Empowering Patients To Use Self-Management Strategies

Welcome back to SpineIQ’s BackBlog! For the past couple of weeks, we have been discussing one of the main topics that is consistent throughout clinical practice guidelines for low back pain: imaging. This week, we discuss another one of the topics that is consistent throughout clinical practice guidelines for low back pain: self-management.1 A group of researchers that are leading pragmatic clinical trials for chronic pain, including Dr. Goertz, recently wrote an article with a call to action to improve the implementation of self-management strategies for chronic pain. In this blog, we summarize their call to action and provide clinically relevant suggestions to empower patients to use self-management strategies.

What is self-management?

Self-management has been defined as intentionally attempting to manage your own pain experience.2 The potential for self-management is associated with self-efficacy, which is the belief that one can achieve successful pain management. In a previous blog, we discussed that patients tend to feel positive towards self-management, but self-doubt can decrease this positive feeling towards self-management. This is where the provider plays an extremely important role in being able to reassure, foster increased resilience, and empower the patients to work through these periods of self-doubt.3

What are the clinically relevant competencies for self-management?

In the article by Kerns et al. titled “self-management of chronic pain: psychologically guided core competencies for providers”, the authors discuss clinically relevant competencies for self-management. These include the 4 overarching competencies of recognizing the multidimensional nature of pain, pain assessment, pain management, and the clinical and social context. Each overarching competency provides clinicians with suggestions on how to empower patients and promote self-management strategies. Some of the clinically relevant suggestions are:

  • Use active listening and motivational interviewing skills to educate on the multidimensional, biopsychosocial nature of pain while acknowledging the patients unique pain experience
  • Reassure patient by letting them know that they are in charge, can manage their pain and the effect it has on their life
  • Through a shared decision making process, identify barriers and facilitators to self-management and build a plan to empower self-management
  • Promote healthy behaviors (e.g., exercise and nutrition), while actively listening and discussing potential barriers to increasing healthy behavior and building a plan through shared decision making to limit the effect of those barriers
  • When appropriate, ask to engage friends/family that can help empower patients to get back to doing the things they love to do

Conclusions

The evidence is strong for the importance of self-management for chronic pain. This has led to consistent clinical practice guideline recommendations encouraging clinicians to promote self-management. However, the authors of this article acknowledge the need of a call to action in the implementation of self-management strategies in routine clinical practice. The authors list two key factors that have influenced the slow up-take of self-management for chronic pain: training and reimbursement. We hope that the clinically relevant suggestions in this blog, along with previous blogs on (1) guidance for self-management, (2) how to build successful self-management plans, and (3) barriers and facilitators to supporting self-management, can help increase the knowledge and training of self-management among clinicians. We recognize that this is a very difficult challenge for clinicians, however even one successful patient who has been successful in self-management will provide the momentum and encouragement to both the patient and the clinician. The reward of self-management which is gratifying for the patient and clinician, will yield confidence from staff and other patients who will soon recognize that this practice and practitioner are different.

References:

  1. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  2. Medicine I of. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.; 2011. doi:10.17226/13172
  3. Bourke MJ, Ferguson D, Cooke M. Patient Experiences of Self-Management for Chronic Low Back Pain: A Qualitative Study. Phys Ther. Published online March 30, 2022:pzac030. doi:10.1093/ptj/pzac030

 

 

Low Back Pain Imaging: Are Patients & Clinicians on the Same Page?

Welcome back to SpineIQ’s Back Blog! Last week, we summarized the overarching literature surrounding clinicians’ beliefs of barriers and facilitators for guideline concordant imaging of low back pain. Many of the results surrounded clinician beliefs about patient expectation for low back pain.1,2 A systematic review by Sharma et al. was conducted to assess whether these beliefs by clinicians are concordant with patients’ beliefs about imaging for low back pain.3 This study titled, “Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis” found 69 studies that explored patient or general public beliefs about diagnostic imaging for low back pain and compared the beliefs to clinician beliefs about patients. In this blog, we summarize the findings and discuss the clinically relevant results.

Findings

After screening 6109 studies, 69 studies were included and analyzed in this systematic review. Several themes were found throughout the studies with moderate to high confidence. These themes found beliefs that were concordant and discordant between patient and clinician.

