Start	Current	Aim1
Physical Activity
Aerobic activity		20 minutes (Meng and Yue 2014)
Sleep		8 hours in bed resting- ideally sleeping (Alsaadi et al. 2012)
Nutrition & Biochemistry
Protein		1gram of protein for every kg of body weight (Wood et al. 2006)
Carbohydrate Grams Fibre		<15% of calories (Wood et al. 2006)
Omega 3’s		1g (Lopez-Garcia et al. 2004, Maroon and Bost 2006)
Fruits		2-3 portions of different fruit (Watzl et al. 2005, Bhupathiraju and Tucker 2011)
Vegetables		5-6 portions of different vegetables (Watzl et al. 2005, Bhupathiraju and Tucker 2011)
Multivitamin and mineral		(Wood et al. 2006)
Probiotics		(Shiranian et al. 2014)
Antioxidants		400mg Vit C (Wannamethee et al. 2006)
Liquids and Hydration		Urine clear
Alcohol		Up to 2 units
Coffee		Up to 3 shots of coffee (Kotani et al. 2008)
Stress Management and Behavioural Modification
Relaxation		30 minutes mindfulness 5 days per week (Linger 2014, Morone et al. 2008)
Environment Exposure
Sunlight		1 hour of sunshine or 500IUs of vitamin D (Pitaway et al. 2013)

Discussion

The literature review overviews the various different methods currently used in practice to give an overview of the background to which these decisions are being made.

Why these physiotherapists practice

The literature review showed the breadth of approaches available to clinicians and informed the interview process. This research sheds some light on how and why clinicians choose which of these interventions to use. The central theoretical code identified was the physiotherapists looked to do what was best for the patient from a variety of motivations. This is similar to previous grounded theory work, which found that all physiotherapist expressed a commitment to caring (Resnik and Jensen 2003). One of the key open codes supporting this concept was that of empathy. Interestingly a study of 1111 students found that physiotherapists in training had the highest levels of empathy compared with other allied health professions (Williams et al. 2014). This suggests empathy could have more influence over behaviour in physiotherapists than other professions. Empathy is known to increase helping behaviours and this has both strengths and weaknesses. The pioneering work of Goleman (1996) highlighted the many benefits of empathy such as “success” in multiple professions and more specifically in a healthcare setting treatment outcomes, satisfaction and job performance. Back pain patients report more satisfaction when treated by clinicians with more empathy (May 2001). However this increased desire to help others can lead to more empathetic individuals feeling more pressure and helplessness, leading to negative health outcomes. This is important for physiotherapists to be aware of as it can lead to being taken advantage of, helping colleagues and patients more than is necessary and feeling greater responsibility than those with less empathy. Thus this trait can lead to significant difficulties that can transcend the professional life and affect all areas of a physiotherapist’s life.

Human beings typically achieve more fulfilment in work than in our social activities (Csikszentmihalyi 1991). This comes as a surprise to many. Nonetheless in this research it seemed that a sense of personal pride in their work was central to reasons for why physiotherapist wanted to help patients. The finding of professional competitiveness was very surprising. KM strove to come from a clear mind as suggested by Descartes (1637) that would be ideal for an inductive piece of research. Despite this an affinity for the physiotherapists who gave up their time to help with the study developed. This made the emergence of the code all the more troubling. Initially there was an eagerness to dismiss this due to this affinity, however it’s repeated emergence meant it needed to be analysed and considered as shown in KM’s theoretical memo.

Memo 1^st October 2015

The disdain for other professionals and repeated allusions to mistakes made by other professionals appears to be part of giving experienced physiotherapists their self-worth in practice. It may be that this comes from an innate competitive drive that shows its self in these statements. Further this may help push therapists to improve and enjoy their practice further.

This finding may be more particular to this group of physiotherapists. Perhaps due to their experience they were all confident. For example all felt comfortable with the patient having yellow flags and described their strategies for managing this. In contrast previous work has suggested physiotherapists may not feel that comfortable or well trained in managing the psychological aspects of patient care (Hemmings and Povey 2002).

This research cannot give direct recommendations for how to assess and potentially change a physiotherapist’s motivation to practice. However, perhaps it can be of value by encouraging the interested reader to reflect on their own motivations to practice and consider how this may affect decisions in practice on a day-to-day basis.

 

What’s technically best for the patient

The results of this study show that “how” physiotherapists try to help patients is by finding what is technically best for them. The model of how and what is interesting when viewed in the context of previous grounded theory work in to physiotherapists’ clinical reasoning. The clinical reasoning of the “what” would fit with Jensen et al.’s (2000) diagnostic reasoning. Jensen et al. describe a narrative reasoning, reasoning and procedure element within diagnosis, which would equate to the understanding, whilst their interactive and collaborative reasoning would equate to the rapport element highlighted in developing adherence. Jensen et al.’s predictive, ethical and teaching reasoning components are not included within the theory here, but are more the underlying processes of deciding how to empower the patient, based on the other elements. Jensen et al. split these elements across diagnosis and treatment; whilst the data gathered here suggested the clinical audit process clinicians used makes such distinctions difficult. Thus the integrative diagram in the previous article can be updated as seen below.

Figure 1 Update cycle of Iterative cycle to help patients do what is best for them

The finding of how clinicians came to their clinical reasoning decisions may be a disappointment to policy makers and proponents of the contemporary descriptions of evidence based medicine. The term evidence based medicine is evolving and whilst all physiotherapists alluded to it or mentioned it directly there was broad variation in what they appeared to mean with the term. The physiotherapists interviewed used a combination of trial based evidence, experience and expert opinion as well as the patient’s wishes. This suggests these physiotherapist are generally practicing somewhere between traditional expert based medicine (Smith and Rennie 2014) and Sackett et al.’s (1996) definition of evidence-based medicine, which discussed the integration of the best evidence with what the patient presents and the clinician’s experience. Current definitions have progressed to focus on using the best available evidence to make decisions (Gray 2014), with an emphasis on a hierarchy of evidence prioritising meta-analyses, systematic reviews and higher quality trials over expert opinion and basic science (Moore and Jull 2006). Greenlagh et al. (2014) argue that the movement has had significant benefit but that there is too much evidence for clinicians to consume, guidelines are too large and rules have become inflexible and mechanical. Greenlagh et al. (2014) argue that clinicians should return to “real evidence-based medicine” using expert analysis of evidence to deliver patient centred care. They argue this should be done using higher levels of analysis and human intuition as described by the Dreyfus brothers (1987). Nonetheless physiotherapists struggle to apply trial based evidence to practice (Jette et al. 2003). In a sample of 488 American Physical Therapy Association members lack of time was seen as the major limiting factor. Similarly, Hannes et al. (2009) highlighted several barriers to the implementation of evidence-based practice by Belgian physiotherapist. They conducted a grounded theory approach analysis of 43 purposively sampled physiotherapists with varied interests and expertise in evidence based medicine. The problem tree they developed highlighted the key obstacles to the implementation of evidence-based practice as a lack of autonomy and authority to decide treatments. Interestingly questions were raised of the quality, applicability and accessibility of evidence. A lack of motivation from physiotherapists to use evidence-based practice was alluded to but not expanded on. However, this returns us to a fundamental human conundrum. Behavioural economics has shown us human intuition is not reliable and following simple algorithms is often more effective (Tversky and Khaneman 1981). Interestingly we prefer human error to computer error and would usually prefer to trust a human rather than an algorithm (Kahneman 2011). Nonetheless at this time reducing the treatment of CLBP patients with yellow flags to an algorithm is out of reach due to it’s complexity but it is not impossible that in the fullness of time we may be able to develop more useful “mechanical” guidelines.

At the superficial level it is interesting to compare “what” the different physiotherapists wanted to do with the patient in the vignette. The background and literature review highlighted the varying different approaches and emphasised their differences across the spectrum of physiotherapy. The interviews found a similar breadth of approaches likely extenuated by the purposive sampling. This was evident in sub-grouping where physiotherapists would use overt and covert sub-grouping. Sometimes using specific methods and other times interviewees were able to specify specific conditions under which they would give one style of intervention or use a specific questionnaire. Given the effectiveness shown by the classification-based approaches in the literature review it is not surprising most interviewees were using some form of classification. Clinicians often prefer classification-based or more individualised treatment-based approaches. However, Karayannis et al. (2015) showed that across the most prominent forms of classification there is both overlap and discord. Thus whilst there is utility in sub classification there are certainly discrepancies in application. It may be that this is because they allow more autonomy. The social sciences have shown as autonomy in our work decreases so does our motivation and performance (Cerasoli et al. 2014). Thus it makes sense that these approaches are more appealing in comparison to approaches that simplify treatment and perhaps suggest there is less skill involved in the work of physiotherapists. This area has become contentious in the physiotherapy literature as governing bodies push for more physiotherapists to follow guidelines and evidence begins to suggest all exercise has a fairly similar response (Searle et al. 2015). Thus clinicians desire for autonomy which may be central to the desire to continue to practice, appears at loggerheads with policy makers who may acknowledge the need for individual based treatment but focus guidelines and policy around delivering one size fits all programmes.

