good health. We suggest a need for 'upstream' solutions using community-based approaches to address cultural, environmental, economic and social determinants of health, guided by principles of equity, civil society and social justice. As a starting point, we recommend appraising the ways human society appreciates the aetiology, actions and solutions towards alleviating persistent pain.

"I don't want to be a burden" A qualitative study of the beliefs of women with chronic low back pain in relation to their painful experience

BACKGROUND

Women's pain is still poorly understood. Moreover, maladaptive pain beliefs contribute to the disability associated with low back pain and play a key role in the transition from acute to chronic symptoms.

OBJECTIVES

To explore the beliefs of women with non-specific chronic low back pain in terms of nature of symptoms, fears associated with pain, expectations for recovery, family, social and work-related limitations, and perceived self-efficacy.

DESIGN AND METHODS

A qualitative study with an interpretative approach was undertaken. Face-to-face, semi-structured individual interviews were performed. Study participants were 10 women with non-specific chronic low back pain living in the Metropolitan Region of Chile. Thematic analysis was used to analyze the data. A deductive process was used to code the text and categorize the data.

RESULTS

Participants described maladaptive beliefs about pain, leading to fearful attitudes and low expectations for recovery. These beliefs seemed to perpetuate pain and limit engagement in daily tasks and meaningful activities. Some of these beliefs were associated with information provided by healthcare professions. Despite having maladaptive beliefs, women perceived themselves as self-effective.

CONCLUSION

Women with chronic low back pain described a range of different pain beliefs across a complex categorial structure. The contents of such structure may interfere with their decisions about therapeutic options. Their beliefs were often ungrounded in scientific principles, even if the information may have been provided by healthcare providers. Physical therapists would benefit from these findings to improve communication with their patients and assess the role of beliefs in decision-making.

Beliefs about back pain and associations with clinical outcomes: a primary care cohort study

OBJECTIVE

To investigate associations between beliefs about low back pain (LBP) at baseline and pain intensity and disability at 2-week, 13-week and 52-week follow-up.

DESIGN

Observational cohort study.

SETTING

Primary care private chiropractic clinics in Denmark.

PARTICIPANTS

A total of 2734 adults consulting a chiropractor for a new episode of LBP, with follow-up data available from 71%, 61% and 52% of the participants at 2, 13 and 52 weeks, respectively.

OUTCOME MEASURES

Beliefs about LBP were measured by the Back Belief Questionnaire (BBQ) before consulting the chiropractor. Pain (Numerical Rating Scale 0-10) and disability (the Roland-Morris Disability Questionnaire) were measured at baseline and after 2, 13 and 52 weeks. Associations were explored using longitudinal linear mixed models estimating interactions between BBQ and time, and by estimating associations between single items of BBQ and 13-week outcomes.

RESULTS

More positive beliefs about LBP were weakly associated with a reduction in pain at 2 weeks (β interaction BBQ#Time=-0.02 (95% CI -0.04 to -0.001)), at 13 weeks (-0.03 (95% CI -0.05 to -0.01)) and at 52 weeks of follow-up (-0.03 (95% CI -0.05 to -0.01); p=0.003). For disability, the association was uncertain (p=0.7). The item 'Back trouble means periods of pain for the rest of one's life' had the strongest association with both reduction in pain (-0.29, 95% CI -0.4 to -0.19, p<0.001) and disability (-2.42, 95% CI -3.52 to -1.33, p<0.001) at 13-week follow-up.

CONCLUSION

Positive beliefs regarding LBP, measured by the BBQ, were associated with a reduction in pain intensity at both short-term and long-term follow-up. However, the association was weak, and the clinical relevance is therefore questionable. No clear association was demonstrated between beliefs and disability. This study did not show promise that back beliefs as measured by the BBQ were helpful for predicting or explaining the course of LBP in this setting.

Cross-cultural adaptation, reliability and validity of the Marathi versions of the Back Beliefs Questionnaire and Pain Self-Efficacy Questionnaire in people living with chronic low back pain

PURPOSE

To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) and Pain Self-Efficacy Questionnaire (PSEQ) into Marathi, and to evaluate their clinimetric properties in a native Marathi speaking population with chronic low back pain.

MATERIAL AND METHODS

The BBQ and PSEQ were translated into Marathi using international published guidelines. Fifty native Marathi speakers were recruited. Reliability (n = 43) was evaluated in terms of internal consistency (Cronbach α) and test-retest reliability [intra class correlation coefficient, ICC (2, 1)] and 95% confidence interval (CI). Convergent validity (n = 50) was assessed by correlating the Marathi versions of BBQ and PSEQ with the Marathi version of Roland Morris Disability Questionnaire (RMDQ).

