Biopsychosocial factors associated with chronic low back pain disability in rural Nigeria: a population-based cross-sectional study

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study

PURPOSE

Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study.

MATERIAL AND METHODS

This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study.

RESULTS

Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists.

CONCLUSION

The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

Occupational biopsychosocial factors associated with neck pain intensity, neck-disability, and sick leave: A cross-sectional study of construction labourers in an African population

INTRODUCTION

The burden and impact of neck pain is high in African countries including Nigeria. This study investigated the occupational biomechanical and occupational psychosocial factors associated with neck pain intensity, neck disability and sick leave amongst construction labourers in an urban Nigerian population.

METHODS

This cross-sectional study measured clinical neck pain outcomes, occupational biomechanical factors, and occupational psychosocial factors. Descriptive, and univariate/multivariate inferential statistical analyses were conducted.

RESULTS

Significant independent factors associated with neck pain intensity were order and pace of tasks being dependent on others (β = 0.35; p<0.0001); inability to take breaks in addition to scheduled breaks (β = 0.25; p<0.0001); inability to work because of unexpected events (β = 0.21; p<0.0001); inability to control the order and pace of tasks (β = 0.20; p<0.0001); and weight of load (β = 0.17; p<0.0001); accounting for 53% of the variance in neck pain intensity. Significant independent factors associated with neck disability were weight of load (β = 0.30; p<0.0001); duration of load carriage (β = 0.16; p = 0.01); working under time pressure/deadlines (β = 0.16; p = 0.02); and accounting for 20% of the variance in neck disability. Significant independent factor associated with sick leave was duration of load carriage (β = 0.15; p = 0.04), in a non-significant regression model explaining -4% of the variance in sick leave. Addition of pain intensity significantly explained more variance in neck disability (31.0%) but less variance in sick leave (-5%), which was not statistically significant (F (10, 190) = 0.902, p = 0.533).

CONCLUSIONS

Occupational biomechanical factors may be more important than occupational psychosocial factors in explaining neck disability and sick leave. In contrast, occupational psychosocial factors may be more important than occupational biomechanical factors in explaining neck pain intensity in this population in Nigeria.

Challenges of Measuring Self-Reported Exposure to Occupational Biomechanical Risk Factors Amongst People with Low Literacy Engaged in Manual Labour: Findings from a Cross-Cultural Adaptation and Psychometric Investigation in an African Population with Chronic Low Back Pain

PURPOSE

Occupational biomechanical factors are implicated in the aetiology and progression of low back pain (LBP). This study cross-culturally adapted and psychometrically investigated the Occupational Risk Factor Questionnaire (ORFQ) in a low literate Nigerian Igbo population with chronic LBP.

METHODS

Forward and back translation of the original ORFQ by clinical and non-clinical translators was followed by an expert committee review. The adapted ORFQ was pre-tested amongst rural Nigerian adults with chronic LBP using cognitive think-aloud interviewing. Internal consistency (Cronbach's alpha) and test-retest reliability (unweighted and linear weighted k statistic for item-by-item agreement, and intra-class correlation coefficient-ICC) were investigated amongst 50 rural and urban Nigerian dwellers with chronic LBP. Spearman's correlation and regression analyses were conducted with the Igbo-ORFQ, and measures of disability [World Health Organisation Disability Assessment Schedule (WHODAS 2.0), Roland Morris Disability Questionnaire (RMDQ), Back performance scale (BPS)], pain intensity [Eleven-point box scale (BS-11)] and social support [Multidimensional Scale of Perceived Social Support (MSPSS)], to test construct validity with 200 rural Nigerian dwellers with chronic LBP.

RESULTS

Cross-cultural adaptation highlighted difficulty conceptualising and concretising exposure to biomechanical risk factors. Item-by-item agreement, internal consistency (α = 0.84) and intraclass correlation coefficient (ICC = 0.83) were good. Some unexpected direction of associations between the biomechanical components of the Igbo-ORFQ, and disability, pain intensity, and social support prohibits establishment of construct validity.

CONCLUSION

Prospective studies comparing the Igbo-ORFQ to other measures of exposure to occupational biomechanical risk factors are required to establish the construct validity of the Igbo-ORFQ.

What do people believe to be the cause of low back pain? A scoping review

OBJECTIVE

To explore how causal beliefs regarding non-specific low back pain (LBP) have been quantitatively investigated.

METHODS

A scoping review based on the guidelines by the JBI (former Joanna Briggs Institute) was conducted. We searched Medline, Embase, Psychinfo, and CINAHL for relevant studies and included peer-reviewed original articles that measured causal beliefs about non-specific LBP among adults and reported results separate from other belief domains.

RESULTS

A total of 81 studies were included, of which 62 (77%) had cross sectional designs, 11 (14%) were cohort studies, 3 (4%) randomized controlled trials, 4 (5%) non-randomized controlled trials, and 1 (1%) case control. Only 15 studies explicitly mentioned cause, triggers, or etiology in the study aim. We identified the use of 6 questionnaires from which a measure of causal beliefs could be obtained. The most frequently used questionnaire was the Illness Perception Questionnaire which was used in 8 of the included studies. The studies covered 308 unique causal belief items which we categorized into 15 categories, the most frequently investigated being causal beliefs related to "structural injury or impairment", which was investigated in 45 (56%) of the studies. The second and third most prevalent categories were related to "lifting and bending" (26 studies [32%]) and "mental or psychological" (24 studies [30%]).

CONCLUSION

There is a large variation in how causal beliefs are measured and a lack of studies designed to investigate causal beliefs, and of studies determining a longitudinal association between such beliefs and patient outcomes. This scoping review identified an evidence gap and can inspire future research in this field.

Identifying chronic low back pain phenotypic domains and characteristics accounting for individual variation: a systematic review

ABSTRACT

Interpatient variability is frequently observed among individuals with chronic low back pain (cLBP). This review aimed at identifying phenotypic domains and characteristics that account for interpatient variability in cLBP. We searched MEDLINE ALL (through Ovid), Embase Classic and EMBASE (through Ovid), Scopus, and CINAHL Complete (through EBSCOhost) databases. Studies that aimed to identify or predict cLBP different phenotypes were included. We excluded studies that focused on specific treatments. The methodological quality was assessed using an adaptation of the Downs and Black tool. Forty-three studies were included. Although the patient and pain-related characteristics used to identify phenotypes varied considerably across studies, the following were among the most identified phenotypic domains and characteristics that account for interpatient variability in cLBP: pain-related characteristics (including location, severity, qualities, and duration) and pain impact (including disability, sleep, and fatigue), psychological domains (including anxiety and depression), behavioral domains (including coping, somatization, fear avoidance, and catastrophizing), social domains (including employment and social support), and sensory profiling (including pain sensitivity and sensitization). Despite these findings, our review showed that the evidence on pain phenotyping still requires further investigation. The assessment of the methodological quality revealed several limitations. We recommend adopting a standard methodology to enhance the generalizability of the results and the implementation of a comprehensive and feasible assessment framework to facilitate personalized treatments in clinical settings.

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.

Effectiveness of patient education plus motor control exercise versus patient education alone versus motor control exercise alone for rural community-dwelling adults with chronic low back pain: a randomised clinical trial

BACKGROUND

Chronic low back pain (CLBP) is a common health problem in rural Nigeria but access to rehabilitation is limited. Current clinical guidelines unanimously recommend patient education (PE) including instruction on self-management, and exercises as frontline interventions for CLBP. However, the specific content of these interventions and how they are best delivered remain to be well-described, particularly for low-resource communities. This study determined the effectiveness of PE plus motor control exercise (MCE) compared with either therapy alone among rural community-dwelling adults with CLBP.

METHODS

A single-blind, three-arm parallel-group, randomised clinical trial including 120 adult rural dwellers (mean [SD] age, 46.0 [14.7] years) with CLBP assigned to PE plus MCE group (n = 40), PE group (n = 40), and MCE group (n = 40) was conducted. The PE was administered once weekly and the MCE twice weekly. Each group also received stretching and aerobic exercises twice weekly. All interventions were administered for 8 weeks. Blinded assessments for pain intensity and disability level as primary outcomes, and quality of life, global perceived recovery, fear-avoidance beliefs, pain catastrophising, back pain consequences belief and pain medication use as secondary outcomes were conducted at baseline, 8-week (immediately after intervention) and 20-week follow-ups.

