Received: 9 January 2019 | Revised: 27 March 2019 | Accepted: 29 March 2019

DOI: 10.1002/nop2.290

RESEARCH ARTICLE

Struggling to be seen and understood as a person – Chronic

back pain patients’ experiences of encounters in health care:
An interview study

Renée Allvin1,2 | Erika Fjordkvist3 | Karin Blomberg2

1
Clinical Skills Center, Örebro University
Hospital, Örebro, Sweden Abstract
2
Faculty of Medicine and Health, School of Aim: The aim of this study was to describe how patients with chronic back pain expe‐
Health Sciences, Örebro University, Örebro,
rience encounters with health care. Persons with chronic back pain are a stigmatized
Sweden
3
Departments of Orthopedics, Örebro
group often treated based on stereotypes, which may lead to misunderstandings and
University Hospital, Örebro, Sweden create frustrated patients and healthcare personnel. Few studies have examined the

Correspondence
generic aspects of quality of care in this context.
Renée Allvin, Faculty of Medicine and Design: A descriptive design with a qualitative approach was used.
Health, Örebro University Hospital, School
of Health Sciences, Örebro University, S‐702
Methods: Nine individual interviews were conducted with chronic back pain patients
81 Örebro, Sweden. after admission to an orthopaedic hospital ward. Data were analysed using content
Email: rene.allvin@regionorebrolan.se
analysis.
Results: The patients’ experiences of healthcare encounters can be described by the
theme “Struggling to be seen and understood as a person,” comprising the categories
“Lack of access and trust to care,” “A desire to be taken care of and listened to” and
“Own strength to handle healthcare situations.”

KEYWORDS
chronic back pain, experiences, patient–provider relationship, person‐centred care

1 | I NTRO D U C TI O N small (Tymecka‐Woszczerowicz, Wrona, Kowalski, & Hermanowski,

2015).
Chronic back pain (CBP) is a major health problem and a leading
cause of disability in industrialized countries. Worldwide the prev‐
alence ranges between 4.2%–25.4% and in Sweden 16.4% (Meucci, 2 | BAC KG RO U N D
Fassa, & Faria, 2015). CBP is defined as “persistent or recurrent pain
that arises as a part of a disease process directly affecting musculo‐ Persons with CBP have been described as a stigmatized group often
skeletal issues” lasting over three months (Treede et al., 2015). No treated based on a stereotypical image in both society and health
single treatment is generally effective, so patients and healthcare care (Slade, Molloy, & Keating, 2009). They experience both subtle
personnel must identify the optimum treatment for each individual. and overt stigmatization, especially when no specific pathology vali‐
Aside from personal suffering, back pain can also be regarded as dates their pain experience. A need for legitimation when there are
a social burden; approximately 50% of people suffering from CBP no external signs of disease is often described (Hopayian & Notley,
still cannot work six months after pain onset, and the chance of re‐ 2014). The absence of physiological explanations may lead to the
turning to work after being on sick leave more than two months is underassessment of patients’ pain intensity by both healthcare

This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in
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© 2019 The Authors. Nursing Open published by John Wiley & Sons Ltd.

Nursing Open. 2019;1–8. 

wileyonlinelibrary.com/journal/nop2 | 1
2 | ALLVIN et al.

