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Objective For many, low back pain (LBP) is a lifelong condition with symptoms varying over time. Previous studies have investigated long-term risk factors and triggers for onset of LBP. No study has examined causes for less distinct fluctuations of symptoms, such as “flares,” which individuals with LBP identify as a significant and worrisome part of LBP. As little is known about what triggers this type of fluctuation, we aimed to investigate individuals’ perspectives on LBP flare triggers. Methods We conducted an online survey of 130 people with LBP, asking what they think triggers their flares. Data were qualitatively examined using content analysis. Results Most participants identified biomedical (84.8%) triggers, endorsing physical/biological factors to explain the flare occurrence. Themes included active movements (35% of participants), static postures (28.1%), overdoing a task (5.3%), biomechanical dysfunction (4.4%), comorbidities (4%), lack of exercise (3.3%), work (1.8%), and medications (1.5%). Nonbiomedical triggers were reported by 15.2% and included psychosocial and contextual factors, including psychological state (6%), weather (5%), sleep (2%), diet (1.2%), and fatigue (1%). These results indicate that individuals consider biomedical factors to be the main triggers of LBP flares, but some acknowledge nonbiomedical triggers. Conclusions Study findings contrast with current pain theories, which suggest that there is a need for a reduced emphasis on biomedical causes of LBP pain, especially when persistent. Recognition of patients’ views on causes of LBP flares is crucial to better guide clinical practice and inform further research. The validity of triggers identified by LBP patients requires further investigation.
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What Triggers an LBP Flare? A Content Analysis of Individuals’
Nathalia Costa,* Paul W. Hodges, PhD,* Manuela L. Ferreira, PhD,
Joanna Makovey, PhD,
Jenny Setchell, PhD*
*School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia;
Institute of Bone and Joint Research/The Kolling
Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
Correspondence to: Jenny Setchell, PhD, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland,
4072, Australia. Tel: þ61733654506; Fax: þ617334687889; E-mail:
Funding sources: This study was supported by a Program grant (APP1091302), Centre of Research Excellence grant (APP1079078), and Fellowship
(PH – APP1102905) from the National Health and Medical Research Council (NHMRC) of Australia. MLF holds a National Medical and Health Research
Council of Australia Fellowship, is a Sydney Medical Foundation Fellow and Sydney University SOAR Fellow.
Conflicts of interest: The authors have no conflicts of interest to declare.
Objective. For many, low back pain (LBP) is a lifelong condition with symptoms varying over time. Previous studies have
investigated long-term risk factors and triggers for onset of LBP. No study has examined causes for less distinct fluctua-
tions of symptoms, such as “flares,” which individuals with LBP identify as a significant and worrisome part of LBP. As
little is known about what triggers this type of fluctuation, we aimed to investigate individuals’ perspectives on LBP flare
triggers. Methods. We conducted an online survey of 130 people with LBP, asking what they think triggers their flares.
Data were qualitatively examined using content analysis. Results. Most participants identified biomedical (84.8%)
triggers, endorsing physical/biological factors to explain the flare occurrence. Themes included active movements
(35% of participants), static postures (28.1%), overdoing a task (5.3%), biomechanical dysfunction (4.4%), comorbid-
ities (4%), lack of exercise (3.3%), work (1.8%), and medications (1.5%). Nonbiomedical triggers were reported by
15.2% and included psychosocial and contextual factors, including psychological state (6%), weather (5%), sleep
(2%), diet (1.2%), and fatigue (1%). These results indicate that individuals consider biomedical factors to be the main
triggers of LBP flares, but some acknowledge nonbiomedical triggers. Conclusions. Study findings contrast with cur-
rent pain theories, which suggest that there is a need for a reduced emphasis on biomedical causes of LBP pain, es-
pecially when persistent. Recognition of patients’ views on causes of LBP flares is crucial to better guide clinical
practice and inform further research. The validity of triggers identified by LBP patients requires further investigation.
Key Words: Low Back Pain; Flare; Triggers; Content Analysis
Low back pain (LBP) is the most common and burden-
some musculoskeletal condition globally in terms of
years lived with disability [1]. Along with individual and
social impact of activity limitation, the economic impact
of this condition is considerable, including high costs as-
sociated with health care and work productivity losses
[2,3]. LBP has been described by patients as characterized
by fluctuations in intensity [4]. Although not all fluctua-
tions are bothersome, flares are a fluctuation with a ma-
jor impact on LBP outcome. For example, greater
disability and work absenteeism are associated with the
occurrence of LBP flares in individuals with persistent
symptoms [5], and after an acute episode, higher flare
frequency is associated with worse disability outcomes
[6]. Qualitative studies have also revealed that the occur-
rence of flares disrupts work ability [4,79].
LBP flares are considered different than LBP episodes
[5,6,9,10]. Flares generally represent an increase in symp-
toms/bothersomeness, not necessarily preceded by at
least a month without symptoms, a requirement used to
define a new LBP episode [11,12]. People who experience
C2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: 1
Pain Medicine, 0(0), 2019, 1–8
doi: 10.1093/pm/pnz021
Original Research Article
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LBP consider a flare of their condition to be an increase
in pain and/or other symptoms associated with impaired
function and emotional and cognitive changes [13].
Although some work has been conducted to better under-
stand factors that increase risk of a new LBP episode, lit-
tle attention has been directed to understanding what
causes LBP to fluctuate and trigger a flare.
People with LBP believe their symptoms persist and
recur mainly due to anatomical/biomechanical causes
[14]. Patients and physiotherapists agree that lifting,
bending, and prolonged sitting are the most important
triggers for LBP episodes [15]. Health care clinicians in
general consider triggers for new LBP episodes to be
mainly biomechanical and rarely endorse individual and
psychological/psychosocial factors [16]. A recent study
confirmed that patients can reliably identify a number
of biomechanical factors as triggers for their LBP epi-
sode (e.g., tasks involving heavy loads and vigorous
physical activity), but they underestimate the risk asso-
ciated with behavioral and psychological triggers [17],
even though the latter play an important role in devel-
opment of a new LBP episode [18]. It is unknown
whether people with LBP similarly emphasize biome-
chanical factors as triggers for their LBP flares. As an
LBP flare is different than a new episode, it may have
different triggers. For instance, weather parameters
have been shown to not increase the risk of developing
an LBP episode, yet patients commonly argue that cer-
tain weather conditions influence their symptom sever-
ity [19]. Although individuals’ perspectives on what
constitutes a flare [13] and their views on why symp-
toms persist/recur have been previously investigated
[14], what people think triggers their symptoms to flare
remains undetermined. We argue that views of people
with LBP on potential triggers for flares may provide
insights into triggers not discussed in the literature re-
garding triggers for episodes.
This study aimed to investigate individuals’ views
on triggers for LBP flare, as distinct from causes of an
episode. Addressing this gap in the literature is impor-
tant as the identification of potential flare triggers can
help manage this bothersome aspect of the LBP
Study Design
A mixed-methods online survey examined individuals’
experiences and understanding of LBP flare. Details of
this online survey are reported elsewhere [13]. To specifi-
cally investigate patients’ views on triggers for LBP flare,
we asked the following question: “What do you think
causes your low back pain to flare up? For example,
things that you do, things that happen to you, or things
that change in your environment.” Eight text boxes with-
out word limits were provided for answers. Data were
analyzed using content analysis to identify themes of trig-
gers highlighted by participants.