RESULTS

All the groups showed significant improvements in all the primary and secondary outcomes evaluated over time. Compared with PE alone, the PE plus MCE showed a significantly greater reduction in pain intensity by an additional -1.15 (95% confidence interval [CI], -2.04 to -0.25) points at the 8-week follow-up and -1.25 (95% CI, -2.14 to -0.35) points at the 20-week follow-up. For disability level, both PE plus MCE and MCE alone showed a significantly greater improvement compared with PE alone by an additional -5.04% (95% CI, -9.57 to -0.52) and 5.68% (95% CI, 1.15 to 10.2) points, respectively, at the 8-week follow-up, and -5.96% (95% CI, -9.84 to -2.07) and 6.57% (95% CI, 2.69 to 10.4) points, respectively, at the 20-week follow-up. For the secondary outcomes, at the 8-week follow-up, PE plus MCE showed a significantly greater reduction in fear-avoidance beliefs about physical activity compared with either therapy alone, and a significantly greater reduction in pain medication use compared with PE alone. However, compared with PE plus MCE, PE alone showed a significantly greater reduction in pain catastrophising at all follow-up time points, and a significantly greater improvement in back pain consequences belief at the 20-week follow-up. Additionally, PE alone compared with MCE alone showed a significantly greater improvement in back pain consequences belief at all follow-up time points. No significant between-group difference was found for other secondary outcomes.

CONCLUSIONS

Among rural community-dwelling adults with CLBP, PE plus MCE led to greater short-term improvements in pain and disability compared with PE alone, although all intervention strategies were associated with improvements in these outcomes. This trial provides additional support for combining PE with MCE, as recommended in current clinical guidelines, to promote self-management and reduce the burden of CLBP in low-resource rural communities.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03393104), Registered on 08/01/2018.

Developing tailored intervention strategies for implementation of stratified care to low back pain with physiotherapists in Nigeria: a Delphi study

BACKGROUND

Stratified care approach involving use of the STarT-Back tool to optimise care for patients with low back pain is gaining widespread attention in western countries. However, adoption and implementation of this approach in low-and-middle-income countries will be restricted by context-specific factors that need to be addressed. This study aimed to develop with physiotherapists, tailored intervention strategies for the implementation of stratified care for patients with low back pain.

METHODS

A two-round web-based Delphi survey was conducted among purposively sampled physiotherapists with a minimum of three years of clinical experience, with post-graduation certification or specialists. Thirty statements on barriers and enablers for implementation were extracted from the qualitative phase. Statements were rated by a Delphi panel with additional open-ended feedback. After each Delphi round, participants received feedback which informed their subsequent responses. Additional qualitative feedback were analysed using qualitative content analysis. The criteria for consensus and stability were pre-determined using percentage agreement (≥ 75%), median value (≥ 4), Inter-quartile range (≤ 1), and Wilcoxon matched-pairs test respectively.

RESULTS

Participants in the first round were 139 and 125 of them completed the study, yielding a response rate of 90%. Participants were aged 35.2 (SD6.6) years, and 55 (39.6%) were female. Consensus was achieved in 25/30 statements. Wilcoxon's test showed stability in responses after the 5 statements failed to reach consensus: 'translate the STarT-Back Tool to pidgin language' 71% (p = 0.76), 'begin implementation with government hospitals' 63% (p = 0.11), 'share knowledge with traditional bone setters' 35% (p = 0.67), 'get second opinion on clinician's advice' 63% (p = 0.24) and 'carry out online consultations' 65% (p = 0.41). Four statements strengthened by additional qualitative data achieved the highest consensus: 'patient education' (96%), 'quality improvement appraisals' (96%), 'undergraduate training on psychosocial care' (96%) and 'patient-clinician communication' (95%).

CONCLUSION

There was concordance of opinion that patients should be educated to correct misplaced expectations and proper time for communication is vital to implementation. This communication should be learned at undergraduate level, and for already qualified clinicians, quality improvement appraisals are key to sustained and effective care. These recommendations provide a framework for future research on monitored implementation of stratified care in middle-income countries.

[Comparative analysis of the use of symptomatic slow acting drugs for osteoarthritis containing chondroitin sulfate or affecting its biosynthesis in patients with non-specific low back pain]

OBJECTIVE

Retrospective comparative analysis of the use of SYSADOA preparations containing chondroitin sulfate (Chondroguard, 2 ml, 25 amp., glycosaminoglycan-peptide complex, 1 ml 25 amp., bioactive concentrate of small marine fish, 2 ml, 10 amp.) in patients with chronic non-specific low back pain (LBP) of lumbar and sacral localization caused by spondylosis and osteochondrosis of the lumbar spine, at the stage of outpatient care.

MATERIAL AND METHODS

Data of medical records of patients (n=120; men - 32, women - 88, age - 54.1±7.6 years, duration of disease exacerbation 4.0±1.7 months) with nonspecific LBP were systematized according to the inclusion/exclusion criteria. All patients were divided into 4 groups: Group 1 (n=30) received Chondroguard im., 2 ml every other day, the course of treatment was 25 injections, 25 days; Group 2 (n=30) received glycosaminoglycan-peptide complex on the 1st day - 0.3 ml, on the 2nd day - 0.5 ml, and then 3 times a week for 1 ml, course of treatment - 25 injections, 25 days; Group 3 (n=30) received bioactive concentrate of small marine fish, 2 ml im., every other day, the course of treatment was 10 injections; repeated courses of treatment - after 6 months; Group 4 (n=30) received Amelotex (meloxicam) at a dose of 15 mg once a day for 15 days. All patients of the first 3 groups received Amelotex at a dose of 15 mg with the possibility of reducing the dose to 7.5 mg or completely discontinuing the drug if necessary. Retrospectively, dynamic monitoring was performed in the medical records of outpatients after 50 days and 6 months from the start of therapy according to the following parameters: intensity of pain according to VAS, short form of the McGill pain questionnaire, vital signs of patients (Oswestry Disability Index, version 2.1a [Oswestry Disability Index], and Roland-Morris questionnaire), propensity to chronic pain syndrome according to the STarT Back Screening Tool questionnaire, the presence and severity of comorbid fibromyalgia according to the Fibromyalgia Rapid Screening Tool questionnaire, the level of pain catastrophization according to the Pain Catastrophizing Scale, the severity of comorbid anxiety and depression according to the Hospital Anxiety and Depression Scale, the severity comorbid insomnia (Insomnia Severity Index), quality of life according to the SF-36 scale, the effectiveness of drugs according to the patient on a 5-point scale, the need to take NSAIDs and analgesics, tolerability on a 4-point system. The safety of therapy was monitored using the WHO and Naranjo scales.

RESULTS

In patients with nonspecific LBP, a greater degree of reduction in the intensity of the pain syndrome, a smaller number of exacerbations of the pain syndrome over 6 months of observation, an improvement in the functional status and life activity, a tendency to a decrease in the severity of anxiety and depression, sleep disturbances and comorbid fibromyalgia, limiting the risk of chronicity and catastrophization of pain, the presence of a structure-modifying effect on IVD and degenerative changes in the facet joints, a significant improvement in the physical and mental components of health, high satisfaction and safety of therapy, which included taking Chondroguard with meloxicam, with a decrease in the need to take the latter by the 50th day observation period compared to other regimens. The effects of Chondroguard and meloxicam turned out to be long-term and were recorded by the 6th month in the absence of Chondroguard, which indicated the preservation of the influence of highly purified cholesterol on the pathogenetic mechanisms of the formation of LBP.

CONCLUSION

The study allows us to recommend the use of a parenteral form of cholesterol (Chondroguard, CJSC «PharmFirma «Sotex», Russia) for the treatment of nonspecific LBP with moderate or severe pain, chronic relapsing or persistent course, in combination with NSAIDs and their subsequent cancellation or administration on demand.

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.

Exploring patients' lived experience on the barriers to accessing low back pain health services

BACKGROUND

The burden of chronic low back pain (CLBP) is a major concern to public health. However, the treatment of CLBP in primary care has shown to be ineffective in South Africa. Understanding the barriers encountered by patients in accessing CLBP healthcare services is paramount in the development of context-specific intervention strategies.

AIM

To explore the patients' lived experiences on the barriers to accessing diagnostic, referral and treatment services for CLBP.

SETTING

A health facility-based study conducted at five primary public hospitals in KwaZulu-Natal, South Africa.

METHODS

A phenomenological study by means of in-depth interviews using the general interview guide approach. Interviews were conducted by a research assistant with relevant experience and qualifications in qualitative methods. A total of 15 participants were recruited to participate in this study. All interviews were audio-recorded and transcribed. Data were analysed iteratively until saturation was reached, where no new themes were emerging. All the transcripts were exported to NVivo 12 Pro for analysis.

RESULTS

The results of this study identified the following barriers: travel, long waiting periods, shortage of personnel, poor infrastructural development, inadequate healthcare personnel, communication barrier, social influence, beliefs around cause and effect, misdiagnosis and inappropriate and/or ineffective treatment approaches.

