Article

Traduction en français du « back pain attitudes questionnaire » et étude de ses qualités métrologiques

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  • University of Otago Wellington
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Abstract

Introduction Compte tenu de l’existence repandue des croyances deleteres relatives au mal de dos [1] ; [2] et des limites des questionnaires existant, le « back pain attitudes questionnaire (Back-PAQ) » a recemment ete developpe pour mieux les identifier [3]. L’objectif de cette etude etait de traduire en francais la version courte (10 items) de ce questionnaire et d’evaluer les qualites psychometriques de cette nouvelle version (le Back-PAQ-Fr). Materiel, population et methode Le processus de traduction a ete realise en respectant les differentes etapes decrites dans les recommandations internationales [4] (Figure 1). Le Back-PAQ-Fr a ete soumis a 105 patients presentant une lombalgie (LB), afin de rechercher la presence d’un eventuel effet plancher/plafond et d’examiner sa coherence interne. Pour examiner la validite de construit, les patients ont egalement ete soumis au « back beliefs questionnaire (BBQ) » et au « brief illness perception questionnaire (Brief IPQ) ». Enfin, 55 patients ont ete invites a completer a nouveau le Back-PAQ-Fr une semaine plus tard (re-test) pour examiner sa reproductibilite. Resultats Les patients etaient âges en moyenne de 45,3 ans et 71 % d’entre eux souffraient de LB chronique. Seuls 2 patients n’ont pas complete tous les items du questionnaire. L’analyse des scores totaux minimum et maximum n’a indique aucun effet plancher/plafond. Le coefficient alpha de Cronbach caracterisant la coherence interne du questionnaire etait 0,54. De facon attendue, l’etude de validite a confirme l’existence de correlations significatives entre les scores BACK-PAQ-Fr et les scores aux questionnaires Brief IPQ (rho = 0,25, p < 0,05) et BBQ (rho = −0,26, p < 0,01). Les resultats de l’etude de reproductibilite (Figure 2) indiquent une bonne reproductibilite du BACK-PAQ-Fr. Conclusion ou discussion Compte tenu des consequences potentiellement importantes de certaines croyances relatives a la LB [1] ; [2], contribuer au developpement d’outils permettant d’identifier les croyances deleteres de facon a pouvoir les corriger est indispensable. En plus de traduire en francais le Back-PAQ, cette etude a permis de mettre en evidence les qualites psychometriques satisfaisantes de la version francophone de ce nouvel outil. Des etudes ulterieures s’averent necessaires pour examiner la sensibilite au changement du questionnaire et examiner ses qualites et son interet lors de son utilisation, pour examiner les croyances de sujets sains ou de therapeutes.

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... As shown in Table 1, six published studies have presented Back-PAQ translations to date including Arabic (Kanaan et al., 2021), Argentine Spanish (Pierobon et al., 2020b), Brazilian Portuguese (Krug et al., 2021), Danish (Nicolaysen et al., 2021), French (Demoulin et al., 2017), and Turkish (Tay et al., 2022). Several other translations are currently underway (e.g., Dutch, Chinese Mandarin, Czech, German, Greek, Hebrew, Italian, Latvian, Persian, Portuguese, Swedish, and Urdu). ...
... Test-retest reliability was assessed in each validation study (Table 1). Most studies found excellent reliability (ICC > 0.90) with exception of the French (ICC ¼ 0.73) and the Danish (ICC ¼ 0.80) versions (Demoulin et al., 2017;Nicolaysen et al., 2021). Internal consistency of the 34-item version was assessed in all the translations (with values ranging from α ¼ 0.60 to 0.92) except the Danish version that assessed the internal consistency of each item, which ranged from 0.38 to 0.90, with a mean value of 0.75. ...
... The Brazilian validation explored correlations with the TSK for convergent validity and the Depression and Anxiety subscales from the EuroQol questionnaire for divergent validity (Krug et al., 2021). The French validation explored correlation with the BBQ, finding a low negative correlation (r ¼ À0.33), which might be explained by differences in the development of both questionnaires (Demoulin et al., 2017). ...
... This study included five questionnaires: a self-developed socio-demographic questionnaire, the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) [17,18], the 10-item version of the Back Pain Attitudes Questionnaire (Back-PAQ-10) [19,20], the revised Neurophysiology of Pain Questionnaire (NPQ) [21,22] and questions relating to two clinical vignettes (one about a patient with non-specific LBP [23] and one about a patient with a specific LBP). All questionnaires were available in the language of the participant (either French or Dutch). ...
... Normality tests of outcomes results were performed (Kolmogorov-Smirnov Test). Kruskall-Wallis and Mann-Whitney tests with a significance of 0.05 were used to compare the total score of the questionnaires with the knowledge of the guidelines, groups of physiotherapists seeing less (<15) or more (15)(16)(17)(18)(19)(20) patients with LBP per month and the ability to suspect or detect the specific diagnosis of LBP. Both vignettes were analysed using descriptive statistics to determine the number of physiotherapists giving guideline-inconsistent recommendations and being able to suspect or detect a specific cause of LBP. ...
... Descriptive statistics are detailed in Table 2. No significant differences were found in the scores of the questionnaires between physiotherapists seeing less (<5) or more (15)(16)(17)(18)(19)(20) patients with LBP per month except for the Back-PAQ (p = 0.02). No significant differences were found between Belgium and France for these questionnaires (data not shown). ...
Article
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Background: Clinical practice guidelines promote bio-psychosocial management of patients suffering from low back pain (LBP). The objective of this study was to examine the current knowledge, attitudes and beliefs of physiotherapists about a guideline-adherent approach to LBP and to assess the ability of physiotherapists to recognise signs of a specific LBP in a clinical vignette. Methods: Physiotherapists were recruited to participate in an online study. They were asked to indicate whether they were familiar with evidence-based guidelines and then to fill in the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), as well as questions related to two clinical vignettes. Results: In total, 527 physiotherapists participated in this study. Only 38% reported being familiar with guidelines for the management of LBP. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognised the signs of a specific LBP. Conclusions: The high proportion of physiotherapists unfamiliar with guidelines and demonstrating attitudes and beliefs not in line with evidence-based management of LBP is concerning. It is crucial to develop efficient strategies to enhance knowledge of guidelines among physiotherapists and increase their implementation in clinical practice.
... The short version of the French version [30] of the Back-Pain and Attitudes Questionnaire [31] which is comprised of 10 items (statements) rated on a 5-point Likert scale ranging from 1 (false) to 5 (true) was used. The total score (ranging from 10 to 50) was calculated by summing the score for each item (the scores for items 6, 7 and 8 are reversed). ...
... Higher scores indicate more negative beliefs. This questionnaire has good reliability and the minimum detectable change (MDC) is 6.8 points [30]. ...
... Despite the high initial score, the Back-PAQ score increased significantly after viewing, suggesting that the video reinforced and amplified participants' LBP-related misbeliefs. This increase was greater than the minimal detectable change (MDC) [30] for 11.4% of participants. Moreover, 55% of participants stated that they would consider changing how they performed their daily activities and would take more care to protect their backs after watching the video. ...
Article
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Background: Low back pain (LBP)-related misbeliefs are a risk factor for chronicity and thereby require further attention. Objective: To assess the influence of a mediatised video on LBP-related misbeliefs in the general population and to examine whether these individuals intended to change their behavior to protect their back after viewing the video. Method: French-speaking adults within the general population were recruited through advertisements and were asked to complete a self-administered questionnaire, available online between January 2021 to April 2021. The questionnaire asked about socio-demographic information and back pain beliefs (the 10-item Back-PAQ). Participants were then prompted to watch a mediatised video conveying negative messages. Immediately after viewing the video, participants indicated their degree of agreement with the messages conveyed they completed the Back-PAQ a second time and they indicated whether they intended to change their behavior as a result of watching the video. Changes in mean Back-PAQ score after viewing the video and the percentage of participants planning to protect their backs more were investigated. The influence of a history of LBP was also analysed. Results: 1338 participants were included. The initial mean Back-PAQ score was high (28.3 (SD 6)) and increased significantly after viewing the video (Cohen d: 0.42), indicating an increase in negative beliefs. This change was greater than the minimum detectable change (6.8) for 11.4% of participants. In total, 55% of respondents reported that they would protect their backs more after watching the video. Pain history did not influence the change in Back-PAQ score post viewing. Conclusions: This study demonstrates that a mediatized video which conveys negative messages about LBP reinforces LBP-related misbeliefs and may promote maladaptive behavior in a significant number of individuals. This study also confirms the prevalence of such misbeliefs in the general population and thereby, the necessity for clinicians to explore patients’ misbeliefs and their origin.
... The items of Back-PAQ evaluate psychological influences on recovery, prognosis of back pain, activity participation when experiencing back pain, relationship between injury and back pain and vulnerability of the back (Darlow et al., 2014). While the Back-PAQ has been validated and cross-culturally adapted into French (Demoulin et al., 2017), Brazilian-Portuguese (Krug et al., 2020), Arabic (Kanaan et al., 2021), Argentinian-Spanish (Pierobon et al., 2020), andDanish (Scott Nicolaysen et al., 2021), it has not been translated and adapted into Turkish. ...
... The sample in the present study consisted of only individuals with back pain, similar to the studies conducted by Kanaan et al. (2021) and Demoulin et al. (2017). In other studies, in which Back-PAQ was translated, individuals who did not have back pain were included as well as individuals who did have pain (Krug et al., 2020;Scott Nicolaysen et al., 2021). ...
... A good level of internal consistency was detected for the Back-PAQ-Tr & Back-PAQ-Tr-20 (0.82, 0.78 respectively). The detected internal consistency level of 34-item version of Back-PAQ-Tr was consistent with the values reported by previous Back-PAQ translation studies (Darlow et al., 2014;Demoulin et al., 2017;Kanaan et al., 2021;Pierobon et al., 2020). In studies with higher internal consistency levels compared to the results of our study, either only HCPs were included (Moran et al., 2017) or 52.5% of the participants participating in the study were HCPs (Krug et al., 2020). ...
