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Experiences of chronic low back pain: a meta-ethnography of qualitative research ab

a

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Padraig MacNeela , Catherine Doyle , David O'Gorman , Nancy bc

Ruane

& Brian E. McGuire

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School of Psychology, National University of Ireland, Galway, Galway, Ireland b

Centre for Pain Research, National University of Ireland, Galway, Ireland c

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Division of Pain Medicine, Department of Anaesthesia, Galway University Hospital, Galway, Ireland Published online: 06 Nov 2013.

To cite this article: Padraig MacNeela, Catherine Doyle, David O'Gorman, Nancy Ruane & Brian E. McGuire (2015) Experiences of chronic low back pain: a meta-ethnography of qualitative research, Health Psychology Review, 9:1, 63-82, DOI: 10.1080/17437199.2013.840951 To link to this article: http://dx.doi.org/10.1080/17437199.2013.840951

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Health Psychology Review, 2015 Vol. 9, No. 1, 63–82, http://dx.doi.org/10.1080/17437199.2013.840951

Experiences of chronic low back pain: a meta-ethnography of qualitative research

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Padraig MacNeelaa,b*, Catherine Doylea, David O’Gormanb,c, Nancy Ruaneb,c and Brian E. McGuirea,b,c a School of Psychology, National University of Ireland, Galway, Galway, Ireland; bCentre for Pain Research, National University of Ireland, Galway, Ireland; cDivision of Pain Medicine, Department of Anaesthesia, Galway University Hospital, Galway, Ireland

(Received 5 January 2012; accepted 18 July 2013)

Chronic low back pain (CLBP) is associated with a number of costly disabilityrelated outcomes. It has received increasing attention from qualitative researchers studying its consequences for personal, social, and health care experiences. As research questions and methods diversify, there is a growing need to integrate findings emerging from these studies. A meta-ethnography was carried out to synthesise the findings of 38 separate qualitative articles published on the subjective experience of CLBP between 1994 and 2011. Studies were identified following a literature search and quality appraisal. Four themes were proposed after a process of translating the meaning of text extracts from the findings sections across all the articles. The themes referred to the undermining influence of pain, its disempowering impact on all levels, unsatisfying relationships with health care professionals, and learning to live with the pain. The findings are dominated by wide-ranging distress and loss but also acknowledge self-determination and resilience. Implications of the metaethnography for clinicians and future qualitative research are outlined, including the need to study relatively unexamined facets of subjective experience such as illness trajectory and social identity. Keywords: meta-ethnography; chronic low back pain; chronic pain; qualitative; primary care; person-centred care

Chronic low back pain (CLBP) is one of the most common forms of musculoskeletal disorder (Breivik, Collett, Ventafridda, Cohen, & Gallacher, 2006). It involves pain localised ‘below the costal margin and above the inferior gluteal folds’, persisting for three months and not attributable to a specific pathology (Airaksinen et al., 2006, p. S208). The condition involves continuous pain or recurrent flare-ups that result in severe distress and disability for sufferers (Airaksinen et al., 2006). In recognition of this, multidisciplinary approaches to rehabilitation for people with CLBP have emerged. The resulting guidelines and behavioural interventions are predicated on partnership, person*Corresponding author. Email: [email protected] © 2013 Taylor & Francis

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centred engagement, and awareness of biopsychosocial domains (Kaba & Sooriakumaran, 2007). Specific psychological, social, and work-related initiatives have been developed to support coping and active self-management of pain and related behaviours (Gatchel, Peng, Peters, Fuchs, & Turk, 2007; Waddell & Burton, 2005). Despite these developments, and the consequent scope for improving care and supporting sufferers, the evidence suggests a lack of implementation of biopsychosocial rehabilitative programmes within everyday practice in primary care (Chaudhary, Longworth, & Sell, 2004; MacNeela, Gibbons, McGuire, & Murphy, 2010). Studies of general practitioners (GPs) have identified numerous obstacles to the utilisation of evidence-based interventions, including pressure of time, inadequacy of professional preparation, and doubts about the veracity of patient claims (Breen, Austin, Campion-Smith, Carr, & Mann, 2007). The feelings of frustration and mistrust expressed by doctors in research on attitudes to patients suggest a conception of CLBP at variance with the experience of sufferers themselves. A body of qualitative research has developed, largely in the past decade, to describe and interpret the subjective experiences of individuals with CLBP. These studies demonstrate an association with traumatising discomfort and hardship (Smith & Osborn, 2007). This research base is an important contextualising resource which has the potential to raise awareness of person-centredness among health care practitioners. The dissemination of qualitative findings is complicated by the increasing number of individual studies of CLBP, which range across different methodologies and focal areas. The proliferation of qualitative research in recent years is a positive feature in one respect, as different perspectives have become available but can also be interpreted as signifying a body of work lacking coherence. Qualitative studies of CLBP sufferers have ranged across personal, social, and health care experiences but have yet to be reviewed in an integrated manner. The purpose of this study is to synthesise research findings on the subjective meaning of back pain (Nelson, 2002). Meta-synthesis of existing qualitative reports on a particular phenomenon is increasingly prominent as a methodological strategy, arising partly as a response to the increasing number and diversity of individual studies (Sim & Madden, 2008; Yu, Lee, Kwong, Thompson, & Woo, 2008). The synthesis method in this study is meta-ethnography, a systematic process of secondary analysis to synthesise existing qualitative research findings on a particular phenomenon into a new conceptualisation or interpretation (Noblit & Hare, 1988). This strategy was developed to manage the problematic issue of identifying patterns and divergences across studies based on different orienting concepts and interpretative strategies. Meta-ethnography is one of several commonly used qualitative synthesis methods (Pope, Mays, & Popay, 2007). Meta-ethnographic synthesis has recently begun to be applied in a health services research context (Atkins et al., 2008; Elmir, Schmeid, Wilkes, & Jackson, 2010), suggesting its relevance for integrating a diverse set of qualitative studies on CLBP. It is distinctive in outlining a stepwise methodology for translating the findings of individual studies into a common conceptual framework, acknowledging concepts that are divergent between studies and representing the synthesis in a line of argument. Methods Meta-ethnography is used to devise an interpretive synthesis of the findings of individual qualitative studies of a particular experience (Finfgeld, 2003; Noblit &

