Journal of Physiotherapy 65 (2019) 124–135

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s

Research

People with low back pain want clear, consistent and personalised information
on prognosis, treatment options and self-management strategies:
a systematic review
Yuan Z Lim a, Louisa Chou a, Rebecca TM Au a, KL Maheeka D Seneviwickrama a, Flavia M Cicuttini a,
Andrew M Briggs b, Kaye Sullivan c, Donna M Urquhart a, Anita E Wluka a
a
Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne; b School of Physiotherapy and
Exercise Science, Curtin University; c Monash University Library, Monash University, Melbourne, Australia

K E Y W O R D S A B S T R A C T

Health information Question: What health information needs are perceived by people with low back pain? Design: Systematic
Low back pain review of publications examining perceived health information needs related to low back pain identified
Need
through Medline, EMBASE, CINAHL and PsycINFO (1990 to 2018). Participants: Adults with low back pain of
Patient perspective
any duration. Data extraction and analysis: Two reviewers independently extracted descriptive data
Preference
Systematic review regarding study design and methodology, and assessed risk of bias. Aggregated findings of the perceived
needs of people with low back pain regarding health information were meta-synthesised. Results: Forty-one
studies (34 qualitative, four quantitative and three mixed-methods) were identified. Two major areas of
perceived health information needs for low back pain emerged. The first major area was needs related to
information content: general information related to low back pain, its cause and underlying pathology;
strong desire for diagnosis and imaging; prognosis, future disability and effect on work capacity; precipitants
and management of flares; general management approaches; self-management strategies; prevention; and
support services. The second major area of needs related to how the information was delivered. People with
low back pain wanted clear, consistent information delivered in suitable tone and understandable language.
Conclusion: Available data suggest that the information needs of people with low back pain are centred
around their desire for a diagnosis, potentially contributing to expectations for and overuse of imaging.
People with low back pain expressed a strong desire for clear, consistent and personalised information on
prognosis, treatment options and self-management strategies, related to healthcare and occupational issues.
To correct unhelpful beliefs and optimise delivery of evidence-based therapy, patient and healthcare pro-
fessional education (potentially by an integrated public health approach) may be warranted. [Lim YZ, Chou L,
Au RTM, Seneviwickrama KLMD, Cicuttini FM, Briggs AM, Sullivan K, Urquhart DM, Wluka AE (2019)
People with low back pain want clear, consistent and personalised information on prognosis, treatment
options and self-management strategies: a systematic review. Journal of Physiotherapy 65:124–135]
© 2019 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction doctor.8 In Australia, the proportion of people seeking medical care

for LBP has surged by 20% over 10 years.5
In the Global Burden of Disease study, low back pain (LBP) is There are a number of published national and international clin-
ranked highest in terms of years lived with disability, with one in ten ical guidelines to support the management of LBP.9 Although many
people experiencing LBP at any point in time worldwide.1 Approxi- groups have developed these clinical practice guidelines for LBP
mately 90% of LBP cases have no identifiable pathoanatomical cause, management, they tend to contain relatively uniform recommenda-
and are called ‘non-specific LBP’.2 Despite the high prevalence of LBP tions incorporating best available evidence, clinician expertise and
globally, recommended treatments have only modest effects.2,3 A patients’ preferences.9 However, these guidelines, as in other areas,
large range of diagnostic and therapeutic interventions are frequently have not resulted in change to clinical practice.10–12 The uptake of
applied, despite evidence that they are of low value.2,3 Although guidelines is determined by a complex interplay between clinicians,
many people with LBP do not seek medical care, LBP is still one of the patients and available resources within the healthcare system. First,
most common reasons for general practice or physician visits clinicians must decide to follow the guidelines in daily clinical prac-
worldwide, with a pooled prevalence of care-seeking of 58%.4–7 In the tice. Various clinician-related factors have been identified to explain
United States, LBP is the third most common reason for visiting a clinicians’ suboptimal use of guideline recommendations in practice:

https://doi.org/10.1016/j.jphys.2019.05.010
1836-9553/© 2019 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
 Research 125

inadequate education and awareness of current guidelines; insuffi- Two investigators (RA and YL) independently assessed the
cient time and resources to appropriately engage patients; pressure eligibility of available studies using a three-stage determination
to maintain patient-clinician relationships; concern for liability; method: title screening, abstract screening, followed by full text.
previous clinical experience; and financial disincentives.11,13,14 Sec- Studies were included if inclusion criteria were met: studies had to
ond, whether patients follow their healthcare providers’ advice is concern patients aged . 18 years; studies had to report on pa-
influenced by their engagement in their own care and their rela- tients’ perspectives regarding their needs, expectations and re-
tionship with the healthcare provider.15,16 Dissatisfied patients tend quirements related to health information; and studies had to
to use more healthcare resources, seek care from multiple providers, concern patients with LBP.
have less favourable LBP rehabilitation outcomes, and are less likely
to return to work than satisfied patients.15–18 As such, better under-
Data extraction and synthesis
standing of patients’ goals, preferences and expectations related to
the management of LBP may improve patient satisfaction, better
Two authors (YL and RA) independently extracted characteristics
facilitate delivery of patient-centred care, and potentially improve
of the included studies using a standardised data extraction form
LBP outcomes.18–20
developed for this review. Data were extracted on: year of publica-
Although education is recommended in most guidelines, the focus
tion; country; study design; study population, including baseline
has been on management strategies, especially on minimising im-
characteristics of the participants (number of participants, gender,
aging use in LBP, rather than how to maximise function and live well
age); primary study aim; and study results. Data extraction syntheses
with LBP.21–23 Most guidelines do not specify what content should be
were performed according to principles of meta-ethnography to
included in patient education, leaving this open to interpretation and
synthesise qualitative data.29 A framework of concepts and underly-
marked heterogeneity in the clinical approach.21,23 In particular,
ing themes was developed, initially based on primary data in the
strategies to link LBP education (knowledge) with positive behaviour
studies and any pertinent points raised by the authors, which was
change and effective pain-coping behaviours (skills) are lacking in
further independently refined by another author (YL), and then
guidelines. Guidelines usually suggest that patients should be reas-
independently reviewed by two experienced rheumatologists (FC and
sured and advised to remain active. Additionally, previous studies
AW) and a physiotherapist (AB) to ensure clinical meaningfulness and
have recognised gaps between patients’ and clinicians’ beliefs in LBP
construct validity.
management, which could negatively impact on the practitioner-
patient therapeutic relationship.24–26 Hence, it is important to:
explicitly seek and understand patients’ perspectives; understand Assessment of methodological quality
and address patients’ attitudes, concerns and beliefs, especially in the
domains of diagnostic uncertainty; and encourage resuming normal Two reviewers (YL and LC) independently assessed the quality of
activity that is meaningful to patients. Increased clinician awareness the studies. The Critical Appraisal Skills Programme tool was used for
of patients’ perspectives and expectations has the potential to qualitative studies.30 External and internal validity of quantitative
improve outcomes in LBP. studies were assessed through the 11 criteria in Hoy’s risk of bias tool,
Therefore, the research question for this systematic review was: where overall quality of studies was scored as low risk if scoring  8
‘yes’ answers, moderate risk of bias if scoring 6 to 7 ‘yes’ answers, and
What health information needs are perceived by people with low high risk of bias if scoring  5 ‘yes’ answers.31
back pain?
Results