CONCLUSION

This study concluded that barriers to patients' accessing diagnostic, referral and treatment services exist. Efforts should be made towards developing health systems in underserved communities.Contribution: This is the first study to be conducted in South Africa that explored the barriers associated with accessing healthcare services for chronic low back pain. Based on the results of this study, in order to improve health outcomes for low back pain there need to be a change of emphasis in primary health care by ensuring sufficient allocation of resources towards musculoskeletal disorders.

Prevalence and biopsychosocial factors associated with chronic low back pain in urban and rural communities in Western Africa: a population-based door-to-door survey in Benin

PURPOSE

This study aimed to assess the prevalence of chronic low back pain (CLBP) and related biopsychosocial factors in urban and rural communities in Benin.

METHODS

This is a population-based observational cross-sectional survey. An interviewer-administered electronic questionnaire was used to collect information on demographic, socio-economic, behavioral, and psychological factors relating to CLBP risk factors and medical history of participants. The numeric pain rating scale and the Beck Depression Inventory were used to assess pain intensity and the level of depression, respectively. Bivariate analyses were performed to investigate the association between sociodemographic, behavioral, and psychological factors and CLBP. Sequential multiple regression analyses were subsequently performed to predict the occurrence of CLBP.

RESULTS

A total of 4320 participants, with a mean age ± SD of 32.9 ± 13.1 years, of which 40.7% were females and 50.1% from an urban area, were enrolled in the study. We found a global prevalence rate of CLBP of 35.5% [95% CI 34.1-36.9%]. The prevalence in urban areas was 30.68% [95% CI 28.9-32.8%]) while 40.2% was found in rural areas [95% CI 38.1-42.2%]). Age (p < 0.001), level of education (p = 0.046), marital status (p < 0.001), working status (p < 0.003), tobacco use (p < 0.016) and regular physical activity (p < 0.011) were associated with CLBP. In urban areas, only the level of education was able to predict the prevalence of CLBP (R2 = 61%). In rural areas, CLBP was predicted by age, marital and working status (R2 = 89%).

CONCLUSIONS

This study showed a high prevalence of CLBP among urban and rural communities in Benin. Age, level of education, marital status, and working status were significantly associated with CLBP in Benin.

The economic burden of low back pain in KwaZulu-Natal, South Africa: A prevalence-based cost-of-illness analysis from the healthcare provider's perspective

Background

Low back pain (LBP) is a multifactorial and the most prevalent musculoskeletal disorder, whose economic burden is of global concern. Evidence suggests that the burden of LBP in increasing and will continue rising with the greatest burden occurring in low-and-middle-income-countries (LMICs). This study sought to determine the economic burden of LBP in KwaZulu-Natal, South Africa from the providers perspective.

Methods

We used a retrospective prevalence-based cost-of-illness methodology to estimate the direct medical cost of LBP. Direct medical costs constituted costs associated with healthcare utilisation in inpatient care, outpatient care, investigations, consultations, and cost of auxiliary devices. We used diagnostic-specific data obtained from hospital clinical reports. All identifiable direct medical costs were estimated using a top-down approach for costs associated with healthcare and a bottom-up approach for costs associated with inpatient and outpatient care.

Results

The prevalence of chronic low back pain CLBP was 24.3% (95% CI: 23.5–25.1). The total annual average direct medical costs associated with LBP was US$5.4 million. Acute low back pain (ALBP) and CLBP contributed 17% (US$0.92 million) and 83% (US$4.48 million) of the total cost, respectively. The per patient total annual average direct medical cost for ALBP and CLBP were US$99.43 and US$1,516.67, respectively. The outpatient care costs contributed the largest share (38.9%, US$2.10 million) of the total annual average direct medical cost, 54.9% (US$1.15 million) of which was attributed to nonsteroidal-anti-inflammatory drugs (NSAIDs). The total average cost of diagnostic investigations was estimated at US$831,595.40, which formed 15.4% of the average total cost.

Conclusion

The economic burden of LBP is high in South Africa. Majority of costs were attributed to CLBP. The outpatient care costs contributed the largest share percent of the total cost. Pain medication was the main intervention strategy, contributing more than half of the total outpatient costs. Measures should be taken to ensure guideline adherence. Focus should also be placed towards development of prevention measures to minimise the cost.

Nonspecific chronic low back pain conditions and therapeutic practices in Burkina Faso

Background

The management of nonspecific chronic low back pain (NCLBP) is complex because of its multifactorial origin.

Objectives

To investigate NCLBP care by evaluating patients’ condition and therapeutic management of health practitioners.

Method

A cross-sectional survey was carried out among 92 patients with NCLBP, 30 medical practitioners (MP) and 20 physiotherapists (PT) from four public health institutions in Burkina Faso. Patients completed the Visual Analogue Scale, Roland Morris Disability Questionnaire and Fear-Avoidance Beliefs Questionnaire. Practitioners were asked about therapy and continuing professional training.

Results

Pain was moderate to intense for 80% of participants with NCLBP. They were functionally affected and showed fear-avoidance beliefs related to physical and work activities. The majority (97%) of medical practitioners prescribed analgesics and 53% prescribed nonsteroidal anti-inflammatory drugs (NSAIDs). Physiotherapy was the most frequently recommended nonpharmacological treatment. Forty-three per cent of medical practitioners referred to physiotherapy; 20% never did. Physiotherapists practised both passive treatments, such as massage (50%), electrotherapy (55%) and thermotherapy (50%), as well as active treatments, such as general exercises (55%), specific exercises (70%), functional revalidation (50%) and back school (40%). Having had recent continuing professional training and assessing risk factors for chronicity were associated with MPs’ and PTs’ therapeutic choices.

Conclusion

Participants with NCLBP showed fear-avoidance beliefs, correlated with their algo-functional status. Prescribing habits of MPs were drug-based. Treatments by PTs were passive and active. Continuing professional training of healthcare practitioners and assessment of risk factors had a positive impact on therapeutic choices.

Clinical implications

Our study is an invitation to the health care system to improve the relationship between a patient’s NCLBP and therapeutic choices.

Patients' and physiotherapists' perspectives on implementing a tailored stratified treatment approach for low back pain in Nigeria: a qualitative study

BACKGROUND

Stratified care has the potential to be efficient in addressing the physical and psychosocial components of low back pain (LBP) and optimise treatment outcomes essential in low-income countries. This study aimed to investigate the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of LBP, exploring barriers and enablers to implementation.

METHODS

A qualitative design with semistructured individual telephone interviews for physiotherapists and patients with LBP comprising research evidence and information on stratified care was adopted. Preceding the interviews, patients completed the Subgroups for Targeted Treatment tool. The interviews were recorded, transcribed and analysed following grounded theory methodology.

RESULTS

Twelve physiotherapists and 13 patients with LBP participated in the study (11 female, mean age 42.8 (SD 11.47) years). Seven key categories emerged: recognising the need for change, acceptance of innovation, resistance to change, adapting practice, patient's learning journey, trusting the therapist and needing conviction. Physiotherapists perceived stratified care to be a familiar approach based on their background training. The prevalent treatment tradition and the patient expectations were seen as major barriers to implementation of stratified care by the physiotherapists. Patients see themselves as more informed than therapists realise, yet they need conviction through communication and education to cooperate with their therapist using this approach. Viable facilitators were also identified as patients' trust in the physiotherapist and adaptations in terms of training and modification of the approach to enhance its use.

CONCLUSION

Key barriers identified are the patients' treatment expectations and physiotherapists' adherence to the tradition of practice. Physiotherapists might facilitate implementation of the stratified care by communication, hierarchical implementation and utilisation of patients' trust. Possibilities to develop a consensus on key strategies to overcome barriers and on utilisation of facilitators should be tested in future research.

A cross-sectional hospital-based study of correlates of disability in patients with chronic low back pain in KwaZulu-Natal, South Africa

BACKGROUND

Chronic low back pain (CLBP) is the leading cause of disability globally and is a major concern in public health. However, there is limited evidence on the prevalence and correlates of disability among adults in Sub-Saharan Africa. Thus, this study aimed at determining factors influencing disability among adult patients with CLBP in KwaZulu-Natal.

METHODS

This analytical cross-sectional hospital-based study was conducted among adult CLBP patients in KwaZulu-Natal, South Africa. Data on disability, fear avoidance beliefs and illness behavior were gathered from 554 adult participants using self-administered questionnaires. Multiple linear regression analysis was conducted to determine factors associated with disability. Statistical significance was set at p < 0.05.