Article
Background As the Back Pain Attitudes Questionnaire (Back-PAQ), a validated instrument, could be performed to evaluate biopsychosocial dimensions of back pain, it has not been translated and adapted for Turkish population. Objectives It was aimed to translate and cross-culturally adapt the Back-PAQ (versions of 34-item, 20-item, and 10-item) into Turkish language and analyse the validity and reliability of the Back-PAQ-Turkish version (Back-PAQ-Tr). Study design Study of diagnostic accuracy/assessment scale. Methods The translation and cross-cultural adaptation process were carried out in several steps according to international best-practice guidelines. 173 participants with back pain were recruited. Turkish version of the Tampa Scale of Kinesiophobia (TSK-Tr) and Fear Avoidance Beliefs Questionnaire (FABQ-Tr) were used to investigate the convergent validity. Results Internal consistency of the Back-PAQ-Tr, Back-PAQ-Tr-20, and Back-PAQ-Tr-10 were 0.82, 0.78 and 0.68, respectively. Test-retest reliability was excellent for Back-PAQ-Tr (ICC = 0.95) and Back-PAQ-Tr-20 (ICC = 0.95), but weak for Back-PAQ-Tr-10 (ICC = 0.50). A weak correlation was found between all versions of Back-PAQ-Tr and TSK-Tr & FABQ-Tr, except for the moderate correlation between Back-PAQ-Tr-10 and TSK-Tr (r = −0.51) & the physical activity score of FABQ-Tr (r = −0.51). Back-PAQ-Tr, Back-PAQ-Tr-20, and Back-PAQ-Tr-10 accounted for 66.2%, 60.5%, and 78.2% of the variance in the data set, respectively. Conclusion The versions of 34-item and 20-item Back-PAQ-Tr are reliable and valid questionnaire to assess Turkish populations' attitudes and beliefs regarding back pain. Since the reliability of the 10-item version was determined to be quite low, we particularly recommend the use of the versions of Back-PAQ-Tr and Back-PAQ-Tr-20.
... It was used to evaluate back beliefs of both patients and healthcare professionals (Darlow et al., 2014b;Moran et al., 2017). The questionnaire was validated in different languages with good to excellent psychometric properties (Demoulin et al., 2017;Krug et al., 2020;Pierobon et al., 2020). ...
... Back-PAQ total scores range from 34 to 170, with higher scores indicating more unhelpful beliefs. Internal consistency varies between 0.63 and 0.92 and test-retest reliability between 0.73 and 0.94 (Darlow et al., 2014a;Demoulin et al., 2017;Krug et al., 2020;Pierobon et al., 2020). The Back-PAQ-ArgSpan is available at www.otago.ac.nz/backpaq. ...
... The MDC values in our study are similar to those reported in the Brazilian (MDC 90 11.3 and MDC 95 14.2) (Krug et al., 2020) and French (MDC 95 14.5) versions (Demoulin et al., 2017). Although the MDC 90 was reported in the New Zealand version, the values are not comparable due to the different scoring system applied (Darlow et al., 2014a). ...
Article
Background Negative attitudes and beliefs about back pain in patients with low back pain (LBP) are associated with high levels of pain and negatively influence clinical outcome. The Back Pain Attitudes Questionnaire (Back-PAQ) was developed to assess back beliefs of patients and healthcare professionals. The minimal detectable change (MDC) is defined as the smallest amount of change that can be detected not due to inherent variation or “noise” in the measure. The MDC values at 68%, 90% and 95% confidence levels of the Back-PAQ ArgSpan are unknown. Objective to calculate standard error measurement (SEM) and minimal detectable change (MDC) to confirm the feasibility of Back-PAQ ArgSpan as a reliable outcome measure in clinical and research settings. Study design a secondary analysis was carried out using a subgroup of data from the cross-cultural adaptation and validation of the Argentine version of the Back PAQ. Method SEM was calculated (SD × √1 – ICC) and MDC as (SEM × z-value × √2). MDC was calculated as percentage as well. Results the SEM was 5.16 points. The MDC68, MDC90 and MDC95 of the Back-PAQ were 7.30, 12 and 14.3 points, respectively. The percentages of MDC68, MDC90 and MDC95 of the Back-PAQ were 6.7%, 11.0% and 13.1%, respectively. Conclusion The present study demonstrated that the Back-PAQ ArgSpan is a reliable and interpretable measurement tool. When assessing a patient, a change in the score in the Back-PAQ ArgSpan over 15 points shows a true change at 95% confidence level.
... The questionnaire covers 5 different dimensions: (1) vulnerability of the back; (2) relationship between back pain and injury; (3) activity participation during back pain; (4) psychological influences on back pain and; (5) prognosis of back pain. 24 The Back-PAQ has been previously cross-culturally adapted into French and Argentinian-Spanish. 25,26 The primary aim of this study was to translate and crossculturally adapt the Back-PAQ into Brazilian-Portuguese. The secondary aim was to determine the questionnaire's measurement properties, including internal consistency, reproducibility (reliability and agreement), ceiling and floor effects, and construct validity in a Brazilian sample of people with and without back pain, including HCPs. ...
... Scores range from -68 to 68, with negative scores reflecting unhelpful beliefs whereas positive scores reflect helpful beliefs. The 10-item Back-PAQ is composed of items 6,11,13,14,25,27,30,31,32, and 33 from the full version, with the score ranging from -20 (unhelpful beliefs) to 20 (helpful beliefs). 24 ...
... n > 50) for testing of reliability and agreement of an instrument. 32,33,45,56 25 Another strength of this study was that data were collected across four different regions of Brazil. 57---59 Internal consistency for the Back-PAQ-Br was excellent (Cronbach's alpha = 0.92). ...
Article
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Background The Back Pain Attitudes Questionnaire (Back-PAQ) was developed to evaluate attitudes and beliefs of the general public, people with back pain, and healthcare professionals about the spine. Objectives To translate and cross-culturally adapt the Back-PAQ (34-item and 10-item versions) into Brazilian-Portuguese (Back-PAQ-Br) and test its measurement properties in a Brazilian sample. Methods The cross-cultural adaptation and testing of the measurement properties followed the recommendations of international guidelines. Members of the general public, people with back pain, and healthcare professionals, for a total of 139 individuals, took part in the assessment of internal consistency, construct validity, and ceiling and floor effects. The Hospital Anxiety and Depression Scale (HADS) and the Brazilian-Portuguese version of the Tampa Scale of Kinesiophobia (TSK) were used to evaluate construct validity. Test-retest reproducibility was determined on 77 participants. Retest was performed a minimum of 1 week and a maximum of 2 weeks from the original test. Results There was very high agreement between translators (88.2%). The Back-PAQ-Br showed excellent internal consistency (Cronbach’s alpha 0.92) and excellent reproducibility (ICC 0.94; SEM 5.14 points on a 136 point scale), with a smallest detectable change (90% confidence level) of 11.93 points. There was strong correlation between Back-PAQ-Br and TSK (r = -0.72) and very weak correlation between Back-PAQ-Br and HADS (r = -0.23 for both depression and anxiety domains). No ceiling/floor effects were observed. Conclusion The translation process and cross-cultural adaptation had very high agreement between translators. The Back-PAQ-Br has excellent measurement properties that are similar to the properties of the original version.
... The questionnaire has shown acceptable internal consistency and test-retest reliability and has been validated in the general population (including people with and without LBP) and amongst health professionals (Darlow et al., 2014;Moran et al., 2017). It has been translated and validated for the French population and is currently being translated into other languages (Demoulin et al., 2017). ...
... For the translation and cross-cultural adaptation we followed the guideline proposed by Beaton et al. (1976). After the pilot study, we had to modify one of the item (# 26) with which participants had difficulty; the French validation had similar issues with that item (Demoulin et al., 2017). Instead of using the word "vigoroso" we used A. Pierobon et al. ...
... Similar to previous studies, neither a ceiling nor a floor effect was observed (Darlow et al., 2014;Demoulin et al., 2017). The minimum and maximum scores were 41 and 141, respectively. ...
Article
Background: low back pain (LBP) is the main cause of years lived with disability worldwide. Psychosocial factors have been shown to be good predictors of persistent LBP. Within these, unhelpful beliefs about the back seem to be important in the development and chronicity of the symptoms. The Back Pain Attitudes Questionnaire (Back-PAQ) is an instrument that explores beliefs about the back that has been validated for people with and without back pain and healthcare professionals. However, until now, it has not been translated and validated for the Argentine population. Objective: translate into Spanish, cross-cultural adapt and validate the Back-PAQ for the Argentine population with and without back pain. Study design: study of diagnostic accuracy/assessment scale. Methods: the study was carried out in three consecutive phases: translation, cross-cultural adaptation and validation. We included Argentinians aged 18 years or more. We used the Back-PAQ, modified Fear Avoidance Beliefs Questionnaire (mFABQ) and the Global Rating of Change (GROC) scale to assess the psychometric properties. Results: three hundred and seventy-two participants were included for the analysis. The time taken to answer and score the questionnaire was 5.6 and 1.6 min, respectively. Neither a ceiling nor a floor effect was observed. Internal consistency was 0.76. One hundred and eighty-six participants were considered stable. Test-retest reliability was 0.90. A weak correlation (0.33) was found between the Back-PAQ and the mFABQ. Conclusion: the Argentine version of the Back-PAQ is a viable, reliable and valid tool for the assessment of the back beliefs of the Argentine population.
... La version française du Back-PAQ a été utilisée pour évaluer les croyances des étudiants, des nouveaux diplômés, des praticiens et des enseignants à l'égard de la lombalgie (38) . Le Back-PAQ a été élaboré par une équipe multidisciplinaire de cliniciens et de chercheurs dirigée par Darlow et al. (25) . ...
... De plus, il s'agit également d'un défi car il n'existe aucun outil de référence pour évaluer les croyances et attitudes à l'égard de la lombalgie (32) . La version française du Back-PAQ a en outre été validée pour des patients lombalgiques francophones belges (38) . Les données psychométriques de cet outil ne sont pas disponibles pour une population d'étudiants et de professionnels de l'ostéopathie français. ...