Flow of studies through the review

Methods

A total of 3733 studies were identified by the initial search. After

This systematic review was performed within a larger project
removal of duplicates, 2794 studies were screened and 2694 studies
examining patients’ perceived needs relating to musculoskeletal
were excluded on screening of the title and abstract, leaving 100
health,27 based on the framework proposed by Arksey and O’Malley
studies for full-text review. Of the 100 full-text articles that were
for scoping reviews.28
assessed, 59 studies were excluded. Thus, 41 studies were included in
this systematic review. Details of the study selection and reasons for
Identification and selection of studies exclusion are shown in the flow diagram (Figure 1). The PRISMA
extension for scoping reviews checklist32 is presented in Appendix 2
Electronic searches of Medline, EMBASE, CINAHL and PsycINFO on the eAddenda.
were performed from 1990 to July 2018. A comprehensive search
strategy combining both MeSH terms and text words was used to Characteristics of included studies
capture information about patients’ perceived health information
needs related to LBP (see Appendix 1 on the eAddenda). It was Table 1 provides an overview of the characteristics of the included
developed by a multidisciplinary team involving an academic studies. Most of the included studies were from the United Kingdom
librarian (KS), and input from one patient representative and three or Europe,24,25,33–60 six were from the United States of America,61–66
clinician researchers (rheumatologists, FC and AW, and physiothera- two from Australia,67,68 and one each from Iran,69 Israel70 and New
pist, AB). The review’s focus on patients’ perceived health information Zealand.71
needs was interpreted to encompass a broad concept involving pa- Twelve studies recruited participants from primary care
tients’ needs, expectations and requirements related to health infor- practice,24,25,35,44,49–51,59,61,66,68,70 eight from tertiary pain clinics,33,
mation. LBP was defined as non-specific LBP, with or without leg pain, 38,52–55,63,64
nine from hospital or rehabilitation clinics,34,36,37,41,45,
excluding back pain related to fractures, malignancy, infection and 48,57,60,62
three from specialist spine or osteopathy clinics,39,40,42
inflammatory back conditions. In order that the review would capture four from the general community,43,46,56,71 two from research cen-
the breadth of patients’ perspectives on health information needs and tres,47,69 one from the intervention arm of a trial,58 one from an
back pain, studies were not excluded based on study methods. The education forum,67 and one from an occupational health clinic.65
reference lists of published articles were examined to identify addi- The duration of LBP was either undefined or mixed in 15
tional sources. All review papers, conference papers, reports or studies,24,25,40,41,46,47,49–51,56–58,66,70,71 subacute ( 6 weeks) in one
literature reviews were excluded. Studies were limited to English- study,59 chronic (. 3 months) in 22 studies,33–39,42–45,48,52–55,
language reports of studies of humans. 60,61,63,64,67,69
and acute in three studies.62,65,68
126 Lim et al: Health information needs for low back pain

Results of review
Titles and abstracts screened (n = 3733)
• EMBASE 1990 to July 2018 (n = 1736) Two major areas of patients’ perceived health information needs
• CINAHL 1990 to July 2018 (n = 1046) for LBP emerged from the review: information content and infor-
• MEDLINE 1990 to July 2018 (n = 771)
mation delivery. Selected results from individual studies relating to
• PsycINFO 1990 to July 2018 (n = 180)
each of these themes are presented in Boxes 1 and 2, respectively. For
a complete list of results supporting these themes, see Appendices 3
Duplicate papers excluded (n = 939) and 4 on the eAddenda.

Patients’ perceived needs regarding health information content related to

Screening of titles and abstracts (n = 2794) low back pain
General information content related to low back pain: Nine studies
identified patients’ needs for general information about
Papers excluded after screening LBP.35,41,42,57,60,65,69–71 Participants were keen to learn about simple
titles and abstracts (n = 2694) and basic information regarding LBP. Specifically, they wanted a clear
and detailed explanation of the nature of LBP, largely related to its
unpredictable, intermittent and fluctuating course to further improve
Potentially relevant papers retrieved for
their understanding of LBP.35,41,42,57,60,65,69–71
evaluation of full text (n = 100)
Diagnosis and cause or aetiology for low back pain: Twenty-seven
studies identified patients’ needs for a diagnosis for LBP and/or an
explainable cause of LBP.25,33–35,38–41,43–50,52–55,57–59,61,68–70 Findings
Papers excluded after evaluation of included participants’ needs for an ‘exact’ diagnosis of LBP for a va-
full text (n = 59) riety of reasons, including the validation and legitimisation of pa-
• did not examine the needs for tients’ symptoms.34,43,52,54,59,61 The lack of a diagnosis was associated
health information perceived by with frustration.38 Some participants believed that their pain could
people with LBP (n = 42) not be substantiated without a specific diagnosis.45 Additionally,
• review papers, conference patients felt that a lack of a diagnosis indicated that health pro-
papers or commentaries (n = 11) fessionals did not know what they were doing, resulting in a
• related to other musculoskeletal perceived lack of a therapeutic relationship with the health practi-
pain (n = 6) tioner.46,47 Participants in Ong’s study required a diagnosis as the
starting point for therapy.47 Invariably, most participants wanted to
know the cause of symptoms.25,33–35,38–41,43–50,52–55,57–59,61,68,70 Many
were dissatisfied with being told that the pain was ‘age related’ or
Papers included (n = 41)
‘wear and tear’.33,38 Some participants demanded and were insistent
on having a biomechanical or physical explanation.38,48,54,57 In a
Figure 1. Flow of studies through the review. single study by Toye, participants identified that both a physical and
LBP = low back pain.
psychological explanation were relevant.54
Perceived needs for imaging: Eight papers found that participants
believed imaging to be an essential component of the assessment of
Of the included studies, 33 were qualitative studies,25,33–35,38, LBP.24,46,49,52,59,61,68,70 This was thought to be required and necessary
40,42–61,63,64,67–71
five were quantitative studies,24,36,37,62,65 and three to confirm the diagnosis and identify structural damage and the cause
used mixed methods.39,41,66 Of the qualitative studies, 30 used in- of LBP. Two studies identified the relief that participants felt when a
terviews or semi-structured interviews,25,33–35,38–40,42,44–55,57,58, structural cause to LBP was identified.40,52
60,61,63,66–68,70,71
eight used focus groups,25,41,43,56,57,59,69,70 and two Prognosis, including future disability and effect on work capacity: The
used narrative methods. Of the quantitative studies, all five used importance of information regarding the natural history of LBP was
questionnaires.24,36,37,62,65 identified in 15 studies.34,39,41–43,47,49,50,54,57,58,64,65,68,71 Participants
Eight of the included studies had over 100 partici- in these studies wanted information about the prognosis of LBP, in
pants.24,36,37,41,46,62,64,65 The age of the participants in the included particular its favourable prognosis and benign nature. LBP was
studies ranged from 18 to 86 years, but was not reported for two commonly associated with significant fears,34,43,50,58,64 with some
studies.41,63 The included studies had a female predominance: 28 participants being concerned about future disability.34,43,50,64 Coole
studies had  50% female participants,24,34–37,40–43,45–47,50–54, found that participants were interested in information about work
57–60,62,64,66–69,71
while two studies did not specify the gender capacity, particularly knowing their ability to work with LBP.34
distribution.25,33 Information about precipitation of flares: Four studies identified par-
ticipants’ needs to learn about potential precipitants of flares for
LBP.34,35,54,69 Participants attributed this need to the unpredictable
Quality assessment nature of LBP flares,34,35 whereby knowledge in this area would help
them to deconstruct fear of specific movements perceived to be
Tables 2 and 3 provide details of the risk of bias and quality associated with LBP54 and, hence, gained self-control with flare-up
assessment of the included studies. The initial agreement between management.34
the two reviewers was 94% for qualitative assessment criteria and General information about low back pain management: Twenty-one
97% for quantitative risk of bias criteria. Differences in scoring be- studies found that that participants wanted information about
tween reviewers were evaluated and resolved by discussion. Where management of LBP.24,25,33,35,39,40,42,43,48–50,52,53,56–58,60,64,66,69,71
the two reviewers could not achieve consensus, a third reviewer Many participants wanted information on general treatment op-
(AW) adjudicated. The overall quality of the qualitative studies was tions, including pharmacological and non-pharmacological strate-
poor, especially for the Critical Appraisal Skills Programme criteria gies.24,25,35,39,43,48,50,53,56–58,60,64 Participants wanted to be provided
relating to recruitment strategy, data collection and recognition of with information about the available options.
any impact of the relationship between researcher and participants. With regards to pharmacological strategies, participants wanted
The quality of quantitative studies was low to moderate. Overall, the information about different analgesia options for the management of
low to moderate quality scores of both qualitative and quantitative LBP, prior to taking the medicine.34,49,64,66 In the study by Liddle,
studies related to possible biases in recruitment and data collection. participants wanted to know the role and efficacy of analgesia in
Table 1
Characteristics of the included studies.

