Do Teaching General Practitioners’ FearAvoidance Beliefs Influence Their Management of Patients with Low Back Pain? Vincent Gremeaux, MD, PhD*,†,‡; Emmanuel Coudeyre, MD, PhD§,¶; Thomas Viviez, MD**; Philippe Jean Bousquet, MD, PhD††; Arnaud Dupeyron, MD, PhD‡‡,§§ *Multithematic Clinical Investion Center (CIC-P) Inserm 803, University Hospital, Dijon; Inserm U1093, Dijon; ‡Department of Rehabiliation, University Hospital, Dijon; §Clermont University, University of Auvergne, Clermont-Ferrand; ¶Department of Rehabilitation and Physical Medicine, University Hospital, Hospital G. Montpied, Clermont-Ferrand; **Medical Office, Aigues-Mortes; ††BESPIM, University Hospital, N^ımes; ‡‡Department of Physical Medicine and Rehabilitation, University Hospital, N^ımes; §§Movement to Health (M2H), Montpellier-1 University, Montpellier, France †
& Abstract Objectives: To describe fear-avoidance beliefs about low back pain (LBP) in a sample of teaching general practitioners (TGPs) and to investigate the impact on following the guidelines for LBP. Methods: A sample of 112 French TGPs were contacted to complete a self-administered questionnaire including sociodemographic and professional data, personal history of LBP, CME about LBP and usual practices, and their low back pain beliefs using the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Back Belief Questionnaire (BBQ). Results: Forty-seven responded, 48% treated more than 10 LBP patients per month, and 45% participated in an educational session on LBP during the previous 3 years. Seventy
Address correspondence and reprint requests to: Arnaud Dupeyron, partement de me decine physique et re adaptation, GHRU MD, PhD, De meau, place du Professeur-Debre , 30029 N^ımes Cedex 09, France. Care E-mail: [email protected]
Submitted: September 9, 2013; Revised July 20, 2014; Revision accepted: July 21, 2014 DOI. 10.1111/papr.12248
© 2014 World Institute of Pain, 1530-7085/14/$15.00 Pain Practice, Volume 15, Issue 8, 2015 730–737
percent reported a previous episode of acute LBP, while 30% suffered from chronic LBP. The median scores for the FABQphys and work were 8 (4 to 10) and 17 (11 to 21), and 35 (31 to 38) for the BBQ. There were no correlations between age or years of practice and FABQ scores. TGPs suffering more than 1 acute LBP episode per month had a lower BBQ score (P < 0.05). Those prescribing more imaging exams in acute LBP had higher FABQ and lower BBQ scores, while those who recommended rest in both acute and chronic LBP had a higher FABQ-phys score. Discussion: Teaching general practitioners’ fear-avoidance beliefs about LBP are lower than previously reported by their GP colleagues but still negatively influence the way they follow guidelines for LBP patients. This may influence the way they teach the management of LBP. & Key Words: low back pain, behavioral medicine, fear avoidance, medical education, fear-avoidance beliefs questionnaire, back relief questionnaire
INTRODUCTION Psychosocial factors are thought to play a major role in the persistence of low back pain (LBP).1 Cognitive
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factors may be more important than socio-demographic factors in the development of disability related to these symptoms.1,2 Among these cognitive factors, fearavoidance beliefs may be the most important in the development of chronic disability in patients with LBP.3,4 Fear-avoidance beliefs have been shown to predict disability in daily or occupational activity, treatment outcomes, and patients’ return to work after a functional rehabilitation program.5,6 On the other hand, adequate information provided to LBP patients has been shown to have a positive effect on their fearavoidance beliefs.7–9 In the international practice guidelines,10 there is consensus on the interest of limiting rest, reassuring patients about the benign nature of the pain, and giving advice about the use of analgesics during acute episodes of LBP (Table 1). This strategy diminishes the likelihood of progressing to the chronic form of the disease and attenuates the impact of low back pain on professional and everyday life11. However, there are a certain number of barriers with regard to the application of these guidelines in current medical practice.12 Several studies have suggested that the fear-avoidance beliefs of health care providers could influence how they manage patients.13 Recent studies have suggested that general practitioners (GP) or rheumatologists do not always follow these guidelines.14–18 Moreover, Coudeyre et al.18 showed that GPs’ fear-avoidance beliefs about LBP negatively influence the way they follow guidelines concerning physical and occupational activities for patients with LBP.
