Samantha Bunzli

Lives on hold: A qualitative synthesis exploring the experience of chronic low-back pain

Objectives:Chronic nonspecific low-back pain (CLBP) is a prevalent, costly condition that is remarkably resistant to intervention. Substantial evidence suggests that a mismatch exists between the biomedical beliefs held by clinicians and patients and the biopsychosocial nature of CLBP experience. The aim of this metasynthesis of qualitative studies was to provide clinicians with a richer understanding of their patients’ CLBP experience to highlight the importance of moving away from biomedical paradigms in the clinical management of CLBP. Methods:Qualitative studies exploring the CLBP experience from the perspective of the individual were included. Twenty-five articles representing 18 studies involving 713 participants were subjected to the 3-stage analytic process of extraction/coding, grouping, and abstraction. Results:Three main themes emerged: the social construction of CLBP; the psychosocial impact of the nature of CLBP; and coping with CLBP. Discussion:The authors conceptualize the experience of CLBP as biographical suspension in which 3 aspects of suspension are described: suspended “wellness,” suspended “self,” and suspended “future”. The implications of improved clinician understanding of the CLBP experience and directions for future research are discussed.

Consumers’ experiences of back pain in rural Western Australia: access to information and services, and self-management behaviours

BackgroundCoordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP.MethodsFourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals’ access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes.ResultsFive key themes were identified that affected individuals’ experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP.ConclusionsConsumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care.

Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear

Objectives The fear-avoidance model describes how the belief that pain is a sign of damage leads to pain-related fear and avoidance. But other beliefs may also trigger the fear and avoidance responses described by the model. Experts have called for the next generation of fear avoidance research to explore what beliefs underlie pain-related fear and how they evolve. We have previously described damage beliefs and suffering/functional loss beliefs underlying high pain-related fear in a sample of individuals with chronic back pain. The aim of this study is to identify common and differential factors associated with the beliefs in this sample. Design A qualitative study employing semistructured interviews. Setting Musculoskeletal clinics in Western Australia. Participants 36 individuals with chronic back pain and high scores on the Tampa Scale (mean 47/68). Results The overarching theme was a pain experience that did not make sense to the participants. The experience of pain as unpredictable, uncontrollable and intense made it threatening. Attempting to make sense of the threatening pain, participants with damage beliefs drew on past personal experiences of pain, societal beliefs, and sought diagnostic certainty. Met with diagnostic uncertainty, or diagnoses of an underlying pathology that could not be fixed, they were left fearful of damage and confused about how to ‘fix’ it. Participants with suffering/functional loss beliefs drew on past personal experiences of pain and sought help from healthcare professionals to control their pain. Failed treatments and the repeated failure to achieve functional goals left them unable to make ‘sensible’ decisions of what to do about their pain. Conclusions The findings raise the suggestion that sense-making processes may be implicated in the fear-avoidance model. Future research is needed to explore whether fear reduction may be enhanced by considering beliefs underlying fear and providing targeted intervention to help individuals make sense of their pain.

Engaging consumers living in remote areas of Western Australia in the self-management of back pain: a prospective cohort study.

BackgroundIn Western Australia (WA), health policy recommends encouraging the use of active self-management strategies as part of the co-care of consumers with persistent low back pain (LBP). As many areas in WA are geographically isolated and health services are limited, implementing this policy into practice is critical if health outcomes for consumers living in geographically-isolated areas are to be improved.MethodsIn this prospective cohort study, 51 consumers (mean (SD) age 62.3 (±15.1) years) participated in an evidence-based interdisciplinary pain education program (modified Self Training Educative Pain Sessions: mSTEPS) delivered at three geographically isolated WA sites. Self report measures included LBP beliefs and attitudes (Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)), use of active and passive self-management strategies, and health literacy, and global perceived impression of usefulness (GPIU) recorded immediately pre-intervention (n = 51), same day post-intervention (BBQ; GPIU, n = 49) and 3 months post-intervention (n = 25).ResultsAt baseline, consumers demonstrated adequate health literacy and elements of positive health behaviours, reflected by the use of more active than passive strategies in self-managing their persistent LBP. Immediately post-intervention, there was strong evidence for improvement in consumers’ general beliefs about LBP as demonstrated by an increase in BBQ scores (baseline [mean (SD): 25.8 (7.6)] to same day post-intervention [28.8 (7.2); P < 0.005], however this improvement was not sustained at 3 months post-intervention. The majority of consumers (86.4%) reported the intervention as very useful [rated on NRS as 7–10].ConclusionsTo sustain improved consumer beliefs regarding LBP and encourage the adoption of more positive health behaviours, additional reinforcement strategies for consumers living in remote areas where service access and skilled workforce are limited are recommended. This study highlights the need for aligning health services and skilled workforce to improve the delivery of co-care for consumers living in geographically isolated areas.