personnel and laypersons (De Ruddere et al., 2014). Healthcare according to the inclusion criteria to participate in the study the day
personnel have described emotional frustration in dealing with pa‐ after admission to the ward. The inclusion criteria were having back
tients without physiological explanations of their pain (Matthias et pain for a period of three months or more and previous contact with
al., 2010). It has been found that healthcare personnel take the pain health care due to back pain. Patients undergoing back surgery or
of patients they have a poor relationship with less seriously than the nerve blocks at the time of study or suffering from dementia or other
pain of patients they like (De Ruddere et al., 2011). cognitive impairments were excluded. The first ten patients were
Persons with CBP sometimes feel obliged to adapt their be‐ invited by one of the authors (EF) to participate in the study. One
haviour to others’ expectations, resulting in withdrawal from social person was excluded after the request due to newly diagnosed acute
contacts (Osborn & Smith, 2015) and sometimes in reluctance to cognitive failure. In total, nine persons, five women and four men
seek care for their pain (Matthias et al., 2010). 39–74 years old (median, 66 years) participated in the interviews.
Considerable medical research activity has targeted CBP. They had been suffering from back pain for between 1–57 years
Previous qualitative research in the area has investigated expecta‐ (median, 23 years). Everyone was of Nordic origin and lived with a
tions and beliefs underlying diagnostic tests and treatment (Dima et partner; one had children living at home. Four persons worked, one
al., 2013; Georgy, Carr, & Breen, 2009; Verbeek, Sengers, Riemens, had retired early, one was unemployed (due to back pain), and three
& Haafkens, 2004), lived experiences (Hopayian & Notley, 2014; were retirement pensioners.
Osborn & Smith, 2006; Walker, Sofaer, & Holloway, 2006) and ac‐
cess to treatment services (Slade et al., 2009). Other studies have
3.2 | Data collection
focused on developing instruments to measure back pain‐specific
expectations regarding consultant outcome (Georgy, Carr, & Breen, Individual semi‐structured interviews (Kvale & Brinkmann, 2009)
2013). Few studies have examined the generic aspects of adequate were conducted between April to May–September to November
care (for example a person‐centred care and appropriate treatment) 2014 by one of the authors (EF) using an interview guide designed
in this context. The relationship between healthcare personnel according to the aim of the study (Appendix). The interviews started
and patients is essential. Persons with CBP might experience dif‐ with an open‐ended question: “Please, tell me about your back pain.”
ficulties in encounters with health care due to stigma. Improved If patients did not know what to say, they were asked to start from
knowledge and understanding of patient experiences may lead to the time their pain began. Afterwards more specific questions were
changed healthcare personnel behaviour, which in turn could gener‐ asked, such as “How have you experienced yourself being treated
ate changed patient responses, contributing to better and safer care. by healthcare personnel in relation to your back pain?”; “Can you
The aim of this study was therefore to describe how patients with tell me how you handle your pain?”; and “How do you behave so
CBP experience encounters with health care. that healthcare personnel understand your pain?” To reach a deeper
understanding, probing questions were asked, such as “Could you
describe that in more detail?”
3 | M E TH O DS A pilot interview was conducted to improve the interview guide.
This resulted in an emphasis on creating a relaxed atmosphere, so
The study has a qualitative descriptive design (Polit & Beck, 2016) the interviews started with the more general invitation to talk about
where individual interviews were conducted with CBP patients. experiences of back pain, before proceeding to more sensitive is‐
sues, such as experiences of treatment by healthcare personnel. The
pilot interview was not included in the data analysis. Demographic
3.1 | Participants and setting
data were verbally collected at the beginning of each interview. The
Participants who were included in the study were persons who interviews were conducted at a time during the daytime that suited
experience CBP and contact the health care to get help with their the patients, in a room in an orthopaedic hospital ward, free of dis‐
pain. They are admitted to the hospital by a referral from primary turbances. The patients chose whether they preferred to sit on a
care doctors or through the emergency department. In Sweden, the chair or lie on a bed brought into the room, depending on their back
health care is managed and run either by the county council, local pain. All the interviews were audio‐recorded and lasted 35–95 min.
authority or municipality. This study was carried out at an ortho‐ At the end of each interview, the interviewer summarized the con‐
paedic department at a University hospital in the middle of Sweden. tent of the interview to ensure that all were understood and if the
The department included two inpatient wards divided into different participant would add or revise something. All interviews were tran‐
sections of which one cared for patients with back disorders. Other scribed verbatim by one of the authors (EF).
sections cared for patients after a variety of surgical procedures, for
example hip replacement and knee replacement, trauma and recon‐
3.3 | Data analysis
structive surgery and ligament reconstructions. Registered nurses
on the ward were responsible for the overall care of patients. Demographic data were managed using Excel. The interview data
Patients who sought acute hospital care for CBP were identi‐ were analysed using qualitative content analysis (Graneheim &
fied on the departments’ inpatient lists and consecutively invited Lundman, 2004). As a first step, the transcribed interviews were read
ALLVIN et al. | 3