Article
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Les facteurs psychosociaux jouent un rôle essentiel dans le pronostic et la prise en charge des patients présentant une lombalgie non-spécifique (LNS). Les données scientifiques indiquent que les croyances d'un individu concernant la douleur sont associées aux attitudes et aux croyances du clinicien consulté. Cette étude a exploré les attitudes, croyances et orientations cliniques des étudiants, des nouveaux diplômés, des enseignants et praticiens non-enseignants issus de deux instituts français d'enseignement de l'ostéopathie en ce qui concerne la prise en charge de la LNS. Cette population a été étudiée au moyen d'une enquête transversale réalisée en ligne entre août et octobre 2021 comprenant un recueil des caractéristiques socio-démographiques, un questionnaire (Back-PAQ) et une vignette clinique. 798 participants ont répondu à l'enquête (556 étudiants, 47 nouveaux diplômés, 88 enseignants, 107 praticiens). Les résultats des étudiants au Back-PAQ ont montré une diminution progressive des scores (croyances plus adaptées) de la première année (113 ± 10,2) à la cinquième année (81,4 ± 12,1) (p < 0,001) avec une diminution plus importante entre les étudiants de 5ème année (81,4 ± 12,1) et les nouveaux diplômés (48,4 ± 7,5) (p < 0,001). Les orientations cliniques basées sur les questions de la vignette (score moyen : 1,7/3) étaient modérément corrélées au score du Back-PAQ (r =-0,489, p < 0,001). Ainsi, les participants ayant plus de croyances délétères étaient plus susceptibles d'encourager la limitation de l'activité physique ou professionnelle. Pour que les futurs cliniciens puissent aborder de manière adéquate les facteurs psychosociaux associés à la LNS, il semble crucial d'évaluer leurs attitudes pendant leur formation afin de mieux appréhender les croyances qui les sous-tendent.
... The third section evaluated perceptions of unsafe movement strategies using a custom-made tool composed of photographs (see below), and the fourth section assessed evaluations and beliefs regarding LBP using the Back Pain Attitudes Questionnaire (Back-PAQ). 21 Movement strategy safety questionnaire Eight photographs of different strategies used to lift a key ring from the floor were presented (Fig. 1). After observing the photographs, participants were asked to select photographs in response to the following two questions: ...
... 8,24,25 The short version (French version) was used. 21 It is composed of 10 items classified into five categories: back vulnerability (items 1 and 2), the relationship between back pain and injury (items 3 and 4), participation in activities during back pain (items 5 and 6), the psychological influences of back pain (items 7 and 8), and the prognosis of back pain (items 9 and 10). 5 Each item is scored from À2 ("True") to +2 ("False") and the total score ranges from À20 to +20 (the scores of items 6, 7, and 8 are reversed for the calculation). ...
Article
Background A common misconception about low back pain (LBP) is that the spine is weak and that lumbar flexion should be avoided. Because the beliefs of health-care professionals (HCPs) influence patients, it is important to understand the attitudes of health care professionals towards LBP and lifting. Objectives To assess and compare the perceptions of different categories of HCPs regarding the safety of specific movement strategies used to lift a light load, and their beliefs regarding back pain. The secondary aim was to determine whether certain factors influenced the beliefs of HCPs. Methods Data were collected via an electronic survey. Student and qualified physical therapists (PTs), medical students, and general practitioner (GP) trainees were included. The questionnaire included eight photographs, depicting eight different strategies to lift a light load. Respondents were requested to select the strategy(s) they considered as “unsafe” to use for asymptomatic people with a previous history of LBP and people with chronic LBP. Beliefs and attitudes towards LBP were evaluated using the Back Pain Attitudes Questionnaire (Back-PAQ). Results Questionnaires from 1005 participants were included. Seventy percent of qualified PTs considered none of the strategies as harmful (versus 32% of PT students, 9% of GP trainees and 1% of medical students). Qualified PTs had higher Back-PAQ scores (mean ± SD: 13.6 ± 5.5) than PT students (8.7 ± 5.7), GP trainees (5.9 ± 5.9) and medical students (4.1 ± 5.2), indicating less misconceptions regarding LBP. Having LBP negatively influenced beliefs while taking a pain education course positively influenced beliefs. Conclusion Misconceptions regarding LBP and the harmfulness of lifting a light load with a rounded back remain common among HCPs, particularly medical doctors.
... The primary outcome was the validated French version of the Back Pain Attitudes Questionnaire (Back-PAQ) [5,80]. The questionnaire is composed of 34 items scoring from 1 to 5 points on a Likert scale (False, Possibly false, Unsure, Possibly true, True). ...
... Lowest scores at associated with more helpful beliefs (1 = false and 5 = true). a scores are reversed for items worded in the reverse direction so that a lower score also indicates that the helpful belief is more strongly held and were all above the minimal detectable change (MDC) of the Back-PAQ (14.5 points) [80]. Conversely, changes before and after the module were below the MDC. ...
Article
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Background Implementation of best-practice care for patients with low back pain (LBP) is an important issue. Physiotherapists’ who hold unhelpful beliefs are less likely to adhere to guidelines and may negatively influence their patients’ beliefs. Pre-registration education is critical in moving towards a biopsychosocial model of care. This study aimed to investigate the changes in 2nd year physiotherapy students’ beliefs about LBP after a module on spinal pain management and determine whether these changes were maintained at the end of academic training. Methods During three consecutive calendar years, this longitudinal cohort study assessed physiotherapy students’ beliefs with the Back Pain Attitudes Questionnaires (Back-PAQ) in their 1st year, before and after their 2nd year spinal management learning module, and at the end of academic training (3rd year). Unpaired t-tests were conducted to explore changes in Back-PAQ score. Results The mean response rate after the spinal management module was 90% (128/143 students). The mean (± SD) Back-PAQ score was 87.73 (± 14.21) before and 60.79 (± 11.44) after the module, representing a mean difference of − 26.95 (95%CI − 30.09 to − 23.80, p < 0.001). Beliefs were further improved at the end of 3rd year (− 7.16, 95%CI − 10.50 to − 3.81, p < 0.001). Conclusions A spinal management learning module considerably improved physiotherapy students’ beliefs about back pain. Specifically, unhelpful beliefs about the back being vulnerable and in need of protection were substantially decreased after the module. Improvements were maintained at the end of academic training one-year later. Future research should investigate whether modifying students’ beliefs leads to improved clinical practice in their first years of practice.
... Physiotherapists were asked to provide information about individual characteristics (see Appendix I for details and Table 1). The validated French version of the Back Pain Attitudes Questionnaire (Back-PAQ) was used to assess physiotherapists' own attitudes and beliefs about LBP (Darlow et al., 2014a;Demoulin et al., 2017). The questionnaire includes 34 items that score on a Likert scale ranging from 1 to 5 points (False, Possibly false, Unsure, Possibly true, True). ...
... Conversely, the sample's mean Back-PAQ score (83) indicated the presence of helpful beliefs in general amongst physiotherapists compared to those of the general population (mean score 113) or patients (mean score 120) (Christe et al., 2021b;Demoulin et al., 2017). ...
Article
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Background Physiotherapists' biomedical orientation influences the implementation of evidenced-based care for low back pain (LBP) management. However, information on physiotherapists’ own beliefs about their back and LBP and the influence of these on clinical decisions and advice is lacking. Objectives To identify attitudes and beliefs about LBP among physiotherapists and to analyse the association of these beliefs with physiotherapists’ individual characteristics and clinical decisions and advice. Design Cross-sectional survey. Method Attitudes and beliefs about LBP were measured with the Back-Pain Attitudes Questionnaire (Back-PAQ) among French-speaking Swiss physiotherapists. Physiotherapists’ clinical decisions and advice were assessed with a clinical vignette to determine their association with the Back-PAQ score. Results The study included 288 physiotherapists. The mean Back-PAQ score (82.7; SD 17.2) indicated the presence of helpful beliefs in general, but unhelpful beliefs in relation to back protection and the special nature of LBP (nature of pain, impact, complexity) were frequently identified. Individual characteristics explained 17% of the Back-PAQ score. Unhelpful beliefs were associated with clinical decisions toward back protection and movement avoidance (r = - 0.47, p < 0.001). Conclusions While helpful beliefs and guidelines consistent decisions were generally identified, unhelpful beliefs about back protection and the special nature of LBP were frequently present among physiotherapists. These unhelpful beliefs were associated with less optimal clinical decisions. Educational approaches should challenge unhelpful beliefs and empower physiotherapists to provide explanations and management that increases patients’ confidence in the back. Future research should investigate the effect of educational strategies on implementation of best practice for LBP management.
... Cette faible prévalence d'utilisation suggère la nécessité de mettre en place des stratégies/outils pour promouvoir et faciliter leur utilisation. (7) ), à risque de ne pas reprendre leur activité professionnelle (ex : le Orebro Musculoskeletal Pain Screening Questionnaire (8) ) ou les patients présentant une dépression ou une anxiété sévère (ex : l'échelle Hospital Anxiety and Depression (HAD) (9) ), une kinésiophobie (ex : l'échelle Tampa de kinésiophobie (TSK) (10) ), un catastrophisme (ex : l'échelle de dramatisation face à la douleur (PCS) (11) ), des croyances/représentations potentiellement délétères (ex : le questionnaire Brief-Illness Perceived Questionnaire (brief-IPQ) (12) ou le Back Pain Attitudes Questionnaire (Back-PAQ) (13) , un manque de connaissance/compréhension de la douleur (14) , etc. Les résultats du questionnaire permettent de modifier la prise en charge proposée en adaptant les exercices/techniques utilisées ou en impliquant d'autres professionnels de la santé comme un(e) psychologue. De plus, l'utilisation de PROMs incite le patient à réfléchir à son état de santé, à engager un processus de rétroaction/autoréflexion et améliore également la communication avec le thérapeute (15) . ...
... Before and after the module, participants filled in the validated French version of the Back-PAQ questionnaire (34 items version) [55]. This questionnaire assesses attitudes and underlying beliefs about back pain on a 5-point Likert scale. ...