Participant Selection
Participants were recruited through advertisements
placed on social media, local community and health cen-
ters, promotion through pain-related consumer organ-
izations, and by contacting participants from previous
studies. Participants were considered eligible when the
following criteria were met: 1) age of 18 years and above,
2) ability to communicate in English, and 3) self-
identification as having experienced LBP. There was no
exclusion for LBP duration, other coexisting pain, or
comorbidities. If participants chose to answer the ques-
tionnaire and complete the study after reading the study
information page, consent was implied. A total of 622
participants enrolled to participate in the study. Four
hundred ninety-two incomplete questionnaires were re-
ceived and excluded from analysis. The remaining 130
complete questionnaires were included. Sample size was
determined by response rate. Saturation was achieved
with data from 130 questionnaires; that is, there was suf-
ficient depth and repetition of identified themes for flare
triggers, and no new themes were emerging from prelimi-
nary content analysis [20].
Theoretical Underpinnings
Our study is underpinned by relativist assumptions, that
is, reality is understandable through an individual’s
knowledge and interpretation [21]. We sought to better
understand triggers for LBP flares based on individuals
views. In this context, we used content analysis to sys-
tematically analyze the data and code the occurrence of
triggers for LBP flares. In content analysis, a code is most
often a summative, salient, and essence-capturing word/
phrase symbolically assigned to a portion of language-
based data [22]. Themes are groupings of codes into
broader summative categories. These analytical group-
ings of concepts in the data enabled us to report individu-
als’ views of what triggers LBP flare. We used an
inductive approach to analysis, which means we did not
predetermine codes but created them from our reading of
the data. Therefore, we minimized interpretation and
drew meaning from participants’ responses.
Data Analysis
Demographic and clinical data were summarized using
descriptive statistics. Data for content analysis were
obtained from the words and short sentences used by
individuals to answer our survey questions. Content anal-
ysis was conducted independently by two investigators
(NC and JS). First, NC and JS independently read the en-
tire data set and made notes on the main concepts, scope,
and breadth of the data in relation to the research ques-
tions. Second, researchers reread the entire data set, man-
ually coding data extracts into data management
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software (Microsoft Excel) and developing provisional
overarching themes, themes, and codes. Third, coding
was refined after discrepancies were discussed to agree
with each other and subsequently with PH. During this
process, we developed a set of coding rules to guide data
analysis: 1) when participants’ answers related to two or
more codes, investigators decided which code was pre-
dominant, and thus each trigger was coded only once; 2)
answers with unclear meaning were excluded from cod-
ing analysis (e.g., “everything,” “bad choices”); 3) all
codes were included in the results, regardless of the fre-
quency of which codes were mentioned.
Trustworthiness and Rigor
NC and JS coded the entire data set independently, and
discrepancies were discussed to agreement with PH pro-
viding an additional perspective. All other authors
reviewed data set and agreed upon results and analysis. A
researcher external to the project (TH) confirmed the
trustworthiness of the coding. TH is an occupational
therapist with both clinical and qualitative research expe-
rience. Qualitative rigor was secured through STROBE
[23]. All relevant categories of the checklist were satisfied
in research design and reporting.
The characteristics of the participants are described in
Tables 1 and 2. Almost all participants lived in Australia,
they varied considerably in age (mean [range] ¼43 [22–
72] years), and over half were female (74.6%). Eighty-
two percent of the sample experienced LBP daily, and for
over a half of participants symptoms varied daily
One hundred twenty-eight of 130 participants
(98.4%) listed at least one factor they thought triggered
their LBP flares. Most people provided short answers, us-
ing one or two words to describe triggers. Only a few
people answered in a phrase, making some additional
clarifying comments to their answers. Of the 676 trig-
gers, 23 (3.4%) were excluded from coding for lack of
precision (e.g., “bad choices,” “pressure,” “too little”).
The remaining 653 triggers were clustered for existence
and frequency into several themes and codes (Table 3),
and then these were further categorized into two over-
arching themes, biomedical triggers (N ¼554, 84.8%)
and nonbiomedical triggers (N ¼99, 15.2%). The over-
arching themes were intended to give a broad overview
of how the data fit into these categories, and it is ac-
knowledged that some themes and codes could cross over
into both overarching themes. More than half of partici-
pants provided four or more potential triggers for their
LBP flares (55%), and 24% used all text boxes, citing
eight or more flare triggers. Nearly half of participants
(N ¼59, 45.5%) discussed both biomedical and nonbio-
medical triggers. All percentages reported for
overarching themes, themes, and codes were calculated
as a proportion of the total number of responses.
Overarching themes, themes, and codes are discussed
Overarching Theme 1: Biomedical Triggers
Overwhelmingly, people discussed biomedical factors as
triggers for their LBP flare. Fifty-three percent of partici-
pants mentioned only biomedical triggers. Within bio-
medical triggers (N ¼554, 84.8%), a multitude of
different factors were clustered into 11 themes (Table 3).
Active movement (N ¼228, 35%) and static postures
(N ¼183, 28.1%) were the most common themes.
Larger themes included several codes; all are described
Active Movement
Active movement was the most common theme of bio-
medical trigger discussed by participants. Participants
discussed many types of active movement (Table 3).
These were grouped into four codes: moving in a particu-
lar way (N ¼77, 11.8%), physical activity (N ¼65,
10%), life’s daily tasks (N ¼49, 7.5%), and lifting
(N ¼37, 5.6%). Within the code moving in a particular
way, “bending” was the most common trigger, followed
by “twisting.” Some participants specifically addressed
the quality of movement (e.g., “sudden,” “wrongly,” and
“repetitive”), highlighting that their flare causes were not
simply movement but also how movement happens. The
Table 1. Demographic characteristics of study participants
Age, mean 6SD, y 43.2 612.05
Gender, %
Female 74.6
Male 25.4
Country, %
Australia 98.5
Other 1.5
State, %
Queensland 56.9
New South Wales 16.9
Victoria 15.4
Other 10.8
Table 2. Characterization of study participants’ low back pain
Duration of LBP, mean 6SD, y 13.09 610.33
LBP every day, %
Yes 82
No 18
Time frame of LBP variation, %
Daily 55.4
Weekly 23.1
Monthly 7.7
Other 13.8
Periods of no LBP, %
Yes 29.7
No 70.3
LBP ¼low back pain.
Individuals’ Perspectives on LBP Flare Triggers 3
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code physical activity included length, type, and intensity
of exercise, with most participants clearly defining their
own thresholds (e.g., “walking for longer than an hour,”
“long distance running,” “strenuous exercise”). Within
the code life’s daily tasks, a variety of tasks were men-
tioned, such as “gardening,” “vacuuming,” “carrying,”
and activities “where arms are above head.” In the code
lifting, the idea of the load was implicit in most responses
(e.g., “lifting heavy things,” “constant lifting”).
Static Postures
Static postures were the second most common response.
Among participants’ answers used to describe static pos-
tures, most could be coded as sitting (N ¼65, 10%).
