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Back Breaking Beliefs.pptx
- 1. Back-breaking Beliefs A retrospective analysis of survey data Carla Rauseo, PT, DPT, CSCS
- 2. Disclosures
- 3. Background • LBP is still the number 1 cause of disability worldwide • The biggest increase in prevalence has been in low-middle income countries • It is the third largest cause of years lived with disability in the Caribbean • Patient beliefs have a strong influence on outcomes • Unhelpful beliefs lead to behavioural strategies that facilitate the chronicity of LBP and subsequent disability • Failing to address these beliefs is considered low-value care (Buchbinder et al, 2020; Wu et al, 2020; Bonfim et al, 2021
- 4. Purpose To investigate the beliefs of patients with low back pain receiving physical therapy in a private outpatient facility in Trinidad and Tobago
- 5. Participants • A convenience sample of patients with low back pain at the first physical therapy evaluation • With or without leg symptoms • Private practice clinic • Aged 20-80 years • No strict inclusion/exclusion criteria
- 6. Methods • Descriptive retrospective analysis of survey data ✴ Back Pain Attitudes Questionnaire (Back-PAQ) ✴ Patients attending PT during 2018-2019 • Descriptive statistics were used to analyse data
- 7. The Back-PAQ • Measures beliefs associated with back pain • 5-point Likert Scale • Themes: • Protection; Vulnerability; Pain; Special Pain; Activity; Prognosis
- 8. 8 Unhelpful vs Helpful Beliefs to Recovery COLUMN 1 COLUMN 2 COLUMN 3 HELPFUL BELIEFS The back is easy to injure Green marketing is a practice whereby. We need strong muscles and good posture to protect the back Lifting without bending the knees is not good for the back Green marketing is a practice whereby. It is safe to move and exercise with back pain Thoughts and feelings can influence intensity of back pain Stress in your life can make back pain worse Once you have a back problem there is a lot you can do about it Pain is not a good indicator of damage I am not my MRI or X-ray! UNHELPFUL BELIEFS To effectively treat LBP you need to know exactly what is wrong You can injure your back if you are not careful It is difficult to enjoy life if you have back pain
- 9. Results • 128 total surveys received • 62 fully completed surveys • 47 had 1-2 incomplete items but overall scores were calculated • 14 discarded from overall score but used in item/theme scores • 5 completely discarded
- 12. Most Unhelpful Beliefs RANK THEME BELIEF MEAN SCORE 1 PROTECTION Good posture is important to protect your back 4.89 2 PROTECTION It is important to have strong muscles to support your back 4.81 3 SPECIAL PAIN To effectively treat you back, you need to know exactly what is wrong 4.81 4 SPECIAL PAIN It is important to see a health professional when you have LBP 4.78 5 VULNERABILITY You can injure your back and only become aware of it sometime later 4.61
- 13. Most Helpful Beliefs RANK THEME BELIEF MEAN SCORE 1 VULNERABILITY Your back is well designed for the way you use it in daily life 1.97 2 VULNERABILITY Your back is one of the strongest parts of your body 2.22 3 ACTIVITY If you have back pain you should try to stay active 2.31 4 PAIN Stress in your life can make back pain worse 2.5 5 VULNERABILITY Bending your back is good for it 2.61
- 14. Implications and Recommendations • EDUCATE; DON'T PERPETUATE! • Messages about NSLBP should be adapted to foster more helpful beliefs. • Target unhelpful beliefs about protection, vulnerability and the special nature of LBP • Explanation of imaging studies in non-threatening manner • Promotion of the safety and value of exercise in management of LBP
- 15. Implications and Recommendations • Professional education • Public health campaigns • Nuanced messages
- 16. Limitations and Suggestions for Future Research • Weak observational study • Future research: • Stronger comparative/correlational designs with covariates • Qualitative studies to certain effects of culture/religion on beliefs • Expand to Caribbean
- 17. References 1. Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020;8(6):299-299. doi:10.21037/atm.2020.02.175. 2. Stevans JM, Delitto A, Khoja SS, et al. Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Netw Open. 2021;4(2):e2037371. doi:10.1001/jamanetworkopen.2020.37371 3. Raspe H, Hueppe A, Neuhauser H. Back pain, a communicable disease? Int J Epidemiol. 2008;37(1):69-74. doi:10.1093/ije/dym220 4. McCabe E, Jadaan D, Munigangaiah S, Basavaraju N, McCabe JP. Do medical students believe the back pain myths? A cross- sectional study. BMC Med Educ. 2019;19(1):235. doi:10.1186/s12909-019-1676- 5. Darlow B, Forster BB, O’sullivan K, O’sullivan P. It is time to stop causing harm with inappropriate imaging for low back pain. Br J Sports Med. 2017;51(5). http://www.cfwi.org.uk/. 6. Buchbinder R, Van Tulder M, Öberg B, et al. Viewpoint Low back pain: a call for action. Lancet. 2018. doi:10.1016/S0140- 6736(18)30488-4 7. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm, hard to heal: Patient views about the back. Spine (Phila Pa 1976). 