several times in their entirety to gain an overview of the content and

4.1 | Struggling to be seen and understood as
to identify meaning units corresponding to the aim of the study. The
a person
meaning units were then condensed to produce more manageable
material without losing the essence of the text. From the condensed The patients with CBP felt vulnerable in their encounters with health
units, codes were extracted, consisting of words, phrases or short care. They experienced powerlessness, often expressed as frustra‐
sentences. For example, codes might capture specific experiences tion. Although they tried to explain how they felt and what they
of encounters with healthcare personnel when seeking care for needed, they sensed an obligation to adapt to the demands and pre‐
CBP that patients described in the interviews. During the analysis, conditions of care. Ambivalent feelings arose when they felt cared
we attempted to create codes that were close to the original text, for individual persons, simultaneously with feeling not understood.
although more concise as well as abstracted to a higher conceptual They felt disappointed and not taken seriously, so inner strength was
level. Special attention was paid to the context of the meaning units. seen as essential to be able to handle everyday healthcare situations.
The codes were sorted into subcategories based on similarities and The patients expressed a desire for support and confirmation when
differences in the patients’ experiences. From the subcategories, meeting with health care, but often experienced the reverse, which
three categories were abstracted describing patients’ experiences of reinforced the feeling of vulnerability. Although they did experience
encounters with healthcare personnel. Finally, the underlying mean‐ positive responses from healthcare personnel, the feeling of not
ing was formulated into a theme (i.e., the latent content). During the being able to influence their own situation remained.
analysis process, the coding and categorization were reflected and
discussed by the researchers to increase trustworthiness. All nine
4.2 | Lack of access and trust to care
interviews yielded rich and deep descriptions of the patients’ experi‐
ences, which we considered as data saturation. During the process The patients described having insufficient access to health care
of analysis, the researcher's pre‐understandings and aspects that when they needed consultations for back pain. They were often re‐
might have influenced the interpretation of data were considered by fused visits to primary care centres or refused hospitalization. They
dialogues between the researchers. could be denied medical examinations as healthcare personnel con‐
sidered they would not lead to any new results. The experience of
being disbelieved was not based only on verbal communication, but
3.4 | Ethical approval
could also be seen in the expressions and body language of health‐
The study was ethically approved by the Regional Ethics Board in care personnel. The patients experienced a feeling of being de‐
Uppsala (reg. no. 2014/064). The participants were informed, ver‐ pendent of others without getting any help from health care. Their
bally and in writing, that their participation was voluntary and that problems were sometimes downplayed or ignored, or even joked
they had the right to withdraw from the study at any time without about, which is why they felt discredited:
giving any reason. Written informed consent was obtained before
the interviews. It didn’t feel good. I think he [i.e., the doctor] was jok‐
ing, but I got angry since I had been in pain for so long.
It was not proper treatment.  [John, male 39 years]
4 | R E S U LT S
Some patients described being taken more seriously as they
The results indicate that the participants struggled to be seen and got older. Coming down with a serious illness in addition to the
understood as persons. This theme was based on three categories back pain also made healthcare personnel more receptive. Mainly,
identified in the data (Table 1). Quotations are used in the following the female patients reflected about their appearance in relation
text to illustrate the findings (the names in brackets are pseudonyms to visiting healthcare facilities and they felt their problems were
to ensure participant anonymity) and ensure trustworthiness. taken less seriously if they dressed nicely or used makeup. Usually,

TA B L E 1 Subcategories, categories
Subcategories Categories Theme
and an overall theme
Being disbelieved Lack of access and trust Struggling to be seen
Lacking confidence in health care to care and understood as a
person
Being isolated in a system
Wanting to be cared for A desire to be taken care
Being listened to of and listened to

Not being understood

Adapting to conditions of health care Own strength to handle
Finding inner strength healthcare situations
4 | ALLVIN et al.

patients trusted the doctor's knowledge. Sometimes, however, doctors all the time. The lack of continuity and a holistic perspective
they experienced that the doctor from the outset already had the was particularly prominent among patients with complex medical his‐
attitude that nothing more could be done for them, which engen‐ tories. Even the healthcare system itself, which is governed by laws and
dered a sense of powerlessness: regulations, could create a sense of loneliness:

The feeling I get is that “back problems” are very com‐ But I feel they don’t care because it’s beyond their
plicated … and I mean, the physiotherapist … and the reach. They must follow the standards of social
doctors … it feels like they do not want to pay any welfare and not act on their own resolve and will.
attention.  [Leif, male 60 years]  [Fredrik, male 55 years]