Is clinician refusal to treat an emerging problem in injury compensation systems

Objective The reasons that doctors may refuse or be reluctant to treat have not been widely explored in the medical literature. To understand the ethical implications of reluctance to treat there is a need to recognise the constraints of doctors working in complex systems and to consider how these constraints may influence reluctance. The aim of this paper is to illustrate these constraints using the case of compensable injury in the Australian context. Design Between September and December 2012, a qualitative investigation involving face-to-face semistructured interviews examined the knowledge, attitudes and practices of general practitioners (GPs) facilitating return to work in people with compensable injuries. Setting Compensable injury management in general practice in Melbourne, Australia. Participants 25 GPs who were treating, or had treated a patient with compensable injury. Results The practice of clinicians refusing treatment was described by all participants. While most GPs reported refusal to treat among their colleagues in primary and specialist care, many participants also described their own reluctance to treat people with compensable injuries. Reasons offered included time and financial burdens, in addition to the clinical complexities involved in compensable injury management. Conclusions In the case of compensable injury management, reluctance and refusal to treat is likely to have a domino effect by increasing the time and financial burden of clinically complex patients on the remaining clinicians. This may present a significant challenge to an effective, sustainable compensation system. Urgent research is needed to understand the extent and implications of reluctance and refusal to treat and to identify strategies to engage clinicians in treating people with compensable injuries.

Making Sense of Low Back Pain and Pain-Related Fear

&NA; • SYNOPSIS: Pain‐related fear is implicated in the transition from acute to chronic low back pain and the persistence of disabling low back pain, making it a key target for physical therapy intervention. The current understanding of pain‐related fear is that it is a psychopathological problem, whereby people who catastrophize about the meaning of pain become trapped in a vicious cycle of avoidance behavior, pain, and disability, as recognized in the fear‐avoidance model. However, there is evidence that pain‐related fear can also be seen as a common‐sense response to deal with low back pain, for example, when one is told that one’s back is vulnerable, degenerating, or damaged. In this instance, avoidance is a common‐sense response to protect a “damaged” back. While the fear‐avoidance model proposes that when someone first develops low back pain, the confrontation of normal activity in the absence of catastrophizing leads to recovery, the pathway to recovery for individuals trapped in the fear‐avoidance cycle is less clear. Understanding pain‐related fear from a common‐sense perspective enables physical therapists to offer individuals with low back pain and high fear a pathway to recovery by altering how they make sense of their pain. Drawing on a body of published work exploring the lived experience of pain‐related fear in people with low back pain, this clinical commentary illustrates how Leventhal’s common‐sense model may assist physical therapists to understand the broader sense‐making processes involved in the fear‐avoidance cycle, and how they can be altered to facilitate fear reduction by applying strategies established in the behavioral medicine literature. • KEY WORDS: common‐sense model, fear‐avoidance model, low back pain, qualitative research

Fear of (re)injury and return to work following compensable injury: qualitative insights from key stakeholders in Victoria, Australia

