The Enduring Impact of What Clinicians Say to People
With Low Back Pain
Ben Darlow, MSportsPhysio1
Anthony Dowell, MBChB1
G. David Baxter, DPhil2
Fiona Mathieson, MA3
Meredith Perry, PhD2Sarah Dean, PhD4
Department of Primary Health Care andGeneral Practice, University of Otago,
Wellington, New Zealand1

Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand2

3
Department of Psychological Medicine,
University of Otago, Wellington, New
Zealand4
Institute of Health Research, Universityof Exeter Medical School, Exeter, United
Kingdom

ABSTRACTPURPOSE The purpose of this study was to explore the formation and impact of
attitudes and beliefs among people experiencing acute and chronic low back pain.
METHODS Semistructured qualitative interviews were conducted with 12 participants with acute low back pain (less than 6 weeks’ duration) and 11 participants
with chronic low back pain (more than 3 months’ duration) from 1 geographicalregion within New Zealand. Data were analyzed using an Interpretive Description
framework.
RESULTS Participants’ underlying beliefs about low back pain were influenced bya range of sources. Participants experiencing acute low back pain faced considerable uncertainty and consequently sought more information and understanding.
Although participants searched the Internet and looked to family and friends,
health care professionals had the strongest influence upon their attitudes andbeliefs. Clinicians influenced their patients’ understanding of the source andmeaning of symptoms, as well as their prognostic expectations. Such information
and advice could continue to influence the beliefs of patients for many years.
Many messages from clinicians were interpreted as meaning the back needed
to be protected. These messages could result in increased vigilance, worry, guilt
when adherence was inadequate, or frustration when protection strategies failed.
Clinicians could also provide reassurance, which increased confidence, and advice,
which positively influenced the approach to movement and activity.
CONCLUSIONS Health care professionals have a considerable and enduring influ-

ence upon the attitudes and beliefs of people with low back pain. It is importantthat this opportunity is used to positively influence attitudes and beliefs.
Ann Fam Med 2013;527-534. doi:10.1370/afm.1518.

INTRODUCTION

L

Annals Journal Club selection;see inside back cover or www.
annfammed.org/AJC/.

Conflicts of interest: authors report none.

CORRESPONDING AUTHOR

Ben Darlow, MSportsPhysio
Department of Primary Health Care andGeneral Practice
University of Otago, Wellington
PO Box 7343
Wellington South 6242, New Zealandben.darlow@otago.ac.nz

ow back pain is a health condition with major direct and indirect
costs.1-4 Acute low back pain is assumed to have a highly positive
prognosis5; however, a large proportion of patients continue toexperience pain and disability.6
Psychosocial factors are important in the development of low backpain and disability.7,8 Depression, passive coping strategies, fear avoidance
beliefs (the avoidance of movement or activity resulting from fear of pain or
injury), and low expectations of recovery are independently associated withpoor outcome.9,10 A clinical guide to assessing psychosocial warning signs(yellow flags) developed in New Zealand has been adopted internationally.11
Patients’ beliefs need to be better understood to improve managementof low back pain.10,12,13 People with low back pain receive information froma range of sources, but the influence of each source is unknown.14,15 Studies have investigated activities, situations, and anatomic structures thatpeople see as being responsible for their back pain, but not how or why
beliefs have been formed.14,16-18
Health care professionals may negatively influence patient beliefs.19
There is strong evidence that patients’ beliefs about low back pain areassociated with their clinicians’ beliefs, and moderate evidence suggests

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that patient and clinician fear avoidance beliefs are also
associated.20 There is insufficient evidence, however,to conclude that clinicians can change patients’ beliefs,
and there has been no description of the impact of theclinicians’ beliefs.
We undertook this study to understand why people
have particular beliefs about low back pain and theimpact of these beliefs. We also aimed to explore therelationship between patients’ and clinicians’ beliefs.

