Background
Chronic low back pain is an economic and social burden world-wide [
1]. While most people will experience low back pain during their lifetime [
2], much of the suffering and financial costs are associated with the 5–10% of people that experience associated disability [
3]. Hence, the need to identify factors associated with disabling low back pain so that targeted prevention strategies for primary health care can be developed.
Biological, psychological and social factors have been recognised as having a significant impact on the persistence of pain and the development of disability [
4]. In particular, an individual's belief system about pain is considered to be important [
5]. Irrational beliefs about back pain, in which the pain is considered to be a signal of impending threat, can result in fear of movement/(re)injury, reduced function and activity, and subsequently maintenance and exacerbation of chronic disability [
5].
There is evidence that educational strategies are effective in changing beliefs about back pain and reducing fear and associated disability. Clinical trials have reported reductions in both persistent low back pain [
6] and disability [
7] in primary care patients following implementation of educational booklets designed to change misconceptions about back pain. Moreover, a public health prevention program implemented in an employed population in the Australian state of Victoria not only resulted in patients and doctors developing more positive beliefs about back pain, but a decline in the number of claims, rates of days compensated and medical payments for back pain was reported [
8].
Although these studies have investigated beliefs about back pain in clinical and employed populations, there is a paucity of data pertaining to the beliefs of individuals living in the broader community. This is the case even though a Canadian study, which surveyed 2,400 individuals from two provinces, reported that generally pessimistic beliefs about low back pain were held by the population [
9]. Moreover, there are limited studies examining the relationship between beliefs and both low back pain and disability in community-based cohorts. Such information is important if are to understand the predictive nature of beliefs in the general population and subsequently design and tailor education strategies to communities' needs. The aims of this study were to characterize the beliefs of community-dwelling women about back pain and its consequences, and determine whether individuals with varying levels of pain intensity and disability differ in their beliefs about back pain.
Results
Of the 542 subjects who agreed to take part in this study, 506 (93.4%) returned the study questionnaire. Their median (minimum, maximum) age and BMI was 58 (24, 80) years and 26.4 (15.6, 54.0) kg/m
2 respectively (Table
1). 91.9% of the women reported they have 'ever' experienced back pain, while 69.7% and 75.1% reported back pain in the past 6 and 12 months respectively, and 22.5% reported back pain 'now' (at the time of questionnaire completion). According to the CPG, 140 (27.7%), 284 (56.1%) and 82 (16.2%) women reported no, low and high pain intensity respectively, while 398 (78.7%), 71 (14.0%) and 37 (7.3%) women were classified as having no, low and high disability.
Table 1
Characteristics of study participants (n = 506)
Age (years)†
| 58 (24, 80) |
Body mass index (BMI) (kg/m2)†€
| 26.4 (15.6, 54.0) |
Smoking status: Yes°
| 52 (10.3) |
Alcohol consumption: Yes±
| 405 (80.7) |
Partner status: Partnered#
| 342 (67.7) |
Employment status: Employed¥
| 260 (53.3) |
Menopause status: Postmenopausal | 328 (64.8) |
Back pain prevalence:
| |
Now | 114 (22.5) |
6 months∝
| 352 (69.7) |
12 months | 380 (75.1) |
Ever | 465 (91.9) |
Level of pain intensity:
| |
No | 140 (27.7) |
Low | 284 (56.1) |
High | 82 (16.2) |
Level of disability:
| |
No | 398 (78.7) |
Low | 71 (14.0) |
High | 37 (7.3) |
Beliefs about back pain
The mean (SD) belief score for the cohort was 30.7 (6.0) (Table
2). Of the 9 statements examining beliefs about back pain, over 30% of women agreed or strongly agreed with 4 negative statements. Of note, 50% of women agreed that 'once you have had back trouble there is always a weakness' and at least 30% agreed that 'back trouble means periods of pain for the rest of one's life', 'back trouble makes everything in life worse' and 'later in life back trouble gets progressively worse'. A further 16% and 18% of women agreed that 'back trouble will eventually stop you from working' and 'back trouble must be rested' respectively.
