http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(11): 936–941 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.948135
RESEARCH PAPER
Low back pain patients’ beliefs about effective/ineffective constituents of a counseling intervention: a follow-up interview study Niels Buus1, Lone Donbæk Jensen2, Thomas Maribo3, Birgitte Krøis Gonge2, and Sanne Angel4 1
Institute of Public Health, University of Southern Denmark, Odense C, Denmark, 2Department of Occupational Medicine, Danish Ramazzini Center, Aarhus University Hospital, Aarhus, Denmark, 3Department of Rehabilitation, Public Health and Quality Improvement, Marselisborg Centret, Aarhus, Denmark, and 4Institute of Public Health, Aarhus University, Aarhus, Denmark
Abstract
Keywords
Purpose: Everyday activities are important factors for avoiding the development of chronic low back pain (LBP). The purpose this study was to explore LBP patients’ perspective on long-term effects of participating in a counseling intervention designed to motivate them to change work routines and to exercise. Method: Follow-up qualitative study. Semi-structured interviews were made of 25 LBP patients who had received the counseling intervention. Interviews were transcribed and explored with an interpretative thematic analysis. The findings were organized around Kleinman’s conception of ‘‘explanatory models’’. Results: For the individual participant the beliefs about the illness were internally coherent, but most often they were idiosyncratic and fitted to the particular participants’ overall explanatory model. Participation in the counseling intervention had created a sense of certainty and potential control over the disease and had legitimized their sick role at work and at home. The majority of the patients reported having integrated exercise into their explanatory models and understood exercise to be beneficial in their continual and concrete management of their LBP. Conclusions: The intervention had affected the patients’ personal agency and space for action. We suggest that this effect was linked to the individually tailored approach drawing on both educational and motivational agents.
Directive counseling, exercise, low back pain, occupational health, qualitative research History Received 8 October 2013 Revised 13 April 2014 Accepted 21 July 2014 Published online 8 August 2014
ä Implications for Rehabilitation
Maintaining everyday activities, including retaining one’s occupation, is an important factor in low back pain rehabilitation. Counselling on low back pain rehabilitation must be aligned with people’s beliefs about their illness. A counselling intervention made patients adopt exercising into their long-term management of low back pain.
Introduction It has proved to be difficult to design effective bio-psychosocial intervention programs for sustaining people’s jobs and everyday activities [1]. Maintaining everyday activities, including retaining one’s occupation, is an important factor in avoiding the development of chronic low back pain (LBP) [2]. A central challenge in the rehabilitation of people with LBP is therefore to overcome the occupational and psychosocial barriers for a safe return to work. Further, physical activity can reduce chronic and sub-acute LBP [3], and may also effectively stimulate return to work [4]. Patients’ personal beliefs about illness and treatment are major determinants of health behavior, and patients’ perspectives
Address for correspondence: Niels Buus, User Involvement, Institute of Public Health, University of Southern Denmark, J.B. Winsløwsvej 9B, 5000 Odense C, Denmark. Tel: +45 6550 4400 (office); +45 2814 1517 (mobile). Fax: +45 6550 3682. E-mail: [email protected].
on LBP have been extensively examined in qualitative studies [5–9]. These studies have emphasized an array of problems of personally experienced challenges related to living with unpredictable pain, diagnostic uncertainty and illegitimate sick roles, as well as social isolation and fear of losing work. The study of patients’ personal beliefs about illness and treatment is complex. This is, firstly, because patients draw on socially and culturally available notions of illness to recognize and describe their concrete experiences of illness [10], and, secondly, because patients’ describe their experiences of illness relative to the conversational context [11]. Ong et al. [7] exemplified both points in a study of how LBP patients describe their encounters with clinicians. The patients drew on clinical vocabulary or juxtaposed it with lay terminology in order to make their experiences of LBP appear authentic during the clinical encounter, and, at the same time, they positioned themselves during the research interview by stating that they fulfilled their social obligations despite the pain and that there was tangible clinical evidence explaining the pain [7].
Low back pain patients’ beliefs
DOI: 10.3109/09638288.2014.948135
LBP and the treatment of LBP are not isolated parts of patient’s lives [12–14], and it is within this wider context of patients’ lives that the introduction of new health care actions inevitably will be in conflict with and compete with existing habits regarding time and attention [15,16]. Previous studies in this area of research have been focused on the impact of LBP on people’s lives, for instance by reporting two coping strategies among LBP patients: They either ignore the pain and live as normally as possible or, at the other extreme, organize their lives round their concerns for their LBP [8,13]. Much less emphasis has been put on examining the LBP treatment’s impact on people’s everyday lives. Changing and sustaining change of behavior is central in health care interventions and may target one or more strategies to introduce new habits in patients’ everyday life. We designed and tested a simple, short time secondary prevention counseling intervention strategically encouraging patients’ motivation to personally engage in their own LBP treatment by changing work routines and by exercising. Counseling was individually tailored and included both emotional and cognitive-behavioral elements [17]. The trial participants were Danish LBP patients who, independently of sick leave status, expressed concerns about their ability to maintain their current job. The intervention consisted of two counseling sessions conducted by an occupational physician addressing both workplace barriers and leisure-time physical activity. A workplace visit was carried out if it was required. The intervention was given in addition to treatment as usual, which included a brief introduction to exercising and two tests of physical performance. The results indicated that the counseling intervention had a significant, positive effect on the participants’ pain, physical functioning and self-reported sick leave after three months [17]. We have previously reported from a qualitative analysis of clinical interview data from the intervention [5], and this analysis suggested that most participants described themselves as successful in adopting advise/new insight from the counseling session into their everyday lives. In the present study, we wanted to study if and how the participants were able sustain these changes in their long-term management of their LBP problems. In this study, we draw on the social theory ‘‘interactionism’’ [18] to conceptualize patients’ beliefs about health and illness and their actions related to health and illness. According to this psychosocial framework, people perceive their environment according to their personal perspective, which is an ordered set of ideas, and their actions flow reasonably from this perspective [19]. The links between ideas and actions are neither causal nor pre-sequenced. In some instances, actions flow from and are justified by ideas; in others, ideas are developed post hoc to justify actions; and, finally, actions and ideas may develop simultaneously, when a person is confronted by an unusual and challenging situation. An examination of people’s perspectives presupposes interpretation of their statements and actions. We designed a qualitative interview study [20,21] to explore the LBP patients’ perspectives on receiving the counseling intervention. Qualitative methods are appropriate for gaining nuanced insight into changes of patients’ everyday lives, and the study of the patients’ perspective can be seen as a comprehensive and unique way of accounting for the effects of health care interventions, which can be used for designing counseling interventions that are capable of changing and sustaining health behavior. The aim of the study was to explore the LBP patients’ beliefs about effective/ineffective constituents of the intervention and how they understood them as having/not having affected their personal agency and space for action in their everyday lives.
937
Methods Design Qualitative follow-up interviews with 25 LBP patients 1–4 years after concluding the counseling intervention. Participants The study population included participants from the intervention arm of the trial who had completed follow-up (n ¼ 110), and we posted invitations to potential interview participants. We used scores from the Fear Avoidance Beliefs Questionnaire (FABQ) (the difference between the trial’s baseline scores and follow-up scores) to strategically recruit a sample with both minor and major benefits of the intervention. The purposeful sample [22] included 25 participants (see a description of the sample and a comparison to the study population in Table 1). Interviews Two trained and experienced research-interviewers (N.B. and S.A.) performed the semi-structured interviews in January-April 2012. Participants and the interviewers had no relationship prior to the interview. The interviews lasted 45 minutes on average (range 12–78). The interviews were mostly conducted at the participants’ homes or, occasionally, at the Department of Occupational Medicine. The interviewers used an interview guide, which included open-ended questions about the participants’ ‘‘explanatory models of illness’’ as well as their experiences of participating in the intervention and to what extent the intervention had influenced their everyday life and their ability to work (see an outline of the interview guide in Table 2). An ‘‘explanatory model of illness’’ is a flexible set of ideas about a particular illness episode, which typically includes ideas about aetiology, onset and timing, pathophysiology, course of illness and sick role, and treatment [10]. All interviews were digitally recorded and transcribed verbatim by research assistants, and the accuracy of each transcript was checked against the recording by the interviewers.
