Population based intervention to change back pain beliefs and disability: three part evaluation Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain Why is a treatment aimed at psychosocial factors not effective in patients with (sub)acute low back pain? Using logic model methods in systematic review synthesis: describing complex pathways in referral management interventions How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists Absence Resulting From Low Back Trouble Can Be Reduced by Psychosocial Intervention at the Work Place Prediction of physician visits and prescription medicine use for back pain The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status Does Teaching Physical Therapists to Deliver a Biopsychosocial Treatment Program Result in Better Patient Outcomes? A Randomized Controlled Trial Health beliefs of adults with asthma: toward an understanding of the difference between symptomatic and preventive use of inhaler treatment. Predictors of return to work in patients sick listed for sub-acute low back pain: a 12-month follow-up study. Do psychological factors predict outcome in both low-back pain and shoulder pain? 2001 Volvo Award Winner in Clinical Studies: Effects of a Media Campaign on Back Pain Beliefs and Its Potential Influence on Management of Low Back Pain in General Practice Factors Associated with Choosing a Chiropractor for Episodes of Back Pain Care A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up. Population based intervention to change back pain beliefs: three year follow up population survey Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Reliability, validity and responsiveness of the fear-avoidance beliefs questionnaire: methodological aspects of the Norwegian version. [Psychological mechanisms in the transition from acute to chronic pain: over- or underrated?]. A systematic review of workplace interventions to prevent low back pain. A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement. Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's 'high-risk' intervention (StarT Back; ISRCTN 37113406). Managing low back pain: attitudes and treatment preferences of physical therapists.
Abstract Objective : To evaluate the effectiveness of a population based , state-wide public health intervention design ed to alter beliefs about back pain , influence medical management , and reduce disability and costs of compensation . Design : Quasi-experimental , non-r and omised , non-equivalent , before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of cl aims data base . Setting : Two states in Australia . Participants : 4730 members of general population before and two and two and a half years after campaign started , in a ratio of 2:1:1 ; 2556 general practitioners before and two years after campaign onset . Main outcome measures : Back beliefs question naire , knowledge and attitude statements about back pain , incidence of workers ' financial compensation cl aims for back problems , rate of days compensated , and medical payments for cl aims related to back pain and other cl aims . Results : In the intervention state beliefs about back pain became more positive between successive surveys ( mean improvement in question naire score 1.9 ( 95 % confidence interval 1.3 to 2.5 ) , P<0.001 and 3.2 ( 2.6 to 3.9 ) , P<0.001 , between baseline and the second and third survey , respectively ) . Beliefs about back pain also improved among doctors . There was a clear decline in number of cl aims for back pain , rates of days compensated , and medical payments for cl aims for back pain over the duration of the campaign . Conclusions : A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers ' compensation costs related to back pain . What is already known on this topic The number of people with disability from back pain has risen rapidly in the past 50 years Most attempts to limit this disability include modification of occupational risk factors or dealing with the problem once it has developed Patients ' attitudes and beliefs play an important part in the development of such chronic disability What this study adds A population based primary prevention intervention that provided explicit advice about back pain improved beliefs about back pain in the general population and knowledge and attitudes in general practitioners The number of workers ' compensation cl aims for back pain decreased and the rate of days compensated and medical payments for back cl aims were Study Design . We conducted an observational study using mailed question naires to 3 r and om sample s of general practitioners from Victoria and New South Wales , Australia in 1997 , 2000 , and 2004 . Objective . To determine whether general practitioners ’ beliefs about low back pain ( LBP ) differ according to whether they have a special interest in back pain , musculoskeletal , or occupational medicine ; and whether these beliefs are modified by having had continuing medical education ( CME ) about back pain in the previous 2 years . Summary of Background Data . Physician surveys continue to demonstrate that general practitioners only partially manage LBP in an evidence -based way . Identified barriers to changing physician behavior , in regard to