Background and aims
Despite lack of support from recent in vivo studies, bending and lifting (especially with a round-back posture) are perceived as dangerous to the back. In light of this view, it has been proposed that pain-free people may hold a common implicit belief that is congruent with the idea that bending and lifting with a round-back represents danger to a person’s back, however this has not been evaluated. The aims of this study were: (1) to evaluate implicit associations between back posture and safety related to bending and lifting in pain-free people; (2) to explore correlations between the implicit measure and explicit measures of back beliefs, fear of movement and safety of bending; (3) to investigate self-reported qualitative appraisal of safe lifting.
Exploratory cross-sectional study including 67 pain-free participants (no pain, or average pain ≤3/10 for less than one week over the previous 12 months) (52% male), who completed an online survey containing demographic data and self-reported measures of: fear of movement (Tampa Scale for Kinesiophobia for General population – TSK-G), back beliefs (Back Pain Attitudes Questionnaire BackPAQ), and bending beliefs (Bending Safety Belief – BSB – a pictorial scale with images of a person bending/lifting with round and straight back postures). Implicit associations between back posture and safety related to bending and lifting were evaluated with the Implicit Association Test (IAT). A qualitative assessment of descriptions of safe lifting was performed.
An implicit association between “danger” and “round-back” bending/lifting was evident in all participants (IATD-score=0.65 (SD=0.45; 95% CI [0.54, 0.76]). Participants’ profile indicated high fear of movement, unhelpful back beliefs, and perceived danger to round-back bending and lifting (BSBThermometer: 5.2 (SD=3.8; 95% CI [4.26, 6.13] range −10 to 10; t(67)=11.09, p<0.001). There was a moderate correlation between IAT and BSBThermometer (r=0.38, 95% CI [0.16, 0.62]). There were weaker and non-statistically significant correlations between IAT and TSK-G (r=0.28, 95% CI [−0.02, 0.47]), and between IAT and BackPAQDanger (r=0.21, 95% CI [−0.03, 0.45]). Qualitative assessment of safe lifting descriptions indicated that keeping a “straight back” and “squatting” when lifting were the most common themes.
Pain-free people displayed an implicit bias towards bending and lifting with a “round-back” as dangerous. Our findings support the idea that pain-free people may have a pre-existing belief about lifting, that the back is in danger when rounded. Research to evaluate the relationship between this implicit bias and lifting behaviour is indicated.
The findings of this study may have implications for ergonomic guidelines and public health information related to bending and lifting back postures. Additionally, clinicians may need to be aware of this common belief, as this may be reflected in how a person responds when they experience pain.
Research funding: JP. Caneiro is supported by an Australian Postgraduate Award (APA) and Curtin University Postgraduate (CUPS) Scholarships.
Conflict of interest: Peter O’Sullivan receives speaker fees for workshops on pain management. All the other authors declare no conflicts of interest.
Informed consent: All participants provided informed consent, and were informed that they could withdraw from the study at any time.
Ethics approval: This study was approved by Curtin University’s Human Research Ethics Committee prior to study commencement (HRE2017-0500).
 Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2163–96.10.1016/S0140-6736(12)61729-2Search in Google Scholar PubMed
 Balague F, Mannion AF, Pellise F, Cedraschi C. Non-specific low back pain. Lancet 2012;379:482–91.10.1016/S0140-6736(11)60610-7Search in Google Scholar PubMed
 Darlow B, Perry M, Stanley J, Mathieson F, Melloh M, Baxter GD, Dowell A. Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. BMJ Open 2014;4:e004725.10.1136/bmjopen-2013-004725Search in Google Scholar PubMed
 Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm, hard to heal: patient views about the back. Spine 2015;40:842–50.10.1097/BRS.0000000000000901Search in Google Scholar PubMed
 Bunzli S, Smith A, Schutze R, O’Sullivan P. Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open 2015;5:e008847.10.1136/bmjopen-2015-008847Search in Google Scholar PubMed