Author (Year) Diagnosis of LBP Participants Aim stated in study publication Study methodology
Country
N Source Age (yr) a
Gender

Allegretti (2010)61 Chronic (.6 months) 23 Primary care practice 45 (28 to 72) Explore paired interviews of shared experiences Qualitative: Interview
US 12M:11F among chronic LBP patients and their physicians

Ali (2015)57 Any duration 18 Hospital and private physio (19 to 81) Explore patients’ expectations and satisfaction with Qualitative: Focus group
UK clinics 9M:9F physiotherapy management of LBP and interview

Amonkar (2011)24 NS 427 General practices .18 Investigate perceptions and expectations of general Quantitative: Questionnaire
UK (206 LBP) 158M:269F practitioners and patients concerning management
of simple LBP

Bishop (2011)62 Acute (89 days) 112 Hospital clinics 40 Examine patients’ expectations related to common Quantitative: Questionnaire
US 54M:58F interventions for LBP and the influence that specific
expectations about spinal manipulation might have
had on disability

Borkan (1995)70 Anyone with  1 66 Primary care practices 40 (18 to 67) Increase understanding of LBP from patients’ Qualitative: Focus groups,
Israel episode of LBP (duration NS) 43M:23F perceptions and experiences interviews, participant observation

Bowman (1994)63 Chronic (duration NS) 15 Pain clinic Age NS Examine the reactions of individuals to chronic LBP Qualitative: Interview
US 9M:6F

Briggs (2012)67 Chronic (3 14 Pain self-management 57 (35 to 77) Explore barriers experienced by consumers in rural Qualitative: Semi structured
Australia months) education forums 5M:9F Western Australia to access information, services and telephone interview
implementing effective self-management behaviours
for CLBP

Research
Buus (2015)58 NS 25 Participants from intervention 47 (9) Explore LBP patients’ perceptions of long-term effects Qualitative: Semi-
Denmark arm of a trial who had 11M:14F of participating in a counselling intervention to change structured interviews
completed follow-up (n=110) work routine and to exercise

Campbell (2007)33 Chronic (1 year) 16 Hospital (patients from pain (34 to 78) Examine treatment expectations, whether they Qualitative: Interviews
UK management programme) Gender NS influence health service consumption in people
with chronic LBP

Coole (2010)34 Chronic (3 months 25 LBP pain rehabilitation 45 (22 to 58) Explore individual experiences and perceptions of Qualitative: Semi-
UK to 35 years) 12M:13F patients awaiting rehabilitation who were structured interview
concerned about their ability to work due to
persistent, or recurrent LBP

Corbett (2007)35 Chronic (duration NS) 37 General practitioner clinic (19 to 59) Illustrate the struggle between hope and despair Qualitative: Narrative
UK 15M:22F through the narrative of people with chronic LBP and interview

Darlow (2013)71 Acute (,6 weeks) 23 General public (18 to 67) Explore the formation and impact of attitudes and Qualitative: Semi-
New Zealand and chronic (.3 months) 9M:14F beliefs among people experiencing acute and structured interview
chronic LBP

Dima (2013)59 Chronic ( 6 weeks) 75 General practitioner or Median 62 (29 to 85) Explore patient preferences and beliefs about LBP Qualitative: Focus groups
UK complementary and 27M:48F treatments
alternative medicine clinics

Farin (2013)37 Chronic ( 6 months) 701 Rehabilitation centre 51 (11) Identify predictors of communication preferences in Quantitative: Questionnaire
Germany 300M:401F patients with chronic LBP

Farin (2012)36 Chronic (duration NS) 703 Rehabilitation centre 51 (11) Develop an instrument that measures the extent of Quantitative: Questionnaire
Germany 301M:402F matching between patient communication preferences
and physician communication behaviour

127
Table 1 (Continued)

128
Author (Year) Diagnosis of LBP Participants Aim stated in study publication Study methodology
Country
N Source Age (yr) a
Gender

Hoffmann (2013)68 Acute (,3 months) 11 Urban general practice 52 (22 to 72) Explore care expectations, influences on expectation Qualitative: Semi-
Australia 1M:10F and congruence with clinical guideline structured interview
recommendations in patients with acute LBP

Holloway (2007)38 Chronic (duration 2 to 22 years) 18 Pain clinic (28 to 62) Explore and conceptualise the experiences of people Qualitative: Interview
UK 12M:6F with chronic LBP in pain clinics

Kawi (2014)64 Chronic (.3 months) 110 Pain clinics 47 (19 to 86) Describe perceptions of chronic LBP patients on their Qualitative: Qualitative
US 45M:65F self-management, self-management support and content analysis on open-ended
functional ability survey questions.

Laerum (2006)39 Chronic (.3 months) 35 8 outpatient spine clinics 46 (23 to 65) Identify core elements of what patients perceive to Mixed: Observation and
Norway M18:F17 be good clinical communication and interaction with semi-structured interview
specialist in chronic LBP

Larsen (2013)40 Patients who are 8 Specialist centre (spine centre) (22 to 57) Illustrate how LBP is expressed and managed in Qualitative: Semi-
Denmark out of work due 3M:5F different contexts: at the clinic, at home and at work structured interviews
to LBP (duration NS)

Lim et al: Health information needs for low back pain

Layzell (2001)41 NS 120 Physiotherapy department Age NS Assess patient satisfaction with current LBP services, Mixed: Questionnaire
UK at Poole Hospital 50M:70F and increase understanding of LBP beliefs from and taped focus group
12 Volunteers from author’s Age NS patients’ perspective
workplace and community 6M:6F

Lee-Treweek (2001)42 Chronic (duration NS) 16 Osteopathic practice (17 to 72) Illustrate patients’ ideas about responsibility and Qualitative: Semi-
UK 8M:8F control over their symptoms structured interview

Liddle (2007)43 Chronic (.3 months) 18 Volunteer (18 to 65) Identify chronic LBP patients’ perceived most value Qualitative: Focus groups
UK 4M:14F components of treatment by exploring their
experiences, opinions and treatment expectations

MacKichan (2012)44 Chronic (duration NS) 23 GP practices (38 to 83) Describe patients’ experience and their views on Qualitative: Interview
UK 12M:11F self-care and provision of support for self-care for
long term LBP

May (2000)45 Chronic ( 1 year) 12 LBP rehabilitation clinic (20 to 55) Explore the ways chronic LBP patients respond to Qualitative: Semi-
UK 6M:6F the problem of medical doubt structured interview

McIntosh (2003)25 Anyone who has LBP 37 Patients from primary (25 to 64) Ascertain patients’ and clinicians’ experiences and Qualitative: Semi-structured
UK (duration NS) care practice Gender NS expectation of information in LBP to aid development interview and focus groups
of “patient-centred” information pack

Moffett (2000)46 NS 507 Community (20 to 60) Compare public and patient perceptions about LBP Qualitative: Interview
UK 253M:254F and its management with current clinical guidelines

Ong (2011)47 Sciatic pain, acute and 37 Selected patients from (19 to 59) Enhance the understanding of patients’ perspectives Qualitative: Interview
UK chronic (,1 month to .3 years) The Keele BeBack cohort study 15M:22F on living with sciatica to improve care and treatment
outcomes

Palazzo (2016)60 Chronic (mean duration 29 Tertiary care hospital 54 (24 to 85) Assess chronic LBP patients’ views concerning Qualitative: Semi-structured
France 4.9 years, SD 3.8) 12M:17F barriers to home-based exercise program adherence interviews
and expectations regarding new technologies

Scheermesser (2012)48 Chronic (.3 months) 13 Rehabilitation centre clinic (38 to 60) Understand the experience of patients with LBP and Qualitative: Semi-structured
Switzerland 9M:4F explore barriers to successful rehabilitation interviews and focus groups

Schers (2001)49 Acute and chronic LBP 20 General practices 43 (25 to 68) Explore factors that determine non-adherence to Qualitative: Semi-
Netherlands (,6 weeks to .12 weeks) 11M:9F the guidelines for LBP structured interview
Table 1 (Continued)

Author (Year) Diagnosis of LBP Participants Aim stated in study publication Study methodology
Country
N Source Age (yr) a
Gender

Shaw (2005)65 Acute (duration NS) 544 Community occupational health 36 (18 to 79) Evaluate the relationship between perceptions of Quantitative: Questionnaire and
US clinics 363M:181F provider communication and treatment satisfaction telephone follow up
for acute, work-related LBP

Skelton (1995)51 .1 recorded visit 52 General practices 41 (18 to 66) Compare patient and general practitioner perceptions Qualitative: Semi-structured
UK (duration NS) 26M:26F of patient education for LBP interviews

Skelton (1996)50 .1 recorded visit 52 General practices 41 (18 to 66) Elicit patients’ views on LBP and its management in Qualitative: Semi structured
UK (duration NS) 26M:26F general practice interviews

