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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 731–737 DOI 10.3233/BMR-140575 IOS Press
Beliefs about low back pain: Status quo in Indian general population Venus K. Pagarea,∗, Teena Dhanraja, Dhaval Thakkarb , Aarti Sareena and Tushar J. Palekara a
b
Dr D.Y. Patil College of Physiotherapy, Pune, India Department of Radiodiagnosis, Dr D.Y. Patil Medical College, Pune, Maharashtra, India
Abstract. BACKGROUND: Low back pain (LBP) is a major public health problem and is the leading musculoskeletal cause of disability. Various bio-behavioral factors which can be associated with disability due to LBP have been identified. When considering these factors associated with LBP, beliefs that people hold are among the most important factors to consider. OBJECTIVE: To find out the prevalence of LBP among the general population and to investigate their beliefs towards LBP. METHODS: A cross-sectional survey of the general population was conducted. Demographic information and information on beliefs regarding low back pain was gathered from 921 individuals. The respondents were asked to rate their agreement with 7 statements, corresponding to Deyo’s 7 myths. RESULTS: 75% of the population reported lifetime prevalence of LBP. Regarding the beliefs about LBP, general population exhibited diverse attitudes. Out of 7 myths explored, 3 myths were found to be dead and buried in more than 50% of the sampled population. However, 4 out of 7 myths still exist among the population. CONCLUSIONS: Prevalence of Low Back Pain was found to be high among the general population sampled and also myths regarding LBP still exist among them. Keywords: Bio-behavioral factors, bio-psychosocial model, disability, kinesiophobia, myths, low back pain
1. Introduction Low back pain (LBP) is a major public health problem all over the world. It is the leading musculoskeletal cause of disability [1–6] and is the most frequently reported condition for which people receive outpatient physical therapy [1–4]. In India, the occurrence of low back pain (LBP) is high, with nearly 60% individuals having significant back pain at some or the other time in their lives [7,8]. The natural course of LBP is self-limiting whereas an estimated 10% of patients develop chronic LBP as defined by duration of more than 12 weeks [9,10]. Though this percentage is small, it represents a high socioeconomic burden due to the associated disability. ∗ Corresponding author: Venus Pagare, Padmashree Dr. D.Y. Patil College of Physiotherapy, Pune, Maharashtra, India. Tel.: +91 879 3393626; E-mail: [email protected].
The traditional methods and concept of management of low back pain are based on the biomedical model of disease and pain. According to this model, direct positive correlation exists among pathology/disease/pain, impairment, functional limitation, and disability [11– 13]. Identifying the physical impairments and their correction can therefore have a positive effect on the disability [14–19]. Studies have however, identified lack of physical factors to explain the reason for development of chronicity in these people [20]. In addition, in individuals with low back pain particularly those whose symptoms have persisted beyond a predictable period of tissue healing, the functional limitation, degree of pain reported and the disability is frequently disproportionate to the observed pathology [12,21,22]. In such patients, the traditional methods of management are often ineffective. This proves that, in addition to the nociceptive response from injured tissues, other factors may be associated with patients’s perception of pain and behavioral response [23].