BackgroundReturn to work (RTW) is important for recovery post-injury. Fear of (re)injury is a strong predictor of delayed RTW, and therefore much attention has been given to addressing injured workers’ fear beliefs. However, RTW is a socially-negotiated process and it may be important to consider the wider social context of the injured worker, including the beliefs of the key people involved in their RTW journey.MethodsThis paper involves data collected as part of a wider study in which semi-structured interviews explored RTW from the perspectives of 93 key stakeholders: injured workers, GPs, employers and insurance case managers in Victoria, Australia. Inductive analysis of interview transcripts identified fear of (re)injury as a salient theme across all stakeholder groups. This presented an opportunity to analyse how the wider social context of the injured worker may influence fear and avoidance behaviour. Two co-authors performed inductive analysis of the theme ‘fear of (re)injury’. Codes identified in the data were grouped into five categories. Between and within category analysis revealed three themes describing the contextual factors that may influence fear avoidance and RTW behaviour.ResultsTheme one described how injured workers engaged in a process of weighing up the risk of (re)injury in the workplace against the perceived benefits of RTW. Theme two described how workplace factors could influence an injured workers’ perception of the risk of (re)injury in the workplace, including confidence that the source of the injury had been addressed, the availability and suitability of alternative duties. Theme three described other stakeholders’ reluctance to accept injured workers back at work because of the fear that they might reinjure themselves.ConclusionsOur findings illustrate the need for a contextualised perspective of fear avoidance and RTW behaviour that includes the beliefs of other important people surrounding the injured worker (e.g. employers, family members, GPs). Existing models of health behaviour such as The Health Beliefs Model may provide useful frameworks for interventions targeting the affective, cognitive, social, organisational and policy factors that can influence fear avoidance or facilitate RTW following injury.

The unmet needs of Aboriginal Australians with musculoskeletal pain: A mixed method systematic review

Musculoskeletal pain (MSP) conditions are the biggest cause of disability, and internationally, indigenous peoples experience a higher burden. There are conflicting reports about Aboriginal Australians and MSP. We conducted a systematic review to describe the prevalence, associated factors, impacts, care access, health care experiences, and factors associated with MSP among Aboriginal Australians.

Barriers and facilitators to orthopaedic surgeons’ uptake of decision aids for total knee arthroplasty: a qualitative study

Objectives The demand for total knee arthroplasty (TKA) is increasing. Differentiating who will derive a clinically meaningful improvement from TKA from others is a key challenge for orthopaedic surgeons. Decision aids can help surgeons select appropriate candidates for surgery, but their uptake has been low. The aim of this study was to explore the barriers and facilitators to decision aid uptake among orthopaedic surgeons. Design A qualitative study involving face-to-face interviews. Questions were constructed on the Theoretical Domains Framework to systematically explore barriers and facilitators. Setting One tertiary hospital in Australia. Participants Twenty orthopaedic surgeons performing TKA. Outcome measures Beliefs underlying similar interview responses were identified and grouped together as themes describing relevant barriers and facilitators to uptake of decision aids. Results While prioritising their clinical acumen, surgeons believed a decision aid could enhance communication and patient informed consent. Barriers identified included the perception that one’s patient outcomes were already optimal; a perceived lack of non-operative alternatives for the management of end-stage osteoarthritis, concerns about mandatory cut-offs for patient-centred care and concerns about the medicolegal implications of using a decision aid. Conclusions Multifaceted implementation interventions are required to ensure that orthopaedic surgeons are ready, willing and able to use a TKA decision aid. Audit/feedback to address current decision-making biases such as overconfidence may enhance readiness to uptake. Policy changes and/or incentives may enhance willingness to uptake. Finally, the design/implementation of effective non-operative treatments may enhance ability to uptake by ensuring that surgeons have the resources they need to carry out decisions.

The Lived Experience of Pain-Related Fear in People with Chronic Low Back Pain

Low back pain (LBP) is a leading cause of disability worldwide. One of the strongest predictors of LBP disability is pain-related fear. The fear avoidance model (FAM) describes how the belief that pain signals damage to the spine can lead individuals into a cycle of fear and avoidance, which in turn sustain pain and physical and psychosocial disability. A large body of research has supported the relationships proposed by the FAM; however, randomized controlled trials based on the model have reported modest effect sizes for reductions in fear and disability. Limitations of the model in its current form may be impeding its clinical utility and applicability to the wider population of people with LBP and high pain-related fear. In particular, while the FAM conceptualises pain-related fear as a “phobia” driven by the underlying belief that pain signals damage, it is possible that “non-phobic” processes also trigger pain-related fear and avoidance. In this chapter, we examine the lived experience of LBP and pain-related fear. We explore personal explanations and narratives related to the beliefs underlying pain-related fear, the factors associated with these beliefs and how fear may change over time. We consider how individual variance in qualitative data relates to scores on quantitative measures of fear. Finally, we offer an alternative framework to understand the lived experience of pain-related fear, based on “common sense” rather than only “phobic” processes. We will propose that incorporating a “common sense” perspective into future iterations of the FAM may extend its clinical utility and have implications for the next generation of fear avoidance research.