RESULTS

Based on the multivariable linear regression, being a female (β = 0.343, p < 0.001) and fear avoidance beliefs about work (β = 0.221, p = 0.044) were significantly associated with greater disability, while, smoking 1 to 10 cigarettes per day (β = -0.106, p = 0.011) and higher illness behaviour scores (β = -0.165, p = 0.024) were significantly associated with less disability The model accounted for 20% of the total variance in Oswestry disability scores.

CONCLUSION

This study has concluded that disability in CLBP is predicted by multiple of factors, with psychosocial factors (fear avoidance beliefs and heavy cigarette smoking) playing a significant role. Manual work was also identified as a significant predictor of CLBP disability. Therefore, guidelines should emphasize on early identification of these yellow flags in primary care.

A Scoping Review on the Epidemiology of Chronic Low Back Pain among Adults in Sub-Saharan Africa

BACKGROUND

The global burden of chronic low back pain (CLBP) is a major concern in public health. Several CLBP epidemiological studies have been conducted in high-income-countries (HICs) with little known in low-and-middle-income-countries (LMICs) due to other competing priorities of communicable diseases. The extrapolation of results of studies from HICs for use in LMICs is difficult due to differences in social norms, healthcare systems, and legislations, yet there is urgent need to address this growing burden. It is against this backdrop that we conducted this review to map the current evidence on the distribution of CLBP in Sub-Saharan Africa (SSA).

METHODS

A comprehensive literature search was conducted from the following databases: PubMed, Google Scholar, Science Direct databases, World Health Organizations library databases, EMBASE, EBSCOhost by searching the following databases within the platform; academic search complete, CINAHL with full text, health sources: nursing/academic and MEDLINE. The title, abstract and the full text screening phases were performed by two independent reviewers with the third reviewer employed to adjudicate discrepancies. The reference list of all included articles was also searched for eligible articles. This scoping review was reported in accordance with the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation, as well as guided by Arksey and O'Malley's scoping review framework. A thematic content analysis was used to give a narrative account of the review.

RESULTS

The electronic search strategy retrieved 21,189 articles. Title/abstract and full text screening only identified 11 articles, which were included in this review. The prevalence of CLBP among the general population ranged from 18.1% to 28.2% and from 22.2% to 59.1% among LBP patients. The prevalence of occupation based CLBP ranged from 30.1% to 55.5%. Identified risk factors for CLBP are multifactorial and included biomechanical, psychological, socioeconomic and lifestyle factors, with psychosocial factors playing a significant role. Hypertension, diabetes mellitus, peptic ulcer disease were the most common comorbidities identified. CLBP disability was significantly associated with psychosocial factors. The management of CLBP in primary care follows the traditional biomedical paradigm and primarily involves pain medication and inconsistent with guidelines.

CONCLUSIONS

There are limited epidemiological data on CLBP in SSA, however, this study concluded that the prevalence and risk factors of CLBP in SSA are comparable to reports in HICs. Considering the projected increase in the burden of CLBP in LMICs extensive research effort is needed to close this knowledge gap.

The prevalence and psychosocial risk factors of chronic low back pain in KwaZulu-Natal

BACKGROUND

 Chronic low back pain (CLBP) is the leading cause of disability and has been extensively investigated in high-income countries (HICs), with little done in low-and middle-income countries. Biomechanical stressors do not have a major pathogenic role, but psychosocial predisposition is important. The occurrence and progression of CLBP are significantly affected by psychosocial risk factors. Guidelines recommend the early identification of psychosocial factors that could predict CLBP.

AIM

 To determine the prevalence and psychosocial risk factors for CLBP amongst adults in KwaZulu-Natal, South Africa.

SETTING

 The study was conducted at five randomly selected public hospitals in KwaZulu-Natal.

METHODS

 Analytical cross-sectional hospital-based study utilising a self-administered questionnaire to collect data on (1) sociodemographic, (2) disability, (3) fear-avoidance beliefs and (4) illness behaviour. The Statistical Package for the Social Sciences (SPSS) 24.0 was used for data cleaning and descriptive statistics. Chi-square test was used for categorical variables. Standard Edition of the Statistical Software for Data Science version 17.0 (STATA 17.0 SE) was used to identify risk factors using the logistic regression analysis. A p-value of ≤ 0.05 was deemed statistically significant.

RESULTS

 Overall prevalence of CLBP was 22.2% (95% confidence interval [CI]: 18.8-25.9). Females had a higher prevalence of CLBP than males, 23.9% (95% CI: 19.4-28.9) and 19.7% (95% CI: 14.8-25.5), respectively; however, the difference was not significant p = 0.243. The multivariate regression analysis identified the following risk factors: female gender, middle-aged adults 38-47 years, obesity, disease conviction, affective disturbance, denial and fear-avoidance behaviour-work subscale.

CONCLUSION

 There is a high prevalence of CLBP amongst the study participants. Psychosocial factors (disease conviction, affective disturbance and fear-avoidance behaviour about work) are significant predictors of CLBP.

Only two subscales of the Coping Strategies Questionnaire are culturally relevant for people with chronic low back pain in Nigerian Igbo populations: a cross-cultural adaptation and validation study

BACKGROUND

Pain coping strategies are important in the chronicity of low back pain and the associated disability. However, their exact influence is unknown in many African contexts such as rural Nigeria due to lack of outcome instruments with which to measure them. This study aimed to cross-culturally adapt and psychometrically test the Coping Strategies Questionnaire (CSQ) in Igbo populations in Nigeria.

METHODS

The CSQ was forward and back translated by clinical and non-clinical translators; evaluated by an expert review committee. The translated measure was piloted amongst twelve rural Nigerian dwellers with chronic low back pain (CLBP) using the think-aloud cognitive interviewing style. Internal consistency (Cronbach's alpha), test-retest reliability (intra-class correlation coefficient-ICC and Bland-Altman plot), and minimal detectable change were examined amongst 50 people with CLBP in rural and urban Nigerian populations. Construct validity was determined by assessing the correlations between the adapted CSQ and measures of disability, pain intensity, fear avoidance beliefs, and illness perceptions using Spearman's correlation analyses with 200 adults with CLBP in rural Nigeria. Exploratory factor analyses using Kaiser criterion (eigenvalue) and parallel analysis as methods for determining dimensionality were conducted with the same sample.

RESULTS

Fourteen out of 42 items were routinely adopted in this population including all items of catastrophising subscale, and all but one item of praying and hoping subscale. Catastrophising and praying and hoping subscales had the highest Cronbach's alpha. All subscales had high ICCs with Bland-Altman plots that showed good agreement. All coping strategies were positively correlated with self-reported disability and pain intensity with catastrophising subscale having the highest values. Seven-factor and three-factor structures were produced with the Kaiser criterion and parallel analysis, with different items from the original CSQ, except for catastrophising.

CONCLUSIONS

Catastrophising and praying and hoping may be the relevant coping strategies in this population. More culturally relevant measures of pain coping strategies that include adaptive coping strategies may need to be developed for African contexts such as rural Nigeria.

The Igbo Brief Illness Perceptions Questionnaire: A cross-cultural adaptation and validation study in Nigerian populations with chronic low back pain

BACKGROUND

Illness perceptions predict chronic low back pain (CLBP) disability. This study cross-culturally adapted and validated the Igbo Brief Illness Perceptions Questionnaire (Igbo-BIPQ) in people with CLBP in rural/urban Nigeria.

METHODS

A cross-cultural adaptation and validation of the Igbo-BIPQ was undertaken. The BIPQ was forward/back-translated by clinical/non-clinical translators. An expert review committee appraised the translations. The questionnaire was pre-tested on twelve rural Nigerian dwellers with CLBP. Internal consistency using Cronbach's alpha; test-retest reliability using intra-class correlation coefficient and Bland-Altman plot; and minimal detectable change were investigated amongst 50 people with CLBP in rural and urban Nigeria. Construct validity was determined by correlating the Igbo-BIPQ score with those of eleven-point box scale and Igbo Roland Morris Disability Questionnaire (Igbo-RMDQ) using Pearson's correlation analyses in 200 adults with CLBP in rural Nigeria. Ceiling and floor effects were investigated in both samples.

RESULTS

Good face/content validity, internal consistency (α= 0.76) and intraclass correlation coefficient (ICC = 0.78); standard error of measurement and minimal detectable change of 5.44 and 15.08 respectively; moderate correlations with pain intensity and self-reported disability (r⩾ 0.4); no ceiling/floor effects were observed for Igbo-BIPQ.

CONCLUSION

This study provides evidence of some aspects of validity and reliability of the Igbo-BIPQ.

