The Psychosocial Factors That Can Cause Low Back Pain

If you have low back pain, you are not alone. Many people suffer from back pain at some point in their lives and low back pain is now the leading cause of disability worldwide, according to studies. While low back pain is common, luckily, the majority of cases are not life threatening. However, it is important that you understand what causes low back pain and when you should be concerned.

 Causes of Low Back Pain:

While there are many potential causes, including biomechanical and anatomical factors, recent research has shown that psychosocial factors related to fear, stress, and negative emotions often play a role in the development and persistence of low back pain.

Fear Avoidance Beliefs: Fear-avoidance beliefs refer to the idea that movement or activity will worsen your pain and lead to injury. This can cause you to become more sedentary, which leads to deconditioning and further worsening of your symptoms.

Catastrophizing: Catastrophizing is when you catastrophize or magnify the potential consequences of your pain. For example, you may believe that your pain means you have a life- threatening problem when in reality this is not the case. Catastrophizing can lead to heightened anxiety and avoidance of activity.

Depression: Depression is associated with persistent, severe low back pain and disability. This condition can lead to changes in sleep, appetite, and energy level as well as increase your perceived level of pain. Depression can make it difficult to stick with a treatment plan to manage back pain.

Stress: Stress refers to the body’s response to any demand placed upon it, from in the workplace to relationships to financial issues. When you perceive a threat, real or imagined, your body responds by releasing stress hormones like cortisol. These hormones prepare your body for fight-or-flight by increasing heart rate, blood pressure, and respiration as well as suppressing nonessential functions like digestion. While this stress response is important for survival, chronic stress can lead to problems like headaches, high blood pressure, heart disease, and depression—all of which are associated with low back pain. In fact, one study found that the severity of a nurse’s back pain is directly linked to how stressed they are.

Other Factors that May be Associated with Low Back Pain:

In addition to psychosocial factors, several other factors are sometimes associated with low back pain.

Age: People who are between the ages of 30 and 50 are most likely to have problematic low back pain.

Smoking: It is unknown if smoking causes low back pain or if people who smoke are more likely to have other characteristics or habits that can also cause low back pain.

Sedentary lifestyle: People who are less active may be more likely to have low back pain.

Conclusion:

There are many potential causes of low back pain, including biomechanical and anatomic abnormalities as well as psychosocial factors. Psychosocial factors refer to the psychological and social aspects of your life that can influence your experience of pain. Some examples of psychosocial factors that have been linked to low back pain include fear avoidance beliefs, catastrophizing, depression and anxiety, and stress. Understanding these psychosocial factors can help you better manage your low back pain. If you are struggling with low back pain, consider seeing a clinician who specializes in care for low back pain, such as a doctor of chiropractic, who can conduct a thorough history and examination, provide assurance that you do not have a life-threatening condition and talk with you about what steps you can take to decrease your pain.

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Low Back Pain Severity, Falls, and Falls-Related Injury in Older Adults

Welcome back to SpineIQ’s Back Blog! Most of our blogs summarize studies where the primary outcomes are pain, disability, and return to work. While these are consistently rated as some of the most important outcomes for patients, payers, and clinicians, they are not the only outcomes that matter. In fact, there are numerous other ways that low back pain can impact a person’s life, such as, fall risk.1 Approximately 684 thousand people have a fatal fall every year around the world.2 Falls commonly happen in older adults with risk increasing every decade. In fact, people in their 70’s have double the prevalence of falls than people in their 60’s.2 Fall pose a huge health, economic, and disability burden on society. There is some preliminary evidence that suggests older people experiencing low back pain may be more at risk for falls compared to older people without low back pain. However, the evidence is usually in people in their 60’s and has not considered recurrent falls or falls leading to injury. Therefore, this week we are summarizing the clinically relevant findings of a study by Tse et al evaluating the association between low back pain and recurrent falls and the association between level of pain severity and fall-related injuries in people at least 70 years old. 3

Methods

The participants were asked pain-related and fall-related questions in order evaluate their association with each other.