management of back pain , have included patient factors such as their past back pain experiences and preferences for care as well as physician beliefs about the association of pain and activity ; although the influence of physician special interests has not been studied . Methods . Back pain beliefs of different subsets ( special interests vs. no special interests and CME vs. no CME ) were compared using relative risks ( RRs ) adjusted for state and survey . The analysis was then repeated including all special interests and recent back pain CME in the model . Results . Responses were received from 3831 general practitioners ( overall response rate [ RR ] : 38.2 % ) . Physicians with a special interest in LBP were more likely to believe that complete bed rest and avoidance of work is appropriate for acute low back pain ( RR : 1.89 [ 95 % CI : 1.53–2.33 ] and 1.55 [ 95 % CI : 1.31–1.83 ] , respectively ) and lumbar spine radiographs are useful ( RR : 1.36 [ 95 % CI : 1.21–1.51 ] ) . The disparity between those with and without a special interest in LBP was still evident after adjusting for the presence of other special interests and recent CME . After adjusting for the presence of other special interests and recent CME , therewere no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine , while those with a special interest in occupational medicine and those who had received recent CME had better beliefs . Conclusion . A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence . This has serious implication s for management of back pain in the community & NA ; Psychosocial factors have been shown to play an important role in the development of chronic low back pain ( LBP ) . In our recently completed cluster‐r and omized trial we found , however , no evidence of an effect of our minimal intervention strategy ( MIS ) aim ed at psychosocial factors , over usual care ( UC ) in patients with (sub)acute LBP . To explore the reasons why , this paper presents an evaluation of the processes presumably underlying the effectiveness of MIS . General practitioner ( GP ) attitude was evaluated by the Pain Attitudes and Beliefs Scale and two additional questions . GP behaviour was evaluated by analysing treatment registration forms and patients ' responses to items regarding treatment content . Patients also scored items on satisfaction and compliance . Modification of psychosocial measures was evaluated by analysing changes after 6 and 52 weeks on the Fear Avoidance and Beliefs Question naire , the Coping Strategies Question naire and the 4‐Dimensional Symptom Question naire . A total of 60 GPs and 314 patients participated in the study . GPs in the MIS‐group adopted a less biomedical orientated attitude than in the UC‐group , but were only moderately successful in identification of psychosocial factors . Treatment contents as perceived by the patient and patient satisfaction differed significantly between both groups . Changes on psychosocial measures , however , did not differ between groups . The suboptimal identification of psychosocial factors in the MIS‐group and the absence of a relevant impact on psychosocial factors may explain why MIS was not more effective than UC Background There is increasing interest in innovative methods to carry out systematic review s of complex interventions . Theory-based approaches , such as logic models , have been suggested as a means of providing additional insights beyond that obtained via conventional review methods . Methods This paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesis e a broad range of literature . The potential value of the model produced was explored with stakeholders . Results The review identified 295 papers that met the inclusion criteria . The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles . A logic model was systematic ally built from these studies . The model outlines interventions , short term outcomes , moderating and mediating factors and long term dem and management outcomes and impacts . Interventions were grouped into typologies of practitioner education , process change , system change , and patient intervention . Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge , beliefs or attitudes and also interventions related to changed doctor-patient interaction . A range of factors which may influence whether these outcomes lead to long term change were detailed . Dem and management outcomes and intended impacts included content of referral , rate of referral , and doctor or patient satisfaction . Conclusions The logic model details evidence and assumptions underpinning the complex pathway from interventions to dem and management impact . The method offers a useful addition to systematic review method ologies . Trial registration number PROSPERO registration number : CRD42013004037 & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes Study Design A 1-year prospect i ve study in industry , assessing effects of an educational pamphlet on various psychosocial parameters and absenteeism result ing from low back trouble . Objectives To determine the value of distributing an educational psychosocial pamphlet to reduce absenteeism result ing from back trouble . The pamphlet was design