Article
Introduction: Low back pain (LBP) is ranked as the first musculoskeletal disorder considering years lived with disability worldwide. Despite numerous guidelines promoting a bio-psycho-social (BPS) approach in the management of patients with LBP, many health care professionals (HCPs) still manage LBP patients mainly from a biomedical point of view. Objective: The purpose of this pilot study was to evaluate the feasibility of implementing an interactive e-learning module on the management of LBP in HCPs. Methods: n total 22 HCPs evaluated the feasibility of the e-learning module with a questionnaire and open questions. Participants filled in the Back Pain Attitude Questionnaire (Back-PAQ) before and after completing the module to evaluate their attitudes and beliefs about LBP. Results: The module was structured and easy to complete (91%) and met the expectations of the participants (86%). A majority agreed that the module improved their knowledge (69%). Some participants (77%) identified specific topics that might be discussed in more detail in the module. HCPs knowledge, beliefs and attitudes about LBP significantly improved following module completion (t = -7.63, P < .001) with a very large effect size (ds = -1.63). Conclusion: I The module seems promising to change knowledge, attitudes and beliefs of the participants. There is an urgent need to develop and investigate the effect of educational interventions to favor best practice in LBP management and this type of e-learning support could promote the transition from a biomedical to a bio-psycho-social management of LBP in HCPs.
... Before and after the module, participants filled in a validated French version of the Back-PAQ questionnaire [54]. This questionnaire assesses attitudes and underlying beliefs about back pain [37]. ...
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BACKGROUND Low back pain (LBP) is ranked as the first musculoskeletal disorder considering years lived with disability worldwide. Despite numerous guidelines promoting a bio-psycho-social (BPS) approach in the management of patients with LBP, many health care professionals (HCPs) still manage LBP patients mainly from a biomedical point of view. This is reflected by overuse of medical imaging and medication, advice to restrict work and activities, and insufficient attention towards psychosocial risk factors during actual consultation, which is all guideline discordant. Implementation strategies designed until now to change HCPs behavior had only limited effects or were not effective at all. OBJECTIVE The purpose of this pilot study was to evaluate the feasibility and effectiveness of implementing an interactive e-learning module on the management of LBP in HCPs. HCPs’ perceptions of their change in knowledge and beliefs about LBP as well as the content, structure, length and access of the module were assessed. METHODS In total 22 HCPs have been recruited. Participants completed and evaluated the e-learning module with an online questionnaire including 20 items based on similar feasibility studies. Likert Scales (n=15) and qualitative open questions (n=5) were both used. Before and after completing the module, participants filled in the Back-PAQ questionnaire to evaluate the potential effect of the module on their attitudes and beliefs about LBP. The Back-PAQ data were analyzed with the paired Student t-test. RESULTS The feasibility of the module was confirmed, it was structured and easy to complete (91%) and met the expectations of the participants (86%). A majority agreed that the module improved their knowledge (69%). According to the HCPs the time to complete the module (36 ± 9.6 minutes) was adequate (91%). Some participants (77%) identified specific topics that might be discussed in more detail in the module. Moreover, HCPs’ knowledge, beliefs and attitudes about LBP significantly improved following module completion (P < .001). CONCLUSIONS The interactive e-learning module seems feasible and effective. Participants were positive regarding the content, they found it sufficient and clear. The module was appealing, structured and easy to complete. Moreover, the module has been effective to change knowledge and beliefs of the participants. Suggestions have been made to improve it in the future.
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Objetivo: Identificar las creencias de los deportistas acerca del dolor lumbar. Como objetivo secundario, proponemos averiguar si las creencias reportadas difieren según la experiencia del dolor lumbar. Materiales y método: Estudio transversal tipo encuesta. Se invitó a atletas (recreacionales, amateurs y profesionales), mayores de 18 años con o sin dolor lumbar, a participar de una encuesta online a través de las redes sociales. Se utilizó el cuestionario Back Pain Attitudes Questionnaire (Back-PAQ) para evaluar las creencias sobre la espalda. Las opciones de las preguntas del Back-PAQ fueron clasificadas como “positivas”, “neutras” o “negativas”. Resultados: Un total de 1591 respuestas fueron incluidas en el análisis. La media del puntaje total del Back-PAQ fue 113,1 (Intervalo de Confianza 95%, 112,5 - 113,7) con un puntaje mínimo de 63 y máximo de 148. No se encontraron diferencias estadísticamente significativas entre los grupos observados (p= 0,51). Los atletas con dolor actual tuvieron creencias menos útiles que aquellos con historia de dolor lumbar: mediana de 115 (rango intercuartílico 108 - 121) versus 113 (rango intercuartílico 105 - 120); p= 0,002. Conclusión: Los atletas presentaron creencias predominantemente negativas sobre el dolor de espalda, independientemente del nivel de competencia. Prevalecieron los conceptos erróneos sobre la vulnerabilidad de la espalda y la necesidad de protegerla. Se expresaron creencias positivas sobre el pronóstico de un episodio de dolor lumbar.
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Resumen Objetivo: Identificar las creencias de los deportistas acerca del dolor lumbar. Como objetivo secundario, propo-nemos averiguar si las creencias reportadas difieren según la experiencia del dolor lumbar. Materiales y método: Estudio transversal tipo encuesta. Se invitó a atletas (recreacionales, amateurs y profe-sionales), mayores de 18 años con o sin dolor lumbar, a participar de una encuesta online a través de las redes sociales. Se utilizó el cuestionario Back Pain Attitudes Questionnaire (Back-PAQ) para evaluar las creencias sobre la espalda. Las opciones de las preguntas del Back-PAQ fueron clasificadas como "positivas", "neutras" o "negativas". Resultados: Un total de 1591 respuestas fueron incluidas en el análisis. La media del puntaje total del Back-PAQ fue 113,1 (Intervalo de Confianza 95%, 112,5-113,7) con un puntaje mínimo de 63 y máximo de 148. No se encontraron diferencias estadísticamente significativas entre los grupos observados (p= 0,51). Los atletas con dolor actual tuvieron creencias menos útiles que aquellos con historia de dolor lumbar: mediana de 115 (rango intercuartílico 108-121) versus 113 (rango intercuartílico 105-120); p= 0,002. Conclusión: Los atletas presentaron creencias predominantemente negativas sobre el dolor de espalda, inde-pendientemente del nivel de competencia. Prevalecieron los conceptos erróneos sobre la vulnerabilidad de la espalda y la necesidad de protegerla. Se expresaron creencias positivas sobre el pronóstico de un episodio de dolor Fuentes de financiamiento: Los autores declaran no tener ninguna afiliación financiera ni participación en ninguna organización comercial que tenga un interés financiero directo en cualquier asunto incluido en este manuscrito. Conflicto de intereses: Los autores declaran no tener ningún conflicto de intereses.
Article
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Objetivo: Identificar las creencias de los deportistas acerca del dolor lumbar. Como objetivo secundario, proponemos averiguar si las creencias reportadas difieren según la experiencia del dolor lumbar. Materiales y método: Estudio transversal tipo encuesta. Se invitó a atletas (recreacionales, amateurs y profesionales), mayores de 18 años con o sin dolor lumbar, a participar de una encuesta online a través de las redes sociales. Se utilizó el cuestionario Back Pain Attitudes Questionnaire (Back-PAQ) para evaluar las creencias sobre la espalda. Las opciones de las preguntas del Back-PAQ fueron clasificadas como "positivas", "neutras" o "negativas". Resultados: Un total de 1591 respuestas fueron incluidas en el análisis. La media del puntaje total del Back-PAQ fue 113,1 (Intervalo de Confianza 95%, 112,5-113,7) con un puntaje mínimo de 63 y máximo de 148. No se encontraron diferencias estadísticamente significativas entre los grupos observados (p= 0,51). Los atletas con dolor actual tuvieron creencias menos útiles que aquellos con historia de dolor lumbar: mediana de 115 (rango intercuartílico 108-121) versus 113 (rango intercuartílico 105-120); p= 0,002. Conclusión: Los atletas presentaron creencias predominantemente negativas sobre el dolor de espalda, independientemente del nivel de competencia. Prevalecieron los conceptos erróneos sobre la vulnerabilidad de la espalda y la necesidad de protegerla. Se expresaron creencias positivas sobre el pronóstico de un episodio de dolor Fuentes de financiamiento: Los autores declaran no tener ninguna afiliación financiera ni participación en ninguna organización comercial que tenga un interés financiero directo en cualquier asunto incluido en este manuscrito. Conflicto de intereses: Los autores declaran no tener ningún conflicto de intereses.
Article
Background Beliefs and attitudes about back pain are relevant factors in relation to developing back pain. A Danish version of the Back Pain Attitudes Questionnaire (Back-PAQ) could be a way of assuring a more systematic examination of attitudes about back pain within patients with back pain, laypeople and healthcare professionals in Denmark. Objectives The aim of this study was to develop a Danish version of the Back-PAQ and assess its psychometric properties. Study design Study of diagnostic accuracy/assessment scale. Method The adaptation was performed in several steps following the dual-panel method. The psychometric analyses included testing the reliability and validity. Results Thirty-seven individuals participated in the translation process, and the main findings were that the translated version was considered to reflect the original version and that it was considered relevant to address beliefs related to back pain. Five hundred and thirteen patients were included in principal component analysis and sixty were included in the test-retest analysis. The analysis on the 10-item version revealed a structure that was similar to the original questionnaire and explained 82% of the variance in the dataset. The test-retest analysis showed an ICC of 0.80 (95% CI 0.67-0.88) and SDC ranged from 0.78- 2.35 with a mean of 1.61. Conclusion The Back-PAQ was successfully translated and cross-culturally adapted into Danish. Its psychometrics properties showed that the Danish version of the questionnaire is valid and reliable for assessment of beliefs and attitudes regarding back pain, and may prove useful in both clinical settings and research in Denmark.