Whilst there was a dearth of literature that met the selection criteria considering the significance of the problem, those that did highlighted the benefits of passive, active; more comprehensive and simple education interventions. The physiotherapists interviewed all mentioned a process KM used the code “graded exposure” for. This was a process of getting the patient to do what they could from both activities of daily living perspective and an exercise perspective and then gradually increase it. Interviewees used their own paradigms to explain how this approach was having an effect; often using biomechanics based explanations, which may be at least partially accurate. However, it appears this approach can definitely work to reduce pain related fear, catastrophising and pain related disability (Vlaeyen et al. 2001). Macedo et al.’s (2010) systematic review suggested graded exposure was effective for reducing back pain of longer than 6-weeks duration in the short term compared to minimal interventions but no different to other exercise interventions. This is not a fair comparison as many of the different approaches coded as “graded exposure” would fit within the other exercise approaches compared in Macedo et al.’s review. This is a common problem in physiotherapy where semantics and how techniques are labelled leads to disagreements where there is much common ground.

The literature appeared to show that while passive interventions can improve pain, more whole body active approaches such as whole body weight training or walking may be necessary to positively impact the psychosocial aspects. Interviewees appeared conscious of this and almost conflicted about the role of passive approaches, in particular manual therapy. As demonstrated in the memo below:

Memo 27^th September 2015

Physiotherapists appear conflicted over the role of manual therapy. They appear to want to use it and feel it will help, but are fearful patients will become dependent on it, and it will not lead to long-term recovery. All interviewees seem to feel that there may be specific manual restrictions that can significantly benefit from manual therapy and improve symptoms.

This is an interesting concept and when examined the potential for the development of dependency does not appear to have been well examined. Indeed it is not discussed in guidelines for the management of CLBP (Koes et al. 2010). Indeed for acute symptoms manipulation is actively encouraged (Koes et al. 2010), although it’s benefit for CLBP is at best no greater than other interventions and may not be superior to sham (Rubenstein et al. 2011). Furthermore manual therapy has been found to outperform exercise at one year follow up in patients with greater than 8-weeks of low back pain in a 49 patient randomised controlled trial (Aure et al. 2003). Culture was mentioned as one factor to sub-classify patients to receive manual therapy. The implication from the interviewees was that patients from certain culture expect manual therapy and respond favourably at least in part due to their expectations. Interestingly Bishop et al. (2011) investigated the role of patient expectations in manual therapy for CLBP. Their analysis suggested that patients expected active interventions and manual therapy to help their pain and disability more than medication, electrotherapy or rest. However, they found that if patient’s met the clinical prediction rule for a positive prognosis for a manipulative technique this superseded the patient’s beliefs. Thus whilst the use of manual therapy is a broad area the fears of the physiotherapists interviewed do not appear fully warranted.

The literature found good strength evidence demonstrating the benefits of comprehensive CBT and functional restoration programmes. However, whilst all interviewees indirectly mentioned functional restoration, they directly mentioned pain education and specifically “explain pain”. Approaches involving pain neurophysiology education and pain acceptance were both effective compared with more traditional back school and pain avoidance approaches respectively in the literature review. Physiotherapists interviewed described using a combination of these approaches in practice. Neuroscience education for musculoskeletal pain, disability, anxiety and stress has been found to be effective in a systematic review, which retrieved eight papers of good quality (Louw et al. 2011). Importantly whilst not all the papers reviewed were on CLBP some looked at longer term follow ups than the very short terms considered by the two studies included in the literature review. Thus demonstrating longer-term benefits to neuroscience education.

The code “clinical audit” was used to describe a process of assessment and re-assessment to see if a patient’s symptoms could be modified during the session. Liebenson (2010) describes this process as using active techniques to carry out the assessment, whilst some of the interviews used passive techniques, such as the general nociceptive screen outlined by one interviewee. This process coded as the clinical audit, is an interesting example of where a technique is used widely in practice but has not been studied extensively. This is likely due to the flexibility of the technique as any movement that reproduces the mechanical sensitivity can be used for the assessment and any technique that may reduce the mechanical sensitivity can be used for treatment. Thus clinicians are attracted to the flexibility and researchers and policy makers are afraid of the lack of reproducibility. Furthermore, the analysis showed that physiotherapists used this modification of symptoms as a way to get the patient to understand their symptoms could be changed and to see the benefit in the treatment used. In particular they suggested using this to get patient “buy-in”.

 

How to get the patient to do what’s technically best for them

The second aspect of “how” identified was how physiotherapists get patients to do what is technically best for them. The individual elements of the iterative flow identified of understanding, rapport, adapting, and empowering the patient have received some investigation in the literature but overall this half of the “how” receives far less attention. For example the clinical guidelines for the management of CLBP focus on the “what” and not how to get patients to do this (Koes et al. 2010). McCrum et al. (2015) highlight the importance of understanding CLBP patient’s perspectives in helping physiotherapists adapt their communication to gain compliance and empower patients to engage in self-management. A Cochrane systematic review of 42 studies looking at improving adherence to exercise in patients with musculoskeletal pain indicated that these interventions had moderate sized effects (Jordan et al 2010). One of the key criticisms of the studies was their lack of a relevant behaviour change theory that might explain the underlying processes. In fact only two were based on a relevant behaviour change theory. Therefore as Lonsdale et al. (2010) state the most effective methods for behaviour change and how they work remains to be ascertained. Work in this area is currently developing with pioneering work looking at the use of a theory based on a self-determination intervention to improve exercise adherence in CLBP currently underway (Lonsdale et al. 2012).

In the realm of adapting the empathy identified as a frequent trait in these physiotherapists and in student physiotherapists by Williams et al. (2014) may help in improving adaptability. Empathy is central to Goleman’s (1996, Goleman 1998a) concept of emotional intelligence (EI) and is theorised to play a central role in all communication. Potentially most important is managing feelings and reactions to others’ communication. This allows an individual to look for the real meaning, which is frequently not what is initially perceived. Individuals that are empathetic are attentive to emotional cues and listen well (Goleman 2000). Further they show sensitivity and understand other’s perspectives. This allows them to communicate in a way, which is effective for each individual and the group as a whole. The key to empathy is actively listening to effective communication. Goleman (1998b) states that the mark of having truly heard someone else is to respond appropriately, even if that means making some change in what you do.

 

Nonetheless until further high quality research is conducted this area of practice will continue to be led by clinicians working in practice. Reflecting on the model outlined here may prove useful for novice clinicians and to hep stimulate and challenge more experienced clinicians to develop improve their own ability to help patients do what is technically best for themselves.

Limitations

This research has several limitations. Most notably that the research was conducted and analysed by a novice researcher. Six interviews were conducted and whilst theoretical saturation was achieved these findings are not generalisable. KM’s lack of experience relative to the more experienced clinicians may have limited the quality of interviews, meaning they were less challenging than they could be. This may have encouraged interviewees to make more comments about other healthcare professionals and increased the likelihood of the findings around egotistic drives. Whilst not invalidating this finding it may have come across differently with a more experienced clinician interviewing. Further the interviewees were all experienced clinicians and thus the results are not applicable to inexperienced clinicians, although they may be useful to stimulate reflection and generate ideas in novice therapists. KM struggled with the dichotomy of being objective in collecting data whilst getting close enough to obtain rich data. The use of a vignette means the “what” the findings are not generalisable around what to do with a patient cannot be generalised and more suitable as idea generators for clinicians and to help challenge current practice and physiotherapists own motivations. Furthermore, the other findings are likely influenced both by the context of the vignette and by KM’s involvement in the interview and analysis process. The interviews focused on the “what” to analyse the why and how, however this meant there was no questioning of how clinicians paradigms were formed. It would have been very informative to probe this area, by asking their own views and getting an overview of their formative physiotherapy experiences. The study relied solely on interviews where Glaser  (1992) stated that to have a proper grounded theory required observation. The implication of this would be that this research is focused more on the lived experiences of the participants rather than the social processes (McCann and Clark 2004). However, the by interviewing participants about the “what” and analysing this to uncover the social processes, the “why” and “how” this potential criticism is less valid.

 

Implications for practice

Given the limitations and methodology of the study it is hard to make any firm recommendations for practice. Nonetheless this research should provide a useful insight in to a framework of what experienced physiotherapists do to manage a typical patient with CLBP and yellow flags. The research may potentially be of more value by aiding clinicians in considering their own “why”, stimulating thought and reflection on their own motivations to practice. Furthermore, the two step “how” process of working out what is technically best for the patient and then how to get the patient to do this may help stimulate physiotherapists to consider their own processes. Additionally, the iterative flow highlighted in this research may provide a framework for therapists to consider how they get patients to do what is technically best for them and whether there are ways they could be better at doing this.

Conclusion

The importance of the researcher in a qualitative study such as this in co-creating the data means the inexperience of KM is a key inherent limitation to this research. The analysis produced the grounded theory; physiotherapists seek to help CLBP patients with yellow flags for altruistic and egotistic reasons, by establishing what they feel is technically best for the patient and working out how to get the patient to do that. What they do with patients relies on “Sackettian” reasoning, paradigm-based approaches, sub-classification, clinical auditing, graded exposure, education, and an uneasy relationships with manual therapy. This theory along with the framework physiotherapists used to decide what do with patients and the updated iterative flow used to help patients do what is best will provide points for reflection to help develop the practice of physiotherapists. This study would benefit from being repeated by another more experienced researcher and further understanding may be gained by repeating the research in novice clinicians. These findings will also be of use to policy makers as it may help them understand how clinicians are choosing treatment approaches and help the target guidelines more effectively. In particular it is hoped it will draw some attention to the need to focus on compliance and how physiotherapists achieve this. It is clearly an important, under researched area and is ignored within guidelines.

Below are the results of my MSc research in to how different physiotherapists manage chronic low back pain patients with yellow flags. I’ve spared you the details of the methodology but if a few people are interested I will share them as well. Essentially I conducted interviews with six different physiotherapists on how they would manage a chronic low back pain patient with yellow flags using a vignette. These interviews were transcribed and analysed and the results are below.