Tavafian (2008)69 Chronic (.90 days) 24 Rheumatology research centre at 43 (18 to 70) Explore Iranian women’s beliefs regarding the cause Qualitative: Focus groups
Iran Tehran university of medical sciences. 0M:24F of LBP

Toye (2009)52 Chronic (duration NS) 20 Hospital pain management programme (29 to 67) Explore how patients with persistent unexplained Qualitative: Interview
UK 7M:13F pain interpret and utilise the bio-psychosocial model

Toye (2012)54 Chronic (duration range 20 Hospital (pain management programme) (29 to 67) Explore the differences between patients with Qualitative: Interviews
UK 3 to 23 years) 7M:13F persistent LBP who benefited from a pain
management programme, and those who did not

Toye (2012)53 Chronic (duration NS) 20 Hospital (chronic pain management (29 to 67) Analyse patients’ experience of general practice in Qualitative: Semi-
UK programme) 7M:13F relation to their persistent non-specific LBP structured interviews

Turner (1998)66 Acute and chronic LBP 68 Primary care practices (18 to 75) Examine the content of primary care visit for LBP Mixed: Questionnaire,
US (1 month to . 1 year) 24M:44F interview

Walker (1999)55 Chronic (2 to 50 years) 20 Pain clinic (28 to 80) Explore the lived experience of chronic LBP Qualitative: Interview

Research
UK 12M:8F and narrative

Young (2011)56 Anyone with a history 31 Community volunteers with LBP (20s to mid 70s) Understand LBP recurrence and how to measure Qualitative: Focus groups
UK of LBP (duration NS) 17M:14F it by describing experiences of those with LBP

F = female, LBP = low back pain, M = male, NS = not stated.

a
Single number is mean unless specified. Number in parentheses is SD. Number range in parentheses is range.

129
130 Lim et al: Health information needs for low back pain

Table 2
Quality of the qualitative studies according to the Critical Appraisal Skills Programme criteria.30

Study Clear Qualitative Appropriate Appropriate Appropriate Researcher Ethical Rigorous Clear statement Research
statement methodology research recruitment data collection reflexivity consideration data analysis of findings value
of aim appropriate design strategy

Allegretti 201061 Y Y Y N N N Y Y Y Y
Ali 201557 Y Y Y Y Y Y Y Y Y Y
Borkan 199570 Y Y Y Y N N N Y Y Y
Bowman 199463 Y Y Y N N N N N Y Y
Briggs 201267 Y Y Y Y Y Y Y Y Y Y
Buus 201558 Y Y Y Y N Y Y N Y Y
Campbell 200733 Y Y Y N Y U Y N Y Y
Coole 201034 Y Y Y Y N N Y Y Y Y
Corbett 200735 N Y Y Y N Y N Y Y Y
Darlow 201371 Y Y Y Y Y Y Y N Y Y
Dima 201359 Y Y Y Y Y U Y Y Y Y
Hoffmann 201368 Y Y Y Y Y N Y Y Y Y
Holloway 200738 Y Y Y N N N Y N Y N
Kawi 201464 Y Y N N N U Y Y Y Y
Laerum 200639 Y Y Y Y N Y Y N Y Y
Larsen 201340 Y Y Y Y N Y Y Y Y Y
Layzell 200141 Y Y Y Y Y N N Y N N
Lee-Treweek 200142 N Y Y N N N N N N N
Liddle 200743 Y Y Y N N N Y Y Y N
MacKichan 201244 Y Y Y Y N N Y N Y Y
May 200045 Y Y Y N N N Y N Y Y
McIntosh 200325 Y Y Y Y N N Y Y Y Y
Moffett 200046 Y Y Y N N N N N Y Y
Ong 201147 Y Y Y Y N N N N Y Y
Palazzo 201660 Y Y Y Y Y N Y Y Y Y
Scheermesser 201248 Y Y Y N Y N Y N Y N
Schers 200149 Y Y Y Y N N Y Y Y Y
Skelton 199551 Y Y Y Y N N N N N N
Skelton 199650 Y Y Y Y N N N N N N
Tavafian 200869 Y Y Y N N N Y N Y N
Toye 200952 Y Y Y N N Y Y N Y N
Toye 201253 Y Y Y N N Y Y N Y N
Toye 201254 Y Y Y N N Y Y N Y N
Turner 199866 Y Y Y Y N N N N Y N
Walker 199955 Y Y Y Y N Y Y Y Y Y
Young 201156 Y Y Y N N Y Y N Y Y

N = no, U = unclear, Y = yes.

symptom control.43 Participants in only one study expressed the need lifestyle needs.37,43,57,59,64 Darlow and colleagues’ results illustrated
for information on complementary therapy.50 the importance of patient-specific advice, as patients were more
Non-pharmacological treatment was highly valued. Participants likely to reject advice if it conflicted with their lived experience, life
specifically wanted information about the role of physiotherapy, goals and beliefs.71 Some participants were frustrated with the pro-
osteopathy, postural advice and back muscle exer- vision of general principles and generic exercises instead of individ-
cises.24,25,39,40,42,48,49,53,57,58,60,71 They also wanted to know about ually tailored and specific exercise advice.51,57,59,60
which physical activities would be beneficial and which would not, in Information about pain management: Five studies described patient-
order to avoid flares of LBP.39,40,42,49,56,57,71 Some participants iden- perceived needs for pain management in LBP.34,43,49,64,66 Whilst
tified the need for information to help them psychologically deal with participants wanted general information about pain management,
LBP and improve their ability to cope.33,35,53,56 In the context of this included both pharmacologic and non-pharmacologic options.64
coping with LBP, maintaining independence was valued by many Participants wanted information about role, efficacy, safety, and side
participants.33–35,39,43,56,64,66 effects of pharmacological therapies.34,43,49
The need for tailored information about low back pain manage- Information about management of flares and preventive measur-
ment: Nine studies identified participants’ desires for personalised or es: Seven studies described patients’ perceived needs relating to the
tailored treatment for LBP.37,43,51,57,59,60,62,64,71 They believed that management of flares and prevention of LBP.33,41,43,51,56,65,71 Three of
management should be specific to their own circumstances, taking these found that participants wanted information about how to deal
into account their other health conditions,59,62 age,37,59 and specific with flares when they occurred.41,43,71 They valued information that

Table 3
Quality of the quantitative study according to the Hoy risk of bias tool criteria.31

Study Representative Appropriate Random Minimal Data collected Acceptable Valid and Consistent Appropriate Numerator and
study sampling selection non-response directly from case reliable mode of data data collection denominator
population frame or census bias participants definition measurements collection period appropriate

Amonkar 201124 N Y N N Y N N Y N N
Bishop 201162 N N N N Y Y N Y N N
Farin 201337 N N N N Y Y Y Y N N
Farin 201236 N N N N Y N Y Y N N
Layzell 200141 N N N N Y N N Y N N
Shaw 200565 N N N Y Y Y N Y Y Y

N = no, Y = yes.
 Research 131

Box 1. Selected examples of participant-perceived needs regarding health information content related to low back pain. For a more
extensive list, see Appendix 3 on the eAddenda.

