Living with low back pain-Stories of hope and despair

"Finding a new normal: the lived experience of persons' journey towards coping with persistent low back pain"

INTRODUCTION

Persistent low back pain (PLBP) is the biggest global cause of disability. Persons with PLBP experience biographic disruption and existential crisis. Guidelines recommend a biopsychosocial approach to management, with the emphasis on coping strategies.

PURPOSE

However, there is a paucity of research exploring the lived experience of persons who self-identify as coping with PLBP.

METHOD

The study used an interpretive phenomenological approach, analyzing transcripts from 1:1 interviews with six persons who self-identify as coping with PLBP. Poetic language was used to elicit empathic, embodied relational understanding and convey a richer understanding of the phenomenon that authentic quotations might not able to reveal.

FINDINGS AND CONCLUSION

Participants' descriptions conveyed the sense of a journey, starting with the loss of a sense of self as they engaged in the pain battle, followed by a transition toward a new 'normal,' in which time, acceptance and trust in their own intuition were meaningful components. Although anxiety and fear were a continued presence, but they became more manageable. Society's role in the coping process was significantly meaningful and is something which requires reflections from therapists' and more widely.

Preference for Hedonic Goals in Fibromyalgia; Is It Always an Avoidance Mechanism? Looking the Relationship with Pain Acceptance from a Positive Psychology Perspective

The aim of this study was to analyze the effect of openness to experience on pain acceptance through positive affect (PA) considering the moderating role of preference for mood management goals in women with fibromyalgia (FM). A cross-sectional study (n = 231) was carried out. A simple mediation model and a moderate mediation model were conducted by SPSS macro-PROCESS. Results showed that PA mediated positively the effect of openness to experience on acceptance (B = 0.46, SE = 0.80, t = 5,59; 95% CI = [0.3016, 0.6298], p < .001) and that the contribution of openness to experience to PA varied at different values of mood management goals (medium: - .04; ß = .40, p < .001; high: .95; ß = .61, p<.001). Findings may serve as a foundation for tailored interventions to promote activity through acceptance focusing on PA and mood management goals among women with medium to high level of hedonic goals.

Power of narrative: a case study about documenting private insightful experiences while dealing with pain and associated disability

Objective

People adjusting to living with a chronic disability, such as chronic pain, seek support and resources from societal systems, including health systems, to help them cope with this reality. This case study describes the use of a digital health platform designed to help in that quest.

Method

MyHealthMyRecord (MHMR), is being developed to record, register and curate personal private experiences of a chronic condition. MHMR allows users to record and log short (30-90s) personal and private audio-videos of their accommodation-seeking journey in a way that can be encrypted, registered, curated and shared privately. This case study describes the use of a prototype version of the platform by a participant co-designer who experienced a sudden onset of a chronic pain condition, of undetermined origin. System use began three months after the onset of the condition and just after being discharged from several months of hospitalization without any definitive diagnosis.

Result

During a three-month period, 65 short unstructured contributions were authored and logged. This paper presents a qualitative analysis of that content. The clips used various communication styles that documented experiences, concerns, issues, positive and negative interactions and pain episodes. Using thematic analysis with open coding, three domains (person-facing, accessibility and system-facing) and eight themes (pain, joy, therapy, environmental, recommendations, technical, culture and communication) were identified. Comments about pain, stress, etc., were the most common and occurred in 75% of all videos while technical and therapy/physio related comments were the fewest and occurred in 3 and 9% of the videos, respectively.

Conclusion

We conclude that it is possible to create recordings of events, thoughts, reflections and issues on different aspects affecting an individual's health and well-being impact, including effects of the chronic condition as well as tangential outcomes such as accessibility (or lack of it), using MHMR over a longer period of time. The next steps will be to develop functionality to annotate the recordings, automatically analyze and summarize collections of recordings to make them consumable, useful and understandable to the individual and others, and then to share those analyses and summaries with others. In addition, evaluate this functionality longitudinally with more users.

"I felt uncertain about my whole future"-a qualitative investigation of people's experiences of navigating uncertainty when seeking care for their low back pain

ABSTRACT

Uncertainty pervades low back pain (LBP). This study aimed to explore individuals' experiences of navigating uncertainty when seeking care for their LBP, with a view to better understanding the contexts in which they experience uncertainty and gaining insight into how uncertainty may be better navigated during clinical encounters. We conducted 15 semistructured interviews with people who have experienced LBP. Interviews were audio-recorded, transcribed, and analysed using reflexive thematic analysis. Analysis produced 4 themes. To reflect the unsettled nature of participants' discussions of navigating uncertainty, themes are framed as questions: (1) What will happen over time?; (2) Can clinicians help me? Are they willing to?; (3) What are clinicians talking about?; and (4) Am I being taken seriously? Participants also discussed how clinicians could better navigate these uncertainties. Suggestions included making time to (actively) listen to, and acknowledge, patients' concerns; asking open-ended questions; being honest about uncertainty; creating management plans and returning to them; challenging assumptions; remaining curious about patients' context; and providing guidance on how to manage LBP rather than simply giving certainty that symptoms will worsen, lessen, or continue. These findings indicate that many of the uncertainties individuals with LBP experience are intertwined with relational aspects of their interactions with clinicians. Clinicians therefore may need to consider these broader and relational aspects of care when navigating uncertainty with people who experience LBP, bringing attention to the importance of drawing from knowledge produced outside of the usual hierarchy of evidence (eg, systematic reviews and randomised controlled trials).

The impact of aggregate positive lifestyle behaviors on low back pain resilience and care seeking

BACKGROUND CONTEXT

Low back pain (LBP) is a global issue, and the high associated costs are mainly attributed to a small proportion of people with LBP who seek care. Importantly, the impact of aggregate positive lifestyle behaviors on LBP resilience and care seeking is not known.

PURPOSE

This study aimed to evaluate the relationship between positive lifestyle behaviors and LBP resilience.

STUDY DESIGN

This study was a prospective longitudinal cohort study.

PATIENT SAMPLE

Data was collected as part of the AUstralian Twin BACK Study (AUTBACK). Participants who reported a lifetime previous history of LBP at baseline were included in this analysis (n = 340).

OUTCOME MEASURES

The outcomes of interest were the number of weeks without activity limiting LBP and total number of days of healthcare usage, health practitioner care, self-management care, and medication intake.