 

Results

The theoretical, selective and open codes were organised in to a coding tree as shown in appendix 8 (which I can send you if interested it, it is not below). The integrative diagram in figure 6.1 helped to organise some of the codes, and understand their role in what is done with patients.

Figure 6.1: A grounded theory of why, how and what physiotherapists do to help a typical CLBP patient with yellow flags

The analysis produced the grounded theory;

Physiotherapists seek to help CLBP patients with yellow flags for altruistic and egotistic reasons, by establishing what they feel is technically best for the patient and working out how to get the patient to do that. What they do with patients relies on “Sackettian” reasoning, paradigm-based approaches, sub-classification, clinical auditing, graded exposure, education, and an uneasy relationships with manual therapy.

6.1 Help the patient

In looking at how and why clinicians choose to do what they do with patients the central theme that emerged was that everything appeared to be for the good of the patient. Some clinicians used language that suggested a strong empathy to help the patient, others a professional pride in getting the best results and others competitiveness with colleagues. For example the first two open codes to be identified in interview 1 were empathy and understanding. It became clear from the non-verbal clues in particular that this was a genuine interest in the patient as opposed to a superficial interest. Then in subsequent interviews it became clear physiotherapists would avoid giving certain questionnaires, as they did not want to burden patients. Interview 5 stated he would go to the gym with patients to get them started on an exercise programme. Furthermore KM’s interview notes stated on several occasions that there were genuine signs of caring for the patient in the vignette, such as appearing to wince when discussing the patient’s symptoms and changes in tonality and pace of speech, which suggested caring. There was a clear altruistic drive.

The other codes that developed highlight some of the reasons physiotherapists continue to practice. All therapists indicated a confidence in being able to help the patient. Confidence was one of the earliest open codes to emerge. For example phrases like the below were used.

Interviewee 1: “I would be confident I can help”

Interviewee 1: “I would expect progress in 1-2 sessions”

Interviewee 2: “You think that you would be 80-90% certain you could sort this”

Interviewee 4: “I get results”

The interviewees were so confident that only one even mentioned the possibility of referring to another healthcare professional and this was only if the patient did not follow what they suggested. Suggesting that even this physiotherapist felt he was able to help the patient. Generally this confidence was associated with a professional pride, with two of the interviews generating the open code confidence coming from a place of doubting the patient. Their primary aim was to help the patient to get results but they felt that the patient’s feedback could be a barrier to this and that their own approach could avoid potential misdirection from the patient’s feedback. Yet the approach came from a position of care for the patient. For example interview 6 generated the open code “treatment independent of patient” based on the description of this concept as shown below.

Interviewee 6: It is quicker for me to find out from the patient’s objective signs, if this is a good movement or not. Then I don’t even really need the patient to tell me if they feel better or not.

One particular interviewee would often start sentences by highlighting common mistakes other therapists make. Initially this was not coded for specifically but on re-analysis it was a key feature in the communication.

Interview 5: It’s one of the naïve things, that people who have had slight contact with the subgrouping approach would almost certainly put him in the flexion category, because he says he’s got pain on sitting.

Interview 5: I think it can be a trap to fall into, particularly with patients who may present with yellow flags, of thinking, “I have all this pain science information in my brain. I must insert it into your brain, and you must understand it”, and going down that route.

This was initially coded as “derision of colleagues” and later as “professional competitiveness”. On re-analysing the other transcripts this element came through in all the interviews to a degree. So much so that it may be that being professionally competitive, achieving professional competitive success and helping patients others cannot, may be part of the egotistic, for the self, motivation for these physiotherapists in helping the patient.

Two key theoretical codes explain how physiotherapists chose to do what they did with the patient in the vignette; what’s technically best for the patient, and, helping the patient to do what’s technically best.

 

6.2 What is technically best for the patient

 

Figure 6.2 How physiotherapists decided what was best and what they would do

 

In order to help the patient as best they could, whatever the motivation, the physiotherapists would strive through their assessment to establish what was technically best for the patient as show integrative diagram in figure 6.2. Given the breadth of approaches covered there were significant differences in how each physiotherapist would manage the patient, these differences were driven by the different paradigms the therapists had as the reasoning processes were broadly very similar. Yet despite the differences in paradigms the approach used was very similar when the analysis was taken to a partial level of abstraction.

All therapists had their own paradigms. These varied broadly around the areas for which they were selected purposively, but all interviewees considered multiple approaches. The physiotherapist purposively sampled for using Sahrmann approach commented on using various different exercise methodologies, Stuart McGill’s work, Diane Lee and Lind-Joy Lee’s work, McKenzie’s work, Mulligan’s and Maitlands. This was typical of the interviewees and highlights that whilst each had their own paradigms these were generally very broad. Interestingly their entire approaches appeared to emerge from these paradigms. So whilst all interviewees said they would use education, their descriptions were based within their own paradigms. For example those with more of a biomechanics leaning would talk of explaining the biomechanics to the patient. In contrast, interview 2 used the concept of finding the “primary driver” to help explain what was causing the patient’s symptoms and how this could be improved. Furthermore, one clinician went so far as to refer almost all questions around clinical reasoning to patient individuality. Using phrases like,

Interviewee 1: It just depends on the patient

Interviewee 1: All patients are different

Further within education all interviewees specified the importance of some form re-assurance. Again this would always be explained with their paradigms. Interestingly whilst interviewees described varying language to suit patients they very much stuck to their own paradigms in education.

The clinical reasoning behind the choices came down to four key factors, the patients presentation, trial based evidence, experience, and expert opinion as shown in the integrative diagram in figure 6.3.

 

Figure 6.3 “Sackettian reasoning”

The emphasis between these varied between interviewees. It was clear that all were keen to highlight they were “evidence-based” practitioners, although the transcripts suggest they were using more experience and expert opinion in clinical reasoning than would be fit with current definitions of evidence based practice. Thus this was coded as “Sackettian” reasoning, as KM felt it represented a transitioning from expert opinion based medicine towards the evidence based medicine paradigm (Smith and Rennie 2014).

Memo 14^th September

The interviewees so far are very keen to appear evidence-based. Yet there are references to expert opinion and this appears to be forming a fourth component to Sackett’s description.

At first look the different approaches would manage the patient in the vignette in divergent ways. For example interview 2, outlined a detailed approach to exercise selection, while interview 4 suggested all exercises were broadly similar and interview 6 suggested exercises should be based around movements done during infant development. However, with a level of abstraction it was clear all interviewees were describing a graded approach to exercise as outlined within the integrative diagram in figure 6.4.

 

Figure 6.4 Outline of “what” physiotherapist would do to hep the patient in the vignette

One of the most interesting findings was the use of sub-classifying. It became clear that whilst some interviewees would use it in quite typical ways, by following models described by McKenzie (McKenzie and May 2003), O’Sullivan (Vibe Fersum et al. 2010, 2013) or McGill (2007) for example, others would vehemently state the individuality of the patient as a reason to avoid sub-classifying. Initially this seemed like a difference between interviewees but as more interviews were conducted it became clear that even those not labelling their decision making as sub-classifying were indeed covertly sub-classifying. They would specify specific criteria, which would lead them to carry out an intervention such as education or prescribing cardiovascular exercise.

This would be followed by a combination of exercise and education. Within these areas there are differences but all interviewees mentioned looking at movement patterns for compensations of some description throughout the kinetic chain. Within the exercise programme those with a more biomechanical paradigm were less keen on cardiovascular exercise whilst those with a more bio-psycho-social based paradigm were keen on giving this type of patient cardiovascular exercise. All interviews touched on the concept of graded exposure, pacing and functional restoration, placing an emphasis doing what they could now and gradually increasing this as they were able both in their exercise programme and in everyday life.

All interviewees appeared to feel that manual therapy could be useful but were very concerned about patients becoming reliant on manual therapy and wanted to place the emphasis on patient’s doing their home exercise programme.

Interview 4: I’d also be conscious, in doing that, [manual therapy] that there’s the danger of breeding that dependency on the physiotherapy service. Particularly if they are sedentary and they think, “Well, I’m going to go in. [interviewer 4] will fix my back with his acupuncture or his mobs [mobilisations] or manipulation.”

Three mentioned the use of manual therapy as a good time to deliver education interventions. Two also mentioned the potential for manual therapy to be more suitable for patients from certain cultures or with certain personalities and all suggested that when a specific restriction that was affecting function was present manual therapy could be useful.

Interview 2: I would normally start treating if things are not helping that much and after a couple of sessions, unless there is a cultural implication, in that there are certain cultures that you can treat and they just get better. Arabs sometimes

Every physiotherapist highlighted the importance of education. Some would deliver this in a seated 1:1 discussion whilst others would deliver the education more informally during exercise or manual therapy interventions and with handouts or suggested books. The key open codes that developed around education were being wary of inflammatory language, pacing, use of analogies and explaining pain. Similarly all interviewees made comments to the effect that they were concerned about the issue of their language with patients. One in particular used the emotive term, “inflammatory language” which became an open code representing the fear of language that exacerbates symptoms. Within reconceptulising pain, there was a consistent thread of all physiotherapists wanting to uncouple the association of pain with harm. There was some contradiction in the attention the physiotherapists wanted to give to pain. One of the most interesting parts of this was the juxtaposition of physiotherapists that felt their role was to help patients out of pain, but feel they cannot ask a patient about their pain too frequently or place an emphasis on the pain for fear of contributing towards the patient having a fixation on their pain. However, some wanted to bring attention to the pain and use it to motivate patients. For example;

Interviewee 2: …letting him feel associated with his body as they are often so disassociated with the body. They are ignoring it and part of the rehabilitation process is to make them aware of the pain, so they often get a bit worse because they suddenly realise it’s around them.