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Hare, 1988). In this case, the phenomenon of interest was the subjective experience of CLBP. Noblit and Hare’s (1988) meta-ethnographic method structures the task of reanalysing existing findings through sequential, progressive steps, beginning with study identification and review, followed by the development, refinement, and expression of narrative themes. Identifying and appraising the review articles A literature search of journal articles was conducted in May 2012 to identify relevant peer-reviewed articles published up to the end of 2011. The databases chosen were MEDLINE, PsycINFO, CINAHL, Scopus, PubMed, EBSCO Academic Search Complete, and EBSCO Health Source: Nursing/Academic Edition. These were chosen to provide a basis for identifying articles from multiple disciplines including psychology, medicine, physiotherapy, nursing, and applied social sciences. Our decision to use a multidisciplinary literature search strategy was taken to ensure that the study included practice-focused disciplines such as physiotherapy. In general, these latter examples presented less evidence of thick description and subjective meaning and had more diverse samples including participants in paid employment. We concluded that it was important to include these studies to ensure that our findings make a relevant statement about patient evaluations from an applied perspective. The databases were searched using the keywords ‘qualitative’ AND ‘chronic low back pain’ OR ‘CLBP’ (see supplemental data Figure 1). We examined the references cited by the articles reviewed to ensure inclusion of other relevant studies that were not found in the search. Abstracts identified in the search results were screened using inclusion criteria that required studies to have used a qualitative research design and be in the English language. Closer examination of the remaining studies followed, using the research query of understanding the subjective experience of CLBP. Studies were excluded if they had a mixed quantitative/qualitative design, a mixed sample of health care practitioners and CLBP sufferers, or a focus judged to be something other than experiences of back pain. Studies with mixed samples included health care professionals and sufferers of conditions other than CLBP. These were excluded due to uncertainty about how the subjective experience of individuals with CLBP was incorporated alongside the views of professionals. There were minor exceptions made to the exclusion rules. Carnes and Underwood’s (2008) study of musculoskeletal pain was included because 10 of the 13 participants had CLBP. Another exception was made for one study with a quantitative component (McPhillips-Tangum, Cherkin, Rhodes, & Markham, 1998), as a follow-up questionnaire to respondents was derived from a content analysis of interview transcripts. A number of applied studies were identified in the literature search, referring to appraisals of medical treatments, health care or educational initiatives, with the possibility that subjective experience was superficial or peripheral to the research aim. Slade, Molloy, and Keating’s (2009b) study of participation in an exercise programme was included as it was judged to foreground subjective experience, whereas studies excluded at this point focused primarily on the functional evaluation of specific initiatives. We then applied Meyrick’s (2006) criteria for quality appraisal in qualitative health psychology research to evaluate the rigour and quality of the studies. We used Meyrick’s framework as it is a frequently cited framework for appraising qualitative research, especially suited to considering contributions from multiple disciplines related to public

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health, psychology, sociology, and anthropology. Her criteria are based on the principles of transparency and systematicity. Transparency is taken to refer to clarity and disclosure in the description of the research process, so that the interpretive claims made in each study can be evaluated. Systematicity is operationalised through reference to the use of specific strategies (e.g., clear aims/objectives, multiple coding, respondent validation), with an acknowledgement that qualitative approaches differ as to the strategies considered necessary for a rigorous, systematic process. Using Meyrick’s framework for quality, the studies were appraised in respect of research questions, rationale for the selected qualitative approach, statements of recruitment and sampling strategies, and the coherence of data collection and analytic processes. Studies that departed significantly from the standards Meyrick (2006) suggests were excluded, for instance, on the basis of omitting information on interview content or presenting quotes that lacked researcher contextualisation and interpretation. Overview of the studies reviewed Thirty-eight separate articles were included in the meta-ethnography following the evaluation and exclusion process (supplemental data Table 1), representing 28 separate empirical investigations. Research aims and focal areas Different aspects of the back pain experience were identified in statements of study aims and focal areas. Broadly classified, the research goals that were described concerned the exploration of pain experiences, management and intervention strategies, the psychosocial consequences of back pain, and the meaning of being a patient. Individual studies focused on one or more of these domains, with perceptions of health care and treatment especially prominent alongside the impact of back pain on the self. Qualitative approaches identified The most common qualitative approaches used in the articles reviewed were the framework approach (nine studies), thematic analysis (eight studies), interpretative phenomenological analysis (IPA, six studies), and content analysis (six studies), followed by grounded theory (five studies) and phenomenology (four studies). Low sample sizes in IPA studies were explicitly justified by the idiographic nature of the analysis (Crowe et al., 2010) while the conceptual basis to the research design was less clearly stated in studies aligned to the framework approach or content analysis. Participant sampling and recruitment Studies typically recruited participants through health care services such as pain treatment clinics, primary care, and physiotherapy services. Information on age and gender were almost always clearly reported but less consistent information was provided on work status or ethnic identity. Where provided, information on work status is included in supplemental data Table 1. Sample sizes were typically up to 25 individuals, with several examples of larger samples (e.g., McPhillips-Tangum et al., 1998). Strunin and Boden’s (2004) study of 414 individuals with work-related disability employed the largest sample and was also distinctive in using a structured telephone interview. Participants were usually recruited on a convenience basis, with some exceptions (Strunin & Boden, 2004).

