Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey

Low back pain (LBP) is the leading musculoskeletal problems contributing significantly to personal and community health burden [1]. Around 40% of people globally experience LBP. For many it is persistent, recurrent and bothersome [2–4]. Reducing the impact of ongoing LBP is a major research priority – with research of trajectories over time an underexplored aspect [5]. Over the last two decades, there has been a comprehensive shift in the understanding of why LBP becomes persistent or recurrent [6, 7]. A large body of research has taken understandings of persistent pain from the predominantly biomedical model that argues LBP is reducible to anatomical or biomechanical factors, to a biopsychosocial model where persistent pain is considered to be largely modified/maintained by a complex combination of biological, psychological and social factors [8–11] that interact. For example, moderation of the biological processes of sensitisation by psychosocial features [10, 12–14], or the development of ongoing musculoskeletal conditions due to avoidance of activity resulting from a fear of exacerbating pain/damage (e.g. the Fear-Avoidance Model outlined by Lethem, Slade, Troup and Bentley [15]).

The clear linking of psychosocial factors with persistent pain highlights that how people think about their pain is an important predictor of severity and chronicity [16, 17]. Amongst other factors, pain beliefs contribute to prognosis [18]. For example, in a study on 1591 patients attending general practices, poor clinical outcomes 6 months after initial consultation were more likely in individuals who expected their LBP to last a long time, perceived serious consequences, and believed they had little control over their pain [19]. Further, excessively negative orientation towards pain correlates with greater pain [20, 21]. People’s beliefs about how physical activity and work affect their LBP account for variance in pain and disability [22–24]. Recent best practice guidelines reflect that understanding and addressing these pain beliefs is an important component of reducing the burden of LBP (e.g., [25]).

This psychosocial understanding of painful conditions, including LBP, is inconsistently reflected in the beliefs and practices of clinicians or people with LBP. Parsons, Harding, Breen, Foster, Tamar, Vogel and Underwood [26] reviewed 22 qualitative studies concluding that physician’s beliefs about painful musculoskeletal conditions were primarily biomedical and, in a cross-sectional study of 453 musculoskeletal physiotherapists, Bishop and Foster [27] highlighted that while these clinicians often recognised the importance of psychosocial factors they contradicted evidence based best practice guidelines by frequently highlighting biomedical over psychosocial factors of LBP cases. Observational studies show clinicians and patients consider risk factors for a sudden onset of LBP to be mainly biomechanical and rarely endorse psychosocial risk factors [28, 29]. Little research has considered why these beliefs and practices persist regarding LBP despite evidence this view is outdated and inaccurate.

There is insufficient knowledge about why people (including clinicians and individuals with the condition) adopt or resist considering pain beliefs (and other psychosocial factors) as contributors to ongoing LBP. One possibility is that the biopsychosocial approach involves a paradigm shift, which challenges (amongst other things) existing biomedical structures and beliefs. Change would necessarily need to be reflected in people’s underlying systems of belief. Little research has investigated these belief systems. The primary aim of this study was to investigate what patterns of thinking (discourses) underlie what people say caused their LBP to persist or recur. The secondary aim was to investigate where people with the condition considered these patterns of thinking came from.

We report results in three sections: analysis of participant responses to the first and second questions and then the cross analysis of the two.

The key finding of this study is that people with LBP predominantly consider their condition to persist or recur because of biomechanical or structural reasons (machines that can be broken, and if not ‘fixed’ will continue to be in pain/damaged). Participants discussed factors such as joint damage, nerve injury and/or muscle imbalance as the main reasons why their LBP was ongoing. While there were counter-narratives, these were much less common. This finding indicates that overwhelmingly individual’s beliefs about their LBP are aligned with (Western) traditional biomedical discourses of health and the body. A secondary finding of this study was that participants overwhelmingly considered health professionals, and the internet to be sources of their understandings. This highlights the likely value of ensuring good quality information from both sources. This study can only discuss where people with LBP say they learnt about the causes of their condition and thus findings may not reflect what health professionals believe or do in their healthcare practice, nor the quality of internet resources. However, as discussed, other studies have shown that health professionals, such as physicians [26] and physiotherapists [27], demonstrate primarily biomedical pain beliefs and practices, and that this is strongly associated with the beliefs of their patients [36]. This primarily Western belief system has also been shown to have potential effects across cultures [37].

Why do the LBP-related discourses found in this study matter? There is considerable evidence to suggest harm is done by this way of thinking. People might modify their behaviour in a manner that may worsen their LBP, placing emphasis on avoiding causes that are not relevant. Greater beliefs in the anatomical causes of persistent pain have been related to greater beliefs in physical disability [17] and thus avoidance of activities. There are strong associations between low perception of controllability of LBP and poor clinical outcomes [19] and this belief is likely to underpin strongly negative beliefs about pain. Encouragingly, some people have a more complex understanding of LBP, aligned with more contemporary biopsychosocial discourses, but this was rare in our data and is often largely overshadowed by biomedical discourses.