Data analyses The interpretative thematic analysis [23] consisted of four stages. First, two researchers (N.B and S.A.) coded the dataset using a preliminary, open ‘‘incident to incident’’ [24] strategy, which led to the construction of 14 distinct categories that were used to systematically compare the 25 participants. The categories included: ‘‘how it all began’’, ‘‘perspective on exercise’’ and ‘‘managers and colleagues at work’’, etc. and the categories were compared across the participants by inquiring, for instance, how was ‘‘how it all began’’ described by different participants and how could similarities and differences be explained? Second, open coding was succeeded by a theory-driven reorganization of the codes around three new categories in line with Kleinman’s notion of explanatory models: A. Beliefs about illness (onset, causes and pathophysiology), B. Beliefs about the course of illness and sick role and C. Beliefs about treatment. This reorganization was made in order to prioritize between the codes and focus the analysis on the research question. Third, participant’s perspective on receiving the counseling intervention was constructed by interrogating these three categories by systematically comparing the participants’ explanatory models. Memos [24], analytical reflections, were written and gradually developed throughout all stages of the analysis and formed the basis for the final interpretation. Fourth, the original transcripts were re-read aiming at challenging and corroborating a balanced and nuanced interpretation of the themes.
938
N. Buus et al.
Disabil Rehabil, 2015; 37(11): 936–941
Table 1. RCT baseline characteristics of the study population (the RCTs intervention group completing follow-up) and the study sample (interviewees). Study population [n ¼ 110]
Study sample [n ¼ 25]
46.2 [9.5] 50.9 26.6 [4.3] 23.2
46.8 [8.6] 56.0 25.7 [4.8] 12.5
21.8 20.9 57.3 40.9 19.2 14.6
20.0 20.0 60.0 44.0 20.8 16.0
Current job DISCO 1: leaders and high educated (%) DISCO 3,4,5: office, teaching and nursing (%) DISCO 6,7,8,9: blue collar (%) Rate of Perceived Exertion; physical strain [0–14], mean [SD]
25.5 53.6 20.9 5.8 [3.0]
16.0 56.0 28.0 5.9 [2.9]
Quality of life SF-36 Physical Component Summary, mean [SD] SF-36 Mental Component Summary, mean [SD]
38.2 [8.9] 51.5 [8.8]
37.2 [9.7] 51.2 [9.2]
Psychosocial factors Fear-Avoidance Beliefs – work [0–30], mean [SD] Fear-Avoidance Beliefs – physical activity [0–24], mean [SD]
11.4 [7.9] 11.2 [5.1]
13.3 [7.8] 11.8 [5.0]
Pain Numerical Rating Scale [0–10], mean [SD] SF-36 bodily pain [0–100], mean [SD]
6.5 [2.6] 45.1 [20.2]
6.9 [2.4] 42.8 [20.8]
Function Roland Morris Questionnaire [0–23], mean [SD] SF-36 physical functioning [0–100], mean [SD] Maximal oxygen uptake [ml2/min/kg], mean [SD]
11.7 [5.9] 68.0 [22.6] 29.9 [8.8]
11.8 [6.1] 67.4 [21.6] 29.7 [7.8]
Age, mean [SD] Female gender (%) Body Mass Index, mean [SD] Current Smoking (%) Quebec Task Force classification 1: without radiating pain (%) 2: with radiating pain, not below knee level (%) 3: with radiating pain below knee level (%) 4: neurologic deficit (%) On-going workers compensation (%) 540 weeks of work within the 2nd year of inclusion (%)a
DISCO: The Danish version of the International Standard Classification of Occupations [D ISCO 88]. Register-based data.
a
Table 2. Outline of the thematic, non-standardized interview guide. Explanatory models of low back pain How did your low back pain problems begin? In your own words, what do you think caused the problems? How did it affect your everyday life and your work life? Where did you seek assistance? What happened? Motivation for adhering to agreements made during intervention Describe in detail what you experienced during the intervention? What did you bring home from the intervention? Were there issues discussed/exemplified/presented during the intervention thatyou found important consideringyour particularly situation? Which? Did the intervention affect your ability to sustain your occupational job? How? Suggestions for improvements of the intervention Did you feel safe and ready to manage your low back problems on your own after the intervention had ended?
Ethics In full concordance with Danish legislation, the Danish Data Protection Agency was notified about the interview study. There were no objections to the study’s approach, and the Danish Data Protection Agency’s regulations regarding data storage were observed throughout the study. All participants gave their consent to participate based on written and verbal information about the study. Data were handled anonymously.
Results The participants’ perspective on the intervention and how they understood it as possibly having affected their personal agency
and space for action in their everyday lives will be presented under three headings: the illness, course of illness and sick role, and treatment. Theme 1. The illness The first theme was concerned with the participants’ beliefs about the onset, causes and pathophysiology of the illness. For the individual participant the beliefs about the illness were internally coherent, but most often they were idiosyncratic and fitted to the particular participants’ overall explanatory model. Most participants understood their problems as caused by a strenuous working life and/or as linked to an inborn weak back. Two participants understood their problems as being caused by external trauma. All participants accounted for their illness with a high level of certainty regarding the character of the illness. The explanations were not elaborate, but idiosyncratic and complex descriptions that combined medical terminology, such as ‘‘a herniated disc’’, with lay metaphors, such as ‘‘something toothpaste-like is pressed against the discs that look like onion rings’’ (Participant 18). There were two distinct explanations of the present LBP problems, reflecting an understanding of an intermittent or a more continuous LBP problem. The first was to understand recurring unpleasant experiences of the stiffening of muscles as an early warning of severe crisis in the spine, which could be avoided by taking appropriate actions, such as exercising or massage. The second was to understand pain as a relatively predictable response to particular strenuous activities, which had to be managed with rest and pain-relieving medication.
Low back pain patients’ beliefs
DOI: 10.3109/09638288.2014.948135
The counseling intervention’s focus on creating relief at work made intuitive sense for all participants. Contrary to this, the advice about exercising had been surprising for many and counterintuitive for some. When participant 22, a 54-year-old woman, was introduced to the idea of exercising she found it counterintuitive, because she was used to lie passively on the couch when she was in pain. It was turned upside down for me. I was told that that worst thing to do is to sit down or lie down and just do nothing. I’ve been wondering, because I was told that my lower vertebrae were worn down. It might have improved. New cartilage may have been formed or something like that. (Participant 22) Participant 22 believed that a worn down back caused her pain, and she explained her experienced improvement by suggesting that new cartilage could have counteracted the deterioration. Participant 22’s reasoning combined clinical knowledge and lay knowledge and illustrated the flexibility of her explanatory model. While some participants saw exercising as a way to strengthen a weak back, others feared that exercising would damage it further. Despite the professional counseling, the basic lay idea was, that exercising could cause fragile joints to disjoint or break, or that exercising would wear a worn down back even further down. The participants had developed meaningful and acceptable perspectives on their illness that were integrated into their personal biographies on the basis of their illness experiences and contacts with health care providers. Theme 2. Course of illness and sick role The second theme was concerned with the participants’ beliefs about the course of illness and with their expectations of the sick role. In particular, this included the participants’ beliefs about the legitimacy of their evolving problems – at home and at work. The interviews indicated that most participants changed their understanding of the course of illness during or after the intervention and that the few remaining participants used the counseling sessions as a confirming second opinion. Most participants stated that before the intervention they felt powerless in the face of their LBP and feared that it would be chronic, but that the intervention had created a sense of certainty and potential control. Participant 3, a 62-year-old man, was frustrated because none of the clinicians, he had previously consulted, would give him straight answers as to what caused his LBP. However, during the counseling session, he had come to understand and accept that it was common not to have complete certainty and tangible evidence about the cause of LBP.