Table 1. Recommendations for Diagnosis and Treatment of Low Back Pain10,11 Diagnosis of low back pain Screen for serious pathology using red flags Screen for neurologic signs Consider psychosocial factors using yellow flags in case of non improvement Do not use routine imaging for nonspecific low back pain Acute and sub-acute phase Reassure patients (favorable prognosis) Advise to stay active Prescribe medication if necessary (preferably time-contingent) Discourage bed rest Do not advise a supervised exercise program Chronic phase Discourage us of passive modalities (heat/cold, traction, massage, ultrasound, electrotherapy) Short term use of medication/manipulation Brief educational interventions Supervised exercise therapy Cognitive behavioral therapy Multidisciplinary treatment (bio-psycho-social model)
In France, teaching general practitioners (TGP) host residents at their consulting rooms to provide them with experience in primary care and educate them on physician–patient relationships. This close relationship between the resident and the physician may also affect their respective practices. Among other things, TGPs are responsible for teaching general medicine at medical school. They may also contribute to the development of research in primary care. Teaching is evaluated by the TGPs and the residents; however, to our knowledge, there have been no studies about the way TGPs practice medicine, notably concerning the management of low back pain. The aim of this work was to determine, in a sample of TGPs, fear-avoidance beliefs about LBP and to investigate the impact of these beliefs on the way they followed guidelines for bed rest, physical activity maintenance, pharmacological and nonpharmacological prescription, and sick leave. It was hypothesized that scores for fearavoidance beliefs in TGPs would be lower than those among their GP colleagues, and this could affect the way patients with LBP are managed.
METHODS Design A cross-sectional, descriptive, and analytical study was conducted in a sample of TGPs in the south of France. Criteria for TGP inclusion were as follows: primary care activity, at least 3 years of professional experience, and < 70 years. The 112 TGPs of the regional medical school who met these criteria were invited to take part by telephone. They were deemed “unreachable” if they had not been contacted after 5 calls. Outcomes After agreeing to take part, the TGPs were sent the study dossier by e-mail. The dossier contained 2 files in the Microsoft Word format. The first file was a description of the study and a consent form. The second file contained a self-administered questionnaire, where the first part aimed to collect demographic and professional data (years and environment of practice), the physician’s personal history of back pain (none/acute/recurrent/ chronic), as well as self-limitation of physical activities related to the back pain (never/sometimes/often/always). The second part dealt with TGPs’ specific education about LBP and usual management of LBP: participation
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in specific education sessions on back pain in the last 3 years (yes/no); knowledge about multidisciplinary bio-psycho-social rehabilitation programs for LBP (yes/ no); specific information on back pain delivered to patients (yes/no) and type (oral, booklet, multimedia); patients referred to spine specialists (yes/no) and type (medical specialist, rheumatologist, physical medicine and rehabilitation, surgeon); length of sick leave prescription for acute LBP if needed (≤3 days, 3 to 8 days, > 8 days); advice about physical activities during sick leave for acute back pain (bed rest, rest at home, keep maximum bearable activities); attitude to adapt with patients with chronic back pain concerning job adaptation, sick leave prescription for increased pain; advice to keep maximum bearable physical activities; and advice to keep maximum bearable occupational activities (always, often, sometimes, never). The last part assessed TGPs’ fear-avoidance beliefs using slightly modified versions of the Fear-Avoidance Beliefs Questionnaire (FABQ)5,19 and the Back Beliefs Questionnaire (BBQ),20 adapted to healthcare professionals. We adapted the first sentence of instructions of the FABQ (“these are statements that other patients have expressed about their low back pain . . .”) just removing the word “other” to render it more adapted to explore TGP’s beliefs. The FABQ is designed to assess patients’ fear-avoidance beliefs and consists of 2 independent subscales. The FABQ-phys assesses fear-avoidance beliefs related to general physical activities (4 items, range 0 to 24), and the FABQ Work assesses fear-avoidance beliefs related to occupational activities (7 items, range 0 to 42). According to the authors of the original validation of this scale, a score ≥ 14 for the FABQ-phys scale indicates high beliefs.21 The BBQ is a semiquantitative scale with 5 levels (total disagreement = 1, total agreement = 5) that includes 14 items, 5 of which are decoys (possible scores from 9 to 45). It explores beliefs concerning the inevitable consequences of low back pain. High scores indicate positive beliefs about low back pain, suggesting a greater capacity of adaptation. There is no threshold value in the literature. This scale has been used in major studies8,22,23 but has never been validated in French; we therefore used the translated version from a previous study culturally adapted for healthcare professionals.24,25 Study Process The study took place over a 3-month period. When completed, the files were returned by e-mail or mail. If a
dossier was not returned, the TGP was contacted twice at an interval of 1 month by telephone and by e-mail with the attached dossier. An e-mail was sent to nonresponders at the end of the study, asking why they had not responded. Their reasons for refusing to take part were recorded. This study was conducted in compliance with the principles of Good Clinical Practices and the Declaration of Helsinki. The study protocol received the agreement of medical school research board. In accordance with French national law, GPs gave their written agreement to participate after being informed about the study protocol. Statistical Analysis Numbers and percentages described the population characteristics; medians and interquartile ranges (IQRs) were used for variables with non-normal distribution. Student’s t-test or Fisher’s exact test was used to compare qualitative variables, depending on the application. Qualitative and quantitative variables were compared using the Wilcoxon test or Kruskal–Wallis test, depending on the number of classes of the qualitative variable (> or < 2). The statistical analysis was performed using SAS v9 (SAS Inst., Cary, NC, USA) for Windows XP. The threshold for significance was set at P < 0.05.