General information content related to LBP

Ali17  Participants were keen to have information and explanation about their LBP.
Darlow71  I had just no frame of reference to figure out like what it was.with a back. I don’t know. I’m just completely in the
dark.
Diagnosis and cause/aetiology for LBP
Ali 57
 Biomechanical and ‘anatomical’ explanation of their back problems: he must explain the wrong movements and
positions.; I wanted to know what are the lumbar, coccygeal vertebrae made of and what is spondylosis.
Walker55  Need explanation of pain, cause of pain and why the pain developed: desperate to know what was causing the pain
Perceived needs for imaging
Dima59  Participants believed accurate diagnosis could only be achieved through detailed examination (assessment though
physical touch) and/or imaging (X-rays and MRI).
Hoffmann68  Need imaging tests to provide reassurance and confirmation of diagnosis: Xray was to establish whether.was just a
pulled muscle or whether it was a herniated disc.
Toye52  Need tests or imaging to confirm legitimacy of LBP: I kind of cried with relief when I saw what was wrong. but you
don’t want this unexplained pain.
Prognosis, including future disability and effect on work capacity
Coole 34
 Patients need information about their ability to work with LBP due to concern about their ability to retain work and to
reduce uncertainty about future working capacity.
Liddle43  It actually really really frightened me.You start to worry about paralysis or whatever.
Information regarding precipitation of flares
Coole34  Participants wanted to gain self-control of the unpredictable nature of LBP, especially with flare-ups: I’d lost confidence
in my back because it can go at any time.; They’re getting fed up at work you know, when flare-up happens.
Toye54  If you bent a certain way, and your disc slipped and you are incapacitated.
General information regarding LBP management
Ali17  Patients wanted to be responsible for their back care and had a desire for explanation and to learn their role in the
treatment process. They wanted advice and exercise prescription for LBP: It is my back, it’s my responsibility to
always look after it; .must explain the plan in steps within a timeframe and the benefits of every exercise.
Darlow 71
 Patients wanted to be reinforced on the importance of remaining active during acute episodes and be equipped with
information on correct postures, specific back muscle strengthening to help ‘protect the spine’. They valued
reassurance about safety of movement in setting of LBP.
Turner66  Need advice on how to return to normal activities.
Tailored information regarding LBP management
Ali57  I cannot pull my knees to my chest at work can I? I sit for 8 hours to take calls.
Bishop62  Need tailored advice regarding range of management options available for LBP, including non-interventional and
interventional therapies
Farin 37
 Important to consider personal circumstances in managing chronic LBP, especially for older patients.
Information regarding pain management
Coole34 Patients wanted to know the role of simple analgesia in LBP, in relation to the safety profile, side effects, effectiveness
and impact on work.
Information regarding management of flares and preventive measures
Layzell41  Need information on how to cope and deal with acute flare of LBP.
Young56  Patients desired strategies to prevent exacerbation of LBP, to reduce anxiety from the unpredictable nature of LBP.
Self-management strategies
Laerum39  Want to know what kind of activity he/she preferably could do and should avoid.
Walker55  Patients wanted to know about self-management, ie, what they could do about the pain and future treatment plan:
I’m crying out for somebody to take an interest in me for I’m a fighter and I want to improve my health.
Information regarding support services for LBP
Bowman63  Need information regarding social network/support groups available.
Briggs67  I don’t even know where to look.; Information is just not there; it’s not available.
Coole34  Patients wanted information from employer regarding absence management policy and procedures, eg, extent of time
off allowed for LBP as they were particularly worried about the effect of company bonus schemes on their decision to
take time off.

did not conflict with their previous lived experience, and wanted identified the need for information about work-specific support ser-
practical information that could be applied under difficult circum- vices, for example information from an employer about the absence
stances, such as at work.51,71 Five studies also identified the need for management policy.34
information about how they may prevent LBP.33,43,56,65,71
Self-management strategies: Six studies focused on patients’ Patients’ perceived needs relating to the mode of delivery of health in-
perceived needs about self-management strategies in LBP manage- formation related to low back pain
ment.25,39,44,55,67,69 Most participants wanted to learn specific exer- Eleven studies addressed patients’ perceived needs related
cises that they could perform to manage their LBP.39,44,67,69 Many to the mode of delivery of information relating to
participants were interested in knowing the limit of exercise in self- LBP.25,33,36,37,39,48,50,53,55,59,67 The needs related to the quality of in-
managed LBP.39,44 formation provided, the language and tone used, and the sources of
Information about support services for low back pain: Five studies information.
identified patients’ needs for information about support services for The need for high-quality information: Three studies described the
LBP.34,41,58,63,67 Some wanted information about availability of medi- need for high-quality health information about LBP.25,53,67 With
cal and allied health services, with one study focusing specifically on regards to the quality of information provided by various healthcare
barriers to access as perceived by rural patients.41,67 One study practitioners, participants valued valid, trustworthy and consistent
described the need for information about non-medical support from information.25,53 They disliked receiving conflicting and discordant
social networks and support groups.63 Participants in another study advice from different health professionals.25,53 In one study,
132 Lim et al: Health information needs for low back pain

participants were not satisfied with the quality of information ob- shown to have sustained impact on changing public LBP misconception
tained from general practitioners.67 of activity avoidance in LBP.81
The need for health information to be delivered in a suitable tone and In terms of other health information needs, patients wanted clear,
understandable language: Eight studies identified that patients wan- trustworthy, consistent information about the nature of LBP, its
ted health information to be delivered in a suitable tone and under- benign prognosis, and advice on both pharmacological and non-
standable language.25,36,37,39,48,50,55,56 Patients perceived a need for pharmacological management strategies. However, while informa-
information to be communicated in an open and clear way,36,37,39,48,55 tion about general strategies for managing LBP was wanted, there was
with emotional support,36,37,55,56 and using simple language without also a clear preference for the health practitioners’ advice to be
medical jargon39,48,55 and with acceptable tone.25 Patients also tailored to the individual’s age, lifestyle, and occupational sta-
preferred information to be delivered in their own language, without tus37,51,57,59,60,64,71 and be delivered in a suitable tone and under-
using medical jargon.48 standable language. In addition to the need for customised advice on
Source of information: Five studies described the need for information options, safety and efficacy of pain management in LBP, this review
on how to source information about LBP.25,33,39,59,67 Participants also revealed a consistent preference among patients to explore other
wanted information about where to obtain credible informa- non-pharmacological domains, including exercise, self-management
tion.39,59,67 They found that information not obtained from the and support services available for LBP. However, most LBP clinical
medical practitioner – but from physiotherapists, osteopaths, chiro- guidelines have generic recommendations, for example recommen-
practors, family, friends or magazines – may have provided unhelpful, dation to consider group exercise to minimise cost, with little
conflicting information.25,33 emphasis on how to approach ‘patient-tailored’ management21,82 and
how to appropriately integrate physical activity with the other factors
contributing to the LBP experience. This further illustrates the
Discussion mismatch between patients’ perceived needs and current recom-
mendations in LBP management.
This review identified 41 relevant studies that addressed aspects Approaches such as Cognitive Functional Therapy are likely to help
of patients’ perceived health information needs related to LBP. Within bridge this gap.83 Practising clinicians and physicians have been re-
these studies, two major areas of patient-identified needs emerged: ported to be inadequately trained and lack confidence in managing
health information content-related needs; and needs related to in- long-term musculoskeletal pain conditions and have expressed
formation delivery. Participants sought information about to the difficultly in adopting and implementing a biopsychosocial approach
cause of LBP, underlying pathology and prognosis, with a consistent to LBP management.84–87 This may contribute to patients receiving
desire for a legitimate diagnosis. Participants also wanted personal- inconsistent advice from different healthcare professionals, which
ised information about self-management strategies, including the often results in the provision of low-value care, leading to frustration,
available support services, related to both healthcare and occupa- which threatens the therapeutic practitioner-patient relationship.
tional issues. Educating practitioners to address patients’ underlying unhelpful
Underlying much of patients’ needs for health information about beliefs and attitudes around LBP may improve long-term LBP out-
LBP was the strong need to obtain a ‘definitive diagnosis’, which comes.88 Hence, new educational approaches to upskill clinicians in
underscored the perceived need for imaging for a diag- the provision of effective LBP education may be required to ensure
nosis.33,35,41,46,52–54,57,59,61,65,70,71 A definitive diagnosis was perceived that correct, consistent information is delivered. Innovative ap-
by many to justify, reassure and legitimise their LBP symptoms, and proaches such as interactive group learning or computer-assisted
many were frustrated with the generic ‘age-related wear and tear’ virtual learning, instead of the traditional guideline dissemination
explanations.33,34,40,43,45,52 However, this is contradictory to current and educational updates, have been used successfully.85,89 Further-
evidence-based LBP management that strongly advises against routine more, the use of non-threatening, suitable language could be
back imaging in the absence of red flags, with imaging considered to be emphasised in these new educational approaches to ensure better
low-value healthcare and a potential driver for unhelpful beliefs.2,12,72 success in delivering effective LBP education.90
This finding highlights the clear mismatch between patients’ perceived This review also underscored the impact of LBP on employment
health information needs and clinicians’ knowledge in LBP manage- and the work environment from patients’ perspectives. There is a
ment. In the United States, the ‘Choosing Wisely’ campaign was consistent strong desire for information about prognosis, manage-
launched in 2012, with the aim of raising awareness and educating ment and prevention of flares, with a personalised approach to back
patients and clinicians to avoid unnecessary medical tests and treat- safety at work, information about workers’ rights, uncertainties about
ments across various specialties.73 However, a trial examining the ef- future work capacity, leave entitlement and informing the workplace
fect of reminders for clinicians committing to not image patients with about their condition, to avoid being considered a malin-
uncomplicated low back pain following these guidelines failed to show gerer.34,35,57,65 In line with our findings, despite being a common
any sustained decrease in clinicians’ routine LBP imaging orders. This problem, LBP often elicits scepticism from workplace colleagues, with
was interpreted as indicating the significant role of patient factors (eg, the problem being viewed as psychogenic or malingering, which
needs and preferences) in explaining this mismatch.74 Despite patients’ further exacerbates patients’ distress, delaying participation in LBP
strong desire for imaging to reach an accurate diagnosis to relieve rehabilitation.91,92 Furthermore, other work-related factors, including
anxiety about diagnosis, when performed, imaging was not associated negative responses from supervisors, job demands and failure by
with any psychological benefits.52,68,75,76 Effective interventions to employers to provide suitable modification to work tasks, were also
correct patients’ unhelpful beliefs may require enabling clinicians to shown to contribute to unsuccessful return to work,91 suggesting that
communicate the role of imaging more effectively and provide reas- education interventions need to target not only patients, employers
surance and a meaningful management plan to patients. However, and clinicians, but also the entire societal attitudes and beliefs to-
limited time and financial pressures in clinical practice make this wards LBP. The Victorian WorkCover Authority mass media campaign
challenging.11,77 A variety of strategies, such as customised patient ‘Back Pain: Don’t Take It Lying Down’ successfully altered community
education videos and a consumer-focused pamphlet intervention via beliefs in LBP, resulting in a significant sustained reduction in the
community pharmacies, has been used to correct LBP-related beliefs number of workers’ compensation claims for LBP and healthcare
outside the clinical consultation, with promising results.78,79 However, utilisation.93 This campaign had been replicated by three other
these strategies were implemented on a small scale, where the effect countries, with reasonably positive results,93 making it a compelling
may differ when they are more widely implemented. Hence, to effec- evidence-based example for a similar societal approach to enhance
tively target the unhelpful belief about the need for imaging in LBP in LBP outcomes, incorporating all patients’ perceived important health
the community, a large-scale public mass media campaign is information content about LBP.
required.80 A large-scale mass media campaign in Canada targeting This review had several limitations. There were few publications
general public attitude to stay active, while experiencing LBP was that directly assessed the patients’ perceived needs for health
 Research 133

