Fiona Mathieson

The Enduring Impact of What Clinicians Say to People With Low Back Pain

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.

Easy to Harm, Hard to Heal: Patient Views About the Back.

Study Design. Qualitative interview study. Objective. Explore attitudes, beliefs, and perceptions related to low back pain (LBP) and analyze how these might influence the perceived threat associated with back pain. Summary of Background Data. Psychological factors that 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. Methods. Semistructured qualitative interviews were conducted with 12 participants with acute LBP (<6-wk duration) and 11 participants with chronic LBP (>3 mo duration). Data were analyzed thematically using the framework of Interpretive Description. Results. 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 that 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. Conclusion. 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 that 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. Level of Evidence: 3

Are we as good as we think we are? Self-assessment versus other forms of assessment of competence in psychotherapy

The Oracle of Delphis admonition to ‘know thyself’ may be more difficult than it seems, when it comes to self-assessment of competence in cognitive behaviour therapy (CBT). This paper investigates the accuracy of self-rating of competence in relation to other measures such as ‘direct’ assessment of videotaped sessions or supervisor ratings. Self-assessment of competence is something most of us do and arguably has an important role in professional development, but it may also be biased and unreliable. Two measures were developed, based on the Cognitive Therapy Scale – Revised, to assess student and supervisor assessments of competence at the start and end of a CBT training course. Competence data across a range of measures from a 5-year audit of a postgraduate CBT course is presented and the relationship between self-rated and other-rated measures explored. Results are discussed and it is suggested that trainee self-assessment, while not found in this study to be correlated with other measure of competence, may provide important information about confidence development, and areas where a trainee perceives they have strengths and weaknesses.

Cross-sectional survey of attitudes and beliefs about back pain in New Zealand

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.

Assessing the Development of Competence during Postgraduate Cognitive-Behavioral Therapy Training

This article investigates the development of competency in cognitive-behavioral therapy (CBT) as a result of a postgraduate training course in CBT in Wellington, New Zealand. Thirteen experienced mental health professionals attended the half-time 30-week-long course. Preliminary data are presented on the development of knowledge as assessed at the beginning and end of the course by a modified version of the Behaviour Therapy Scale (Freiheit & Overholser, 1997), other-rated competence as measured by the Cognitive Therapy Scale—Revised (Blackburn, Milne, & James, 1997), and supervisor and student evaluations of competence in particular skill areas. All students improved in specific CBT skills as a result of training. The extent that students improved and variations around the other outcome measures, together with the limitations of this pilot study and suggestions for improvements for future investigations, are discussed.

The development and exploratory analysis of the Back Pain Attitudes Questionnaire (Back-PAQ)

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-PAQs construct validity, reliability, responsiveness to change and predictive ability needs to be conducted.

Acceptability of a guided self-help mental health intervention in general practice

BACKGROUND People with subthreshold mental health syndromes are common in general practice and represent an important morbidity and disability burden. Management options are currently limited. We examined the acceptability of a novel ultra-brief guided self-help intervention designed specifically for use in this setting. OBJECTIVE To assess clinician and patient satisfaction with an ultra-brief guided self-help intervention to address subthreshold mental health syndromes in the primary care setting. METHODS Consenting patients were given the ultra-brief intervention in a series of three 15- to 30-minute coaching sessions over a 5-week period. DESIGN survey interview of clinician and patient satisfaction with and acceptability of the intervention. SETTING general practices in Wellington, New Zealand. MAIN OUTCOME MEASURE clinician and patient acceptability of the intervention was assessed by survey questionnaire at 3 months. Baseline and follow-up mental health status assessments were undertaken using the Kessler-10 measure of psychological distress. RESULTS Six clinicians recruited 19 patient participants, 16 of whom completed the intervention. Based on questionnaire feedback, clinician and patient satisfaction ratings were very positive. However, clinicians expressed a concern that the length of the sessions was sometimes inadequate. The psychological well-being of the patients, as measured by the Kessler-10, was also significantly improved post-intervention. CONCLUSION The intervention appeared to improve the psychological well-being of the patients and was regarded positively by both clinicians and patient participants. Further testing of the efficacy of the intervention on a larger sample with a randomized controlled trial study design is warranted.