Detecting anxiety and depression among people with limited literacy living with chronic low back pain in Nigeria: adaptation and validation of the hospital anxiety and depression scale

Background

The Hospital Anxiety and Depression Scale (HADS) is one of the most popular measures of anxiety and depression. The original HADS is mostly used in Nigeria precluding people with limited literacy. This study aimed to cross-culturally adapt and psychometrically test the HADS for rural and urban Nigerian Igbo populations with chronic low back pain (CLBP) who have limited literacy.

Methods

The HADS was forward translated, back translated, and appraised. Face and content validity was ensured by pre-testing the translated measure among a convenience sample of twelve rural Nigerian dwellers with CLBP. Reliability utilising Cronbach’s alpha, intraclass correlation coefficient, Bland–Altman plots and minimal detectable change were investigated amongst a convenience sample of 50 people living with CLBP in rural and urban Nigerian communities. Construct validity testing involving correlations between Igbo-HADS and Roland Morris Disability Questionnaire measuring self-reported back pain-specific disability, World Health Organisation Disability Assessment Schedule assessing generic self-reported disability, Fear Avoidance Beliefs Questionnaire measuring fear avoidance beliefs, and eleven-point box scale assessing pain intensity, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) among a random sample of 200 adults with CLBP in rural Nigerian communities were conducted.

Results

Idioms and colloquialisms were difficult to adapt. Internal consistency was good (α = 0.78) and acceptable (α = 0.67) for anxiety and depression subscales respectively. Intraclass correlation coefficients were very good (ICC ≃ 0.8) for both subscales. Minimal detectable change was 6.23 and 5.06 for anxiety and depression subscales respectively. The Igbo-HADS and the anxiety subscale had strong correlations (≃ 0.7) with generic self-reported disability; moderate correlations (≃ 0.5–0.6) with pain intensity, self-reported back pain-specific disability, and fear avoidance beliefs. The depression subscale had the lowest correlations (≃ 0.3–0.4) with these outcomes. The EFA produced a two-factor structure with cross-loading of items. The CFA showed poor fit indices for the EFA structure, the original two-factor structure, and one-factor structure.

Conclusion

The HADS may not be suitable for assessing anxiety and depression, or emotional distress in this population due to difficulty achieving cross-cultural equivalence with western idioms; and the expression of emotional distress through somatisation in this culture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00586-4.

Validation of the Yoruba Version of the Pain Self-Efficacy Questionnaire in Patients with Chronic Low Back Pain

STUDY DESIGN

Cultural adaptation and psychometric analysis.

OBJECTIVE

This study determined the test-retest reliability, acceptability, internal consistency, divergent validity of the Yoruba pain self-efficacy questionnaire (PSEQ-Y). It also examined the ceiling and floor effects and the small detectable change (SDC) of the PSEQ-Y among patients with chronic low back pain (LBP).

SUMMARY OF BACKGROUND DATA

There are various indigenous language translations of the PSEQ and none adapted to African language. However, translations of the PSEQ into Nigerian languages are not readily available.

METHODS

The validity testing phase of the study involved 131 patients with LBP, while 83 patients with LBP took part in the reliability phase. Following the Beaton recommendation for cultural adaptation of instruments, the PSEQ was adapted into the Yoruba language. The psychometric properties of the PSEQ-Y determined comprised: internal consistency, divergent validity, test-retest reliability, and SDC.

RESULTS

The mean age of the participants was 52.96 ± 17.3 years. The PSEQ-Y did not correlate with the Yoruba version of Visual Analogue Scale (VAS-Y) scores (r = -0.05; P = 0.59). The values for the internal consistency and the test-retest reliability of the PSEQ-Y were 0.79 and 0.86, with the 95% confidence interval of the test-retest reliability ranging between 0.82 and 0.90. The standard error of measurement (SEM) and the SDC of the PSEQ-Y were 1.2 and 3.3, respectively. The PSEQ-Y had no floor or ceiling effect, as none of the respondents scored either the minimal or maximal scores.

CONCLUSION

This is the first study in Nigeria to culturally adapt PSEQ. The PSEQ-Y showed adequate psychometric properties similar to existing versions. Therefore, the tool can be used to assess pain self-efficacy in clinical and research settings and help to improve the health outcomes of patients chronic LBP.Level of Evidence: 3.

Development of the Hausa version of the Pain Catastrophizing Scale: translation, cross-cultural adaptation and psychometric evaluation in mixed urban and rural patients with chronic low back pain

Background

Catastrophizing has been recognized as an important contributor to chronicity in individuals with chronic pain syndromes including low back pain (LBP). The Pain Catastrophizing Scale (PCS) is perhaps the most widely used tool to evaluate the degree of pain catastrophizing. However, its use is limited in Hausa-speaking countries due to the lack of a validated translated version.

Objective

To translate and cross-culturally adapt the PCS into Hausa (Hausa-PCS), and evaluate its psychometric properties in mixed urban and rural patients with chronic LBP.

Methods

The PCS was translated and cross-culturally adapted into Hausa in accordance with established guidelines. To evaluate its psychometric properties, a consecutive sample of 200 patients with chronic LBP was recruited from urban and rural Nigerian hospitals. Validity was evaluated by exploring content validity, factorial structure (confirmatory factor analysis [CFA]), construct validity (Spearman’s rho for a priori hypotheses) and known-groups validity. Reliability was evaluated by calculating internal consistency (Cronbach’s α), intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC) and limits of agreement with 95% confidence interval (LOA_95%).

Results

The Hausa-PCS was comprehensible with good content validity. The CFA confirmed a 3-factor structure similar to the original English version. The concurrent validity was supported as 83% (5/6) of the a priori hypotheses were confirmed. Known-groups comparison showed that the questionnaire was unable to differentiate between male and female or urban and rural patients (p > 0.05). Internal consistency and ICC were adequate for the Hausa-PCS total score (α = 0.84; ICC = 0.90) and the subscale helplessness (α = 0.78; ICC = 0.89) but for the subscales rumination (α = 0.69; ICC = 0.68) and magnification (α = 0.41; ICC = 0.43). The LOA_95% for the Hausa-PCS total score was between − 8.10 and + 9.75, with SEM and MDC of 3.47 and 9.62 respectively.

Conclusion

The Hausa-PCS was successfully developed and psychometrically adequate in terms of factorial structure, construct validity, internal consistency and test–retest reliability when applied in mixed urban and rural patients with chronic LBP. However, the internal consistency and reliability coefficients (ICC) for the individual subscales are inadequate. Thus, we support the use of the total score when evaluating pain catastrophizing for clinical or research purposes.

Cross-cultural translation, adaptation, and validation of the Amharic version pain self-efficacy questionnaire in people with low back pain in Ethiopia

BACKGROUND

The Pain Self-Efficacy Questionnaire (PSEQ) is a valid and reliable instrument that evaluates pain self-efficacy beliefs in people with pain conditions. However, it has not been validated and used in Ethiopia. We conducted this study to translate, adapt, and test the psychometric properties of the PSEQ in the Amharic language and Ethiopian context for its use with people experiencing low back pain (LBP).

METHODS

The PSEQ was translated into Amharic and then back-translated into English. An expert review committee created a final Amharic version of the tool (PSEQ-Am), followed by pilot testing and cognitive debriefing with a sample of 20 people with LBP. The psychometric properties of the final version of PSEQ-Am were assessed in a sample of 240 people with LBP recruited from three rehabilitation centers in Ethiopia. Cronbach's alpha and Intra-class correlation coefficient were calculated to describe the reliability and internal consistency of the tool. The SF-36-Am bodily pain subscale was used to assess convergent validity. Confirmatory Factor Analysis (CFA) and Exploratory Factor Analysis (EFA) were performed to determine the dimensionality of the instrument.

RESULTS

PSEQ-Am demonstrated excellent test-retest reliability (ICC = 0.93) and internal consistency (Cronbach's alpha = 0.91). As hypothesized, the tool demonstrated a significant moderate correlation with the Bodily Pain subscale of the SF-36-Am (Rho = 0.51, p < 0.01). EFA analysis shows that the Amharic version of PSEQ is a dominant one factor and secondary two factor structure.