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In cases where information on ethnic identity was provided, the majority of participants were described as Caucasian, with occasional reference to ethnically diverse samples including Afro-Caribbean, Pakistani/Bangladeshi, Middle Eastern, or South Asian individuals. This reflects the breakdown of studies by location. Participants in 24 of the articles were recruited in the UK, compared with five in Australia, three in the US, and one each in six countries (Canada, New Zealand, Norway, Sweden, Israel, Iran). Data collection and analysis Data collection methods almost always included face-to-face individual interviews and/or focus groups. There were a few exceptions, such as observation alongside interviews (Borkan, Reis, Hermoni, & Biderman, 1995) and telephone interviews (Strunin & Boden, 2004). The interview structure was usually described in general terms as comprising a semi-structured interview schedule. A brief overview was typically provided of openended questions and prompts. There were just a few counter-examples where comprehensive information was provided on question topics (Ashby, Richards, & James, 2010; Carnes & Underwood, 2008; Crowe et al., 2010). Analysis procedures were usually described as involving two researchers, at least in terms of initial theme construction and validity checks. Specific analytic techniques cited were justified by reference to the qualitative research design that was employed. Only a small number of studies gave extensive detail on analysis processes or reflection by the researchers (Cooper, Smith, & Hancock, 2009; Crowe et al., 2010; Snelgrove & Liossi, 2009). Analysis The results section of each relevant study was used as data with the aim of synthesising existing research findings on the subjective back pain experience. The breadth of the investigation was necessary considering the diversity and large size of the body of qualitative research on CLBP, combined with a lack of previous attempts to integrate findings. Meta-ethnography has been used to manage and represent relatively large sets of studies on previous occasions (Atkins et al., 2008; Elmir et al., 2010). The use of a stepwise approach in meta-ethnography is consistent with the principle of transparency (Meyrick, 2006). At the same time, meta-ethnography is an interpretive approach, concerned with constructing a plausible, coherent representation of the body of research rather than one claiming to capture the definitive nature of the phenomenon. Researchers must therefore be reflective when engaging in a synthesis process to maintain awareness of how our own experiences and professional background influence the interpretations that are adopted. The study was carried out as a preparatory phase for an IPA study of CLBP that we conducted. Our choice of a phenomenological article (Smith & Osborn, 2007) as the initial reference point for the meta-ethnography reflects our initial framing of CLBP as a phenomena that impacts on self-concept and identity. The authors are active in pain research, including CLBP, using a range of phenomenological, clinical, and biomedical orientations. Team members primarily concerned with clinical utility contributed a pragmatic concern with making a clear statement of how people with CLBP cope with the condition. We used two meta-ethnographic strategies to compare the findings of the studies and identify patterns. Firstly, the process of reciprocal translation is used to identify similarities between studies by comparing the analogies and metaphors used in each

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investigation (Elmir et al., 2010). This strategy is used to translate the findings of different studies to develop an interpretation that is meaningful across these investigations. The translation of findings was complemented by a second strategy, refutational analysis, which was used to challenge the emerging interpretations by accommodating exceptions to the general patterns presented by a divergent subset of studies. The analysis process began with the first and second authors reading an index article (Smith & Osborn, 2007). The article was chosen because its theoretical focus on the impact of CLBP on the self clearly prioritised subjective experience. Each subsequent study was read several times by the first and second authors to initiate the reciprocal translation of themes and findings (Atkins et al., 2008). The reciprocal translation was structured by tabulating the perceptions, feelings, experiences, and evaluations described in the findings of each study, prioritising direct participant quotes to formulate themes and develop the meta-ethnography. Comparable patterns between studies were identified, with relevant text and participant quotes from the findings sections of the studies compiled for each proposed theme in a process of iterative revision. The refutational component of the meta-ethnographic methodology led to the proposal of a distinctive theme of selfmanagement and resilience, which was divergent from and challenged the dominant motif of suffering shared between most of the studies. The analysis resulted in four themes and 13 subthemes (supplemental data Table 2). Each theme was set out in a narrative with descriptive and interpretive elements, grounded by verbatim participant quotes from the studies (Elmir et al., 2010). The metaethnographic process concludes with the integration of themes into a line of argument, a final level of synthesis that combines the distinctive patterns in the thematic findings into a narrative (Nelson, 2002, p. 516–517). The line of reasoning developed in this metaethnography proposed an overarching experience of distress and loss, contextualised in subjectively valued domains, with a secondary emphasis on determination and selfmanagement.

Findings The meta-ethnography suggested an experience in which severe pain evokes wideranging distress and loss that can undermine individuals on all levels. The final theme represented self-management and adaptation as a counterpoint to the distress dominating most studies. The undermining influence of pain The sensation of back pain, its pervasive consequences and the prospect of future disability led to inescapable discomfort, distress, and loss. This undermined the person’s capacity to remain independent as well as beliefs about personal control and sustainability. Discomfort, distress, and loss The constant presence of pain was commonly emphasised (e.g., Borkan et al., 1995; Snelgrove & Liossi, 2009). Severe and intense sensations were illustrated by descriptors of pain such as twisting, crippling, raw, red, shooting, aching, and burning (De Souza & Frank, 2000, p. 214; ‘[it’s] like somebody pulling you apart’, ‘sometimes it’s like someone’s sticking a skewer into you’, p. 212).

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Pain was usually described as an ever-present sensation or impending threat, varying in severity between good and bad days (‘some days it’s really bad and you don’t want to get out of bed’, Snelgrove & Liossi, 2009, p. 740). The study conducted by Young, Wasiak, Phillips, and Gross (2011) was distinctive in that most participants were still working. For them, periods of relative normality were interrupted by periodic flare-ups and sudden attacks (‘I bent over to pick up the walker, then whamo… I didn’t think I was going to walk again after that experience’, p. 207). Surges in intensity occurred among those who had ongoing pain, an aggressive sensation that can ‘knock your breath away’ (Snelgrove & Liossi, 2009, p. 740), which ‘just happens’ without warning (Crowe et al., 2010, p. 589). Heightened episodes of pain were totally debilitating and led to dismay: ‘when you get these attacks, and when you’re having to crawl on all fours to get to the toilet, and it’s took you 15–20 min to get out of bed’ (Coole, Drummond, & Watson, 2010, p. 476). Pain was directly responsible for disrupted, unsatisfying sleep, reduced mobility, and impaired self-care (Carnes & Underwood, 2008; De Souza & Frank, 2007; Hush et al., 2009; Skelton, Murphy, Murphy, & O’Dowd, 1996). The result was a severe threat to the person’s lifestyle and undermined ability to carry out essential daily activities (‘I can barely walk to my car … I have to sit for a little while before I can drive the car home … I cannot cook. I have to sit on a stool to do any cooking’, McPhillips-Tangum et al., 1998, p. 291; ‘not to mention what it does to your sex life’, Young et al., 2011, p. 207). In turn, such losses impacted on valued roles and routines, such as parenting, gardening, exercise, and driving (Carnes & Underwood, 2008; De Souza & Frank, 2007; Hush et al., 2009). The inability to perform familiar and necessary tasks was highly distressing: ‘I get so frustrated sometimes I have broken down and cried… I can’t do anything’ (Walker, Sofaer, & Holloway, 2006, p. 202). The emerging lifestyle for those disabled by pain was impoverished and confined (‘I’m living much quieter … I’d go solitary for a while and read for three or four days and not talk to anybody’, Ashby et al., 2010, p. 236). Worry and fear for the future The future harboured the potential for further losses or at the least promised the continuation of hardship (‘sometimes I just panic … There’s always that worry in my mind that something bad might happen to me’, Ashby et al., 2010, p. 235; Corbett, Foster, & Ong, 2007; Crowe et al., 2010; Osborn & Smith, 1998). The feeling that pain had taken over severely tested hopes for the future. This was the case at the end of the working life (‘I worked all my life and now I can’t enjoy my life … this is my future’, Campbell & Guy, 2007, p. 648), and also in the midst of it (I’ve still got another 21 years left at work … if me back’s killing me now, what am I going to be like in later times. And am I still going to be earning the money to pay the mortgage?’, Coole, Drummond, & Watson, 2010, p. 475). Bleak visions of the future included frightening images of dependency: ‘I was like: Oh, my, God, here it is. I’m not going to be able to walk. Oh, I’m going to have to be in a wheelchair’ (Bowman, 1994; Corbett et al., 2007, p. 1591; Crowe et al., 2010). Concern about further damage helps makes sense of this person’s attitude of activity avoidance: ‘I saw a man in there who had the same problem as me, he had a bulging disc. He made me really frightened. He couldn’t walk, he shuffled. That could be me if I do something silly’ (Ashby et al., 2010, p. 235). Although described as currently not in severe pain, the next person described despair alternating with hope: ‘well, sometimes you look on the black