METHODSThis qualitative investigation used the framework ofInterpretive Description, a methodology that aims to
inform clinical understanding by capturing themes
and patterns within subjective perceptions of a clinicalphenomenon.21,22 An interpretivist perspective assumes
reality is constructed between people, researchers’ values and knowledge are part of research processes, andemergent findings are situated in a particular context
and time.22,23
The study researchers acknowledged the risk that
their prior knowledge and understanding could bias
the outcome. The primary investigator and interviewer(B.D.) acknowledged his own position and beliefs at the
study outset. This disclosure assisted with identificationof any influence upon study design, conduct, or analysis.

pended when no new themes or variants on establishedthemes occurred with subsequent interviews. The
research team debated and agreed theme saturation.
Data Analysis
Interview recordings were transcribed verbatim. Participants did not review transcripts or validate findings.22 Data on acute and chronic low back pain wereanalyzed separately. A thematic framework was createdbased upon broad themes identified in the first 3 transcripts. Individual comments from participants were
subsequently coded by theme within nVivo 9.2 software (QSR International Pty Ltd). Emergent themes
were integrated into the existing framework, or theframework was reorganized to accommodate the newperspective. An external researcher (M.P.), previously
uninvolved in the study, independently analyzed thethird transcripts. Comparison of analyses resulted insome theme reorganization, but there were no significant conflicts. After analyzing 6 interviews, detailed
theme summaries were discussed by the research team,resulting in reorganization of thematic frameworks andsuggestions of new avenues to explore with subsequentinterviews. During initial coding, themes relating to
influences upon participants’ beliefs, as well as theimpact of these beliefs, emerged strongly in both theacute and chronic low back pain groups. Consequently,
all transcripts were recoded to identify core beliefs,

Participant Recruitment
The researchers advertised the study in a range ofhealth care facilities and public spaces in one region of
New Zealand, and respondents were screened by telephone. Respondents were invited to participate if they
had acute (less than 6 weeks) or chronic (longer than 3months) low back pain, were older than 18 years, andwere fluent in English. They were excluded from thestudy if they had received surgery for low back pain
or treatment from the primary investigator. Purposive
sampling was used to maximize the range of viewpoints
recorded in terms of characteristics thought likely tointeract with beliefs about low back pain—age, sex,ethnicity, occupation, low back pain experience, andinteraction with health care professionals.21

Table 1. Semistructured Interview Question Guide
Account of their back pain, including how and why the back pain
came about
The meaning of the pain
Premorbid ideas or beliefs about back pain and how these havechangedAnything that concerns them about back pain
Who they have discussed their back pain with and whom they trust
Other places they have looked for information
Any health care professionals they have consulted
Any investigations they have received
Things that have helped or are helping them manage their pain
Their own thoughts about the best way to manage low back pain
Their thoughts about statements from the New Zealand Acute Low
Back Pain Guide
Their thoughts about why people may be scared of moving during
an episode of low back pain
Their thoughts about why people may worry about the consequences of low back pain
Anything they think may have helped them manage their low backpain more effectively
Nonphysical influences on their pain

Data Collection
After giving informed consent, participants took part in
face-to-face semistructured interviews that were audiorecorded. An interview guide with open-ended questions (Table 1) allowed flexibility to discuss items as theyarose. Afterward, participants completed a demographic
information sheet, a Tampa Scale of Kinesiophobia,24
and a Roland Morris Disability Questionnaire.25
Data collection and analysis occurred concurrently,
informing each other iteratively. Recruitment was sus-

How much they focus on their back pain
Their expectations for the future with regards to their backThe meaning of terms for low back pain commonly used by healthcare professionals
Any additional thoughts or information they considered relevant

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Table 2. Characteristics of Participants With Acute Low Back Pain
ParticipantCode, SexAgey

Occupation

Pain
DurationdClinical Consultation
This EpisodePrevious
Consultation for
Low Back Pain

RMDQa

TSKb
43

ALBP01, female

18

Student

5

No

No

1

ALBP02, female

29

Administrator

2

No

Physiotherapist

19

41

ALBP03, male

50

Student

14

Physiotherapist

No

16

44
36

ALBP04, male45

Solicitor

30

Osteopath

Osteopath

10

ALBP05, female

19

Student

5No

Chiropractor

1242

ALBP06, female

55

Doctor

41

No

4

34

ALBP07, female

24

30

41

36

5

Family doctor,
physiotherapist
No

14

ALBP08, female

543

ALBP09, male25

3

Family doctor

No

14

44

ALBP10, male

44

20
4

12

43

ALBP12, female

52

Administrator

4

No

Family doctor,
physiotherapist
Family doctor, Chinese
medicine practitioner
Family doctor, physiotherapist, chiropractor

25

37

Family doctor, physiotherapist,
occupational health nurse
Emergency department

1

ALBP11, male

Research
assistant
Early childhood
teacher
Orange juice
production
Clinical psychologist, lecturer
Baker

Family doctor, emergency
department
Family doctor, physiotherapist,massage therapist
Family doctor

16

47

Mean (SD)

36.2(13.1)

10.3
(6.1)

40.3
(6.0)