Negative experiences of healthcare encounters caused a lack of The feeling of being isolated in a system also occurred when the
trust. Several patients stated that medical treatment and care were patients perceived that healthcare personnel did not want them to stay
often performed based on the premises of the healthcare personnel. in the ward. They often felt as if they were in the way, in the wrong
For example, one patient described being forced to stay in extremely place.
painful positions during X‐rays, even though she was screaming and
crying. They believed that healthcare personnel were probably follow‐
4.3 | A desire to be taken care of and listened to
ing guidelines and routines instead of listening to the patients’ wishes.
However, healthcare personnel could change if proved wrong: The patients expressed a desire to be cared for in their encounters
with healthcare. They appreciated when healthcare personnel took
I cannot forgive them – there must be other ways. time, even though they were under pressure and when they of‐
They got no [x‐ray] images using their way of doing fered care without being asked. Healthcare personnel were often
it. When they realized it, they changed and said that described as friendly and kind, which were considered essential
I would be x‐rayed in a standing position – THEN it qualities. The patients also highlighted the importance of humour
worked!  [Anne‐Catrine, female 69 years] and despite being in a serious situation, they needed that type of
response.
Realising that healthcare personnel did not understand their prob‐ It was considered important to know that pain medication and
lems resulted in frustration and resignation: even hospitalization were options if needed and that healthcare per‐
sonnel would evaluate the effects of administered treatments:
I feel resigned because I know I cannot do anything
about it. I can only accept that they do not do any‐ I know that I never will be completely pain free, I’ve
thing. I cannot change that.  [Fredrik, male 55 years] never been. He [i.e., the doctor] sort of helped me …
titrated the dose needed, didn’t just give “30 mor‐
The patients also described huge differences between different phine”, for example, but took one step at a time and
healthcare providers, which resulted in a lack of confidence: finally found the right level.  [Ulrika, female 42 years]

When I’ve been taken care of at other hospital wards, A feeling of being listened to arose when healthcare per‐
they’ve given me hot rice bags and hot water gloves. sonnel clearly demonstrated that they understood the patient's
If I’ve been crying, they’ve stayed by my side. Sort of problems:
taking me away from the pain and giving me positive
thoughts. In this hospital ward, no one has done that. They show empathy, they care, particularly the nurses.
It might differ a lot from ward to ward, one almost Of course, they work in this profession because they
gets scared.  [Ulrika, female 42 years] care about people. As do the doctors, when you are
really in pain…  [Fredrik, male 55 years]
The patients often experienced being shuttled between healthcare
providers, with no one being able or willing to answer for the whole This feeling could also be achieved when personnel apologized
picture. Each specialist saw only a minor part of a complex problem: for bad behaviour and explained that it was due to heavy workload
or stress. The value of being confirmed in their right to seek care was
Our specialists are skilled, but sometimes they are emphasized:
blinkered regarding the whole. [Ulla, female 74 years]
She [i.e., the doctor] never thought I was one of those
Coordination and cooperation between different specialties re‐ who want to consult the doctor all the time, if they
duced the sense of hopelessness. However, the patients could even even exist … I have a hard time believing it. 
feel abandoned within a single specialty if they had to meet different  [Britta, female 70 years]
ALLVIN et al. | 5

The patients also felt cared for when they perceived different patients said that they knew their body and how it functioned and
healthcare providers and organizations coming together to provide that they had their own purpose for the future, which gave them
them with care based on a holistic perspective and they were seen as inner strength. Some of the patients experienced frustration when
individual persons instead of simply diagnoses. In contrary, a sense of healthcare personnel did not understand or listen, but through their
not being accurately cared for triggered negative feelings. The patients inner strength they had the power to be stubborn and go on explain‐
often felt that nobody took the time to answer questions. Although ing until they perceived that the personnel understood. Several pa‐
they often understood the underlying reasons for it, the patients still tients also had a strong self‐image, which gave them the strength to
did not like unpleasant treatment. They had experienced doctors who question therapy proposals that they did not feel comfortable with.
did not fully agree on their diagnoses, problems and requests for treat‐ Sometimes this strength could be an obstacle, as they did not want
ment. One patient explained that she had been prescribed psychotro‐ to show weakness and therefore made greater efforts than they
pic drugs, even though she herself thought her sadness was due to her could handle:
back pain:
I don’t want people to feel sorry for me and that
I’d probably said something silly, when I didn’t get a makes it difficult for me. If someone says, “Sit down
response … Then I asked the doctor if the next step and relax because you’re in pain”, then I instead do
was to die. That was when she prescribed antidepres‐ more to show that I’m not disabled. 
sants.  [Ulla, female 74 years]  [John, male 39 years]