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Background Unhelpful beliefs about non-specific low back pain (LBP) are associated with poorer coping strategies and unhelpful behaviours. Furthermore, targeting unhelpful beliefs about back pain has been advanced as a major priority to decrease the burden of LBP. Therefore, studies exploring these beliefs are needed to adapt the message delivered to the population. Objectives To identify attitudes and beliefs about LBP in the general population in French-speaking Switzerland and to analyse their association with individual characteristics and the belief that exercise is an effective treatment for LBP. Design Cross-sectional study. Method Attitudes and beliefs were measured with the Back-Pain Attitudes Questionnaire (Back-PAQ). Individual characteristics and participants’ beliefs about the effectiveness of exercise for LBP were collected to determine their association with Back-PAQ score. Results The questionnaire was completed by 1129 participants. Unhelpful beliefs were widespread (mean (SD) Back-PAQ score: 113.2 (10.6)), especially those that the back needs protection, is easy to injure and that the nature of LBP is special. Only 55% of the participants believed exercise to be one of the most effective treatment for LBP. Individual characteristics only explained 4% of the Back-PAQ score variance. Conclusion French-speaking Swiss general population has high levels of unhelpful beliefs and moderate confidence in the effectiveness of exercise for LBP, though the message “staying active is good for LBP” was well understood. The messages to decrease the level of unhelpful beliefs about LBP in the population should specifically target the vulnerability, protection and special nature of LBP, and promote exercise therapy.
Technical Report
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Low back pain (LBP) is a considerable public health problem which combines high frequency, healthcare consumption and societal cost. In Belgium, according to the 2013 Health interview survey, 21% of the 15 years old and plus declared to have suffered from low back disorder or other chronic back defect in the past 12 months.1 Low back pain is a common cause for seeking health care. In 2004, in Belgium, one-fourth of patients between 18 and 75 years had visited a GP in the preceding 10 years because of LBP and 40.000 multiple-day and 46.000 one-day hospitalizations were reported for patients with LBP problems. Episodes of back pain are usually transient. For many patients with acute LBP or radicular pain, the complaints will disappear without any intervention. However for up to one third of patients, a pain of at least moderate intensity persists one year after the onset, leading to an important use of healthcare services and work absenteeism.3, 4 The National Institute for Health and Disability Insurance (RIZIV/INAMI) is aware of the costs linked to low back pain in terms of interventions’ reimbursement but also sickness leave. In 2006, the KCE had published a report (KCE report n° 48) on chronic low back pain focusing on the evaluation and treatment of patients, as well as on the incidence, costs and (occupational) consequences of this disorder. Ten years later, one could wonder whether new evidence is available and if the recommendations should be changed. A focus on non-invasive and nonpharmacological treatment was initially proposed since several conservative multidisciplinary therapeutic programmes exist without a definition of the precise composition of such programs. The invasive treatment was however also considered to be important, because, in the Belgian situation, injections and surgery appeared frequently used as treatment option for LBP with regional variations highlighting professional uncertainty and controversy.
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Objective: to summarize the knowledge regarding the maladaptive beliefs of patients with non-specific low back pain. Methods: A narrative literature review on these beliefs was conducted by an international and multidisciplinary team of experts in the field. Results: these beliefs, which can result in negative consequences on functioning and on patient prognosis, have various origins: family and friends, media, previous experience and/or health care professionals' messages. The latter, who have a considerable and enduring influence, have the potential to change and correct the patients' misbeliefs; however, they can also reinforce them in case of inappropriate messages and attitudes. Informing and educating the patient (by means of reassurance, explanations of the non-systematic association pain-injury, encouragement to get and stay physically active) are the basis of treatment. Taking into account the consequences of some words which may be misinterpreted, the results of imaging should be wisely discussed with the patient. Pain neurophysiology education and cognitive behavioral therapy (i.a., in vivo graded exposure techniques) are effective additional treatments. Conclusions: Misbeliefs are frequent in patient with low back pain. They do need to be looked for and corrected.
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Background Low back pain (LBP) is a major health problem. Globally it is responsible for the most years lived with disability. The most problematic type of LBP is chronic LBP (pain lasting longer than 3 mo); it has a poor prognosis and is costly, and interventions are only moderately effective. Targeting interventions according to risk profile is a promising approach to prevent the onset of chronic LBP. Developing accurate prognostic models is the first step. No validated prognostic models are available to accurately predict the onset of chronic LBP. The primary aim of this study was to develop and validate a prognostic model to estimate the risk of chronic LBP. Methods and Findings We used the PROGRESS framework to specify a priori methods, which we published in a study protocol. Data from 2,758 patients with acute LBP attending primary care in Australia between 5 November 2003 and 15 July 2005 (development sample, n = 1,230) and between 10 November 2009 and 5 February 2013 (external validation sample, n = 1,528) were used to develop and externally validate the model. The primary outcome was chronic LBP (ongoing pain at 3 mo). In all, 30% of the development sample and 19% of the external validation sample developed chronic LBP. In the external validation sample, the primary model (PICKUP) discriminated between those who did and did not develop chronic LBP with acceptable performance (area under the receiver operating characteristic curve 0.66 [95% CI 0.63 to 0.69]). Although model calibration was also acceptable in the external validation sample (intercept = −0.55, slope = 0.89), some miscalibration was observed for high-risk groups. The decision curve analysis estimated that, if decisions to recommend further intervention were based on risk scores, screening could lead to a net reduction of 40 unnecessary interventions for every 100 patients presenting to primary care compared to a “treat all” approach. Limitations of the method include the model being restricted to using prognostic factors measured in existing studies and using stepwise methods to specify the model. Limitations of the model include modest discrimination performance. The model also requires recalibration for local settings. Conclusions Based on its performance in these cohorts, this five-item prognostic model for patients with acute LBP may be a useful tool for estimating risk of chronic LBP. Further validation is required to determine whether screening with this model leads to a net reduction in unnecessary interventions provided to low-risk patients.
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Patient beliefs play an important role in the development of back pain and disability, as well as subsequent recovery. Community beliefs about the back and back pain which are inconsistent with current research evidence have been found in a number of developed countries. These beliefs negatively influence people's back-related behaviour in general, and these effects may be amplified when someone experiences an episode of back pain.In-depth qualitative research has helped to shed light on why people hold the beliefs which they do about the back, and how these have been influenced. Clinicians appear to have a strong influence on patients' beliefs. These data may be used by clinicians to inform exploration of unhelpful beliefs which patients hold, mitigate potential negative influences as a result of receiving health care, and subsequently influence beliefs in a positive manner.
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Objectives To develop an instrument to assess attitudes and underlying beliefs about back pain, and subsequently investigate its internal consistency and underlying structures. Design The instrument was developed by a multidisciplinary team of clinicians and researchers based on analysis of qualitative interviews with people experiencing acute and chronic back pain. Exploratory analysis was conducted using data from a population-based cross-sectional survey. Setting Qualitative interviews with community-based participants and subsequent postal survey. Participants Instrument development informed by interviews with 12 participants with acute back pain and 11 participants with chronic back pain. Data for exploratory analysis collected from New Zealand residents and citizens aged 18 years and above. 1000 participants were randomly selected from the New Zealand Electoral Roll. 602 valid responses were received. Measures The 34-item Back Pain Attitudes Questionnaire (Back-PAQ) was developed. Internal consistency was evaluated by the Cronbach α coefficient. Exploratory analysis investigated the structure of the data using Principal Component Analysis. Results The 34-item long form of the scale had acceptable internal consistency (α=0.70; 95% CI 0.66 to 0.73). Exploratory analysis identified five two-item principal components which accounted for 74% of the variance in the reduced data set: ‘vulnerability of the back’; ‘relationship between back pain and injury’; ‘activity participation while experiencing back pain’; ‘prognosis of back pain’ and ‘psychological influences on recovery’. Internal consistency was acceptable for the reduced 10-item scale (α=0.61; 95% CI 0.56 to 0.66) and the identified components (α between 0.50 and 0.78). Conclusions The 34-item long form of the scale may be appropriate for use in future cross-sectional studies. The 10-item short form may be appropriate for use as a screening tool, or an outcome assessment instrument. Further testing of the 10-item Back-PAQ's construct validity, reliability, responsiveness to change and predictive ability needs to be conducted.
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Objectives To explore the prevalence of attitudes and beliefs about back pain in New Zealand and compare certain beliefs based on back pain history or health professional exposure. Design Population-based cross-sectional survey. Setting Postal survey. Participants New Zealand residents and citizens aged 18 years and above. 1000 participants were randomly selected from the New Zealand Electoral Roll. Participants listed on the Electoral Roll with an overseas postal address were excluded. 602 valid responses were received. Measures Attitudes and beliefs about back pain were measured with the Back Pain Attitudes Questionnaire (Back-PAQ). The interaction between attitudes and beliefs and (1) back pain experience and (2) health professional exposure was investigated. Results The lifetime prevalence of back pain was reported as 87% (95% CI 84% to 90%), and the point prevalence as 27% (95% CI 24% to 31%). Negative views about the back and back pain were prevalent, in particular the need to protect the back to prevent injury. People with current back pain had more negative overall scores, particularly related to back pain prognosis. There was uncertainty about links between pain and injury and appropriate physical activity levels during an episode of back pain. Respondents had more positive views about activity if they had consulted a health professional about back pain. The beliefs of New Zealanders appeared to be broadly similar to those of other Western populations. Conclusions A large proportion of respondents believed that they needed to protect their back to prevent injury; we theorise that this belief may result in reduced confidence to use the back and contribute to fear avoidance. Uncertainty regarding what is a safe level of activity during an episode of back pain may limit participation. People experiencing back pain may benefit from more targeted information about the positive prognosis. The provision of clear guidance about levels of activity may enable confident participation in an active recovery.
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Purpose: The purpose of this study was to explore the formation and impact of attitudes and beliefs among people experiencing acute and chronic low back pain. Methods: Semistructured qualitative interviews were conducted with 12 participants with acute low back pain (less than 6 weeks' duration) and 11 participants with chronic low back pain (more than 3 months' duration) from 1 geographical region within New Zealand. Data were analyzed using an Interpretive Description framework. Results: Participants' underlying beliefs about low back pain were influenced by a range of sources. Participants experiencing acute low back pain faced considerable uncertainty and consequently sought more information and understanding. Although participants searched the Internet and looked to family and friends, health care professionals had the strongest influence upon their attitudes and beliefs. Clinicians influenced their patients' understanding of the source and meaning of symptoms, as well as their prognostic expectations. Such information and advice could continue to influence the beliefs of patients for many years. Many messages from clinicians were interpreted as meaning the back needed to be protected. These messages could result in increased vigilance, worry, guilt when adherence was inadequate, or frustration when protection strategies failed. Clinicians could also provide reassurance, which increased confidence, and advice, which positively influenced the approach to movement and activity. Conclusions: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.