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
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According to Engel, the scientific knowledge and technology that has been developed is directed towards “the body and its aberrations”, but the understanding of “human behavior and the psychological and social aspects of illness and patient care” is very limited [24]. This led to identification of the various bio-behavioral factors which can be associated with disability due to LBP. These biobehavioral factors are a set of psychological, environmental, and psycho-physiological processes [23]. Thus, today LBP can be best explained from a viewpoint of bio-psychosocial model [25,26]. This model lays emphasis on interactions between biological, psychological, and social factors which are implicated in persistence of pain and the development of disability [27,28]. According to Predisposing-Reinforcing-Enabling Causes Educational Diagnosis (PRECED) model, knowledge, perception and belief are predisposing factors necessary for changing behavior [29]. When considering the bio-behavioral factors associated with LBP, beliefs that people hold are among the most important factors to consider [30]. These can attenuate or exacerbate the discrepancy among pathology, pain, impairment, functional limitation, and disability and also with respect to response to treatment. The extent of functional impairment that an individual experiences is also dictated by the extent to which the patients believe that they are disabled by their pain. Cross sectional studies have found strong association between the beliefs of people and physical dysfunction [31]. It also determines the nature of seeking healthcare and their response to the treatment [32,33]. These beliefs that people hold are based on prior learning and social influences, including health care provision. Various beliefs have been linked to low back pain and these include beliefs such as back pain is inevitably negative, catastrophisation (hopelessness, magnification and rumination regarding pain) and fear-avoidance beliefs [34–37]. Belief that the pain is stable and unchangeable is associated with poor compliance with physical and psychological treatment [38]. On the other hand, patients who believe that they have greater control over their pain may be more likely to participate and benefit from rehabilitation programs [39]. There is an increase in evidence like staying active and continuing or resuming ordinary activities is more effective than rest and that early investigation and referral to a specialist are unwarranted in most cases. Previous study has found that a population based intervention regarding spreading of positive messages about back pain can improve population’s
beliefs, influences medical management and reduces disability and workers’ compensation costs related to back pain [40]. Thus, re-education can change attitudes and beliefs and alter patients’ expectations and behavior and can reverse or interrupt the rising incidence of disability from low back pain [40]. Thus, in response to increasing evidence on the role of psychosocial factors in the development of persistent pain and disability, the aim of this study was to find out the prevalence of LBP among the general population and to investigate their beliefs towards LBP.
2. Materials and methods A cross-sectional survey of the general population was conducted in Pimpri region of Pune, India. The study was approved by the institutional sub-ethics committee of Padm. Dr D.Y. Patil college of Physiotherapy. The general population data was sampled during early 2014. 2.1. Participants Convenient sampling method was employed for this prospective hospital-based survey and relatives of patients seen at the physiotherapy outpatient department formed the study subjects. The age group was 18– 60 years and data was collected from individuals who were not related to any health care profession, irrespective of past/present history of low back pain. Of the 994 individuals who were contacted, 921 individuals agreed to be involved. No incentives were offered to the subjects. 2.2. Instruments 2.2.1. Demographic information Information including age, gender, Occupation, Qualification, Work status: part time/full time was obtained from survey respondents but are not considered at this point and will be reported in a subsequent article. To obtain data on low back pain prevalence, participants were asked if they had experienced low back pain at the following time points/periods; now, past 1 year or ever in lifetime. Also, they were asked to report their coping strategies and data on LBP-related care seeking in the last month. 2.2.2. Beliefs about back pain To gather information on beliefs of people regarding low back pain, the individuals were asked to rate their agreement with 7 statements, corresponding to Deyo’s
V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population
7 myths [41]. The responders were asked to rate the statements on a 5-point likert scale (totally disagree, disagree, neither disagrees nor agrees, agree, and totally agree). The 7 statements were: 1. If you have a slipped disc (also known as a herniated or ruptured disc), you must have surgery. 2. Radiographs and newer imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI] scans) can always identify the cause of pain. 3. If your back hurts, you should take it easy until the pain goes away. 4. Most back pain is caused by injuries or heavy lifting. 5. Back pain is usually disabling. 6. Everyone with back pain should have a spine radiograph. 7. Bed rest is the mainstay of therapy. The same were translated in local language (Marathi) by experienced Marathi school teacher and were validated. 2.3. Statistical analyses Before the analysis, the responses to the myths were categorized into agreeing (totally agree, agree), unsure (neither agreeing nor disagreeing), and disagreeing (disagreeing, totally disagreeing). Frequencies of responses were calculated for the general population as percentages.
3. Results Nine hundred and twenty-one individuals participated in the survey. Their median (minimum, maximum) age was 52 (21, 58) years, 557 females and 364 males. High prevalence of back pain was reported with a lifetime prevalence of 78%, 1 year prevalence of 53% and point prevalence (at the time of questionnaire completion) of 48%. 3.1. Beliefs about low back pain Regarding the beliefs about low back pain, the general population exhibited diverse attitudes. Out of the 7 myths explored, 3 myths were found to be dead and buried in more than 50% of the sampled population. However, 4 out of 7 myths still exist among the population. Figure 1 shows Frequencies (%) of disagreeing, being unsure, and agreeing with Deyo’s 7 myths for the general population.