METHODS

A lifestyle behavior score was built using variables of body mass index (BMI), physical activity, smoking status, and sleep quality. Negative binomial regression analyses were used to assess the relationship between the positive lifestyle behavior score and the count outcomes of number of weeks without activity limiting LBP and number of days participants used care.

RESULTS

After adjusting for covariates, no association was found between participants' positive lifestyle behavior score and their number of weeks without activity limiting LBP (IRR: 1.02, 95% CI 1.00-1.05). There was a statistically significant relationship between higher positive lifestyle behavior scores and fewer number of days of participants' total healthcare usage (IRR:0.69, 95% CI 0.56-0.84), healthcare practitioner visits (IRR:0.62, 95% CI 0.45-0.84), use of self-management strategies (IRR:0.74, 95% CI 0.60-0.91), and use of pain medication (IRR:0.55, 95% CI 0.44-0.68).

CONCLUSION

People who adopt optimal lifestyle behaviors, such as engaging in adequate physical activity, achieving optimal quality sleep, maintaining an ideal BMI, and not smoking, may not experience less time suffering from activity limiting LBP, but are less likely to use healthcare and pain medication for their LBP.

Doctors Speak: A Qualitative Study of Physicians' Prescribing of Antidepressants in Functional Bowel Disorders

Tricyclic antidepressants (TCAs) are frequently prescribed for chronic functional pain disorders. Although the mechanism of action targets pain perception, treating patients with TCAs for disorders conceptualized as "functional" can promote stigmatization in these patients because it hints at psychological dimensions of the disorder. The goal of this study was to understand how physicians prescribe TCAs in the face of this challenge. We interviewed eleven gastroenterologists in tertiary care clinics specializing in functional gastrointestinal disorders, such as irritable bowel syndrome. We found that the physicians interviewed (1) were aware of the stigma attached to taking antidepressants for a medical condition, (2) emphasized biological, as opposed to psychological, mechanisms of action, (3) while focusing on biological mechanisms, they nevertheless prescribed TCAs in a way that is highly attentive to the psychology of expectations, making specific efforts to adjust patients' expectations to be realistic and to reframe information that would be discouraging and (4) asked patients to persist in taking TCAs despite common and, at times, uncomfortable side effects. In this context of shared decision making, physicians described nuanced understanding and behaviours necessary for treating the complexity of functional disorders and emphasized the importance of a strong patient-provider relationship.

A Qualitative Investigation of the Psychosocial Impact of Chronic Low Back Pain in Ghana

INTRODUCTION

Chronic low back pain (CLBP) is a global health concern associated with multidimensional/biopsychosocial levels of affectation in developed countries, with holistic management requiring consideration of these factors. There has been minimal research exploring the psychosocial impact of CLBP, and the factors influencing it, in African contexts, with none in Ghana.

OBJECTIVES

To explore the psychosocial impact of CLBP among patients with CLBP in Ghana.

DESIGN

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

PARTICIPANTS

Thirty patients with CLBP attending physiotherapy at two hospitals in Ghana.

RESULTS

Five categories: loss of self and roles, emotional distress, fear, stigmatisation and marginalisation, financial burden, and social support and three mechanisms: acquired biomedical/mechanical beliefs from healthcare professionals (HCPs), sociocultural beliefs and the socioeconomic impact of CLBP were derived.

CONCLUSION

CLBP adversely affects multidimensional/biopsychosocial aspects of individuals experiencing CLBP in Ghana. This delineates the need for a biopsychosocial approach to care. There is the need for HCPs in Ghana to reassess current CLBP management strategies to address the influence of adverse HCPs biomedical inclinations on patients' psychosocial consequences. Population-based education strategies and consideration of formal support systems for persons with disabling CLBP may also be beneficial.

An Interpretative Phenomenological Analysis of Living with Chronic Low Back Pain in Ethiopia

Background

People with chronic low back pain experience myriads of problems from living with their condition. This study aimed to explore the lived experience of people with chronic low back pain in Ethiopia.

Design

This is a qualitative semi-structured study design which used an interpretative phenomenological analysis approach for data analysis.

Participants

Fifteen adults (10 women and 5 men) with chronic low back pain (duration ≥ 3 months) with age ranging from 19 to 66 years old were interviewed.

Setting

Participants were recruited from the outpatient departments of the University of Gondar hospital in Gondar, Ethiopia.

Methods

Data was collected through an in-depth semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Data were analyzed through an iterative process, beginning with a line-by-line coding to identify the lived experience of chronic low back pain.

Findings

Five main themes related to the lived experience of people with chronic low back pain emerged: 1) CLBP impacts life on a day-to-day basis, 2) The invisibility of pain results in misunderstanding, misjudgment, and loneliness, 3) The cause of pain is a mystery, 4) The search for the cure is a quest, 5) Each person has their ways of managing, coping, and living with pain.

Conclusion

The findings from this study improve our understanding of the experience of people with chronic low back pain and its impact on their day-to-day life in Ethiopia. The findings from this study could inform the development of culturally centered chronic low back pain interventions such as self-management programs in the Ethiopian context.

"Let's see what happens:"-Women's experiences of open-label placebo treatment for menopausal hot flushes in a randomized controlled trial

Open-label (honestly prescribed) placebos are an ethical way to evoke placebo effects in patients. As part of a mixed-methods study, we conducted in-depth interviews with eight menopausal women who underwent and benefitted from open-label placebo treatment in a randomized-controlled trial of hot flushes. Data were analyzed using Interpretative Phenomenological Analysis. We found that the women had low expectations about the placebo treatment yet endorsed what they referred to as “hope” and openness to “see what happens”. Recording hot flushes via the symptom diary was viewed as a valuable opportunity for self-examination and appraising outcomes. Receiving relief from the placebo treatment empowered women and enhanced their sense of control and agency. In summary, participants’ initial openness towards placebos, their hopes to get better, monitoring symptoms closely, and taking the initiative to address symptoms were components of a positive open-label placebo experience.

Pelvic organ prolapse: The lived experience

BACKGROUND

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life. This study explores the lived experience of women with POP.

METHODOLOGY

A qualitative study was undertaken. Following institutional ethical approval women from an online peer support group (n = 930 members) were recruited to participate in semi-structured interviews. Inclusion criteria stipulated women (> 18years), pre-menopausal, at least one-year post-partum, diagnosed with POP and aware of their diagnosis. Semi-structured interviews were undertaken with a clinician specialising in pelvic health. A battery of questions was designed to elicit discussion on their experience of being diagnosed with POP and its impact on daily life and relationships. Interviews were carried out via Zoom, recorded and transcribed. Thematic analysis was undertaken.