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side, you know, when you get a bit down. And you think “Oh, I’m not going to end up in a bloomin’ wheelchair?” And other times you think “Well I’m coping”’ (May, 2007, p. 130). A disempowering impact on all levels

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The distress and loss of capacity arising from back pain had disempowering consequences across personal and social domains of experience, ranging from an inability to hold a self concept separate from the pain to income insecurity and social isolation. Hopelessness Osborn and Smith (1998) identified a bewilderment with the experience of CLBP (‘I don’t know why you have to keep suffering it and suffering it and suffering it for ever’, p. 69). This general hopelessness is illustrated more specifically by examples from Young, Wasiak, Phillips, and Gross (2011): ‘I really have to be very, very careful about everything I do’ (p. 207), ‘the doctor eventually put me on a drug and now I cannot live without it’ (p. 208), ‘I can’t do anything – work or pleasure’ (p. 208). Feeling weak and overwhelmed set the context for strong emotional responses (‘the disc is out a little bit, operation is not worth it, I’m scared to do anything, pain is terrible, no chance … better off dead, said so many times’, Ashby et al., 2010, p. 235; Carnes & Underwood, 2008; Chew & May, 1997; Walker et al., 2006). The intensity of feelings of anger and depression could extend to suicidal ideation, of being ‘very upset, agitated and angry with myself’ (Snelgrove & Liossi, 2009, p. 742). An oppressive intrusion on the self CLBP sufferers endured a traumatising challenge to personal identity, described by Smith and Osborn (2007, p. 531) as an ‘assault on the self’ (Bowman, 1994; Crowe et al., 2010; Osborn & Smith, 1998, 2006; Snelgrove & Liossi, 2009). The emerging pain identity represented an unwelcome intrusion: ‘it’s like the mean me, my mean head all sour and horrible, I can’t cope with that bit, I cope with the pain better’ (Smith & Osborn, 2007, p. 523). The unremitting suffering conveyed in this quote indicates how pain insinuated itself into the person’s subjective experience: ‘I just dread going to sleep at night because I know what it’s going to be the next morning when I wake up, pain… It’s not really living, it’s existing’ (Bowman, 1994, p. 451). Resistance of the ‘bad’, pain self by the ‘good’, core self was a continuing struggle (Strunin & Boden, 2004). Dysfunctional and unreliable, the body was externalised and placed outside oneself: ‘it’s like it’s not part of me, it won’t obey’ (Crowe et al., 2010; Osborn & Smith, 2006, p. 219). Conceiving of oneself as a back pain patient additionally impacted on personal self-worth, arising from guilt or embarrassment about the label (Chew & May, 1997; De Souza & Frank, 2011; May, Rose, & Johnstone, 2000; Osborn & Smith, 1998; Smith & Osborn, 2007; Strunin & Boden, 2004). Family strain Spousal and parental relationships were highly stressed by back pain, with reports of diminished trust and mutual understanding (Ashby et al., 2010; Campbell & Guy, 2007; De Souza & Frank, 2011; Holloway, Sofaer-Bennett, & Walker, 2007; Strunin & Boden, 2004; Tavafian, Gregory, & Montazeri, 2008; Young et al., 2011). Depictions of spousal relationships emphasised hardship, dependence on help from the partner, negative

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feelings, and relationship breakdown (Holloway et al., 2007; Strunin & Boden, 2004). There were only a few counter-examples of understanding, sympathetic partners (‘she supports me, gives me strength, keeps my mind strong’, Ashby et al., 2010, p. 236). Back pain placed strain on the person and the family itself, compromising the ability to perform expected roles. This example illustrates a wounding self-examination: ‘my oldest son, a four-year-old, says, “What is it Daddy, you used to hold me in your arms why don’t you now?”’ (Borkan et al., 1995, p. 982). Some of the references to threats and losses concerning the family played out differently depending on gender. Thus, the role of mother shaped the experiences of Tavafian, Gregory, and Montazeri’s female participants: ‘when I have too much work to do, I even forget to take my pills. You know, we forget ourselves and pay attention to our family all the time’ (2008, p. 343). Ashby, Richards, and James’ study illustrated the impact of a man being undermined as the family breadwinner: ‘I have a big rent, all the money is not enough. I have to pay the bills that are coming in, for the car, for my children’s instruction at school’ (2010, p. 236). Loss of job and lack of money Back pain devastated economic security through disruptions and threats to the ability to work (Coole, Drummond, & Watson, 2010; Corbett et al., 2007; Hush et al., 2009; Young et al., 2011). This could threaten the whole family if the sufferer was the main earner: ‘we used to have a three-storey town house, a nice pine kitchen, fitted carpets everywhere, now we’re in a council place with unfitted carpets and not very nice furniture’ (Walker et al., 2006, p. 203). The next example stands apart in depicting disability payments as a sufficient basis for financial comfort: ‘being disabled means being granted this security. In fact, we get our salary and can sit back and relax’ (Magnussen, Nilsen, & Raheim, 2007, p. 194). That example contrasted with another participant in the same study who identified loss of the worker role as undermining self-esteem (‘does something to your self confidence. Suddenly you are totally incapacitated and then you are not worth anything’, p. 193). There were divergences between studies in the extent to which participants were economically active and remained in work, although a number of studies did not provide information on work status. Some study participants were not working due to caring responsibilities or retirement, however occupational status was in most cases a marker of the ability to cope with the demands of a job. Typically, individuals in work felt less productive than before (‘I’m lucky if I can do about two or three days a week now’, Coole, Drummond, & Watson, 2010, p. 475), struggling to meet expectations (‘it’s like letting the team down, because you want to be able to do your quota’, Coole, Watson, & Drummond, 2010b, p. 5). For those in manual jobs, continued duties were worrying as they were perceived to be causing damage through ‘wear and tear’ (Coole, Drummond, & Watson, 2010, p. 475). Compounding these structural issues, supervisor attitudes were typically cited as unsupportive (‘I told him, there has to be a change, this is making me ill. He laughed at me’, Magnussen et al., 2007, p. 193). Social withdrawal The disempowering reach of back pain extended to social identity in the community. Back pain was described by sufferers as a stigmatised illness lacking in authenticity and legitimacy (‘I just want to say “hello,” you know, “how are you” and I go “alright

