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!


  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