Low back pain (LBP) is a common condition that affects people of all ages in developed and developing countries , . LBP often leads to poor quality of life, absence from work, early retirement and costly healthcare , , . It is estimated that years lost to disability caused by LBP will further increase in the next decades . Lessening the economic, individual and social burden of this prevalent condition is a major research priority .
A large volume of research has studied the efficacy of various approaches to reduce LBP . At best, treatment strategies have modest effects on symptoms, quality of life and/or function . For instance, physical activity and exercise have been shown to reduce pain and improve physical function, yet their effects are mostly small-to-moderate . Some interventions such as lumbar support  and transcutaneous electrical nerve stimulation  are known not to work, and some interventions may be harmful to some groups such as rest , surgery  and commonly used medications . Despite this evidence, and its reflection in clinical guidelines , , numerous ineffective and potentially harmful techniques and pharmaceutical treatments are commonly delivered in attempts to manage chronic LBP.
Investigating the decisions individuals with the condition make in order reduce their LBP can provide valuable input into management and may be instructive for LBP researchers, clinicians and other “experts” to help them focus management. There has been a small amount of research considering how individuals with LBP manage their condition outside of clinical care. For example, a qualitative survey showed that people with chronic LBP self-managed their symptoms with medication, maintaining physical activity, changing lifestyle behaviours, using heat and cold applications, rest and relaxation, and using other physical and alternative modalities . Similarly, Crowe et al.  found, in another qualitative study, that people with LBP most commonly used medication, exercise and the application of heat to manage their chronic LBP. Although informative, what these data lack is information regarding choices people make about treatment beyond self-management.
The purpose of this study was to broadly explore what individuals with LBP believe reduces their LBP. A better understanding of individuals’ perspectives is likely to assist in improving clinical practice and quality of care.
2 Materials and methods
This study reports on an analysis of 130 participants’ eight short text box responses to questions about what reduces their LBP. Data were collected via an online questionnaire. We employed content analysis to analyse these responses. The institutional Medical Research Ethics Committee approved the study.
2.2 Methodology theoretical underpinnings
This study employed an inductive descriptive qualitative design. This means that, while some degree of interpretation is inevitable in any research design, we sought to minimise our interpretation to draw findings directly from the responses provided by participants by describing the data . The content analysis was underpinned by a relativist epistemological perspective that considers that reality varies depending on perspectives of different individuals or groups. Content analysis involves considering the frequency of themes or concepts that are present in data . In relation to this study, we were interested in the perspectives of individuals with LBP, and what their insights might add to existing understandings about what decreases LBP.
Individuals with LBP were invited to participate in this study via pain groups, previous studies, and broadly via posting on community notice boards (including on-line). Inclusion criteria were: residing in Australia, adults (18 years or older), self-identification as having (or having had) LBP. All participants gave informed consent after reading and information sheet before progressing into the study.
Data were collected using an online survey which included a wide range of questions about LBP and its fluctuations and a series of demographic questions. Demographic details were collected in order to describe the sample. This paper reports on eight responses to two questions. The first question asked: “What makes your LBP decrease?”. There were seven text boxes available for short answers to this question. The first question had some prompts to encourage a broader investigation of factors beyond simply self-management strategies: “For example, things that you do, things that happen to you, or things that change in your environment.” The second question prompted further for “any other things that cause your LBP to decrease” with a final text box.
2.5 Data analysis
To analyse data produced from the survey, we employed an established inductive descriptive technique “content analysis”. As discussed by Vaismoradi et al. , content analysis involves a largely descriptive analysis of the frequency of concepts (themes) within a dataset. Both the frequency that particular types of concepts were mentioned was analysed as well as the order in which participants mentioned these concepts. Categories were derived from the data, not pre-imposed. Analysis involved five iterative steps. Step 1 involved the first author (an experienced qualitative researcher) reading through the entire dataset and making initial notes regarding potential categories (which we call will “themes”). Step 2 involved refinement of these categories into provisional themes. In Step 3, this provisional coding was shared with the three other authors to provide further perspectives on the coding. Step 4 involved refinement of the themes and coding in response to the team feedback. Finally, findings were shared with a qualitative researcher external to the study who confirmed that the analysis was grounded in the data. The number of data entries that were listed under each theme were quantified as both a total (n) and a percentage (%) of participant responses. We also calculated which themes were mentioned earlier in the responses by presenting the number of responses pertaining to each theme as a percentage of the total number of responses across each of the eight text boxes.