Concordant beliefs between patient and clinician:

  • Imaging is helpful to find and locate the pathoanatomical source of low back pain (high confidence)
  • Findings on imaging legitimized (patient belief) and reassured (clinician belief) the low back pain experience

Discordant beliefs between patient and clinician

  • Some clinicians were aware that imaging is not helpful for diagnosing non-specific low back pain, but patients were not aware of this
  • Some clinicians believed that patients would be reassured by a negative test, however, negative tests distressed patients since it “showed nothing”
  • Patients felt scared if the findings of the imaging were described as permanent, degenerative, or irreversible and some clinicians were unaware of this possibility

Conclusions

These findings add context to our blog summarizing clinicians’ beliefs about barriers and facilitators to guideline concordant low back pain imaging. There are 5 patient beliefs that were high or moderate confidence with 2 of them concordant and 3 discordant with clinicians’ beliefs. While some clinicians were aware that imaging is not a helpful diagnostic tool and can lead to negative consequences (e.g., radiation or waste of resources), not all clinicians were aware of this, and no patients were aware. In order to inform patients, informational one-page handouts, posters in waiting area, and evidence-based information on the website or through patient facing weekly blogs may increase patient awareness of the evidence surrounding low back pain imaging.4 For clinicians that are not aware of the most up-to-date evidence surrounding low back pain imaging, it is possible that dissemination of evidence for the busy clinician may be useful.5 Clinics with numerous clinicians can dedicate a weekly time to discuss evidence or give presentations in order to stay up-to-date with the current evidence. Finally, clinicians were not aware that both “inconclusive” and “degenerative” findings could lead to stress for patients. This is a negative consequence that clinicians should be aware when deciding whether to order imaging for low back pain and should communicate the possibilities of these findings with their patient prior to ordering the imaging. Through conversation about the low correlation between imaging findings (whether inconclusive or degenerative) and prognosis for low back pain, the patient may be less stressed and uncertain when imaging results return or best-case scenario, patient chooses to not want imaging since the findings are unlikely to provide useful information on management or prognosis.

References

  1. Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of Magnetic Resonance Imaging. JAMA Intern Med. 2013;173(9):823-825. doi:10.1001/jamainternmed.2013.3804
  2. Downie A, Hancock M, Jenkins H, et al. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. Br J Sports Med. 2020;54(11):642-651. doi:10.1136/bjsports-2018-100087
  3. Sharma S, Traeger AC, Reed B, et al. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020;10(8):e037820. doi:10.1136/bmjopen-2020-037820
  4. Sharma S, Traeger AC, Tcharkhedian E, Middleton PM, Cullen L, Maher CG. Effect of a Waiting Room Communication Strategy on Imaging Rates and Awareness of Public Health Messages for Low Back Pain. Int J Qual Health Care. 2021;(mzab129). doi:10.1093/intqhc/mzab129
  5. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189. doi:10.7326/0003-4819-154-3-201102010-00008

 

 

Tips To Overcome Barriers Surrounding Unnecessary Imaging

Welcome back to SpineIQ’s BackBlog! As most of you know, we are strong advocates for appropriate care for spinal pain as outlined in numerous evidence-based guidelines. Such guidelines have been created by a variety of organizations with the goal of assisting clinicians in in adhering to best practices for care.1 The majority of clinical practice guidelines have recommended conservative care, such as manual therapy and exercise, as first-line treatment for spinal pain.2 Another consistent recommendation is to avoid imaging (x-ray or MRI) for the majority of patients who are likely experiencing non-specific low back pain, defined as low back pain with no specific cause.3,4 Studies have shown that nearly half of the imaging currently ordered for low back pain is unnecessary, leading the Choosing Wisely campaign chose it as one of its aims to reduce low value care.4,5 In this week’s BackBlog, we summarize the research on barriers and facilitators to following clinical practice guideline recommendations on imaging. Our goal is to ensure that this critically important but overused diagnostic tool is only utilized in those instances when it is appropriate, such as suspicion of underlying disease.

Barriers and Facilitators

Several studies have qualitatively assessed clinicians’ thoughts on barriers and facilitators to appropriate low back pain imaging. These studies have been conducted in different health care settings (e.g., primary care and emergency department) and different countries. However, the same themes of barriers and facilitators are reported, including the following:

  • Patients want imaging and pressure clinicians into providing it (barrier)
    • Alternative – patients may be reassured by education on why imaging is not necessary in their particular situation
  • Reassuring the patient (barrier)
    • Alternative – patients may be reassured by the confident evidence-based approach to diagnosis and treatment taken by the clinician
  • Lack of time to inform patients that imaging is not needed (barrier)
    • Alternative – indicating that imaging is not needed initially but may be considered later may reassure the patient that the clinician is aware of other diagnostic options.
  • Fear of missing a serious illness (barrier)
    • Alternative – it is important that the benefits vs risks be considered for each individual patient. The benefit of catching a rare underlying condition must be weighed against the risk to the patient of unnecessary imaging (cost and the potential for worse outcomes)5
  • Using one-page patient handouts to help inform the patient in a timely manner (facilitator) Patient information sheets that are discussed with the patient and noted in the chart demonstrates that imaging was not overlooked but rather not deemed appropriate at this particular time.
  • Staying up-to-date with the evidence increases confidence in not ordering imaging (facilitator).