 Bunzli S, Smith A, Watkins R, Schutze R, O’Sullivan P. What do people who score highly on the Tampa Scale of Kinesiophobia really believe?: A mixed methods investigation in people with chronic nonspecific low back pain. Clin J Pain 2015;31:621–32.10.1097/AJP.0000000000000143Search in Google Scholar PubMed
 Nolan D, O’Sullivan K, Stephenson J, O’Sullivan P, Lucock M. What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskelet Sci Pract 2018;33:35–40.10.1016/j.msksp.2017.10.010Search in Google Scholar PubMed
 Adams MA, Hutton WC. The mechanics of prolapsed intervertebral disc. Int Orthop 1982;6:249–53.10.1007/BF00267146Search in Google Scholar PubMed
 Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clin Biomech (Bristol, Avon) 2001;16:28–37.10.1016/S0268-0033(00)00063-2Search in Google Scholar PubMed
 Gallagher S, Marras WS. Tolerance of the lumbar spine to shear: a review and recommended exposure limits. Clin Biomech (Bristol, Avon) 2012;27:973–8.10.1016/j.clinbiomech.2012.08.009Search in Google Scholar PubMed
 Koblauch H. Low back load in airport baggage handlers. Denmark: Department of Neuroscience and Pharmacology, University of Copenhagen, 2015.Search in Google Scholar
 Nachemson A. The influence of spinal movements on the lumbar intradiscal pressure and on the tensil stresses in the annulus fibrosus. Acta Orthop Scand 1963;33:183–207.10.3109/17453676308999846Search in Google Scholar PubMed
 Nachemson A. The load on lumbar disks in different positions of the body. Clin Orthop Relat Res 1966;45:107–22.10.1097/00003086-196600450-00014Search in Google Scholar PubMed
 Nachemson A. The effect of forward leaning on lumbar intradiscal pressure. Acta Orthop Scand 1965;35:314–28.10.3109/17453676508989362Search in Google Scholar PubMed
 Hagen KB, Harms-Ringdahl K. Ratings of perceived thigh and back exertion in forest workers during repetitive lifting using squat and stoop techniques. Spine 1994;19:2511–7.10.1097/00007632-199411001-00004Search in Google Scholar PubMed
 Anderson CK, Chaffin DB. A biomechanical evaluation of five lifting techniques. Appl Ergon 1986;17:2–8.10.1016/0003-6870(86)90186-9Search in Google Scholar PubMed
 Nachemson A. Towards a better understanding of low-back pain: a review of the mechanics of the lumbar disc. Rheumatol Rehabil 1975;14:129–43.10.1093/rheumatology/14.3.129Search in Google Scholar PubMed
 Darlow B. Beliefs about back pain: the confluence of client, clinician and community. Int J Osteopath Med 2016;20:53–61.10.1016/j.ijosm.2016.01.005Search in Google Scholar
 de Jong JR, Vlaeyen JW, Onghena P, Goossens ME, Geilen M, Mulder H. Fear of movement/(re)injury in chronic low back pain: education or exposure in vivo as mediator to fear reduction? Clin J Pain 2005;21:9–17; discussion 69–72.10.1097/00002508-200501000-00002Search in Google Scholar
 Leeuw M, Peters ML, Wiers RW, Vlaeyen JW. Measuring fear of movement/(re)injury in chronic low back pain using implicit measures. Cogn Behav Ther 2007;36:52–64.10.1080/16506070601070400Search in Google Scholar
 Goubert L, Crombez G, Hermans D, Vanderstraeten G. Implicit attitude towards pictures of back-stressing activities in pain-free subjects and patients with low back pain: an affective priming study. Eur J Pain 2003;7:33–42.10.1016/S1090-3801(02)00054-XSearch in Google Scholar PubMed
 Hofmann W, Gawronski B, Gschwendner T, Le H, Schmitt M. A meta-analysis on the correlation between the implicit association test and explicit self-report measures. Pers Soc Psychol Bull 2005;31:1369–85.10.1177/0146167205275613Search in Google Scholar PubMed
 Darlow B, Perry M, Mathieson F, Stanley J, Melloh M, Marsh R, Baxter GD, Dowell A. The development and exploratory analysis of the Back Pain Attitudes Questionnaire (Back-PAQ). BMJ Open 2014;4:e005251.10.1136/bmjopen-2014-005251Search in Google Scholar PubMed PubMed Central
 George SZ, Valencia C, Beneciuk JM. A psychometric investigation of fear-avoidance model measures in patients with chronic low back pain. J Orthop Sports Phys Ther 2010;40:197–205.10.2519/jospt.2010.3298Search in Google Scholar PubMed
 Nosek BA, Hawkins CB, Frazier RS. Implicit social cognition: from measures to mechanisms. Trends Cogn Sci 2011;15:152–9.10.1016/j.tics.2011.01.005Search in Google Scholar PubMed PubMed Central