When the patients experienced nobody listening to what they con‐

sidered a problem, they got the impression that no one really cared.
The patients said that healthcare personnel sometimes did not 5 | D I S CU S S I O N
seem to understand their situation. For example, it was a negative
experience when personnel asked a lot of questions, even though This study describes CBP patients’ experiences of everyday health‐
the patient was in severe pain: care encounters. The findings reveal that these patients’ struggle to
be seen and understood as the unique persons they are. They want
It felt too bad that the doctor did not understand to be acknowledged as individuals with goals and responsibilities be‐
that I was in pain – he should understand. He could yond their pain. Instead, they subject themselves to the healthcare
have returned when the pain was less intense, but he personnel's decisions and assessments regarding their condition and
kept asking me questions … Those times you get frus‐ do not always experience understanding of their unique situation.
trated.  [John, male 39 years] This is in contrast to the framework of person‐centred care, which
requires knowledge of the person's own view of his or her health
Patients also felt misunderstood when they felt blamed for their and resources (Morgan & Yoder, 2012). Increased awareness of what
own problems. One patient had experienced back pain her whole life, CBP patients confront could result in an understanding of situations
even when she was younger and weighed less. She perceived that the they experience as problematic, thereby preventing the reinforce‐
healthcare personnel linked her back problems to her weight, suggest‐ ment of stereotypical images. Previous research has shown that
ing that they understood neither her nor her entire life situation. The legitimizing the pain experience through person‐centred care can
patients wanted explanations of why they were suffering from back encourage people with CBP to regain control of their life situation
pain. They wanted themselves and the healthcare personnel to aim for (Howarth, Warne, & Haigh, 2014). Showing confidence in the patient
the same goal. They wanted personnel to listen and to give honest an‐ and his or her pain experience is crucial for building a trusting part‐
swers and information: nership. It has been claimed that persons with different chronic pain
conditions (Howarth et al., 2014; Upshur, Bacigalupe, & Luckmann,
I can understand the doctors when they do not know 2010) and long‐term illness (Fox & Chesla, 2008; Jangland, Larsson,
what to do. But often they could be more forthcom‐ & Gunningberg, 2011) wish to interact and reach consensus with
ing, or explain why. They have difficulty saying “I do healthcare personnel to achieve comfort. In line with this reason‐
not know” … I would feel better if they explained ing, the participants in the present study expressed frustration when
more.  [Britta, female 70 years] they lacked dialogue with nurses and doctors. They sometimes felt
that guidelines and routines based on laws and regulations were re‐
garded as more important than them as individuals. This frustration
might be reduced by a different approach to dealing with CBP pa‐
4.4 | Own strength to handle healthcare situations
tients. Honest and open dialogue taking both patients’ hopes and
The patients described extended previous experience with multiple medical/healthcare limitations into account, with a clearer focus on
healthcare contacts. They had learned to observe the work situation the patient experience (e.g., through a more comprehensive nursing
of healthcare personnel and chose to accept and adapt to it. Several investigation), may be part of an effort to minimize this frustration.
6 | ALLVIN et al.

