Meredith Perry

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.

Utility of the RT3 triaxial accelerometer in free living: An investigation of adherence and data loss

There is strong evidence for the protective effects of physical activity on chronic health problems. Activity monitors can objectively measure free living occupational and leisure time physical activity. Utility is an important consideration when determining the most appropriate monitor for specific populations and environments. Hours of activity data collected, the reasons for activity hours not being recorded, and how these two factors might change over time when using an activity monitor in free living are rarely reported. This study investigated user perceptions, adherence to minimal wear time and loss of data when using the RT3 activity monitor in 21 healthy adults, in a variety of occupations, over three (7 day) repeated weeks of measurement in free living. An activity diary verified each day of monitoring and a utility questionnaire explored participant perceptions on the usability of the RT3. The RT3 was worn for an average of 14 h daily with 90% of participants having complete data sets. In total 6535.8 and 6092.5h of activity data were collected from the activity diary and the RT3 respectively. An estimated 443.3h (6.7%) of activity data were not recorded by the RT3. Data loss was primarily due to battery malfunction (45.2%). Non-adherence to wear time accounted for 169.5h (38.2%) of data loss, of which 14 h were due to occupational factors. The RT3 demonstrates good utility for free living activity measurement, however, technical issues and strategies to manage participant adherence require consideration with longitudinal and repeated measures studies.

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

IF I DIDN'T HAVE ANYBODY, WHAT WOULD I HAVE DONE?: EXPERIENCES OF OLDER ADULTS AND THEIR DISCHARGE HOME AFTER LOWER LIMB ORTHOPAEDIC SURGERY

OBJECTIVE To explore the perceptions of being discharged home following lower limb orthopaedic surgery in older adults. METHODS Qualitative interviews with 11 patients over the age of 65 years were conducted between 6 and 12 weeks afterdischarge home and analysed using interpretative phenomenological analysis (IPA). RESULTS Three themes were identified from analysis of the participants’ experiences of rehabilitation during the 6–12 weeks following discharge: (i) lack of a shared decision on when to go home; (ii) dependent on family to go home and to feel confident there; and (iii) trial and error rehabilitation.A further theme: a paternalistic medical model was also identified in participants’ experiences of contact with health professionals. CONCLUSION Participants had positive experiences of being discharged home from hospital. However, few participants played an active role in their discharge, all required the support of family to go home, and many were left unsure of how and when to return to usual activities. A paternalistic medical model was apparent. Family support, not without costs,was integral to discharge and rehabilitation at home.

Older adults' experiences regarding discharge from hospital following orthopaedic intervention: a metasynthesis

Purpose: To identify and synthesise qualitative literature on the older adults’ perspectives of being discharged from hospital following orthopaedic intervention. Methods: A systematic search of nine databases, for qualitative research published between 1950 and December 2010, exploring the lived experience of older adults being discharged from hospital following orthopaedic surgery was undertaken. Included papers were evaluated using the Critical Appraisal Skills Programme (CASP) quality guidelines. Data were extracted and themes synthesised, using an EXCEL spreadsheet to assist with organisation of data. Results: From the 16 papers included in the review, four themes were identified: 1) mental outlook; 2) loss of independence; 3) function and activity limitations; and 4) coping with pain. Mental outlook was central to the other three themes. Conclusions: Older adults’ experiences around hospital discharge, collected through qualitative research, provide health authorities with valuable information that could be used in care pathway planning. Health professionals involved in in-patient and community care should be aware that a perceived loss of independence, function and activity limitations, and the ability to cope with pain can influence mental outlook and consequently rehabilitation. Implications for Rehabilitation Mental outlook should be discussed prior to older adults being discharged home, as maintaining a positive mental outlook facilitates a successful transition home and the confidence to increase independence. Coping with pain, a loss of independence, and adjusting to limitations in function and participation in activities during the early and later stages of being discharged home are problems which are frequently encountered by older adults following lower limb orthopaedic surgery. Consistent reinforcement of clear information may help older adults feel more confident to cope with these problems.

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.

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.

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.

What makes an interprofessional education programme meaningful to students? Findings from focus group interviews with students based in New Zealand

ABSTRACT It is important to understand what an interprofessional education (IPE) experience means to students and what makes it meaningful so that optimal use can be made of IPE opportunities and resources. This article reports qualitative data from a larger study evaluating an 11-hour IPE programme which focused on long-term condition management. Qualitative analysis aimed to explore students’ perspectives of the programme. Forty-one students from dietetics, medicine, physiotherapy, and radiation therapy were invited to participate in interprofessional focus groups. Data gathered from 34 students who participated in two focus groups were analysed inductively using thematic analysis. Three key themes emerged related to (i) learning, (ii) perceived long-term professional benefits, and (iii) the structure and content of the programme. Participants considered the programme to be a valuable learning opportunity with direct relevance to their future clinical careers. Findings indicated that providing students with an opportunity to learn about each other should be prioritised within IPE programmes and that this process should be student-led. This may help students to effectively learn with and from each other. Students perceived active learning activities, including interviewing a patient in their home and presenting findings to their peers, to be particularly valuable.

“Not always a straight path”: patients’ perspectives following anterior cruciate ligament rupture and reconstruction

Abstract Purpose: To explore patients’ perspectives following anterior cruciate ligament rupture and subsequent reconstructive surgery. Methods: A qualitative study design was employed, using validated questionnaires, interviews and general inductive methodology. Semi-structured interviews were conducted with five men and four women who had undergone an anterior cruciate ligament reconstruction in the past 6–36 months. Participants completed the Knee Osteoarthritis Outcome Score and the Tegner Activity Score. Descriptive statistics were used to analyze quantitative data. Interviews were recorded, transcribed and analyzed using the general inductive approach to develop key themes. Results: Participants had not returned to pre-injury knee-related activity levels (Tegner score: 7 pre-injury; 4 current). The theme of a disruptive “journey” emerged with two sub-themes of “loss of identity” and “life at the present,” influenced positively and negatively by “support systems” and experience with the “care pathway.” This unequivocally negative experience resulted in irrevocable changes to their lives, reflected by current lower knee-related quality of life. Conclusions: Anterior cruciate ligament injury and rehabilitation thereof have a profound influence in the individual’s identity. The results imply that a broader approach is needed within the rehabilitation process to address psychosocial factors, in addition to physical impairments and function. Implications for rehabilitation Anterior cruciate ligament rupture has a profound influence on patients’ understanding of their individual identity. Support systems the patients have in place influence the patients’ experience of the care pathway. Understanding psychosocial responses and implementing appropriate strategies and interventions for these may be critical for rehabilitation of these patients.