Sitting was often mentioned as a trigger, with a qualify-
ing description of length of sitting (e.g., “for too long,”
“over thirty mins,” “all day,” “too much”). Similarly,
exposure to prolonged standing (N ¼35, 5.4%) was con-
sidered a potential trigger. The code posture (N ¼36,
5.5%) covered impressions of bad postural habits during
both waking and sleeping hours (e.g., “not sitting
straight while biking,” “sleeping in a bad position”), as
well as maintenance of a certain position for a long pe-
riod of time (e.g., “static posture”). The code travel/driv-
ing (N ¼24, 3.7%) incorporated both car and airplane
trips, overlapping with sitting but adding other
components to it, as there are possible effects of factors
such as changes in air pressure and whole-body vibra-
tion. Type of mattresses/seats (N ¼23, 3.5%) included
sitting or lying on unfamiliar surfaces (e.g., “different
bed for a few nights,” “sitting in other people’s houses as
with uncomfortable sofas”).
Overdoing a Task
The theme overdoing a task (N ¼35, 5.3%) clustered
answers provided by participants that referred to behav-
iors such as not pacing and/or overdoing a task or activ-
ity. This relationship is captured well by one
participant’s comment: “It’s a fine line between doing as
much as you can re: exercise, social, home and that a tiny
bit too much. Some days you can get away with doing
something and the next day it will stop you.” Answers
provided by patients alluding to overdoing a task at their
workplace were clustered exclusively within the theme
work (discussed below).
Biomechanical Dysfunction
The theme biomechanical dysfunction incorporated code
changes in motor control (N ¼15, 2.3%) and damage to
the spine (N ¼14, 2.1%). In the group of codes empha-
sizing changes in motor control (N ¼15, 2.3%), partici-
pants identified poor core strength and overuse of lower
back muscles as causes for their flares. An interesting
finding in this code was that some participants discussed
a lack of cognitive control over movements as a potential
trigger (e.g., “moving without thinking,” “not paying at-
tention to how I move”). The second code clustered trig-
gers that referred to structural spinal changes, often
portrayed as recurrent or irreversible (e.g., “recurring
bulging disk,” “I have lumbar osteoarthritis. It is
Other Biomedical Themes
There were eight smaller themes with no codes (Table 3).
In the theme comorbidities (N ¼26, 4%), a range of
other conditions such as knee pain, endometriosis, and
constipation were highlighted by participants as potential
triggers for their LBP flare. For example, one participant
highlighted “flare-ups in other places causing chain reac-
tion.” Lack of exercise (N ¼22, 3.3%) arose as a theme
in two different contexts: inactivity (e.g., “being too sed-
entary,” “reduced walking”) and lack of specific exer-
cises, highlighting the idea of exercise as medicine (e.g.,
“lack of correct exercise,” “not doing specific strengthen-
ing exercises”). The theme work (N ¼12, 2%) was also
identified from participants’ responses, indicating that
they believed their work triggered their flares. Some
responses overlapped with the theme overdoing a task,
described above (e.g., “work too hard at the office,”
“increased workload”). The theme medications (N ¼10,
2%) was mainly associated with medicine intake as part
of management of LBP, which participants discussed as a
Table 3. Summary of qualitative analysis findings
Overarching Themes,
Themes, and Codes
Biomedical triggers 554 84.8
Active movements 228 35
Moving in a particular way 77 11.8
Physical activity 65 10
Life’s daily tasks 49 7.5
Lifting 37 5.6
Static postures 183 28.1
Sitting 65 10
Posture 36 5.5
Standing 35 5.4
Travel/driving 24 3.7
Types of mattresses/seats 23 3.5
Overdoing a task 35 5.3
Biomechanical dysfunction 29 4.4
Changes in motor control 15 2.3
Damage to the spine 14 2.1
Comorbidities 26 4
Lack of exercise 22 3.3
Work 12 1.8
Medications 10 1.5
Sex 4 0.6
Type of shoes 3 0.4
Medical treatment 2 0.3
Nonbiomedical triggers 99 15.2
Psychological state 39 6
Weather 33 5
Quality of sleep 14 2
Diet 8 1.2
Fatigue 5 1
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trigger for flares when failed (e.g., “forget pain medi-
cation,” “cortisone injections wearing out”). The themes
sex (N ¼4, 0.6%), shoes (N ¼3, 0.4%), and medical
treatment (N ¼2, 0.3%) were cited only for a few
Overarching Theme 2: Nonbiomedical Triggers
Participants identified considerably fewer nonbiomedical
(N ¼99, 15.2%) than biomedical triggers (N ¼554,
84.8%). Only two participants (one male and one fe-
male) reported only nonbiomedical triggers without any
concomitant biomedical parameters. Both participants
reported stress and weather as the only triggers of their
LBP flares. In the overarching theme nonbiomedical trig-
gers, among five identified themes (no codes as themes
were not large), the most frequently discussed were psy-
chological state (N ¼39, 6%) and weather (N ¼33, 5%).
Psychological State
Within this theme, participants most frequently reported
“stress” as a trigger for LBP flares. Some also discussed
other mood states such as “anxiety” and “emotional
lows.” Some answers were more specific and outlined
specific reasons for emotional and psychological reper-
cussions, for example: “life complications,” “money
problems,” “family issues,” and “attitude to pain.” A
few people associated occurrence of flares with the neces-
sity to be productive: “need to feed my creativity,” “need
to do anything constructive.”
Within the theme weather, participants mostly pointed to
cold weather and barometric pressure changes as poten-
tial triggers (e.g., “cold weather,” “being too cold espe-
cially in air conditioning,” and “barometric pressure
changes”). Temperature changes, rainy weather, and
warm weather were each mentioned by at least one
Other Nonbiomedical Themes
Quality of sleep (N ¼14, 2%) clustered responses refer-
ring to “lack of or restless sleep” and “poor sleep qual-
ity.” Only a few participants referred to triggers that
could be classified under the themes diet (N ¼8, 1.2%)
or fatigue (N ¼5, 1%). We classified fatigue separately
from psychological state as most responses were ambigu-
ous as to whether this referred to mental or physical ex-
haustion. One participant referred to both: “When I’m
mentally and physically exhausted, its [sic] the first thing
to flare up.”
This study surveyed people who have experienced LBP to
determine what they believe to be triggers for their LBP
flares. Our primary finding is that participants
considered biomedical factors to be the main triggers of
their LBP flares, but some also cited nonbiomedical trig-
gers. The most frequently reported reasons for experienc-
ing this type of fluctuation of symptoms were active
movements and static postures. When considered to-
gether, these triggers represent over half of the total num-
ber of participant-identified causes for an LBP flare.
Predominance of Biomedical Triggers
Although our study is the first to seek patients’ perspec-
tives of what triggers flares of LBP, our finding of a prev-
alence of biomedical triggers is not surprising. Previous
literature indicates that people with LBP emphasize bio-
mechanical causes for their symptoms [7,24]. A cross-
sectional survey investigating triggers for new LBP epi-
sodes revealed that individuals hold biomedical/biome-
chanical beliefs about causes for a new LBP episode and
rarely endorse psychosocial aspects [15]. The most com-
mon types of triggers were also unsurprising (e.g., bend-
ing, twisting, and prolonged sitting) and largely coincide
with those of a new LBP episode [15]. However, our data
revealed a layer of complexity regarding the role of
movement in triggering LBP flares: Lack of exercise was
believed to be a trigger, indicating that some participants
might consider maintenance (rather than avoidance) of
physical activity to be an important factor to reduce LBP
flares. This perspective agrees with previous research,
which found that a lack of regular physical activity pre-
dicts future sick leave due back pain [25]. To our knowl-
edge, no other research has shown that people with LBP
recognize lack of exercise as a risk factor for their LBP
Our data also revealed that participants may not al-
ways be able or willing to avoid triggers or their conse-
quences. This is captured well by one participant’s
comment: “Some experiences are worth the pain you
know you will get later—it’s your choice.” Another par-
ticipant stated: “Making love with my partner will al-
ways make it worse the next day—something I prefer to
accept.” These responses highlight the need to recognize
the complex interaction between flares and patients’
quality of life as part of management strategies and indi-
cate that individuals may be able to exert control over
certain triggers better than others, which might play a
role in their coping strategies.