939
accomplishment. Most participants described how the counselor’s focus on workplace conditions encouraged them to ask for changes at their present work, to ask for a period with special privileges or inspired them to look for less strenuous work. Participant 11 was a 57-year-old woman and her LBP was classified as a work-related injury. She felt that her colleagues had been accommodating in relieving her from physical strain, but she was convinced that these privileges would not last forever and had started to look for other solutions. Considerations were taken. I did not have to lift children [working at a nursery]. But I knew that there were limits to colleagues’ good will. I’d seen it before. At some points it’s ‘‘get cracking’’, and they’d think that about me too. And that was when Liz [the counselor] came and we talked about my options (. . .) she organized that I could lie down on a mattress and stretch my back at noon. (Participant 11) The counselor was instrumental in suggesting ingenious practical arrangements that could give the participant some relief. Furthermore, most of the participants who had a work place visit stated that the occupational physician’s presence legitimized their problems towards work place management. However, the interview participants did not ascribe eventual lasting effects of changed workplace conditions to the intervention, but regarded long-term changes at the workplace as caused by their own initiative, luck and ingenuity. The counselor’s advice about physical activity was reinforced during the physical tests. The participants described the tests as surprising, either because their objective physical capability was much poorer than they had anticipated and/or because they were able to exercise in ways they were convinced they could not, for instance, Participant 8 stated her surprise to find out that she at age 31 was unable to stand on her toes without falling over: ‘‘I was astonished that it was so bad that I couldn’t keep my balance and that stuff, and I thought ‘‘Blimey, this is completely wrong.’’’’ (Participant 8). All participants found that the intervention had concentrated on their personal initiative and efforts, which were potentially a means to achieve better management of their illness. However, the participants identified different parts of the intervention as crucial for increasing their personal engagement and changing their sick role, for instance: Being emotionally calmed down by the counselor; a reinvigorated self-confidence in own physical capabilities; a personal quest to improve physical scores at follow-up; a legitimate focus on potential change at work and realistic and even enjoyable changes of everyday life. Theme 3. Treatment
Liz [the counselor] said it in a different way. She said that that there are many small muscles that we know only little about and we can’t see. She looked me in the eyes much more than she examined by back. The first therapist said that nothing could be done, which was very unsatisfying. (Participant 3) Participant 3 found it important to have his personal concerns addressed by a reassuring professional. In line with participant 3, several participants described having initially struggled to convince therapists of the severity of their LBP problems, but that the counselor had legitimized their experienced problems, for instance by emphasizing that their problems were real even though the symptoms were not confirmed objectively by X-ray images or MRI. In spite of LBP, all participants had tried to continue going to work because of a strong sense of obligation and personal
The third theme was concerned with the participants’ beliefs about treatment and effective everyday management LBP. All participants believed that exercising was an effective treatment of LBP, and most participants stated that they continued to use exercising proactively against recurring LBP problems after the intervention had ended. However, three participants explained that the character of their particular illness made them exemptions to the rule. Participant 21, a 54-year-old woman, believed that it was very important to stay active to counter LBP, but that her back was so worn down, that it prevented her from exercising: ‘‘It is important to exercise your back. I’ve always done that, but my back is worn down and I can’t do it’’. Therefore, her beliefs about her back made it counterintuitive to follow the counselors’ advice about exercising. Most participants stated that their LBP problems were presently manageable and they linked their progress to either
940
N. Buus et al.
changes in their work situation, such as new functions, new jobs, or early retirement, or to their proactive use of exercising. A few participants continued full body exercising several times a week, as recommended during the intervention, while most participants created less extensive routines for keeping their back healthy. These routines included full body exercising in combination with back strength training and caution about specific activities. Several participants were convinced about an absolute minimum number of exercises needed to keep their problems at bay. Participant 7, a 42-year-old man, had suffered from LBP since his teens and was convinced that the key to his successful management was to accept that he would always suffer from LBP – also when he had no pain. He had adopted advice from the counseling sessions and set up some basic rules about alcohol and lifting that he would not allow himself to break: ‘‘My back could be a mess if I don’t observe the rules I’ve set up for myself’’. Most participants struggled being motivated to continue exercising during and after the intervention. Participant 16, a 38-year-old woman, stopped exercising because she did not experience any pain, which was a crucial motivator: ‘‘I quit exercising after a couple of years. When there is no pain, you don’t do it. I was very resolute about exercising, but when I felt strong again, I was not quite as motivated’’. A few were explicitly downright bored with exercising and stopped as soon as they felt improvement, while others stated that they continued exercising until disability or competing obligations made it impossible for them to continue. Despite the participants finding exercise therapeutic, many participants stated that they felt too much on their own after the intervention, where they were instructed to continue exercising while observing reactions from their body. They suggested that patients should have further professional follow-up to give them certainty about treatment of their illness.
Discussion We explored the participants’ perspectives on receiving the counseling intervention by means of a qualitative research strategy based on an interpretative analysis of non-standardized, rich data from a relatively small number of participants [25]. The interview guide included open-ended questions, which stimulated nuanced accounts of explanatory models and experiences during the intervention. The qualitative analysis indicated that the majority of the interview participants integrated exercising into their explanatory models and understood exercising to be more or less beneficial in their continual and concrete management of their LBP problems. Making sense of and finding personally and socially legitimate explanations of LBP problems is crucial for LBP patients [7,8,26,27]. Patients’ construction of acceptable explanatory models has been described as crucial for restoring their hope for the future [9]. Qualitative research has indicated that LBP patients search and try to determine objective reasons for their pain [28,29]. They may use medical terminology to further legitimize their explanations [30], which in some situations will be in conflict with their personal experiences [31]. The majority of the participants in the present study had vague and general explanations of their illness, which could indicate that they at the time of interviewing were no longer in a position dominated by intense needs for legitimizing their LBP problems by referring to medical tests and terminology. It was likely that the need for officially legitimate explanations diminished as problems were managed in everyday life. In the same vein, research has emphasized the uncertain and unpredictable character of LBP [6,32]. In opposition to this, the majority of participants described
Disabil Rehabil, 2015; 37(11): 936–941
their (recurring) LBP as treatable and relatively controllable, which could indicate a high level of control over the course of the illness. It is possible, that these differences came forth because the studies included different samples of LBP patients who were at different stages of their illness careers and had time to learn new ways to accept and manage their pain. The participants recalled prominent experiences during the counseling intervention that were meaningful for them in their particular situation. They had adapted some of these experiences into their explanatory models, and they described how their explanatory models influenced their present day management of their LBP problems. In particular, the participants’ had adopted and adapted exercising into their explanatory models and used it actively – some continually others intermittingly – in their practical management of their LBP problems. On the basis of the dataset, we suggest that the encouragement of the patients’ motivation combined with a counselor’s skillful suggestions on how to gently fit exercising into the particular patient’s everyday life was one of the crucial influences on the self-reported longterm effect reported here. Further exploration of such long-term adaption of counseling advice would benefit from collecting ethnographic data from patients’ everyday lives, such a diaries, self-presentation photos, observation of contact with health care professionals, etc. When LBP patients return to work, they are reportedly troubled by uncertainty about their physical capabilities and about recognition from managers and colleagues [33,34]. The participants described similar concerns about their work situation and described some short-term benefits of the intervention. However, they did not regard the strategies targeting workplace changes as having long-term effects and did not adopt such strategies to the same extent as they took up exercising. Special privileges at work may be viewed as temporary opportunities because workers want to appear loyal and responsible [12], and, therefore, these strategies were not acceptable for the LBP patients over time. In line with our trial of the counseling intervention [17], a recent trial tested ‘‘motivational interviewing’’ [35] in addition to tailored physical therapy to LBP patients and identified significant positive changes of motivation and exercise compliance as well as physical function [36]. We believe that such testing and measuring the short-term effects of such interventions are important, but that they should be accompanied by examinations of the more general effects on people’s everyday lives. The sampling strategy was to recruit all interview participants 1–2 years after they had completed the intervention, which was considered an appropriate balance between, one the one hand, sufficient time for eventual long-term effects of the counseling intervention to be adapted into everyday life, and, on the other hand, not too long to hamper the participants’ ability to recall the events linked to the counseling intervention. Unfortunately, the planned strategy was not feasible because of an unexpected low rate of consent and we decided to gradually invite all trial participants. This influenced on some interview participants’ ability to recall details about the counseling, but not on the participants ability to draw together events round their LBP management into a temporally organized whole. Furthermore, all participants had gone through a specialized evaluation at a rheumatological outpatient clinic before participating in the intervention and many had been in contact with several health care services after the counseling intervention had ended. Their explanatory models were complex and it was not possible to link the emergence and/or change of particular ideas to particular encounters at work or with health care providers, including educational and motivational agents during the counseling intervention.