RESULTS

Internal consistency of BBQ (Cronbach α  =  0.67) was good and that for PSEQ (Cronbach α  =  0.93) was high. Test-retest reliability for BBQ (ICC =  0.80; 95% CI: 0.66 to 0.89) was good and PSEQ (ICC = 0.85; 95% CI: 0.74 to 0.92) was excellent. A significant, low negative correlation was found between RMDQ and BBQ scores (r = -0.298; p = 0.036) and PSEQ (r = -0.28; p = 0.049).

CONCLUSIONS

The BBQ and PSEQ were successfully cross-culturally adapted into Marathi. Clinimetric evaluation of these questionnaires in a sample of native Marathi speaking populations with chronic low back pain demonstrated good acceptability, acceptable internal consistency, and high test-retest reliability.Implications for rehabilitationThe Back Beliefs Questionnaire (BBQ) and Pain Self Efficacy Questionnaire (PSEQ) were successfully cross-culturally adapted into Marathi.The Marathi versions of BBQ and PSEQ have good acceptability, acceptable internal consistency, and high test-retest reliability.They can be used by clinicians and researchers to evaluate beliefs about back pain and pain self-efficacy in Marathi speaking patients with chronic low back pain.

Investigating Individuals’ Perceptions Regarding the Context Around the Low Back Pain Experience: Topic Modeling Analysis of Twitter Data

Background

Low back pain (LBP) remains the leading cause of disability worldwide. A better understanding of the beliefs regarding LBP and impact of LBP on the individual is important in order to improve outcomes. Although personal experiences of LBP have traditionally been explored through qualitative studies, social media allows access to data from a large, heterogonous, and geographically distributed population, which is not possible using traditional qualitative or quantitative methods. As data on social media sites are collected in an unsolicited manner, individuals are more likely to express their views and emotions freely and in an unconstrained manner as compared to traditional data collection methods. Thus, content analysis of social media provides a novel approach to understanding how problems such as LBP are perceived by those who experience it and its impact.

Objective

The objective of this study was to identify contextual variables of the LBP experience from a first-person perspective to provide insights into individuals’ beliefs and perceptions.

Methods

We analyzed 896,867 cleaned tweets about LBP between January 1, 2014, and December 31, 2018. We tested and compared latent Dirichlet allocation (LDA), Dirichlet multinomial mixture (DMM), GPU-DMM, biterm topic model, and nonnegative matrix factorization for identifying topics associated with tweets. A coherence score was determined to identify the best model. Two domain experts independently performed qualitative content analysis of the topics with the strongest coherence score and grouped them into contextual categories. The experts met and reconciled any differences and developed the final labels.

Results

LDA outperformed all other algorithms, resulting in the highest coherence score. The best model was LDA with 60 topics, with a coherence score of 0.562. The 60 topics were grouped into 19 contextual categories. “Emotion and beliefs” had the largest proportion of total tweets (157,563/896,867, 17.6%), followed by “physical activity” (124,251/896,867, 13.85%) and “daily life” (80,730/896,867, 9%), while “food and drink,” “weather,” and “not being understood” had the smallest proportions (11,551/896,867, 1.29%; 10,109/896,867, 1.13%; and 9180/896,867, 1.02%, respectively). Of the 11 topics within “emotion and beliefs,” 113,562/157,563 (72%) had negative sentiment.

Conclusions

The content analysis of tweets in the area of LBP identified common themes that are consistent with findings from conventional qualitative studies but provide a more granular view of individuals’ perspectives related to LBP. This understanding has the potential to assist with developing more effective and personalized models of care to improve outcomes in those with LBP.

Several low back pain-related misbeliefs are still around in 2020: A cross-sectional survey in Belgium

BACKGROUND AND PURPOSE

Low back pain (LBP)-related misbeliefs are known to be among risk factors for LBP chronification and for persistence of chronic pain. The main objective of this study was to investigate the current LBP-related beliefs in the general population in Belgium, considering the fact that the last survey in Belgium about the topic was conducted more than 15 years ago.

METHODS

A cross-sectional study design was used. Belgian adults (>17 years old) were recruited in the three regions of the country by means of non-probabilistic recruitment methods. Participants were invited to fill in a battery of questionnaires including demographic questions as well as questions about their LBP history and the LBP Beliefs Questionnaire (LBPBQ).

RESULTS

A total of 3724 individuals participated in the study. The LBPBQ scores indicated several LBP-related misbeliefs. About 15%-25% of participants still think that imaging tests can always identify the cause of pain and that bed rest is the mainstay of therapy. The majority of the participants think that "unnecessary" movements should be avoided when having LBP (58% of the respondents), and that they should "take it easy" until the pain goes away (69%). Most respondents also had maladaptive/wrong expectations, for example, a systematic worsening with time (65%) and a need for surgery in case of disc herniation (54%).

CONCLUSIONS

The present study suggests that in 2020 several LBP-related misbeliefs are still current in Belgium, particularly regarding the vulnerability of the spine. Therefore, further efforts to improve LBP-related beliefs/knowledge in the general population are necessary.