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4. Discussion Biological, psychological and social factors, particularly an individual’s belief system play an important role in the persistence of pain and the development of disability in low back pain. Irrational beliefs about back pain can lead to kinesiophobia (fear of movement)/re-injury, reduction in activity, function and subsequently disability. The present populationbased survey was therefore, done to find out the prevalence of low back pain among the general population and to find out the beliefs regarding low back pain among them. Deyo identified 7 common myths among the people regarding low back pain [41]. These wrong beliefs have been found to be strongly associated with and implicated for maintenance or development of disability due to low back pain. The results of the present survey showed that of these 7 myths, the beliefs of more than 50% of the population were in harmony with the current scientific evidence for 3 statements. The general population showed disagreement with statement “Most back pain is caused by injuries or heavy lifting”. In reality, over half of the people with back pain develop it gradually without a specific injury [41]. They also disapproved that “Back pain is usually disabling” and that “Bed rest is the mainstay of therapy”. Evidence suggests that although the pain can sometimes be very severe, it is rarely disabling. This disability which develops is mainly due to bio-behavioral factors rather than physical injury associated with LBP. Also, bed rest as a mainstay for treatment is strongly discouraged as it causes rapid deconditioning making a person more susceptible to developing chronicity and perpetuates kinesophobia [41]. This pain-kinesiophobia-pain then forms a viscous cycle. Scientific research demonstrates that those who remain at least active after an injury do better than those who rest in bed [41]. Though the general population is aware of certain myths regarding LBP, they are not completely dead and buried. Some of the wrong beliefs regarding LBP still exist in the population sampled. People still believe that “for a slip disc (also known as a herniated or ruptured disc), surgery is a must”. This holds completely wrong as 90% of all herniated discs heal without surgery [41]. Most of the times, LBP can be managed by staying active and educating people about anatomy and physiology of pain. Surgery is generally not considered until conservative measures have failed. Also, surgery carries higher risk and also chances of failure: ‘failed back syndrome’ also exist. Surgery for
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2. Radiographs and newer imaging tests can always idenfy the cause of pain
1. If you have a slipped disc, you must have surgery 80%
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3. If your back hurts, you should take it easy unl the pain goes away
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4. Most back pain is caused by injuries or heavy liing
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Fig. 1. Shows Frequencies (%) of disagreeing, being unsure, and agreeing with Deyo’s 7 myths for the general population.
LBP is therefore reserved for those with high severity or associated complications. Another common myth which was found to be prevalent in Indian population was that “Radiographs and newer imaging tests (computed tomography [CT]
and magnetic resonance imaging [MRI] scans) can always identify the cause of pain” and that “Everyone with back pain should have a spine radiograph”. This shows misconception among the general population regarding use of investigative procedures for low back
V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population
pain. Firstly, according to evidence based guidelines only 15% of patients with low back pain (LBP) are given specific diagnosis, the remaining 85% are diagnosed as ‘non-specific low back pain (NSLBP)’ [42] The term ‘non-specific’ is used to describe an entity whose pathoanatomical etiology is unknown [42]. Therefore, in most cases of LBP, X-rays or other investigations are not needed. Even when indicated, these investigations may not identify the cause or source of LBP, with not much contribution to better management [43–45]. Secondly, some of the changes such as ‘disc bulge or degenerative changes’ identified by these investigations may only be incidental which may even be present in the age and gender matched population without low back pain [46–48]. Thirdly, diagnostic scans are not reassuring for the patients [49]. A recent study in the USA demonstrated that disability was high among the patients who were sent for an early MRI as compared to those who did not have an MRI scan [50]. Lastly, these investigations also carry a potential hazard of exposure to radiation. Thus, it is highly recommended to reserve these expensive investigations for those with signs of serious pathology who can easily be identified by appropriate history taking and systematic clinical examination. The last myth reported in high proportion of population was “If your back hurts, you should take it easy until the pain goes away”. This