Table 2
Percentage of participants that responded negatively to statements (i.e. selected agree or completely agree (4 or 5)) about back pain from the Back Beliefs Questionnaire (n = 506)
1 | There is no real treatment for back trouble | 49 (9.7) |
2 | Back trouble will eventually stop you from working | 81 (16.0) |
3 | Back trouble means periods of pain for the rest of one's life | 154 (30.4) |
4 | Back trouble makes everything in life worse | 164 (32.4) |
5 | Back trouble may mean you end up in a wheelchair | 58 (11.5) |
6 | Back trouble means long periods of time off from work | 49 (9.7) |
7 | Once you have had back trouble there is always a weakness | 252 (49.8) |
8 | Back trouble must be rested | 91 (18.0) |
9 | Later in life back trouble gets progressively worse | 180 (35.6) |
|
Total score (mean, SD)
| 30.7 (6.0) |
Beliefs about back pain and self-reported pain intensity
The mean (SD) belief scores for women with no, low and high pain intensity were 30.2 (6.3), 31.5 (5.8) and 28.5 (5.7) respectively (Table
3). There were differences in the proportion of negative responses between individuals with no, low and high pain intensity for 5 of the 9 statements. However, while the high pain intensity group had the greatest proportion of negative responses for 3 of the statements, more women in the group with no pain responded negatively to 2 statements; 'back trouble makes everything in life worse' and 'back trouble means long periods of time off from work'.
Table 3
Association between beliefs about back pain and self-reported low back pain intensity
There is no real treatment for back trouble | 12 (8.6) | 24 (8.5) | 13 (15.9) | 0.1 |
Back trouble will eventually stop you from working | 22 (15.7) | 36 (12.7) | 23 (28.0) | 0.004 |
Back trouble means periods of pain for the rest of one's life | 28 (20.0) | 84 (29.6) | 42 (51.2) | <0.0001 |
Back trouble makes everything in life worse | 56 (40.0) | 80 (28.2) | 28 (34.1) | 0.047 |
Back trouble may mean you end up in a wheelchair | 22 (15.7) | 24 (8.5) | 12 (14.6) | 0.05 |
Back trouble means long periods of time off from work | 23 (16.4) | 18 (6.3) | 8 (9.8) | 0.004 |
Once you have had back trouble there is always a weakness | 64 (45.7) | 143 (50.4) | 45 (54.9) | 0.4 |
Back trouble must be rested | 27 (19.3) | 48 (16.9) | 16 (19.5) | 0.8 |
Later in life back trouble gets progressively worse | 42 (30.0) | 96 (33.8) | 42 (51.2) | 0.004 |
Total score (mean, SD)
| 30.2 (6.3) | 31.5 (5.8) | 28.5 (5.7) | 0.051 |
Beliefs about back pain and self-reported disability
The mean (SD) belief scores for women with no, low and high disability were 31.3 (5.7), 30.2 (6.3) and 24.8 (5.7) respectively (Table
4). Women with high level disability had more negative responses for 4 of the 9 belief statements than those with no or low disability. These included 'back trouble will eventually stop you from working' (p < 0.0001), 'back trouble means periods of pain for the rest of one's life' (p < 0.0001), 'back trouble means long periods of time off from work' (p = 0.02) and 'later in life back trouble gets progressively worse' (p = 0.002).