FINDINGS

Fourteen women (32-41 years), para 1-3 participated. All had at least one vaginal birth; three had vacuum, four had forceps operative births. All had Grade 1-3 POP. Interviews lasted 40-100 minutes. Three core themes with subthemes were identified; biological/physical, psychological and social. Women were particularly affected in terms of sport and exercise participation, their own perceptions of their ability as mothers and fear of their condition worsening. They described societal attitudes, reporting stigma around POP and women's pelvic health in general, expectations placed on women to put up with their symptoms and an idealised perception of new motherhood.

CONCLUSIONS

The impact of POP from a biopsychosocial perspective reflects other chronic conditions. Prevention, early education and supports for developing strong self-management approaches would be beneficial for long term management of this condition.

What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education

ABSTRACT

Pain education is a popular treatment approach for persistent pain that involves learning a variety of concepts about pain (ie, target concepts), which is thought to be an important part of recovery. Yet, little is known about what patients value learning about pain. A mixed-methods survey was conducted to identify pain concepts that were valued by people with persistent pain who improved after a pain science education intervention. An online survey was distributed to 123 people who were treated for persistent pain with a pain science education approach; responses of participants who self-identified as "improved" were analysed. Open-ended survey questions were analysed using reflexive thematic analysis and close-ended questions were analysed for frequency of responses. Each question-type was analysed separately, before integration for complementarity. We analysed the data of 97 participants. We constructed 3 themes from the open-ended questions. Pain does not mean my body is damaged (theme 1) captured the importance of abandoning preexisting ideas that pain indicated damage. Thoughts, emotions and experiences affect pain (theme 2) captured the value of recognising multifactorial influences on pain. I can retrain my overprotective pain system (theme 3) captured the importance of conceptualising pain as a heightened protective response that could be lessened. Responses from close-ended questions confirmed that the target concepts represented by these themes are among those most valued, although divergence with the qualitative data suggests differences between patient and clinician language. These data offer patient-centred conceptualizations and language that could assist in further refining pain education interventions.

A process evaluation of the Mind Your Back trial examining psychologically informed physical treatments for chronic low back pain

Background

In chronic conditions, such as back pain, the use of interventions that address physical, social and psychological aspects within a biopsychosocial framework are encouraged, however, applying this holistic multimodal approach in physical therapy practice (i.e., chiropractic and physiotherapy) is challenging. To explore the problem of delivering a biopsychosocially informed package of care in physical therapy practice a recent randomised control trial (RCT) called ‘Mind Your Back’ was conducted to evaluate the effectiveness of a combined physical and internet-delivered psychological intervention (psychologically informed physical treatments) compared to standard treatment for improving disability and self-efficacy in people with chronic LBP. The results of the trial indicated no difference between the two intervention groups. Although high-quality RCTs are considered gold standard for effectiveness of interventions, qualitative research methods embedded within a process evaluation framework are also used to reveal other issues and important information that help to explain clinical trial results, and to further the field of digital health interventions research. Therefore, within a process evaluation framework, the aim is to explore participants experiences of the interventions received throughout the Mind Your Back trial which led to a null result.

Methods

In-line with recommendations for a process evaluation this study used in-depth interviews and qualitative thematic analysis with participants of both arms of the trial 5–6 months after study completion. Semi-structured telephone interviews were conducted with twenty-five participants to explore their experiences of taking part in the Mind Your Back trial. Interviews were conducted in November 2017, transcribed verbatim and data analysed thematically.

Results

Two main themes were identified: (1) Personalised support and therapeutic alliance are important, and (2) MoodGYM lacked relevant, personalised and tailored support.

Conclusion

It is important to deliver tailored digital health supports that is personalised and fosters a therapeutic alliance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00389-y.

The Eight Limbs of Yoga can be Maintained in a Veteran Friendly Yoga Program

Background

Posttraumatic stress disorder (PTSD) may occur after a traumatic event and has deleterious effects on individuals, including decreased quality of life and function. Yoga is an intervention that may help with the management of PTSD symptoms, however yoga interventions in research studies frequently only include postures and breathwork, not all eight limbs of yoga.

Aims and Objectives

The aims of this qualitative study was to examine whether participants with PTSD in a group yoga program discussed the benefits of yoga in a way that represented the eight limbs of yoga, when answering questions about their experience of the yoga program.

Methods

Qualitative data were collected after participants completed a 16-week yoga intervention. Qualitative data were collected via survey, reviewed, coded, and categorized into themes representing each of the eight limbs of yoga.

Results

Overall, 108 people were randomized to the yoga intervention and 67 individuals completed the intervention and follow up questions used in these analyses. The mean age of the 67 participants in this study was 52.4 years (±12.0), the majority were male (70.2%), and most had combat-related trauma (62.7%). All eight limbs of yoga were represented in the data, including each of the five yamas and niyamas, even though the yoga intervention did not explicitly include Sanskrit terms, definitions, or education about yoga philosophy or the eight limbs of yoga.

Conclusion

Results may indicate that yoga, even when only including postures, breathwork, intentions, and relaxation/meditation, may still address all of the yamas, niyamas, and the other eight limbs of yoga.

Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation

BACKGROUND

The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms.

OBJECTIVES

An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis.

DATA SOURCES

Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019.

PARTICIPANTS

Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes.

INTERVENTIONS

Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes.

RESULTS

Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000.

LIMITATIONS

Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points.

CONCLUSIONS

Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study).

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015025520.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.

Psychosocial consequences of diagnosing nonspecific low-back pain radiologically: a qualitative study

BACKGROUND

Chronic low back pain (CLBP) is a complex biopsychosocial problem with financial implications for society. Most LBP is categorized as nonspecific CLBP (NS-CLBP); magnetic resonance imaging (MRI) is increasingly used in the investigation of LBP but has a high false-positive rate for NS-CLBP.

PURPOSE

To explore the psychosocial factors associated with diagnosing NS-CLBP by MRI in Saudi Arabia.

METHODS

Using a qualitative design, 11 patients with CLBP without a clear medical diagnosis who had received an MRI scan were interviewed using a semi-structured technique, and transcripts were analyzed using framework analysis.