2015. doi:10.1097/BRS.0000000000000901 8. Goubert L, Crombez G, De Bourdeaudhuij I. Low back pain, disability and back pain myths in a community sample: Prevalence and interrelationships. Eur J Pain. 2004. doi:10.1016/j.ejpain.2003.11.004 9. Urquhart DM, Bell RJ, Cicuttini FM, Cui J, Forbes A, Davis SR. Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women. BMC Musculoskelet Disord. 2008;9(May 2014). doi:10.1186/1471- 2474-9-148 10. Darlow B, Perry M, Mathieson F, et al. The development and exploratory analysis of the Back Pain Attitudes Questionnaire (Back- PAQ). BMJ Open. 2014;4. doi:10.1136/bmjopen-2014 11. Pierobon A, Policastro PO, Soliño S, et al. Beliefs and attitudes about low back pain in Argentina: A cross-sectional survey using social media. Musculoskelet Sci Pract. 2020;49. doi:10.1016/j.msksp.2020.102183 12. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013. doi:10.1370/afm.1518 13. Darlow B. Beliefs about back pain: The confluence of client, clinician and community. Int J Osteopath Med. 2016;20(April):53-61. doi:10.1016/j.ijosm.2016.01.005 14. Main CJ, Foster N, Buchbinder R. How important are back pain beliefs and expectations for satisfactory recovery from back pain? Chris. Best Pract Res Clin Rheumatol. 2010;24:205-217. doi:10.1016/j.berh.2009.12.012
Editor's Notes
- Hello everyone, My sincere thanks to TCOS for once again allowing me to share my work with you. Today I’ll be presenting the results of a small study I did at Total Rehab on the beliefs of patients coming to the clinic with low back pain.
- There is a vast amount of discussion on the management of LBP in the literature, but despite this, LBP is still the #1 cause of LBP in the world, and the biggest increase in prevalence has been seen in the low-middle income countries. LBP is the third largest cause of disability in the Caribbean. LBP is multifactorial in nature, and often with little correlation to biomechanical factors or structural damage. This presents a challenge to providers who must consider a multitude of biopsychosocial factors in the provision of patient-centred care for the condition. Part of these factors include patient beliefs. Patients often present with biomedical beliefs that lead to unhelpful behavioural strategies aimed at protecting the back and ignoring other beneficial behaviours such as stress management, an active lifestyle and sleep. Given the importance that these beliefs have on patient outcomes, failing to address these beliefs in the management of low back pain, is considered low-value care that perpetuates the cycle of pain and disability associated with the condition The common sense model (Goldsmith, 2019)
- So in order to provide better care for this population, we need to understand their beliefs surrounding LBP. While there are studies that investigate the beliefs of persons with this condition, most of these studies are done in developed countries. There are no studies that look at beliefs among patients with back pain in the Caribbean, where beliefs may be subject to different cultural influences. Therefore, the purpose of this study is to investigate the beliefs of patients with low back pain receiving physical therapy in a private outpatient facility in Trinidad and Tobago
- During the years of 2018-2019, patients between 18-80 years visiting Total Rehabilitation Centre with a diagnosis of LBP, with or without referred or radicular pain or radiculopathy were included in this study.
- At that time before the pandemic, all patients with LBP coming to Total Rehab for that diagnosis completed the Back Pain Attitudes Questionnaire as an outcome measure that was used in their treatment. For this study, I returned to the Back-PAQ measures in a retrospective analysis of these surveys. Descriptive statistics were used to analyse the data.
- So this slide is just a little bit of background information on the Back-PAQ to better understand the measure. This questionnaire was elaborated from a qualitative study including people with acute and chronic LBP, which explored underlying beliefs associated with pain-related fear, low outcome expectations and catastrophizing (Darlow et al., 2013). Based on this study, six themes were identified and were used to create this 34 items questionnaire, each question belonging to one theme. The themes were ‘the vulnerability of the back’ (vulnerability), ‘the need to protect the back’ (protection), ‘the correlation between pain and injury’ (pain), ‘the special nature of back pain’ (special pain), ‘activity participation while experiencing back pain’ (activity) and ‘the prognosis of back pain’ (prognosis). Each item scores on a five-point Likert scale (False, Possibly false, Unsure, Possibly true, True), with higher scores meaning more unhelpful beliefs. The total score ranges from 34 to 170 points. For the analysis of this study, I collapsed the False and possibly false categories into one “False” category and did likewise with the “true” and “possibly true” categories, collapsing them into a “true” category.