Article
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Low back pain (LBP) is a major public health problem and the identification of individuals at risk of persistent LBP poses substantial challenges to clinical management. The STarT Back questionnaire is a validated nine-item patient self-report questionnaire that classifies patients with LBP at low, medium or high-risk of poor prognosis for persistent non-specific LBP. The objective of this study was to translate and cross-culturally adapt the English version of the STarT Back questionnaire into French. The translation was performed using best practice translation guidelines. The following phases were performed: contact with the STarT Back questionnaire developers, initial translations (English into French), synthesis, back translations, expert committee review, test of the pre-final version on 44 individuals with LBP, final version. The linguistic translation required minor semantic alterations. The participants interviewed indicated that all items of the questionnaire were globally clear and comprehensible. However, 6 subjects (14%) wondered if two questions were related to back pain or general health. After discussion within the expert committee and with the developer of the STarT Back tool, it was decided to modify the questionnaire and to add a reference to back pain in these two questions. The French version of the STarT Back questionnaire has been shown to be comprehensible and adapted to the French speaking general population. Investigations are now required to test the psychometric properties (reliability, internal and external validity, responsiveness) of this translated version of the questionnaire.
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For patients with low back pain, fear-avoidance beliefs (FABs) represent cognitions and emotions that underpin concerns and fears about the potential for physical activities to produce pain and further harm to the spine. Excessive FABs result in heightened disability and are an obstacle for recovery from acute, subacute, and chronic low back pain. This article summarizes past research concerning the etiology, impact, and assessment of FABs; reviews the results and relevance to clinical practice of trials that have addressed FAB as part of low back pain treatment; and lists areas in need of further study. This article reports on a plenary presentation and discussion of an expert panel and workshop entitled "Addressing fear-avoidance beliefs in a fear-avoidant world--translating research into clinical practice" that was held at Forum X, Primary Care Research on Low Back Pain, during June 2009, at the Harvard School of Public Health in Boston, MA, USA. Important issues including the definition, etiology, impact, and treatment of FAB on low back pain outcomes were reviewed by six panelists with extensive experience in FAB-related research. This was followed by a group discussion among 40 attendees. Conclusion and recommendations were extracted by the workshop panelist and summarized in this article. Fear-avoidance beliefs are derived from both emotionally based fears of pain and injury and information-based beliefs about the soundness of the spine, causes of spine degeneration, and importance of pain. Excessively elevated FABs, both in patients and treating health care providers, have a negative impact on low back pain outcomes as they delay recovery and heighten disability. Fear-avoidance beliefs may be best understood when patients are categorized into subgroups of misinformed avoiders, learned pain avoiders, and affective avoiders as these categories elucidate potential treatment strategies. These include FAB-reducing information for misinformed avoiders, pain desensitizing treatments for pain avoiders, and fear desensitization along with counseling to address the negative cognition in affective avoiders. Although mixed results have been noted, most clinical trials have documented improved outcomes when FAB is addressed as part of treatment. Deficiencies in knowledge about brief methods for assessing FAB during clinical encounters, the importance of medical explanations for back pain, usefulness of subgroup FABs, core points for information-based treatments, and efficient strategies for transferring FAB-reducing information to patients hamper the translation of FAB research into clinical practice. By incorporating an understanding of FAB, clinicians may enhance their ability to assess the predicaments of their patients with low back pain and gain insight into potential value of corrective information that lessen fears and concerns on well-being of their patients.
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Originally the term "yellow flags" was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability.
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This discussion paper argues that both the use of Cronbach's alpha as a reliability estimate and as a measure of internal consistency suffer from major problems. First, alpha always has a value, which cannot be equal to the test score's reliability given the interitem covariance matrix and the usual assumptions about measurement error. Second, in practice, alpha is used more often as a measure of the test's internal consistency than as an estimate of reliability. However, it can be shown easily that alpha is unrelated to the internal structure of the test. It is further discussed that statistics based on a single test administration do not convey much information about the accuracy of individuals' test performance. The paper ends with a list of conclusions about the usefulness of alpha.
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Musculoskeletal disorders are among the main causes of short- and long-term disability. Identify the methods for assessing multidimensional components of illness representations. An electronic literature search (French, English) from 1980 to the present was conducted in medical, paramedical and social science databases using predetermined key words. After screening titles and abstracts based on a specific set of criteria, sixty-four articles were reviewed. Qualitative approaches for assessing illness representation were found mainly in the fields of anthropology and sociology and were based on the explanatory models of illness. The interviews reviewed were: the Short Explanatory Model Interview, the Explanatory Model of Illness Catalogue and the McGill Illness Narrative Interview. Quantitative approaches were found in the health psychology field and used the following self-administered questionnaires: the Survey of Pain Attitudes, the Pain Beliefs and Perceptions Inventory, the Pain Beliefs Questionnaire, the Fear-Avoidance Beliefs Questionnaire, the Implicit Model of Illness Questionnaire, the Illness Perception Questionnaire, including its derivatives, and the Illness Cognition Questionnaire. This review shows the actual use and existence of multiple interviews and questionnaires in assessing multidimensional illness representations. All have been used and/or tested in a medical context but none have been tested in a work disability context. Further research will be needed to determine their suitability for use in a work disability context.
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To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes. Inception cohort study. Primary care. 103 patients with acute localised non-specific back pain lasting less than 72 hours. Complete recovery (disappearance of both pain and disability) and return to work. 90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender. The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.
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The purpose of this study was to survey the level of fear-avoidance beliefs for practicing general practitioners and physical therapists and to relate this to self-reported practice behaviors for patients with back pain. To this end, 60 general practitioners and 71 physical therapists were recruited. These participants completed a questionnaire including 11 items slightly revised from instruments designed to assess fear-avoidance beliefs in patients, and four items about treatment practices. The results indicated that these health care practitioners on the average generally held beliefs that are consistent with the current evidence, but there were also indications that some practitioners held beliefs reflecting fear-avoidance. More than two-thirds reported that they would advise a patient to avoid painful movements, more than one-third believed a reduction in pain is a prerequisite for return-to-work, while more than 25% reported that they believe sick leave is a good treatment for back pain. These beliefs were found to be related to reported practice behavior. Those with high levels of fear-avoidance beliefs were compared to those with low levels. Those with high levels of fear-avoidance belief had an increased risk for believing sick leave to be a good treatment (RR = 2.0; 90%CI = 1.02-3.92), not providing good information about activities (RR = 1.7; 90%CI = 1.19-2.45), and being uncertain about identifying patients at risk for developing persistent pain problems (RR = 1.5; 90%CI = 1.00-2.27). It is concluded that some practitioners hold beliefs reflecting fear-avoidance and that these beliefs may influence treatment practice.
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This study investigated the prevalence of back pain, disability, and, of most importance, the presence of misconceptions about low back pain (LBP), its diagnosis and treatment in a bicultural community sample (Belgium). Using the Graded Chronic Pain Scale [Pain 50 (1992) 133] persons were classified according to pain intensity and disability in five subgroups. The interrelationship between LBP beliefs and these five subgroups was also investigated. In our sample (n=1624) the 6-month prevalence of low back pain was 41.8%. Only in 8.2% back pain was disabling. Misconceptions about back pain were widespread, even in the group reporting no back pain. The least misconceptions were found to exist in participants with mild LBP without disability. It is suggested that recovery from an episode of acute low back pain is an active process that involves a correction of beliefs about harm, about the need to restrict physical activities and about medical diagnosis and cure. Finally, it is argued that community actions may be useful to correct LBP myths in order to prevent the development of long-term disability due to LBP.
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Recently, an increasing number of systematic reviews have been published in which the measurement properties of health status questionnaires are compared. For a meaningful comparison, quality criteria for measurement properties are needed. Our aim was to develop quality criteria for design, methods, and outcomes of studies on the development and evaluation of health status questionnaires. Quality criteria for content validity, internal consistency, criterion validity, construct validity, reproducibility, longitudinal validity, responsiveness, floor and ceiling effects, and interpretability were derived from existing guidelines and consensus within our research group. For each measurement property a criterion was defined for a positive, negative, or indeterminate rating, depending on the design, methods, and outcomes of the validation study. Our criteria make a substantial contribution toward defining explicit quality criteria for measurement properties of health status questionnaires. Our criteria can be used in systematic reviews of health status questionnaires, to detect shortcomings and gaps in knowledge of measurement properties, and to design validation studies. The future challenge will be to refine and complete the criteria and to reach broad consensus, especially on quality criteria for good measurement properties.
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Research studies focusing on the fear-avoidance model have expanded considerably since the review by Vlaeyen and Linton (Vlaeyen J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317--332). The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem. This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities. Furthermore, support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain, will be highlighted. Finally, available evidence on recent clinical applications is provided, and unresolved issues that need further exploration are discussed.
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Inappropriate imaging for low back pain (LBP) can cause harm in three ways: 1. Misinterpretation of results by clinicians resulting in unhelpful advice, needless subsequent investigations (downstream testing) and invasive interventions, including surgery;1 2. Misinterpretation of results by patients resulting in catastrophisation, fear and avoidance of movement and activity, and low expectations of recovery;2 3. Side effects such as exposure to radiation.3 Problems associated with excessive imaging for LBP are well recognised (http://www.choosingwisely.org) and useful evidence-based guidelines have been developed to help clinicians determine when investigation is appropriate.3 However, currently, 42% of patients with LBP receive an X-ray, CT or MRI within 1 year of diagnosis, and of these, 80% receive imaging within 1 month of presentation.4 The uptake of imaging guidelines is likely to be similarly insufficient among the sports medicine community, where lumbar imaging is frequently used. As well as recognising when imaging is appropriate, evidence-based reporting and interpretation of imaging findings is critical. The contents of …
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Objective: Intraclass correlation coefficient (ICC) is a widely used reliability index in test-retest, intrarater, and interrater reliability analyses. This article introduces the basic concept of ICC in the content of reliability analysis. Discussion for researchers: There are 10 forms of ICCs. Because each form involves distinct assumptions in their calculation and will lead to different interpretations, researchers should explicitly specify the ICC form they used in their calculation. A thorough review of the research design is needed in selecting the appropriate form of ICC to evaluate reliability. The best practice of reporting ICC should include software information, "model," "type," and "definition" selections. Discussion for readers: When coming across an article that includes ICC, readers should first check whether information about the ICC form has been reported and if an appropriate ICC form was used. Based on the 95% confident interval of the ICC estimate, values less than 0.5, between 0.5 and 0.75, between 0.75 and 0.9, and greater than 0.90 are indicative of poor, moderate, good, and excellent reliability, respectively. Conclusion: This article provides a practical guideline for clinical researchers to choose the correct form of ICC and suggests the best practice of reporting ICC parameters in scientific publications. This article also gives readers an appreciation for what to look for when coming across ICC while reading an article.