CONCLUSION

This study shows that PSEQ-Am is a reliable and valid tool that can be used in both clinical practice and research in the Ethiopian low back pain population.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

Fear-Avoidance Behavior and Sickness Absence in Patients with Work-Related Musculoskeletal Disorders

(1) Background and objectives: The purpose of this work is to determine the association of fear-avoidance attitudes with sickness absence status, its duration and disability in a work accident context. (2) Materials and Methods: This is a descriptive observational design, conducting the study in two occupational insurance provider clinics with patients with nonspecific low back and neck pain during the study period. Clinical variables were the Fear Avoidance Questionnaire, Roland Morris Disability Questionnaire, Neck Disability Index, Numerical Pain Scale; sociodemographic variables were sex, age, occupational, educational level, sickness absence status, and duration in days of absence from work. Multiple logistic and linear regressions were used to explore the association between variables. (3) Results: Fear-avoidance behavior is related to sickness absence status (OR = 1.048, p = 0.007), and the physical activity dimension (OR = 1.098, p = 0.013) is more relevant than the work dimension (OR = 1.056, p = 0.028). The duration of sickness absence is related to higher values on the fear-avoidance behavior scale in its global dimension (b = 0.84, p = 0.003, r = 0.327), and the results of the physical activity dimension (B = 1.37, p = 0.035, r = 0.236) were more relevant than the work dimension (B = 1.21, p = 0.003, r = 0.324). Fear-avoidance behavior is related to disability in both dimensions (B = 0.912, p ˂ 0.001, r = 0.505). (4) Conclusions: Fear-avoidance behaviors may influence the typification of sickness absence status, its duration both in its physical activity and work dimension, and its disability reported with higher values than in other healthcare contexts.

World Health Organisation Disability Assessment Schedule (WHODAS 2.0): development and validation of the Nigerian Igbo version in patients with chronic low back pain

Background

Globally, the leading cause of years lived with disability is low back pain (LBP). Chronic low back pain (CLBP) is responsible for most of the cost and disability associated with LBP. This is more devastating in low income countries, particularly in rural Nigeria with one of the greatest global burdens of LBP. No Igbo back pain specific measure captures remunerative or non-remunerative work outcomes. Disability measurement using these tools may not fully explain work-related disability and community participation, a limitation not evident in the World Health Organisation Disability Assessment Schedule (WHODAS 2.0). This study aimed to cross-culturally adapt the WHODAS 2.0 and validate it in rural and urban Nigerian populations with CLBP.

Methods

Translation, cultural adaptation, test–retest, and cross-sectional psychometric testing was performed. WHODAS 2.0 was forward and back translated by clinical/non-clinical translators. Expert review committee evaluated the translations. Twelve people with CLBP in a rural Nigerian community piloted/pre-tested the questionnaire. Cronbach’s alpha assessing internal consistency; intraclass correlation coefficient and Bland–Altman plots assessing test–retest reliability; and minimal detectable change were investigated in a convenience sample of 50 adults with CLBP in rural and urban Nigeria. Construct validity was examined using Spearman’s correlation analyses with the back-performance scale, Igbo Roland Morris Disability Questionnaire and eleven-point box scale; and exploratory factor analysis in a random sample of 200 adults with CLBP in rural Nigeria. Ceiling and floor effects were investigated in both samples.

Results

Patient instructions were also translated. ‘Waist pain/lower back pain’ was added to ‘illness(es)’ to make the measure relevant for this study whilst allowing for future studies involving other conditions. The Igbo phrase for ‘family and friends’ was used to better represent ‘people close to you’ in item D4.3. The Igbo-WHODAS had good internal consistency (α = 0.75–0.97); intra class correlation coefficients (ICC = 0.81–0.93); standard error of measurements (5.05–11.10) and minimal detectable change (13.99–30.77). Igbo-WHODAS correlated moderately with performance-based disability, self-reported back pain-specific disability and pain intensity, with a seven-factor structure and no floor and ceiling effects.

Conclusions

Igbo-WHODAS appears psychometrically sound. Its research and clinical utility require further testing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03763-8.

Cognitive Behavioral Therapy With Stabilization Exercises Affects Transverse Abdominis Muscle Thickness in Patients With Chronic Low Back Pain: A Double-Blinded Randomized Trial Study

OBJECTIVE

Nonspecific chronic low back pain (NCLBP) is a major public health and global socioeconomic burden with a variety of symptoms, such as fear-avoidance behaviors. This study aimed to evaluate the effect of cognitive behavioral therapy (CBT) associated with stabilization exercise (SE) on thickness of transverse abdominis (TrA) muscle in patients with NCLBP.

METHODS

Forty patients with NCLBP were randomly assigned into experimental CBT associated with SE (n = 20) and control groups without SE (n = 20). Transverse abdominis muscle thickness was assessed during abdominal drawing in maneuver (ADIM) and active straight leg raise (ASLR) of the right lower limb using ultrasound imaging. Fear-avoidance belief and disability were evaluated using a fear-avoidance belief questionnaire (FABQ) and a Roland-Morris disability questionnaire (RMDQ) before and after intervention.

RESULTS

Mixed-model analysis of variance indicated that the effect of time was significant for the right and left TrA contraction thickness during ADIM and left TrA contraction thickness during ASLR (P < .05). However, the experimental group exhibited higher right and left TrA muscle thickness compared with the control group during ADIM (P = .001). Moreover, there were no significant differences between groups in the thickness of TrA muscle during ASLR (P > .05). The effect of time was significant for FABQ (P = .02) and RMDQ (P = .01); however, the effect of group was significant for the FABQ after intervention (P = .04).

CONCLUSIONS

Stabilization exercise associated with CBT is more effective than SE alone in improving fear avoidance belief and in increasing the thickness of the TrA muscle during ADIM task.

Psychosocial Correlates of Objective, Performance-Based, and Patient-Reported Physical Function Among Patients with Heterogeneous Chronic Pain

BACKGROUND

Improving all aspects of physical function is an important goal of chronic pain management. Few studies follow recent guidelines to comprehensively assess physical function via patient-reported, performance-based, and objective/ambulatory measures.

PURPOSE

To test 1) the interrelation between the 3 types of physical function measurement and 2) the association between psychosocial factors and each type of physical function measurement.

METHODS

Patients with chronic pain (N=79) completed measures of: 1) physical function (patient-reported disability; performance-based 6-minute walk-test; objective accelerometer step count); 2) pain and non-adaptive coping (pain during rest and activity, pain-catastrophizing, kinesiophobia); 3) adaptive coping (mindfulness, general coping, pain-resilience); and 4) social-emotional dysfunction (anxiety, depression, social isolation and emotional support). First, we tested the interrelation among the 3 aspects of physical function. Second, we used structural equation modeling to test associations between psychosocial factors (pain and non-adaptive coping, adaptive coping, and social-emotional dysfunction) and each measurement of physical function.

RESULTS

Performance-based and objective physical function were significantly interrelated (r=0.48, p<0.001) but did not correlate with patient-reported disability. Pain and non-adaptive coping (β=0.68, p<0.001), adaptive coping (β=-0.65, p<0.001) and social-emotional dysfunction (β=0.65, p<0.001) were associated with patient-reported disability but not to performance-based or objective physical function (ps>0.1).

CONCLUSION

Results suggest that patient-reported physical function may provide limited information about patients' physical capacity or ambulatory activity. While pain and non-adaptive reactions to it, adaptive coping, and social-emotional dysfunction may potentially improve patient-reported physical function, additional targets may be needed to improve functional capacity and ambulatory activity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03412916.

The burden of non-specific chronic low back pain among adults in KwaZulu-Natal, South Africa: a protocol for a mixed-methods study

INTRODUCTION

Low back pain (LBP) is a major public health concern, affecting individuals of all age groups across the world. In about 90% of LBP cases, there is no specific cause identified and is, therefore, referred to as non-specific LBP. Due to the non-specific nature of LBP, investigations such as radiological and laboratory investigations are unnecessary and results to delayed diagnosis and improper treatment culminating in LBP progressing into chronic LBP (CLBP). LBP is now the leading cause of disability with a significant socioeconomic burden. Despite all these challenges, CLBP is regarded as a trivial condition in low-and-middle-income countries and remains poorly investigated. The distribution of CLBP in Africa is unclear.

METHODS AND ANALYSIS

The research will be conducted in two phases. The initial phase will be an observational, cross-sectional hospital-based study that will be recruiting 650 participants, to determine the prevalence and risk factors of CLBP. A standardised questionnaire will be used to collect baseline data on the socio-demographic characteristics of participants and other variables of interest (exercise history, occupational posture, level of education and the income status). Disability will be assessed using the Oswestry Disability Questionnaire and the psychological risk factors will be assessed using the Illness-Behaviour Questionnaire (IBQ) and the Fear-Avoidance Belief Questionnaire (FABQ). The second phase will be a retrospective, top-down, prevalence-based cost-of-illness study of the 2018-2019 health records, to estimate the burden of CLBP from the healthcare system's perspective. The SPSS V.25.0 statistical package will be used for data entry and analysis. Statistical analysis will include descriptive statistics by means of graphs and cross tabulations, inferential statistics by means of logistic regression and χ² test. A p value of 0.05 will be deemed statistically significant.