RESULTS

Four themes of relevance to the psychosocial consequences of using MRI to diagnose CLBP were identified: 1) impact on social participation after MRI diagnosis; 2) psychological impact of MRI diagnosis; 3) conflicting advice; and 4) patient education. Although some patients expressed a sense of relief following the identification of an objective explanation of their symptoms by MRI, a number of negative consequences were also identified. In particular, fear-avoidance behavior and anxiety were apparent.

CONCLUSION

The use of MRI scanning in the diagnosis of LBP may lead to psychosocial factors influencing participation in physical and social daily activities.

Living With Parkinson's: The Process of Finding Optimism

Individuals with Parkinson's disease (PD) often experience poor mental and emotional well-being, which negatively affect their quality of life. Optimism is a protective factor which has been shown to promote resiliency, reduce distress in health crises, and protect against the effects of negative mental health outcomes. The current article utilized grounded theory methodology to examine personal accounts (N = 85) detailing how individuals were able to cultivate optimism despite challenges presented by PD. The grounded theory indicated that a process occurs in which individuals with PD move through the following five phases on their journey toward optimism: (a) diagnosis, (b) initial reactions, (c) adjustment, (d) acceptance, and (e) living with optimism. These findings indicate that individuals with PD often struggle to experience optimism. Nevertheless, by reframing optimism as a choice rather than a feeling, participants were able to make decisions that allowed them to progress on their journey toward optimism.

Everyday life with chronic back pain: a qualitative study among Turkish immigrants in Denmark

BACKGROUND

Chronic back pain has a major physical and psycho-social impact. There have been few subjective assessments of everyday life in relation to migration and ethnicity. Through a descriptive and qualitative cross-cultural design, the aim was to develop an in-depth understanding of how Turkish immigrants experience living with back pain.

METHODS

We conducted a qualitative study based on interviews with Turkish immigrants suffering from CBP recruited from a rheumatology outpatient clinic. The analysis was based on Giorgi's phenomenological analysis.

RESULTS

Eleven Turkish participants with chronic back pain (mean age 47.6) were recruited. Three essences resulted from the analysis: "Overwhelming and prevailing pain" - reflecting pain taking control of everyday life, "Being distressed in community life" - encompassing how pain causes changes in social roles, and "Looking for a way out of pain" - referring to feeling lost when being treated in the healthcare system, finding pain-management strategies and returning to Turkey for assistance.

CONCLUSION

Chronic back pain has a significant influence on daily life. Pain changes the feeling of identity relating to close relationships and in the Labor market. Most participants' proficiency in Danish language skills posed a challenge for the existing treatment paradigm, in which information is crucial for successful rehabilitation.IMPLICATIONS FOR REHABILITATIONTo improve access to both info on chronic back pain and its treatment, it is crucial that rehabilitation be offered in a range of languages.Proficiency in Danish varies greatly among immigrants, despite years of stay in Denmark. Engaging a professional interpreter early on in the rehabilitation program might improve patient compliance to the preferred treatment regimen.Including a peer-to-peer educational approach in parts of the rehabilitation program might be beneficial, as some immigrants remain skeptical towards the health care system in Denmark.

People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review

QUESTION

What health information needs are perceived by people with low back pain?

DESIGN

Systematic review of publications examining perceived health information needs related to low back pain identified through Medline, EMBASE, CINAHL and PsycINFO (1990 to 2018).

PARTICIPANTS

Adults with low back pain of any duration.

DATA EXTRACTION AND ANALYSIS

Two reviewers independently extracted descriptive data regarding study design and methodology, and assessed risk of bias. Aggregated findings of the perceived needs of people with low back pain regarding health information were meta-synthesised.

RESULTS

Forty-one studies (34 qualitative, four quantitative and three mixed-methods) were identified. Two major areas of perceived health information needs for low back pain emerged. The first major area was needs related to information content: general information related to low back pain, its cause and underlying pathology; strong desire for diagnosis and imaging; prognosis, future disability and effect on work capacity; precipitants and management of flares; general management approaches; self-management strategies; prevention; and support services. The second major area of needs related to how the information was delivered. People with low back pain wanted clear, consistent information delivered in suitable tone and understandable language.

CONCLUSION

Available data suggest that the information needs of people with low back pain are centred around their desire for a diagnosis, potentially contributing to expectations for and overuse of imaging. People with low back pain expressed a strong desire for clear, consistent and personalised information on prognosis, treatment options and self-management strategies, related to healthcare and occupational issues. To correct unhelpful beliefs and optimise delivery of evidence-based therapy, patient and healthcare professional education (potentially by an integrated public health approach) may be warranted.

Varieties of Hope Among Family Caregivers of Patients With Lymphoma

In this study, 16 family caregivers of patients with lymphoma were interviewed on their changing perceptions of hope. The changing process starts from diagnosis to the present treatment state. We found that the changing perception of hope can be divided into three stages: the stage of generalized hope focusing merely on treatment and passive hope focusing on harm-avoidance, the stage of specified hope and active hope aiming at comfort-seeking, and the stage of multifaceted hope. Family caregivers' understanding of the past experience of and new information on the disease are the foundation of the perception of hope. The perception of hope in cancer patients' family caregivers develops from "therapeutic hope" to "psychosocial hope," shifting from "consequential hope" to "procedural hope."

Patient Perspectives on Communication with Primary Care Physicians about Chronic Low Back Pain

OBJECTIVES

Chronic low back pain (CLBP) is a common health problem with challenges for providing satisfactory care. This study was undertaken to identify opportunities to improve key aspects of physicians' communications with CLBP-affected patients.

METHODS

A series of 3 focus groups, each with 7 to 11 patients with CLBP, were recruited from primary care settings and grouped by risk level of reduced function resulting from back pain, to elicit perspectives about interactions with their primary care physicians. Analysis of focus group transcripts used an iterative process based on a thematic approach and a priori concepts.

RESULTS

A total of 28 patients participated in the focus groups. Patient comments about communicating with physicians around CLBP fit into themes of listening and empathy, validating pain experiences, conducting effective CLBP assessment, providing clear diagnosis and information, and collaboratively working on treatment. Patients shared that physicians can foster positive interactions with CLBP-affected patients by sharing personal experiences of chronic pain, being truthful about not having all the answers and being clear about how patients can benefit from referrals, reviewing the patient's previous treatments before beginning conversations about treatment options, providing follow-up instructions, giving patients a diagnosis beyond "chronic pain," and explaining the role of imaging in their care.