Low back pain patients’ beliefs
DOI: 10.3109/09638288.2014.948135
Finally, the sampling strategy aimed at recruiting participants with both minor and major benefits of the intervention. However, almost all the interview participants spoke very favorably about the intervention, and it is possible that trial participants that did not experience benefits from the intervention were less likely to participate in an interview. However, as indicated by Table 1, the sample did not differ significantly from the population at the RCTs baseline. Having two researchers interviewing, coding the total dataset, sharing memos and developing interpretations together ensured trustworthiness and rigor in the interpretative process. We did not regard this as a way of increasing precision in the interpretations, but as a way of stimulating dialog, creativity and reflexivity, and thus suggesting several ways of reading the dataset, which inspired and balanced the interpretative process.
Conclusions It had been crucial that the counselor could reconcile the participants’ perspective on the illness with the idea that exercising the back would not be harmful and could be beneficial, and the present follow-up study could indicate a successful longterm secondary prevention strategy. Most participants described that they had adapted and adopted exercising into their everyday management of LBP. It is possible that this significant outcome of the intervention was related to the combination of individually tailored educational and motivational agents during the intervention. This highlights the need for high-quality training of counselors in skillfully communicating and assessing participants’ perspectives and everyday lives where change can be motivated and possibly sustained.
10. 11. 12. 13. 14. 15. 16. 17.
18. 19. 20. 21. 22. 23. 24.
Declaration of interest
25.
The authors report no declarations of interest. The Danish Health Insurance Foundation funded the study.
26.
References 1. Karjalainen KA, Malmivaara A, van Tulder MW, et al. Multidisciplinary biopsychosocial rehabilitation for subacute lowback pain among working age adults. Cochrane Database Syst Rev 2003;(2):Art. No. CD002193. DOI: 10.1002/14651858.CD002193. 2. Abenhaim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine (Phila Pa 1976) 2000;25: 1S–33S. 3. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005;CD000335. 4. Staal JB, Rainville J, Fritz J, et al. Physical exercise interventions to improve disability and return to work in low back pain: current insights and opportunities for improvement. J Occup Rehabil 2005; 15:491–505. 5. Angel S, Jensen LD, Gonge BK, et al. Patients’ interpretations of a counselling intervention for low back pain: a narrative analysis. Int J Nurs Stud 2012;49:784–92. 6. Corbett M, Foster NE, Ong BN. Living with low back pain – stories of hope and despair. Social Sci Med 2007;65:1584–94. 7. Ong BN, Hooper H, Dunn K, Croft P. Establishing self and meaning in low back pain narratives. Sociol Rev 2004;52:532–49. 8. Borkan J, Reis S, Hermoni D, Biderman A. Talking about the pain: a patient-centered study of low back pain in primary care. Social Sci Med 1995;40:977–88. 9. Toye F, Barker K. ‘I can’t see any reason for stopping doing anything, but I might have to do it differently’ – restoring hope to
27. 28. 29. 30. 31. 32. 33.
34. 35. 36.
941
patients with persistent non-specific low back pain – a qualitative study. Disabil Rehabil 2012;34:894–903. Kleinman A. Patients and healers in the context of culture. Berkeley: University of California Press; 1980. Bury M. Illness narratives: fact or fiction? Sociol Health Illn 2001; 23:263–85. Larsen EL, Nielsen CV, Jensen C. Getting the pain right: how low back pain patients manage and express their pain experiences. Disabil Rehabil 2013;35:819–27. Vroman K, Warner R, Chamberlain K. Now let me tell you in my own words: narratives of acute and chronic low back pain. Disabil Rehabil 2009;31:976–87. De Souza LH, Frank AO. Experiences of living with chronic back pain: the physical disabilities. Disabil Rehabil 2007;29:587–96. Dreier O. Psychotherapy in everyday life. Cambridge: Cambridge University Press; 2008. Hush JM, Kamper SJ, Stanton TR, et al. Standardized measurement of recovery from nonspecific back pain. Arch Physical Med Rehabil 2012;93:849–55. Jensen LD, Maribo T, Schiottz-Christensen B, et al. Counselling low-back-pain patients in secondary healthcare: a randomised trial addressing experienced workplace barriers and physical activity. Occup Environ Med 2012;69:21–8. Atkinson P, Housley W. Interactionism. London: Sage; 2003. Becker HS, Geer B, Hughes EC, Strauss AL. Boys in white. New Brunswick: Transaction Publishers; 1977. Kvale S, Brinkmann S. InterViews. Learning the craft of qualitative research interviewing. Thousand Oaks: Sage; 2009. Holstein JA, Gubrium JF. The active interview. Thousand Oaks: Sage Publications; 1995. Patton MQ. Qualitative research and evaluation methods. Thousand Oaks: Sage; 2002. Miles MB, Huberman AM. Qualitative data analysis. Thousand Oaks: Sage; 1994. Charmaz K. Constructing grounded theory. Thousand Oaks: Sage; 2006. Maxwell JA. Qualitative research design: an interactive approach. Thousand Oaks: Sage; 2012. Osborn M, Smith JA. The personal experience of chronic benign lower back pain: An interpretative phenomenological analysis. Br J Health Psychol 1998;3:65–83. Snelgrove S, Liossi C. An interpretative phenomenological analysis of living with chronic low back pain. Br J Health Psychol 2009;14: 735–49. Rhodes LA, McPhillips-Tangum CA, Markham C, Klenk R. The power of the visible: the meaning of diagnostic tests in chronic back pain. Social Sci Med 1999;48:1189–203. Glenton C. Chronic back pain sufferers – striving for the sick role. Social Sci Med 2003;57:2243–52. Ong BN, Konstantinou K, Corbett M, Hay E. Patients’ own accounts of sciatica: a qualitative study. Spine 2011;36:1251–6. Toye F, Barker K. ‘Could I be imagining this?’ The dialectic struggles of people with persistent unexplained back pain. Disabil Rehabil 2010;32:1722–32. Crowe M, Whitehead L, Gagan MJ, et al. Listening to the body and talking to myself – the impact of chronic lower back pain: a qualitative study. Int J Nurs Stud 2010;47:586–92. Stewart AM, Polak E, Young R, Schultz IZ. Injured workers’ construction of expectations of return to work with sub-acute back pain: the role of perceived uncertainty. J Occup Rehabil 2012;22: 1–14. Coole C, Watson PJ, Drummond A. Low back pain patients’ experiences of work modifications; a qualitative study. BMC Musculoskeletal Disorders 2010;11:277. Miller WR, Rollnick S. Motivational interviewing. Preparing people for change. New York: The Guilford Press; 2002. Vong SK, Cheing GL, Chan F, et al. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Physical Med Rehabil 2011;92:176–83.