ETHICS AND DISSEMINATION

This protocol was approved by the University of KwaZulu-Natal's Biomedical Research Ethics Committee (Ref. No.: BREC/00000205/2019) and the KwaZulu-Natal Department of Health Research Ethics (Ref. No.: KZ_201909_002). This will be the first LBP cost-of-illness study in the sub-Saharan Africa, and, therefore, it will close these knowledge gaps and present important evidence on the estimated burden of CLBP in this context. The results of this study will be presented to the Department of Health and to the respective stakeholders and decision-makers to discuss the findings and draw their attention to the prioritisation of LBP research, its management, prevention programmes and implementation of educational programme and for the planning of cost-containment policies.

Evidence, theory and context: using intervention mapping in the development of a community-based self-management program for chronic low back pain in a rural African primary care setting - the good back program

BACKGROUND

Rural Nigeria has one of the greatest burdens of low back pain but there are no effective evidence-based interventions to manage it in this population. This paper presents the application of the intervention mapping (IM) approach in the development of a complex behavior change intervention - The Good Back program, aimed at reducing non-specific chronic low back pain (CLBP) disability in rural Nigeria.

METHODS

The first four steps of IM were applied. A critical review of the literature, 2 qualitative studies and a population-based cross-sectional study in rural Nigeria helped to identify two key program objectives in order to reduce CLBP disability in this population: reduce the impact of illness perceptions, fear avoidance beliefs, catastrophising, anxiety and depression by targeting maladaptive illness perceptions about CLBP; and facilitate the adoption of exercises and good posture to limit disability. A systematic review plus these studies, identified the personal and environmental determinants of the performance objectives including health literacy, self-awareness, self-efficacy, personal preference, health professional skills, health facility structure and family/community support. The theory, techniques and strategies for modifying personal and environmental determinants were also identified from these studies. Intervention components and materials were then produced for practical application. The initial developed intervention was described.

RESULTS

The feasibility and acceptability of the developed program was then tested using a small pragmatic non-randomised controlled study incorporating qualitative exit feedback interviews in a rural Nigerian primary health care centre. The program appeared feasible and acceptable when delivered by a highly trained physiotherapist. There were promising clinical outcomes in disability, pain intensity, illness perceptions, fear avoidance beliefs and pain medication use. Suggestions for program improvement included shorter but ongoing sessions, video demonstration of exercises/good posture, spacious exercise/demonstration rooms, and community legitimisation of exercise as treatment for back pain. Subsequent modifications to program content and delivery were then described. Theoretical modification included the addition of aspects of the social cognitive theory to the Leventhal's self-regulatory model of illness cognitions.

CONCLUSIONS

IM appears to be a suitable framework for designing complex behavior change interventions in rural Nigeria. The need for further testing of the intervention was highlighted.

A user-friendly clinical practice guideline summary for managing low back pain in South Africa

Background

Clinical practice guidelines (CPGs) provide conveniently packaged evidence-based recommendations to inform clinical decisions. However, intended end-users often do not know how to source, appraise, interpret or choose among CPGs. Moreover, it can be confusing when recommendations on the same topic differ among CPGs, in wording, intent and underpinning evidence.

Objectives

This article reports on the processes of: (1) identifying current CPGs for acute and subacute low back pain (LBP) to fit the needs of South African physiotherapists, (2) collating and summarising CPG recommendations to produce a user-friendly end-user product and (3) testing the utility of the summary CPG document on South African physiotherapy clinicians to efficiently determine acceptability, appropriateness and feasibility to inform clinical decision-making.

Method

An adapted approach was followed by systematically searching online CPG repositories and online databases for LBP CPGs; screening and critically appraising identified CPGs; summarising recommendations from relevant CPGs and organising them into clinical practice activities. Feedback on utility was obtained from 11 physiotherapists.

Results

Three high-quality, international CPGs provided 25 recommendations on the assessment and management of acute and subacute LBP relevant to South African physiotherapy practice. They were organised into 10 headings. Physiotherapy user feedback suggested that this document would assist in clinical decision-making.

Conclusion

Organised recommendations extracted from multiple, relevant CPGs provide an end-user-friendly resource for physiotherapists treating LBP.

Clinical implications

Collated and organised CPG recommendations may effectively assist South African physiotherapists’ clinical decision-making in assessing and managing patients with acute and subacute LBP.

Chronic low back pain beliefs and management practices in Africa: Time for a rethink?

BACKGROUND

Chronic low back pain (CLBP) beliefs are important psychosocial risk factors affecting the occurrence and progression of CLBP. To address pain beliefs and implement recommended biopsychosocial approaches for CLBP management, an understanding of the beliefs of patients and healthcare professionals (HCPs), and also CLBP management practices, is necessary. A narrative review was conducted to explore CLBP beliefs and practices in African countries.

METHODS

Two systematic searches were conducted using seven databases (MEDLINE, Embase, PsychInfo, CINAHL Plus, AMED, PubMed and Web of Science) with combined variations of the terms "Management", "Guidelines", "Chronic Low Back Pain", "Beliefs", "Patients", "Healthcare Professionals" and "Africa".

RESULTS

Five studies and one standard treatment guideline document were included. No systematically developed African CLBP treatment guideline was found, although CLBP practices were identified in two African countries. CLBP management in African countries appears to be biomedically orientated. Only three research articles investigated the CLBP beliefs of patients in Africa, with none assessing HCP beliefs. Unhelpful CLBP beliefs (catastrophizing and fear avoidance) and biomedical thoughts about the causes of CLBP were identified. Unhelpful CLBP beliefs were associated with increased disability.

CONCLUSIONS

Management practices for CLBP in African countries appear to contradict recommended biopsychosocial management guidelines by developed countries and are not sufficiently documented. Research on CLBP beliefs and CLBP management practices in Africa is lacking. To enhance the uptake of biopsychosocial approach in Africa, research around CLBP beliefs in African CLBP patients and HCPs is required.

Updating EuroSCORE by including emotional, behavioural, social and functional factors to the risk assessment of patients undergoing cardiac surgery: a study protocol

INTRODUCTION

Conventional risk assessment in cardiac surgery focus on medical and physiological factors and have been developed to predict mortality. Other relevant risk factors associated with increased risk of poor outcomes are not included. Adding non-medical variables as potential prognostic factors to risk assessments direct attention away from specific diagnoses towards a more holistic view of the patients and their predicament. The aim of this paper is to describe the method and analysis plan for the development and validation of a prognostic screening tool as a supplement to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict mortality, readmissions and prolonged length of admission in patients within 90 days after cardiac surgery, as individual outcomes.

METHODS AND ANALYSIS

The development of a prognostic screening tool with inclusion of emotional, behavioural, social and functional factors complementing risk assessment by EuroSCORE will adopt the methods recommended by the PROGnosis RESearch Strategy Group and report using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis statement. In the development stage, we will use data derived from three datasets comprising 1143, 3347 and 982 patients for a prospective cohort study of patients undergoing cardiac surgery, respectively. We will construct logistic regression models to predict mortality, prolonged length of admission and 90-day readmissions. In the validation stage, we will use data from a separate sample of 333 patients planned to undergo cardiac surgery to assess the performance of the developed prognostic model. We will produce validation plots showing the overall performance, area under the curve statistic for discrimination and the calibration slope and intercept.

ETHICS AND DISSEMINATION

The study will follow the requirements from the Ethical Committee System ensuring voluntary participation in accordance with the Helsinki declarations. Data will be filed in accordance with the requirements of the Danish Data Protection Agency.

Translation, cultural adaptation and psychometric testing of Igbo fear avoidance beliefs questionnaire in mixed rural and urban Nigerian populations with chronic low back pain

INTRODUCTION

Low back pain (LBP) is highly prevalent in Nigeria and is more devastating in rural Nigeria due to adverse living and working conditions, reinforced by maladaptive illness beliefs. There is a need to develop measures for assessing such beliefs in this population. This study aimed to cross-culturally adapt the Fear Avoidance Beliefs Questionnaire (FABQ) and test its psychometric properties in mixed rural and urban Nigerian populations with chronic LBP.

METHODS

Translation, cultural adaptation, test-retest, and cross-sectional psychometric testing. FABQ was forward and back translated by clinical/non-clinical translators. A review committee evaluated the translations. Twelve people with chronic LBP in a rural Nigerian community pre-tested the questionnaire. Cronbach's alpha assessing internal consistency; intra-class correlation coefficient and Bland-Altman plots assessing test-retest reliability; and minimal detectable change were investigated in a convenient sample of 50 chronic low back pain sufferers in rural and urban Nigeria. Construct validity was examined using Pearson's correlation analyses with the eleven-point box scale and Igbo Roland Morris Disability Questionnaire (Igbo-RMDQ), and exploratory factor analysis in a random sample of 200 adults with chronic low back pain in rural Nigeria. Ceiling and floor effects were investigated in all samples.