Pain-related questions:

  • “Do you experience pain on most days? Yes/No”
  • “Where in your body do you feel this pain?”
  • “How severe has your pain been most of the time in the last week? 0 (no pain) – 10 (maximum pain)”
    • Participants were categorized based on the answer to this question into: mild (1-3), moderate (4-6) and severe (7-10) pain

Fall-related questions

  • “In the past year have you had any falls? Yes/no”
  • “How many falls in total have you had in the last 12 months?”
    • Recurrent falls were at least 2 falls
  • “In the last 12 months have any of the falls caused an injury such as large cruise, cut or broken bone/fracture? Yes/no”

Results

There was a total of 2,220 participants who reported 1 fall and 1,983 participants who reported at least 2 falls (recurrent fallers). The average age of the participants was 76 years old.

Clinically relevant results:

  • 34% reporting low back pain on most days
  • 47% reporting falls-related injury
  • Participants with severe low back pain were more likely to be recurrent fallers compared to participants with mild low back pain
    • Males were 70% more likely
    • Females were 50% more likely
  • Only female recurrent fallers with severe low back pain were more likely (by 30%) to report a falls-related injury compared to female recurrent fallers who reported mild low back pain
    • No association in males

 

Conclusion

This study provides clinically relevant findings about the importance of conservative spine clinicians for older adults with low back pain. Not only can conservative spine clinicians provide treatment to reduce low back pain, but these findings suggest that reducing the low back pain severity may lead older adult patients to be less likely to fall and female older adult patients to be less likely to have a fall-related injury. Conservative spine clinicians are especially important because older adults are more likely to be taking multiple medications that may not mix well with pharmacological care for low back pain.4,5 Also, it is important for conservative spine clinicians treating older adults for low back pain to consider risk of falls when creating the care plan with the patient. It may be appropriate for clinicians to recommend balance exercises or ergonomic aids to help reduce the likelihood of falling.
References

  1. Marshall LM, Litwack-Harrison S, Cawthon PM, et al. A Prospective Study of Back Pain and Risk of Falls Among Older Community-dwelling Women. J Gerontol A Biol Sci Med Sci. 2016;71(9):1177-1183. doi:10.1093/gerona/glv225
  2. James SL, Lucchesi LR, Bisignano C, et al. The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017. Inj Prev. 2020;26(Suppl 2):i3-i11. doi:10.1136/injuryprev-2019-043286
  3. Tse A, Ward S, McNeil J, et al. Severe low back or lower limb pain is associated with recurrent falls amongst older Australians. Eur J Pain Lond Engl. Published online July 21, 2022. doi:10.1002/ejp.2013
  4. Domenichiello AF, Ramsden CE. The silent epidemic of chronic pain in older adults. Prog Neuropsychopharmacol Biol Psychiatry. 2019;93:284-290. doi:10.1016/j.pnpbp.2019.04.006
  5. Morin L, Johnell K, Laroche ML, Fastbom J, Wastesson JW. The epidemiology of polypharmacy in older adults: register-based prospective cohort study. Clin Epidemiol. 2018;10:289-298. doi:10.2147/CLEP.S153458

Click here to see recommended exercises to help older patients with low back pain.  

 

Patient Education and Self-Management

Welcome back to SpineIQ’s Back Blog! In previous blogs we have discussed the high value of self-management, strategies to promote self-management, and how patient education can fit into self-management. There is a myth that self-management must be done without help from clinicians.1–3 In fact, clinicians can play a pivotal role in patient self-management. Many patients will not know how to self-manage, when it is appropriate, or lack the skills to progress their self-management.4 Clinicians can help patients feel more confident with self-management, develop self-management skills, and empower continued self-management. This can typically be done by patients’ education from clinicians. While patient education is a key feature in patient centered care and subsequently guideline concordant care, there is a lack of knowledge on what patient education messages will be more likely to promote self-management and what patients’ attitudes are towards these messages. Therefore, this week we summarize a study by O’Hagan et al. that evaluated patients’ attitudes towards self-management messages and whether the attitudes towards these messages were associated with intention to self-manage their low back pain.5

Methods

An online survey was created to assess the attitudes towards self-management messages and their association with intention to self-manage low back pain among people without low back pain, with acute low back pain, and with chronic low back pain. A Delphi study was conducted to develop the key messages to be tested in this study. The participants consisted of low back pain experts, which after discussion resulted in the 10 key messages that were used in this study. The themes of the self-management messages consisted of staying active, explicit self-management, professional help, and patient information.

