‘Pain free if I ever will be’: lived experience of workers seeking care for pain attributed to musculoskeletal disorders

Abstract

Background

Pain attributed to musculoskeletal disorders are a significant hinderance to work ability and economic growth, especially in developing countries. Quality of life and lived experience of workers with musculoskeletal disorders have not been explored enough to determine whether person-centred care is provided. There is a wealth of evidence for using the biomedical approach in the management of workers with musculoskeletal disorders, which has proved ineffective in reducing absenteeism and symptoms experienced by workers. The purpose of this study was to explore the lived experience of workers seeking care for musculoskeletal disorders and how their pain attitudes and beliefs influenced their experience.

Methods

A qualitative approach with thematic analysis was used. Purposive sampling was used to recruit six participants for semi-structured interviews. All participants were either experiencing pain attributed to a musculoskeletal disorder or had received care for a musculoskeletal disorder.

Results

Pain attitudes and beliefs of workers with a musculoskeletal disorder and healthcare professionals greatly influenced the care and recovery process of musculoskeletal disorders. There is a primary biomedical lens informing care of workers with musculoskeletal disorders received. Workers expect healthcare professionals to explore their concerns further, but the focus of care for most participants was their presenting complaint. There is also a need for the autonomy of workers to be preserved, and communication between healthcare professionals and workers with musculoskeletal disorders needs to improve.

Conclusions

Many stakeholders are involved in the recovery process from musculoskeletal disorders. There is a need for a biopsychosocial informed practice to improve return-to-work (RTW) in workers with musculoskeletal disorders. Change is needed at all healthcare system levels to reduce the negative experiences of workers and maladaptive pain beliefs that is associated with persisting symptoms and extended absenteeism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-024-07879-z.

Background

Pain is an unpleasant sensory and emotional experience that is associated with or resembling that associated with actual or potential tissue damage [1]. This is the definition that modern neuroscience has created and displays the complexity of pain. The idea that pain reflects the state of tissues has been challenged over the last three decades, but a four-hundred-year-old methodology persists [2]. This persistence has manifested an idea that chronic pain is a disease, creating medicalised healthcare systems and the development of a false sanctuary that pain is a biomedical certainty [3]. Advances in research have been vehement in refuting this idea, but the approach is still to treat the pain rather than the person [4]. This approach resulted in medical communities believing that pain is a purely physical experience of the body, absent of the individual’s influence and that persistent pain is psychological malingering [5].

Pain attributed to musculoskeletal disorders has hindered workers in industries vital to economic growth, with a far more significant impact in developing countries [6]. Its incidence rate has continued to rise unimpeded, mainly due to a poor understanding of it and a lack of implementation of evidence-based clinical practice guidelines to treat it [7]. In South Africa there is some evidence that demonstrates a silent epidemic that has already impacted workers in the mining, transport and performing arts sectors with multiple site pain often being reported [8–10]. The burden of musculoskeletal disorders in South Africa was made evident in a study by Parker and Jelsma [11] found that at least 362 /100 000 community members attending a clinic reported musculoskeletal disorders, which is more than double the expected 144 / 100 000 for sub–Saharan Africa. South Africa relies on its diverse economy, which includes agriculture, fishing, forestry, automotive, textiles, and metalworks sectors, making it significantly vulnerable to musculoskeletal disorders. The healthcare system in the post-apartheid era exacerbates the vulnerability due to the inequality of access to health services and financial resources amongst its populace [12]. The origins of the inequality can be traced back to the health system administration that resulted in staff shortages, financial waste from litigation challenges, equipment shortages and poor record-keeping [13]. South Africa still exists in a tense socioeconomic climate as it tries to navigate through the post-apartheid era. The majority of the population faces these challenges daily, which creates a prolonged state of ill-health and sentiments of despair, resulting in an increased incidence of disease [14].

Quality of life depreciates as pain persists, leading to additional psychological and social issues, emotional distress and work disability, ultimately creating a dysfunctional individual [15]. There is a need to understand the individual experience as pain, as it is a perception that emphasises the influence a worker’s role or culture has, as pain is not an equivalent sensation to everybody [16]. Paradigms must shift to healthcare professionals focusing on people, not just their condition, which is achievable with a care consensus within an interdisciplinary approach [17]. Achieving high-quality person-centred care requires obtaining the story, building a relationship, avoiding generic reassurance and providing cognitive reassurance [18, 19]. These components are imperative for regarding the patient-as-person, emphasising a biopsychosocial perspective, preservation of autonomy, and collaborative work outcomes [19].