13.6
(13.4)ALBP = acute low back pain participant; RMDQ = Roland Morris Disability Questionnaire; TSK = Tampa Scale of Kinesiophobia.
abScored on a range from 0 to 24, with higher scores indicating greater disability.
Scored on a range from 17 to 68, with higher scores indicating greater levels of fear avoidance beliefs.

how these beliefs appeared to have been formed, andtheir impact.
The Research TeamThe initial research team consisted of academics and clinicians with backgrounds in physiotherapy (B.D., D.B.,
S.D.), family medicine (T.D.), and psychology (F.M.,
S.D.). Several researchers (T.D., D.B., S.D.) had previous
experience with qualitative research in low back pain.
After external verification of themes, a physiotherapist
with qualitative research experience in low back pain
(M.P.) reviewed subsequent theme summaries to ensureongoing consistency and joined the research team.
The New Zealand Central Regional Ethics Committee granted ethical approval (CEN/11/EXP/014).

RESULTSInterviews were conducted with 12 acute and 11
chronic low back pain participants. Thirteen further
eligible respondents were not interviewed because
their characteristics were similar to previous participants. Interview duration ranged between 31 and 101
minutes. Participants had varied histories of low backpain, diverse exposure to health care professionals, andwide-ranging disability levels and fear avoidance beliefs(Tables 2 and 3).

A number of factors influenced the participants’beliefs, but clinicians appeared to be the most important. The thematic framework is displayed in Figure 1.
We present participants’ reports of what they had been
told; the actual communication that took place with
their clinicians is unknown. Supporting quotes representing important themes are shown in the Supplemental Appendix (available at www.annfammed.org/
content/11/6/527/suppl/DC1).
Influences on Beliefs
Participants arrived at their initial experience of low
back pain with varied frameworks based upon messages
received throughout their lives (Supplemental Appendix, Box 1). These frameworks were further developed
during episodes of low back pain. Observing others’
experience influenced participants’ views about the
back’s vulnerability, their own genetic predisposition
to low back pain, and ultimately the threat associatedwith low back pain.
Many participants reported being very uncertain
about what was going on and what they should dowhen experiencing acute low back pain:
I had just no frame of reference to figure out like what itwas...with a back. I don’t know, and I don’t know what I needto do to heal it, so I’m just completely in the dark (acute lowback pain participant [ALBP]08).

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L OW B AC K PA I NConsequently, participants sought more certainty;
they wished to find out about the problem, the prognosis, and how to prevent or manage recurrence.
Participants commonly sought information on theInternet, but they interpreted this information cautiously (Supplemental Appendix, Box 2). Advice fromfamily and friends, particularly those with experienceof low back pain, was usually valued above the Internet, but their advice could be conflicting, and often
they recommended consulting a clinician.
Clinicians were seen as providing the most certainty;
they could provide person-specific assessment andadvice that participants hoped might prevent chronic
low back pain from developing. Because participants hadhigh levels of trust in their clinicians and often did notlook for information elsewhere, these clinicians were in aposition to be very influential on participants’ beliefs.
Some participants described instances of rejecting aclinician’s explanations or advice. The major reason was
doubt about the clinician’s competence, indicated by an
inadequate assessment or a poor response to treatment.
Participants also reported rejecting advice when it conflicted with their lived experience, life goals, strongly
held beliefs, or their perception of the severity of theirproblem. As a result, they maintained their own beliefs,

did not adhere to recommendations, stopped treatment,or changed clinicians. One participant reported how
a disagreement with her doctor about management
resulted in their relationship breakdown:
My doctor put me on amitriptyline, but every time I said thepain was worse, he’d just increase the dose ‘til I was just likea zombie, but still had the pain. So, [I] refused to take any
more amitriptyline, so he refused to prescribe anything else,
because I wouldn’t do what he wanted (chronic low backpain participant [CLBP]02).