The overall healthcare system is facing major challenges when research has described how healthcare personnel sometimes expe‐
it comes to creating organizations that promote a person‐centred rience frustration and a sense of guilt in meeting patients with CBP
approach to dealing with CBP patients. The participants in this study (Matthias et al., 2010). The patients may discern this frustration and
argued that the high level of specialization meant that the doctors, make incorrect interpretations, which could explain why the patients
nurses and physiotherapists they met saw only minor parts of a in this study described what they perceived as bad behaviour by
complex problem. Their experience was that no one had a holistic healthcare personnel. Having a common approach to back pain and a
perspective. There is a need for balance between fixed structures structured plan for treatment and care created through cooperation
for care and treatment, on the one hand and individual wishes and between healthcare personnel and patients might well improve the
needs, on the other. Both perspectives are in various ways prereq‐ care relationship, benefitting both patients and personnel.
uisites for safe and quality care. The healthcare professions can be
expected to find this balance. Persons with CBP often seek care
repeatedly and from multiple healthcare providers, so it may be 6 | M E TH O D O LO G I C A L LI M ITATI O N S
beneficial to have a contact person who helps the person maintain
continuity in care. A review of qualitative studies of patient expe‐ In responding to the study's aim, the choice of a qualitative descrip‐
riences with care showed that having a trusted clinician who helps tive design allowed the participants to express their own experiences
the patient navigate the healthcare system and sees the patient as and that is a strength of this study. This is particularly important in
a partner strengthens continuity (Haggerty, Roberge, Freeman, & the light of the few studies in this research area. One limitation is
Beaulieu, 2013). Introducing contact nurses for people with CBP the convenience sample of patients, which might have selectively
and evaluating the treatment outcomes could be interesting from included patients who were “healthier,” as they had sufficient energy
the patient and healthcare personnel perspectives. Furthermore, and ability to attend an interview. It might also be that patients who
prioritizing reflection in the team around the patient could be en‐ had negative experiences of health care responded to the study to
lightening, helping develop healthcare personnel working with peo‐ a greater extent. These limitations must be taken into consideration
ple with CBP. when interpreting the results. Another limitation of the study is the
The participants in this study described contradictions in their few participants included and conclusions should therefore be made
encounters with health care. They described feeling alone in the with cautions. However, all the interviews yielded rich and deep de‐
healthcare system, forced to adapt to care and its conditions, at the scriptions of the phenomena of interest. Several illustrative exam‐
same time as they said that the healthcare personnel were fantastic ples were cited throughout the interviews. The sample also included
and treated them properly. It has been said to be of secondary im‐ participants of both genders and various ages. The credibility of the
portance that a person‐centred approach be used at the individual study was strengthened by striving for a comprehensive methodol‐
level between patients and healthcare personnel, if the healthcare ogy where the different stages of the analysis phase are presented.
organization is not structured in a person‐centred way (Morgan & In the analysis process, consensus about the meaning of the data
Yoder, 2012). A misalignment between the organizational structure was reached after reflections and several discussions between the
and the attitude of individual healthcare personnel might explain the researchers to ensure confirmability.
contradictory feelings of being well cared for and simultaneously
alone in the system. To break a negative pattern, it is important for
healthcare personnel to understand patient dissatisfaction with the 7 | CO N C LU S I O N S
relationship to the healthcare organization and use this insight to
bring about improvements (Jangland et al., 2011). The present findings provide insight and understandings of CBP pa‐
It could be debated whether the description of being disbelieved tients’ encounters with health care. They described that they experi‐
in the present study can be linked to distrust. The participants said ence vulnerability based on not having the opportunity to influence
that they longed for explanations of why they were suffering from their own situation in healthcare organizations that lack flexibility.
back pain. The fact that healthcare personnel did not propose fur‐ Instead of feeling seen and understood as individual persons, they
ther investigations could have reinforced a feeling of distrust, as the often leave encounters with health care with a sense of disappoint‐
patients did not have diagnoses that identified the source of their ment, powerlessness and impaired self‐confidence. All healthcare
pain. Earlier studies confirm that patients with CBP experience their professionals who meet CBP patients must understand that their
pain as legitimate when there is physiological evidence for it (Slade own approach in these meetings can be decisive for how the patients
et al., 2009). A possible explanation of the negative communication handle their life situation. It is a major challenge to create an organi‐
pattern is the stigmatized view of the patient's discomfort, which zation that promotes a person‐centred approach in meeting patients
creates a barrier to communication that complicates person‐centred with CBP. Creating and implementing structured plans for treatment
care. Dinc and Gastmans [22] characterized trust as “an attitude of and care, taking both patients’ hopes and medical/healthcare limita‐
relying with confidence on someone.” To recognize patient vulner‐ tions into account, are crucial for creating the basis of a trusting re‐
ability, nurses must be aware of the unequal power relationships lationship. Prioritizing reflection in the team around the patient and
between them and patients (Dinc & Gastmans, 2012). Previous introducing contact nurses (i.e. a special nurse for every patient, who
ALLVIN et al. | 7

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Georgy, E. E., Carr, E. C., & Breen, A. C. (2013). Back pain management in
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