Conclusion

There are numerous self-reported barriers and facilitators that influence a clinician’s imaging behaviors related to low back pain. While some patients are likely to want imaging regardless, there are things that clinicians can do to lower this expectation. For example, purposefully using the poster and wall area in the clinic to hang informational posters focused on evidence-based information about when imaging is unnecessary and the cascade of unnecessary care that can happen when inappropriate imaging is ordered can help inform patients while they’re waiting.6 Clinicians can also have one-page handouts ready for patients to inform them in a timely manner. While clinicians report that they believe patients will be reassured by imaging, studies show that this is often not the case. Instead, patients are often confused when imaging does not identify a specific cause for their pain.7 While ordering imaging may be faster in the short run, the time saved from ordering the imaging may be lost due to future conversations explaining why imaging findings don’t strongly correlate with symptoms or prognosis. Finally, some clinicians use imaging as a “fail-safe” to protect themselves from missing something. It is important, not only for the patient, but for the clinician to remember that less than 1% of low back pain is due to a threatening disease.8

Reference

  1. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  2. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  3. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189. doi:10.7326/0003-4819-154-3-201102010-00008
  4. Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low-Value Back Imaging Associated With The “Choosing Wisely” Campaign, 2012-14. Health Aff Proj Hope. 2017;36(4):671-679. doi:10.1377/hlthaff.2016.1263
  5. Delitto A, Patterson CG, Stevans JM, et al. Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial. eClinicalMedicine. 2021;34. doi:10.1016/j.eclinm.2021.100795
  6. Sharma S, Traeger AC, Tcharkhedian E, Middleton PM, Cullen L, Maher CG. Effect of a Waiting Room Communication Strategy on Imaging Rates and Awareness of Public Health Messages for Low Back Pain. Int J Qual Health Care. 2021;(mzab129). doi:10.1093/intqhc/mzab129
  7. Sharma S, Traeger AC, Reed B, et al. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020;10(8):e037820. doi:10.1136/bmjopen-2020-037820
  8. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X

 

 

 

Long-Term Effectiveness of Epidural Steroid Injections

Welcome back to SpineIQ’s Back Blog! While we usually write blogs geared towards treatments within the scope of conservative spine clinicians, it is important that conservative spine clinicians keep up regarding the evidence base of treatments commonly administered by other clinicians for spine pain. Patients will ask your opinion about treatments they are considering and you need to be able to make informed referrals. Therefore, this week we are summarizing the clinically relevant findings of Curatolo et al. titled “Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults.”1

Aims and Methods

In 2018, there were 2.2 million epidural steroid injections performed on older adults (65+ years).2 Epidural steroid injections are commonly performed for low back pain that involves radicular pain. The goal of this study was to determine whether 1) patients that receive epidural steroid injections are in worse pain at baseline compared to patients that do not receive epidural steroid injections and 2) if epidural steroid injections have an effect on pain, function, or quality of life in older adults with radicular pain and low back pain.

Patients age 65 and older that had not sought care for low back pain within the last 6 months were included in the study. Participants were separated into three groups. Group 1 included  patients who received epidural steroid injection within 6 months of recruitment. Group 2 included patients who did not receive epidural steroid injection, lumbar surgery, other injection, or radiofrequency ablation within 6 months. Group 3 included patients who did not receive epidural steroid injection or other low back procedure but were matched with patients in Group 1 based on their baseline pain characteristics. Pain intensity, function, and quality of life were collected at baseline and then again at 3, 6, 12, and 24 months.

Results

295 patients were included in Group 1, 4809 patients were included in Group 2 and 483 patients were included in Group 3. 74% of patients in Group 1 received an epidural steroid injection within 3 months, with the rest receiving it between 3 and 6 months.

Study authors found that patients who received epidural steroid injections had worse symptoms (pain intensity 5.8 on a 0-10 scale) compared to those that did not receive epidural steroid injections (pain intensity 2.9 on a 0-10 scale). Further, when they compared Group 1 participants to Group 3 participants, they found that both groups experienced significant improvement over time but there was no difference between the groups.