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In a prospective study of 230 episodes of low-back pain presenting in primary care, the natural history of the symptom of low-back pain has been described. Clinical features predictive of outcome have been identified in order to define groups of patients who were relatively homogeneous with respect to the outcome of the episode. A Disability Questionnaire performed more satisfactorily as an outcome measure than either absence from work or a simple pain-rating scale. Guidelines for future trials of treatment of back pain in primary care are described.
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Qualitative interview studyObjective. Explore attitudes, beliefs, and perceptions related to low back pain (LBP), and analyze how these might influence the perceived threat associated with back pain. Psychological factors which contribute to the perceived threat associated with LBP play an important role in back pain development and the progression to persistent pain and disability. Improved understanding of underlying beliefs may assist clinicians to investigate and assess these factors. Semi-structured qualitative interviews were conducted with 12 participants with acute LBP (<6 weeks' duration) and 11 participants with chronic LBP (>3 months' duration). Data were analyzed thematically using the framework of Interpretive Description. The back was viewed as being vulnerable to injury due to its design, the way in which it is used, and personal physical traits or previous injury. Consequently participants considered they needed to protect their back by resting, being careful with or avoiding dangerous activities, and strengthening muscles or controlling posture. Participants considered LBP to be special in its nature and impact, and they thought it difficult to understand without personal experience. The prognosis of LBP was considered uncertain by those with acute pain and poor by those with chronic pain. These beliefs combined to create a negative (mis)representation of the back. Negative assumptions about the back made by those with LBP may affect information processing during an episode of pain. This may result in attentional bias toward information indicating the spine is vulnerable, an injury is serious, or the outcome will be poor. Approaching consultations with this understanding may assist clinicians to have a positive influence on beliefs.
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Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP). The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP. The design of this study was a systematic review. In October 2011, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. To ensure the completeness of the search, a hand search and a search of bibliographies was conducted and all relevant references included. A total of 2,031 references were retrieved, leaving 566 references after the removal of duplicates. For 53 references, the full-text was assessed and, finally, 21 studies were included in the analysis. The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP). Four cohort studies, conducted by disability insurance companies in the United States, Canada, and Belgium, included 258 to 1,068 patients mostly with nonspecific LBP. These researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. The odds ratio (OR) ranged from 1.05 (95% confidence interval [CI] 1.02-1.09) to 4.64 (95% CI, 1.57-13.71). The highest OR was found when applying a high cutoff for FABQ Work subscale scores. This may indicate that the use of cutoff values increases the likelihood of positive findings. This issue requires further study. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive. Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.
Article
Background: Despite common usage of the back beliefs questionnaire (BBQ) in a variety of studies, important validity evidence is missing. The objective of this study was to examine the validity of the BBQ in the general population. Methods: A population-based, cross-sectional study design was used. Adult residents in two Canadian provinces were randomly sampled. To examine structural validity, items from the BBQ were subjected to factor analysis. Construct validity was tested by examining two hypotheses: BBQ scores would be most pessimistic in those with a recent history of back pain and in those who utilized passive treatments for back pain. Multiple linear regression was used to analyse the two hypotheses. Results: Complete data were available for 6171 subjects. The best structure for the BBQ was to use eight or nine of the 14 items for scoring, which is consistent with the structure reported by the BBQ developers. BBQ scores varied based on participants' history of low back pain (LBP) and depended on pain severity. Those with severe pain and a recent history of LBP had the most pessimistic BBQ scores. In addition, participants who utilized passive management behaviours such as bed rest and activity avoidance had more pessimistic BBQ scores compared with those that did not. Conclusions: This study provides strong validity evidence supporting the current structure and scoring of the BBQ. In addition, construct validity was evidenced by the behaviour of BBQ scores in a manner congruent with our hypotheses, further supporting use of the BBQ in the general population.
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A primary goal of scale development is to create a valid measure of an underlying construct. We discuss theoretical principles, practical issues, and pragmatic decisions to help developers maximize the construct validity of scales and subscales. First, it is essential to begin with a clear conceptualization of the target construct. Moreover, the content of the initial item pool should be overinclusive and item wording needs careful attention. Next, the item pool should be tested, along with variables that assess closely related constructs, on a heterogeneous sample representing the entire range of the target population. Finally, in selecting scale items, the goal is unidimensionality rather than internal consistency; this means that virtually all interitem correlations should be moderate in magnitude. Factor analysis can play a crucial role in ensuring the unidimensionality and discriminant validity of scales. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population. Electronic databases were systematically searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was appraised and strength of evidence was determined. Seventeen studies from eight countries which investigated the attitudes and beliefs of general practitioners, physiotherapists, chiropractors, rheumatologists, orthopaedic surgeons and other paramedical therapists were included. There is strong evidence that HCP beliefs about back pain are associated with the beliefs of their patients. There is moderate evidence that HCPs with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities, and are less likely to adhere to treatment guidelines. There is moderate evidence that HCP attitudes and beliefs are associated with patient education and bed rest recommendations. There is moderate evidence that HCP fear avoidance beliefs are associated with reported sick leave prescription and that a biomedical orientation is not associated with the number of sickness certificates issued for LBP. HCPs need to be aware of the association between their attitudes and beliefs and the attitudes and beliefs and clinical management of their patients with LBP.
Article
Health literacy, the ability to seek, understand and utilise health information, is important for good health. Suboptimal health literacy has been associated with poorer health outcomes in many chronic conditions although this has not been studied in chronic low back pain (CLBP). We examined the health literacy of individuals with CLBP using a mixed methods approach. One-hundred and seventeen adults, comprising 61 with no history of CLBP and 56 with CLBP (28 with low and high disability, respectively, as determined by a median split in Oswestry scores) participated. Data regarding severity of pain, LBP-related disability, fear avoidance, beliefs about LBP and pain catastrophizing were collected using questionnaires. Health literacy was measured using the Short-form Test of Functional Health Literacy in Adults (S-TOFHLA). A sub-sample of 36 participants with CLBP also participated in in-depth interviews to qualitatively explore their beliefs about LBP and experiences in seeking, understanding and using information related to LBP. LBP-related beliefs and behaviours, rather than pain intensity and health literacy skills, were found to be important correlates of disability related to LBP. Individuals with CLBP-high disability had poorer back pain beliefs and increased fear avoidance behaviours relating to physical activity. Health literacy (S-TOFHLA) was not related to LBP beliefs and attitudes. Qualitatively, individuals with CLBP-high disability adopted a more passive coping style and had a pathoanatomic view of their disorder compared to individuals with CLBP-low disability. While all participants with CLBP had adequate health literacy scores (S-TOFHLA), qualitative data highlighted difficulties in seeking, understanding and utilising LBP information.
Article
Low back pain is extremely common. Early identification of patients more likely to develop persistent disabling symptoms could help guide decisions regarding follow-up and management. To systematically review the usefulness of individual risk factors or risk prediction instruments for identifying patients more likely to develop persistent disabling low back pain. Electronic searches of MEDLINE (1966-January 2010) and EMBASE (1974-February 2010) and review of the bibliographies of retrieved articles. Prospective studies of patients with fewer than 8 weeks of low back pain from which likelihood ratios (LRs) were calculated for prediction of persistent disabling low back pain for findings attainable during the clinical evaluation. Two authors independently assessed studies and extracted data to estimate LRs. A total of 20 studies evaluating 10,842 patients were identified. Presence of nonorganic signs (median [range] LR, 3.0 [1.7-4.6]), high levels of maladaptive pain coping behaviors (median [range] LR, 2.5 [2.2-2.8]), high baseline functional impairment (median [range] LR, 2.1 [1.2-2.7]), presence of psychiatric comorbidities (median [range] LR, 2.2 [1.9-2.3]), and low general health status (median [range] LR, 1.8 [1.1-2.0]) were the most useful predictors of worse outcomes at 1 year. Low levels of fear avoidance (median [range] LR, 0.39 [0.38-0.40]) and low baseline functional impairment (median [range] LR, 0.40 [0.10-0.52]) were the most useful items for predicting recovery at 1 year. Results were similar for outcomes at 3 to 6 months. Variables related to the work environment, baseline pain, and presence of radiculopathy were less useful for predicting worse outcomes (median LRs approximately 1.5), and a history of prior low back pain episodes and demographic variables were not useful (median LRs approximately 1.0). Several risk prediction instruments were useful for predicting outcomes, but none were extensively validated, and some validation studies showed LRs similar to estimates for individual risk factors. The most helpful components for predicting persistent disabling low back pain were maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.
Article
Functional disability is one of the main components of low back pain (LBP)-associated morbidity and should be taken into account in the evaluation and care of patients. This article describes the French-language adaptation and validation of the Roland and Morris Disability Questionnaire. This self-administered questionnaire proved rapid, simple to use, reliable, valid, and sensitive to changes in clinical status, suggesting that its widespread use may be possible in settings ranging from epidemiological or clinical research to individual LBP patient evaluation in daily clinical practice.
Article
In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al. (Lethem J, Slade PD, Troup JDG, Bentley G. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401-408).ntroduced a so-called 'fear-avoidance' model. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. The latter, however, leads to the maintenance or exacerbation of fear, possibly generating a phobic state. In the last decade, an increasing number of investigations have corroborated and refined the fear-avoidance model. The aim of this paper is to review the existing evidence for the mediating role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability. We first highlight possible precursors of pain-related fear including the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity may play. Subsequently, a number of fear-related processes will be discussed including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. We also review the available assessment methods for the quantification of pain-related fear and avoidance. Finally, we discuss the implications of the recent findings for the prevention and treatment of chronic musculoskeletal pain. Although there are still a number of unresolved issues which merit future research attention, pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.