All interviewees described some variation of the “clinical audit”. This involves taking an objective marker and performing a treatment and then re-assessing the patient afterwards. For example one physiotherapist described doing a “general nociceptive screen” where key tender points throughout the body would be assessed from head to toe. Whilst another described it simply as;

Interview 5: I really want to see, “Can I modify this patient’s pain?”

Then an intervention would be performed and this general nociceptive screen would be repeated. Several described using the specific movements patients complained of pain in, in this case sitting. They would apply an intervention and then re-assess sitting. Often this was used as way to gain patient compliance.

6.3 Help the patient do what is technically best

The last selective code that was developed was that in helping patients get better, physiotherapists felt the need to adapt their communication, assessment and interventions to help the patient do what’s technically best as shown in integrative diagram in figure 6.5.

Figure 6.5 Iterative cycle to help patients do what is best for them

All interviews placed a strong emphasis on understanding. There were two elements to this one more focused on the technical aspect and another more focused on understanding the patient’s expectations, beliefs and past experience so as to develop rapport and adapt the assessment and treatment to better suit the patient. For example interview 3 outlined how she would vary her treatment approach based on the patient’s previous experiences.

Interviewee 3: So if a patient comes in and he would have in addition to what we know now. He would say, “I have been to 2 different physio’s and they all
manipulated my back and each time it was terrible afterwards.” So of
course I would go over what I need to do, so I guess again it has a
lot to do with what the patient tells me.

There was a wide range of styles displayed for building rapport. For example interview 5 placed particular emphasis on rapport using humour.

Interviewee 5: I will probably say that to him. I would probably say, “You just keep going until I get bored”, or something like that, to make a bit of a joke of it. Because if I can get that kind of jokey link with him I always feel that I can get better compliance with things. I will probably tease him a bit about something along the way, just to make sure he knows that’s what’s going to happen.

All physiotherapists interviewed mentioned re-assurance and using the patients language. Broadly these were all strategies under rapport building which helped the physiotherapist to get the patient to do what the physiotherapist felt was technically best for them.

The simplest example of interviewees adapting is that they frequently stated they may only give a patient one or two exercises to gain compliance, despite that fact they felt the patient would benefit from more. This same theme shows up through the assessment and treatment process. For example interview 3 explained how adapted her approach to delivering a questionnaires depending on the patient.

Interviewee 3: Sometimes I would be a bit careful with handing them these
questionnaires. I would not just want to give them a questionnaire, I
would want to explain to them that I am interested to understand their
problems from a lot of different aspects.

Whilst interview 5 described using manual therapy if that was what the patient expected so that the patient would comply with his more active approach.

Interviewee 5: Just to see if I can get the jump on them in terms of if they expect a manual approach, and you don’t give it to them, then I feel like they don’t listen as well to my active approach.

There was a strong emphasis throughout the interviews on empowering patients to manage their own symptoms, for example.

Interviewee 1: The homework is the most important bit

In particular clinicians described using the clinical audit process to get buy in for a patient to complete their home exercises. Furthermore education was used to empower patients to understand their symptoms. For example interview 3 went as far as to state it was probably the biggest influence on the therapeutic outcome.

Interviewee 3: What I believe is that if I can manage this problem of pain
equals harm, if I can address this successfully then usually it can
be very successful in these patients. But it is probably mainly can I
get his trust and compliance. I guess this is the interaction between
myself and him. It is probably the main thing which I believe makes a
successful intervention or not.

The analysis shows that these therapists primarily made their decisions to help the patient as best they could, potentially with varied motivations. In order to do this they looked to find what was technically best for the patient using their paradigms. These decisions were based on a mixture of evidence from trials, expert opinion, experience and how the patient presented. With a level of extraction it was clear there were many commonalities as all interviewees used a variation of the clinical audit process, education, sub-classification, graded exposure and had an “uneasy” relationship with manual therapy. In order to help patients do what was technically best physiotherapists used an iterative cycle of understanding, building rapport, adapting and empowering.

1. Introduction

 

Low back pain (LBP) is usually defined as pain localised below the costal margin (ribs) and above the inferior gluteal folds (buttock crease). It is the leading cause of disability worldwide and is becoming increasingly prevalent (Harkness et al. 2005, Hoy et al. 2012, Vos et al. 2012). Chronic low back pain (CLBP) is variously defined as lasting longer than 7-12 weeks, to 3 months (Anderrson 1999, Frymoyer 1988). LBP is typically classified as “specific” or “non-specific”. Specific LBP refers to symptoms caused by specific pathophysiologic causes, such as hernia nucleus, infection, inflammatory disease, osteoporosis, rheumatoid arthritis, fracture or tumour (Van Tulder and Koes 2010). There is no effective cure for non-specific low back pain (NSCLBP) (Van Middelkoop et al. 2011) and this represents the 90% of the LBP population that cannot be classified as specific LBP (Deyo et al. 1992). Most guidelines are based on the assumption that symptoms resolve spontaneously and that return to work equals recovery (Anderrson 1999, Van Tulder et al. 2006). However, when pain is assessed it appears patients may be returning to work despite their pain (Bowey-Morris 2011), and whilst spontaneous recovery occurs in approximately a third of patients after 3 months, 71% still have pain after 1 year (Itz et al. 2013).

CLBP patients with psychosocial, psychological and social, risk factors are known to have poorer outcomes and increased management costs (Grimmer-Somers 2006, Nicholas et al. 2011). The term “yellow flags” was originally used to describe psychosocial risk factors that predict disability in LBP patients (Kendall et al. 1999). These risk factors are predictors of return to work and disability in CLBP patients (Glattacker et al. 2013). The risk factors can be identified using a questionnaire or a clinical diagnosis (Watson and Kendall 2000). Questions cover beliefs that are associated with delayed return to work and disability. These include fears about pain, injury, recovery and being despondent or anxious. It is suggested that having a few strongly held negative beliefs or several weaker ones could be used to identify at risk patients (Nicholas et al. 2011). These beliefs increase a patient’s perception of threat and modern neuroscience suggests that pain is the conscious interpretation that tissue is in danger (Moseley 2007). These beliefs can be viewed as “thought viruses” (Butler and Moseley 2013). The term yellow flag has now been refined to encompass psychological factors that a physiotherapist could manage, whereas orange flags are now used for psychopathology, which requires specialist psychological management. Alternatively, when the yellow flag belief is positive, for example, an expectation that they will recover; it can be viewed as a positive “pink flag” (Gifford 2005). The more subjective components of the workplace such as perception are termed “blue flags”, and the more objective risk factors such as the nature of the work are termed “black flags” (Main et al. 2004).

2. Background

Yellow flags are now included in most LBP guidelines although there is wide variation in suggestions in how to assess and manage these patients (Koes et al. 2010). The New Zealand guidelines (National Health Committee 2004) suggest assessment with the acute low back screening tool and the Canadian guidelines are similarly specific (Rossignol et al. 2007), suggesting assessment at 4 weeks or straight away if chronic. However, the other guidelines are less specific in their assessment. The Australian, American, Dutch, French, German and United Kingdom guidelines suggest early assessment but are not specific about how to assess (Australian Acute Musculoskeletal Pain Guidelines Group 2003, Chou et al. 2007, The Dutch Institute for Healthcare Improvement (CBO) 2003, Agence Nationale d’Accreditation et d’Evaluation en Sante 2000, Drug Committee of the German Medical Society 2007, NHS 2008). Similarly, the Finnish and Norwegian guidelines list signs of “yellow flags” and are even more ambiguous on assessment (Malmivaara et al. 2008, Laerum et al. 2007). The European guidelines propose an initial assessment of “yellow flags” and then a review in detail if there is no progress in acute and sub acute low back pain (van Tulder et al. 2006) or assess initially in chronic patients (Airaksinen et al. 2006). In contrast the Italian guidelines recommend assessing psychosocial factors after 2 weeks (Negrini et a 2006) and after 2-6 weeks is suggested in the Spanish guidelines (Spain, the Spanish Back Pain Research Network 2005). The Austrian guidelines are less specific and they suggest patients who do not progress over time should be assessed (Friedrich and Likar 2007). In treatment patients with yellow flags are not specifically addressed but all guidelines at least briefly state the need for re-assurance and return to normal activities, which may aid yellow flag management. The European guidelines suggest the inclusion of a cognitive behavioural approach and the German guidelines suggest psychotherapy may be an education option for referral for multi-disciplinary treatment. Thus within the guidelines the importance of yellow flags is appreciated in assessment and for triage but there is ambiguity in the specifics of management.

The differences seen across the full range of physiotherapy approaches is far greater than within the guidelines. Within physiotherapy there are many different approaches to managing these patients as shown in table 2.1.