Illness perceptions and illness behaviours in back pain: A cross-sectional cluster analysis

BACKGROUND

Individuals' perceptions of back pain may shape what they do in response to manage their pain, for example, self-care, medication and seeking healthcare. Illness perceptions encompass a variety of beliefs such as how long pain is expected to last and whether treatments are perceived to control pain. Whether these beliefs meaningfully cluster and whether these clusters are associated with how people manage their back pain are currently unknown.

METHODS

1,343 individuals with back pain from a general population sample completed the brief Illness Perceptions Questionnaire and measures about their pain and illness behaviours. Using a two-stage cluster analysis, we identified four distinct clusters of individuals. Logistic regression was used to investigate relationships between cluster membership and illness behaviours.

RESULTS

After adjustment for socio-demographic characteristics, pain severity, interference and duration, relative to a low threat illness perception cluster, a high threat cluster was more likely to have contacted a general practitioner (OR: 3.03, 95% CI: 1.75, 5.23) and a moderate threat-high treatment control cluster was more likely to have consulted a physical therapist (OR: 2.21, 95% CI: 1.26, 3.87). Both the moderate threat-high treatment control cluster and high threat cluster were also less likely to have reported self-care (OR: 0.64, 95% CI: 0.43, 0.95; OR: 0.53, 95% CI: 0.34, 0.83, respectively).

CONCLUSIONS

The cluster analysis provided a meaningful classification of individuals based on their cognitive illness perceptions of their back pain, as these clusters were associated with different illness behaviours. Interventions which modify clusters of illness perceptions may be effective in influencing how individuals respond to back pain.

SIGNIFICANCE

Within a general population setting, we identified four clearly distinct groups of people based on the perceptions they held about their back pain. These groupings seemed to reflect meaningful characterisations as they differed based on the characteristics of their pain (e.g., severity and duration) and, after adjustment for these characteristics, were associated with different ways of managing pain. Interventions which focus on targeting the sets of illness perceptions that people hold may be effective in influencing how individuals manage back pain.

Attitudes and beliefs of older adults with acute low back pain: 12-month results from the Brazilian cohort back complaints in the elders

BACKGROUND

Psychosocial factors have been identified as important predictors of onset, course and persistence of low back pain (LBP) in the general population.

OBJECTIVE

To identify factors associated with attitudes/beliefs in older adults with LBP throughout a 12-month follow-up.

METHODS

A longitudinal investigation was conducted with 500 participants aged ≥60 years reporting a new (acute) episode of nonspecific LBP. Data were obtained at baseline, 6-week, 3-, 6-, 9-, and 12-month interviews. The study variables were: [dependent] LBP-related attitudes/beliefs that were assessed by the Back Beliefs Questionnaire (BBQ); [independent] age; sex; LBP intensity 'at-the-present-time' of interview and 'over-the-past-week' before interview; LBP frequency; LBP-related treatments; disability; mobility; depressive symptoms; self-perceived recovery; expectation of pain improvement; and expectation for returning to activities. Data were analysed by multiple linear regression analysis.

RESULTS

At baseline, 85.7% of the participants were female, had mean age of 69.0 (6.3) years, mean BBQ score of 24.5 (6.5), and 79.6% reported pain complaints after an acute episode of LBP. After 12 months, participants maintained a mean BBQ score of 24.6 (6.6) and 63.3% still reported pain complaints after an acute episode of LBP at baseline. Multivariate analysis showed that disability, advancing age, poor expectation of pain improvement in 3 months, and mobility decline were significantly associated with worse BBQ scores during all follow-ups.

CONCLUSION

Ageing, hopelessness, and physical and functional impairment impact pain-related behaviours among older patients seeking healthcare due to acute LBP complaints. Their screening may assist in strategies to manage symptoms and prevent the persistence of pain.

How Do People Communicate About Knee Osteoarthritis? A Discourse Analysis

OBJECTIVE

To explore the ways in which people talk about knee osteoarthritis and how this may influence engagement in physical activity and activity-based interventions as recommended by clinical practice guidelines.

DESIGN

A qualitative synthesis using discourse analysis methods.

METHODS

Systematic review methods were used to identify qualitative studies exploring the perceptions of people with knee osteoarthritis, their carers, and/or clinicians. Methodological quality was evaluated through the use of the Critical Appraisal Skills Programme. Raw quotes extracted from each study were analyzed with inductive discourse analysis.

RESULTS

A search of five electronic databases from inception until August 2019 yielded 778 articles. Sixty-two articles from 56 studies were included, reporting data (1,673 direct quotes) from people with knee osteoarthritis, carers, and clinicians in 16 countries. Two overarching discourses were identified-impairment and participation. The overarching impairment discourse prevailed in all participant groups and study settings. In this discourse, knee osteoarthritis was likened to a machine that inevitably wore down over time and required a doctor to repair. The overarching participatory discourse almost always coexisted alongside an impairment discourse. According to this discourse, a "busy body" was perceived as "healthy," and people could remain active despite knee osteoarthritis.