Potential Underestimation of Nonbiomedical
Within the group of nonbiomedical triggers, the theme
psychological state revealed stress as a potential trigger.
This has been reported in the literature related to LBP
flares [5]. Other psychological factors such as anxiety,
changes in mood, and emotional lows were identified as
triggers in our content analysis. Those factors have been
discussed as long-term exposure risk factors for LBP.
There is evidence that distress, depressive mood, and
Individuals’ Perspectives on LBP Flare Triggers 5
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somatization are predictors of disability and chronicity
of LBP [26]. A bidirectional relationship has been sug-
gested between back pain and mental health, as back
pain symptoms are associated with increased odds of de-
pression, psychosis, anxiety, stress, and sleep disturban-
ces [27]. However, whether psychological factors have a
causal relationship to fluctuation of symptoms such as
flares remains unknown.
Few participants endorsed the theme sleep as a poten-
tial flare trigger. This contrasts with research that out-
lines a bidirectional relationship between sleep
disturbance/quality and LBP pain intensity [28]. A study
conducted with people with LBP showed that a night of
poor sleep quality, difficulty falling sleep, waking after
sleep onset, or low sleep efficiency is followed by a day
with higher pain intensity [28]. Weather was also identi-
fied as a potential trigger for LBP flare in our analysis.
Past research has demonstrated that changes in weather
parameters (i.e., temperature, humidity, pressure) are not
associated with risk of developing a new LBP episode af-
ter a period without pain [19]. Whether weather changes
can trigger a fluctuation of severity of ongoing pain is
unknown and cannot be excluded.
Fatigue was the least commonly reported nonbiomedi-
cal trigger for LBP flare. People who experience a new
episode of LBP rarely consider fatigue to be a trigger
[17]. However, it is likely that the risks associated with
this psychosocial trigger have been underestimated.
Previous research has shown that manual tasks involving
heavy loads and engaging in physical activity are more
likely to cause a new onset of back pain when fatigued
[18]. For other musculoskeletal conditions, fatigue has
been identified by patients as an important domain of
flare, in addition to being considered a potential trigger
for this experience [2931]. Whether there is an associa-
tion between feeling fatigue and an increase in the likeli-
hood of experiencing LBP flares is undetermined, and
therefore further investigation is warranted.
Contextualizing Findings
This study adds to our previous investigation of individu-
als’ perspectives on what constitutes an LBP flare [13]
and their explanations for why symptoms persist and re-
cur [14]. It is important to understand not only what
flares are [13], but also why [14] and when they occur.
There is a current life course conceptualization of LBP as
an underlying condition with histories of LBP across mul-
tiple life stages, in which the unpredictable fluctuation
course differs from the course marked by recurrent epi-
sodes [32]. It has been argued that there is a back pain
subtype (with flares) that is etiologically distinct from
LBP without flares [33]. Thus, triggers for LBP flares
might differ from risk factors for prevalence and recur-
rence of LBP. The bias toward biomedical triggers for
LBP in our findings contrasts with current evidence,
which argues that psychosocial factors such as negative
beliefs and pain catastrophizing are associated with per-
sistence of LBP [26,27,34]. In order to enhance education
and management of this condition, it is imperative to test
the validity of the triggers identified in our study. As this
study provides insights about what people believe trig-
gers their LBP, the results are likely to be a valuable
source of information for clinicians who work with indi-
viduals with LBP. These findings provide insights into
how clients conceptualize their condition, and also work
toward a better understanding of triggers for LBP flares.
Both elements are likely to help with clinical manage-
ment of LBP and its fluctuations.
Although this exploratory study provided insights into
individuals’ beliefs about what triggers their LBP flares, a
number of factors should be considered when interpret-
ing the findings. The study was conducted online in a sur-
vey format. Although this means that participants are
likely to have felt comfortable expressing their thoughts
anonymously, and that it therefore likely represents what
participants believe triggers their LBP flares, the method-
ology is not intended to determine causation (i.e., it does
not investigate whether a specific factor actually triggers
a flare). Further research designed to investigate causa-
tion could utilize the triggers reported in this study. We
also acknowledge that the phrasing of our question may
have led participants to provide certain answers. We ac-
knowledge that our use of the terms “biomedical” and
“nonbiomedical” are somewhat restrictive in their divi-
sion of the data discussed in our study; yet the dominance
of biomedical themes remained clear regardless of occa-
sional potential anomalies. There was a large difference
between the number of people who commenced the sur-
vey and those who completed it and were included in the
sample. We believe this was due to survey length (55
questions). Those completing the survey might have been
individuals with a greater personal interest in the topic;
this may be one reason why our sample had a high repre-
sentation of people with daily and severe symptoms.
There are also limitations to transferability of findings to
be considered when applying findings to different popu-
lations. For example, most of the participants live in
Australia. Thus, although there may be similarities, our
findings may not be entirely transferable to individuals
with LBP from other countries. Further, the sample was
mostly female, and participants frequently had severe
and persistent symptoms; thus perhaps not all people
who experience LBP would describe similar triggers.
Future studies could be designed to test possible differen-
ces between such subgroups. Data on education level and
socioeconomic status of participants were not collected.
Whether such parameters influence an individual’s con-
ceptualization of triggers for flare is unknown and could
be considered in future work. Finally, we did not provide
participants with a definition of flare, but rather relied
on participants’ interpretation of the term. This can be
considered both a strength and a limitation of our study.
By not constraining participants to a specific definition,
6Costa et al.
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we allowed them to highlight triggers that matched their
own unique experience of LBP flares. However, this also
means that we might have identified triggers for flare
that mean different things to different individuals. Recent
work has identified that individuals with LBP regard
flares of LBP as more than an increase in pain, including
other elements such as interference with function and
emotions [13]. This could be considered in future work.
Participants believed that the triggers for their LBP flares
are primarily biomedical. Nevertheless, some partici-
pants recognized the existence of nonbiomedical triggers.
As both clinical practice and research should be guided
by a person-centered perspective, the triggers identified
in this study should be investigated further. Future re-
search assessing symptoms over time would be valuable
to quantitatively identify the biomedical and nonbiomed-
ical triggers that increase the likelihood of experiencing
an LBP flare. The examination of LBP triggers helps de-
velop optimal prevention strategies in clinical practice
and better guides how to modify maladaptive illness per-
ceptions. Management of LBP flares may lead to an in-
crease in productivity and less time off at work, with the
potential to contribute to a decrease in the large LBP bur-
den on health care systems worldwide.
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... An online survey revealed that individuals with LBP highlight a range of factors they consider to increase the risk for flare [6]. This work highlighted a bias to biomedical factors, but some consideration of psychosocial features. ...
... This has important implications. Although individuals who experience LBP argue that engaging in physical activity can trigger their LBP flares [6], our findings indicate that sedentary behaviour was a risk factor whereas being active was protective. Additionally, although a person's perception of exposure to moderate and vigorous physical activity has been suggested to increase the risk of a new episode of LBP [43], our objective data suggest that activity is unlikely to cause patients to experience a flare. ...