- So let us operationalise false (or helpful) beliefs and true or unhelpful beliefs. As you can see here, the unhelpful beliefs centre around the need to protect the back and thinking that the back is weak and vulnerable, and the need to obtain a specific diagnosis, and the idea that back pain is a “special kind of pain” that makes it challenging to enjoy life. The helpful beliefs are more optimistic and promote the facts that it is safe to move, even when there is pain. These recognise the facts that emotions and stress have a big impact on how pain is experienced, and the fact that pain and damage do not correlate well, which has implications for how patients interpret their imaging studies.
- In total 128 surveys were received. 5 were discarded because they were incomprehensible. There were 62 fully completed surveys. 47 surveys had 1-2 items missing. A score of 3 (unsure) was given to these items, and the total score and item scores were used in the final analysis. 14 surveys had more than 2 items missing. These surveys were not used in the total score analysis, but those items that were answered, were used in the item analysis.
- This is a stacked bar graph of the proportions of helpful vs unhelpful beliefs per question. The red refers to the unhelpful beliefs and the blue to the beliefs that are helpful to the recovery from LBP. They yellow category refers to those who scored the question as “unsure.” As you can see, there is a very large proportion of unhelpful beliefs compared to the helpful beliefs.
- Generally, the sample studied had unhelpful beliefs to the recovery from back pain, as we can see here from the total score, and the means and median scores of most themes are above 3, into the unhelpful half of the graph. The themes with the most unhelpful beliefs are protection and the belief that back pain is a special kind of pain. This is similar results to other studies conducted by Christie in Switzerland and by Darlow in New Zealand. There is also a wide range of beliefs regarding activity and low back pain, and the relationship between pain and injury as seen in the orange and dark blue boxes respectively.
- This is a table of the most unhelpful beliefs based on the mean score of each item on the BACK-PAQ. Again we see that the themes of protection and special pain are dominating at the top with the idea that good posture is important and it is necessary to have strong muscles to protect the back. This related to the idea that core strengthening is important for back pain, but studies have shown that it is no better than other forms of exercise. In terms of special pain, we can see here that the need to get professional assistance to manage back pain is important. This has implications for public health, as if we can change such beliefs to support a greater internal locus of control within the patient, and promote self management, it is possible that we can affect the problem that is LBP on a public health level. But that’s another discussion.
- This chart shows the lowest scoring statements on the Back-PAQ, which indicate the most helpful beliefs. We can see here that people do not think that the back is that vulnerable, as per agreeing that the back is strong and well designed for use in daily life. Interesting that while the back is seen to be not very vulnerable, there are strong beliefs surround its need to be protected. Raises questions about an understanding of what LBP really is and the powerful myths surrounding the condition. Something for further investigation. As we can see, there are generally good attitudes towards exercise and movemen, and the idea that pain may be affected by other psychosocial factors such as stress and emotions and worry.
- Given the fact that patient beliefs about LBP have an impact on outcomes, it is important, as healthcare providers, that we try to elicit these beliefs and address them in the clinical encounter. From this study, whose outcomes are similar to other studies, it is recommended that we target unhelpful beliefs relating to protection and the “special nature” of LBP, while addressing other patient-specific beliefs in the clinical encounter It is also recommended that we promote safety surrounding movement and the importance of exercise in the management of LBP, that the back is strong and well designed for what it is needed to do. I often tell my patients that “motion is lotion.”
- Setchel et al reported that most patients learn their unhelpful beliefs from their providers. Therefore, it is crucial that our professional education addresses pain neuroscience, the biopsychosocial components of back pain and that management techniques are seeped in scientific inquiry. Medical and allied health schools must properly equip their students to deal with the multi-faceted nature of LBP so that the perpetuation of the myths and unhelpful beliefs can stop with the healthcare provider. Schools do not do nearly enough of this. In fact, McCabe et al found prevalent misconceptions about LBP among medical students in 2019. Public health campaigns are also crucial to changing beliefs at the population level. There have been very successful campaigns in Alberta in Canada and also in Australia. However, nuanced messages are important here, as red flags must be considered. Individuals need to know what to look for to understand when they should see a physician.
- Although these results are supported by larger studies, this is a very weak observational study, that is purely descriptive. No other data was analysed besides Back-PAQ scores, and data was gathered from only one private outpatient facility, whose clientele can self-pay. These issues limit generalisability to the greater population and challenge the validity of the study. Further research should employ a more robust design, that can incorporate covariates such as SES, occupation, age, gender, etc to look at the variation in beliefs depending on these variables.