CONCLUSION

The prevailing impairment discourse may potentially discourage people from using knees that have passed their "use-by date" and increase reliance on doctors to repair joint damage. Consistent with recommendations in clinical practice guidelines, a participatory discourse may provide an alternative way of communicating that may encourage people with knee osteoarthritis to continue to engage in physical activity by focusing on what they can do, rather than what they cannot do.

What do the general public believe about the causes, prognosis and best management strategies for low back pain? A cross-sectional study

Background

Low back pain (LBP) is one of the most common reasons for seeking health care and is costly to the health care system. Recent evidence has shown that LBP care provided by many providers is divergent from guidelines and one reason may be patient’s beliefs and expectations about treatment. Thus, examining the nature of patient beliefs and expectations regarding low back pain treatment will help coordinate efforts to improve consistency and quality of care.

Methods

This study was a cross-sectional population-based survey of adults living in Newfoundland, Canada. The survey included demographic information (e.g. age, gender, back pain status and care seeking behaviors) and assessed outcomes related to beliefs about the inevitable consequences of back pain with the validated back beliefs questionnaire as well as six additional questions relating beliefs about imaging, physical activity and medication. Surveys were mailed to 3000 households in July–August 2018 and responses collected until September 30th, 2018.

Results

Fout hundred twenty-eight surveys were returned (mean age 55 years (SD 14.6), 66% female, 90% had experienced an episode of LBP). The mean Back Beliefs Questionnaire score was 27.3 (SD 7.2), suggesting that people perceive back pain to have inevitable negative consequences. Large proportions of respondents held the following beliefs that are contrary to best available evidence: (i) having back pain means you will always have weakness in your back (49.3%), (ii) it will get progressively worse (48.0%), (iii) resting is good (41.4%) and (iv) x-rays or scans are necessary to get the best medical care for LBP (54.2%).

Conclusions

A high proportion of the public believe LBP to have inevitable negative consequences and hold incorrect beliefs about diagnosis and management options, which is similar to findings from other countries. This presents challenges for clinicians and suggests that considering how to influence beliefs about LBP in the broader community could have value. Given the high prevalence of LBP and that many will consult a range of healthcare professionals, future efforts could consider using broad reaching public health campaigns that target patients, policy makers and all relevant health providers with specific content to change commonly held unhelpful beliefs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10664-5.

Unhelpful beliefs and attitudes about low back pain in the general population: A cross-sectional survey

BACKGROUND

Unhelpful beliefs about non-specific low back pain (LBP) are associated with poorer coping strategies and unhelpful behaviours. Furthermore, targeting unhelpful beliefs about back pain has been advanced as a major priority to decrease the burden of LBP. Therefore, studies exploring these beliefs are needed to adapt the message delivered to the population.

OBJECTIVES

To identify attitudes and beliefs about LBP in the general population in French-speaking Switzerland and to analyse their association with individual characteristics and the belief that exercise is an effective treatment for LBP.

DESIGN

Cross-sectional study.

METHOD

Attitudes and beliefs were measured with the Back-Pain Attitudes Questionnaire (Back-PAQ). Individual characteristics and participants' beliefs about the effectiveness of exercise for LBP were collected to determine their association with Back-PAQ score.

RESULTS

The questionnaire was completed by 1129 participants. Unhelpful beliefs were widespread (mean (SD) Back-PAQ score: 113.2 (10.6)), especially those that the back needs protection, is easy to injure and that the nature of LBP is special. Only 55% of the participants believed exercise to be one of the most effective treatment for LBP. Individual characteristics only explained 4% of the Back-PAQ score variance.

CONCLUSION

French-speaking Swiss general population has high levels of unhelpful beliefs and moderate confidence in the effectiveness of exercise for LBP, though the message "staying active is good for LBP" was well understood. The messages to decrease the level of unhelpful beliefs about LBP in the population should specifically target the vulnerability, protection and special nature of LBP, and promote exercise therapy.

Standard measurement error and minimal detectable change of the Back-PAQ ArgSpan questionnaire: Secondary analysis

BACKGROUND

Negative attitudes and beliefs about back pain in patients with low back pain (LBP) are associated with high levels of pain and negatively influence clinical outcome. The Back Pain Attitudes Questionnaire (Back-PAQ) was developed to assess back beliefs of patients and healthcare professionals. The minimal detectable change (MDC) is defined as the smallest amount of change that can be detected not due to inherent variation or "noise" in the measure. The MDC values at 68%, 90% and 95% confidence levels of the Back-PAQ ArgSpan are unknown.

OBJECTIVE

to calculate standard error measurement (SEM) and MDC to confirm the feasibility of Back-PAQ ArgSpan as a reliable outcome measure in clinical and research settings.

STUDY DESIGN

a secondary analysis was carried out using a subgroup of data from the cross-cultural adaptation and validation of the Argentine version of the Back PAQ.