Risk factors for low back pain (LBP) flares have been considered with respect to self-reported measures. This case-crossover study aimed to investigate whether: i) objective measures of physical activity and sleep were associated with risk of experiencing LBP flares; and ii) these associations differed for flares defined as pain 2 or more points greater than average pain over the period using an 11-point Numerical Rating Scale (NRS; 0-no pain, 10-worst pain imaginable)(pain-defined flare: PDF) and flares identified by participants according to a broader definition that considered emotions/coping (self-reported flare: SRF). We included 126 participants who had experienced LBP for >3 months. Physical activity and sleep were monitored for 28 days using wearable sensors. Occurrence of flares (PDF/SRF) were assessed daily using a smartphone application. Data on exposure to risk factors one, two and three days preceding PDF/SRF were compared to non-flare control periods. Conditional logistic regression determined association between each factor and flares. Data show that day-to-day variation in physical activity and in-bed time are associated with risk of LBP flares, but associations differ depending on how flare is defined. Longer in-bed time increased the risk of PDF, but not SRF. Although physical activity was not associated with risk of PDF, greater sedentary behaviour increased risk of SRF and being more physically active decreased risk for SRF. These results highlight the potential role of targeting sleep and physical activity in interventions to prevent LBP flares, and indicate that risk factors differ depending on how LBP flares are defined.
... Pain is influenced by a complex mixture of biopsychosocial factors, 4 and there has been an increased interest in documenting how pain negatively affects an individual's objective function. Periods of LBP may result in living with the burden of disability, 1,5 hallmarked by activity limitations, [6][7][8] which can be objectively measured. These limitations are partially explained by biopsychosocial changes in individuals with LBP that modify how they interact with the world. ...
Full-text available
Objective: Biomechanics represents the common final output through which all biopsychosocial constructs of back pain must pass, making it a rich target for phenotyping. To exploit this feature, several sites within the NIH Back Pain Consortium (BACPAC) have developed biomechanics measurement and phenotyping tools. The overall aims of this paper were to: 1) provide a narrative review of biomechanics as a phenotyping tool; 2) describe the diverse array of tools and outcome measures that exist within BACPAC; and 3) highlight how leveraging these technologies with the other data collected within BACPAC may elucidate the relationship between biomechanics and other metrics used to characterize low back pain (LBP). Methods: The narrative review highlights how biomechanical outcomes can discriminate between those with and without LBP, as well as the severity of LBP. It also addresses how biomechanical outcomes track with functional improvements in LBP. Additionally, we present the clinical use case for biomechanical outcome measures that can be met via emerging technologies. Results: To answer the need of measuring biomechanical performance our results section describes the spectrum of technologies that have been developed and are being used within BACPAC. Conclusion: and future directions: The outcome measures collected by these technologies will be an integral part of longitudinal and cross-sectional studies conducted in BACPAC. Linking these measures with other biopsychosocial data collected within BACPAC increases our potential to use biomechanics as a tool for understanding the mechanisms of LBP, phenotyping unique LBP subgroups, and matching these individuals with an appropriate treatment paradigm.
... Table 7 Self-reported self-regulation strategies that were reported by chronic pain participants in the driving diary. Previous research has shown participants with chronic pain reported moderate to great difficulties with driving for more than one hour (Takasaki et al., 2012), and indicated that prolonged sitting could flare pain (Costa et al., 2020). This finding raises the question of how long a person with chronic pain should drive, which might be a useful subject for further research. ...
Full-text available
In road safety research, few studies have examined driving behaviour in chronic pain cohorts. The aim of this study was to investigate driving behaviour among drivers experiencing chronic pain. We compared individuals with chronic pain with age-gender matched healthy controls. Participants completed: (i) an anonymous online survey that included participant demographics, transport characteristics, self-reported driving behaviour, and pain characteristics (ii) a response-time hazard perception test and a verbal-response hazard prediction test for drivers, and (iii) a driving diary in which participants recorded their driving over two weeks. The results showed that participants with chronic pain were not significantly worse than controls for hazard perception and prediction test scores, self-reported attention-related errors, driving errors, driving violations, and involuntary distraction. Drivers with chronic pain did report significantly more driving lapses but this effect became non-significant when variables confounded with chronic pain, such as fatigue, were adjusted for. We also found that participants who reported particularly high levels of chronic pain performed worse in the hazard prediction test compared to the control group (and this effect could not be accounted for by other variables associated with chronic pain). In addition, participants with chronic pain reported significantly higher driving workload (mental demand, physical demand, effort, and frustration) compared with controls. The findings of this study provide new insights into driving behaviour in individuals with chronic pain and recommendations for future research in terms of driving assessment and self-regulation strategies are provided.
... 31 Besides, people believe that the main reason for their LBP is mainly of biomedical nature and, to a lesser extent, of biopsychosocial etiology. 32 Noteworthy, there is a notion that people tend to relate their pain to humidity and weather conditions as it possibly affects mood and physical activity. 33 Identification of biopsychosocial factors, patient-centered communication, empowering of self-management, and embracing patient education to assist behavioral changes and convey evidence-based facts are some of the main actions that have to be taken for the management of pain, irrespective of the body area. ...
Full-text available
Low back pain (LBP) is a common clinical problem imposing a prominent socio-economic burden. The purpose of this systematic review was to investigate the biopsychosocial effects of the Mulligan Concept (MC) of manual therapy (MT) when applied to patient's with LBP. Three researchers independently evaluated the literature quality, and completed a review on five online databases (Medline, Cochrane Library, Science Direct, ProQuest and Google Scholar) for articles published from January 1st 2010 to November 20th 2021, using a combination of free words, Wildcards and Medical Subject Headings (MESH) terms: " Mulligan mobilization " AND " back pain " OR " SNAGs." In total, 62 studies were selected for full-text reading, from which finally 6 studies were included in the present review. The results revealed that the studies where the MC of MT was applied to treat LBP mainly lacked concern regarding the effect that the intervention has on the cognitive and behavioural parameters. The ones that introduced measure outcomes for at least some parts of the cognitive behavioural components, showed that the MC has a positive effect, even though without a long-term follow-up assessment. This review summarized that the evidence of the MC on cognitive behavioural (CB) aspects of patients with LBP is controversial and scarce.
... " [4] Flares of LBP are periods of transient worsening of symptoms which can reflect an increase in pain intensity or other factors associated with pain such as impaired physical function or changes in mood [6]. Individuals with LBP often attribute flares to recent physical activities [7,8]. Although it is generally accepted that physical activity and flares of LBP are related, the evidence for the directionality of these associations is mixed. ...
Full-text available
Background Although it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up. Methods Up to 550 adults of working age (18—65 years) seen for LBP in primary care complete up to 36 “Scheduled” surveys over 1-year follow-up, and also complete unscheduled “Flare Window” surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1–4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1–4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers. Discussion FLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP. Trial Registration NCT04828330 , registered April 2, 2021.
... Although spinal manipulative therapy has a small immediate effect on the functionality of patients with cLBP [24], there is no specific patient characteristic that identifies patients more likely to benefit from this intervention [25]. Recognising patients' perceptions about the causes of pain and reducing the LBP is essentially better to guide clinical practice and future research [26,27]. Patients with LBP consider temporary (hourly) relief an acceptable outcome, while clinical trials tend to consider an efficacy for long-term outcomes [27]. ...