Article
With the increase in the number of multinational and multicultural research projects, the need to adapt health status measures for use in other than the source language has also grown rapidly. 1,4,27 Most questionnaires were developed in English-speaking countries, 11 but even within these countries, researchers must consider immigrant populations in studies of health, especially when their exclusion could lead to a systematic bias in studies of health care utilization or quality of life. 9,11 The cross-cultural adaptation of a health status selfadministered questionnaire for use in a new country, culture, and/or language necessitates use of a unique method, to reach equivalence between the original source and target versions of the questionnaire. It is now recognized that if measures are to be used across cultures, the items must not only be translated well linguistically, but also must be adapted culturally to maintain the content validity of the instrument at a conceptual level across different cultures. 6,11‐13,15,24 Attention to this level of detail allows increased confidence that the impact of a disease or its treatment is described in a similar manner in multinational trials or outcome evaluations. The term “cross-cultural adaptation” is used to encompass a process that looks at both language (translation) and cultural adaptation issues in the process of preparing a questionnaire for use in another setting. Cross-cultural adaptations should be considered for several different scenarios. In some cases, this is more obvious than in others. Guillemin et al 11 suggest five different examples of when attention should be paid to this adaptation by comparing the target (where it is going to be used) and source (where it was developed) language and culture. The first scenario is that it is to be used in the same language and culture in which it was developed. No adaptation is necessary. The last scenario is the opposite extreme, the application of a questionnaire in a different culture, language and country—moving the Short Form 36-item questionnaire from the United States (source) to Japan (target) 7 which would necessitate translation and cultural adaptation. The other scenarios are summarized in Table 1 and reflect situations when some translation and/or adaptation is needed. The guidelines described in this document are based on a review of cross-cultural adaptation in the medical, sociological, and psychological literature. This review led to the description of a thorough adaptation process designed to maximize the attainment of semantic, idiomatic, experiential, and conceptual equivalence between the source and target questionnaires. 13 . Further experience in cross-cultural adaptation of generic and diseasespecific instruments and alternative strategies driven by different research groups 18 have led to some refinements
Article
Fear-avoidance beliefs have been identified as an important psychosocial variable in patients with chronic disability doe to low back pain. The importance of fear-avoidance beliefs for individuals with acute low back pain has not been explored. Seventy-eight subjects with work-related low back pain of less than 3 weeks'duration were studied. Measurements of pain intensity, physical impairment, disability, nonorganic signs and symptoms, and depression were taken at the initial evaluation. Fear-avoidance beliefs were measured with the work and physical activity subscales of the Fear-avoidance Beliefs Questionnaire. Disability and work status were re-assessed after 4 weeks of physical therapy. Patterns of correlation between fear-avoidance beliefs and other concurrently-measured variables were similar to those reported in patients with chronic low back pain. Fear-avoidance beliefs did not explain a significant amount of the variability in initial disability levels after controlling for pain intensity and physical impairment. Fear-avoidance beliefs about work were significant predictors of 4-week disability and work status even after controlling for initial levels of pain intensity, physical impairment, and disability, and the type of therapy received. Fear-avoidance beliefs are present in patients with acute low back pain, and may be an important factor in explaining the transition from acute to chronic conditions. Screening for fear-avoidance beliefs may be useful for identifying patients at risk of prolonged disability and work absence.
Article
A prospective cohort study was conducted on workers claiming earnings-related compensation for low back pain. Information obtained at the time of the initial claim was linked to compensation status (still claiming or not claiming) 3 months later. To identify individual, psychosocial, and workplace risk factors associated with the transition from acute to chronic occupational back pain. Despite the magnitude of the economic and social costs associated with chronic occupational back pain, few prospective studies have investigated risk factors identifiable in the acute stage. At the time of the initial compensation claim, a self-administered questionnaire was used to gather information on a wide range of risk factors. Then 3 months later, chronicity was determined from claimants' computerized records. The findings showed that 3 months after the initial assessment, 204 of the recruited 854 claimants (23.9%) still were receiving compensation payments. A combined multiple regression model of individual, psychosocial, and workplace risk factors demonstrated that severe leg pain (odds ratio [OR], 1.9), obesity (OR, 1.7), all three Oswestry Disability Index categories above minimal disability (OR, 3.1-4), a General Health Questionnaire score of at least 6 (OR, 1.9), unavailability of light duties on return to work (OR, 1.7), and a job requirement of lifting for three fourths of the day or more all were significant, independent determinants of chronicity (P < 0.05). Simple self-report measures of individual, psychosocial, and workplace factors administered when earnings-related compensation for back pain is claimed initially can identify individuals with increased odds for development of chronic occupational disability.
Article
In the United States alone, the annual cost associated with the diagnosis and care of musculoskeletal trauma amounts to tens of billions of dollars [Occupational Musculoskeletal Disorders: Function, Outcomes and Evidence. Lippincott Williams and Wilkins, Philadelphia]. Moreover, these costs are continuing to increase at an alarming rate. In fact, in the United States today, occupational musculoskeletal disorders are the leading causes of work disability. Changes in health care policy and demand for improved allocation of health care resources by the Federal government have also recently placed greater pressure on health care professionals to provide the most cost-effective treatment for these disorders, as well as to validate treatment effectiveness. Indeed, treatment-outcome monitoring has assumed new importance in medicine. It is particularly essential in musculoskeletal care, which is currently targeted for attention by health care planners because of its high cost and perceived traditional inefficient care. With these facts in mind, the purpose of the present article is to review the status of current primary and secondary interventions for musculoskeletal disorders. Before doing so, a brief discussion of the biopsychosocial model of pain and disability, which is currently the most heuristic approach to intervention, will be provided.
Article
In 2001, several myths of low back pain still were alive in the general population in Norway, myths that were not in concordance with current guidelines. To investigate perceptions about back pain in Norwegian general practitioners and physiotherapists and to compare these with perceptions in the general population. During June 2001, 436 general practitioners (mean age 44.8, range 26-69 years) and 311 physiotherapists (mean age 47.6, range 25-70) were asked to rate their agreement with 7 statements, corresponding to Deyo's 7 myths that formulate 7 common misbeliefs on back pain. The corresponding data from the general population of 807 individuals (mean age 45.5, range 25-70) were sampled during early spring 2001. There were significant differences between the general population, general practitioners, and physiotherapists for all myths, the general population being more likely to agree with all myths. The differences were maintained even after controlling for educational level in the general population. There were no differences between general practitioners and physiotherapists except for the myths "radiographs and newer imaging tests can always identify the cause of pain" and "back pain is usually disabling," whereas general practitioners were less likely to disagree with the myths. Few gender and age differences were found in the professional groups. In Norwegian general practitioners and physiotherapists, Deyo's 7 myths mostly seem to be dead and buried. However, it does not seem that this has extended to the public yet, as many myths still are alive in the general population.
Article
This study evaluates the Brief Illness Perception Questionnaire (Brief IPQ), a nine-item scale designed to rapidly assess the cognitive and emotional representations of illness. We assessed the test-retest reliability of the scale in 132 renal outpatients. We assessed concurrent validity by comparing the Brief IPQ with the Illness Perception Questionnaire-Revised (IPQ-R) and other relevant measures in 309 asthma, 132 renal, and 119 diabetes outpatients. Predictive validity was established by examining the relationship of Brief IPQ scores to outcomes in a sample of 103 myocardial infarction (MI) patients. Discriminant validity was examined by comparing scores on the Brief IPQ between five different illness groups. The Brief IPQ showed good test-retest reliability and concurrent validity with relevant measures. The scale also demonstrated good predictive validity in patients recovering from MI with individual items being related to mental and physical functioning at 3 months' follow-up, cardiac rehabilitation class attendance, and speed of return to work. The discriminant validity of the Brief IPQ was supported by its ability to distinguish between different illnesses. The Brief IPQ provides a rapid assessment of illness perceptions, which could be particularly helpful in ill populations, large-scale studies, and in repeated measures research designs.
Article
Population-based survey. To assess the back pain beliefs in 2 provinces in Canada to inform a population-based educational campaign. Beliefs, attitudes, and recovery expectations appear to influence recovery from back pain, yet prevailing public opinions about the condition have been little studied. Telephone surveys were conducted with 2400 adults in 2 Canadian provinces. Surveys included the Back Beliefs Questionnaire, and additional questions concerning age, gender, recent and lifetime back pain, coping strategies for back pain, and awareness and persuasiveness of media information concerning back pain. A high prevalence of back pain was reported, with a lifetime prevalence of 83.8%, and 1-week prevalence of 34.2%. Generally, a pessimistic view of back pain was held. Most agreed that back pain makes everything in life worse, will eventually stop one from working, and will become progressively worse with age. Mixed opinions were observed regarding the importance of rest and staying active. A significant minority (12.3%) reported taking time off from work for their last back pain episode. Those individuals taking time off from work held more negative back pain beliefs, including the belief that back pain should be rested until it gets better. Public back pain beliefs in the 2 Canadian provinces sampled are not in harmony with current scientific evidence for this highly prevalent condition. Given the mismatch between public beliefs and current evidence, strategies for reeducating the public are needed.
Article
We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire (IPQ-R). Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ) and patients' global rating of change. Associations between patients, perceptions and poor outcome were analysed using unadjusted and adjusted risk ratios (RR) and 95% confidence intervals. 1591 completed questionnaires were received at baseline and 810 at 6 months. Patients had a mean age of 44 years and 59% were women. Mean (SD) RMDQ score at baseline was 8.6 (6.0) and 6.2 (6.1) at 6 months. 52% and 41% of patients had a poor clinical outcome at 6 months using RMDQ and global rating scores, respectively. There were strong, statistically significant, associations (RRs of 1.4 and over) between IPQ-R baseline consequences, timeline acute/chronic, personal control and treatment control scores and poor outcome. Patients who expected their back problem to last a long time, who perceived serious consequences, and who held weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes 6 months after they consulted their doctor. These results have implications for the management of patients, and support the need to assess and address patients' cognitions about their back problems.
Global Burden of Disease Study C. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study
Global Burden of Disease Study C. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743-800.