 Fazio RH, Olson MA. Implicit measures in social cognition. research: their meaning and use. Annu Rev Psychol 2003;54:297–327.10.1146/annurev.psych.54.101601.145225Search in Google Scholar PubMed
 George SZ, Valencia C, Zeppieri G, Jr, Robinson ME. Development of a self-report measure of fearful activities for patients with low back pain: the fear of daily activities questionnaire. Phys Ther 2009;89:969–79.10.2522/ptj.20090032Search in Google Scholar PubMed PubMed Central
 Leeuw M, Goossens ME, van Breukelen GJ, Boersma K, Vlaeyen JW. Measuring perceived harmfulness of physical activities in patients with chronic low back pain: the Photograph Series of Daily Activities—short electronic version. J Pain 2007;8:840–9.10.1016/j.jpain.2007.05.013Search in Google Scholar PubMed
 Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol 1998;74:1464–80.10.1037/0022-3518.104.22.1684Search in Google Scholar PubMed
 Greenwald AG, Banaji MR. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychol Rev 1995;102:4–27.10.1037/0033-295X.102.1.4Search in Google Scholar PubMed
 Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med 2013;28:1504–10.10.1007/s11606-013-2441-1Search in Google Scholar PubMed PubMed Central
 Grumm M, Erbe K, von Collani G, Nestler S. Automatic processing of pain: the change of implicit pain associations after psychotherapy. Behav Res Ther 2008;46:701–14.10.1016/j.brat.2008.02.009Search in Google Scholar PubMed
 Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health 2012;102:988–95.10.2105/AJPH.2011.300621Search in Google Scholar PubMed PubMed Central
 Caneiro JP, O’Sullivan P, Smith A, Moseley GL, Lipp OV. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending. Scand J Pain 2017;17:355–66.10.1016/j.sjpain.2017.09.012Search in Google Scholar PubMed
 Van Ryckeghem DM, De Houwer J, Van Bockstaele B, Van Damme S, De Schryver M, Crombez G. Implicit associations between pain and self-schema in patients with chronic pain. Pain 2013;154:2700–6.10.1016/j.pain.2013.07.055Search in Google Scholar PubMed
 Barke A, Preis MA, Schmidt-Samoa C, Baudewig J, Kroner-Herwig B, Dechent P. Neural correlates differ in high and low fear-avoidant chronic low back pain patients when imagining back-straining movements. J Pain 2016;17:930–43.10.1016/j.jpain.2016.05.005Search in Google Scholar PubMed
 Taylor AM, Harris AD, Varnava A, Phillips R, Taylor JO, Hughes O, Wilkes AR, Hall JE, Wise RG. A functional magnetic resonance imaging study to investigate the utility of a picture imagination task in investigating neural responses in patients with chronic musculoskeletal pain to daily physical activity photographs. PLoS One 2015;10:e0141133.10.1371/journal.pone.0141133Search in Google Scholar PubMed PubMed Central
 Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, Wyatt M, Cassidy JD, Rossignol M, Leboeuf-Yde C, Hartvigsen J, Leino-Arjas P, Latza U, Reis S, Gil Del Real MT, Kovacs FM, Oberg B, Cedraschi C, Bouter LM, Koes BW, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine 2008;33:95–103.10.1097/BRS.0b013e31815e7f94Search in Google Scholar PubMed
 Caneiro JP, O’Sullivan P, Smith A, Ovrebekk IR, Tozer L, Williams M, Teng MLW, Lipp, O. V. Physiotherapists have an implicit bias to bending and lifting with a round back. World Congress Phys Ther 2017. Available at: www.abstractstosubmit.com/wcpt2017/abstracts/.Search in Google Scholar
 Mallan KM, Lipp OV. Does emotion modulate the blink reflex in human conditioning? Startle potentiation during pleasant and unpleasant cues in the picture-picture paradigm. Psychophysiology 2007;44:737–48.10.1111/j.1469-8986.2007.00541.xSearch in Google Scholar PubMed
 Forster KI, Forster JC. DMDX: A Windows display program with millisecond accuracy. Behav Res Methods Instrum Comput 2003;35:116–24.10.3758/BF03195503Search in Google Scholar PubMed
 Greenwald AG, Nosek BA, Banaji MR. Understanding and using the implicit association test: I. An improved scoring algorithm. J Pers Soc Psychol 2003;85:197–216.10.1037/0022-3522.214.171.124Search in Google Scholar PubMed
 Greenwald AG, Poehlman TA, Uhlmann EL, Banaji MR. Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. J Pers Soc Psychol 2009;97:17–41.10.1037/a0015575Search in Google Scholar PubMed