Table 4
Association between beliefs about back pain and self-reported low back disability
There is no real treatment for back trouble | 33 (8.3) | 9 (12.7) | 7 (18.9) | 0.07 |
Back trouble will eventually stop you from working | 46 (11.6) | 16 (22.5) | 19 (51.4) | <0.0001 |
Back trouble means periods of pain for the rest of one's life | 104 (26.1) | 21 (29.6) | 29 (78.4) | <0.0001 |
Back trouble makes everything in life worse | 123 (30.9) | 24 (33.8) | 17 (45.9) | 0.2 |
Back trouble may mean you end up in a wheelchair | 42 (10.6) | 8 (11.3) | 8 (21.6) | 0.1 |
Back trouble means long periods of time off from work | 37 (9.3) | 4 (5.6) | 8 (21.6) | 0.02 |
Once you have had back trouble there is always a weakness | 194 (48.7) | 34 (47.9) | 24 (64.9) | 0.2 |
Back trouble must be rested | 68 (17.1) | 12 (16.9) | 11 (29.7) | 0.2 |
Later in life back trouble gets progressively worse | 128 (32.2) | 30 (42.3) | 22 (59.5) | 0.002 |
Total score (mean, SD)
| 31.3 (5.7) | 30.2 (6.3) | 24.8 (5.7) | <0.0001 |
Associations between beliefs about back pain and pain intensity and disability
Multivariable analyses revealed a non-linear relationship between beliefs about back pain and self-reported pain intensity (Table
5). When comparing women with low and high pain intensity, there was an association, although not strong, between negative beliefs and high levels of pain, after adjusting for confounders (OR = 0.93, 95% CI: 0.88, 0.99; p = 0.02). However, there was no association between back pain beliefs and pain intensity when comparing those women with no and low intensity pain (OR = 1.03, 95% CI: 0.99, 1.07; p = 0.1). There was also a statistically significant, but not strong, association between beliefs about back pain and levels of self-reported disability, after adjusting for confounders, with more negative beliefs being associated with high levels of disability (OR = 0.93 (95% CI: 0.89, 0.97), p = 0.001) (Table
5).
Table 5
Associations between beliefs about back pain and self-reported levels of low back pain intensity and disability
Age (years)* | 0.89 (0.78, 1.02) | 0.1 | 0.67 (0.50, 0.89) | 0.007 | 1.08 (0.91, 1.28) | 0.4 | 0.94 (0.66, 1.34) | 0.7 |
BMI (kg/m2)* | 1.26 (1.07, 1.48) | 0.005 | 1.22 (1.02, 1.45) | 0.03 | 1.73 (1.43, 2.10) | <0.0001 | 1.61 (1.31, 1.98) | <0.0001 |
Smoking status | 1.16 (0.67, 2.00) | 0.6 | 0.99 (0.53, 1.87) | 1.0 | 0.85 (0.42, 1.76) | 0.7 | 0.99 (0.45, 2.16) | 1.0 |
Alcohol intake | 1.26 (0.81, 1.96) | 0.3 | 1.75 (1.03, 2.97) | 0.04 | 0.69 (0.42, 1.16) | 0.2 | 1.10 (0.58, 2.12) | 0.8 |
Partner status | 1.28 (0.89, 1.84) | 0.2 | 1.13 (0.74, 1.73) | 0.6 | 1.02 (0.65, 1.61) | 0.9 | 0.99 (0.57, 1.72) | 1.0 |
Employment status | 0.82 (0.58, 1.17) | 0.3 | 0.62 (0.38, 1.01) | 0.05 | 0.64 (0.41, 0.99) | 0.045 | 0.74 (0.41, 1.35) | 0.3 |
Menopause status^ | 0.91 (0.64, 1.30) | 0.6 | 1.08 (0.53, 2.19) | 0.8 | 1.19 (0.76, 1.85) | 0.5 | 0.86 (0.36, 2.04) | 0.7 |
Back pain now | 20.8 (12.1, 35.7) | <0.0001 | 18.8 (10.3, 34.2) | <0.0001 | 4.78 (3.03, 7.55) | <0.0001 | 4.58 (2.71, 7.72) | <0.0001 |
Back beliefs score^ | 0.98 (0.96, 1.01) | 0.3 | 1.03 (0.99, 1.07) | 0.1 | 0.91 (0.88, 0.95) | <0.0001 | 0.93 (0.89, 0.97) | 0.001 |
Menopause status | Low versus high pain intensity | | 3.24 (1.32, 7.96) | 0.01 | | | | |
Back beliefs score | Low versus high pain intensity | | 0.93 (0.88, 0.99) | 0.02 | | | | |
Discussion
This study indicates that women recruited from a community setting generally have positive beliefs about back pain. However, within the study population, women who reported a high level of pain intensity and disability held more pessimistic views, which are not consistent with evidence-based practice.
The level of beliefs about back pain in our community dwelling women was similar to that reported in an Australian population-based study of people in 2000 [
8] and 2002 [
17]. However, our findings differ from more pessimistic beliefs reported by two population-based studies undertaken in Australia in 1997 [
8] and Canada in 2005 [
9]. These more negative results may be explained by the timing of these studies, as both were undertaken prior to the implementation of large public health campaigns about back pain. Taken together, these results indicate that our study population of women has a relatively optimistic view of back pain and its consequences.