Clinicians’ Influence on Participants
All participants with chronic and 9 of the 11 participants
with acute low back pain who had interacted with a clinician made one or more specific connections between
something their clinician had said and their subsequent
behavior; this influence is reflected in Figure 2.
Symptom Evaluation and Prognosis
Participants’ understanding about the source of their
symptoms was influenced by their interpretation of
information from their clinicians (Supplemental Appendix, Box 3). It appeared this information was generally
delivered within a biomedical framework. Knowing
what was happening “in my back” in turn influenced

Table 3. Characteristics of Participants With Chronic Low Back Pain
ParticipantCode, SexAgey

Occupation

Pain
Durationy

Clinical Consultation

RMDQa

TSKb

CLBP01, male

45

Doctor30

Family doctor, physiotherapist, rheumatologist

1024

CLBP02, female

65

Administration
manager

16

Family doctor, physiotherapist, osteopath, acupuncturist, orthopedic surgeon, clinical psychologist,
Chinese medicine practitioner
Family doctor, physiotherapist, orthopedic surgeon

625

CLBP03 female

52

Librarian

31

CLBP04, female

39

Writer, editor

20

CLBP05, female

32

8

CLBP06, male

37

Performing arts
teacher, performer
Builder, student

CLBP07, female

48

CLBP08, female

15
4

25

Quality improvement
coordinator
Student

5

15

57

Family doctor, physiotherapist, osteopath, chiropractor, acupuncturist, orthopedic surgeon, Feldenkrais
practitioner, massage therapist
Physiotherapist, acupuncturist, sports physician

7

36

4

37

Family doctor, physiotherapist, osteopath, chiropractor, orthopedic surgeon
Physiotherapist, orthopedic surgeon

13

34

20

48

CLBP09, male

67

Retired

30

Family doctor, physiotherapist, osteopath, chiropractor, acupuncturist, orthopedic surgeon, craniosacral
therapist, reflexologist, spiritual healer
Physiotherapist, chiropractor, acupuncturist

22

49

CLBP10, male60

20

Family doctor

1041

CLBP11, female

32

Information technology manager
Sickness beneficiary9

Family doctor, physiotherapist, osteopath, chiropractor,
orthopedic surgeon, clinical psychologist, Chinese
medicine practitioner, multidisciplinary pain clinic

1240

Mean (SD)

45.6(14.1)

11.2
(6.0)

38.0
(10.5)

17.1(10.1)

CLBP = chronic low back pain participant; RMDQ = Roland Morris Disability Questionnaire; TSK = Tampa Scale of Kinesiophobia.
abScored on a range from 0 to 24, with higher scores indicating greater disability.
Scored on a range from 17 to 68, with higher scores indicating greater levels of fear avoidance beliefs.

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4

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symptom interpretation. Even the diagnosis of a simple
sprain, which a doctor might provide as a form of reassurance to show the problem was not serious, could
influence the perceived safety of movement:[The doctor] said most likely it was just a lumbar sprain...
when I get that sharp pain, I guess that I’ve moved in a way
that’s continually putting strain on an area of the muscle that

I’ve damaged...my assumption would be that I was making it
worse (ALBP08).

Symptom evaluation, based on interpretation of
explanatory models from the clinicians, was also usedas the reference for appraising future symptoms. One
participant, whose chiropractor had explained histreatment around “aligning the back,” assumed his backwas out of alignment again whenever hefelt any pain in his lower back:Figure 1. Thematic framework.
Media

Family and friends

Previous experience

Framework for evaluating low back pain experience

Insufficientcertainty

Health care
professionals

When [the current episode] first happened,
the only thing that was going through mymind is the seriousness of my dis-alignment[sic] of my back.... I was really petrified...you
get scared in the sense that you could damage your spinal cord, or anything, to suchan extent that you might become paralyzed(CLBP09).

Explanations also influenced participants’ prognostic expectations andresulted in 2 participants withdrawing
from physical occupations:Sufficientcertainty[The orthopedic specialist] looked at myback MRIs for a little while and turned
around with a grin on his face and said,“You’re a builder, aren’t you?” and I said,“Yes,” and he said, “You’re [expletive], ha ha
ha,” and went back to his computer again....
So, you know, I think that was his rather odd

Familyand friends

Internet

Figure 2. Health care professionals’ influence on participants.
Guilt
Muscles
Frustration
Avoidance

Protect the back

Worry
PostureHealth care
professional

Symptom
evaluation

Attend to backPrognosis

Expectation

Activation andreassurance

Increased
confidence

Positive approachto activity

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specialist way of breaking the news to me that I wouldn’t beworking as a builder for very long.... Every time I felt a little
bit wrong [after that], I started to sort of add it up in myhead. And then my usual way of thinking, “Oh, that’s fine,that’s nothing, that’ll go away, that’s not major enough tostop me working, I’ll carry on [changed]”...him saying thatwas definitely the point, because I probably would have justcarried on (CLBP06).