 Nosek BA, Greenwald AG, Banaji MR. Understanding and using the Implicit Association Test: II. Method variables and construct validity. Pers Soc Psychol Bull 2005;31:166–80.10.1177/0146167204271418Search in Google Scholar PubMed
 Houben RM, Leeuw M, Vlaeyen JW, Goubert L, Picavet HS. Fear of movement/injury in the general population: factor structure and psychometric properties of an adapted version of the Tampa Scale for Kinesiophobia. J Behav Med 2005;28:415–24.10.1007/s10865-005-9011-xSearch in Google Scholar PubMed
 Moran RW, Rushworth WM, Mason J. Investigation of four self-report instruments (FABT, TSK-HC, Back-PAQ, HC-PAIRS) to measure healthcare practitioners’ attitudes and beliefs toward low back pain: reliability, convergent validity and survey of New Zealand osteopaths and manipulative physiotherapists. Musculoskelet Sci Pract 2017;32(Supplement C):44–50.10.1016/j.msksp.2017.08.008Search in Google Scholar PubMed
 Straker LM. A review of research on techniques for lifting low-lying objects: 1. Criteria for evaluation. Work 2002;19:9–18.Search in Google Scholar PubMed
 Straker LM. A review of research on techniques for lifting low-lying objects: 2. Evidence for a correct technique. Work 2003;20:83–96.Search in Google Scholar PubMed
 van Dieen JH, Hoozemans MJ, Toussaint HM. Stoop or squat: a review of biomechanical studies on lifting technique. Clin Biomech (Bristol, Avon) 1999;14:685–96.10.1016/S0268-0033(99)00031-5Search in Google Scholar PubMed
 Wai EK, Roffey DM, Bishop P, Kwon BK, Dagenais S. Causal assessment of occupational bending or twisting and low back pain: results of a systematic review. Spine J 2010;10:76–88.10.1016/j.spinee.2009.06.005Search in Google Scholar PubMed
 Wai EK, Roffey DM, Bishop P, Kwon BK, Dagenais S. Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J 2010;10:554–66.10.1016/j.spinee.2010.03.033Search in Google Scholar PubMed
 Dreischarf M, Shirazi-Adl A, Arjmand N, Rohlmann A, Schmidt H. Estimation of loads on human lumbar spine: a review of in vivo and computational model studies. J Biomech 2016;49:833–45.10.1016/j.jbiomech.2015.12.038Search in Google Scholar PubMed
 Nachemson AL. Disc pressure measurements. Spine 1981;6:93–7.10.1097/00007632-198101000-00020Search in Google Scholar PubMed
 Nachemson AL. Advances in low-back pain. Clin Orthop Relat Res 1985;200:266–78.10.1097/00003086-198511000-00031Search in Google Scholar
 Dreischarf M, Rohlmann A, Graichen F, Bergmann G, Schmidt H. In vivo loads on a vertebral body replacement during different lifting techniques. J Biomech 2016;49:890–5.10.1016/j.jbiomech.2015.09.034Search in Google Scholar PubMed
 Kingma I, Faber GS, van Dieen JH. How to lift a box that is too large to fit between the knees. Ergonomics 2010;53:1228–38.10.1080/00140139.2010.512983Search in Google Scholar PubMed
 Kwon BK, Roffey DM, Bishop PB, Dagenais S, Wai EK. Systematic review: occupational physical activity and low back pain. Occup Med (Oxford, England) 2011;61:541–8.10.1093/occmed/kqr092Search in Google Scholar PubMed
 Holder L. The effect of lumbar posture and pelvis fixation on back extensor torque and paravertebral muscle activation (Doctoral dissertation), Auckland University of Technology; 2013.Search in Google Scholar
 Van Hoof W, O’Sullivan K, O’Keeffe M, Verschueren S, O’Sullivan P, Dankaerts W. The efficacy of interventions for low back pain in nurses: a systematic review. Int J Nurs Stud 2018;77:222–31.10.1016/j.ijnurstu.2017.10.015Search in Google Scholar PubMed
 Leventhal H, Meyer D, Nerenz D. The common sense model of illness danger. In: Rachman S, editor. Medical Psychology, Vol. 2. New York: Pergamon, 1980:7–30.Search in Google Scholar
 Leventhal H, Phillips LA, Burns E. The Common-Sense Model of Self-Regulation (CSM): a dynamic framework for understanding illness self-management. J Behav Med 2016;39:935–46.10.1007/s10865-016-9782-2Search in Google Scholar PubMed
 Kroska EB. A meta-analysis of fear-avoidance and pain intensity: the paradox of chronic pain. Scand J Pain 2016;13:43–58.10.1016/j.sjpain.2016.06.011Search in Google Scholar PubMed
 Vlaeyen JWS. The intricate relationship amongst pain intensity, fear and avoidance. Scand J Pain 2016;13:128–9.10.1016/j.sjpain.2016.08.010Search in Google Scholar PubMed
The online version of this article offers supplementary material (https://doi.org/10.1515/sjpain-2018-0056).
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