Table 2.1 Matrix of different Physiotherapy Approaches

	Hands on		Hands off
More focused on the local tissue	Maitland (2013), Society of Musculoskeletal Medicine (Atkins et al. 2010)	McKenzie (McKenzie and May 2003)	McGill (2007),Sahrmann (2002)
		Lee/ Vleeming (2001), O’Sullivan (Fersum et al. 2009)
More focused on central processes	Dorko (2003)	Neuro-developmental (Kolar et al. 2014)	NOI/ Mind body group (Butler and Moseley 2013)

 

 

The Maitland and McKenzie approaches are the most utilised in the UK (Foster et al. 1999). These approaches and the traditional orthopaedic medicine approach (Atkins et al. 2010) are perhaps the most bio-medical focused, placing emphasis on finding and treating the tissues that is the cause. Other approaches such as that derived by O’Sullivan (Fersum et al. 2009) and, Lee and Vleeming (Lee 2001) attempt to classify patients that need more psychosocial input. With the new clinical model 4, the Society of Musculoskeletal Medicine is moving in the same direction (Atkins et al. In Press). The Neuro Orthopaedic Institute and Mind In Body groups place the most emphasis on a hands-off approach to psychosocial aspects (Butler and Moseley 2013). This approach is based on an understanding of the importance a patient’s perception has on their symptoms and thus the benefits of education and a graded return to normal activities. In contrast Dorko (2003) is a proponent of a hands-on approach to addressing the psychosocial aspects. Clinicians are aware of the importance of psychosocial factors in these patients (Scheermesser at al. 2012) but feel underprepared and may sometimes stigmatise these patients (Synnott et al. 2015). Thus whilst yellow flags are clearly important there remains a lack of clarity for clinicians looking at how to specifically manage these patients from guidelines and clinicians are using an incredibly varied set of approaches. This study aims to investigate how and why different physiotherapists choose to use the different approaches.

3. Literature Review

The literature review was undertaken with grounded theory in mind. The aim was to get an overview of the various different methods currently used in practice to provide context for the interviews. Issues around clinical reasoning and motivation to practice to were not reviewed so that the exploration of these areas would be more inductive.

 

3.1 Search strategy

Three approaches were used for retrieving literature. Searches were conducted initially using the terms yellow flags and low back pain, and treatment, or assessment, or management, using the databases PubMed, Embase, PEDro and CINHAL up to September 2015. This however did not identify any papers and it became clear that whilst the term yellow flags is used in the assessment literature it is not used in treatment papers. As such the searches were repeated using the term psychosocial and low back pain, and treatment, or assessment, or management. In addition content experts were consulted to ensure no additional papers were missed and citation tracking was implemented. No time limit was set for papers and foreign language papers that were identified using the English terms were included. Refworks was used to store and remove duplicates from the searches.

 

3.2 Selection of studies

The student researcher, KM, initially screened the title and abstract of the identified studies. The full text was then analysed. Studies were selected on the basis of the following selection criteria;

1. Primary experimental design study of human participants with chronic (>12weeks) or recurrent (repeated episodes over 12 months) low back pain
2. Participants must have yellow flags or measured psychosocial status commensurate with yellow flags
3. Studies must cover the management of patients

Studies were excluded if;

1. The intervention group did not have yellow flags or measurable psychosocial factors

2. Looked at post surgical patients

3. Mixed groups of sub-acute and chronic patients

4. Mixed groups of neck and CLBP patients

5. The intervention was purely psychological (CBT) and outside the scope of traditional physiotherapy practice

 

3.3 Data management

Risk of bias was assessed as suggested by the Cochrane Back Review Group (Bendix et al. 1996) as shown in table 4.1. Studies with a score above 6 were considered low risk of bias. Studies with a score below 6 were considered high risk. Where any doubt remained an author of the study was contacted via email.

Table 3.1 Criteria for risk of bias analysis

1	Was the method of randomisation adequate?
2	Was the treatment allocation concealed?Was knowledge of the allocated interventions adequately prevented during the study?
3	Was the patient blinded to the intervention?
4	Was the care provider blinded to the intervention?
5	Was the outcome assessor blinded to the intervention?Were incomplete outcome data adequately addressed?
6	Was the drop-out rate described and acceptable?
7	Were all randomised participants analysed in the group to which they were allocated?
8	Are reports of the study free of suggestion of selective outcome reporting?Other sources of potential bias:
9	Were the groups similar at baseline regarding the most important prognostic indicators?
10	Were co-interventions avoided or similar?
11	Was the compliance acceptable in all groups?
12	Were the timing of the outcome assessment similar in all groups?

 

3.4 Search Results

In total 367 studies were identified, after screening titles and abstracts 11 remained. All 11 papers met the inclusion criteria. One foreign language paper met the inclusion criteria was included (Pfingsten and Hilderbrandt 2001), this paper was translated using google translate so that it could be included in the analysis. One paper (Bergstrom et al. 2012) was excluded as it included both neck and back patients in one homogenous group with no separate analysis of back pain patients. A clear limitation is that these studies look at groups of CLBP patients that show yellow flags on average, but within each cohort there will have likely been patients with very few yellow flags and possibly some with very significant yellow flags. Using table 4.1 of the Cochrane Back Review Group (Bendix et al. 1996) the studies were classified as high or low risk. One paper was high risk (Pfingsten and Hilderbrandt 2001) and nine were classified as low risk. The oldest trial that met the selection criteria was Alantra et al. (1994) as despite it’s age it met all quality criteria for selection. The 10 studies all looked at patients of 18 years or older with CLBP, using at least 6 months follow up. All but three were randomised controlled trials, with two being cohort studies (Pfingsten and Hilderbrandt 2001, O’Sullivan et al. 2015) and another with no randomisation (Vowles et al. 2007).

 

Figure 4.1 Flow diagram of literature review

3.5 Findings

The studies identified cover a broad spectrum of biopsychosocial interventions, with some focusing on more biomedical interventions, psychosocial interventions or a combination. Six studies looked at a predominantly biomedical approach.

3.5.1 Biomedical approaches: Passive approaches

Two studies with a low risk of bias from the same group have examined a passive biomedical intervention. Weiner et al. (2003, 2008) conducted randomised controlled trials of percutaneous electrical nerve stimulation (PENS). This involves delivering a low voltage electrical current through a specially designed needle to the adipose layer close to the nerves near the site of pain. In both studies patients were aged 65 or older, lived in the community and experienced moderate CLBP almost every day for more than 3-months. In their earlier study (Weiner et al. 2003) the authors measured psychosocial factors with the Geriatric Depression Scale and the mean score was 6.81, which equates to mild depression, indicative of yellow flags. In their later study (Weiner et al. 2008) psychosocial function measures showed mild to moderate levels of psychosocial stress across the Geriatric Depression Scale, the Chronic Pain Self-Efficacy Scale, the Catastrophizing Scale of the Cognitive Strategies Questionnaire and the Fear-Avoidance Beliefs Questionnaire. The combination of the scores across these measures shows these patients had yellow flags.

In their earlier study subjects were randomised to receive 6-weeks of twice weekly PENS and physical therapy or sham PENS stimulation and physical therapy (Weiner et al. 2003). The PENS and physical therapy group had significant reductions in pain intensity and pain related disability, the sham PENS and physical therapy group did not. These improvements remained at 3-month follow up. Furthermore, significant improvements in sit to stand, psychosocial function and lifting endurance were also seen in the PENS and physical therapy group. In their later study (Weiner et al. 2008) they had 200 participants, randomised to receive either PENS, brief PENS to control for treatment expectancy, PENS with general conditioning or brief PENS and general conditioning. All interventions were done twice a week for 6 weeks. The general conditioning consisted of up to 30-minutes walking and a further nine motor control exercises for 2-minutes each with 1-minute rest. This was accompanied by a home exercise programme of 12 stretches to be done for 3 repetitions, 3 times a day, and 30 minutes of additional walking above normal activity levels. After the 6-week intervention all four groups produced statistically significant improvements in present, average and greatest pain intensity measured on the short form McGill Pain Questionnaire. Interestingly the brief PENS of 5-minutes produced an equal improvement to that of the 30-minute PENS. Furthermore, the general conditioning protocol had no additional benefit on pain measures above that of the PENS interventions, however it did significantly improve fear avoidance in comparison to PENS. These studies suggest that whilst sham PENS is ineffective, 5-minutes is sufficient to have treatment effect, casting significant doubt over the authors proposed mechanism of effect and suggesting the effects may be more centrally driven. Furthermore they indicate the potential benefits of active interventions, in particular general conditioning, on fear avoidance beliefs.

 

3.5.2 Biomedical approaches: Exercise-based interventions

Four of the studies examined exercise-based interventions. Murtezani et al. (2011) found high intensity aerobic exercise outperformed a passive electrotherapy group not dissimilar to the approach of Weiner and colleagues. They randomised 101 patients to either a high intensity aerobic exercise group or a passive modalities group. They used the Hospital Anxiety and Depression Scale to measure psychosocial factors. The scores suggest the patient’s as a group were indicative of patients with yellow flags. The active group produced a 3.9 mean decrease in the visual analogue scale. Interestingly the control group produced no improvements in pain intensity, toe touch, anxiety and depression scores and disability. Suggesting the passive intervention was far less effective than that the results seen in Weiner and colleague’s studies (2003, 2008). Nonetheless the high intensity aerobic exercise intervention produced improvements across all these measures.