METHOD

SEM was calculated (SD × √1 - ICC) and MDC as (SEM × z-value × √2). MDC was calculated as percentage as well.

RESULTS

the SEM was 5.16 points. The MDC₆₈, MDC₉₀ and MDC₉₅ of the Back-PAQ were 7.30, 12 and 14.3 points, respectively. The percentages of MDC₆₈, MDC₉₀ and MDC₉₅ of the Back-PAQ were 6.7%, 11.0% and 13.1%, respectively.

CONCLUSION

The present study demonstrated that the Back-PAQ ArgSpan is a reliable and interpretable measurement tool. When assessing a patient, a change in the score in the Back-PAQ ArgSpan over 15 points shows a true change at 95% confidence level.

Preoperative patient expectations and pain improvement after adult spinal deformity surgery

OBJECTIVE

Patients' expectations for pain relief are associated with patient-reported outcomes after treatment, although this has not been examined in patients with adult spinal deformity (ASD). The aim of this study was to identify associations between patients' preoperative expectations for pain relief after ASD surgery and patient-reported pain at the 2-year follow-up.

METHODS

The authors analyzed surgically treated ASD patients at a single institution who completed a survey question about expectations for back pain relief. Five ordinal answer choices to "I expect my back pain to improve" were used to categorize patients as having low or high expectations. Back pain was measured using the 10-point numeric rating scale (NRS) and Scoliosis Research Society-22r (SRS-22r) patient survey. Preoperative and postoperative pain were compared using analysis of covariance.

RESULTS

Of 140 ASD patients eligible for 2-year follow-up, 105 patients (77 women) had pre- and postoperative data on patient expectations, 85 of whom had high expectations. The mean patient age was 59 ± 12 years, and 46 patients (44%) had undergone previous spine surgery. The high-expectations and low-expectations groups had similar baseline demographic and clinical characteristics (p > 0.05), except for lower SRS-22r mental health scores in those with low expectations. After controlling for baseline characteristics and mental health, the mean postoperative NRS score was significantly better (lower) in the high-expectations group (3.5 ± 3.5) than in the low-expectations group (5.4 ± 3.7) (p = 0.049). The mean postoperative SRS-22r pain score was significantly better (higher) in the high-expectations group (3.3 ± 1.1) than in the low-expectations group (2.6 ± 0.94) (p = 0.019).

CONCLUSIONS

Despite similar baseline characteristics, patients with high preoperative expectations for back pain relief reported less pain 2 years after ASD surgery than patients with low preoperative expectations.

Beliefs and attitudes about low back pain in Argentina: A cross-sectional survey using social media

BACKGROUND

low back pain (LBP) is highly prevalent, very disabling and carries an enormous economic burden. The multifactorial nature of LBP often does not allow identification of a single pathoanatomic driver of pain. Unhelpful beliefs are associated with elevated levels of pain and may have a negative impact on the recovery of an episode of LBP. Beliefs about the back and back pain have not been evaluated in the Argentine general population.

OBJECTIVE

to assess the beliefs about the back and back pain of the Argentine population. The secondary objective was to compare the beliefs between respondents with and without LBP and between those who had and had not seen a health care professional (HCP).

STUDY DESIGN

cross-sectional study.

METHOD

we included Argentinians aged 18 years or more with or without LBP. The Argentine version of Back Pain Attitudes Questionnaire (Back-PAQ) was used to assess back beliefs.

RESULTS

one thousand and ninety-two participants responded the survey. Current LBP was reported by 42.3% (95% CI 39.3-45.2) of respondents and the life-time prevalence was 88.4% (95% CI 82.6-94.5). The mean Back-PAQ score was 111.7 (95% CI 111-112.5). Significant differences were found when comparing means scores of the current pain group with past and never LBP groups (p < 0.001). There were no difference in mean scores between respondents who were and were not exposed to a HCP.

CONCLUSION

Survey respondents sampled from the Argentine population had in general negative beliefs about back pain. Respondents with current pain had more unhelpful beliefs than pain free respondents in relation to the prognosis and recovery of an episode of LBP. Small differences were found in the beliefs of respondents who had received care for LBP from a HCP and those who did not seek care.

Patient education materials for non-specific low back pain and sciatica: a protocol for a systematic review and meta-analysis

INTRODUCTION

Low back pain accounts for more disability than any other musculoskeletal condition and is associated with severe economic burden. Patients commonly present with negative beliefs about low back pain and this can have detrimental effects on their health outcomes. Providing evidence-based, patient-centred education that meets patient needs could help address these negative beliefs and alleviate the substantial low back pain burden. The primary aim of this review is to investigate the effectiveness of patient education materials on immediate process, clinical and health system outcomes.