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thanks.” Not look at me as though I’m a cripple. I’m not a cripple’, Osborn & Smith, 1998, p. 73; Chew & May, 1997; Smith & Osborn, 2007; Walker et al., 2006). In consequence, one motive for social withdrawal was to avoid actual or anticipated rejection and suspicions of malingering (‘the problem is with back pain is – nobody can see it’, Coole, Drummond, & Watson, 2010, p. 476; May et al., 2000; Slade, Molloy, & Keating, 2009c; Snelgrove & Liossi, 2009). A further reason for withdrawal was the sense of social invisibility arising from reduced circumstances, no longer able to afford going out for drinks or to bring food to a party (‘they ring once, twice, three times, then they forget. I don’t ring them because I never have any money…. now all I’m doing is sitting at home. It makes me go crazy, really crazy’, Ashby et al., 2010, p. 236). Irritability arising from pain was the final motivating factor to withdraw from others and avoid interaction: ‘they get on my nerves. If I’m going to be around them, I’ll be around them right quick and then I’m going to get away from them’ (Bowman, 1994, p. 450). The next example illustrates an even stronger sense of agitation and antagonism toward other people: ‘I swear and cuss and be as mean and nasty as I feel like I want to be because my back hurts’ (Smith & Osborn, 2007; Young et al., 2011, p. 207). The person as patient: unsatisfying relationships with health care Initial expectations for effective medical treatments were largely disappointed. With the exception of perceptions held of physiotherapists and occupational health physicians, which were mixed, health services and interactions with professionals were evaluated critically or even cynically. Doctors generally disappointed expectations regarded as legitimate, for a meaningful cause, good communication, and the resolution (or at least control) of pain. Needing confirmation CLBP was viewed as a vague label, whereas a specific physical cause, such as a prolapsed disc, helped to address the personal and public discomfort of an ambiguous illness (‘I kind of felt relieved. I felt like, well, here’s proof. It’s not just me going crazy or complaining. This is proof. It’s black and white, and anybody can see it’, McPhillipsTangum et al., 1998, p. 293; Campbell & Guy, 2007; Cooper, Smith, & Hancock, 2008; Liddle, Baxter, & Gracey, 2007). It was more common that clear-cut causes were elusive, contributing to feelings of inequity (‘you hear of people, you know, certain discs have collapsed or whatever and they can remove it, you know and they’re ok … why can’t that happen to me’, Corbett et al., 2007, p. 1589). A lack of clear causes had applied implications, such as being regarded as malingering at work (‘you can see the disbelief in the manager’s eyes’, Coole, Drummond, & Watson, 2010, p. 474). Disappointment with health care Frustration with medical treatment was a recurrent feature (Campbell & Guy, 2007; Liddle et al., 2007; McPhillips-Tangum et al., 1998; Slade, Molloy, & Keating, 2009a; Snelgrove & Liossi, 2009). Care could be depersonalising rather than person-centred: ‘you don’t feel that you are being treated as a person at all’ (Walker, Holloway, & Sofaer, 1999, p. 623). In particular, the typical GP was perceived as having limited resources and skills (Campbell & Guy, 2007; Chew & May, 1997; Coole, Watson, & Drummond, 2010a; Slade et al., 2009a). This description of the standard GP protocol for care

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illustrates both frustration and resignation: ‘“oh yes have some painkillers and rest.”… I always felt they didn’t really want to know - it was just something you just put up with’ (May, 2007, p. 131). A similar tone was struck internationally, as in this appraisal of primary care in Iran: ‘the physicians are too busy to consult their patients, let alone to educate us about the structure and function of the vertebra column’ (Tavafian et al., 2008, p. 344). It was therefore perceived as desirable to secure a referral to specialist care from a medical consultant, physiotherapist, or osteopath (‘I would push … to see a professional and not take advice from the GP’, Liddle et al., 2007, p. 1905), although this could involve delays and exposure to depersonalising care (‘passed from consultant to another’, Snelgrove & Liossi, 2009, p. 744). Studies of occupational health and physiotherapy care offered more mixed evaluations, partly refuting negative appraisals of health care services. Thus, one occupational health physician is perceived here as offering support on a valued work issue: ‘he’s given quite good advice I think and given them [management] a bit of a kick as well actually’ (Coole, Watson, & Drummond, 2010b, p. 4). This is in the context of the participant profile in Coole et al.’s studies, with all still in employment. In contrast to the lack of progress associated with GP care, physiotherapy was also appraised as an active approach, albeit subject to contrasting evaluations as empowering or overly directive (‘he got a model of the spine and he explained he showed me the bits. It makes it easier for me’, Cooper, Smith, & Hancock, 2008, p. 246, ‘it was like being at school to be honest with you, just, sort of get on with it’, p. 249). Similarly mixed evaluations of physiotherapy effectiveness were made (May, 2001). Listening and communication The perception of not being listened to was an important facet of the negative appraisal made of medical practitioners and other health care professionals. A vivid demonstration is provided in this example: ‘I looked at him and said what are you giving me antidepressants for? I’m not depressed, my back hurts – that’s why I’m depressed and you people are depressing me because you’re not listening’ (Young et al., 2011, p. 207). The next extract illustrates a preference for active collaboration in physiotherapy care, including an implicit reference to this not being always achieved: ‘if they haven’t got that bedside manner, I think you rebel, I think “Ooh I don’t like her, I’m not doing, I’m not having this,” but if you get a physio that is good with you… and find that they’re helping you it goes a long way’ (May, 2001, p. 12). Such quotes illustrate the value attributed to the clinician being a skilled listener, even if the problem could not be solved. This is seen in Cooper, Smith, and Hancock’s (2008) study of physiotherapy: ‘somebody was taking an interest… It was something I’d never, ever been offered before’, p. 247). Nevertheless, the same study also cited examples of lack of communication: ‘first two times they had wrote to my doctor and said I was better and I wasn’t. I was actually worse. They never came to me and said, are you better’ (p. 247). Specific recommendations made by participants provide advice to doctors consistent with improved communication skills and specialised training: ‘there should be a course … to engage with the person, be a part of that person, explain things, do not use medical or terminology, plain speak and say why they want you to do that exercise’ (Slade et al., 2009a; Slade, Molloy, & Keating, 2009b, p. 151). The desire to share experiences with