Results

A total of 607 participants (295 without low back pain, 68 with acute low back pain, and 277 with chronic low back pain) completed the survey and their results were analyzed in this study. Overall, all participants had mostly positive attitudes toward all of the self-management messages. Certain messages were received with more positive attitudes than others and this differed by whether the patient did not have low back pain, had acute low back pain, or had chronic low back pain.

For patients without low back pain, the messages with the most positive attitude were:

  • “When you have back pain, staying active is important. You need to pace yourself to return to your usual activities”,
  • “Staying active helps prevent long-term back problems”
  • “Persistent low back pain is influenced by a number of factors- physical, emotional, environmental; so it is important to address each of these areas”

For patients with acute low back pain, the messages with the most positive attitudes were:

  • “Staying active helps prevent long-term back problems”
  • “When you have low back pain it is important to take ownership of your own wellbeing”
  • “Imaging, for example x-ray, CT scan, or MRI, is usually not needed in the majority of cases of low back pain, particularly when your pain has been present for less than 6 weeks, talk to your doctor about this”

For patients with chronic low back pain, the messages with the most positive attitudes were:

  • “When you have back pain, staying active is important. You need to pace yourself to return to your usual activities”
  • “Staying active helps prevent long-term back problems”
  • “When you have low back pain it is important to take ownership of your own wellbeing”

The association between attitudes towards messages and intention to self-manage also differed by patients without low back pain, with acute low back pain, and with chronic low back pain.

For patients without low back pain, the messages that were most associated with increased likelihood of intent to self-manage were:

  • “It is not necessary to know the specific cause of your back pain in order to manage the pain effectively”
  • “Imaging, for example x-ray, CT scan, or MRI, is usually not needed in the majority of cases of low back pain, particularly when your pain has been present for less than 6 weeks. Talk to your doctor about this”
  • “It is rare for low back pain to be caused by a more serious health problem”

For patients with acute low back pain, the messages that were most associated with increased likelihood of intent to self-manage were:

  • “Your pain may not necessarily be related to the extent of damage in your back. Hurt does not necessarily mean harm”
  • “It is not necessary to know the specific cause of your back pain in order to manage the pain effectively”

For patients with chronic low back pain, the messages that were most associated with increased likelihood of intent to self-manage were:

  • “It is not necessary to know the specific cause of your back pain in order to manage the pain effectively”
  • “It is rare for low back pain to be caused by a more serious health problem”
  • “Imaging, for example x-ray, CT scan, or MRI, is usually not needed in the majority of cases of low back pain, particularly when your pain has been present for less than 6 weeks. Talk to your doctor about this”

Conclusion

The results of this study have several clinically relevant findings. First, patients tend to have positive feelings overall towards evidence-based messages about self-management and low back pain. Second, there are some messages that depending on the length of low back pain are received with more positive attitude. Third, there are some messages that depending on the length of low back pain are more likely to increase intention to self-manage. It is imperative to remember that low back pain self-management does not have to be done alone by patients and clinicians can play a key role in teaching self-management skills, reinforcing and empowering patients. Finally, the messages used in this study are not a strict guideline, they better represent a theme and potential conversation starters to discuss these topics. For example, clinicians may want to discuss topics with a patient experiencing chronic low back pain that they are likely to have a more positive attitude towards such as: theme of staying active. This conversation may lead to topic with the intent of empowering the patient with chronic low back pain to increase their intent to self-manage their low back pain such as: theme of patient information especially the rarity of serious disease and lack of need for imaging. These findings play a key role in informing clinicians what messages may be better suited for certain patient populations.