CONCLUSION

This study provides specific steps that physicians in the US can take to improve physician-patient interactions during primary care visits pertaining to CLBP. The findings could inform physician training, development of educational materials for patients, and future research.

Self-care of chronic musculoskeletal pain - experiences and attitudes of patients and health care providers

BACKGROUND

Self-care is often the first choice for people with chronic musculoskeletal pain. Self-care includes the use of non-prescription medications with no doctor's supervision, as well as the use of other modern and traditional treatment methods with no consultation of the health care provider. Self-care may have positive effects on the successful outcome of a multidisciplinary approach to treatment. The aim of this study was to investigate the experiences and attitudes of patients and health care providers to the self-care of chronic musculoskeletal pain.

METHODS

Qualitative Phenomenological study, where the data were collected by the method of an audio-taped interview in 15 patients at the outpatient clinic for pain management and in 20 health care providers involved in the treatment of those patients. The interviews were transcribed verbatim and analyzed by principles of Interpretative Thematic Analysis.

RESULTS

Topics identified in patients: a) positive aspects of self-care, b) a need for pain self-care, c) social aspects of pain self-care. Topics identified in health care providers: a) aspects of self-care, b) a need for self-care c) risks of self-care. Most of patients have positive attitude to self-care and this is the first step to pain management and to care for itself. The most frequent factors influencing decision about the self-care are heavy pain, unavailability of the doctor, long awaiting time for the therapy, or ineffectiveness of methods of conventional medicine. The health care providers believe that self-care of chronic musculoskeletal pain may be a patient's contribution to clinical treatment. However, good awareness of methods used is important in this context, to avoid adverse effects of self-care.

CONCLUSION

Patients understand the self-care of musculoskeletal pain as an individually adjusted treatment and believe in its effectiveness. Health care providers support self-care as an adjunction to clinical management only, and think that self-care of musculoskeletal pain acts as a placebo, with a short-lived effect on chronic musculoskeletal pain.

Expectations towards participation in easily accessible pain management interventions: a qualitative study

BACKGROUND

People with chronic pain use a range of healthcare services, but they also report a high degree of dissatisfaction with treatments. One reason for dissatisfaction might be participants' expectations towards treatments. The aim of this study was to explore expectations of people with chronic pain towards participation in easily accessible pain management interventions delivered in public primary care.

METHODS

A qualitative study using semi-structured individual face-to-face interviews with 21 informants. The informants were recruited among participants enrolled in a randomised controlled trial on the effect of an easily accessible self-management course for people with chronic pain. The data were analysed thematically using Systematic Text Condensation.

RESULTS

Having experienced pain for a long time, there was no specific expectation of a cure or a significant alleviation of the pain. The informants' expectations mainly concerned a hope that participation could lead to a better everyday life. The informants said that hope was important as it motivated them to keep going and continue self-care activities. The hope acted as a driving force towards trying new interventions and maintaining motivation to do activities they experienced as beneficial. Both concrete aspects of the current intervention and an understanding of what interventions in general could offer contributed to the informants hope. The expectations centred about the interventions being something new, as they had not previously tried this service, an opportunity to gain and reinforce skills, to help them continue to grow as a person, to meet others in similar situations, and to access professional support in an easy manner. Participating in interventions provided by healthcare services was seen by some as an act of self-care, where they did something active to manage their health.

CONCLUSIONS

Expectations towards the interventions were related to a hope for participation leading to a better everyday life. The role of hope for peoples' motivation to self-care implies that service providers should be aware of and help to maintain hope for a better everyday life. The importance of social support as part of self-care should be acknowledged when developing interventions targeting chronic pain.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02531282 . Registered on August 21 2015.

Narratives of life with long-term low back pain: A follow up interview study

Background

Long-term low back pain is associated with multiple challenges to a person’s identity and social position. Despite efforts to understand the challenges of low back pain, recovery remains a major problem both personally and socially. This indicate a need for a different approach. Although personal stories have been used to extend knowledge of issues that relate to low back pain, they also make i possible to learn about how people understand themselves and their lives. As such, analysis of narrative: may provide further insights into people’s coping processes and novel insights about how best to support them.

Objective

The aim of the study was to analyse personal recovery narratives to gain an insight into how people understand themselves and cope with long-term low back pain 2-4 years after a bio-psycho-social counselling intervention.

Study design

Using a Ricoeurian phenomenological-hermeneutic perspective, qualitative in-depth interviews were undertaken and interpreted to explore people’s narratives of long-term recovery after an intervention.

Methods

We interviewed 25 informants 2-4 years after participating in a counselling intervention for low back pain where they were advised to exercise regularly; they were part of the intervention group in a randomised clinical trial. The sample included both informants who had benefited from the intervention and some who had not. Analysis was informed by Ricoeur’s interpretation theory.

Findings

The informants’ stories revealed two main narratives regarding themselves and their lives: (1) getting on with life without pain, (2) life with continual pain and variations of the emplotment. The first included Recovering from low back pain and returning to prior lifestyle if possible, Keeping low back pain in check by strict regimes, or Developing strategies when low back pain recurs. The second related to Finding a way to a functioning everyday life with continual pain while narratives of being stuck with low back pain and finding no way out highlight the significance of being able to configure a narrative that can support an understanding of the pain and how to deal with it to have a functioning life. Furthermore, the health professional has a significant role to play in the configuration of narratives.

Conclusions

The challenge for people with low back pain was to find ways of getting on with life, and this included their ability to configure an understandable narrative that opened up for a future, implying new understandings of the self and how life could be lived. When healthcare professionals offered personal and realistic suggestions to the informants’ configuration of narratives of life with low back pain, they supported a positive change in the informants’ ways of coping with their situation.

Implications

Health professionals can play an important role in low back pain sufferers’ configuration of meaningful narratives that help in coping with pain and learning about the relationship between pain and everyday life.

Qualitative meta-synthesis: the experience of chronic pain across conditions

AIM

To synthesize qualitative descriptions of the experience of chronic pain across conditions.

BACKGROUND

Chronic pain is a transdiagnostic symptom in that while somatic pathology plays a role in activating pain pathways, psychological and social factors contribute to the experience of pain over time. The treatment of the underlying condition may require both biomedical intervention and biopsychosocial approaches.