completely contrasts the current scientific evidence according to which, after an initial back injury, it is advisable to avoid aggravating or causative activities/movements. However, there is very strong evidence that keeping active and returning to all usual activities is important in recovery and reducing the risk of disability [41,51]. Most acute injuries recover well, and natural recovery may explain the improvement felt in many cases, especially in cases of acute or recent-onset LBP. In contrast, prolonged bed rest is unhelpful, and is associated with higher levels of pain, greater disability, poorer recovery and greater absence from work [52–56]. Given the high agreement with this belief, it could be in line with the fear avoidance model introduced by Lethem et al. [57,58], and developed specifically to relate to LBP by Vlaeyen et al. [59]. According to this model, experience of can can be interpreted in 2 different ways by the central pathways. When an individual perceives the acute pain as non-harmful and non-threatening, he/she is able to perform the activities of daily living which in turn facilitates functional recovery [60]. However, on the other hand, if the pain is misinterpreted as threatening, it can lead to excessive and aber-
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rant concerns regarding the activities which are considered to cause (re) injury. These beliefs become significant when it leads to behavioral changes in individuals (fear-avoidance behavior), the restriction of activity by the ‘avoiders’, escape and hyper-vigilance being of utmost importance. This is believed to predispose them towards reducing fitness (disuse), depression, persisting pain and increasing disability [59]. Thus, the results of the study showed that for this highly prevalent condition of low back pain, the public back pain beliefs sampled were not in harmony with current scientific evidence. Due to this mismatch, there is a need to disseminate corrected information to the general population. Thus, strategies for re-educating the public with focus on changing their attitudes and promoting their perception so as to create more adequate expectations and behavior are required.
5. Conclusion Prevalence of Low Back Pain was found to be high among the general population sampled and also the myths regarding LBP still exist among them.
Acknowledgements We would like to thank all the participants, Dr. (Brig) Amarjit Singh, Dean for his support, Dr. Soumik Basu and Mr. Karan Udasi for their help in data collection.
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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 731–737 DOI 10.3233/BMR-140575 IOS Press
Beliefs about low back pain: Status quo in Indian general population Venus K. Pagarea,∗, Teena Dhanraja, Dhaval Thakkarb , Aarti Sareena and Tushar J. Palekara a
b
Dr D.Y. Patil College of Physiotherapy, Pune, India Department of Radiodiagnosis, Dr D.Y. Patil Medical College, Pune, Maharashtra, India
Abstract. BACKGROUND: Low back pain (LBP) is a major public health problem and is the leading musculoskeletal cause of disability. Various bio-behavioral factors which can be associated with disability due to LBP have been identified. When considering these factors associated with LBP, beliefs that people hold are among the most important factors to consider. OBJECTIVE: To find out the prevalence of LBP among the general population and to investigate their beliefs towards LBP. METHODS: A cross-sectional survey of the general population was conducted. Demographic information and information on beliefs regarding low back pain was gathered from 921 individuals. The respondents were asked to rate their agreement with 7 statements, corresponding to Deyo’s 7 myths. RESULTS: 75% of the population reported lifetime prevalence of LBP. Regarding the beliefs about LBP, general population exhibited diverse attitudes. Out of 7 myths explored, 3 myths were found to be dead and buried in more than 50% of the sampled population. However, 4 out of 7 myths still exist among the population. CONCLUSIONS: Prevalence of Low Back Pain was found to be high among the general population sampled and also myths regarding LBP still exist among them. Keywords: Bio-behavioral factors, bio-psychosocial model, disability, kinesiophobia, myths, low back pain
1. Introduction Low back pain (LBP) is a major public health problem all over the world. It is the leading musculoskeletal cause of disability [1–6] and is the most frequently reported condition for which people receive outpatient physical therapy [1–4]. In India, the occurrence of low back pain (LBP) is high, with nearly 60% individuals having significant back pain at some or the other time in their lives [7,8]. The natural course of LBP is self-limiting whereas an estimated 10% of patients develop chronic LBP as defined by duration of more than 12 weeks [9,10]. Though this percentage is small, it represents a high socioeconomic burden due to the associated disability. ∗ Corresponding author: Venus Pagare, Padmashree Dr. D.Y. Patil College of Physiotherapy, Pune, Maharashtra, India. Tel.: +91 879 3393626; E-mail: [email protected].