Conclusions

These findings are relevant for clinicians that treat people with low back pain for several reasons. First, it is essential to provide evidence-based answers to questions posed by patients about alternative treatment options, including patients with higher levels of pain. Second, understanding that epidural steroid injections may not be significantly more effective than the passing of time for older adults with low back pain and radicular pain may influence your decision-making process when making referrals, especially when also considering the risk of serious spinal adverse events (5.1 per one million) associated with this procedure .3 Legal note: clinicians should proceed with caution when discussing treatments that are out of their scope even with evidence to support their suggestions. It is important to inform patients of the risks and benefits regarding a range of treatment options and, as always, appropriately document these conversations in the patient record.

References

  1. Curatolo M, Rundell SD, Gold LS, et al. Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults. Eur J Pain Lond Engl. Published online May 23, 2022. doi:10.1002/ejp.1975
  2. Manchikanti L, Sanapati MR, Soin A, et al. An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018. Pain Physician. 2020;23(2):111-126.
  3. Eworuke E, Crisafi L, Liao J, et al. Risk of serious spinal adverse events associated with epidural corticosteroid injections in the Medicare population. Reg Anesth Pain Med. 2021;46(3):203-209. doi:10.1136/rapm-2020-101778

How Choice of Words can be Clinically Meaningful for Diagnostic Labelling of Low Back Pain

Welcome back to the SpineIQ BackBlog! This week, we will be discussing one of the most often discussed topics surrounding low back pain. A recent publication by O’Keeffe et al. sought to study the potential effects of diagnostic labelling of low back pain using a novel online randomized controlled trial approach.1 Currently, most guidelines state that majority of low back pain (85-95%) is not likely to be sinister or come from a specific structure like fractures, infections, or malignancy.2–4 In fact, research on imaging of people without low back pain revealed that degeneration, arthritis, and disc bugles are common in asymptomatic people leading to guideline recommendations to avoid unnecessary imaging.5,6 However, communicating that positive prognosis of most low back pain without making the patient feel like their low back pain is not important can be troubling for clinicians. This has led to a debate on what is the best way to communicate a diagnosis of low back pain to patients. Therefore, O’Keeffe et al. assessed whether diagnosis label for low back pain influences the likelihood to perceive need for imaging, surgery, secondary opinion, seriousness of low back pain, recovery expectations, and ability to engage in work.

Aims and Methods

Using an online survey website (Qualtrics.com) this study randomized people with low back pain that sought care, people with low back pain that have not sought care, and people that have never experienced low back pain to a specific scenario.

Scenario: Participants were all told that they were seeking care for low back pain from a primary care clinician. They were then randomized to receiving one of the 6 diagnosis for their low back pain of “disc bulge”, “degeneration”, “arthritis”, “lumbar sprain”, “non-specific low back pain”, or “episode of low back pain.” After receiving the diagnosis, all participants were reassured with “I’m not worried that there is anything serious going on here. I think overall your outlook is good. Movement will help. The sooner we can get you back to your normal activity and work, the more likely your back pain is to get better.”

After the scenario, participants were asked on a Likert scale from definitely not to definitely do, whether they perceived need for imaging, surgery, second opinion, seriousness of low back pain, recovery expectations, and ability to work.

Results

Overall, 1,375 participants were randomized to one of the 6 diagnostic labels for low back pain. Importantly but to little surprise, the hardest group to recruit was people that had never experienced low back pain. This is likely due to most people experiencing low back pain at some point. Below are the results for each outcome from best to worst diagnosis.

  • For imaging, “episode of low back pain” (best), “lumbar sprain” and “non-specific low back pain” led to significantly less perceived need for imaging compared to “disc bulge”, “degeneration”, and “arthritis” (worst).
  • For surgery, “non-specific low back pain” (best), “lumbar sprain”, and “episode of low back pain” led to significantly less perceived need for surgery compared to “disc bulge”, “arthritis”, and “degeneration” (worst).
  • For second opinion, “lumbar sprain” (best), “episode of low back pain”, and “non-specific low back pain” led to significantly less perceived need for secondary opinion compared to “disc bulge”, “degeneration”, and “arthritis” (worst).
  • For seriousness of low back pain. “non-specific low back pain” (best), “lumbar sprain”, and “episode of low back pain” led to less perceived seriousness of low back pain compared to “disc bulge”, “arthritis”, and “degeneration” (worst).
  • For recovery expectations, “lumbar sprain” (best), “episode of low back pain”, and “non-specific low back pain” led to higher recovery expectations compared to “degeneration, “disc bulge”, and “arthritis” (worst).
  • For engaging in work, “non-specific low back pain” (best), “lumbar sprain”, “episode of low back pain”, “arthritis”, and “disc bugle” are more likely to engage in work compared to “degeneration” (worst).