Copyright of Disability & Rehabilitation is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
RESEARCH PAPER
Low back pain patients’ beliefs about effective/ineffective constituents of a counseling intervention: a follow-up interview study Niels Buus1, Lone Donbæk Jensen2, Thomas Maribo3, Birgitte Krøis Gonge2, and Sanne Angel4 1
Institute of Public Health, University of Southern Denmark, Odense C, Denmark, 2Department of Occupational Medicine, Danish Ramazzini Center, Aarhus University Hospital, Aarhus, Denmark, 3Department of Rehabilitation, Public Health and Quality Improvement, Marselisborg Centret, Aarhus, Denmark, and 4Institute of Public Health, Aarhus University, Aarhus, Denmark
Abstract
Keywords
Purpose: Everyday activities are important factors for avoiding the development of chronic low back pain (LBP). The purpose this study was to explore LBP patients’ perspective on long-term effects of participating in a counseling intervention designed to motivate them to change work routines and to exercise. Method: Follow-up qualitative study. Semi-structured interviews were made of 25 LBP patients who had received the counseling intervention. Interviews were transcribed and explored with an interpretative thematic analysis. The findings were organized around Kleinman’s conception of ‘‘explanatory models’’. Results: For the individual participant the beliefs about the illness were internally coherent, but most often they were idiosyncratic and fitted to the particular participants’ overall explanatory model. Participation in the counseling intervention had created a sense of certainty and potential control over the disease and had legitimized their sick role at work and at home. The majority of the patients reported having integrated exercise into their explanatory models and understood exercise to be beneficial in their continual and concrete management of their LBP. Conclusions: The intervention had affected the patients’ personal agency and space for action. We suggest that this effect was linked to the individually tailored approach drawing on both educational and motivational agents.
Directive counseling, exercise, low back pain, occupational health, qualitative research History Received 8 October 2013 Revised 13 April 2014 Accepted 21 July 2014 Published online 8 August 2014
ä Implications for Rehabilitation
Maintaining everyday activities, including retaining one’s occupation, is an important factor in low back pain rehabilitation. Counselling on low back pain rehabilitation must be aligned with people’s beliefs about their illness. A counselling intervention made patients adopt exercising into their long-term management of low back pain.
Introduction It has proved to be difficult to design effective bio-psychosocial intervention programs for sustaining people’s jobs and everyday activities [1]. Maintaining everyday activities, including retaining one’s occupation, is an important factor in avoiding the development of chronic low back pain (LBP) [2]. A central challenge in the rehabilitation of people with LBP is therefore to overcome the occupational and psychosocial barriers for a safe return to work. Further, physical activity can reduce chronic and sub-acute LBP [3], and may also effectively stimulate return to work [4]. Patients’ personal beliefs about illness and treatment are major determinants of health behavior, and patients’ perspectives
Address for correspondence: Niels Buus, User Involvement, Institute of Public Health, University of Southern Denmark, J.B. Winsløwsvej 9B, 5000 Odense C, Denmark. Tel: +45 6550 4400 (office); +45 2814 1517 (mobile). Fax: +45 6550 3682. E-mail: [email protected].
on LBP have been extensively examined in qualitative studies [5–9]. These studies have emphasized an array of problems of personally experienced challenges related to living with unpredictable pain, diagnostic uncertainty and illegitimate sick roles, as well as social isolation and fear of losing work. The study of patients’ personal beliefs about illness and treatment is complex. This is, firstly, because patients draw on socially and culturally available notions of illness to recognize and describe their concrete experiences of illness [10], and, secondly, because patients’ describe their experiences of illness relative to the conversational context [11]. Ong et al. [7] exemplified both points in a study of how LBP patients describe their encounters with clinicians. The patients drew on clinical vocabulary or juxtaposed it with lay terminology in order to make their experiences of LBP appear authentic during the clinical encounter, and, at the same time, they positioned themselves during the research interview by stating that they fulfilled their social obligations despite the pain and that there was tangible clinical evidence explaining the pain [7].
Low back pain patients’ beliefs
DOI: 10.3109/09638288.2014.948135
LBP and the treatment of LBP are not isolated parts of patient’s lives [12–14], and it is within this wider context of patients’ lives that the introduction of new health care actions inevitably will be in conflict with and compete with existing habits regarding time and attention [15,16]. Previous studies in this area of research have been focused on the impact of LBP on people’s lives, for instance by reporting two coping strategies among LBP patients: They either ignore the pain and live as normally as possible or, at the other extreme, organize their lives round their concerns for their LBP [8,13]. Much less emphasis has been put on examining the LBP treatment’s impact on people’s everyday lives. Changing and sustaining change of behavior is central in health care interventions and may target one or more strategies to introduce new habits in patients’ everyday life. We designed and tested a simple, short time secondary prevention counseling intervention strategically encouraging patients’ motivation to personally engage in their own LBP treatment by changing work routines and by exercising. Counseling was individually tailored and included both emotional and cognitive-behavioral elements [17]. The trial participants were Danish LBP patients who, independently of sick leave status, expressed concerns about their ability to maintain their current job. The intervention consisted of two counseling sessions conducted by an occupational physician addressing both workplace barriers and leisure-time physical activity. A workplace visit was carried out if it was required. The intervention was given in addition to treatment as usual, which included a brief introduction to exercising and two tests of physical performance. The results indicated that the counseling intervention had a significant, positive effect on the participants’ pain, physical functioning and self-reported sick leave after three months [17]. We have previously reported from a qualitative analysis of clinical interview data from the intervention [5], and this analysis suggested that most participants described themselves as successful in adopting advise/new insight from the counseling session into their everyday lives. In the present study, we wanted to study if and how the participants were able sustain these changes in their long-term management of their LBP problems. In this study, we draw on the social theory ‘‘interactionism’’ [18] to conceptualize patients’ beliefs about health and illness and their actions related to health and illness. According to this psychosocial framework, people perceive their environment according to their personal perspective, which is an ordered set of ideas, and their actions flow reasonably from this perspective [19]. The links between ideas and actions are neither causal nor pre-sequenced. In some instances, actions flow from and are justified by ideas; in others, ideas are developed post hoc to justify actions; and, finally, actions and ideas may develop simultaneously, when a person is confronted by an unusual and challenging situation. An examination of people’s perspectives presupposes interpretation of their statements and actions. We designed a qualitative interview study [20,21] to explore the LBP patients’ perspectives on receiving the counseling intervention. Qualitative methods are appropriate for gaining nuanced insight into changes of patients’ everyday lives, and the study of the patients’ perspective can be seen as a comprehensive and unique way of accounting for the effects of health care interventions, which can be used for designing counseling interventions that are capable of changing and sustaining health behavior. The aim of the study was to explore the LBP patients’ beliefs about effective/ineffective constituents of the intervention and how they understood them as having/not having affected their personal agency and space for action in their everyday lives.
937
Methods Design Qualitative follow-up interviews with 25 LBP patients 1–4 years after concluding the counseling intervention. Participants The study population included participants from the intervention arm of the trial who had completed follow-up (n ¼ 110), and we posted invitations to potential interview participants. We used scores from the Fear Avoidance Beliefs Questionnaire (FABQ) (the difference between the trial’s baseline scores and follow-up scores) to strategically recruit a sample with both minor and major benefits of the intervention. The purposeful sample [22] included 25 participants (see a description of the sample and a comparison to the study population in Table 1). Interviews Two trained and experienced research-interviewers (N.B. and S.A.) performed the semi-structured interviews in January-April 2012. Participants and the interviewers had no relationship prior to the interview. The interviews lasted 45 minutes on average (range 12–78). The interviews were mostly conducted at the participants’ homes or, occasionally, at the Department of Occupational Medicine. The interviewers used an interview guide, which included open-ended questions about the participants’ ‘‘explanatory models of illness’’ as well as their experiences of participating in the intervention and to what extent the intervention had influenced their everyday life and their ability to work (see an outline of the interview guide in Table 2). An ‘‘explanatory model of illness’’ is a flexible set of ideas about a particular illness episode, which typically includes ideas about aetiology, onset and timing, pathophysiology, course of illness and sick role, and treatment [10]. All interviews were digitally recorded and transcribed verbatim by research assistants, and the accuracy of each transcript was checked against the recording by the interviewers.