DESIGN

Qualitative meta-synthesis using Confidence in the Evidence from Reviews of Qualitative Research (CERQual) developed by Grading of Recommendations Assessment Development and Evaluation (GRADE) working group to evaluate the strength of the evidence.

DATA SOURCES

PubMed and Ovid Medline from 2000-2015.

REVIEW METHODS

Following a systematic search strategy all papers were assessed in relation to inclusion criteria and quality. Themes were extracted from each study and a meta-synthesis conducted before completing an evaluation of confidence in the findings.

RESULTS

Forty-one papers exploring the experience of chronic pain were included in the review. Five meta-themes were identified across the studies: 1) the body as obstacle; 2) invisible but real; 3) disrupted sense of self; 4) unpredictability; and 5) keeping going. There was high confidence in the evidence for three themes: 'the body as obstacle'; 'disrupted sense of self' and 'keeping going'; and moderate confidence in the evidence for 'invisible but real' and 'unpredictability'.

CONCLUSIONS

The findings in this review suggest there are similarities in the experience of chronic pain across a range of conditions that have implications for the development of transdiagnostic pain management strategies and interventions.

What do patients value about spinal manipulation and home exercise for back-related leg pain? A qualitative study within a controlled clinical trial

BACKGROUND

Patient perceptions may influence the effectiveness and utilization of healthcare interventions, particularly for complex health conditions such as sciatica or back-related leg pain (BRLP).

OBJECTIVES

To explore BRLP patients' perceptions of spinal manipulative therapy (SMT) and home exercise with advice (HEA).

DESIGN

Qualitative study in a controlled clinical trial.

METHOD

Semi-structured interviews conducted after 12 weeks of treatment asked participants about satisfaction with care and whether treatment was worthwhile. An interdisciplinary research team conducted content analysis using qualitative data analysis software to identify and summarize themes.

RESULTS

Of 192 trial participants, 174 (91%) completed interviews (66% female, age 57.0 ± 11.5 years). Participants identified interactions with providers and staff, perceived treatment effects, and information as key contributors to both their satisfaction and the worthwhile nature of treatment. HEA was liked for its convenience and ability to foster an exercise habit. SMT was liked for specific aspects of the modality (e.g. manipulation, stretching) and provider competency. Most participants reported no dislikes for SMT or HEA, but some noted the dose/time commitment for SMT and discipline of HEA as least liked aspects of the interventions.

CONCLUSIONS

The quality of patient-provider interactions, perceived treatment effects, and information sharing influenced BRLP patients' satisfaction with care. Qualitative research describing patients' preferences can facilitate translation of study findings into practice and allow clinicians to tailor treatments to facilitate compliance and satisfaction with care.

Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain

BACKGROUND

Cognitive functional therapy (CFT) has been shown to reduce pain and disability in people with chronic low back pain.

OBJECTIVES

The purpose of this study was to investigate participants' experience of CFT by comparing participants who reported differing levels of improvement after participation in CFT, potentially yielding insight into the implementation of this approach.

DESIGN

This was a noninterventional, cross-sectional, qualitative study with an interpretive description framework.

METHODS

Individuals who had participated in CFT in 2 physical therapy settings (in Ireland and Australia) were recruited through purposive sampling based on disability outcomes postintervention (n=9), and theoretical sampling (n=5). This sampling strategy was used to capture a range of participant experiences but was not used to define the final qualitative groupings. Semistructured interviews were conducted 3 to 6 months postintervention.

RESULTS

Three groups emerged from the qualitative analysis: large improvers, small improvers, and unchanged. Two themes encapsulating the key requirements in achieving a successful outcome through CFT were identified: (1) changing pain beliefs and (2) achieving independence. Changing pain beliefs to a more biopsychosocial perspective required a strong therapeutic alliance, development of body awareness, and the experience of control over pain. Independence was achieved by large improvers through newly cultivated problem-solving skills, self-efficacy, decreased fear of pain, and improved stress coping. Residual fear and poor stress coping meant that small improvers were easily distressed and lacked independence. Those who were unchanged continued to feel defined by their pain and retained a biomedical perspective.

CONCLUSIONS

A successful outcome after CFT is dependent on instilling biopsychosocial pain beliefs and developing independence among participants. Small improvers may require ongoing support to maintain results. Further study is needed to elucidate the optimal approach for those who were unchanged.

Hope is a four-letter word: riding the emotional rollercoaster of illness management

In this autoethnography, I explore the process and emotional experience of trying a new drug to improve my quality of life. In so doing, I synthesise personal history with extant research on chronic illness by analysing ways in which my experiences reflect and reject social norms. I also incorporate perspectives from research on aspirations and attainment, and the mental health consequences of cyclical disappointment. By weaving together lessons from each of these literatures, I articulate an integrative psychosocial understanding of the micro-level processes and experiences involved in illness management as well as the ways that experiences of illness management may require integration of varied sociological insights concerning health. In closing, I draw out theoretical implications for understanding the integration and variation of insights from many areas of health research in the lived experiences of people with chronic conditions. A Virtual Abstract of this article can be seen at: https://youtu.be/5aoaWGItDgM.

Ways of Hoping: Navigating the Paradox of Hope and Despair in Chronic Pain

In this paper, we explore hope in the context of living with chronic pain. Individuals with chronic pain from temporomandibular disorder(s) were interviewed four to five times over the course of their 18-month participation in a clinical trial investigating the effectiveness of Traditional Chinese Medicine. We sought to understand shifts in participants' descriptions of expectations and hopefulness, particularly with regard to the work involved in counterbalancing positive thinking with buffers against disappointment. We found hope to be a dynamic and multifaceted mindset as distinct from being a single entity to be measured. Drawing upon Polanyi's concept of tacit knowing, we explore how different ways of hoping emerge and index one another in participant narratives. We offer a working typology of hope and raise as an issue the manner in which the paradox of hope--hoping enough to carry on while keeping hopes in check to avoid the ever-present possibility of despair--complicates simplistic notions of the relationship between positive thinking and the placebo response.

Botlhoko, botlhoko! How people talk about their musculoskeletal complaints in rural Botswana: a focused ethnography

Background

Conflicting interpretations about the structure and function of the body contribute to discordance in communication between healthcare professionals and lay people. Understanding musculoskeletal (MSK) complaints presents additional complexities when discussed in more than one language or in cross-cultural settings. In low- and middle-income countries (LMICs), few healthcare professionals have specialist MSK training and not all practitioners speak the primary language of patients.