Full-text available
Background Low back pain is one of the main public health concerns. Chronic low back pain (cLBP) reduces functional capacity and affects postural stability. Although health professionals widely use spinal manipulation, its immediate effect on painful sensitivity and postural stability is lacking. This study aims to verify the immediate effects of lumbar spinal manipulation on the pressure pain threshold and postural stability in individuals with cLBP. Methods A two-arm, placebo-controlled clinical trial with parallel groups and examiner-blinded will be conducted with 80 participants with cLBP from an outpatient physical therapy department, randomly allocated at a 1:1 distribution. The experimental group will receive a lumbar spinal manipulation technique, and the placebo group will receive a simulated lumbar spinal manipulation. Both groups will receive one session of treatment and will be evaluated before and immediately after the intervention. The primary outcomes will be the pressure pain threshold and postural stability. Pain intensity and patient’s expectation will be assessed as a secondary outcome. The pressure pain threshold will be assessed using a pressure algometer in 6 different anatomical regions. The evaluation of postural stability will be performed in a baropodometry exam by displacing the centre of pressure. The pain intensity will be measured using the Numeric Pain Rating Scale. A Likert scale will be used for the patient’s expectation about the treatment. A two-way analysis of variance will compare the effect of the interventions between groups. Discussion This study will provide insights regarding the immediate effects of spinal manipulation in patients with cLBP against a simulated spinal manipulation using objective outcomes and considering patients’ expectations regarding the treatment. Trial registration Brazilian Registry of Clinical Trials RBR-3ksq2c . Registered on 13 July 2020
... Other factors such as poor sleep quality and heightened stress were also implicated with pain flares in qualitative studies among patients with fibromyalgia 65 . Moreover, pain fluctuations have also been associated with external factors such as weather 65,66 and daily temperature variations 67 , smoking 25 among other reported factors 68 . Altogether, these findings support the view that the pain experience over time is a highly complex and dynamic process, and teasing apart which factors contribute most to pain fluctuations for a particular individual may assist in developing personalized treatment strategies aimed at reducing those fluctuations and their deleterious effects to global health self-perception. ...
Full-text available
Temporomandibular disorders (TMD) patients can present clinically significant jaw pain fluctuations which can be debilitating and lead to poor global health. The Graded Chronic Pain Scale evaluates pain-related disability and its dichotomous grading (high/low impact pain) can determine patient care pathways and in general high-impact pain patients have worse treatment outcomes. Individuals with low-impact TMD pain are thought to have better psychosocial functioning, more favorable disease course, and better ability to control pain, while individuals with high-impact pain can present with higher levels of physical and psychological symptoms. Thereby, there is reason to believe that individuals with low- and high-impact TMD pain could experience different pain trajectories over time. Our primary objective was to determine if short-term jaw pain fluctuations serve as a clinical marker for the impact status of TMD pain. To this end, we estimated the association between high/low impact pain status and jaw pain fluctuations over three visits (≤ 21-day-period) in 30 TMD cases. Secondarily, we measured the association between jaw pain intensity and pressure pain thresholds (PPT) over the face and hand, the latter measurements compared to matched pain-free controls (n = 17). Jaw pain fluctuations were more frequent among high-impact pain cases (n = 15) than low-impact pain cases (n = 15) (OR 5.5; 95% CI 1.2, 26.4; p value = 0.033). Jaw pain ratings were not associated with PPT ratings ( p value > 0.220), suggesting different mechanisms for clinical versus experimental pain. Results from this proof-of-concept study suggest that targeted treatments to reduce short-term pain fluctuations in high-impact TMD pain is a potential strategy to achieve improved patient perception of clinical pain management outcomes.
Full-text available
Objective: Low back pain (LBP) is hallmarked by activity limitations, especially for tasks involving bending. Back exosuit technology reduces low back discomfort and improves self-efficacy of individuals with LBP during bending and lifting tasks. However, the biomechanical efficacy of these devices in individuals with LBP is unknown. This study sought to determine biomechanical and perceptual effects of a soft active back exosuit designed to assist individuals with LBP sagittal plane bending. To understand patient-reported usability and use cases for this device. Methods: Fifteen individuals with LBP performed two experimental lifting blocks once with and without an exosuit. Trunk biomechanics were measured by muscle activation amplitudes, and whole-body kinematics and kinetics. To evaluate device perception, participants rated task effort, low back discomfort, and their level of concern completing daily activities. Results: The back exosuit reduced peak back extensor: moments by 9%, and muscle amplitudes by 16% when lifting. There were no changes in abdominal co-activation and small reductions maximum trunk flexion compared to lifting without an exosuit. Participants reported lower task effort, back discomfort, and concern about bending and lifting with an exosuit compared to without. Conclusion: This study demonstrates a back exosuit not only imparts perceptual benefits of reduced task effort, discomfort, and increased confidence in individuals with LBP but that it achieves these benefits through measurable biomechanical reductions in back extensor effort. The combined effect of these benefits implies back exosuits might be a potential therapeutic aid to augment physical therapy, exercises, or daily activities.
Low back pain (LBP) is complex. This study aimed to use collaborative modeling to evaluate conceptual models that individuals with LBP have of their condition, and to compare these models with those of researchers/clinicians. Twenty-eight individuals with LBP were facilitated to generate mental models, using “fuzzy cognitive maps,” that represented conceptualization of their own LBP and LBP “in general.” “Components” (ie, causes, outcomes and treatments) related to pain, disability and quality of life were proposed, along with the weighted “Connections” between Components. Components were classified into thematic categories. Weighting of Connections were summed for each Component to judge relative importance. Individual models were aggregated into a metamodel. When considering their own condition, participants’ models included 19(SD = 6) Components and 43(18) Connections with greatest weight on “Biomechanical” components. When considering LBP in general, models changed slightly. Patient models contrasted the more complex models of researchers/clinicians (25(7) Components; 77(42) Connections), with most weight on “Psychological” components. This study provides unique insight into how individuals with LBP consider their condition, which is largely biomedical and narrower than clinician/researcher perspectives. Findings highlight challenges for changing public perception of LBP, and provide a method with potential utility to understand how individuals conceptualize their condition. Perspective Collaborative modeling was used to understand how individuals with low back pain conceptualize their own condition, the condition in general, and compare this with models of expert researchers/clinicians. Data revealed issues in how individuals with back pain conceptualize their condition, and the method's potential utility for clinical evaluation of patients.
Full-text available
Background: Low back pain is one of the main public health concerns. Chronic low back pain (cLBP)reduces functional capacity and affects postural stability.Although health professionals widely use spinal manipulation, its immediate effect on painful sensitivity and postural stability is lacking. This study aims to verify the immediate effects of lumbar spinal manipulation on the pressure pain threshold and postural stability in individuals with cLBP. Methods: A two-arm, placebo-controlled clinical trial with parallel groups and examiner-blinded will be conducted with 80 participants with cLBPfrom an outpatient physical therapy department,randomly allocated at a 1:1 distribution. The experimental group will receive a lumbar spinal manipulation technique, and the placebo group will receive a simulated lumbar spinal manipulation. Both groups will receive one session of treatment and will be evaluated before and immediately after the intervention.The primary outcomes will be the pressure pain threshold and postural stability. Pain intensity and patient´s expectation will be assessed as a secondary outcome. The pressure pain threshold will be assessed using a pressure algometer in 6 different anatomical regions. The evaluation of postural stability will be performed in a baropodometry exam by displacing the centre of pressure. The pain intensity will be measuredusing the Numeric Pain Rating Scale. A Likert scale will be used for the patient´s expectationabout the treatment. A two-way analysis of variance will compare the effect of the interventions between groups. Discussion:This study will provide insights regarding the immediate effects of spinal manipulation in patients with cLBPagainst a simulated spinal manipulation using objective outcomes and considering patients’ expectations regarding the treatment. Trial registration: Brazilian Registry of Clinical Trials:RBR-3ksq2c; registered on 13 July 2020.