We found negative beliefs were associated with high pain intensity in individuals living in the community. Previous studies have primarily focused on investigating the relationship between beliefs, measured by the Fear-Avoidance Beliefs Questionnaire, and pain intensity in low back pain patients receiving treatment. Although data examining the relationship between the Fear-Avoidance Beliefs Questionnaire and BBQ are limited, a cross-sectional study of 2,727 acute low back pain patients in primary care practice in France reported an association between pain intensity and fear-avoidance beliefs [
18]. Moreover, a prospective cohort study of 123 patients with acute low back pain recruited from primary health care reported fear-avoidance beliefs to predict pain at 12 months, after adjusting for socio-demographic and pain variables [
19]. While these data suggest that beliefs about back pain are predictive of long-term pain in a clinical population receiving treatment, it is unknown whether this is the case in the general population.
We found the relationship between beliefs about back pain and pain intensity to be dependent on the level of pain intensity. While there was no relationship between beliefs and pain intensity when comparing the no and low pain intensity groups, there was a clear association between these parameters for those with low and high pain intensity. Even though the difference between the mean beliefs scores for the low and high pain intensity groups was small, it is consistent with the degree of change in belief scores following the implementation of a successful public health intervention [
17]. While it is possible that negative beliefs about back pain may lead to women reporting higher intensity pain, greater pain intensity may also result in the development of pessimistic beliefs about back pain. Our study provides evidence to indicate there is an association between back pain beliefs and pain intensity in the broader community and that further longitudinal investigation is needed to determine whether a causal relationship exists.
We found a clear association between back pain beliefs and levels of self-reported disability, with more negative beliefs being associated with high levels of disability. Although, to our knowledge, there are no population-based studies that have comprehensively examined the relationship between back pain beliefs and low back disability, our findings are consistent with studies of the general population that have examined other psychosocial factors, such as kinesiophobia and pain catastrophising [
20,
21] and clinical studies of patients with low back pain that have investigated fear-avoidance beliefs. For instance, a cross-sectional study of 443 patients with sub-acute low back reported an association between patients' fear-avoidance beliefs and perceived disability [
22] and a prospective study of 83 patients with chronic low back pain reported fear-avoidance beliefs about physical activity to predict disability, after adjusting for confounders, such as pain intensity [
23]. While these results indicate that negative beliefs may contribute to disability in acute low back pain, our understanding of whether beliefs lead to, or are a result of disability, in community-dwelling individuals is still unclear.
It is possible that our study may have been affected by selection bias. This may have occurred as we were limited to contacting women from our database who had agreed be involved in future research. However, we recruited subjects from a database established though random sampling from the state electoral roll, which includes all adults residing in the state, and without reference to research into back pain at the time of recruitment. In addition, the demographics of the women in the current study were very similar to those in the original study (mean (SD) age: 50 (14.4) years; mean (SD) BMI: 27.8 (6.5) kg/m2), even though the current study was conducted 4 years later. Although this cross-sectional study limits our ability to investigate factors such as pain duration and health care utilisation, explore predictors of low back pain, and generalise our results to the whole population, we have shown that both pain and disability are independently associated with beliefs.
Conclusion
In conclusion, this study demonstrates that although community-dwelling women generally have positive beliefs about back pain, there are subgroups of women, with intense pain and disability, who hold pessimistic views about back pain which are not concordant with evidence-based practice. The association between back pain beliefs and both pain intensity and disability reported in this community-based study highlights the need for future longitudinal studies to determine the predictive nature of these relationships.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
DU: selected the questionnaires, co-ordinated the data collection, analysed the data and wrote the manuscript; RB: assisted with the co-ordination of the study, data analyses and interpretation and manuscript preparation; FC: assisted with data analyses and interpretation, and manuscript preparation; JC/AF: performed the statistical analysis and reviewed the manuscript. SD: provided access to an established research database, and assisted with co-ordination of the study, data interpretation and critical review of the manuscript.