ed to alter avoidance behaviors by encouraging a positive , active approach . Summary of Background Data Attempts to control back-pain disability have failed . Fear of pain and activity seemingly leads to avoidance behaviors that contribute to chronicity and work loss . Avoidance behaviors are mediated by attitudes and beliefs ; such attitudes and beliefs are a reasonable target for educational interventions design ed to change “ inappropriate ” behaviors ( e.g. , extended absenteeism ) . Health education pamphlets are advocated widely but tested rarely . Methods Three factories participated in the study . Psychosocial data were collected by question naires ; absence data were extracted from company records . A psychosocial pamphlet was distributed in one factory ; the control subjects received either a nonspecific pamphlet or no intervention . The pamphlet emphasized a positive approach to low back trouble ( reduction of negative beliefs and attitudes ) . Results In the company whose employees received pamphlets , a significant reduction occurred for the number of spells with extended absence and the number of days of absence ( 70 % and 60 % , respectively ) compared with extrapolated values . A concomitant positive shift in beliefs concerning the locus of pain control and the inevitable consequences of low back trouble was found . Conclusions A simple industrial intervention using a psychosocial pamphlet , which was design ed to reduce avoidance behaviors by fostering positive beliefs and attitudes , successfully reduced extended absence result ing from low back trouble The primary purpose of this study was to examine the extent to which specific patient attitudes and beliefs about medical care and  self-care for back pain predict future healthcare use . An automated data base allowed examination of the predictive relationships in two primary care patient sample s. In general , beliefs that physicians should find a definitive cause and permanent cure for back pain predicted neither physician visits nor prescription medication fills . Patient attitudes endorsing the benefits of medical treatment for back pain ( as opposed to a permanent cure ) predicted the use of these specific healthcare services . In a third sample of primary care back pain patients , we assessed whether a four-session self-care intervention modified those attitudes and beliefs shown to predict future healthcare use . The group intervention was associated with changes in attitudes about use of physician services but not medication use . A secondary purpose was to examine initial psychometric properties of a proposed back pain Self-Care Orientation Scale made up of the original 11 items . Factor analyses of the item set yielded three factors , but inconclusive results ; the internal consistency of the identified sub-scales was only moderate . However , findings that a subset of items predicted physician visits and prescriptions medication fills , and was sensitive to change following a self-care intervention , suggest avenues for improving measurement of self-care orientation . These findings help clarify specific patient attitudes and beliefs that are related to healthcare utilization and suggest that a subset of these beliefs can be modified through a brief educational intervention & NA ; Fear‐avoidance beliefs have been identified as an important psychosocial variable in patients with chronic disability doe to low back pain . The importance of fear‐avoidance beliefs for individuals with acute low back pain has not been explored . Seventy‐eight subjects with work‐related low back pain of less than 3 weeks ' duration were studied .  Measurements of pain intensity , physical impairment , disability , nonorganic signs and symptoms , and depression were taken at the initial evaluation . Fear‐avoidance beliefs were measured with the  work and physical activity subscales of the Fear‐avoidance Beliefs Question naire .  Disability and work status were re‐assessed after 4 weeks of physical therapy . Patterns of correlation between fear‐avoidance beliefs and other concurrently‐measured variables were similar to those reported in patients with chronic low back pain . Fear‐avoidance beliefs did not explain a significant amount of the variability in initial disability levels after controlling for pain intensity and physical impairment . Fear‐avoidance beliefs about work were significant predictors of 4‐week disability and work status even after controlling for initial levels of pain intensity , physical impairment , and disability , and the type of therapy received . Fear‐avoidance beliefs are present in patients with acute low back pain , and may be an important factor in explaining the transition from acute to chronic conditions . Screening for fear‐avoidance beliefs may be useful for identifying patients at risk of prolonged disability and work absence Background Psychosocial prognostic factors are important in the development of chronic pain , but treatment providers often lack knowledge and skills to assess and address these risk factors . Objective The aim of this study was to examine the effects on outcomes ( pain and disability ) in patients of a course about psychosocial prognostic