METHODS AND ANALYSIS

The search strategy was developed in collaboration with a librarian and systematic searches will be performed in MEDLINE, EMBASE, CINAHL, PsycINFO and SPORTDiscus. We will also search trial registries and grey literature through the OpenGrey database. Study selection will include a title and abstract scan and full-text review by two authors. Only randomised controlled trials will be included in this review. Trials must include patients with low back pain or sciatica and investigate educational interventions with at least one of the following contrasts: (1) education alone versus no intervention; (2) education alone versus another intervention; (3) education in addition to another intervention versus the same intervention with no education. Data extraction, risk of bias and grading of the quality of evidence will be performed independently by two reviewers. Risk of bias will be assessed using the PEDro scale, and the quality of evidence will be assessed with the Grades of Recommendation, Assessment, Development and Evaluation approach. A random-effects model will be used for each contrast, and results will be pooled if the participants, interventions, and outcomes are homogeneous. If heterogeneity is high (I2 >75%), we will evaluate the magnitude and direction of the differences in effect sizes across studies to determine if it remains reasonable to pool the results. Analyses of acute and subacute low back pain (less than 12 weeks duration) will be performed separately from chronic low back pain (12 weeks or greater duration). Likewise, analyses of short-term (less than 6 months) and long-term (6 months or greater) follow-up will be performed separately. Subgroup analyses will be performed on non-specific low back pain, sciatica and mixed populations.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. This study, along with its results, will be published in a peer-reviewed journal.

Do patients with low back pain remember physiotherapists' advice? A mixed-methods study on patient-therapist communication

OBJECTIVES

The primary aim of this study was to determine if the advice physiotherapists think they provide to patients with low back pain (LBP) is what the patients remember and take away from the clinical encounter. The secondary aim was to determine which factors may influence the retention of this advice.

METHODS

The first component of the study used questionnaires completed by patients and therapists after the initial visit. Related questionnaires of patients and therapists were screened for inconsistencies. The second component of the study involved semi-structured interviews.

RESULTS

Ninety pairs of questionnaires were completed. Therapists provided patients with one (N = 90), two (N = 85) or three (N = 51) items of advice regarding the management of their LBP. All patients remembered the first item of advice, 92% remembered a second, and 67% remembered the third piece of advice. All items of advice were deemed either 'relevant' or 'very relevant' by 97% of the patients. After the analysis of 14 interviews, data saturation was reached. Four themes emerged from the data analysis of the interviews: (a) Evaluation type, (b) Exercise factors, (c) Patient concerns about their diagnosis, and (d) Patient expectations.

DISCUSSION

In most cases, patients remembered what therapists told them and considered that the advice provided was relevant. Based on the qualitative data, patients were more likely to remember what therapists said when: (a) shared decision making was used during the initial encounter, (b) prescribed exercises were simple to perform and few in number, (c) patients' concerns about their diagnosis were addressed, and (d) patients' expectations were identified and addressed.

Exposure to greenspaces could reduce the high global burden of pain

Painful conditions are among the leading causes of years lived with disability, and may increase following the coronavirus pandemic, which has led to temporary closure of some healthcare services for people with chronic pain. To reduce this burden, novel, cost-effective and accessible interventions are required. We propose that greenspace exposure may be one such intervention. Drawing on evidence from neuroscience, physiology, microbiology, and psychology, we articulate how and why exposure to greenspaces could improve pain outcomes and reduce the high global burden of pain. Greenspace exposure potentially provides opportunities to benefit from known or proposed health-enhancing components of nature, such as environmental microbiomes, phytoncides, negative air ions, sunlight, and the sights and sounds of nature itself. We review the established and potential links between these specific exposures and pain outcomes. While further research is required to determine possible causal links between greenspace exposure and pain outcomes, we suggest that there is already sufficient evidence to help reduce the global burden of pain by improving access and exposure to quality greenspaces.

Beliefs about the body and pain: the critical role in musculoskeletal pain management

BACKGROUND

Beliefs about the body and pain play a powerful role in behavioural and emotional responses to musculoskeletal pain. What a person believes and how they respond to their musculoskeletal pain can influence how disabled they will be by pain. Importantly, beliefs are modifiable and are therefore considered an important target for the treatment of pain-related disability. Clinical guidelines recommend addressing unhelpful beliefs as the first line of treatment in all patients presenting with musculoskeletal pain. However, many clinicians hold unhelpful beliefs themselves; while others feel ill-equipped to explore and target the beliefs driving unhelpful responses to pain. As a result, clinicians may reinforce unhelpful beliefs, behaviours and resultant disability among the patients they treat.

METHODS

To assist clinicians, in Part 1 of this paper we discuss what beliefs are; how they are formed; the impact they can have on a person's behaviour, emotional responses and outcomes of musculoskeletal pain. In Part 2, we discuss how we can address beliefs in clinical practice. A clinical case is used to illustrate the critical role that beliefs can have on a person's journey from pain and disability to recovery.