Expectations also influenced participants’ interpretation of future episodes of pain. Participants who had
understood their problem would fully resolve looked at
new episodes of pain as being unrelated problems thatwould also resolve. In contrast, those who had received
negative expectations saw new episodes as recurrencesof the previous problem:
I injured my back, and I think they described it as...a slippeddisc.... Something she’d also said to me, “Unfortunately,
because you’ve done this, you have a very high chance of
doing it again.” Now, I connect any pain that I feel roundthere to that (ALBP02).

Protect the Back
Participants reported being advised to adopt certain
postures and strengthen specific muscles to manage
their low back pain, which reinforced their belief that
their spine was vulnerable. They saw muscles as being
important to limit movement, reduce spinal load, maintain structural alignment, and prevent injury (Supplemental Appendix, Box 4). To enact these protective
strategies, participants focused upon their back andmaintained constant vigilance. Participants adhered tothis advice because of the perceived benefits of pain
relief or a feeling of control, but this advice could havevery negative effects upon function (Supplemental
Appendix, Box 5).
The explanatory model that insufficient muscularsupport results in a vulnerable spine can have a dramatic impact upon peoples’ lives:
Basically all I’ve kind of been told to do by physios is towork on my core...I’ve been tested by various different
physios, and Pilates, and I’m apparently ridiculously weak....
I had an abortion because I didn’t think I could have a baby.
I didn’t think I could handle it...carrying it, and having extra
weight on my stomach (CLBP11).

Adopting protective strategies, while not receiving
the expected benefits, was very frustrating. Frustration was often directed at the participants themselves
as having failed the treatment rather than at what may
have been an ineffective strategy. In contrast, participants experienced guilt when they did not adhere:
I feel guilty and bad that I’m not doing the exercises that
I’m supposed to do..., and guilt rides on my shoulder like agremlin, I can’t push that aside (CLBP01).

Advice received from clinicians often seemed to be
based upon an acute model of care and framed aroundprotecting damaged tissue by avoiding certain activities or positions. This advice often continued to influence participants’ approach to activity long after theacute phase.
I hurt my back, went to the hospital and got x-rays, and theysort of sent me home and said to rest until it got better…. So I
was lying in bed for a long time, in pain, and it wasn’t getting
better, and I think I made it a lot worse, doing that (CLBP11).

Clinicians could directly communicate, and ultimately transfer, their own beliefs about the importanceof pain, as well as the dangers of movement and activity, to their patients. A focus upon informing patients
about what they should not do, rather than what theyshould, gave the impression that recovery was more
dependent upon avoidance of, rather than performanceof, movement and activity:
Do all those things that the physio told me to do. Or not todo.... She’s told me more what nots [sic] to do, than what todo. So I think those what nots [sic] to do are more important(CLBP07).

The advice that someone should not perform activities that were necessary for participation in their liferoles could lead to anxiety:
I was worried that...I would do things [at work] that would
further damage my back.... [The doctor] basically said that I
shouldn’t do any bending or lifting. Which is a lot of the job(ALBP08).

Activation and Reassurance
Clinicians were able to influence their patients’ views
about the importance of movement and activity positively and provide reassurance (Supplemental Appendix,
Box 6). One participant reported how during her only
previous episode of low back pain, 6 years earlier, she
had stayed in bed for 2 days before visiting her doctor:
I went to the doctor after that...he said, “No, don’t, that’s theworst thing you can do, by staying in bed. You should keep
moving, keep walking. Keep—keep at it” (ALBP12).

The very different approach to her current episodeof low back pain showed how effective and long lastinga single clear message could be:
I feel that I should keep moving, and keep doing things
as much as possible.... I do believe that you have to keep
going, you have to keep, um, moving, and you have tokeep—I mean going to bed definitely doesn’t help it. So
keep active (ALBP12).

Participants trusted their clinicians; consequently,
their reassurance about prognosis or safety of movement

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could be very powerful. This resulted in some participants having increased confidence and less anxiety:
Lots of reassurance from the [doctor]...made me feel like,“don’t panic, you don’t—you know, this is—this is OK, you’ll
be fine, it’s not the start of something awful” (ALBP06).

Reports of activation and reassurance were muchless frequent than the protective advice reported earlier. Advice to be active was often balanced by protection advice from the same clinician, resulting in mixed
messages.