Reference

  1. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns. 2002;48(2):177-187. doi:10.1016/S0738-3991(02)00032-0
  2. Caiata Zufferey M, Schulz PJ. Self-management of chronic low back pain: an exploration of the impact of a patient-centered website. Patient Educ Couns. 2009;77(1):27-32. doi:10.1016/j.pec.2009.01.016
  3. Devan H, Hale L, Hempel D, Saipe B, Perry MA. What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis. Phys Ther. 2018;98(5):381-397. doi:10.1093/ptj/pzy029
  4. Bair MJ, Matthias MS, Nyland KA, et al. Barriers and facilitators to chronic pain self-management: a qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Med Malden Mass. 2009;10(7):1280-1290. doi:10.1111/j.1526-4637.2009.00707.x
  5. O’Hagan ET, Di Pietro F, Traeger AC, et al. What messages predict intention to self-manage low back pain? A study of attitudes towards patient education. Pain. 2022;163(8):1489-1496. doi:10.1097/j.pain.0000000000002530

 

Click here to access a FREE printable resource to promote patient self-care in your office! 

 

Assessing the Effectiveness and Safety of Treatments for Acute Low Back Pain

Welcome back to SpineIQ’s BackBlog! Most of our blogs discuss chronic spinal pain, as that is the leading cause of the disability burden of spine pain. However, 25% of Americans report having one episode of acute low back pain within the last 3 months and 8% of adults report at least one episode of severe acute low back pain within the last year.1 While the prognosis for acute low back pain is good with 50% recovered within 2 weeks and 80% recovered within 6 weeks, there is still a need for pain reduction in the short-term especially for severe episodes.2–4 This begs the question, what is the most effective treatment for acute low back pain? A systematic review by Gianola et al. set out to assess treatments for acute low back pain and we summarize the clinically relevant findings below.5

Methods

This systematic review aimed to use a statistical model called network meta-analysis. The difference between a network meta-analysis and the traditional meta-analysis (commonly called pairwise meta-analysis) is that it lets you compare different treatments to each other as long the treatments were compared to the same comparator. For example, if study A compared manual therapy (treatment) to placebo (comparator) and study B compared NSAIDs (treatment) to placebo (comparator) then a network meta-analysis allows us to compare NSAIDs to manual therapy using the two studies since they both were compared to the same comparator (placebo). Network meta-analysis will be an important research tool for researchers as the challenge of comparing one mode of treatment is costly and time consuming.  Many comparative modes of care will now become more readily analyzed.  The inclusion criteria for this systematic review were patients with acute low back pain (<6 weeks) and the study must have compared any treatment to placebo or no intervention group.

Results

This systematic review included 46 studies with a total of 8765 participants. They assessed the effectiveness of treatments for acute low back pain on important key issue for patients, pain intensity, disability, and adverse events.

The most effective treatments delivered by a healthcare professional in order of largest significant effect on pain intensity are:

  • Exercise
  • Heat wrap
  • Opioids
  • Manual therapy
  • NSAIDs

The most effective treatments delivered by a healthcare professional in order of largest significant effect on disability are:

  • Exercise
  • Heat wrap
  • Manual therapy
  • NSAIDs
  • Muscle relaxants
  • Education

No adverse were reported for:

  • Acupuncture
  • Education
  • Exercise
  • Manual therapy

Mild-moderate adverse events were reported for:

  • Heat wrap
  • Muscle relaxants
  • NSAIDs
  • Opioids
  • Paracetamol
  • Steroids

Conclusion

These results suggest that the most effective and safest treatments for acute low back pain are treatments commonly delivered by conservative spine clinicians (e.g., exercise and manual therapy). This is consistent with clinical practice guidelines that commonly recommend education, reassurance, and advice to stay active for an episode of acute low back pain.6 If patients are seeking further pain relief then heat wraps should be recommended with education on how to use them properly to avoid burning the skin followed by manual therapy and NSAIDs when appropriate.