Full-text available
Background Most people experience low back pain (LBP), and it is often ongoing or recurrent. Contemporary research knowledge indicates individual’s pain beliefs have a strong effect on their pain experience and management. This study’s primary aim was to determine the discourses (patterns of thinking) underlying people’s beliefs about what causes their LBP to persist. The secondary aim was to investigate what they believed was the source of this thinking. Methods We used a primarily qualitative survey design: 130 participants answered questions about what caused their LBP to persist, and where they learned about these causes. We analysed responses about what caused their LBP using discourse analysis (primary aim), and mixed methods involving content analysis and descriptive statistics to analyse responses indicating where participants learnt these beliefs (secondary aim). Results We found that individuals discussed persistent LBP as 1) due to the body being like a ‘broken machine’, 2) permanent/immutable, 3) complex, and 4) very negative. Most participants indicated that they learnt these beliefs from health professionals (116, 89%). Conclusions We concluded that despite continuing attempts to shift pain beliefs to more complex biopsychosocial factors, most people with LBP adhere to the traditional biomedical perspective of anatomical/biomechanical causes. Relatedly, they often see their condition as very negative. Contrary to current “best practice” guidelines for LBP management, a potential consequence of such beliefs is an avoidance of physical activities, which is likely to result in increased morbidity. That health professionals may be the most pervasive source of this thinking is a cause for concern. A small number of people attributed non-physical, unknown or complex causes to their persistent LBP – indicating that other options are possible.
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Background and purpose: Low back pain (LBP) is a lifelong problem for many. In acute episodes, or as a persistent condition, LBP is fluctuating in nature, with pain and other features of the condition varying in intensity and duration over time. Symptom flares (also known as flare ups) contribute to this variation and can have a great impact on the lives of those who have LBP. An important goal of treatments for, and research on, LBP is arguably to decrease symptom flare in both frequency and severity. However, this goal is problematic with little research, and no consensus, on how to define LBP flare. In particular, patients' understandings of LBP flare have received limited attention in the literature. To appropriately address this issue, we sought to understand how flares are conceptualized by individuals with LBP. Methods: We used an inductive, predominantly qualitative methodology, conducting an online survey with 130 individuals who self-reported experiencing LBP. The survey investigated participants' views on LBP flare including its meaning, features and symptoms, and whether 'flare' and 'pain increase' were synonymous. Qualitative analysis of responses involved thematic and content analysis with descriptive statistics used for the quantitative component. Results: Our data analysis found that participants identified many aspects of a flare to be important. Qualitative analyses highlighted a number of themes including that LBP flare was conceptualized as: (1) an increase in pain and other uncomfortable sensations such as paraesthesia or muscle tension, (2) an increase in the area, quality and/or duration of symptoms, (3) a reduction in physical, cognitive and/or social functioning, and (4) negative psychological and/or emotional factors. Flare was also discussed as a change that was difficult to settle. When participants considered whether 'flare' and 'pain increase' were synonymous, responses were evenly divided between 'no' (47%) and 'yes' (46%) with remaining participants 'unsure'. Conclusions: The key finding was that many people with LBP do not consider their condition to be flared simply on the basis of a pain increase. In general, other features were required to also change. Results highlighted that a narrow focus on pain is unlikely to differentiate minor pain events from a flare. These findings are important as they contrast with most commonly used definitions of a flare that focus predominantly on pain increase. Implications: Our findings have implications for understanding the trajectory of LBP over time. Understandings derived from perspectives of individuals with LBP highlight that defining flare in LBP is complex. In order to provide person-centred care, individual context and experiences should be taken into account. Therefore, understandings of LBP flare require consideration of factors beyond simply an increase in pain. A comprehensive, person-centred understanding of flare that includes a number of features beyond simply an increase in pain intensity is likely to be useful to better identify flares in research settings, assisting endeavours to understand and reduce LBP. Similarly, in clinical settings a nuanced conceptualisation of flare is likely to help health professionals communicate understandings of flare when working with individuals to manage their LBP.
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Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
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Study design: Cross-sectional survey. Objective: To compare patients' and physiotherapists' views on triggers for LBP, and to identify any novel factors not previously reported. Summary of background data: Most research on risk factors for low back pain (LBP) is guided by the views of clinicians and researchers, not patients. Consequently, potentially valuable information about risk factors for LBP is not available from those suffering the condition.This study aimed to compare patients' and physiotherapists' views on triggers for LBP, and to identify any novel factors not previously reported. Methods: 102physiotherapists and 999 patients with a sudden, acute episode of LBP participated in this study. Participating physiotherapistswere asked to nominate the most likely short-term risk factors to trigger a LBP episode. Similarly, patients were asked what they thought had triggered their onset of LBP. Responses were coded into risk factor categories and sub-categories by two independent researchers.Endorsement of each category was compared using the Pearson chi-squared statistic. Results: Both patients and physiotherapists endorsed biomechanical risk factors as the most important risk factor category (87.7% and 89.4% respectively) andhad similar levels of endorsement for three of the top five sub-categories (lifting, bending and prolonged sitting). There were significant differences in endorsement of awkward postures (13.4% vs 1.2%; p < 0.001) sports injuries (15.9% vs 4.7%; p < 0.001), physical trauma (3.4% vs 9.2%; p < 0.001) and unaccustomed activity (2.3%vs7.3%; p < 0.001) by patients and physiotherapists respectively. Conclusions: Overall, patients' and physiotherapists'views were remarkably similar. Both patients and physiotherapistsendorsed lifting as the most important trigger for LBP and agreed on three of the top five (lifting, bending and prolonged sitting).No new risk factors were suggested by patients. Level of evidence: 2.