DISCUSSIONMedia, the Internet, family and friends, previous
experience, and health care professionals contributeto patients’ beliefs about low back pain.14 People trust
their clinicians, who are still the primary source of
information and advice despite the growth of theInternet.14,26 The current study furthers understandingof how and when various sources of information contribute to beliefs, highlighting that clinicians can havea profound and long-lasting influence. Recovery expectations can be heavily influenced by single, at times
off-hand, statements. This finding is important giventhat low recovery expectations are a strong predictorof poor outcome.10
Avoidance of activities because of fear of pain or
injury is an approach to protecting the back that negatively influences outcome.9 Our findings show thatclinicians can contribute to avoidance beliefs directly
by focusing upon what patients should not do and indirectly by providing management advice and pathoanatomic explanations, which are interpreted as meaning
the spine is vulnerable and requires protection. Nearly
all participants reported receiving pathoanatomic
explanations for the cause of their back pain, despite
guideline recommendations against doing so.8 Such
explanations may be provided to justify self-management recommendations13; however, they influence not
only evaluation of current symptoms but also appraisalof future episodes.
Participants viewed lifting techniques, postural control, and muscle strengthening as strategies to protect
the back. Evidence does not support the idea that protection prevents pain, however. Rather, there is strong
evidence that education in lifting techniques or reducing lifting load does not prevent low back pain.27,28 Furthermore, although exercise interventions may prevent
low back pain or reduce recurrence, improved outcomesare not associated with changes in any aspect of muscle
performance.28-30 Our study shows that these protection
strategies may result in increased vigilance, worry, frustration, and guilt for patients with low back pain.

These data paint a discouraging picture of the role
clinicians unwittingly play in the management of low
back pain. Even so, we have made an effort to highlight
positive influences because they show that unambiguous
activity advice can be very empowering, and that appropriate reassurance and positive prognostic expectations
can have a very beneficial effect. These approaches
positively influence participants’ beliefs about their current and subsequent episodes of low back pain.
Limitations
The interviews and primary analysis were conductedby the same researcher (B.D.); the risk of bias was identified, and steps were taken to minimize its influence.
Data presented are the researchers’ interpretation ofparticipants’ interpretations of what their clinicians andothers have said to them, representing a type of double
hermeneutic. We are not able to say whether linkages
participants made between information from clinicians
and subsequent beliefs and behavior were previously
held (consciously or subconsciously) or made only during (and as a result of) the interview.
Information provided to participants may have beenquite different from what they reported. The ability toprocess and understand health information is variable
among patient populations.31 Patients filter, interpret,and remember information at the level of their understanding and in the context of their preexisting beliefs
and motives. The data are, however, entirely consistent
with what health care professionals report providing,13,32 people with low back pain report receiving,14,15
and direct consultation observations.33 Regardless ofparticipants’ recall and bias, the messages that havestayed with them are probably more important thanwhat was actually said or intended.
Implications for Clinical Practiceand Future Research
Most patients consult their family doctor only once foran episode of acute low back pain despite symptoms
persisting.6 Information and advice received at this consultation can continue to influence patient beliefs formany years. As a result, this information needs to beappropriate, not only for the remainder of the current
episode but also for informing the approach to subsequent episodes. Confirming the patient’s understandingof what has been said can help ensure information isinterpreted as intended31 and avoid unintentional validation or reinforcement of unhelpful beliefs and behaviors.
These findings suggest patients interpret commonlyused low back pain management strategies as meaning
their spine needs protection. Pathoanatomic explanations can contribute to negative symptom appraisal
and avoidance beliefs. Health care professionals need

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to take these potentially negative consequences into
consideration when deciding what to say or which
treatment to provide. Our findings also show clear
activity advice and appropriate reassurance can beempowering. Further research should investigate waysof supporting clinicians to identify messages that may
be interpreted negatively and instill the confidence todeliver positive messages instead. We recommend prospective studies to investigate ways of packaging information and advice that enables people to use their backfreely, potentially reducing the persistence of disability.
To read or post commentaries in response to this article, see it
online at www.annfammed.org/content/11/6/527.
Key words: low back pain; attitude; patients; health personnel; physician-patient relations; health knowledge, attitudes, practice
Submitted September 9, 2012; submitted, revised, December 20, 2012;
accepted January 2, 2013.
Funding support: This study received a Searchwell Grant from the Wellington Branch of Physiotherapy New Zealand. Dr Dean’s time is fundedby the National Institute for Health Research (NIHR) Collaboration for
Leadership in Applied Health Research and Care (CLAHRC) for the SouthWest Peninsula.
Previous presentations: The New Zealand Pain Society 37th Annual
Scientific Meeting, April 12-15, 2012, Wellington, New Zealand.
NOI2012: Neurodynamics and the Neuromatrix Conference, April
25-28, 2012, Adelaide, Australia.

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