RESULTS

Amendments allowed interviewer-administration. Item 8 was modified to 'I have a compensation or gains I get from having my pain' as there is no benefit system in Nigeria. Igbo phrase for 'physical activity' could also mean 'being active', 'moving the body' or 'moving about' and was used in the items with 'physical activity'. The Igbo-FABQ had good internal consistency (α = 0.80-0.86); intra class correlation coefficients (ICC = 0.71-0.72); standard error of measurements (3.21-7.40) and minimal detectable change (8.90-20.51). It correlated moderately with pain intensity and disability, with a two-factor structure and no floor and ceiling effects.

CONCLUSIONS

Igbo-FABQ is valid, reliable, and can be used clinically and for research.

Community-based self-management of chronic low back pain in a rural African primary care setting: a feasibility study

A small pragmatic non-randomised controlled study investigated the feasibility and acceptability of a novel theory-informed community-based self-management programme targeting the biopsychosocial factors associated with chronic low back pain disability in a rural Nigerian primary care centre. Participants either received the programme, once weekly for 6 weeks, or usual care. The programme combined group exercise sessions with group/individual discussion sessions, informed by cognitive behavioural therapy and motivational interviewing. Recruitment rate, intervention delivery, proportion of planned treatment attended, retention/dropout rate, adherence to recommended self-management strategies and biopsychosocial outcomes were used to determine feasibility. Structured qualitative exit feedback interviews ascertained acceptability. Recruitment rate was 100%, treatment uptake was 83% and loss to follow-up was 8%. Greater benefits for the self-management group compared with control were observed for primary and secondary biopsychosocial outcomes. Although the programme appears promising, the exploratory design of this study warrants more rigorous intervention testing following suggested programme improvement.

Effects of motor control exercise and patient education program in the management of chronic low back pain among community-dwelling adults in rural Nigeria: a study protocol for a randomized clinical trial

Background

The impact of chronic low back pain (CLBP) is disproportionally higher in rural Nigeria than in urban areas but lack access to rehabilitation. While exercise and education are commonly advocated interventions for the rehabilitation of CLBP, there is a paucity of community-based randomized clinical trials assessing their benefits among adults with CLBP in rural Nigeria. The purpose of this study is to investigate the effects of motor control exercise (MCE) and patient education (PE) in the management of CLBP among community-dwelling adults in rural Nigeria.

Methods

This is an assessor-blind, three-arm parallel randomized clinical trial and will be conducted at Tsakuwa Primary Health Care Center in Kano, Northwestern Nigeria. One hundred and twenty adults with CLBP will be recruited and randomized to one of three intervention arms; MCE plus PE, MCE, or PE groups. The MCE will be administered twice a week for 8 weeks while the PE will be provided once a week for 8 weeks. Participants will be assessed pre-intervention, immediately post-intervention and at 3-month post-intervention. Primary outcomes will be pain intensity and functional disability. Secondary outcomes will be quality of life, fear-avoidance beliefs, pain catastrophizing, back beliefs, global perceived recovery, and physical performance.

Discussion

This will be the first community-based trial to assess the benefits of exercise and education in the management of CLBP among adults in rural Nigeria. The study may provide a relatively inexpensive, assessable, and effective alternative intervention for reducing CLBP disability in a low-resource rural Nigerian community. Trial registration:This study is registered at ClinicalTrial.gov and the trial registration number is NCT03393104.

Translation, cross-cultural adaptation, and psychometric properties of the Hausa version of the Fear-Avoidance Beliefs Questionnaire in patients with low back pain

Background and aims

The Fear-Avoidance Beliefs Questionnaire (FABQ) is the most widely used self-reported measure of fear-avoidance beliefs about work and physical activity in low back pain (LBP). However, there is no Hausa version for use in patients with LBP. This study aimed to translate, cross-culturally adapt, and test the psychometric properties of the Hausa version of the FABQ in patients with LBP.

Methods

The Hausa form of FABQ was developed using a forward-backward translation procedure according to recommended guidelines. The pre-final version of the questionnaire was pre-tested on 10 patients with acute LBP and 10 patients with chronic LBP. Psychometric testing was performed in 70 patients with acute LBP and 130 patients with chronic LBP. Reliability was assessed using internal consistency (Cronbach α) and test-retest reliability through intraclass correlation coefficient (ICC). Construct validity was assessed by exploratory factor analysis and divergent validity (Spearman rank correlation coefficient). Responsiveness was also investigated on 40 patients with chronic LBP.

Results

The Hausa version of the FABQ was successfully translated and proved to be well-understood. The internal consistency was adequate for the questionnaire (0.773) and its physical activity (0.816) and work (0.606) subscales. Test-retest reliability was excellent with an ICC value of 0.928 for the questionnaire and values of 0.901 and 0.863 for the physical activity and work subscales, respectively. Exploratory factor analysis yielded a three-factor structure in both acute and chronic LBP samples explaining 66.4% and 58.6% of the total variance, respectively. The first factor represents fear-avoidance beliefs due to work, the second factor represents fear-avoidance beliefs due to physical activity whereas the third factor represents the fear that pain aggravates due to work. Divergent validity showed moderate to weak correlation between the questionnaire and pain intensity (r=0.502), disability (r=0.415), lumbopelvic motion (r=0.00). The physical activity and work subscales weakly correlated (r=0.280). The effect size and standardized response mean were moderate to small with the work subscale having the lowest effect size (0.34) and standardized response mean (0.34) values. The MDC of the questionnaire was 5.4 points. The questionnaire had no ceiling or floor effects.

Conclusions

The FABQ was successfully translated into Hausa and cross-culturally adapted with acceptable psychometric properties similar to those of existing versions. The results suggest that the Hausa FABQ can be used to evaluate fear-avoidance beliefs about LBP in Hausa-speaking population for both clinical and research purposes.

Motor control exercise and patient education program for low resource rural community dwelling adults with chronic low back pain: a pilot randomized clinical trial

This pilot randomized clinical trial assessed the feasibility of implementing motor control exercise (MCE) and patient education (PE) program for the management of chronic low back pain (CLBP) in a low resource rural Nigerian community. Thirty patients with CLBP were recruited and randomly assigned to MCE, PE, or MCE plus PE groups. The MCE program was provided twice a week while the PE program was provided once a week all for 6 weeks. Feasibility was assessed through recruitment rate, treatment compliance, retention/dropout rate, report of adverse events, perceived helpfulness, overall satisfaction, and clinical outcome of pain (numeric pain rating scale) and functional disability (Oswestry Disability Index). Many patients were willing to participate in the study and the recruitment rate was 77%. Treatment compliance in all the three groups were >65% for supervised treatment sessions and <50% for prescribed home program. Retention rate was high and greater overall satisfaction with the interventions was reported. Compared with the baseline, all the three groups improved significantly in pain and disability (P<0.05) after 6 weeks. Pairwise comparison revealed that the MCE plus PE group was superior to the PE group for pain and to the MCE for disability (P<0.05), with large effect size. It was concluded that the designed interventions are promising and conducting a full-scale randomized clinical trial in the future is feasible to confirm the effectiveness of the interventions for the management CLBP in rural Nigeria. (Trial registration: ClinicalTrials.gov, NCT03398174).

Unconventional Practitioners' Causal Beliefs and Treatment Strategies for Chronic Low Back Pain in Rural Nigeria

Chronic low back pain (CLBP) is highly prevalent and CLBP disability reinforces poverty and Nigerian rural-urban inequality. Most rural Nigerian dwellers with CLBP consult unconventional practitioners due to difficulty in accessing conventional health care. This interaction may influence back pain beliefs and behaviours, and health outcomes including disability. In line with the recent Lancet Low Back Pain series call to address widespread misconceptions in the population and among health practitioners about low back pain, this study explored the beliefs and management strategies of unconventional practitioners consulted by people living with CLBP in rural Nigeria. Qualitative semi-structured face-to-face individual interviews. Thematic analysis of transcripts was performed using the Framework approach. Nine unconventional practitioners consented to participate in this study. Patent medicine sellers and herbalists had biomedical beliefs about CLBP and encouraged passivity and drug dependence in patients. Pastors adopted spiritual or biopsychosocial-spiritual management models and either encouraged spiritual CLBP causal beliefs and spiritual healing expectations; or patients' resilience and acceptance, respectively. Unconventional practitioners' CLBP beliefs and management strategies aligned with the beliefs and coping strategies of patients who consulted them. Unconventional practitioners' beliefs and management strategies may therefore contribute to the adverse impact of CLBP in rural Nigeria.