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
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
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 .