Data analyses The interpretative thematic analysis [23] consisted of four stages. First, two researchers (N.B and S.A.) coded the dataset using a preliminary, open ‘‘incident to incident’’ [24] strategy, which led to the construction of 14 distinct categories that were used to systematically compare the 25 participants. The categories included: ‘‘how it all began’’, ‘‘perspective on exercise’’ and ‘‘managers and colleagues at work’’, etc. and the categories were compared across the participants by inquiring, for instance, how was ‘‘how it all began’’ described by different participants and how could similarities and differences be explained? Second, open coding was succeeded by a theory-driven reorganization of the codes around three new categories in line with Kleinman’s notion of explanatory models: A. Beliefs about illness (onset, causes and pathophysiology), B. Beliefs about the course of illness and sick role and C. Beliefs about treatment. This reorganization was made in order to prioritize between the codes and focus the analysis on the research question. Third, participant’s perspective on receiving the counseling intervention was constructed by interrogating these three categories by systematically comparing the participants’ explanatory models. Memos [24], analytical reflections, were written and gradually developed throughout all stages of the analysis and formed the basis for the final interpretation. Fourth, the original transcripts were re-read aiming at challenging and corroborating a balanced and nuanced interpretation of the themes.
938
N. Buus et al.
Disabil Rehabil, 2015; 37(11): 936–941
Table 1. RCT baseline characteristics of the study population (the RCTs intervention group completing follow-up) and the study sample (interviewees). Study population [n ¼ 110]
Study sample [n ¼ 25]
46.2 [9.5] 50.9 26.6 [4.3] 23.2
46.8 [8.6] 56.0 25.7 [4.8] 12.5
21.8 20.9 57.3 40.9 19.2 14.6
20.0 20.0 60.0 44.0 20.8 16.0
Current job DISCO 1: leaders and high educated (%) DISCO 3,4,5: office, teaching and nursing (%) DISCO 6,7,8,9: blue collar (%) Rate of Perceived Exertion; physical strain [0–14], mean [SD]
25.5 53.6 20.9 5.8 [3.0]
16.0 56.0 28.0 5.9 [2.9]
Quality of life SF-36 Physical Component Summary, mean [SD] SF-36 Mental Component Summary, mean [SD]
38.2 [8.9] 51.5 [8.8]
37.2 [9.7] 51.2 [9.2]
Psychosocial factors Fear-Avoidance Beliefs – work [0–30], mean [SD] Fear-Avoidance Beliefs – physical activity [0–24], mean [SD]
11.4 [7.9] 11.2 [5.1]
13.3 [7.8] 11.8 [5.0]
Pain Numerical Rating Scale [0–10], mean [SD] SF-36 bodily pain [0–100], mean [SD]
6.5 [2.6] 45.1 [20.2]
6.9 [2.4] 42.8 [20.8]
Function Roland Morris Questionnaire [0–23], mean [SD] SF-36 physical functioning [0–100], mean [SD] Maximal oxygen uptake [ml2/min/kg], mean [SD]
11.7 [5.9] 68.0 [22.6] 29.9 [8.8]
11.8 [6.1] 67.4 [21.6] 29.7 [7.8]
Age, mean [SD] Female gender (%) Body Mass Index, mean [SD] Current Smoking (%) Quebec Task Force classification 1: without radiating pain (%) 2: with radiating pain, not below knee level (%) 3: with radiating pain below knee level (%) 4: neurologic deficit (%) On-going workers compensation (%) 540 weeks of work within the 2nd year of inclusion (%)a
DISCO: The Danish version of the International Standard Classification of Occupations [D ISCO 88]. Register-based data.
a
Table 2. Outline of the thematic, non-standardized interview guide. Explanatory models of low back pain How did your low back pain problems begin? In your own words, what do you think caused the problems? How did it affect your everyday life and your work life? Where did you seek assistance? What happened? Motivation for adhering to agreements made during intervention Describe in detail what you experienced during the intervention? What did you bring home from the intervention? Were there issues discussed/exemplified/presented during the intervention thatyou found important consideringyour particularly situation? Which? Did the intervention affect your ability to sustain your occupational job? How? Suggestions for improvements of the intervention Did you feel safe and ready to manage your low back problems on your own after the intervention had ended?
Ethics In full concordance with Danish legislation, the Danish Data Protection Agency was notified about the interview study. There were no objections to the study’s approach, and the Danish Data Protection Agency’s regulations regarding data storage were observed throughout the study. All participants gave their consent to participate based on written and verbal information about the study. Data were handled anonymously.
Results The participants’ perspective on the intervention and how they understood it as possibly having affected their personal agency
and space for action in their everyday lives will be presented under three headings: the illness, course of illness and sick role, and treatment. Theme 1. The illness The first theme was concerned with the participants’ beliefs about the onset, causes and pathophysiology of the illness. For the individual participant the beliefs about the illness were internally coherent, but most often they were idiosyncratic and fitted to the particular participants’ overall explanatory model. Most participants understood their problems as caused by a strenuous working life and/or as linked to an inborn weak back. Two participants understood their problems as being caused by external trauma. All participants accounted for their illness with a high level of certainty regarding the character of the illness. The explanations were not elaborate, but idiosyncratic and complex descriptions that combined medical terminology, such as ‘‘a herniated disc’’, with lay metaphors, such as ‘‘something toothpaste-like is pressed against the discs that look like onion rings’’ (Participant 18). There were two distinct explanations of the present LBP problems, reflecting an understanding of an intermittent or a more continuous LBP problem. The first was to understand recurring unpleasant experiences of the stiffening of muscles as an early warning of severe crisis in the spine, which could be avoided by taking appropriate actions, such as exercising or massage. The second was to understand pain as a relatively predictable response to particular strenuous activities, which had to be managed with rest and pain-relieving medication.
Low back pain patients’ beliefs
DOI: 10.3109/09638288.2014.948135
The counseling intervention’s focus on creating relief at work made intuitive sense for all participants. Contrary to this, the advice about exercising had been surprising for many and counterintuitive for some. When participant 22, a 54-year-old woman, was introduced to the idea of exercising she found it counterintuitive, because she was used to lie passively on the couch when she was in pain. It was turned upside down for me. I was told that that worst thing to do is to sit down or lie down and just do nothing. I’ve been wondering, because I was told that my lower vertebrae were worn down. It might have improved. New cartilage may have been formed or something like that. (Participant 22) Participant 22 believed that a worn down back caused her pain, and she explained her experienced improvement by suggesting that new cartilage could have counteracted the deterioration. Participant 22’s reasoning combined clinical knowledge and lay knowledge and illustrated the flexibility of her explanatory model. While some participants saw exercising as a way to strengthen a weak back, others feared that exercising would damage it further. Despite the professional counseling, the basic lay idea was, that exercising could cause fragile joints to disjoint or break, or that exercising would wear a worn down back even further down. The participants had developed meaningful and acceptable perspectives on their illness that were integrated into their personal biographies on the basis of their illness experiences and contacts with health care providers. Theme 2. Course of illness and sick role The second theme was concerned with the participants’ beliefs about the course of illness and with their expectations of the sick role. In particular, this included the participants’ beliefs about the legitimacy of their evolving problems – at home and at work. The interviews indicated that most participants changed their understanding of the course of illness during or after the intervention and that the few remaining participants used the counseling sessions as a confirming second opinion. Most participants stated that before the intervention they felt powerless in the face of their LBP and feared that it would be chronic, but that the intervention had created a sense of certainty and potential control. Participant 3, a 62-year-old man, was frustrated because none of the clinicians, he had previously consulted, would give him straight answers as to what caused his LBP. However, during the counseling session, he had come to understand and accept that it was common not to have complete certainty and tangible evidence about the cause of LBP.