Objective

Our goal was to understand how people in rural Botswana perceive and express MSK complaints.

Design

Ethnographic fieldwork for 8 months in the Botswana Central District included participant observations and interviews with 34 community members with MSK complaints. Audio-recorded interviews were typically conducted in Setswana with an interpreter, transcribed verbatim, and contextually translated into English. Abductive qualitative analysis was used as the interpretive methodology.

Results

Whereas initial responses about MSK troubles yielded the exclamation botlhoko, botlhoko! combined with animated non-verbal gestures and facial expressions indicating widespread body pains, in-depth interviews revealed the complexities of pain expression among respondents. MSK pains were described as ‘bursting, exploding, aching, numbness, hot, pricking, stabbing, swollen, and pain in the heart’. Language subtleties manifested during interviews, where ‘meat’ or ‘flesh’ implied soft tissue pains; waist pains were voiced yet portrayed as low back or sacroiliac pain; and ‘veins’ variously referred to structural and functional types of pain. Psychological and social stressors accompanied many accounts of MSK troubles.

Conclusions

Respondents offered diverse MSK symptom descriptions consistent with biopsychosocial illness models, yet few communicated complaints using the biomedical language of healthcare providers. Although research interview and transcription processes may not be practical for clinicians, working with interpreters who communicate detailed patient accounts for MSK troubles will complement patient–provider encounters. Community member perceptions of their MSK pain and associated conditions should be explored and incorporated into healthcare interventions and innovations for rural communities in LMICs.

The lived experience of low back pain among Irish farmers: case studies

Low back pain (LBP) is the most commonly reported musculoskeletal disorder (MSD) among farmers. There is limited researching regarding the lived experience of LBP among farmers. Video interviews were conducted with three dairy farmers who reported having a significant episode of LBP. The interview data were transcribed and analyzed, and results were presented in relation to the constructs explored. The farmers experienced their first significant episode of LBP in their late 20s or early 30s and all attributed their LBP to farm work or a farm-related incident. Hours worked per day ranged from 9 to 13 hours. Tasks identified by farmers that they were unable to do due to LBP included physical work, working with sheep, building work, and "certain jobs." Work changes made due to LBP included getting help, slowing down, avoiding strenuous work, carrying smaller loads, mechanizing the farm, using the tractor more, and wearing a back belt for certain jobs. Each farmer had his own way of preventing or managing his LBP, including a mix of active self-management and passive coping strategies such as swimming, using ice, spinal manipulation, and taking medication. The farmers were unable to quantify how much their LBP had cost them directly or indirectly. The case studies illustrate farmers engaging in ongoing work despite significant pain. All of the farmers have adapted at work and engaged in self-management strategies to reduce the occurrence of LBP. Given the rich data produced by these case studies, future case studies are recommended to gain greater insights into farmers' experiences concerning LBP.

Insights into Pain: A Review of Qualitative Research

Qualitative research exposes and explores important aspects of the pain experience that are inaccessible to other approaches.Qualitative work adopts a different epistemological and ontological perspective to quantitative work.Qualitative research is not well established in the field of pain, but is growing.More interpretative engagement with qualitative data is required.

Comfort and hope in the preanesthesia stage in patients undergoing surgery

PURPOSE

Comfort and hope have been identified as important components in the care of perianesthesia patients. The purpose of this study was to explore the relationship between comfort and hope in the preanesthesia stage in patients undergoing surgery.

DESIGN

A descriptive cross-sectional survey was conducted with 191 surgical patients.

METHODS

Data were collected using the Perianesthesia Comfort Questionnaire and Herth Hope Index.

FINDINGS

Direct and significant relationships were observed between comfort and hope (P≤.001, r=0.65). Also, significant relationships were observed between educational level and marital status with comfort (P≤.01). The relationship between educational level and hope was significant (P≤.001). Significant relationships were also observed between gender and marital status with hope (P≤.01).

CONCLUSIONS

Overall, this study showed that a significant relationship exists between comfort and hope. Additionally, some demographic characteristics influenced comfort and hope in these patients. Health care providers should arrange the environment in a way that allows the surgical patients to experience comfort and hope and recognize the impact of personal characteristics when caring for surgical patients, particularly in the preanesthesia stage.

Ageism, negative attitudes, and competing co-morbidities--why older adults may not seek care for restricting back pain: a qualitative study

Background

Back pain, the most common type of pain reported by older adults, is often undertreated for reasons that are poorly understood, especially in minority populations. The objective of this study was to understand older adults’ beliefs and perspectives regarding care-seeking for restricting back pain (back pain that restricts activity).

Methods

We used data from a diverse sample of 93 older adults (median age 83) who reported restricting back pain during the past 3 months. A semi-structured discussion guide was used in 23 individual interviews and 16 focus groups to prompt participants to share experiences, beliefs, and attitudes about managing restricting back pain. Transcripts were analyzed in an iterative process to develop thematic categories.

Results

Three themes for why older adults may not seek care for restricting back pain were identified: (1) beliefs about the age-related inevitability of restricting back pain, (2) negative attitudes toward medication and/or surgery, and (3) perceived importance of restricting back pain relative to other comorbidities. No new themes emerged in the more diverse focus groups.

Conclusions

Illness perceptions (including pain-related beliefs), and interactions with providers may influence older adults’ willingness to seek care for restricting back pain. These results highlight opportunities to improve the care for older adults with restricting back pain.

Mapping letters from the future: Exploring narrative processes of imagining the future

This article uses Letters from the Future (a health promotion instrument) to explore the human capacity of imagining the future. From a narrative perspective, letters from the future are considered to be indicative of a variety of forms through which human beings construct and understand their future selves and worlds. This is consistent with an interpretive approach to understanding the human mind, which offers an alternative for the current dominant causal-explanatory approach in psychology. On the basis of qualitative analysis of 480 letters from the future, collected online from a diverse group of Dutch and German persons, we first identified five narrative processes operating in the letters: imagining, evaluating, orienting, expressing emotions and engaging in dialogue. Second, using comparative analysis, we identified six types of how these processes are organized in the letters as a whole. These types differ regarding functionality (which of the five processes was dominant); temporality (prospective, retrospective and present-oriented); the extent to which a path between present and future was described; and the vividness of the imagination. We suggest that these types can be used in narrative health practice as ‘pathways’ to locate where letter writers are on their path to imagine the future, rather than as a normative taxonomy. Future research should focus on how these pathways can be used to navigate to health and well-being.