Box 2. Selected examples of participant-perceived needs relating to the mode of delivery of health information regarding low back pain.
For a more extensive list, see Appendix 4 on the eAddenda.

Need for high quality information

Briggs67  Patients wanted reliable information, eg, from specialists as they believed GP is not skilled in pain management and
‘not up to date’ with LBP management.
McIntosh25  Need for updated, evidence-based, valid and trustworthy information as alternative Information received from other
professionals, eg, physiotherapists, osteopaths, chiropractors, ‘was often conflicting’.
Toye53  Patients wanted consistent information, not to be confused by conflicting advices or discordant expert opinion:
We believe you have a trace of spondylolisthesis.and when I went to see the consultant, he said “no, your spine
is fine.; I was very upset.well who you believe? Do you believe an orthopaedic surgeon, or do you believe a
radiologist.; Is somebody else going to say that is something else entirely different later on?
Need for health information to be delivered in a suitable tone and understandable language
Farin37  Need open and clear communication with focus on personal circumstances to provide more emotional support for
patients with LBP.
Walker55  Clinicians need to show better communication and understanding towards patients and avoid using medical terminology
to ‘de-medicalise’ the whole medical consultation process: They treat you as if you don’t understand what they’re talking
about.I’d like to be spoken to on my own level.; They fail to recognise the reality of feelings of the sufferer.
Source of information
Dima59  Patients desired information from credible and trusted sources, personal or professionals: If it was recommended by
somebody I had confidence in...if it’s somebody who’s either had it done or it’s recommended by a GP.
Laerum39  Need to know where to get help.
McIntosh25  Alternative sources of information leading to conflicting advice: When no information obtained from GP, patients
access alternative sources of information from other healthcare professionals such as physiotherapists, osteopaths
and chiropractors, and other sources such as family and friends., which could be conflicting.

information about LBP, such that the identified needs for health in- unhelpful beliefs may better align patients’ expectations with those of
formation content have been extrapolated from heterogeneous healthcare providers.
studies evaluating different primary study aims in different pop-
ulations. Thus, it is possible that all areas of perceived health infor-
mation needs for LBP may not have been identified within this What was already known on this topic: A large range of
review. Most of the studies were performed in the UK where the diagnostic and therapeutic interventions are frequently applied in
National Health Service is the main healthcare provider. LBP out- low back pain management, despite evidence that many of them
comes are affected by compensation status, which differs in various are of low value. Although education is recommended in most
countries and may affect needs; thus, it is unclear whether these LBP guidelines, most guidelines do not specify what content
should be included in patient education.
findings are generalisable to those of different ethnicities and econ-
What this study adds: People with low back pain expressed a
omies. Most of the other studies were also performed in Western
strong desire for clear, consistent and personalised information
countries with developed healthcare systems. Only one was per- on diagnosis, prognosis, treatment options and self-management
formed in Iran,69 and there were none from other low-income or strategies, related to healthcare and occupational issues.
middle-income countries. The social and cultural aspects of infor-
mation needs are unlikely to have been captured outside the UK,
Europe or the United States. The Australian study by Briggs et al was eAddenda: Appendices 1-4 can be found online at https://doi.
centred on rural healthcare.67 Whether those with LBP were in org/10.1016/j.jphys.2019.05.010.
receipt of compensation or not was not addressed in most of the Ethics approval: Nil.
identified studies. This may have impacted on health information Competing interest: Nil.
needs. Source of support: This work was performed in partnership with
The strengths of this review relate to the performance of a Move: muscle, bone & joint health and supported by a partnership
comprehensive systematic scoping review in four complementary grant from the organisation. YZL is the recipient of National Health
databases to identify patients’ perspective of information needs and Medical Research Council (NHMRC) Clinical Postgraduate Schol-
related to LBP. The results were remarkably consistent across the arship (#1133903), Royal Australasian College of Physicians Woolcock
identified studies from high-income countries, spanning care Scholarship, Australian Rheumatology Association Top-Up Scholar-
from the community, primary care, hospital clinics, tertiary pain ship and Monash University Postgraduate Excellence Award. LC is the
clinics and rehabilitation centres, suggesting universality of the recipient of an Australian Postgraduate Award. AMB and AEW are
themes. recipients of NHMRC TRIP Fellowships (APP 1132548 and
This review highlighted that patients’ health information needs APP1150102). The funders had no role in study design, data collection
about LBP remained driven by their need for a diagnosis, in order to and analysis, decision to publish, or preparation of the manuscript.
validate and legitimise their symptoms. This may contribute to the Acknowledgements: Nil.
increasing use of inappropriate imaging for LBP. Additionally, other Provenance: Not invited. Peer reviewed.
work-related and employment concerns were identified, suggesting Correspondence: Anita E Wluka, Department of Epidemiology and
that there is ongoing scepticism associated with LBP, especially in the Preventative Medicine, Monash University, Melbourne, Australia.
workplace. Inability to access individualised and consistent advice Email: anita.wluka@monash.edu
from multiple trustworthy sources may contribute to a deterioration
in the patient’s relationship with their healthcare provider, further
stigmatising them. Thus, an integrated public health approach in References
addition to upskilling clinicians to improve their ability to provide
health information using simple, understandable language, incorpo- 1. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low
rating patients’ personal preferences and needs in LBP are urgently back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis.
2014;73:968–974.
required, to send consistent and accurate information to patients. In 2. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet.
order to improve clinical outcomes in LBP, addressing and correcting 2017;389:736–747.
134 Lim et al: Health information needs for low back pain