CONCLUSIONS

We encourage clinicians to exercise self-reflection to explore their own beliefs and better understand their biases, which may influence their management of patients with musculoskeletal pain. We suggest actions that may benefit their practice, and we propose key principles to guide a process of behavioural change.

Which Psychological Factors Are Involved in the Onset and/or Persistence of Musculoskeletal Pain? An Umbrella Review of Systematic Reviews and Meta-Analyses of Prospective Cohort Studies

OBJECTIVE

The objective of this study was to summarize the current status of knowledge about the longitudinal association between vulnerability or protective psychological factors and the onset and/or persistence of musculoskeletal (MSK) pain.

METHODS

PubMed, CINAHL, PsycINFO, PubPsych, Scopus, Web of Science, gray literature, and manual screening of references were searched from inception to June 15, 2019. Systematic reviews with or without meta-analysis that explored the longitudinal association between psychological factors and the onset and/or persistence of MSK pain were identified. The AMSTAR-2 tool was used to assess the risk of bias.

RESULTS

Fifty-nine systematic reviews that included 286 original research studies were included, with a total of 249,657 participants (127,370 with MSK pain and 122,287 without MSK pain at baseline). Overall, our results found that exposure to many psychological vulnerability factors such as depression, anxiety, psychological distress, and fear, among others, may increase the risk of the onset and persistence of MSK pain across time. In addition, our results also showed that a range of psychological factors considered to be "protective" such as self-efficacy beliefs, better mental health, active coping strategies, or favorable expectations of recovery may reduce the risk of the onset and persistence of MSK pain. However, all these systematic reviews were evaluated to have critically low confidence based on the AMSTAR-2 tool, indicating that findings from these reviews may be informative, but should be interpreted with caution.

DISCUSSION

The large number of methodological flaws found across reviews gives rise to a call to action to develop high-quality systematic reviews in this field.

A systematic review of the effectiveness of mass media campaigns for the management of low back pain

Purpose: To synthesize evidence on the effectiveness of mass media campaigns for the management of LBP on beliefs of the general public and health care providers, LBP-related disability, health utilization, and LBP clinical outcomes.Materials and Methods: Five electronic databases were searched from inception to December 17, 2019. Any studies evaluating the effectiveness of mass media campaigns for LBP were eligible. Primary outcome was general public LBP beliefs, while secondary outcomes included health care provider beliefs as well as LBP-related disability, health utilization, and clinical outcomes.Results: The search resulted in 4,164 unique records, of which 18 studies were included. These 18 studies predominantly used quasi-experimental methods to evaluate seven LBP mass media campaigns conducted in seven countries. All studies evaluating LBP beliefs in the general public detected positive effects. Health care provider beliefs also consistently improved. Results for behavioural outcomes (disability behaviour and health utilization) were mixed and appeared dependent on campaign characteristics and local context.Conclusions: Mass media campaigns for LBP appear effective for improving beliefs of the general public and health care providers.Registration: Prospero CRD42018116797IMPLICATIONS FOR REHABILITATIONMass media campaigns about low back pain (LBP) appear effective for improving beliefs of the general public and health care providers, aligning beliefs with current evidence and self-management principles.Rehabilitation professionals should be aware of and seek to support public education initiatives in their communities related to LBP and other disabling health conditions.Rehabilitation professionals can highlight and reinforce campaign messages when providing education and reassurance to individual patients.Several campaign resources (i.e., posters, pamphlets, electronic resources, etc.) are available for rehabilitation professionals to use in their efforts to reduce disability related to LBP.

Treatment with and without stabilizing lumbar spinal orthosis after one- or two-level spondylodesis: A randomized controlled trial

BACKGROUND AND OBJECTIVE

Musculature affected during spondylodesis surgery may benefit and recover faster if supported by spine orthosis postoperatively.

METHODS

This prospective study included 50 consecutive patients undergoing one- or two-level spondylodesis. The intervention group received a lumbar spine orthosis (n= 23), while the control group remained without orthosis (n= 27). Patients were assessed for pain (Visual Analogue Scale, VAS), Oswestry Disability index (ODI) as well as the use of analgesics.

RESULTS

Patients wearing an orthosis postoperatively reported a higher degree of subjective stability. However, both intervention as well as control group did not show any significant differences for each of the follow-up points regarding VAS, ODI or the use of analgesics.

CONCLUSION

Wearing an orthosis has neither impact on subjective pain, the need for analgesics nor for postoperative functionality. However, patients reported that they profited from wearing the orthosis by feeling more stable, thereby nicely improving their postoperative mobility. Thus, novel patient reported outcome measures have to be developed to assess these features in future studies.

The association between believing staying active is beneficial and achieving a clinically relevant functional improvement after 52 weeks: a prospective cohort study of patients with chronic low back pain in secondary care

BACKGROUND

According to clinical guidelines, advice to stay active despite experiencing pain is recommended to patients with non-specific low back pain (LBP). However, not all patients receive guideline-concordant information and advice, and some patients still believe that activity avoidance will help them recover. The purpose was to study whether guideline-concordant beliefs among patients and other explanatory variables were associated with recovery. The main aim was to investigate whether believing staying active despite having pain is associated with a better functional outcome.