2.6 Trustworthiness and rigour
In addition to the measures outlined above, we used the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide our study reporting and design to increase trustworthiness and rigour . All relevant criteria were met.
One hundred and thirty people responded to the questionnaire. Participants had a mean age of 43, most were female (Table 1). Most participants experienced daily pain and frequent fluctuations (Table 2). In total, there were 574 responses to the survey questions. Most participants responded in at least four of the response boxes provided, and answers were between one word and three sentences in length.
Demographic characteristics of study participants.
|New South Wales||16.9%|
Characterization of study participants’ low back pain (LBP).
|Time frame of LBP variation|
|Periods of no LBP|
Our analysis identified two overarching themes (passive strategies and active strategies) and 12 themes (e.g. medication, rest, and seeing a health professional). An overview of the coding and the number of responses provided that fit within each theme is presented in the Table 3. Findings are reported below. The study was not powered for comparisons by demographic groupings.
Number and percentage of participant responses by theme and presenting order.
|Overarching themes||Themes||1st boxan (%)||2nd box n (%)||3rd box n (%)||4th box n (%)||5th box n (%)||6th box n (%)||7th box n (%)||Additional n (%)||Totalbn/%|
|Reduce aggravating activities||6(4.7)||4(3.4)||11(11.7)||8(10.7)||3(5.4)||3(7.0)||6(19.4)||4(13.3)||45(34.3%)|
|Seeing a HP||10(7.8)||9(7.7)||6(6.4)||9(12.0)||4(7.3)||6(14.0)||2(6.5)||6(20.0)||52(39.7%)|
a“box” refers to the response box participants put each response in. The 1st box was the first response entered by the participant etc. For example, 30 participants (23.3%) put a response categorised as “medication” in their first response (top left numerical entry). b“total” refers to the number of responses in each thematic category as a percentage of the number of participants. Most participants entered more than one response.
Participants most commonly said that their LBP was reduced by: heat/cold (86, 66%), medication (84, 64.1%), and rest (78, 60%). Next most common was activity/exercise (73, 55.7%). Other factors such as seeing a health professional (52, 39.7%), stretching/therapeutic exercise (50, 38.1%), reducing aggravating activities (45, 34.3%), and psychological changes (41, 31.3%) were mentioned less often. Twenty-one of the 574 answers were not coded as they were unclear or did not fit into other codes. For example, “avoiding triggers”, and “focus on personal good habits” were not coded as these responses were not specific enough to classify, whereas electrotherapies “Tens machine”, “tens” and “Interex [electrotherapy]” were not coded as they only had a total of three mentions (i.e. <1% of responses).
There were notable differences between which factors (by theme) that participants reported to reduce their LBP were noted first (Table 3). Medication and rest were individually more than twice as likely to be listed first (23.3%, 24.1%) compared with the next most popular themes (heat/cold: 10.9%; and activity/exercise: 10.9%). Second mentions showed a different trend with heat/cold (22.2%) increasing its percentage of mentions considerably, and rest (16.2%) and medication (12/8%) remaining fairly popular and activity/exercise (14.5%) also increasing its percentage considerably. Psychological changes was the only theme that was identified more commonly in the later response boxes than the initial response boxes.