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other CLBP sufferers was evident in a handful of studies (Borkan et al., 1995; Slade et al., 2009a, 2009b) and noted as a recurrent pattern in one: ‘you learn as well by the other people speaking. Some of them are having the same problems as yourself. So you can relate. And they ask what they’re doing to make themselves better and stuff, what they think helps’ (Cooper et al., 2008, p. 248). Learning to live with pain Although less prominent than the dominant sense of distress and loss, adaptation strategies were a distinctive feature that depicted attempts to live with pain and regain personal control. Although not exclusively so, this theme was particularly associated with studies that explicitly referred to a large proportion of participants still in paid employment (Coole, Drummond, & Watson, 2010; Coole, Watson, & Drummond, 2010a, 2010b; Hush et al., 2009; Liddle et al., 2007; May, 2001, 2007; McPhillipsTangum et al., 1998; Strunin & Boden, 2004; Young et al., 2011). Coming to terms with pain Sufferers had to keep going despite persistent or cyclical back pain and the disturbing realisation that gains in functioning might be only temporary (‘it wasn’t until I had the second episode that I realized it’s not fixed and never will be fixed’, Hush et al., 2009, p. 127, Walker et al., 1999; Young et al., 2011). The discomfort was beyond effective management through medication, requiring an attitude of self-reliance (‘I’d rather work through the pain’, Coole, Drummond, & Watson, 2010, p. 476; Snelgrove & Liossi, 2009). In this context, coming to terms with CLBP was difficult, as it entailed accepting its continuing presence while retaining a sense of being active and purposeful. This reference shows the adoption of self-reliance to maintain partial gains made following physiotherapy: ‘as he explained, he’d gone about as far as he could with me… “To be truthful there’s nothing more I can do for you”… So I said: “Great, I accept that”… it’s just me now keeping it in and doing my own exercises at home’ (May, 2001, p. 14). In the next quote, from a study characterised by more pervasive distress and loss than May’s (2001) study, the participant still makes the commitment to keep going: ‘determination’s most important. Determining that you are going to get up, you are not going to sit there… I want to try to keep struggling on regardless of the pain being there’ (Bowman, 1994, p. 451). Self-management practices Daily practices were integral to putting an attitude of acceptance and determination into action (Campbell & Guy, 2007; Carnes & Underwood, 2008; Cooper et al., 2008; Hush et al., 2009). Borkan et al. (1995) identified the coping style of ‘living with the pain’ as one in which the person strived to remain independent from the medical system, adapting to the demands arising from pain by re-structuring lifestyle and habits. Whereas Borkan et al.’s participants sought to minimise contact with the system, this physiotherapy patient in May’s (2007) study found it possible to reconcile patient-professional collaboration with active personal responsibility: ‘you’ve got to be part of it. Nothing’s going to work if you mentally think it’s not going to’ (p. 131). The coping and self-management strategies CLBP sufferers cited included attempting to ignore the pain (Carnes & Underwood, 2008), use of defiant language to convey identification with resilience (‘I won’t let it beat me … it’s down to your attitude … it’s

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basically down to people’s will to manage and cope’, Campbell & Guy, 2007, p. 647), and downward comparison contrasting the self with others worse off (Carnes & Underwood, 2008; Osborn & Smith, 1998). This example portrays vigilant deliberation and planning as an adaptive strategy to achieve sustainability rather than to avoid movement: ‘when I’m sitting I am very aware of, well I try to be very aware of my posture. I don’t do so much lifting now’, May, 2007, p. 132; Coole, Watson, & Drummond, 2010b). This person’s pain was described as temporarily controlled, with exercise an effective prophylactic: ‘when I started feeling the pain coming on I’d do some exercises, and then that sorted it’ (Young et al., 2011, p. 132). Although exercise and continued physical activity were cited as important in managing pain, adherence to daily routines was hard to maintain (Campbell & Guy, 2007; Cooper et al., 2009). Busch’s (2005) study of individuals who were students or ‘mostly’ (p. 397) in work was distinctive in describing a progressive shift over the course of a CLBP illness trajectory. Initial attempts were made to disregard and ignore distress (‘my back was really aching, but I didn’t pay it much attention. I just kept on going’, p. 398), a strategy of assimilation that was not tenable when the crisis of distress and loss became overwhelming. Some individuals Busch interviewed described having emerged later from despondency and fear of damage, embracing a conscious strategy to monitor prolonged chronic pain as a continuous, manageable threat (‘I’m much more aware of my situation than I’ve ever been before, and I know I must prioritise and take care of my body’, p. 400). Attitudes to collaboration Strategies for self-management occurred in some cases as a result of learning from health professionals, especially physiotherapists. Openness to direction in pursuit of selfmanagement was an important issue in this context. For this individual, active participation in physiotherapy regularised exercise as an ongoing commitment: ‘she explained it well, and said: “You’ve got to do them, it’s going to be part of your life now, you’ve got to do these or it’s back pain”’ (May, 2001, p. 14). Cooper et al. (2008) identified varied preferences for direction among physiotherapy patients, from wanting to be pushed more, to feeling pushed too far, and including compliant, unquestioning attitudes (‘I tend to not question… if the physio said you need this Pilates class you know, then I was going to do it’, p. 248). The most positively evaluated health care interventions were those promoting an active approach, matched with an openness of attitude. This is illustrated in appraisals of a goal-setting exercise programme (‘the discipline, it must be done, accept it. So I set a challenge every day and that’s the reward. I love it’, Slade et al., 2009b, p. 119). The following example shows exercise encouraged in a way that suited personal preferences: I loathe exercise. I don’t like structured exercise. Surely there must be a fun way of doing it. I was offered three free dancing lessons… another creative way of getting exercise. It’s exercise without exercising. (p. 118)