The traditional methods and concept of management of low back pain are based on the biomedical model of disease and pain. According to this model, direct positive correlation exists among pathology/disease/pain, impairment, functional limitation, and disability [11– 13]. Identifying the physical impairments and their correction can therefore have a positive effect on the disability [14–19]. Studies have however, identified lack of physical factors to explain the reason for development of chronicity in these people [20]. In addition, in individuals with low back pain particularly those whose symptoms have persisted beyond a predictable period of tissue healing, the functional limitation, degree of pain reported and the disability is frequently disproportionate to the observed pathology [12,21,22]. In such patients, the traditional methods of management are often ineffective. This proves that, in addition to the nociceptive response from injured tissues, other factors may be associated with patients’s perception of pain and behavioral response [23].
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
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According to Engel, the scientific knowledge and technology that has been developed is directed towards “the body and its aberrations”, but the understanding of “human behavior and the psychological and social aspects of illness and patient care” is very limited [24]. This led to identification of the various bio-behavioral factors which can be associated with disability due to LBP. These biobehavioral factors are a set of psychological, environmental, and psycho-physiological processes [23]. Thus, today LBP can be best explained from a viewpoint of bio-psychosocial model [25,26]. This model lays emphasis on interactions between biological, psychological, and social factors which are implicated in persistence of pain and the development of disability [27,28]. According to Predisposing-Reinforcing-Enabling Causes Educational Diagnosis (PRECED) model, knowledge, perception and belief are predisposing factors necessary for changing behavior [29]. When considering the bio-behavioral factors associated with LBP, beliefs that people hold are among the most important factors to consider [30]. These can attenuate or exacerbate the discrepancy among pathology, pain, impairment, functional limitation, and disability and also with respect to response to treatment. The extent of functional impairment that an individual experiences is also dictated by the extent to which the patients believe that they are disabled by their pain. Cross sectional studies have found strong association between the beliefs of people and physical dysfunction [31]. It also determines the nature of seeking healthcare and their response to the treatment [32,33]. These beliefs that people hold are based on prior learning and social influences, including health care provision. Various beliefs have been linked to low back pain and these include beliefs such as back pain is inevitably negative, catastrophisation (hopelessness, magnification and rumination regarding pain) and fear-avoidance beliefs [34–37]. Belief that the pain is stable and unchangeable is associated with poor compliance with physical and psychological treatment [38]. On the other hand, patients who believe that they have greater control over their pain may be more likely to participate and benefit from rehabilitation programs [39]. There is an increase in evidence like staying active and continuing or resuming ordinary activities is more effective than rest and that early investigation and referral to a specialist are unwarranted in most cases. Previous study has found that a population based intervention regarding spreading of positive messages about back pain can improve population’s
beliefs, influences medical management and reduces disability and workers’ compensation costs related to back pain [40]. Thus, re-education can change attitudes and beliefs and alter patients’ expectations and behavior and can reverse or interrupt the rising incidence of disability from low back pain [40]. Thus, in response to increasing evidence on the role of psychosocial factors in the development of persistent pain and disability, the aim of this study was to find out the prevalence of LBP among the general population and to investigate their beliefs towards LBP.