3.2 Themes 1–3: heat/cold, medication and rest
The three most common themes were all situated within the overarching theme of passive strategies. The most commonly mentioned theme was heat/cold. Most participants (88, 66%) mentioned either hot or cold (and occasionally both) as reducing their LBP. Of the two, heat was much more commonly mentioned with participants entering responses such as “heat”, “heat packs” or “hot shower”. Cold included responses such as “ice”, and “cold packs”. The second most frequently mentioned theme was medication (84, 64.1%). Participants discussed number of medication varieties including: “high dosage Ibuprofen”, “muscle relaxants”, “Targin”, “strong opiate painkillers” and “Panadol”. Often participants simply mentioned “painkillers” or “medication” more broadly. Rest was the third most common theme. We coded responses such as “rest”, “laying down”, and “cease physical activities” as rest. As well as being the most common, all three of these themes (heat/cold, medication, rest) were most frequently mentioned in the first two response boxes available to participants and became less frequent as the boxes progressed.
3.3 Theme 4: activity/exercise
The next most commonly mentioned theme was activity/exercise. This was the only other theme (in addition to the three themes describe above) to be mentioned by over 50% of participants (73, 55.7%). We included both exercise and increases in activity in this theme. Exercise was most commonly mentioned, for example “yoga”, “regular walking”, “keeping fit”, and “swimming”. Increases in activity were less commonly mentioned and included “gentle walking around my house”, “moving around”, and “more movement”. Exercise and activity comprised a higher percentage of participants’ responses in the 4th and 5th boxes than earlier or later entries.
3.4 Other common themes
There were a number of other fairly common themes including seeing a health professional, stretching/exercises, reducing aggravating activities and psychological factors. Seeing a health professional (52, 39.7%) included responses such as “chiropractor”, “massage”, “physio” and “acupuncture”. Massage and physiotherapy were the most commonly mentioned. Stretching/exercises (50, 38.1%) included “stretching”, “stretching hip flexors”, and other therapeutic exercises such as “core stabilisation exercises”, “rehab exercises”, and “rocking my bent knees from side to side”. Participants also mentioned reducing aggravating activities (45, 34.3%), such as “avoiding housework”, “no sex”, “not sitting for too long” and “not walking hills”. Psychological factors (41, 31.3%) were mentioned slightly less often and included responses such as “being listened to”, “being mentally supported”, “mindfulness”, and “less stress”. In terms of when these factors were mentioned, seeing a health professional and reducing aggravating activities were fairly consistent percentage of responses throughout the responses as did. In contrast, stretching/exercise followed a similar pattern to activity/exercises; it was less common initially, increased and then decreased. Psychological factors showed a different pattern; it was the only theme that steadily increased from the 1st to the final response box (from 2.3% to 25.8%).
3.5 Themes rarely mentioned
There were three other themes that were mentioned rarely yet were sufficiently apparent in participant responses to be considered a theme. These included posture/ergonomics (20, 15.3%) including factors such as “right seating options” and “being aware of posture”; time (9, 6.9%) simply stated by participants as “time”; and invasive procedures (5, 3.8%) including “steroid injections”, “neurotomy”, and “facet joint injections”. These themes were mentioned too infrequently to develop clear patterns across the response boxes.
Our principle finding was that the top three factors that individuals living with LBP consider improve their condition are heat/cold, medication and rest. These factors are considered most often and also frequently mentioned earlier than other factors. Exercise/activity was also mentioned; but as the fourth most commonly mentioned factor and usually mentioned later than the other three. These findings are notable as they suggest emphasis on passive treatments and limited consideration of psychosocial aspects of health, both of which are contrary to current recommendations for management of LBP , .
Our findings have similarities with results from previous qualitative investigations focused on self-management of LBP. Kawi  identified a similar set of strategies that people with LBP in the USA used as self-management; medication use was the most prevalent, followed by physical activity, lifestyle decisions and using heat/cold. Although those observations may be related, it is difficult to consider how participants in that study would rate these in relation to all options to reduce LBP as only self-management strategies were considered. Although many of the same factors were identified, our study provides a broader understanding of what people with LBP consider to improve their condition.