In contrast the other two low risk of bias studies looking low intensity aerobic interventions found no significant difference between their intervention and control groups. Hurley et al (2015) conducted a 3-arm assessor blind RCT of an individualised walking programme, an exercise group intervention and usual care physiotherapy, in 246 patients aged 18-62 with CLBP. Participants were recruited from those seeking help at the local hospital and this was used as a baseline as opposed to trials from the general population, which require a baseline pain score for inclusion. The psychosocial baseline assessment of these patients suggests as a group they were representative of patients with yellow flags. The walking programme was individualised and education on functional restoration and addressing fears around movement and the patient’s understanding of their problem were addressed. Patients were given a pedometer to measure their initial activity. From then on they had weekly contact with a physiotherapist, with the aim to progress them to 30-minutes total daily walking 5 times a week. This is in line with the recommendations of the American College of Sports Medicine and previous studies (Garber et al 2011, Tully et al. 2005, 2007). The exercise group attended a class based on the back to fitness programme (Moffett and Frost 2000) endorsed by the UK National Institute of Clinical Excellence guidelines, once per week for eight consecutive weeks. The physiotherapists providing the usual physiotherapy were free to prescribe education, advice, manipulation and exercise as usual but could not refer patients to an exercise group or a walking programme. Similarly, Mannion et al. (1999) compared modern active physiotherapy, muscle reconditioning on training devices, and low-impact aerobics, each done twice a week over 3-months. Modern active physiotherapy was considered to be 30 minutes of individual therapy focused on improving functional capacity and instructions on ergonomic principles. This involved isometric exercises, Theraband exercises and use of general-strength training devices. In addition patients were given home exercises and encouraged to perform them. As is quite typical in many studies the specifics of what was actually done in terms of exercises and all acute variables remains a mystery. Muscle reconditioning involved 12-weeks on the David Back Clinic programme in groups of two to three, which uses progressive isoinertial strengthening in all three planes of motion in a patient’s pain free range of motion. Sessions are proceed by a 5-10 minute cycling or stepping warm up, and relaxation and further undefined strengthening exercises were done between isoinertial exercises. The aerobics and stretching class consisted of a class with 12 people maximum, lasting 1-hour done to music. The initial 20 minutes was used for static stretching and low intensity whole body aerobic exercise. This was followed by 30 minutes of exercises targeted primarily at the legs and trunk. The last 15 minutes was used for cool down and relaxation. 148 participants met the inclusion criteria and 16, 10.8%, dropped out during the study. The three groups did not differ significantly in terms of compliance with 84.1% completing all 24 sessions. Interestingly in both studies all interventions were equally efficacious, despite all three interventions targeting different aspects of physical conditioning. Mannion et al. (1999) suggest this shows that the mechanism of benefit may be more central and possibly due to challenging beliefs around physical activity and chronic low back pain. This is further supported by the correlation between improvement in fear avoidance beliefs and self rated disability. Furthermore these correlations were also present in the devices and aerobics group where these effects were still seen at 6-months, but not in the active physiotherapy group where they were not seen. There were also improvements in spinal flexion and these improvements were correlated with improvements in pain and intensity and self-rated disability. Hurley et al. (2015) highlight that whilst there was no difference in outcomes, the walking programme had the greatest adherence and the lowest costs.

Vincent et al. (2014) compared total body resistance training with lumbar extensor training and a control group in obese individuals. Resistance training sessions were carried out three times a week for 4-months. The total body training group did one set of 12 exercises, for 15 repetitions at 60% of repetition maximum, with 60 seconds rest between sets. Load was increased approximately 2% every week to maintain a BORG perceived exertion from 16-18. The lumbar extension group did just the lumbar extension exercise from the total body resistance-training group. For the first week they did two sets once a week and after that they did one set once a week with same acute variables as the total body group. As is typical in these studies no information on the tempo of the exercises was provided. The control group received advice on healthy nutrition via leaflet from the American Heart Association, information about back pain and information on bodyweight back strengthening exercises. The total body training group had greater reductions in self-reported disability as measured on the Oswestry Disability Index and Roland Morris Disability Questionnaire. Pain Catastrophizing Scale scores decreased in the total body training group more than in the control group at age 4-months. Lumbar extensor training and total body training both decreased walking and chair rise pain severity significantly more than the control. From this it is tempting to imply that the lumbar extensor training was sufficient to improve physical function whilst the total body training provided additional benefits to perceived disability and psychosocial factors.

 

3.5.3 Psychosocial approaches: Pain education

Five studies looked at more directly addressing the psychosocial component of patient’s pain experiences, two of which looked specifically at the effects of pain education and were considered low risk of bias. Moseley and colleagues (2004) conducted a randomised controlled trial comparing pain neurophysiology education with traditional back school education. Each subject took part in a 3-hour 1:1 education session, which included a 20-minute break for a drink. Diagrams and hypothetical examples were used to convey ideas. The experimental neurophysiology education focused on the functional significance of the nervous system, nociception, synapses and how chemicals talk to each other, and the plasticity of the nervous system including peripheral and central sensitisation and movement control. The control group received more typical back education. This covered the anatomy of the spine including the vertebrae, intervertebral discs, trunk and back muscles, normal spinal curves, posture and movement. This included analysis of lifting technique in terms of joint forces and intradiscal pressures, lifting techniques loads and ergonomic advice, as well as advice on stretching, strengthening, endurance and fitness. No information on the nervous system was included. At the end of the session participants were given a 10 section workbook and asked to complete one section a day, each week day for 2-weeks, and then asked to answer the three questions at the end of each section. Subjects returned for assessment 15-week days after the initial assessment. This resulted in significant improvements in pain attitudes, pain catastrophizing scale, straight leg raise and forward bend. Roland Morris Disability Questionnaire was statistically significantly improved although the authors suggest this probably was not a clinically significant improvement. Thus suggesting significant benefits in nervous system based education

Vowles et al. (2007) looked at the effect of pain acceptance, pain control and continued practice instruction strategies on physical impairment, in 74 unemployed individuals on workers compensation with LBP for greater than 3 months. Participants were sent a Beck Depression Inventory, Fear of Pain Questionnaire Short-Form, Pain Anxiety Symptoms Scale-20, McGill Pain Short Form Questionnaire, Chronic Pain Acceptance Questionnaire and the Physical Impairment Index to complete before attending their appointment. The Physical Impairment Index involves seven standardised physical tests; spinal tenderness, a 10 seconds hold of both feet 6 inches off the floor in supine, a 10 seconds hold of both shoulders 6 inches off the floor in supine, total flexion, total extension, total side flexion and passive straight leg raise. After each task patients were asked to rate their pain on a scale of 0-10. These scores were added to create a composite pain score. The instructions for the first test were the same for all participants. For the second test participants were randomised in to three different groups, pain control, pain acceptance and continued practice. The pain control group instructions emphasised that it was possible to control pain through mental strategies or efforts and asked patients to prevent pain during tasks. The pain acceptance group instructions emphasised that pain did not need to influence activity and asked participants not to let pain influence their performance. The continued practice group were asked to continue as they had before, and were informed that improvements can occur with practice. At Baseline the acceptance group had significantly higher levels of physical impairment than the continued practice group. There was no significant difference with the pain control group. After the intervention the pain acceptance group reduced their scores by 16.3%, whilst there was a worsening of 8.3% in the pain control group and 2.5% reduction in the continued practice group. Interestingly there was no significant difference across groups in terms of pain during the tasks. This suggests that the pain acceptance strategy allowed the patients to improve their physical performance without any increase in pain. Conversely it suggests the pain control group had increased physical impairment with no improvement in pain. The authors note that 124 people in total were asked to start the trial and only 91 started. They state that authors experience suggested that the patients that refused to take part were afraid of exacerbating their symptoms. This skews the population of the study towards those who were more likely to do well with this intervention. Nonetheless it provides what appears to be an immediately useful approach for clinicians to use in explaining how to approach pain during exercise and activities of daily living. The combination of pain acceptance with pain neurophysiology education may prove even more advantageous but this remains to be seen.

 

3.5.4 Psychosocial approaches: Intensive cognitive behavioural therapy and functional restoration programmes

Three studies looked at what could be considered intensive rehabilitation programmes, with functional restoration and CBT components. Pfingsten and Hilderbrandt (2001) reported on the results of the functional restoration programme which they trialled over 10 years with 762 CLBP patients, from 1990 to 2000. This was lowest quality study of those identified, with no randomisation, blinding and no explanation of drop outs. Nonetheless, studies such as this provide inform us of methods utilised with this patient group. As expected patients who were off work had increased psychosocial and pain symptoms compared with working patients. Their programme consisted of a 3 week pre-programme of education, stretching and bodyweight exercises followed by an intensive 7 hours a day outpatient programme for 5 weeks. This involved aerobic, functional strength and endurance exercises, back school education, cognitive behavioural group therapy, relaxation training and vocational counselling. The programme reduced Numerical Rating Scale, Pain Disability Index, Allgemiene Depressionsskala (amount of depression), psychological distress (Fear Avoidance Beliefs Questionnaire) and healthcare utilisation. Furthermore work capability significantly improved. However, when they modified it to remove the work hardening component there were no such improvements. These results remained stable at 12-month follow up.

Two studies with a low risk of bias using intensive psychosocial based physiotherapy interventions were identified (Alaranta et al. 1994 and Lee et al. 2013). Alaranta et al. (1994) looked at a combined psychosocial activation and physical intervention in CLBP compared with an inpatient rehabilitation programme in 152 patients, with a control group of 141. All patients had been referred to receive inpatient rehabilitation in Finland. Subjects were stratified according to sex and age and randomised to either group. Both interventions started 3-weeks after assessment and lasted 3-weeks. The intervention group received 37-hours of guided self-controlled physical exercises, without passive physical therapy and 5 hours of discussion groups a week, and individual consultations for work problems. The programme included a range of cardiovascular activities and games, strength and endurance training based off the patients 1 repetition maximum, stretching, relaxation and cognitive-behavioural disability management groups. This group did not receive any passive physiotherapy. The inpatient therapy involved a large amount of passive therapy as well as back education, pool exercises, indoor and outdoor activities. The authors considered this programme to be 40-50% of the intensity of the intervention group. The other study (Lee et al. 2013) directly assessed psychosocial treatment in CLBP patients aged 18-55, with Orebro Musculoskeletal Pain Questionnaire scores of 106-145 indicating moderate psychosocial risk factors. Patients were randomised to either an integrated work rehabilitation group or the conventional treatment group. Physiotherapists in this study had postgraduate qualifications and had received training in the cognitive behavioural approach. Patients received individual treatment for up to 3 months. Conventional treatment typically involved a combination of electrophysical agents, lumbar traction, manual therapy, and exercise therapy. Dictated by the patients’ symptoms at presentation and on their response to treatment. The cognitive behavioural approach group received an individualised graded activity programme, pacing techniques, work conditioning, return-to-work goal setting, self-management strategies, job analysis, and ergonomic advice. The aim was to improve their physical and functional capabilities with thorough attention to return to work. The researchers took the step of calling patients who missed an appointment to remind of them of their next appointment. Patients were discharged when they were able to return to work, had a subjective improvement of 70% or greater or they reached a plateau.