Line of argument: an experience of distress and loss In keeping with the meta-ethnographic method, the synthesis was further developed into a narrative line of argument representing subjective experiences of CLBP (Noblit & Hare, 1988). Distress, disempowering consequences, and a search for help dominated the findings, underpinned by discomfort and loss. CLBP represented an end to certainty in

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the capacity and confidence to engage with life, affecting all levels from private self concept to functional roles and the social self. The primary care experience offered little prospect of future rehabilitation, reliable pain relief, a cure or even clear causes, and thereby contributed to distress and powerlessness. Nevertheless, chronic back pain is associated with disability rather than mortality and sufferers had to live with its continued presence. An active role and personal responsibility were most apparent among individuals who had been able to remain in work. However, determined resistance was seen even among sufferers who had experienced long-term disability. Although secondary features in the synthesis, personal determination, active self-management, and supportive health care relationships offered pathways to endurance. Discussion The distress and loss described in the meta-ethnography were consistent with the hopelessness, low mood, and disability identified in quantitative studies of CLBP sufferers (e.g., Smith et al., 2002). The self as a person, patient, and member of a family or community were distinctive contexts for experiencing the threatening and costly impact of CLBP. Learning to live with the pain was a comparatively minor note but was not silenced. A comparison of the meta-ethnography with qualitative studies of other conditions linked to chronic pain illustrates more similarity than difference. For example, the pain sensations reported by patients with spinal cord injury (Norman et al., 2010) recall those associated with CLBP flare ups (De Souza & Frank, 2000). Uncertainty over causes and future concerns has been described in connection with several other chronic pain conditions, as demonstrated in Sim and Madden’s (2008) meta-synthesis of qualitative research on fibromyalgia. Chronic pelvic pain offers a close comparison in that it is a descriptive label rather than one associated with a clear cause. Similar to CLBP, sufferers report feeling disbelieved and frustration with medical care (McGowan, Luker, Creed, & Chew-Graham, 2007). The impact of CLBP across different domains of subjective experience mirrors studies of other pain conditions. For instance, the undermining ‘assault of the self’ noted by Smith and Osborn (2007) is reflected in Lempp, Scott, and Kingsley’s (2006) qualitative study of rheumatoid arthritis, which described threats to intrapersonal stability, personal independence, and body self-image. The negative impact on work and relationships associated with CLBP is likewise shared with other pain conditions (Lempp, Scott, & Kingsley, 2006). The preference for good communication with health professionals is another point of similarity with other chronic pain conditions (McGowan et al., 2007; Norman et al., 2010; Upshur, Bacigalupe, & Luckmann, 2010). The meta-ethnography represents distress and loss as translatable across a range of focal areas, from the self concept to experiences as a patient. Depending on the study, the individual was variously framed as a person, patient, social actor, or corporeal self. We view these representations as complementary rather than contradictory. The undermining and disempowering influence of CLBP was portrayed in a phenomenological sense in the index article (Smith & Osborn, 2007) and was described in the context of work, family, and ‘patienthood’ domains in other studies (De Souza & Frank, 2011; Ong, Hooper, Dunn, & Croft, 2004, p. 537; Strunin & Boden, 2004; Walker et al., 1999). These domains are separable forms of person-centredness, an interpretive repertoire relevant for understanding CLBP experiences across a range of important contexts (Hughes, Bamford, & May, 2008). Nevertheless, the dimensions of person-centredness described by Hughes, Bamford, and May (2008) were not equally highlighted in the

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studies reviewed. The meta-ethnography can make a particular contribution by providing the basis for critiquing the focal areas studied by qualitative researchers to date. The research we reviewed had critical omissions. There was a relative silence in relation to the social and cultural dimensions of the condition. One theme in the meta-ethnography ran counter to the trend towards distress and loss. A subset of studies described adaptability and defiance despite expectations for continued pain and disability (Borkan et al., 1995; Busch, 2005; Coole, Drummond, & Watson, 2010, 2010a, 2010b; Cooper et al., 2008; Hush et al., 2009; May, 2001, 2007; Slade et al., 2009a, 2009b, 2009c; Young et al., 2011). Occupational health and physiotherapy studies in particular demonstrated the impact of personal responsibility, consistent with rehabilitation guidelines for sustainable activity (Airaksinen et al., 2006). Future investigations of acceptance, sustainability, and coping could help to re-frame CLBP as a condition in which individuals manage to keep going despite distress and loss. In turn, there is a growing need to for compatible theoretical frameworks. Theories of resilience and acceptance offer an adaptation-oriented perspective that can be contextualised to specific chronic health conditions (Sturgeon & Zautra, 2009; Veehof, Oskam, Schreurs, & Bohlmeijer, 2011). It may be that patients have more openness to the pursuit of autonomous self-management than is commonly presumed by doctors (Slade et al., 2009b). Far from recording perceptions of evidence-based interventions, most of the studies in the synthesis characterised the everyday primary care environment in terms of practitioner busyness and limited implementation of rehabilitation guidelines (Breen et al., 2007). GP expectations for patient malingering and passivity support attributions sometimes made by these professionals for patient self-interest in monetary compensation and disability claims (Breen et al., 2007; MacNeela et al., 2010). Yet, self-interested goals were absent from the subjective accounts of back pain sufferers themselves. Instead, patients reported frustration with a limited acknowledgement of individuality by doctors in primary care. A mutually contentious relationship is suggested, in which people with chronic back pain describe personal frustration with primary care doctors while studies of doctors depict professional frustration with patients. Health care encounters were a source of disappointment for patients who had hoped for cause, control, or cure. Implications Several research implications follow directly from the meta-ethnography. For instance, there is a need to expand research into the maintenance of agency and acceptance among CLBP sufferers. These studies represent a broadening of scope from primary care and specialist pain management clinics, but there is still an underrepresentation of CLBP sufferers who rely on self-management and minimise health care utilisation (Borkan et al., 1995; Campbell & Guy, 2007). This has important implications for recruitment in future studies. It is important to acknowledge narratives of distress and loss, but independent self-management has not yet been sufficiently explored. There is also a need to further contextualise our understanding of distress and loss in relation to social, cultural, and developmental domains. The underrepresentation of social and cultural identities that we highlighted could be addressed through increased attention to gender, work status, and ethnic identity. For instance, although certain studies referred to genderised phenomena, such as men feeling guilty for being inactive (e.g., Ashby et al., 2010; Smith & Osborn, 2007; Tavafian et al., 2008), gender identity has not been a focal point for analysing and interpreting interviews. Similarly, family was prominent in