factors for physical therapists . Design This study was a r and omized , controlled trial . Setting The setting was primary care practice . Participants Forty-two primary care physical therapists attended an 8-day university course ( over 8 weeks ) aim ed at identifying and addressing psychosocial risk factors . Intervention The physical therapists were r and omly assigned to either the course or a waiting list . They treated consecutive patients with acute and subacute musculoskeletal pain both before and after the course . Measurements We measured physical therapists ' attitudes and beliefs about psychosocial factors , knowledge , and skills before and after the course . We measured patients ' pain , disability , catastrophizing , and mood at the start of treatment and at a 6-month follow-up . Methods The physical therapists were r and omly assigned to either the course or a waiting list . They treated consecutive patients with acute and subacute musculoskeletal pain both before and after the course . Results Pain and disability outcomes in all patients of physical therapists who had participated in the course or in patients at risk of developing long-term disability who had higher levels of catastrophizing or depression were not significantly different from those outcomes in patients of physical therapists who had not participated in the course . Pain and disability outcomes in patients with a low risk of developing long-term disability— and pain outcomes in patients with a high risk of developing long-term disability — were not dependent upon whether the attitudes and beliefs of their physical therapists changed during the course . However , disability outcomes in patients with a high risk of developing long-term disability may have been influenced by whether the attitudes and beliefs of their physical therapists changed . Limitations A limitation of this study was that actual practice behavior was not measured . Conclusions An 8-day university course for physical therapists did not improve outcomes in a group of patients as a whole or in patients with a risk of developing long-term disability . However , patients who had a risk of developing long-term disability and had higher levels of catastrophizing or depression may have shown greater reductions in disability if the attitudes and beliefs of their physical therapists changed during the course The aim of this study was to examine the potential differences between beliefs relating to symptomatic and preventive inhaler treatment and to analyze the relationship between these beliefs and the use of inhalers by adult patients with asthma in general practice .  Unstructured interviews with a stratified sample of 8 patients , taking a combination of salbutamol and beclomethasone inhalers  , were used to develop themes for a structured interview , where questions relating to 8 main areas of interest were measured on a 5-point Likert scale . Forty patients prescribed the same combination of inhalers were r and omly selected for the structured interview . All agreed to participate ( 100 % response ) . Correlations between the responses to the 8 themes and measures of inhaler use were analyzed . High use of salbutamol for the relief of symptoms and low use of beclomethasone for the prevention of asthma were common . Perceived benefits of the inhalers , a positive attitude to using the inhalers , and concern about side effects had strong influences on the use of both inhalers . Uncertainty about the inhalers , a negative attitude to using the inhalers , and the involvement of others in asthma management had less influence on inhaler use . Satisfaction with the doctor and the ease of obtaining an inhaler were more important issues for beclomethasone use than for salbutamol use . There are important differences in the beliefs that patients hold in relation to symptomatic and preventive use of inhaler treatment . These findings suggest that focusing on very specific attitudes to treatment may be of benefit in the health education of adults with asthma . Further work is planned to refine the themes so that doctors will be able to explore patients ' views about their inhaler treatment by asking a few direct questions OBJECTIVE To investigate whether personal and work-related factors , physical performance and back-specific question naires predict return to work . A prospect i ve study identifying prognostic factors for return to work . SUBJECTS Ninety-three patients sick-listed for 8 - 12 weeks for non-specific sub-acute low back pain included in a r and omized controlled trial . METHODS Patients were examined with regard to demographic variables , a battery of back-specific question naires and physical tests before entering a r and omized controlled trial . A stepwise backward Cox regression model was established to identify the most powerful predictors . RESULTS During follow-up 78.5 % of the patients have returned to full-time work . Fear-avoidance beliefs for work ( relative risk ( RR ) for 1 SD change 0.49 ; 95 % confidence interval ( CI ) 0.38 - 0.64 ) , disability ( RR 1.39 , 95 % CI 1.02 - 1.88 ) and cardiovascular fitness ( RR 1.42 , 95 % CI 1.12 - 1.79 ) were identified as the best predictors for