Similar findings about beliefs of individuals with LBP have been reported elsewhere. For example, Bunzli, Watkins, Smith, Schütze and O’Sullivan [38] synthesized 18 studies with 713 participants with chronic LBP, highlighting the social construction of the condition, and its psychosocial impact. The study discussed that people with chronic LBP often adhere to a biomedical model of their condition and that this results in them “putting their lives on hold” until they receive what they believe to be a viable (biomedical) diagnosis/prognosis. Consistent with our findings, the synthesis suggests that the potential harm in these beliefs is that people may undertake a misdirected search for legitimacy that prevents both acceptance of the condition as well as attention to more evidence based contributors to continuing LBP. The present findings strengthen these observations using a novel approach to uncover underlying discourses and contribute to new understandings of the trajectories of LBP. The present study also reveals that biomedical discourses are prevalent despite many efforts towards changing these beliefs (e.g., [39]), and potential positive clinical outcomes of changing them (e.g., [40]).

Interpretation of these findings poses challenges. It is important to acknowledge we must take seriously the perspectives of people living with LBP [41]. Not doing so has led to issues in the past, such as inadvertent stigmatisation [42] and inadequate attention to the often-complex psychosocial aspects of living with ongoing conditions [43, 44]. If individual perspectives are predominantly produced by an outdated (or at least, incomplete) healthcare paradigm, it is necessary to consider how this might be challenged.

The findings of the discourse ‘LBP as very negative’ were often closely linked with the understanding of the body as ‘a machine that can break’ and as ‘permanent’. This close relationship highlights further that underlying discourses have important effects on beliefs about LBP, which in turn affect prognosis. The conceptualisation of LBP as very negative found here and elsewhere [21] is not surprising given the underlying discourses of the body as a machine that can break, and LBP as permanent. Yet this conceptualistation contrasts with the fact that LBP is so common as to say that it is normal [2], and persistence/recurrence are also very common/normal [4]. Although not directly researched regarding LBP itself, other conditions involving injury, illness and disability have been conceptualised differently including positive possibilities such as those of ‘well-being within illness’ [46], hope [47], and acceptance [48]. These possibilities for more positive reconceptulisations might be a relevant to consider for future work in the LBP population. If LBP was perceived as relatively normal (although at times unpleasant) rather than something to always ‘fix’, potentially harmful beliefs and their negative psychosocial and clinical implications might be avoided.

There are a number of important factors to consider when interpreting the results of this study. Although survey formats have some limitations in qualitative research due to the lack of direct interaction, there are also benefits - due to the online nature of this study, participants were likely to have felt comfortable expressing their views freely. The study was Australian, consequently, care must be taken in extrapolating results to other settings – although similar Western countries are likely to find many contextual similarities. The investigatory team was comprised of researchers with a physiotherapy background (and one social worker). Physiotherapists would be expected to have views on LBP grounded in biomedical aspects and may give less attention to psychological and socio-cultural aspects [49]. Efforts were made to reduce any effect of this viewpoint by assembling a team that includes a social worker (MN), a researcher with graduate training in psychology who focuses on the socio-cultural elements of health (JS), and sourcing external review. Future research can build on the findings of this study. A similar research design could be conducted in different cultural contexts to investigate how LBP is conceptualised elsewhere.

Finding that biomedical discourses underlie most thinking about LBP has implications for how it is possible to change. These discourses challenge deep cultural understandings of what it means to have a body and to be human, including the Cartesian notion of a distinct body/mind division [50]. Changing such deeply held beliefs will not be simple – doing so challenges established institutions of healthcare and the very core of what it means to be a person with LBP, a health researcher, and a clinician [51]. This study provides a strong basis for challenging deeply held traditional beliefs and interventional studies testing these as methods for reducing the burden of LBP are indicated.

We do not want to deny possible biomedical causes of LBP or permanence of the condition. Rather, our aim is to highlight that these discourses are not necessarily true for everyone and can set people up for damaging pain beliefs such as fear avoidance. Described biomedical causes in the current study included various musculoskeletal injuries/diseases and biomechanical factors. Although some biomedical factors have support as the initial cause of LBP [13], there is currently little support for them causing ongoing or recurrent LBP which, as discussed, is likely to be more biopsychosocial and multifactorial [8–11]. There is thus a disconnection between cause of initial injury and the reason it is ongoing, which is worthy of further investigation.

The findings of this study support and add to other studies discussing that biomedical understandings of LBP persist and recur in those who live with musculoskeletal pain conditions. Seeking to understand underlying discourses provides a novel perspective which looks past singular causes to consider the systems of thought that make an adherence to particular patterns of beliefs possible. The findings of this study support a complex and thorough approach to shifting understandings of LBP beyond biological causes to consider psychosocial, cultural and institutional factors that constitute LBP. Finally, our finding that patients believe they learnt their potentially harmful understandings from health professionals encourages further interventions to shift thinking within healthcare.