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Background: Up-to-date evidence about levels and trends in disease and injury incidence, prevalence, and years lived with disability (YLDs) is an essential input into global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013), we estimated these quantities for acute and chronic diseases and injuries for 188 countries between 1990 and 2013. Methods: Estimates were calculated for disease and injury incidence, prevalence, and YLDs using GBD 2010 methods with some important refinements. Results for incidence of acute disorders and prevalence of chronic disorders are new additions to the analysis. Key improvements include expansion to the cause and sequelae list, updated systematic reviews, use of detailed injury codes, improvements to the Bayesian meta-regression method (DisMod-MR), and use of severity splits for various causes. An index of data representativeness, showing data availability, was calculated for each cause and impairment during three periods globally and at the country level for 2013. In total, 35 620 distinct sources of data were used and documented to calculated estimates for 301 diseases and injuries and 2337 sequelae. The comorbidity simulation provides estimates for the number of sequelae, concurrently, by individuals by country, year, age, and sex. Disability weights were updated with the addition of new population-based survey data from four countries. Findings: Disease and injury were highly prevalent; only a small fraction of individuals had no sequelae. Comorbidity rose substantially with age and in absolute terms from 1990 to 2013. Incidence of acute sequelae were predominantly infectious diseases and short-term injuries, with over 2 billion cases of upper respiratory infections and diarrhoeal disease episodes in 2013, with the notable exception of tooth pain due to permanent caries with more than 200 million incident cases in 2013. Conversely, leading chronic sequelae were largely attributable to non-communicable diseases, with prevalence estimates for asymptomatic permanent caries and tension-type headache of 2·4 billion and 1·6 billion, respectively. The distribution of the number of sequelae in populations varied widely across regions, with an expected relation between age and disease prevalence. YLDs for both sexes increased from 537·6 million in 1990 to 764·8 million in 2013 due to population growth and ageing, whereas the age-standardised rate decreased little from 114·87 per 1000 people to 110·31 per 1000 people between 1990 and 2013. Leading causes of YLDs included low back pain and major depressive disorder among the top ten causes of YLDs in every country. YLD rates per person, by major cause groups, indicated the main drivers of increases were due to musculoskeletal, mental, and substance use disorders, neurological disorders, and chronic respiratory diseases; however HIV/AIDS was a notable driver of increasing YLDs in sub-Saharan Africa. Also, the proportion of disability-adjusted life years due to YLDs increased globally from 21·1% in 1990 to 31·2% in 2013. Interpretation: Ageing of the world's population is leading to a substantial increase in the numbers of individuals with sequelae of diseases and injuries. Rates of YLDs are declining much more slowly than mortality rates. The non-fatal dimensions of disease and injury will require more and more attention from health systems. The transition to non-fatal outcomes as the dominant source of burden of disease is occurring rapidly outside of sub-Saharan Africa. Our results can guide future health initiatives through examination of epidemiological trends and a better understanding of variation across countries.
Background Back pain (BP) is a leading cause of global disability. However, population-based studies investigating its impact on mental health outcomes are lacking, particularly among low- and middle-income countries (LMICs). Thus, the primary aims of this study were to: (1) determine the epidemiology of BP in 43 LMICs; (2) explore the relationship between BP and mental health (depression spectrum, psychosis spectrum, anxiety, sleep disturbances and stress). Methods Data on 190,593 community-dwelling adults aged≥18 years from the World Health Survey (WHS) 2002–2004 were analyzed. The presence of past-12 month psychotic symptoms and depression was established using questions from the Composite International Diagnostic Interview. Anxiety, sleep problems, stress sensitivity, and any BP or chronic BP (CBP) during the previous 30 days were also self-reported. Multivariable logistic regression analyses were undertaken. Results The overall prevalence of any BP and CBP were 35.1% and 6.9% respectively. Significant associations with any BP were observed for subsyndromal depression [OR (odds ratio) = 2.21], brief depressive episode (OR=2.64), depressive episode (OR=2.88), psychosis diagnosis with symptoms (OR=2.05), anxiety (OR=2.12), sleep disturbance (OR=2.37) and the continuous variable of stress sensitivity. Associations were generally more pronounced for Chronic BP. Conclusion Our data establish that BP is associated with elevated mental health comorbidity in LMICs. Integrated interventions that address back pain and metal health comorbidities might be an important next step to tackle this considerable burden.
This article aims to show how people with chronic back pain manage the status passage from being well persons to becoming “pain afflicted” patients and how they see their own progression through the pain career path. This is examined through in-depth narrative interviews. The data were processed through thematic analysis. It was found that during the transition, a change in perceived identity occurs and that people grieve over the loss of their former selves, their future, social relationships, and occupational careers. The article also reflects on the value of narratives in revealing transformations over time. This technique is intended to capture evolving self-understandings of personal identity as persons negotiate the path through complex and critical life events.
Objective. To investigate a range of transient risk factors for an episode of sudden-onset, acute low back pain (LBP). Methods. This case–crossover study recruited 999 subjects with a new episode of acute LBP between October 2011 and November 2012 from 300 primary care clinics in Sydney, Australia. Each participant was asked to report exposure to 12 putative triggers over the 96 hours preceding the onset of back pain. Conditional logistic regression was used to estimate odds ratios (ORs) expressing the magnitude of increased risk with exposure to each trigger. Results. Exposure to a range of physical and psychosocial triggers significantly increased the risk of a new onset of LBP; ORs ranged from 2.7 (moderate or vigorous physical activity) to 25.0 (distracted during an activity or task). Age moderated the effect of exposure to heavy loads and sexual activity. The ORs for heavy loads for people ages 20, 40, or 60 years were 13.6, 6.0, and 2.7, respectively. The risk of developing back pain was greatest between 7:00 AM and noon. Conclusion. Transient exposure to a number of modifiable physical and psychosocial triggers substantially increases risk for a new episode of LBP. Triggers previously evaluated in occupational injury studies, but never in LBP, have been shown to significantly increase risk. These results aid our understanding of the causes of LBP and can inform the development of new prevention approaches
The aim of this case-crossover study was to investigate the extent to which patients can accurately nominate what triggered their new episode of sudden onset, acute low back pain (LBP). We interviewed 999 primary care patients to record exposure to 12 standard triggers and also asked the patient to nominate what they believed triggered their LBP. Exposure to the patient-nominated trigger during the case window was compared to exposure in the control window. Conditional logistic regression models were constructed to quantify the risk of LBP onset associated with the patient-nominated trigger. Sensitivity analyses were conducted varying the duration and timing of case/control windows. We compared the extent to which patient-nominated triggers matched standard triggers.The odds ratios for exposure to patient-nominated triggers ranged from 8.60 to 30.00 suggesting that exposure increase the risk of LBP. Patients' understanding of triggers however seem incomplete as we found evidence that while some of the standard triggers were well recognised (such as lifting heavy loads); others (such as being distracted during manual tasks) were under-recognised as possible triggers of an episode of LBP. This study provides some evidence that patients can accurately nominate the activity that triggered their new episode of sudden onset, acute LBP.
Patients with fibromyalgia report periods of symptom exacerbation, colloquially referred to as "flares" and despite clinical observation of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia. The purpose of this qualitative study was to describe fibromyalgia flares in a sample of patients with fibromyalgia. Using seven open-ended questions, patients were asked to describe how they perceived fibromyalgia flares and triggers and alleviating factors associated with flares. Patients were also asked to describe how a flare differs from their typical fibromyalgia symptoms and how they cope with fibromyalgia flares. Content analysis was used to analyze the text. A total of 44 participants completed the survey. Responses to the seven open-ended questions revealed three main content areas: causes of flares, flare symptoms, and dealing with a flare. Participants identified stress, overdoing it, poor sleep, and weather changes as primary causes of flares. Symptoms characteristic of flares included flu-like body aches/exhaustion, pain, fatigue, and variety of other symptoms. Participants reported using medical treatments, rest, activity and stress avoidance, and waiting it out to cope with flares. Our results demonstrate that periods of symptom exacerbation (i.e., flares) are commonly experienced by patients with fibromyalgia and symptoms of flares can be differentiated from every day or typical symptoms of fibromyalgia. Our study is the first of its kind to qualitatively explore characteristics, causes, and management strategies of fibromyalgia flares. Future studies are needed to quantitatively characterize fibromyalgia flares and evaluate mechanisms of flares. Wiley Periodicals, Inc.