Bad is more powerful than good: the nocebo response in medical consultations

Although there has been a lot of research looking at the placebo response, nocebo responses in the healthcare setting have been largely overlooked. This article explores the potential role of negative patient-doctor communication in facilitating nocebo responses in the medical consultation. We suggest that invalidation, that is, communicating a lack of understanding and acceptance to the patient (albeit unintentionally), is a key factor in understanding the nocebo response. This article reviews evidence from the experimental and healthcare setting, which suggests that the negative effects of invalidation may be stronger than we think.

Enhanced Psychological Health Among Chronic Pain Clients Engaged in Hope-Focused Group Counseling

Researchers have begun to evaluate interventions intended to enhance hope in various populations. Chronic pain is a pervasive problem with significant psychosocial consequences. This article presents studies that examined the extent to which a hope-focused group counseling intervention enhances hope and well-being in two community-based samples of participants ( N =10 and N = 24) experiencing chronic pain. A pilot study (Study 1a) and a main study (Study 1b) both used a one-group, pretest–posttest design to determine whether participants experienced changes regarding their hope, well-being, acceptance of pain, and catastrophizing of pain. Both studies showed that participants experienced numerous and significant changes from pre- to post-intervention, including improvements in well-being and pain acceptance in Study 1a and improvements in hope, well-being, and catastrophizing cognitions in Study 1b. Self-reported pain severity, assessed only in Study 1a, did not change. We discuss implications for practice, study limitations, and potential lines of hope-related inquiry for future research.

"I try and smile, I try and be cheery, I try not to be pushy. I try to say 'I'm here for help' but I leave feeling... worried": a qualitative study of perceptions of interactions with health professionals by community-based older adults with chronic pain

Background

Over 50% of community-dwelling older adults experience chronic pain, which threatens their quality of life. Of importance to their pain management is older people's interaction with health professionals that, if unsatisfactory, may impair the outcome.

Aims

To add to the limited research specific to older people living with chronic pain in the community, we explored how they perceive their experiences of interacting with health professionals, seeking factors that might optimise these interactions.

Methods

Purposive sampling was used to recruit men and women >65 years with self-reported musculoskeletal chronic pain. Qualitative individual interviews and one group interview were undertaken with 23 participants. Data were transcribed verbatim and underwent Framework Analysis.

Results

Three themes were identified. Seeking help illustrates issues around why older people in the community may or may not seek help for chronic pain, and highlights the potential involvement of social comparison. Importance of diagnosis illustrates the desire for professional validation of their condition and an aversion to vague explanations based on the person's age. Being listened to and being heard illustrates the importance of empathic communication and understanding expectations, with due respect for the person's age.

Conclusions

In common with people of all ages, an effective partnership between an older person in pain and health professionals is essential if pain is to be reported, appropriately assessed and managed, because of the subjective nature of pain and its treatment responses. For older people with pain, perception about their age, by both parties in the partnership, is an additional factor that can unnecessarily interfere with the effectiveness of this partnership. Health professionals should engage with older adults to clarify their expectations about pain and its management, which may be influenced by perceptions about age; and to encourage expression of their concerns, which may also be affected by perceptions about age.

Low back pain patients' beliefs about effective/ineffective constituents of a counseling intervention: a follow-up interview study

PURPOSE

Everyday activities are important factors for avoiding the development of chronic low back pain (LBP). The purpose this study was to explore LBP patients' perspective on long-term effects of participating in a counseling intervention designed to motivate them to change work routines and to exercise.

METHOD

Follow-up qualitative study. Semi-structured interviews were made of 25 LBP patients who had received the counseling intervention. Interviews were transcribed and explored with an interpretative thematic analysis. The findings were organized around Kleinman's conception of "explanatory models".

RESULTS

For the individual participant the beliefs about the illness were internally coherent, but most often they were idiosyncratic and fitted to the particular participants' overall explanatory model. Participation in the counseling intervention had created a sense of certainty and potential control over the disease and had legitimized their sick role at work and at home. The majority of the patients reported having integrated exercise into their explanatory models and understood exercise to be beneficial in their continual and concrete management of their LBP.

CONCLUSIONS

The intervention had affected the patients' personal agency and space for action. We suggest that this effect was linked to the individually tailored approach drawing on both educational and motivational agents.

IMPLICATIONS FOR REHABILITATION

Maintaining everyday activities, including retaining one's occupation, is an important factor in low back pain rehabilitation. Counselling on low back pain rehabilitation must be aligned with people's beliefs about their illness. A counselling intervention made patients adopt exercising into their long-term management of low back pain.

New perspectives on patient expectations of treatment outcomes: results from qualitative interviews with patients seeking complementary and alternative medicine treatments for chronic low back pain

Background

Positive patient expectations are often believed to be associated with greater benefits from complementary and alternative medicine (CAM) treatments. However, clinical studies of CAM treatments for chronic pain have not consistently supported this assumption, possibly because of differences in definitions and measures of expectations. The goal of this qualitative paper is to provide new perspectives on the outcome expectations of patients prior to receiving CAM therapies for chronic low back pain.

Methods

We conducted semi-structured interviews with 64 individuals receiving massage, chiropractic, acupuncture or yoga for chronic low back pain. Interviews were recorded and transcribed. Transcripts were analyzed by a team of experienced qualitative researchers using an immersion/crystallization approach to coding and analysis.

Results

Overall, participants’ expectations of treatment outcomes tended to cluster in four key domains: pain relief, improved function (including an increase in ability to engage in meaningful activities), improved physical fitness, and improved overall well-being (including mental well-being). Typically, patients had modest expectations for outcomes from treatment. Furthermore, outcome expectations were complex on several levels. First, the concept of expectations overlapped with several related concepts; in particular, hopes. Participants sometimes used expectations and hopes interchangeably and at other times made clear distinctions between these two terms depending on context. A related finding was that participants were cautious about stating that they expected positive outcomes. Finally, participants articulated strong interrelationships among the four key domains and often discussed how changes in one domain might affect other domains.

Conclusions

Overall, these findings contribute to a growing body of literature exploring the role of expectations in patient outcomes. This paper provides important guidance that may help refine the way treatment expectations are studied in the future. In particular, participants’ statements indicate that standardized measures of patient expectations should include items that capture hesitancy to articulate overly optimistic outcomes as well as interrelationships among different outcomes.