939
accomplishment. Most participants described how the counselor’s focus on workplace conditions encouraged them to ask for changes at their present work, to ask for a period with special privileges or inspired them to look for less strenuous work. Participant 11 was a 57-year-old woman and her LBP was classified as a work-related injury. She felt that her colleagues had been accommodating in relieving her from physical strain, but she was convinced that these privileges would not last forever and had started to look for other solutions. Considerations were taken. I did not have to lift children [working at a nursery]. But I knew that there were limits to colleagues’ good will. I’d seen it before. At some points it’s ‘‘get cracking’’, and they’d think that about me too. And that was when Liz [the counselor] came and we talked about my options (. . .) she organized that I could lie down on a mattress and stretch my back at noon. (Participant 11) The counselor was instrumental in suggesting ingenious practical arrangements that could give the participant some relief. Furthermore, most of the participants who had a work place visit stated that the occupational physician’s presence legitimized their problems towards work place management. However, the interview participants did not ascribe eventual lasting effects of changed workplace conditions to the intervention, but regarded long-term changes at the workplace as caused by their own initiative, luck and ingenuity. The counselor’s advice about physical activity was reinforced during the physical tests. The participants described the tests as surprising, either because their objective physical capability was much poorer than they had anticipated and/or because they were able to exercise in ways they were convinced they could not, for instance, Participant 8 stated her surprise to find out that she at age 31 was unable to stand on her toes without falling over: ‘‘I was astonished that it was so bad that I couldn’t keep my balance and that stuff, and I thought ‘‘Blimey, this is completely wrong.’’’’ (Participant 8). All participants found that the intervention had concentrated on their personal initiative and efforts, which were potentially a means to achieve better management of their illness. However, the participants identified different parts of the intervention as crucial for increasing their personal engagement and changing their sick role, for instance: Being emotionally calmed down by the counselor; a reinvigorated self-confidence in own physical capabilities; a personal quest to improve physical scores at follow-up; a legitimate focus on potential change at work and realistic and even enjoyable changes of everyday life. Theme 3. Treatment
Liz [the counselor] said it in a different way. She said that that there are many small muscles that we know only little about and we can’t see. She looked me in the eyes much more than she examined by back. The first therapist said that nothing could be done, which was very unsatisfying. (Participant 3) Participant 3 found it important to have his personal concerns addressed by a reassuring professional. In line with participant 3, several participants described having initially struggled to convince therapists of the severity of their LBP problems, but that the counselor had legitimized their experienced problems, for instance by emphasizing that their problems were real even though the symptoms were not confirmed objectively by X-ray images or MRI. In spite of LBP, all participants had tried to continue going to work because of a strong sense of obligation and personal
The third theme was concerned with the participants’ beliefs about treatment and effective everyday management LBP. All participants believed that exercising was an effective treatment of LBP, and most participants stated that they continued to use exercising proactively against recurring LBP problems after the intervention had ended. However, three participants explained that the character of their particular illness made them exemptions to the rule. Participant 21, a 54-year-old woman, believed that it was very important to stay active to counter LBP, but that her back was so worn down, that it prevented her from exercising: ‘‘It is important to exercise your back. I’ve always done that, but my back is worn down and I can’t do it’’. Therefore, her beliefs about her back made it counterintuitive to follow the counselors’ advice about exercising. Most participants stated that their LBP problems were presently manageable and they linked their progress to either
940
N. Buus et al.
changes in their work situation, such as new functions, new jobs, or early retirement, or to their proactive use of exercising. A few participants continued full body exercising several times a week, as recommended during the intervention, while most participants created less extensive routines for keeping their back healthy. These routines included full body exercising in combination with back strength training and caution about specific activities. Several participants were convinced about an absolute minimum number of exercises needed to keep their problems at bay. Participant 7, a 42-year-old man, had suffered from LBP since his teens and was convinced that the key to his successful management was to accept that he would always suffer from LBP – also when he had no pain. He had adopted advice from the counseling sessions and set up some basic rules about alcohol and lifting that he would not allow himself to break: ‘‘My back could be a mess if I don’t observe the rules I’ve set up for myself’’. Most participants struggled being motivated to continue exercising during and after the intervention. Participant 16, a 38-year-old woman, stopped exercising because she did not experience any pain, which was a crucial motivator: ‘‘I quit exercising after a couple of years. When there is no pain, you don’t do it. I was very resolute about exercising, but when I felt strong again, I was not quite as motivated’’. A few were explicitly downright bored with exercising and stopped as soon as they felt improvement, while others stated that they continued exercising until disability or competing obligations made it impossible for them to continue. Despite the participants finding exercise therapeutic, many participants stated that they felt too much on their own after the intervention, where they were instructed to continue exercising while observing reactions from their body. They suggested that patients should have further professional follow-up to give them certainty about treatment of their illness.
Discussion We explored the participants’ perspectives on receiving the counseling intervention by means of a qualitative research strategy based on an interpretative analysis of non-standardized, rich data from a relatively small number of participants [25]. The interview guide included open-ended questions, which stimulated nuanced accounts of explanatory models and experiences during the intervention. The qualitative analysis indicated that the majority of the interview participants integrated exercising into their explanatory models and understood exercising to be more or less beneficial in their continual and concrete management of their LBP problems. Making sense of and finding personally and socially legitimate explanations of LBP problems is crucial for LBP patients [7,8,26,27]. Patients’ construction of acceptable explanatory models has been described as crucial for restoring their hope for the future [9]. Qualitative research has indicated that LBP patients search and try to determine objective reasons for their pain [28,29]. They may use medical terminology to further legitimize their explanations [30], which in some situations will be in conflict with their personal experiences [31]. The majority of the participants in the present study had vague and general explanations of their illness, which could indicate that they at the time of interviewing were no longer in a position dominated by intense needs for legitimizing their LBP problems by referring to medical tests and terminology. It was likely that the need for officially legitimate explanations diminished as problems were managed in everyday life. In the same vein, research has emphasized the uncertain and unpredictable character of LBP [6,32]. In opposition to this, the majority of participants described
Disabil Rehabil, 2015; 37(11): 936–941
their (recurring) LBP as treatable and relatively controllable, which could indicate a high level of control over the course of the illness. It is possible, that these differences came forth because the studies included different samples of LBP patients who were at different stages of their illness careers and had time to learn new ways to accept and manage their pain. The participants recalled prominent experiences during the counseling intervention that were meaningful for them in their particular situation. They had adapted some of these experiences into their explanatory models, and they described how their explanatory models influenced their present day management of their LBP problems. In particular, the participants’ had adopted and adapted exercising into their explanatory models and used it actively – some continually others intermittingly – in their practical management of their LBP problems. On the basis of the dataset, we suggest that the encouragement of the patients’ motivation combined with a counselor’s skillful suggestions on how to gently fit exercising into the particular patient’s everyday life was one of the crucial influences on the self-reported longterm effect reported here. Further exploration of such long-term adaption of counseling advice would benefit from collecting ethnographic data from patients’ everyday lives, such a diaries, self-presentation photos, observation of contact with health care professionals, etc. When LBP patients return to work, they are reportedly troubled by uncertainty about their physical capabilities and about recognition from managers and colleagues [33,34]. The participants described similar concerns about their work situation and described some short-term benefits of the intervention. However, they did not regard the strategies targeting workplace changes as having long-term effects and did not adopt such strategies to the same extent as they took up exercising. Special privileges at work may be viewed as temporary opportunities because workers want to appear loyal and responsible [12], and, therefore, these strategies were not acceptable for the LBP patients over time. In line with our trial of the counseling intervention [17], a recent trial tested ‘‘motivational interviewing’’ [35] in addition to tailored physical therapy to LBP patients and identified significant positive changes of motivation and exercise compliance as well as physical function [36]. We believe that such testing and measuring the short-term effects of such interventions are important, but that they should be accompanied by examinations of the more general effects on people’s everyday lives. The sampling strategy was to recruit all interview participants 1–2 years after they had completed the intervention, which was considered an appropriate balance between, one the one hand, sufficient time for eventual long-term effects of the counseling intervention to be adapted into everyday life, and, on the other hand, not too long to hamper the participants’ ability to recall the events linked to the counseling intervention. Unfortunately, the planned strategy was not feasible because of an unexpected low rate of consent and we decided to gradually invite all trial participants. This influenced on some interview participants’ ability to recall details about the counseling, but not on the participants ability to draw together events round their LBP management into a temporally organized whole. Furthermore, all participants had gone through a specialized evaluation at a rheumatological outpatient clinic before participating in the intervention and many had been in contact with several health care services after the counseling intervention had ended. Their explanatory models were complex and it was not possible to link the emergence and/or change of particular ideas to particular encounters at work or with health care providers, including educational and motivational agents during the counseling intervention.