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sufferers’ accounts but not developed into full-scale explorations of parenting, family coping, relationship issues, communication, or sexuality (Miller & Timson, 2004). A third area for future research is to study dynamism and temporality as a distinct component of the CLBP experience (Busch, 2005). The impact of developmental issues such as age and lifespan transitions requires dedicated analysis. Studying back pain using cross-sectional interviews overshadows dynamic processes of change over time. Longitudinal research designs should be introduced to better understand the trajectory of meaningmaking, consistency, and change over time (Snelgrove, Edwards, & Liossi, 2013; Whitehead, 2006). This could be extended to consider interactions of disability, attitudes to personal responsibility, and support from health care professionals. Finally, limited use has been made of participatory data collection techniques that could empower participants, such as use of narrative timelines or photovoice (Schrader, Deering, Zahl, & Wallace, 2011). Several implications for practice arise from the meta-ethnography. Discordance between GP attitudes and patient experiences can be readily identified. Lack of implementation of evidence-based rehabilitation guidelines continues to be a significant issue. More generally, it is important for all clinicians to have awareness of similarities between CLBP and other chronic pain conditions, to assist in legitimising it as a genuine, debilitating condition. Equally, clinicians should be aware of individual differences in experiences and goals. The meta-ethnography identified a clear preference for good communication, based on acknowledgement of personal distress, even when it is not possible to offer an effective medical treatment (Slade et al., 2009a). Training in personcentred communication skills could help address the powerlessness experienced by some GPs in relation to psychosocial skills. Finally, given the positive evaluation of active approaches, such as exercise (Slade et al., 2009b), wider use of behaviour change interventions should be investigated (Jepson, Harris, Platt, & Tannahill, 2010). Limitations One potential limitation to the claim of having integrated the body of qualitative research on CLBP arises from the variations across studies in research aims and qualitative approaches. Attempting to reconcile the findings of studies that are fundamentally fragmented would result in a superficial, limited analysis. We resolved this by conceiving of the studies in the meta-ethnography as representing distress and loss in different contexts of personal experience (Hughes et al., 2008). However, the limited coverage of a number of social and cultural facets of the back pain experience mean that the metaethnography is limited in describing the totality of the subjective experience. The homogeneity of data collection methods used to date, heavily dominated by interviews and focus groups, has led to an understanding based on a narrow range of data collection methods. The privileging of these methods is reflected in the findings of the synthesis. Little power has yet been transferred to individuals, and a researcher-led approach to representations of CLBP has been preserved. A final source of narrowness in the findings on which the meta-ethnography is based is the concentration of studies in a limited number of countries, principally the UK. However, research in other countries does compare closely with the findings of British qualitative research on CLBP. Conclusion A substantial body of qualitative research on CLBP has emerged in recent years. Integrating the findings of these studies of subjective experiences through meta-

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ethnography, we demonstrated that back pain extends its devastating impact to all levels of personal experience. The underlying experience of distress and loss had different meanings depending on the context and was predicated on health care input that may not offer clear causes, solutions, or even a listening ear. The meta-ethnography reflects the preponderance of research interest to date in self and identity, the social self, and the person as a patient. Looking to the future, the subjective experience has yet to be sufficiently explored as a dynamic process shaped by influences such as gender, resilience, and progression through the lifespan. Despite the gaps in coverage of some elements relevant to person-centred care, the findings represent a valuable resource for disseminating qualitative research findings to health care practitioners and CLBP sufferers. Acknowledgements The authors wish to acknowledge the support provided by the Irish Research Council for the Humanities and Social Sciences in the form of a project grant.

Supplemental data Supplemental data for this article can be accessed here: http://dx.doi.org/10.1080/ 17437199.2013.840951 References References marked with a * refer to articles included in the meta-ethnography. Airaksinen, O., Brox, J. I., Cedraschi, C., Hildebrandt, J., Klaber-Moffett, J., Kovacs, F., … Zanoli, G. (2006). European guidelines for the management of chronic nonspecific low back pain. European Spine Journal, 15, S192–S300. doi:10.1007/s00586-006-1072-1 *Ashby, S., Richards, K., & James, C. (2010). The effect of fear of movement on the lives of people with chronic low back pain. International Journal of Therapy & Rehabilitation, 17, 232–239. Atkins, S., Lewin, S., Smith, H., Engel, M., Fretheim, A., & Volmink, J. (2008). Conducting a meta-ethnography of qualitative literature: Lessons learnt. BMC Medical Research Methodology, 8(1), 21. doi:10.1186/1471-2288-8-21 *Borkan, J., Reis, S., Hermoni, D., & Biderman, A. (1995). Talking about the pain: A patientcentered study of low back pain in primary care. Social Science and Medicine, 40(7), 977–988. doi:10.1016/0277-9536(94)00156-N *Bowman, J. M. (1994). Reactions to chronic low back pain. Issues in Mental Health Nursing, 15(4), 445–453. doi:10.3109/01612849409006920 Breen, A., Austin, H., Campion-Smith, C., Carr, E., & Mann, E. (2007). “You feel so hopeless”: A qualitative study of GP management of acute back pain. European Journal of Pain, 11(1), 21–29. doi:10.1016/j.ejpain.2005.12.006 Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10(4), 287–333. doi:10.1016/j.ejpain.2005.06.009 *Busch, H. (2005). Appraisal and coping processes among chronic low back pain patients. Scandinavian Journal of Caring Sciences, 19(4), 396–402. doi:10.1111/j.1471-6712.2005.00348.x *Campbell, C. & Guy, A. (2007). “Why can’t they do anything for a simple back problem?” A qualitative examination of expectations for low back pain treatment and outcome. Journal of Health Psychology, 12(4), 641–652. doi:10.1177/1359105307078171 *Carnes, D. & Underwood, M. (2008). The importance of monitoring patient’s ability to achieve functional tasks in those with musculoskeletal pain. International Journal of Osteopathic Medicine, 11(1), 26–32. doi:10.1016/j.ijosm.2007.12.001 Chaudhary, N., Longworth, S., & Sell, P. J. (2004). Management of mechanical low back pain - a survey of beliefs and attitudes in GPs from Leicester and Nottingham. European Journal of General Practice, 10(2), 71–72. doi:10.3109/13814780409094238

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Experiences of chronic low back pain: a meta-ethnography of qualitative research.

Chronic low back pain (CLBP) is associated with a number of costly disability-related outcomes. It has received increasing attention from qualitative ...
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