RESULTS Participants Forty-seven (42%) of 112 TGPs contacted returned the completed dossier, 13 by postal mail and 34 by e-mail. Thirteen nonresponders could not be contacted directly. For the 50 nonresponders remaining, the reasons most frequently given for not taking part in the study were lack of time (18), technical problems (5), and lack of interest (2). Twenty-five nonresponders did not give any reason. There were no differences between responders and nonresponders for age, sex, and location. Characteristics of the TGPs The median age was 53 years (interquartile range 48 to 58 years) (Table 2). Most TGPs had practices in urban or semirural areas, alone or in a group, and 5 to 30 years of experience (66% had more of 20 years experience, 25% more of 10 years, and 9% less than 10 years, with 22 years on average). Three years of professional experience were required for GP at being a TGP. A
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Table 2. Demographic and Professional Characteristics, Personal History of Low Back Pain, Training, Reported Management of Low Back Pain of the Participating Teaching General Practitioners (TGPs) TGPs (n = 47) Age (years), median Sex (M/F), n Number of years in practice, n < 10 10 to 20 21 to 30 > 30 Location of practice, n Rural Semirural Urban Type of practice, n Alone Group Personal history of low back pain (LBP), n Acute LBP (yes) Chronic LBP (yes) Limited physical activity due to LBP, n Never Rarely Frequently Permanently Data on the management of LBP, n Number of consultations for LBP per month 10 Specific information provided (yes) Oral Written (leaflets, booklets. . .) Multimedia (cd-rom, video, Internet)
53 38/9 4 12 22 9 7 23 17 19 24 33 16 24 22 1 0
3 21 22 45 43 19 1
M, male; F, female.
large number of TGPs (70%) had already experienced acute low back pain, and 34% suffered from chronic LBP, with 24% suffering more than 1 acute episode per month, even though they rarely (98%) reported limitations in physical activities. Forty-eight percent of the TGPs reported that they received more than 10 patients with low back pain per month. Forty-six percent had participated in an educational session about LBP in the previous 3 years or had heard about multidisciplinary bio-psycho-social rehabilitation programs for LBP. Acute LBP Management All of the TGPs declared that they provided specific information to their LBP patients (Table 3). The information was oral or written (booklets, sheets), and little use was made of multimedia tools or video/audio supports. In regard to prescription habits, 60% advised rest in acute LBP, and less than half recommended maintaining as much physical activity as possible. Analgesics and NSAIDs were regularly or frequently pre-
Table 3. Management of Acute Low Back Pain as Reported by Teaching General Practitioners (TGPs) TGPs (n = 47) n (%) Prescription of rest Never Sometimes Often Always Prescription of analgesics Never Sometimes Often Always Prescription of NSAIDs Never Sometimes Often Always Prescription of physiotherapy Never Sometimes Often Always Aim of physiotherapy Pain relief Maintain or improve mobility Maintain or improve muscle strength Prescription of radiology Never Sometimes Often Always Duration of sick leave ≤ 3 days 3 to 8 days > 8 days Place of physical activity during sick leave Bed rest Relative rest at home Maximum bearable activity
2 17 13 15
(4) (36) (28) (32)
0 2 7 38
(0) (3) (15) (82)
5 9 9 24
(9) (20) (19) (52)
3 21 12 10
(6) (46) (26) (22)
19 (41) 16 (35) 11 (24) 6 26 9 5
(13) (56) (20) (11)
7 (15) 39 (83) 1 (2) 2 (4) 25 (53) 20 (43)
scribed by 97% and 71% of the physicians in the study, respectively. Almost half (48%) regularly prescribed physiotherapy, mainly for pain relief, and one-third (31%) regularly or frequently prescribed a radiological examination of the spine. In contrast, more than 90% never or only rarely prescribed or recommended a biological test. The reported durations of sick leave were in almost all cases