3. Foster N, Anema J, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and 34. Coole C, Drummond A, Watson PJ, Radford K. What concerns workers with low
treatment of low back pain: evidence, challenges, and promising directions. Lancet. back pain? Findings of a qualitative study of patients referred for rehabilitation.
2018;391:2368–2383. J Occup Rehabil. 2010;20:472–480.
4. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363–370. 35. Corbett M, Foster NE, Ong BN. Living with low back pain-stories of hope and
5. Australian Institute of Health and Welfare. Back problems snapshot. https://www. despair. Soc Sci Med. 2007;65:1584–1594.
aihw.gov.au/reports/chronic-musculoskeletal-conditions/back-problems/contents/ 36. Farin E, Gramm L, Schmidt E. Taking into account patients’ communication pref-
what-role-do-gps-play-in-treating-back-problems. Accessed 17 September, 2018. erences: instrument development and results in chronic back pain patients. Patient
6. Miller J, Barber D, Donnelly C, French S, Green M, Hill J, et al. Determining the Educ Couns. 2012;86:41–48.
impact of a new physiotherapist-led primary care model for back pain: protocol for 37. Farin E, Gramm L, Schmidt E. Predictors of communication preferences in patients
a pilot cluster randomized controlled trial. Trials. 2017;18:526. with chronic low back pain. Patient Prefer Adherence. 2013;7:1117–1127.
7. Ferreira ML, Machado G, Latimer J, Maher C, Ferreira PH, Smeets RJ. Factors 38. Holloway I, Sofaer-Bennett B, Walker J. The stigmatisation of people with chronic
defining care-seeking in low back pain – a meta-analysis of population based back pain. Disabil Rehabil. 2007;29:1456–1464.
surveys. Eur J Pain. 2010;14:747.e1–747.e7. 39. Laerum E, Indahl A, Skouen JS. What is “the good back-consultation”? A combined
8. St Sauver JL, Warner DO, Yawn BP, Jacobson DJ, McGree ME, Pankratz JJ, et al. Why qualitative and quantitative study of chronic low back pain patients’ interaction
patients visit their doctors: assessing the most prevalent conditions in a defined with and perceptions of consultations with specialists. J Rehabil Med.
American population. Mayo Clin Proc. 2013;88:56–67. 2006;38:255–262.
9. Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CW, Chenot JF, et al. Clinical 40. Larsen EL, Nielsen CV, Jensen C. Getting the pain right: how low back pain patients
practice guidelines for the management of non-specific low back pain in primary manage and express their pain experiences. Disabil Rehabil. 2013;35:819–827.
care: an updated overview. Eur Spine J. 2018;27:2791–2803. 41. Layzell M. Back pain management: a patient satisfaction study of services. Br J Nurs.
10. French SD, Green S, Buchbinder R, Barnes H. Interventions for improving the 2001;10:800.
appropriate use of imaging in people with musculoskeletal conditions. Cochrane 42. Lee-Treweek G. I’m not ill, it’s just this back: osteopathic treatment, responsibility
Database Syst Rev. 2010:CD006094. and back problems. Health. 2001;5:31–49.
11. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to primary care clinician 43. Liddle SD, Baxter GD, Gracey JH. Chronic low back pain: patients’ experiences,
adherence to clinical guidelines for the management of low back pain: a systematic opinions and expectations for clinical management. Disabil Rehabil. 2007;29:1899–
review and metasynthesis of qualitative studies. Clin J Pain. 2016;32:800–816. 1909.
12. Rosenberg A, Agiro A, Gottlieb M, Barron J, Brady P, Liu Y, et al. Early trends among 44. MacKichan F, Paterson C, Britten N. GP support for self-care: the views of people
seven recommendations from the choosing wisely campaign. JAMA Int Med. experiencing long-term back pain. Family Pract. 2013;30:212–218.
2015;175:1913–1920. 45. May CR, Rose MJ, Johnstone FCW. Dealing with doubt: how patients account for
13. Bishop FL, Dima AL, Ngui J, Little P, Moss-Morris R, Foster NE, et al. “Lovely Pie in non-specific chronic low back pain. J Psychosom Res. 2000;49:223–225.
the Sky Plans”: a qualitative study of clinicians’ perspectives on guidelines for 46. Moffett JAK, Newbronner E, Waddell G, Croucher K, Spear S. Public perceptions
managing low back pain in primary care in England. Spine. 2015;40:1842–1850. about low back pain and its management: a gap between expectations and reality?
14. Reed SJ, Pearson S. Choosing Wisely® recommendation analysis: prioritizing op- Health Expect. 2000;3:161–168.
portunities for reducing inappropriate care: imaging for nonspecific low back pain. 47. Ong BN, Konstantinou K, Corbett M, Hay E. Patients’ own accounts of sciatica: a
In: Institute for Clinical and Economic Review. 2015: https://collections.nlm.nih. qualitative study. Spine. 2011;36:1251–1256.
gov/catalog/nlm:nlmuid-101654291-pdf. Accessed 13 June, 2018. 48. Scheermesser M, Bachmann S, Schamann A, Oesch P, Kool J. A qualitative study on
15. Sen S, Fawson P, Cherrington G, Douglas K, Friedman N, Maljanian R, et al. Patient the role of cultural background in patients’ perspectives on rehabilitation. BMC
satisfaction measurement in the disease management industry. Dis Manag. Musculoskelet Disord. 2012;13:5.
2005;8:288–300. 49. Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers
16. Sundararajan V, Konrad TR, Garrett J, Carey T. Patterns and determinants of mul- for general practice guidelines on low back pain a qualitative study. Spine.
tiple provider use in patients with acute low back pain. J Gen Intern Med. 2001;26:E348–E353.
1998;13:528–533. 50. Skelton AM, Murphy EA, Murphy RJ, O’Dowd TC. Patients’ views of low back pain
17. Verbeek J, Sengers M, Riemens L, Haafkens J. Patient expectations of treatment for and its management in general practice. Br J Gen Pract. 1996;46:153–156.
back pain: a systematic review of qualitative and quantitative studies. Spine. 51. Skelton AM, Murphy EA, Murphy RJL, O’Dowd TC. Patient education for low back
2004;29:2309–2318. pain in general practice. Patient Educ Couns. 1995;25:329–334.
18. Dionne CE, Bourbonnais R, Frémont P, Rossignol M, Stock SR, Nouwen A, et al. 52. Toye F, Barker K. ‘Could I be imagining this?’-The dialectic struggles of people with
Determinants of “return to work in good health” among workers with back pain persistent unexplained back pain. Disabil Rehabil. 2010;32:1722–1732.
who consult in primary care settings: a 2-year prospective study. Eur Spine J. 53. Toye F, Barker K. Persistent non-specific low back pain and patients’ experi-
2007;16:641–655. ence of general practice: a qualitative study. Prim Health Care Res Dev.
19. Hazard RG, Spratt KF, McDonough CM, Olson CM, Ossen ES, Hartmann EM, et al. 2012;13:72–84.
Patient-centered evaluation of outcomes from rehabilitation for chronic disabling 54. Toye F, Barker K. ‘I can’t see any reason for stopping doing anything, but I might
spinal disorders: the impact of personal goal achievement on patient satisfaction. have to do it differently’ - restoring hope to patients with persistent non-specific
Spine J. 2012;12:1132–1137. low back pain - a qualitative study. Disabil Rehabil. 2012;34:894–903.
20. Montori VM, Brito J, Murad M. The optimal practice of evidence-based medicine: 55. Walker J, Holloway I, Sofaer B. In the system: the lived experience of chronic back
incorporating patient preferences in practice guidelines. JAMA. 2013;310:2503–2504. pain from the perspectives of those seeking help from pain clinics. Pain.
21. Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of 1999;80:621–628.
NICE guidance. BMJ. 2017;356. 56. Young AE, Wasiak R, Phillips L, Gross DP. Workers’ perspectives on low back pain
22. Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated recurrence: “It comes and goes and comes and goes, but it’s always there”. Pain.
overview of clinical guidelines for the management of non-specific low back pain 2010;152:204–211.
in primary care. Eur Spine J. 2010;19:2075–2094. 57. Ali N, May S. A qualitative study into Egyptian patients’ satisfaction with physio-
23. Qaseem A, Wilt TJ, McLean RM, Forciea M, for the Clinical Guidelines Committee of therapy management of low back pain. Physiother Res Int. 2017;22:2.
the American College of Physicians. Noninvasive treatments for acute, subacute, 58. Buus N, Jensen LD, Maribo T, Gonge BK, Angel S. Low back pain patients’ beliefs
and chronic low back pain: a clinical practice guideline from the American College about effective/ineffective constituents of a counseling intervention: a follow-up
of Physicians. Ann Intern Med. 2017;166:514–530. interview study. Disabil Rehabil. 2015;37:936–941.
24. Amonkar SJ, Dunbar AM. Do patients and general practitioners have different 59. Dima A, Lewith GT, Little P, Moss-Morris R, Foster NE, Bishop FL. Identifying pa-
perceptions about the management of simple mechanical back pain? Int Muscu- tients’ beliefs about treatments for chronic low back pain in primary care: a focus
loskelet Med. 2011;33:3–7. group study. Br J Gen Pract. 2013;63:490–498.
25. McIntosh A, Shaw CF. Barriers to patient information provision in primary care: 60. Palazzo C, Klinger E, Dorner V, Kadri A, Thierry O, Boumenir Y, et al. Barriers to
patients’ and general practitioners’ experiences and expectations of information home-based exercise program adherence with chronic low back pain: patient
for low back pain. Health Expect. 2003;6:19–29. expectations regarding new technologies. Ann Phys Rehabil Med. 2016;59:107–113.
26. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Acute low back pain 61. Allegretti A, Borkan J, Reis S, Griffiths F. Paired interviews of shared experiences
management in general practice: uncertainty and conflicting certainties. Fam Pract. around chronic low back pain: classic mismatch between patients and their doc-
2014;31:723–732. tors. Fam Pract. 2010;27:676–683.
27. Wluka A, Chou L, Briggs A, Cicuttini F. Understanding the needs of consumers with 62. Bishop MD, Bialosky JE, Cleland JA. Patient expectations of benefit from common
musculoskeletal conditions: Consumers’ perceived needs of health information, health interventions for low back pain and effects on outcome: secondary analysis of a
services and other non-medical services: A systematic scoping review. Melbourne: clinical trial of manual therapy interventions. J Man Manip Ther. 2011;19:20–25.
MOVE muscle, bone & joint health; 2016. 63. Bowman JM. Reactions to chronic low back pain. Issues Ment Health Nurs.
28. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J 1994;15:445.
Soc Res Methodol. 2005;8:19–32. 64. Kawi J. Chronic low back pain patients’ perceptions on self-management, self-
29. Walsh D, Downe S. Meta-synthesis method for qualitative research: a literature management support, and functional ability. Pain Manag Nurs. 2014;15:258–264.
review. J Adv Nurs. 2005;50:204–211. 65. Shaw WS, Zaia A, Pransky G, Winters T, Patterson WB. Perceptions of provider
30. CASP. CASP Checklists. https://casp-uk.net/casp-tools-checklists/. Accessed 18 June, communication and patient satisfaction for treatment of acute low back pain.
2018. J Occup Environ Med. 2005;47:1036–1043.
31. Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, et al. Assessing risk of bias in 66. Turner JA, LeResche L, Von Korff M, Ehrlich K. Back pain in primary care: patient
prevalence studies: modification of an existing tool and evidence of interrater characteristics, content of initial visit, and short-term outcomes. Spine.
agreement. J Clin Epidemiol. 2012;65:934–939. 1998;23:463–469.
32. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. Prisma 67. Briggs AM, Slater H, Bunzli S, Jordan JE, Davies SJ, Smith AJ, et al. Consumers’ ex-
extension for scoping reviews (PRISMA-SCR): checklist and explanation. Ann Intern periences of back pain in rural Western Australia: access to information and ser-
Med. 2018;169:467–473. vices, and self-management behaviours. BMC Health Serv Res. 2012;12:357.
33. Campbell C, Guy A. ‘Why can’t they do anything for a simple back problem?’: a 68. Hoffmann TC, Del Mar CB, Strong J, Mai J. Patients’ expectations of acute low
qualitative examination of expectations for low back pain treatment and outcome. back pain management: implications for evidence uptake. BMC Fam Pract.
J Health Psychol. 2007;12:641–652. 2013;14:7.
 Research 135