return to work . The prevalence of correct predictions was 69.3 % . CONCLUSION The predictors identified in the present study may reflect personal risk factors in a patient who gets acute low back pain . On the other h and , they may support that fear of pain and injury may be more disabling than pain itself , and that deconditioning is a result of altered behaviour reflecting attitudes towards low back pain in society , and information and advice given in primary healthcare Background and Objective : Psychological factors are assumed to predict persistent or recurrent musculoskeletal pain . The influence of psychological factors in patients with low-back pain ( LBP ) or shoulder pain was explored to study whether there is similarity regarding the factors that predict persisting pain and disability . Methods : Patients presenting in primary care with a new episode of shoulder pain or non-specific (sub)acute low back pain ( LBP ) were enrolled in a prospect i ve study . In both patient groups ,  pain catastrophising , distress , somatisation and fear-avoidance beliefs  were measured at baseline . Primary outcome measures at 3 months were ( 1 ) persistent symptoms , and ( 2 ) < 30 % reduction in functional disability .  Multivariate logistic regression analysis was used to study the associations between psychological factors and outcome . Results : A total of 587 patients with shoulder pain and 171 patients with LBP were enrolled in the study . In patients with shoulder pain , most associations of psychological factors with outcome were weak and not significant . Only in patients with longer symptom duration at baseline ( ⩾3 months ) were higher scores on catastrophising significantly associated with persistent symptoms ( p = 0.04 ) . In patients with LBP , psychological factors were more strongly associated with poor outcome , although most associations were not significant . Conclusion : Psychological factors , with the exception of fear-avoidance beliefs , are more strongly associated with persistent pain and disability in patients with LBP than in those with shoulder pain . This seems to indicate that in a primary care population the influence of psychological factors on outcome may vary across patients with different types of pain Study Design . Quasi-experimental , nonr and omized , nonequivalent , parallel group-controlled study involving before and after telephone surveys of the general population and postal surveys of general practitioners was conducted , with an adjacent state used as a control group . Objectives . To evaluate the effectiveness of a population -based intervention design ed to alter beliefs about back pain , influence medical management , and reduce disability and workers ’ compensation – related costs . Summary of Background Data . A multimedia campaign begun during 1997 in Victoria , Australia , positively advised patients with back pain to stay active and exercise , not to rest for prolonged periods , and to remain at work . Methods . The campaign ’s impact on population beliefs about back pain and fear-avoidance beliefs was measured in telephone surveys , and the effect of the campaign on the potential management of low back pain by general practitioners was assessed by eliciting their likely approach to two hypothetical scenarios in mailed surveys . Demographically identical population groups in Victoria and the control state , New South Wales , were surveyed at three times : before , during , and after intervention in Victoria . Results . The studies were completed by 4730 individuals in the general population and 2556 general practitioners . There were large statistically significant improvements in back pain beliefs over time in Victoria ( mean scores on the Back Beliefs Question naire , 26.5 , 28.4 , and 29.7 ) , but not in New South Wales ( 26.3 , 26.2 , and 26.3 , respectively ) . Among those who reported back pain during the previous year , fear-avoidance beliefs about physical activity improved significantly in Victoria ( mean scores on the Fear-Avoidance Beliefs Question naire for physical activity , 14 , 12.5 , and 11.6 ) , but not in New South Wales ( 13.3 , 13.6 , and 12.7 , respectively ) . General practitioners in Victoria reported significant improvements over time in beliefs about back pain management , as compared with their interstate colleagues . There were statistically significant interactions between state and time for 7 of 10 responses on management of acute low back pain , and for 6 of 10 responses on management of subacute low back pain . Conclusion . A population -based strategy of providing positive messages about back pain improves the beliefs of the general population and general practitioners about back pain and appears to influence medical management Back pain is a common illness and chiropractors provide a large proportion of back pain care in the United States . This is the first study to systematic ally compare  chiropractic patients with those who saw other providers for back pain . The authors analyzed data from the R AND Health Insurance Experiment , a community-based study of the use of health services . Insurance cl aims forms were examined for all visits specified by the patient as