Putting Physical Activity While Experiencing Low Back Pain in Context: Balancing the Risks and Benefits

OBJECTIVE To analyze attitudes and beliefs about movement and physical activity in people with low back pain (LBP) and compare these beliefs between people with acute and chronic LBP. DESIGN Qualitative inductive analysis of data collected via face-to-face semistructured interviews. Interviews were audio-recorded and transcribed verbatim. SETTING Participants were purposively recruited from 1 region of New Zealand. PARTICIPANTS Persons with LBP (N=23), consisting of individuals with acute LBP (<6wk; n=12) and chronic LBP (>3mo; n=11). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Themes that emerged from participant interview transcripts using analysis based on Interpretative Description. RESULTS Participants with acute and chronic LBP made judgments about physical activity and rest using the same conceptual model. Concerns about creating more pain, tissue damage, or impairment influenced the physical activity judgments of most participants with acute and chronic LBP. These perceived risks were balanced against the perceived benefits, the most important of which were psychological or social rather than physical. Judgments made by those with acute and chronic LBP were context dependent and influenced by the nature and duration of pain, the type of physical activity, the importance of the activity, and the participants previous experience. Participants with acute pain who had not experienced back pain previously often expressed more uncertainty, whereas those with chronic LBP appeared to have developed cognitive rules that determined physical activity decisions. CONCLUSIONS Exploring the perceived risks, benefits, and contextual factors that influence decisions about physical activity and rest may help clinicians to understand the behavior of patients with acute and chronic LBP. Clinicians may best support their patients to engage in physical activity by providing an informed assessment of risks and an explanation about the range of potential benefits.

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives.

Given the longstanding controversy about hypnosedative use, we aimed to investigate the attitudes of prescribing psychiatrists and service users towards long-term use of hypnosedative medication, and their perceptions of barriers to evidence-based nonmedication alternatives. Qualitative data from focus groups in Aotearoa/NZ were analysed thematically. A novel research design involved a service user researcher contributing throughout the research design and process. Service users and psychiatrists met to discuss each other’s views, initially separately, and subsequently together. Analysis of the data identified four key themes: the challenge, for both parties, of sleep disturbance among service users with mental health problems; the conceptual and ethical conflicts for service users and psychiatrists in managing this challenge; the significant barriers to service users accessing evidence-based nonmedication alternatives; and the initial sense of disempowerment, shared by both service users and psychiatrists, which was transformed during the research process. Our results raise questions about the relevance of the existing guidelines for this group of service users, highlight the resource and time pressures that discourage participants from embarking on withdrawal regimes and education programmes on alternatives, highlight the lack of knowledge about alternatives and reflect the complex interaction between sleep and mental health problems, which poses a significant dilemma for service users and psychiatrists.

Clinical effectiveness of an ultra-brief intervention for common mental health syndromes in primary care: study protocol for a cluster randomized controlled trial

BackgroundAlthough mild to moderate mental health problems are common and often debilitating, treatment options in primary care settings in New Zealand are often severely limited for patients with these conditions. Previously, we developed an ultra-brief intervention (UBI) to address mild to moderate psychological concerns, designed to be delivered by primary care clinicians. Recent feasibility testing, including an adaptation for Māori individuals (the indigenous people of New Zealand), showed that the brief intervention was feasible and acceptable to both clinicians and their patients. This protocol describes a large pragmatic randomized controlled trial of our UBI in primary care settings across the greater Wellington region, compared with practice as usual.Methods/DesignWe are using a two-arm cluster randomized controlled trial, with primary care practices randomized to exclusively deliver either the UBI or practice as usual to all their recruited participants. The structured, guided self-help UBI is delivered in three brief general practitioner (GP) appointments over a five week period. Participants are invited into the study based on partner primary health organization access criteria (youth, people with low income, or people with Māori or Pacific Island heritage). Improvements in mental health from baseline to post-treatment will be compared between the intervention and control groups using a mixed-models application of analysis of covariance. Data analysis will be on an intention-to-treat basis, to increase the real-world relevance of UBI and to meet the studys objective of releasing UBI to primary care clinicians nationwide.DiscussionThe UBI is a first-line intervention tool for GPs that models the stepped care approach advocated in New Zealand, against a background of limited access to treatments for often-overlooked patient groups. It is proposed to be accessible to clinicians and patients alike, with the potential to be relevant to primary care clinicians across New Zealand.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12613000041752.