69. Tavafian SS, Gregory D, Montazeri A. The experience of low back pain in Iranian 82. Almeida M, Saragiotto B, Richards B, Maher CG. Primary care management of non-
women: a focus group study. Health Care Women Int. 2008;29:339–348. specific low back pain: key messages from recent clinical guidelines. Med J Aust.
70. Borkan J, Reis S, Hermoni D, Biderman A. Talking about the pain: a patient- 2018;208:272.
centered study of low back pain in primary care. Soc Sci Med. 1995;40:977– 83. O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, et al.
988. Cognitive functional therapy: an integrated behavioral approach for the targeted
71. Darlow B, Dowell A, Baxter G, Mathieson F, Perry M, Dean S. The enduring impact management of disabling low back pain. Phys Ther. 2018;98:408–423.
of what clinicians say to people with low back pain. Ann Fam Med. 2013;11:527– 84. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R. Determinants
534. of physician confidence in the primary care management of musculoskeletal dis-
72. O’Connell NE, Cook CE, Wand BM, Ward SP. Clinical guidelines for low back pain: a orders. J Rheumatol. 1996;23:351–356.
critical review of consensus and inconsistencies across three major guidelines. Best 85. O’Dunn-Orto A, Hartling L, Campbell S, Oswald AE. Teaching musculoskeletal
Pract Res Clin Rheumatol. 2016;30:968–980. clinical skills to medical trainees and physicians: a best evidence in medical edu-
73. American Board of Internal Medicine (ABIM). Choosing wisely; 2018. http://www. cation systematic review of strategies and their effectiveness: BEME Guide No. 18.
choosingwisely.org/. Accessed 20 October, 2018. Med Teach. 2012;34:93–102.
74. Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Acharya Y, et al. Pre- 86. Wiitavaara B, Fahlström M, Djupsjöbacka M. Prevalence, diagnostics and man-
committing to choose wisely about low-value services: a stepped wedge cluster agement of musculoskeletal disorders in primary health care in Sweden – an
randomised trial. BMJ Qual Saf. 2018;27:355–364. investigation of 2000 randomly selected patient records. J Eval Clin Pract.
75. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic 2017;23:325–332.
review and meta-analysis. Lancet. 2009;373:463–472. 87. Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O’Sullivan P, O’Sullivan K. Physio-
76. Chou R, Qaseem A, Owens DK, Shekelle P, for the Clinical Guidelines Committee of therapists may stigmatise or feel unprepared to treat people with low back pain
the American College of Physicians. Diagnostic imaging for low back pain: advice and psychosocial factors that influence recovery: a systematic review. J Physiother.
for high-value health care from the American College of Physicians. Ann Intern Med. 2015;61:68–76.
2011;154:181–189. 88. Traeger A, Hubscher M, Henschke N, Moseley G, Lee H, McAuley J. Effect of primary
77. Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non- care-based education on reassurance in patients with acute low back pain sys-
traumatic musculoskeletal pain? Br J Sports Med. 2018:1543–1544. tematic review and meta-analysis. JAMA Intern Med. 2015;175:733–743.
78. Ganguli I, Sikora C, Nestor B, Sisodia RC, Licurse A, Ferris TG, et al. A scalable 89. Tzortziou Brown V, Underwood M, Mohamed N, Westwood O, Morrissey D. Pro-
program for customized patient education videos. Jt Comm J Qual Patient Saf. fessional interventions for general practitioners on the management of musculo-
2017;43:606–610. skeletal conditions. Cochrane Database Syst Rev. 2016:CD007495.
79. Slater H, Briggs AM, Watkins K, Chua J, Smith AJ. Translating evidence for low back 90. Stewart M, Loftus S. Sticks and stones: the impact of language in musculoskeletal
pain management into a consumer-focussed resource for use in community rehabilitation. J Orthop Sports Phys Ther. 2018;48:519–522.
pharmacies: a cluster-randomised controlled trial. PLoS One. 2013;8:e71918. 91. Davis M-C, Ibrahim JE, Ranson D, Ozanne-Smith J, Routley V. Work-related
80. O’Keeffe M, Maher CG, Stanton TR, O’Connell NE, Deshpande S, Gross DP, et al. Mass musculoskeletal injury and suicide: opportunities for intervention and therapeutic
media campaigns are needed to counter misconceptions about back pain and jurisprudence. J Law Med. 2013;21:110–121.
promote higher value care. Br J Sport Med. 2018. 92. Lippel K. Therapeutic and anti-therapeutic consequences of workers’ compensa-
81. Suman A, Bostick GP, Schopflocher D, Russell AS, Ferrari R, Battié MC, et al. Long- tion. Int J Law Psychiatry. 1999;22:521–546.
term evaluation of a Canadian back pain mass media campaign. Eur Spine J. 93. Buchbinder R. Self-management education en masse: effectiveness of the Back Pain:
2017;26:2467–2474. Don’t Take It Lying Down mass media campaign. Med J Aust. 2008;189:S29–S32.