Conclusion

This study provides clinically relevant results of what diagnostic labels may be more likely to increase detrimental perceptions of unnecessary care (e.g., imaging or surgery). The words that clinicians use has been shown to have a large impact on patients in previous studies, therefore, these results should not be too surprising.7 It appears that using diagnostic labels of “lumbar sprain”, “non-specific low back pain”, or “episode of low back pain” can have a positive impact on numerous low back pain-related outcomes (e.g. imaging, surgery, second opinion etc.) compared to “disc bulge”, “degeneration”, or “arthritis.” Simple language change by clinicians can be clinically meaningful for low back pain patients.

References:

  1. O’Keeffe M, Ferreira GE, Harris IA, et al. Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment. Eur J Pain. n/a(n/a). doi:10.1002/ejp.1981
  2. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet Lond Engl. 2017;389(10070):736-747. doi:10.1016/S0140-6736(16)30970-9
  3. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  4. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
  5. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189. doi:10.7326/0003-4819-154-3-201102010-00008
  6. Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low-Value Back Imaging Associated With The “Choosing Wisely” Campaign, 2012-14. Health Aff Proj Hope. 2017;36(4):671-679. doi:10.1377/hlthaff.2016.1263
  7. 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;11(6):527-534. doi:10.1370/afm.1518

 

Patient’s Perceptions and Pain

Welcome back to the SpineIQ Back Blog! This week, we are discussing a topic that is increasingly linked to spine pain: beliefs and perceptions.1,2 In healthcare delivery more broadly, maladaptive beliefs and perceptions have been found to be associated with poorer outcomes and quality of life. In spine pain, beliefs and perceptions are now being looked at more closely, however, they are still less commonly discussed and studied compared to more tangible mediators such as biomechanics and neuroscience.3,4 As a result, there is a gap in our current understanding of the extent to which beliefs and perceptions are meaningful (or not meaningful) for clinicians and patients. To address this gap, De Raaij et al conducted a systematic review exploring the association between belief/perceptions and pain intensity/function.5

Summary of results

Overall, 26 studies were identified that looked at the relationship between beliefs, perceptions, pain intensity and function. Cross-sectional and longitudinal studies show moderate evidence demonstrating that maladaptive beliefs and perceptions are associated with higher levels of pain intensity and worse pain intensity prognosis. There is also moderate evidence that maladaptive beliefs and perceptions are associated with higher limitations and worse prognosis for function.

Clinically relevant findings

These findings are not surprising as we learn more about the relationship that beliefs and perception have with health and disease. It is important that clinicians be aware of the ways in which belief and perceptions, especially maladaptive and negative beliefs, play on the prognosis and subsequent outcomes of their patient’s pain. Working with patients to change their maladaptive beliefs and perceptions, while difficult, may increase the likelihood of better outcomes. Traditionally, clinicians have been taught to screen, assess, and address biomechanics (e.g., joint movement and posture) and psychological conditions (e.g., depression, anxiety). Now we know that there is also an important place for screening, assessing, and addressing maladaptive beliefs and perceptions (e.g., pain = damage or pain is going to be forever).

It is important to ask patients what they believe is causing their pain and how they feel about their prognosis. Maladaptive beliefs, especially thinking that pain is going to disable them for a long time, may be detrimental for recovery. To address this, clinicians can reassure patients that spine pain almost always results in an overall positive prognosis and that most people recover fairly quickly from a pain episode. In fact, such reassurance may be just as important to patients pain recovery as the manual therapy or exercise chosen!

Reference:

  1. Darlow B, Perry M, Stanley J, et al. Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. BMJ Open. 2014;4(5):e004725. doi:10.1136/bmjopen-2013-004725
  2. Nolan D, O’Sullivan K, Stephenson J, O’Sullivan P, Lucock M. What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskelet Sci Pract. 2018;33:35-40. doi:10.1016/j.msksp.2017.10.010
  3. 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;11(6):527-534. doi:10.1370/afm.1518
  4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X
  5. de Raaij EJ, Ostelo RW, Maissan F, Mollema J, Wittink H. The Association of Illness Perception and Prognosis for Pain and Physical Function in Patients With Noncancer Musculoskeletal Pain: A Systematic Literature Review. J Orthop Sports Phys Ther. 2018;48(10):789-800. doi:10.2519/jospt.2018.8072