Low back pain patients’ beliefs
DOI: 10.3109/09638288.2014.948135
Finally, the sampling strategy aimed at recruiting participants with both minor and major benefits of the intervention. However, almost all the interview participants spoke very favorably about the intervention, and it is possible that trial participants that did not experience benefits from the intervention were less likely to participate in an interview. However, as indicated by Table 1, the sample did not differ significantly from the population at the RCTs baseline. Having two researchers interviewing, coding the total dataset, sharing memos and developing interpretations together ensured trustworthiness and rigor in the interpretative process. We did not regard this as a way of increasing precision in the interpretations, but as a way of stimulating dialog, creativity and reflexivity, and thus suggesting several ways of reading the dataset, which inspired and balanced the interpretative process.
Conclusions It had been crucial that the counselor could reconcile the participants’ perspective on the illness with the idea that exercising the back would not be harmful and could be beneficial, and the present follow-up study could indicate a successful longterm secondary prevention strategy. Most participants described that they had adapted and adopted exercising into their everyday management of LBP. It is possible that this significant outcome of the intervention was related to the combination of individually tailored educational and motivational agents during the intervention. This highlights the need for high-quality training of counselors in skillfully communicating and assessing participants’ perspectives and everyday lives where change can be motivated and possibly sustained.
10. 11. 12. 13. 14. 15. 16. 17.
18. 19. 20. 21. 22. 23. 24.
Declaration of interest
25.
The authors report no declarations of interest. The Danish Health Insurance Foundation funded the study.
26.
References 1. Karjalainen KA, Malmivaara A, van Tulder MW, et al. Multidisciplinary biopsychosocial rehabilitation for subacute lowback pain among working age adults. Cochrane Database Syst Rev 2003;(2):Art. No. CD002193. DOI: 10.1002/14651858.CD002193. 2. Abenhaim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine (Phila Pa 1976) 2000;25: 1S–33S. 3. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005;CD000335. 4. Staal JB, Rainville J, Fritz J, et al. Physical exercise interventions to improve disability and return to work in low back pain: current insights and opportunities for improvement. J Occup Rehabil 2005; 15:491–505. 5. Angel S, Jensen LD, Gonge BK, et al. Patients’ interpretations of a counselling intervention for low back pain: a narrative analysis. Int J Nurs Stud 2012;49:784–92. 6. Corbett M, Foster NE, Ong BN. Living with low back pain – stories of hope and despair. Social Sci Med 2007;65:1584–94. 7. Ong BN, Hooper H, Dunn K, Croft P. Establishing self and meaning in low back pain narratives. Sociol Rev 2004;52:532–49. 8. Borkan J, Reis S, Hermoni D, Biderman A. Talking about the pain: a patient-centered study of low back pain in primary care. Social Sci Med 1995;40:977–88. 9. Toye F, Barker K. ‘I can’t see any reason for stopping doing anything, but I might have to do it differently’ – restoring hope to
27. 28. 29. 30. 31. 32. 33.
34. 35. 36.
941
patients with persistent non-specific low back pain – a qualitative study. Disabil Rehabil 2012;34:894–903. Kleinman A. Patients and healers in the context of culture. Berkeley: University of California Press; 1980. Bury M. Illness narratives: fact or fiction? Sociol Health Illn 2001; 23:263–85. Larsen EL, Nielsen CV, Jensen C. Getting the pain right: how low back pain patients manage and express their pain experiences. Disabil Rehabil 2013;35:819–27. Vroman K, Warner R, Chamberlain K. Now let me tell you in my own words: narratives of acute and chronic low back pain. Disabil Rehabil 2009;31:976–87. De Souza LH, Frank AO. Experiences of living with chronic back pain: the physical disabilities. Disabil Rehabil 2007;29:587–96. Dreier O. Psychotherapy in everyday life. Cambridge: Cambridge University Press; 2008. Hush JM, Kamper SJ, Stanton TR, et al. Standardized measurement of recovery from nonspecific back pain. Arch Physical Med Rehabil 2012;93:849–55. Jensen LD, Maribo T, Schiottz-Christensen B, et al. Counselling low-back-pain patients in secondary healthcare: a randomised trial addressing experienced workplace barriers and physical activity. Occup Environ Med 2012;69:21–8. Atkinson P, Housley W. Interactionism. London: Sage; 2003. Becker HS, Geer B, Hughes EC, Strauss AL. Boys in white. New Brunswick: Transaction Publishers; 1977. Kvale S, Brinkmann S. InterViews. Learning the craft of qualitative research interviewing. Thousand Oaks: Sage; 2009. Holstein JA, Gubrium JF. The active interview. Thousand Oaks: Sage Publications; 1995. Patton MQ. Qualitative research and evaluation methods. Thousand Oaks: Sage; 2002. Miles MB, Huberman AM. Qualitative data analysis. Thousand Oaks: Sage; 1994. Charmaz K. Constructing grounded theory. Thousand Oaks: Sage; 2006. Maxwell JA. Qualitative research design: an interactive approach. Thousand Oaks: Sage; 2012. Osborn M, Smith JA. The personal experience of chronic benign lower back pain: An interpretative phenomenological analysis. Br J Health Psychol 1998;3:65–83. Snelgrove S, Liossi C. An interpretative phenomenological analysis of living with chronic low back pain. Br J Health Psychol 2009;14: 735–49. Rhodes LA, McPhillips-Tangum CA, Markham C, Klenk R. The power of the visible: the meaning of diagnostic tests in chronic back pain. Social Sci Med 1999;48:1189–203. Glenton C. Chronic back pain sufferers – striving for the sick role. Social Sci Med 2003;57:2243–52. Ong BN, Konstantinou K, Corbett M, Hay E. Patients’ own accounts of sciatica: a qualitative study. Spine 2011;36:1251–6. Toye F, Barker K. ‘Could I be imagining this?’ The dialectic struggles of people with persistent unexplained back pain. Disabil Rehabil 2010;32:1722–32. Crowe M, Whitehead L, Gagan MJ, et al. Listening to the body and talking to myself – the impact of chronic lower back pain: a qualitative study. Int J Nurs Stud 2010;47:586–92. Stewart AM, Polak E, Young R, Schultz IZ. Injured workers’ construction of expectations of return to work with sub-acute back pain: the role of perceived uncertainty. J Occup Rehabil 2012;22: 1–14. Coole C, Watson PJ, Drummond A. Low back pain patients’ experiences of work modifications; a qualitative study. BMC Musculoskeletal Disorders 2010;11:277. Miller WR, Rollnick S. Motivational interviewing. Preparing people for change. New York: The Guilford Press; 2002. Vong SK, Cheing GL, Chan F, et al. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Physical Med Rehabil 2011;92:176–83.
Copyright of Disability & Rehabilitation is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