2. Materials and methods A cross-sectional survey of the general population was conducted in Pimpri region of Pune, India. The study was approved by the institutional sub-ethics committee of Padm. Dr D.Y. Patil college of Physiotherapy. The general population data was sampled during early 2014. 2.1. Participants Convenient sampling method was employed for this prospective hospital-based survey and relatives of patients seen at the physiotherapy outpatient department formed the study subjects. The age group was 18– 60 years and data was collected from individuals who were not related to any health care profession, irrespective of past/present history of low back pain. Of the 994 individuals who were contacted, 921 individuals agreed to be involved. No incentives were offered to the subjects. 2.2. Instruments 2.2.1. Demographic information Information including age, gender, Occupation, Qualification, Work status: part time/full time was obtained from survey respondents but are not considered at this point and will be reported in a subsequent article. To obtain data on low back pain prevalence, participants were asked if they had experienced low back pain at the following time points/periods; now, past 1 year or ever in lifetime. Also, they were asked to report their coping strategies and data on LBP-related care seeking in the last month. 2.2.2. Beliefs about back pain To gather information on beliefs of people regarding low back pain, the individuals were asked to rate their agreement with 7 statements, corresponding to Deyo’s
V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population
7 myths [41]. The responders were asked to rate the statements on a 5-point likert scale (totally disagree, disagree, neither disagrees nor agrees, agree, and totally agree). The 7 statements were: 1. If you have a slipped disc (also known as a herniated or ruptured disc), you must have surgery. 2. Radiographs and newer imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI] scans) can always identify the cause of pain. 3. If your back hurts, you should take it easy until the pain goes away. 4. Most back pain is caused by injuries or heavy lifting. 5. Back pain is usually disabling. 6. Everyone with back pain should have a spine radiograph. 7. Bed rest is the mainstay of therapy. The same were translated in local language (Marathi) by experienced Marathi school teacher and were validated. 2.3. Statistical analyses Before the analysis, the responses to the myths were categorized into agreeing (totally agree, agree), unsure (neither agreeing nor disagreeing), and disagreeing (disagreeing, totally disagreeing). Frequencies of responses were calculated for the general population as percentages.
3. Results Nine hundred and twenty-one individuals participated in the survey. Their median (minimum, maximum) age was 52 (21, 58) years, 557 females and 364 males. High prevalence of back pain was reported with a lifetime prevalence of 78%, 1 year prevalence of 53% and point prevalence (at the time of questionnaire completion) of 48%. 3.1. Beliefs about low back pain Regarding the beliefs about low back pain, the general population exhibited diverse attitudes. Out of the 7 myths explored, 3 myths were found to be dead and buried in more than 50% of the sampled population. However, 4 out of 7 myths still exist among the population. Figure 1 shows Frequencies (%) of disagreeing, being unsure, and agreeing with Deyo’s 7 myths for the general population.
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4. Discussion Biological, psychological and social factors, particularly an individual’s belief system play an important role in the persistence of pain and the development of disability in low back pain. Irrational beliefs about back pain can lead to kinesiophobia (fear of movement)/re-injury, reduction in activity, function and subsequently disability. The present populationbased survey was therefore, done to find out the prevalence of low back pain among the general population and to find out the beliefs regarding low back pain among them. Deyo identified 7 common myths among the people regarding low back pain [41]. These wrong beliefs have been found to be strongly associated with and implicated for maintenance or development of disability due to low back pain. The results of the present survey showed that of these 7 myths, the beliefs of more than 50% of the population were in harmony with the current scientific evidence for 3 statements. The general population showed disagreement with statement “Most back pain is caused by injuries or heavy lifting”. In reality, over half of the people with back pain develop it gradually without a specific injury [41]. They also disapproved that “Back pain is usually disabling” and that “Bed rest is the mainstay of therapy”. Evidence suggests that although the pain can sometimes be very severe, it is rarely disabling. This disability which develops is mainly due to bio-behavioral factors rather than physical injury associated with LBP. Also, bed rest as a mainstay for treatment is strongly discouraged as it causes rapid deconditioning making a person more susceptible to developing chronicity and perpetuates kinesophobia [41]. This pain-kinesiophobia-pain then forms a viscous cycle. Scientific research demonstrates that those who remain at least active after an injury do better than those who rest in bed [41]. Though the general population is aware of certain myths regarding LBP, they are not completely dead and buried. Some of the wrong beliefs regarding LBP still exist in the population sampled. People still believe that “for a slip disc (also known as a herniated or ruptured disc), surgery is a must”. This holds completely wrong as 90% of all herniated discs heal without surgery [41]. Most of the times, LBP can be managed by staying active and educating people about anatomy and physiology of pain. Surgery is generally not considered until conservative measures have failed. Also, surgery carries higher risk and also chances of failure: ‘failed back syndrome’ also exist. Surgery for
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2. Radiographs and newer imaging tests can always idenfy the cause of pain
1. If you have a slipped disc, you must have surgery 80%
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3. If your back hurts, you should take it easy unl the pain goes away
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4. Most back pain is caused by injuries or heavy liing
90%
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5. Back pain is usually disabling 80% 70% 60% 50% 40% 30% 20% 10% 0% Disagree
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6. Everyone with back pain should have a spine radiograph
7. Bed rest is the mainstay of therapy
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Fig. 1. Shows Frequencies (%) of disagreeing, being unsure, and agreeing with Deyo’s 7 myths for the general population.