METHODS

This was a prospective cohort study involving adults with non-specific LBP referred from general practices to the Spine Centre at Silkeborg Regional Hospital, Denmark. Patients reported on their beliefs about the importance of finding the cause, the importance of diagnostic imaging, perceiving to have received advice to stay active, pain duration, pain intensity, and STarT Back Tool. Agreeing to: 'An increase in pain is an indication that I should stop what I'm doing until the pain decreases' adjusted for age, gender, and education level was the primary explanatory analysis. A 30% improvement in the Roland Morris Disability Questionnaire (RMDQ) score after 52 weeks was the outcome.

RESULTS

816 patients were included and 596 (73.0%) agreed that pain is a warning signal to stop being active. Among patients not considering pain as a warning signal, 80 (43.2%) had a favourable functional improvement of ≥30% on the RMDQ compared to 201 (41.2%) among patients considering pain a warning signal. No difference was found between the two groups (adjusted P = 0.542 and unadjusted P = 0.629). However, STarT Back Tool high-risk patients had a less favourable functional outcome (adjusted P = 0.003 and unadjusted P = 0.002). Chronic pain was associated with less favourable functional outcome (adjusted P < 0.001 and unadjusted P < 0.001), whereas beliefs about finding the cause, diagnostic imaging, perceiving to have received advice to stay active, or pain intensity were not significantly associated with outcome.

CONCLUSIONS

Holding the single belief that pain is a warning signal to stop being active was not associated with functional outcome. However, patients characterised by having multiple psychological barriers (high-risk according to the STarT Back Tool) had a less favourable functional outcome.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (registration number: NCT03058315), 20 February 2017.

Back beliefs in patients with low back pain: a primary care cohort study

Background

The Back Belief Questionnaire (BBQ) measures beliefs about negative consequences of back pain. The aim of this study was to describe the back beliefs of a large clinical population with low back pain (LBP), to investigate the associations between back beliefs and patient characteristics when care-seeking, and between on-going pain and back beliefs at follow up.

Methods

Patients aged over 18, consulting with LBP with or without radicular pain of all symptom durations, were recruited from chiropractic clinics. The BBQ was completed on the first visit and at 3- and 12-month follow-ups. Sociodemographic- and symptom-related questions were answered at baseline. A BBQ sum score was calculated at all three time points, and linear regression was used to analyse the cross-sectional association between baseline patient characteristics and BBQ scores. Wilcoxon signed-rank test was used to test differences in BBQ scores for patients with and without on-going LBP at 3- and 12-months follow up.

Results

The baseline population consisted of 2295 participants. The median BBQ sum scores at baseline, 3 and 12 months had interquartile ranges of 33 [29–36], 33 [29–37], and 31 [27–35] respectively. Patient characteristics and symptoms were associated with baseline BBQ scores (p < 0.05), but most association were weak. The strongest association was with severe disability (4.0 points (95% CI 3.3–4.6) lower BBQ than no disability). Negative beliefs were related to more severe LBP at baseline and with on-going pain at follow up.

Conclusion

At a population level, back beliefs were generally positive and relatively constant over time, but misconceptions about a poor prognosis were common. Studies exploring individual patterns of back beliefs and associations with clinical outcomes over time are recommended.

Neurophysiological changes and chronic pain in cleft patients

The aim of this study was to evaluate if patients after orofacial cleft repair experience neurophysiological changes with consecutive chronic pain states after surgery. Patients (n = 48) with a repaired orofacial cleft (CLP) recruited in a support group took part in a survey including five questionnaires. They revealed pain states, described cleft situation and history, and epidemiological data. Patients' quality of life and psychological comorbidity after the surgical procedures were assessed with the Oral Health Impact Profile (OHIP), the Giessen Subjective Complaints List (GSCL) and the Hospital Anxiety and Depression Scale (HADS). Furthermore, psychosocial impairment was documented. 39 out of 48 subjects with CLP reported to have experienced pain during the last 6 months. Pain was proven to be already chronic for 36 persons. Locations of pain were the orofacial region, back and limbs. Neurophysiological perception to cold, warmth, pressure and touch were found to be inhomogeneous. Local disturbances of subjective sensitivity in hard and soft tissues in the operated region are suspicious for neuropathic disorders and peripheral and central sensitization. 16 participants also reported that during dental interventions higher doses of local analgesia were necessary to achieve a pain free condition. Overall participants with CLP demonstrated elevated levels for anxiety and depression. As a conclusion for daily routine, CLP patients are considered to be at a higher risk to develop chronic pain states. To avoid these, proper pain and psychological management must be performed from early childhood. Further clinical studies examining patients with neurophysiological diagnostic tools are needed.