In both studies the authors suggest the results for the primary intervention group are clinically significant. Alaranta et al. (1994) found that at 3-months lateral trunk flexion, trunk rotation and hamstring flexibility was 11-12% increased in the combined group compared with 2-9% in the inpatient group. Abdominal, back and squatting strength improved significantly more in the intervention group in comparison to the inpatient group. These trends remained at 1-year follow up. The intervention group had greater decreases in pain at 3-month (17.1 vs 9.1) and 12-month (15.9 vs 8.9) follow up as measured using the Million index. Usage of physiotherapy and medical services was significantly decreased in both groups with the intervention group performing best. Mean days of sick leave per year decreased by 14 days in the intervention group, although this was not statistically superior to the inpatient group. At baseline to 3-months and at 12-month follow-up there were significant improvements in depression, subjective symptoms, aspects of personality, beliefs in disease and control and psychosocial adjustment in both groups. Similarly Lee et al. (2013) found that at discharge, the patients in the cognitive behavioural approach group made significant improvements in work recovery expectation, pain self-efficacy, and were more satisfied than the conventional treatment group.

 

3.5.5 Classification based approaches

Two trials with low risk of bias using a classification-based approach were identified (O’Sullivan et al. 2015 and Vibe Fersum et al. 2013). Both approaches used the Cognitive Functional Therapy (CFT) approach developed by O’Sullivan (Dankaerts and O’Sullivan 2011).

O’Sullivan et al. (2015) recruited 47 patients with at least a 1 year history of NSCLBP to a waiting list. 26 met all the selection criteria and underwent an initial 3-months on waiting list where they repeated the baseline assessments at 6-weekly intervals. The study did not have a control group, but went to extensive lengths to establish that participants had a stable condition and establish a clear baseline for the group. Based on the STarT Back screening tool scores, 14 patients were high risk, eight were moderate, and four were considered low risk. These scores indicate that these patients had yellow flags. They were then put through a cognitive functional therapy programme, which, focused on improving functional movements and postures, and tackling pain behaviours. In addition they took patients through cognitive reconceptualisation of their NSCLBP experience. Questioning of beliefs around pain, their relationship to pain, pain coping, and the relationship of stress with their pain were assessed. The primary outcomes were the Oswestry Disability Index and the Brief Pain Inventory, the average of four pain scores, maximum, minimum, average and current pain in the last 24 hours. An average of 7.7 treatments was conducted over 12 weeks. Oswestery Disability Index scores were 22 points lower after treatment, 23 points lower after 3 and 6 months and 24 points lower after 12 months. The initial reduction equates to a 54% reduction from baseline. Pain scores were 1.6 points lower after treatment, 1.5 and 1.6 points lower after 3 and 6 months and 1.7 points lower 12 months. All these results represented statistically significant reductions.

Vibe Fersum et al. (2013) unusually specified that participant’s pain was provoked and relieved by specific activities, movements or postures. The numerical rating scale needed to average at least 2/10 over the proceeding 14 days and the Oswestry Disability Index needed to be greater than 14%. The authors state the selection criteria designed this way to select patients whose movement behaviour had a clear association with their pain disorder. Patients with greater than 4 months sick leave were excluded on the grounds that they would require a specific return to work programme. 121 participants met the inclusion criteria and were randomised to receive either a cognitive behavioural functional therapy or manual therapy and exercise. The three physiotherapists delivering the approach were experienced exponents of using a multidimensional classification system. Based on the classification system each patient received a tailored intervention targeted at improving the cognitive, movement or lifestyle component the classification system suggested was maladaptive or provocative. The Oreboro Musculoskeletal Pain Questionnaire was also used to target psychosocial interventions. The intervention had four main components. For each patient their vicious cycle of pain was explained in a personalised diagram based on their assessment findings. Specific movement exercises designed to normalise their maladaptive movement behaviours were given based on their movement classification diagnosis. Functional restoration based on the movements they reported avoiding or provocative, and a physical activity programme tailored to the movement classification. The initial session was 1 hour and follow-ups were 30-45 minutes. Patients were initially seen once a week for 2-3 weeks and then progressed to follow-ups every 2-3 weeks over the course of the 12-week intervention. The comparison group received joint mobilisation or manipulation techniques to the spine or pelvis as delivered by specialists in orthopaedic manual therapy with an average of 25.7 years experience. These physiotherapists had no prior experience of the classification system or cognitive behavioural functional therapy. 82.5% of the patients received exercises based on the physiotherapists’ findings. Initial appointments in this group were 1 hour and follow-ups lasted 30 minutes. Both sets of therapists underwent a half-day of training with a clinical psychologist on the concepts of a best practice cognitive approach to managing back pain. Both groups received 8 sessions on average. Their primary outcome measures were pain was measured using the pain intensity rating scale and the Oswestry Disability Index. A validated 15-item scale to self-evaluate back specific function. There is some confusion over the pain scale used as the test suggests it was average pain over the proceeding two weeks, whilst the table reporting the data suggests it was one week. There was no difference in medication usage between groups before or after treatment. A lack of compliance withdrawal was set at 50%, leading to 27.1% of the manual therapy and exercise group, and 17.7% from the cognitive functional therapy group failing to complete treatment, which precluded an intention to treat analysis. After the intervention average pain over the last week decreased from 5.3 to 3.8 and stayed 3.8 at 12-month follow up, in the manual therapy group. In cognitive functional therapy group it went from 4.9 to 1.7, and crept back to 2.3 at 12-month follow up. The Oswestry Disability Index decreased from 24.0 to 18.5 after intervention and was 19.7 at 12-month follow up in the manual therapy and exercise group. In the cognitive functional therapy group it decreased from 21.3 to 7.6 and was 9.9 at 12-month follow up. These results were all statistically significant in favour of cognitive functional therapy over manual therapy and exercise. It is clear which intervention they were hoping to prove effective and it is possible that increased effort consciously or unconsciously may have gone in to the treatment group. Further the clinicians treating the control may well have been less invested in the outcome of the subjects they treated. This may account for the treatment group receiving 30-45 minutes for follow-ups compared to 30 minutes in the control group. Nonetheless the results are in keeping with those of O’Sullivan et al. (2015) highlighting the benefit of a classification-based approach.

3.6 Discussion

Given the significant nature of the problem of chronic low back pain it is surprising only 10 studies met the inclusion criteria. These studies show a consistent pattern that a variety of interventions are able to decrease psychosocial symptoms, improve function and decrease perceived pain. Disappointingly none of the research on the popular Maitland and McKenzie approaches met the inclusion criteria. Of the studies included the reporting of how interventions were carried out is often not sufficient to allow reproducibility or use in practice.

Of all the studies those using the CFT approach had the most positive effects as measured by disability and pain. The other particularly effective approach was the walking programme of Hurley and colleagues (2015) which had the same effect as their exercise group and usual physiotherapy interventions for pain, disability and psychosocial measures but the walking programme had greater adherence and lower costs. This fits with some of the emerging research in whiplash pain which suggests a low cost telephone based intervention was equal to a more expensive and time intensive motor control intervention (Michaelef et al. 2014).

The admittedly very limited selection of two studies (Weiner et al. 2003, 2008) suggests that whilst passive interventions could positively affect pain, the addition of general conditioning was required to reduce fear avoidance. Similarly, Vincent et al. (2014) found that the lumbar extensor strengthening was sufficient to increase physical function but the total body programme was required to improve perceived disability and psychosocial measures. Improvements in fear avoidance beliefs are often associated with improved function (Crombez et al. 1999) nonetheless in these studies it appears that active treatment such as walking or whole body exercise is required to improve psychosocial measures. There were only two education-based studies but the positive results suggest pain acceptance and neurophysiology education in combination should be useful. The results from intensive functional restoration and CBT programmes suggests these kind of multidisciplinary programmes are effective across all measures, with Pfingsten and Hilderbrandt (2001) noting the importance of work hardening in promoting return to work.

 

3.7 Conclusion

Considering that CLBP is the leading cause of disability worldwide and those with yellow flags are known to suffer the worst and contribute most to societal cost it is surprising how few studies met the selection criteria. This review has shown that whilst the term yellow flags are used in the assessment literature and guidelines, the term psychosocial and the factors that make it up are used in the treatment literature. The studies selected highlight that passive, active; more comprehensive and simple education interventions can all positively impact the pain experience of this patient group. While passive interventions can improve pain, more whole body active approaches such whole body weight training or walking may be necessary to positively impact the psychosocial aspects. Comprehensive CBT and functional restorations are effective but the inclusion of work hardening may significantly aid in return to work. Pain education approaches involving pain neurophysiology education and pain acceptance were both effective compared with more traditional back school and pain avoidance approaches respectively. A combination of these may be useful clinically. The CFT approach was the most effective in terms of disability and self reported pain. Thus despite the lack of investigation in to several of the most prominent approaches this review shows the breadth of approaches available to clinicians.