occurring for back pain . Visits were grouped into episodes using decision rules and clinical judgment . The primary provider of back pain care was defined as the provider who delivered most of the services . Sociodemographic and health status and attitudes variables of patients were examined for association with the choice of chiropractor . Multivariate logistic regression models were constructed to calculate adjusted odds ratios for independent predictors . There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits . Results indicated that chiropractors were the primary provider for 40 % of episodes , and retained as primary provider a greater percentage of their patients ( 92 % ) who had a second episode of back pain care than did medical doctors . Health insurance experiment site , white race , male sex , and high school education were independent predictors of choosing a chiropractor . Conclusions suggested that chiropractors were the choice of one third of all patients who sought back pain care , and provided care for 40 % of all episodes of care . Geographic site , education , gender , and income were independent patient factors predicting chiropractic use OBJECTIVE This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain ( LBP ) and assesses the influence of doctor type and pain duration on clinical outcomes . DESIGN Prospect i ve , longitudinal , nonr and omized , practice -based , observational study . SETTING Fifty-one chiropractic and 14 general practice community clinics . SUBJECTS A total of 2870 acute and chronic ambulatory patients with LBP of mechanical origin . METHODS Sixty chiropractic ( DC ) and 111 general practice ( MD ) physicians participated . Primary outcomes were pain , using a 100-point visual analogue scale ( VAS ) , and functional disability , using the Revised Oswestry Disability Question naire . These were measured at baseline and 8 time points . Regression analysis compared acute and chronic DC and MD patients after correcting for baseline differences in the 4 cohorts . RESULTS Most improvement was seen by 3 months and sustained for 1 year ; exacerbation was seen thereafter . Acute patients demonstrated greater relief at all time points . A clinical ly important advantage for chiropractic patients was seen in chronic patients in the short-term ( > 10 VAS points ) , and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year ( P<.000 ) . The advantage for DC care was prominent for chronic patients with leg pain below the knee ( P<.001 ) . More than 50 % of chronic patients had over 50 days of pain in the third year . CONCLUSION Study findings were consistent with systematic review s of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP . Patient choice and interdisciplinary referral should be prime considerations by physicians , policymakers , and third-party payers in identifying health services for patients with LBP We previously reported the positive results of a  population based campaign design ed to alter beliefs about back pain in Victoria , Australia.1 2 The campaign consisted of television commercials which gave clear advice about back pain — for example , stay active and exercise , do not rest for prolonged periods , and stay at work . After the intervention , doctors ' and the community 's beliefs about back pain became significantly more positive , and the number of workers ' cl aims for compensation and medical payments for back pain had declined . To measure sustained change in beliefs about back pain three years after the campaign ended , we repeated telephone surveys in Victoria and in adjacent New South Wales as a control . We used computer assisted question naires given by telephone interview to a r and om sample of the population of Victoria and New South Wales in December SUMMARY OF BACKGROUND DATA AND OBJECTIVES Alternative health care was used by an estimated 42 % of the U.S. population in 1997 , and chiropractors accounted for 31 % of the total estimated number of visits . Despite this high level of use , there is little empirical information about who uses chiropractic care or why . METHODS The authors surveyed r and omly sample d chiropractors ( n = 131 ) at six study sites and systematic ally sample d chiropractic patients seeking care from participating chiropractors on 1 day ( n = 1275 ) . Surveys collected data about the patient 's reason for seeking chiropractic care , health status , health attitude and beliefs , and satisfaction . In addition to descriptive statistics , the authors compared data between patients and chiropractors , and between patients and previously published data on health status from other population s , corrected for the clustering of patients within chiropractors . RESULTS More than 70 % of patients specified  back and neck problems  as their health problem for which they sought chiropractic care . Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample . Compared with medical back pain patients , chiropractic back pain patients had significantly worse mental health ( 6 - 8 point decrement ) . Rol and -Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients . The health attitudes and beliefs of chiropractors and their patients were similar . Patients were very satisfied with their care . CONCLUSION These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system OBJECTIVE To evaluate reliability , validity and responsiveness of the Fear-Avoidance Beliefs Question naire ( FABQ ) for use in Norwegian patients with low back pain . DESIGN A prospect i ve cohort study with 2 groups . PATIENTS The question naire was tested in 123 patients with acute low back pain and 50 patients with chronic low back pain . METHODS A translation and cross-cultural adaptation was performed . Test-retest reliability was assessed in 28 patients with chronic low back pain . Responsiveness was assessed in acute low back pain . RESULTS Two factors for the FABQ were confirmed ; fear-avoidance beliefs about work ( FABQ-Work ) and physical activity ( FABQ-PA ) , accounting for 60 % and 54 % of the total variance in acute and chronic low back pain , respectively . For FABQ-Work and FABQ-PA internal consistency was 0.90 and 0.79 , intra-class correlation coefficients 0.82 and 0.66 , minimal detectable changes 12 and 9 points , and coefficients of variation were 16 % and 23 % . The FABQ correlated weakly to moderately with pain , disability , distress , and clinical variables . St and ardized response means were low for FABQ-Work ( 0.32 ) and moderate ( 0.56 ) for FABQ-PA . Both FABQ subscales showed initially floor and /or ceiling effects . CONCLUSION The Norwegian FABQ version had acceptable factor structure , internal consistency , test-retest reliability and construct validity . The responsiveness of the FABQ-Work was low , and for the FABQ-PA moderate , in the acute sample INTRODUCTION During the last 20 years a great number of studies have emphasized the potential role of psychological factors as relevant predictors for the first onset of back pain as well as for the development of chronic pain . The formulation of a biopsychosocial perspective of the etiology and chronicity of back pain was a natural consequence . Actual questions concern the relative impact of psychological risk factors in the process of chronicity of back pain compared to biomedical , social and occupational factors . METHODS Whereas several review articles regarding the role of psychological risk factors are available up to now , a recently published review conducted by Steven Linton was the first systematic analysis of well controlled prospect i ve studies published since 1967 . Using a grading system similar to that recommended for guidelines the author defined a level A evidence when at least two good- quality prospect i ve studies supported the prospect i ve power of a variable . Level B evidence had support from one prospect i ve study . Level C represented inconclusive data and level D indicated that no studies met the criteria . Based on a literature search of more than 900 studies , 37 good- quality prospect i ve studies were analysed in detail . RESULTS The results indicated level A evidence for the following interrelations : ( 1 ) Psychosocial variables , especially chronic distress in daily life , depression and work dissatisfaction were clearly associated with the onset of back and neck pain ( 2 ) . Psychological variables , especially chronic stress in daily life , work dissatisfaction , depression and pain-related cognitions and coping behaviour were clearly linked to the transition from acute to chronic pain and disability ( 3 ) . Psychological variables generally had more prospect i ve power than biomedical , social or objective occupational variables . Among the pain-related cognitions , catastrophizing and fear-avoidance-beliefs yielded the most empirical support . Among coping behaviour passive coping stretegies such as avoiding behaviour was most important . At least level B evidence has been shown for the counterpart of an extreme suppressive coping behaviour . Patients who tended to suppress or ignore pain in order to finish all activities they started , who were unable to integrate phases of passive relaxation into the daily routine displayed a high risk of chronicity of pain 6 months after an acute phase of pain . One international and two German good- quality prospect i ve studies have shown the predictive power of a maladaptive suppressive behaviour pattern . Based on the avoidance-endurance-model of pain chronification , both extreme and one-sided passive pain coping as well as one-sided suppressive coping modes were conceptualized as maladaptive due to the process of chronicity . We assume that extreme passive behaviour will lead to immobility and muscular atrophy . Neurophysiological processes of sensitization will further lead to the development of chronic pain . On the other h and , extreme suppressive behaviour will lead to an overuse of muscles and joints with a repetitive combination of muscular hyperactivity and pain . These repetitive pain experiences will also elicit neurophysiological processes of sensitization . ( 4 ) Psychosocial variables displayed more predictive power than biomedical or biomechanical factors . ( 5 ) Psychosocial factors may be used as predictors of the risk for developing long-term pain and disability . Mixed empirical evidence has been shown for the role of personality factors ( level C evidence ) and no support has been found for the idea of a " pain prone " personality disorder or for the role of sexual and physical abuse . DISCUSSION 20 years of research , several qualitative review s and a recently published systematic review of 37 good- quality prospect i ve studies regarding the role of psychological , biomedical , social and objective occupational factors in the process of chronicity of back pain revealed that psychological factors are significantly related to the onset of back pain as well as to the development of chronic pain . Furthermore , the psychological factors displayed more predictive power than biomedical or biomechanical variables . As a consequence for clinical practice , these psychological risk factors have to be considered as " yellow flags " if a back pain problem wo n't respond to medical treatment for more than four weeks . As a further consequence , special risk factor - based psychosocial interventions should be offered in addition to the medical treatment to patients with high psychological risk factors for the development of chronic pain . The efficacy of such an interdisciplinary care in the very early phases of back pain in order to prevent chronicity of pain and disability has been published recently by our group A systematic review of r and omised controlled trials was undertaken to evaluate the effectiveness of  workplace interventions  to prevent low back pain .  Potential trials were located by a computerised search supplemented with citation tracking . The method ological quality of the trials was assessed on 11 criteria and the level of evidence for each intervention was determined , based upon the amount , consistency and quality of evidence from the trials . The review located 13 trials that were generally of moderate quality . The trials suggest that work place exercise is effective , braces and education are ineffective , and workplace modification plus education is of unknown value in preventing low back pain Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing A new r and omised controlled trial of intervention in low back pain has been described recently . In this trial , a screening and targeted approach was found to be more effective and cost-effective than current best practice . Nested within the intervention arm were three different interventions targeting patients identified as ' low ' , ' medium ' or ' high ' risk dependent on the presence of ( mainly ) psychosocial risk factors . In this paper , the development and content of the STarT Back trial 's ' high-risk ' intervention is described . It offers a systematic approach , termed ' psychologically informed practice ' , to the integration of physical and psychological approaches to treatment for the management of people with low back pain by physiotherapists . The term ' disability ' is used to refer to self-reported pain-associated functional limitations , and ' psychological ' is used to refer to the beliefs/expectations , emotional responses and behavioural responses associated with low back pain BACKGROUND AND PURPOSE We surveyed physical therapists about their attitudes , beliefs , and treatment preferences in caring for patients with different types of low back pain problems . SUBJECTS AND METHODS Question naires were mailed to all 71 therapists employed by a large health maintenance organization in western Washington and to a r and om sample of 331 other therapists licensed in the state of Washington . RESULTS Responses were received from 293 ( 74 % ) of the therapists surveyed , and 186 of these cl aim ed to be practicing in setting s in which they treat patients who have back pain .  Back pain was estimated to account for 45 % of patient visits . The McKenzie method was deemed the most useful approach for managing patients with back pain , and education in body mechanics , stretching , strengthening exercises , and aerobic exercises were among the most common treatment preferences . There were significant variations among therapists in private practice , hospital-operated , and health maintenance organization setting s with respect to treatment preferences , willingness to take advantage of the placebo effect , and mean number of visits for patients with back pain . CONCLUSIONS AND DISCUSSION These variations emphasize the need for more outcomes research to identify the most effective treatment approaches and to guide clinical practice
Themes that emerged included doctors ' attitudes and beliefs , and four factors that influenced attitudes and beliefs : doctors ' specialty , demographic factors , personal beliefs and education .
There was consistent evidence that doctors ' specialty impacted their attitudes and beliefs : lack of consensus regarding the natural history of LBP , around treatment options , and issues regarding work .
There was inconsistent evidence that demographic factors ( age ) and level of education impacted doctors ' attitudes and beliefs .
Long term , these changes in these areas have the potential to maximise patient-care , and reduce costs to health services
The aim of this systematic review was to determine the attitudes and beliefs of doctors to acute low back pain , and the factors that influence these .