Our findings contrast with current recommendations from guidelines for LBP management , , , . The three factors most commonly mentioned by our participants as helping to reduce their LBP have little or no support in the current evidence-base as efficacious to manage LBP. Heat/cold: The review by French et al.  states “the evidence to support the common practice of superficial heat and cold for LBP is limited”. There is moderate evidence for short term effects of one type of heat (heat wraps) in acute or subacute LBP , . However, most of our sample had chronic LBP and would likely respond differently. There is insufficient evidence about the use of cold treatment for LBP . Medications: Many commonly prescribed medications are reported to be ineffective at reducing LBP, these include paracetamol/acetaminophen ,  and corticosteroids . Effects of opioids and non-steroidal anti-inflammatory medication are too small to be considered clinically relevant , , . Rest: Bed rest is now rarely advocated to reduce LBP. This follows a systematic review of bed rest versus advice to stay active which showed moderate quality evidence that individuals with acute LBP may be harmed by rest, but may achieve pain relief and functional improvement when embracing an active approach .
There are several possible explanations for these contrasts. First, individuals with LBP might hold erroneous beliefs about what affects their condition. This is not a new premise, and there has already been considerable effort put into “educating” people about the causes of chronic pain (including LBP) with little evidence of a shift in beliefs . However, this premise should be applied cautiously as it is important not to dismiss the perspectives of people living with conditions regarding what works for them , . Second, a possible reason for the difference between current LBP management literature and our findings is that there may be a discrepancy between what the literature and individuals with LBP consider constitutes a meaningful outcome. For example, most trials would not consider the experience of a short-term reduction of pain or other symptoms (for example 2 h) efficacious whereas someone with LBP might. In fact, most trials do not test for these types of outcomes. Third, people might prioritise treatments for reasons other than efficacy – such as convenience or cost. These factors would be of interest to follow up in further research.
It is encouraging that participants frequently listed multiple and varied management strategies that appeared to be focussed towards various (e.g. biological, psychological, social) aspects of LBP. This concurs with research that advocates for more complex and multi-modal approaches to management , , , , . Chronic pain conditions, such as LBP, are considered to be largely mediated and maintained by a complex combination of interacting biological, psychological and social factors , , . In this view, it would be considered optimal for individuals with LBP to consider managing psychological and social aspects of their condition , . However, the balance was considerably weighted towards biological aspects which falls somewhat short of contemporary views of the key role of psychosocial factors. One explanation for this discrepancy could be that although individuals with LBP might consider psychological and social features to help their overall condition, function and quality of life, they may not be strategies to reduce key aspects of their condition such as pain or other symptoms, at least in the short term.
There were patterns apparent in the order in which participants provided responses. Notably, passive strategies were frequently mentioned earlier than active strategies. This order might provide additional insight into the way people with LBP consider management strategies. For example, people may have entered their preferred management strategies first or strategies for more severe episodes or strategies they consider to be “quick fixes”. This is worthy of further investigation.
There are a number of methodological considerations to keep in mind when interpreting the results of this study. The Australian context in which these data were collected should be considered when generalising the results of these findings beyond the study context. Further, most participants had persistent symptoms so our findings may not apply to those with acute episodes of LBP. It is also possible that participants had different understandings of question “What makes your LBP decrease?”. We used the term “LBP” to describe the condition of LBP (with its multiple possible facets beyond simply pain) as this is the common name for the condition in Australia, and alternative wording such as “low back condition”, may not have been understood. However, it is possible that some participants may have considered that the term “LBP” referred only to pain. Further, the wording of the question which contained the terms “pain” and “decrease” may have led people to prioritise discussing short term pain reduction strategies over longer term approaches.
The implications of this research are diverse. From one perspective, there is the implication that public education about efficacious treatments may need to enhanced. Additionally, there is the suggestion that it may be necessary to re-examine LBP research to focus on outcomes that are valuable to people living with conditions. Noting this apparent discrepancy between patient perspectives and other research findings may also help clinicians tailor management to suit the individual patients by increasing the awareness that patient and research perspectives may at times diverge.
We thank the participants who contributed their time and experience to this study.
Research funding: The study was funded by grants (Program Grant: #1091302; Centre of Research Excellence grant: #1079078) and fellowships (PH – APP1102905; MLF – APP1143593; JS – APP1157199) from the National Health and Medical Research Council (NHMRC) of Australia.
Informed consent: Informed consent was required for participation in this study. Participants gave informed consent before participating in this study.
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