 

Low back pain (LBP) is usually defined as pain localised below the costal margin and above the inferior gluteal folds. It is the leading cause of disability worldwide and is becoming increasingly prevalent (Harkness et al. 2005, Hoy et al. 2012, Vos et al. 2012). Chronic low back pain (CLBP) is variously defined as lasting longer than 7-12 weeks, to 3 months (Anderrson 1999, Frymoyer 1988). LBP is typically classified as “specific” or “non-specific”. Specific LBP refers to symptoms caused by specific pathophysiologic causes, such as hernia nucleus pulposus, infection, inflammatory disease, osteoporosis, rheumatoid arthritis, fracture or tumour (Van Tulder and Koes 2010). There is no effective cure for non-specific low back pain (NSCLBP) (Van Middelkoop et al. 2011) and this represents 90% of the LBP population (Deyo et al. 1992). Most guidelines are based on the assumption that symptoms resolve spontaneously and that the prognosis is favourable. This assumption is founded on studies using return to work as an outcome (Anderrson 1999, Van Tulder et al. 2006). When pain is assessed it appears patients may be returning to work despite their pain (Bowey-Morris 2011). A recent systematic review found that whilst spontaneous recovery occurs in approximately a third of patients after 3 months, 71% still have pain after 1 year (Itz et al. 2013).
The etiologic factors remain to be ascertained for these patients. There have been many studies highlighting the lack of correlation between radiologic findings and LBP in asymptomatic (Baker 2014, Jensen et al. 1994) and symptomatic individuals (Chou et al. 2011, Endean et al. 2011). Even in patients with incidental findings tracked for 3 years there is not a strong association (Suri et al. 2014). The incidence of lbp is 2-4 times higher in Sweden, Germany and Belgium, compared with Nigeria, south China, and South East Asian farmers. Within lower income countries the incidence is lower in rural areas (Volinn 1997). A recent systematic review found a strong positive correlation between a country’s development and the prevalence of LBP (Hoy et al. 2012). These epidemiological features are similar to the prevalent conditions of western society such as diabetes, heart disease and cancer (Wild et al. 2004, Yusuf et al. 2001, Jemal 2011). Thus it may be that diet and lifestyle factors may play a role in the pathogenesis of CLBP.

Pain Physiology, Diet and Lifestyle

The neuromatrix theory of pain (Melzack 1990) outlines how pain is an output of the integration of nociceptive, cognitive and emotion-related input. Building on this Chapman, Tucket and Woo Song (Chapman et al. 2008) propose the nervous, endocrine and immune systems could be viewed as a “supersystem”. This “supersystem” is responsible for the output of chronic pain. Dysregulation of this “supersystem” could lead to chronic pain. They suggest dysregulation could occur due to genetic, epigenetic and environmental factors. Thus in both these models diet and lifestyle could play a role in causation and management of chronic pain through impacting the nervous, endocrine and immune systems, as well as others.

Figure 1. Neuromatrix of Pain

Mechanical pain starts as nociceptive input from a nococipetor through group IV afferents, otherwise known as group C nerve fibers in the periphery. They synapse with second order neurons in the dorsal horn of the spinal cord, where they become part of the spinothalamic tract. From there, thalamocortical fibers, our third order neurons, transmit noxious stimuli to the limbic system where the brain “decides” to place a pain “neurotag” at the location of the original nociception (Moseley 2003).

Figure 2. Nociception transmission from periphery to brain (Scholz and Woolf 2002)

In chronic pain the threshold for firing of the group IV afferents and other nociceptors is decreased. In this state it takes fewer inflammatory mediators such as prostaglandins, leukotrines, bradykinin, serotonin and cytokines to bind on their respective receptors on the nociceptors to stimulate nociceptive input.

Figure 3. Inflammation and Nociception (Seaman and Faye 2005)

An alternative situation is that the level of pro-inflammatory mediators could be increased due to diet and lifestyle as shown as biochemical injury in figure 3. Diet and lifestyle factors can increase the quantity of inflammatory mediators in specific tissues. This reduces the need for additional pro-inflammatory mediators to bind to the afferent to reach threshold (Seaman 2002). In reality the two situations may occur simultaneously to different levels contributing the CLBP experience.

Diet and Lifestyle and Chronic Low Back Pain

Diet and lifestyle has received limited research as a causative factor in CLBP. Pronk and colleagues (2010) examined the effects of an “optimal lifestyle” on chronic health problems over 2 years in 6848 healthy working subjects. They defined optimal lifestyle as, abstinence from smoking, adequate physical activity, eating 5 servings of fruits and vegetables each day, and consuming limited or no alcohol. Adherence to 3 of 4 principles was associated with lower near-term incidence of back pain, and adherence to all 4 increased the protective effect. When viewed in the context of Minich and Bland’s (2013) definition of lifestyle medicine it is evident there are many other factors that could be considered, as shown in table 1.

Table 1. Lifestyle Medicine Factors

* Items in bold added to Minich and Bland’s (2013) definition

Lack of physical activity is associated with an increased risk of CLBP (Nilsen et al. 2011) but the key contributing environmental factors are work to rest ratio (Dijken et al. 2008), the physical demands (Hoogendoorn et al. 1999, Thorbjornsson et al. 2000). Breathing pattern disorders are common among symptomatic chronic pain patients (Perri and Holford 2004) and large-scale studies have found correlations with LBP frequency (Smith et al. 2006) and LBP development (Smith et al. 2009). This may be due to biomechanical (Rousell et al. 2009, Grimstone and Hodges 2003) and biochemical mechanisms (Chaitow 2004).

Table 2. Physical, Biochemical and Psychological Contributions of Breathing Patterns to Chronic Low Back Pain

Similar association have been found for sleep with a 13-year follow up study of LBP among 360 Finnish fire-fighters highlighting those with sleep disturbances were 2.4 times as likely to develop LBP (Lusa et al. 2014). Poorer sleep quality and efficiency in NSCLBP patients is well established via self-reported measures (Kelly et al. 2010) and sleep disturbance increases by 10% for every point increase on a 0-10 visual analogue scale (VAS) in LBP patients (Alsaadi et al. 2011), although there is no difference in sleep quality measured by actigraphy (van der Water et al. 2011).

Nutrition has been investigated as an etiologic factor in NSCLBP through cardiovascular risk factors. Obesity and being overweight are well-established risk factors for NSCLBP (Shiri et al. 2010b). This may be due to increased weight bearing but also due to the secretion of pro-inflammatory mediators such as CRP, interleuikin 6 and tumour necrosis factor by adipose tissue (de Heredia et al. 2012). More specifically atherosclerosis of the aorta and stenosis of the arteries supplying the lumbar spine are associated with disc degeneration and LBP (Kauppila 2009). Furthermore, in a study of over 18 000 Norwegian subjects with and without LBP over 11 years there was an association between low HDL lipids and elevated triglycerides after adjusting for confounding variables (Heuch et al. 2014). Similarly, low vitamin D status is associated LBP among Egyptian women (Lotfi et al. 2007). All these factors can be seen as markers of chronic systemic inflammation and this may be the common thread explaining the associations.
Epidemiological research has suggested meat and fruit consumption is associated with reduced LBP incidence whilst fish consumption is associated with an increased incidence of LBP. Lower omega 6 and polyunsaturated fatty acid intake appeared protective, as did high intakes of carotene and vitamin B6 (Perry et al. 2010). Of the minerals perhaps magnesium deficiency is the most likely to contribute to CLBP. It can enhance nociception and inflammation via neurogenic inflammation (Durlach et al. 2001). Animal models show magnesium deficiency leads to increased serum substance P, which stimulates immune cells and platelets to release pro-inflammatory mediators (Rang et al. 1994).
Of the other nutrition related factors there is a paucity of research investigating the influence of hydration and other beverages on LBP. Alcohol consumption does not appear to be associated with LBP (Ferreira et al. 2013). In addition, nutrition related conditions such as irritable bowel syndrome can impair motor control of the lumbar spine through inhibiting deep stabilizer muscles essential to lumbar spine stability (Tremolaterra et al. 2006, Wallden 2013).
Psychological stress can directly influence the musculoskeletal, endocrine, immune and nervous systems through the limbic system modifying chronic pain (Macphail 2014). Psychosocial risk factors for LBP chronicity are well known to lead to worse outcomes (Grimmer-Sommer 2008). Indeed the assessment of psychosocial factors is included in most guidelines for the management of LBP worldwide (Koes et al. 2010). Childhood abuse is associated with an increase in peripheralising of LBP later in life (Leisner et al. 2014) suggesting psychological processes can modify the pain experience even later in life.
Environmental factors have received little attention in the CLBP literature. A Meta-analysis of studies up to 2009 found that former smokers had a higher prevalence of LBP than non-smokers and lower incidence than current smokers (Shiri et al. 2010a). Similarly a systematic review of twin studies found smoking significantly associated with LBP (Ferreira et al. 2013). Sun exposure and secondary low vitamin D status is also associated LBP among Egyptian women (Lotfi et al. 2007).
Thus it may be that diet and lifestyle factors play a significant role in the pathogensis of chronic low back pain. This role should be considered as part of the potential contributors to the pain experience and the brains “decision” to place a “neurotag” in the low back area.

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