References

  1. Patrick N, Emanski E, Knaub MA. Acute and Chronic Low Back Pain. Med Clin North Am. 2014;98(4):777-789. doi:10.1016/j.mcna.2014.03.005
  2. Schreijenberg M, Chiarotto A, Mauff KAL, Lin CWC, Maher CG, Koes BW. Inferential reproduction analysis demonstrated that “paracetamol for acute low back pain” trial conclusions were reproducible. J Clin Epidemiol. 2020;121:45-54. doi:10.1016/j.jclinepi.2020.01.010
  3. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171. doi:10.1136/bmj.a171
  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. Gianola S, Bargeri S, Castillo GD, et al. Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis. Br J Sports Med. 2022;56(1):41-50. doi:10.1136/bjsports-2020-103596
  6. 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

 

The Role of Educational Materials in Delivering Information to Patients

Welcome back to SpineIQ’s BackBlog! In previous blogs, we have discussed how educational materials can play a key role in delivering information to patients. Not only can these educational materials be used actively throughout a session to lead conversations with patients but they can be used to provide information “passively” as posters in your clinic that patients may read. Educational materials can play a key low-cost, low-time consuming role in care for low back pain.1 Especially as patient education is recommended consistently by clinical practice guidelines for spinal pain regardless of pain duration or intensity.2,3 However, what the best way to present this information has not been studied. The study we summarize in this blog sought to assess whether “fact sheets” or “myths and facts sheets” led to patients remembering the information better and led to a decrease in fear avoidance behavior.4

Aims and methods

Mass media campaigns have been used in public health campaigns for decades. Some of the more famous ones have been advertisements and commercials providing information about the dangers of tobacco. The research on the best way to present educational information has been conflicting. Some studies suggest that presenting “myths” may lead people to mistakenly remember the “myths” as “facts.”5 However, other studies suggest that presenting both “myths and facts” can provide a more persuasive argument than only “facts.”6 This study created two educational materials. One sheet with 6 facts written on it and another sheet with the same 6 myths plus 6 myths related to the facts. Participants were patients seeking care for chronic low back pain, who were randomized to either “facts only” or “myths and facts” sheets. The outcome measures were being able to correctly answer all 6 questions about the facts at their next visit and their score on the FABQ-pa, which measures their fear avoidance beliefs towards physical activity.

Results

151 patients were randomized into one of the two groups and subsequently analyzed. There was no difference in correctly answering 6 questions about the facts between the two groups. An average of 32% correctly answered all 6 questions in each group. The group that received “myths and facts” information sheet had statistically significant better fear avoidance beliefs at follow-up, however the difference was small and unlikely to be clinically meaningful.

Conclusion

These findings present a great opportunity for clinicians to feel comfortable that the educational material that they share with patients, social media, or have in their clinic can be presented in different ways. There appears to be no difference in patient recall, which suggests that presenting “myths” will not lead to patients mistakenly misremembering them as facts. At SpineIQ we provide several  back pain fact sheets on our website. There are also some facts and myths on low back pain sheets that have been used in the published literature, such as the ones used in this study and a study by O’Sullivan et al.7 Finally, this study presented the information as bullet points with no graphics so clinicians that want to create their own but are hesitant due to making them look more artistic should not worry.
References

  1. Engers A, Jellema P, Wensing M, van der Windt D a. WM, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057. doi:10.1002/14651858.CD004057.pub3
  2. 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/
  3. 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
  4. Viana da Silva P, Kamper SJ, Robson E, et al. “Myths and facts” education is comparable to “facts only” for recall of back pain information but may improve fear-avoidance beliefs: an embedded randomized trial. J Orthop Sports Phys Ther. Published online July 8, 2022:1-29. doi:10.2519/jospt.2022.10989
  5. Peter C, Koch T. When Debunking Scientific Myths Fails (and When It Does Not): The Backfire Effect in the Context of Journalistic Coverage and Immediate Judgments as Prevention Strategy. Sci Commun. 2016;38(1):3-25. doi:10.1177/1075547015613523
  6. Cornelis E, Cauberghe V, De Pelsmacker P. Two-Sided Messages for Health Risk Prevention: The Role of Argument Type, Refutation, and Issue Ambivalence. Subst Use Misuse. Published online April 22, 2013. doi:10.3109/10826084.2013.787093
  7. O’Sullivan PB, Caneiro JP, O’Sullivan K, et al. Back to basics: 10 facts every person should know about back pain. Br J Sports Med. 2020;54(12):698-699. doi:10.1136/bjsports-2019-101611