LBP is therefore reserved for those with high severity or associated complications. Another common myth which was found to be prevalent in Indian population was that “Radiographs and newer imaging tests (computed tomography [CT]
and magnetic resonance imaging [MRI] scans) can always identify the cause of pain” and that “Everyone with back pain should have a spine radiograph”. This shows misconception among the general population regarding use of investigative procedures for low back
V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population
pain. Firstly, according to evidence based guidelines only 15% of patients with low back pain (LBP) are given specific diagnosis, the remaining 85% are diagnosed as ‘non-specific low back pain (NSLBP)’ [42] The term ‘non-specific’ is used to describe an entity whose pathoanatomical etiology is unknown [42]. Therefore, in most cases of LBP, X-rays or other investigations are not needed. Even when indicated, these investigations may not identify the cause or source of LBP, with not much contribution to better management [43–45]. Secondly, some of the changes such as ‘disc bulge or degenerative changes’ identified by these investigations may only be incidental which may even be present in the age and gender matched population without low back pain [46–48]. Thirdly, diagnostic scans are not reassuring for the patients [49]. A recent study in the USA demonstrated that disability was high among the patients who were sent for an early MRI as compared to those who did not have an MRI scan [50]. Lastly, these investigations also carry a potential hazard of exposure to radiation. Thus, it is highly recommended to reserve these expensive investigations for those with signs of serious pathology who can easily be identified by appropriate history taking and systematic clinical examination. The last myth reported in high proportion of population was “If your back hurts, you should take it easy until the pain goes away”. This completely contrasts the current scientific evidence according to which, after an initial back injury, it is advisable to avoid aggravating or causative activities/movements. However, there is very strong evidence that keeping active and returning to all usual activities is important in recovery and reducing the risk of disability [41,51]. Most acute injuries recover well, and natural recovery may explain the improvement felt in many cases, especially in cases of acute or recent-onset LBP. In contrast, prolonged bed rest is unhelpful, and is associated with higher levels of pain, greater disability, poorer recovery and greater absence from work [52–56]. Given the high agreement with this belief, it could be in line with the fear avoidance model introduced by Lethem et al. [57,58], and developed specifically to relate to LBP by Vlaeyen et al. [59]. According to this model, experience of can can be interpreted in 2 different ways by the central pathways. When an individual perceives the acute pain as non-harmful and non-threatening, he/she is able to perform the activities of daily living which in turn facilitates functional recovery [60]. However, on the other hand, if the pain is misinterpreted as threatening, it can lead to excessive and aber-
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rant concerns regarding the activities which are considered to cause (re) injury. These beliefs become significant when it leads to behavioral changes in individuals (fear-avoidance behavior), the restriction of activity by the ‘avoiders’, escape and hyper-vigilance being of utmost importance. This is believed to predispose them towards reducing fitness (disuse), depression, persisting pain and increasing disability [59]. Thus, the results of the study showed that for this highly prevalent condition of low back pain, the public back pain beliefs sampled were not in harmony with current scientific evidence. Due to this mismatch, there is a need to disseminate corrected information to the general population. Thus, strategies for re-educating the public with focus on changing their attitudes and promoting their perception so as to create more adequate expectations and behavior are required.
5. Conclusion Prevalence of Low Back Pain was found to be high among the general population sampled and also the myths regarding LBP still exist among them.
Acknowledgements We would like to thank all the participants, Dr. (Brig) Amarjit Singh, Dean for his support, Dr. Soumik Basu and Mr. Karan Udasi for their help in data collection.
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