Knowledge of psychosocial factors and how they influence the pain experience is necessary in assisting people in making sense of their pain and preventing unhelpful beliefs from manifesting [20]. Individuals’ experience of pain is subjectively based on their perceptions, descriptions, and how information is conveyed, which affects the healthcare professional’s interpretation, assessment, and treatment of pain, which is an enormous task [21]. A biomedical lens has become the premise for maladaptive beliefs as it is based upon ideas that pain equals damage, only medication can treat pain, rest is essential, and these problems result from your age [22]. Orhan et al. [23] identified that the person influences pain beliefs, cognition, and behaviours, and this stemmed from what they learned from healthcare professionals, other individuals, and society. The specific influence of interpersonal dimensions on pain is not yet well understood. This supports the need for the Biopsychosocial Model of Health as we may unintentionally influence each other’s pain [24]. If maladaptive beliefs and cognitive dimensions were addressed at all healthcare system levels, the absenteeism rate would decrease, return to work outcomes would improve, and work disability would sharply decline [25]. The person experiencing pain does not bear sole responsibility for these phenomena because at the other end of the spectrum, the healthcare systems and healthcare professionals stigmatise patients and may act without empathy or compassion [26]. If healthcare professionals can address persons with musculoskeletal pain through a wider lens, it permits a comprehensive treatment plan that includes addressing psychosocial contributors to pain where necessary [27].

Previous qualitative studies have examined the experience of workers in a specific treatment program, which provided insight into how their understanding of pain changed over time [28]. A significant proportion of qualitative studies in musculoskeletal pain were done in western or European regions [25]. In Southern Africa, few qualitative studies on musculoskeletal pain focused on a specific diagnosis rather than the process and outcome of seeking care [29, 30]. These studies mainly focused on barriers faced by participants within the health system in seeking care and less on their needs and experiences. This study explores the challenges and successes experienced by workers in attending to their musculoskeletal disorders rather than a specific type of treatment. In this study, we aim to explore the lived experience of workers seeking care for musculoskeletal disorders and how pain attitudes and beliefs manifest and influence their experience.

Methods

The population for this phase included all who had participated in a previous study by the same authors and had agreed to participate in an interview. Purposive sampling was used to select participants for this study. The chosen participants were as unique as possible, resulting in good qualitative exploration of complex phenomena [31]. Six [6] semi-structured interviews were conducted when saturation was reached. The consolidated criteria for reporting qualitative research guidelines were followed while conducting interviews and producing the report [32].Twenty-five [25] participants were identified out of 110 from a previous study by the same authors as this study. The candidates (Table 1) were contacted in the order that they appeared in the data-capturing spreadsheet, and six semi-structured interviews were completed until saturation was reached.

Table 1.

Participant characteristics

Code	Occupation	Work Status	Native Language
A1	Veterinary Nurse	Working in normal duties with difficulty	Afrikaans
E2	IT Administrator	Working in normal duties with difficulty	English
E72	Admin Clerk (Food processing)	Working in alternate duties temporarily	SiSwati
E18	Security Supervisor	Working in normal duties, treatment completed	SiSwati
E152	Health Clinic/Practice Administrator	Working in normal duties with difficulty	English
E97	Principle Human Resources Officer	Working in normal duties, treatment completed	English

A semi-structured interview guide (Additional File 1) was used. The interviews were conducted in English and Afrikaans, and If participants preferred the interview to be done in Siswati an interpreter was used. The interpreter was trained on the purpose of the research project. Additionally, interview techniques were provided to the interpreter to ensure all possible responses or gaining clarity from participants was achieved. The interview guide consisted of open-ended questions which allowed respondents to freely express themselves as they described their experience with pain (past and present), personal strategies in managing pain and the impact of pain on life roles. Semi-structured interviews follow a schedule of predetermined topics but still allow for unanticipated responses or issues that emerge through open-ended questioning [33]. A convenient place and time for the participants was arranged before data collection. Written consent was obtained from the participants to allow an interpreter to be audio recorded during the interviews if needed. Each participant received the interview schedule a week before their interview date to prepare extensive answers. Before the interview started, each participant was reminded of the aims and objectives of the interview and asked to elaborate as extensively as possible on the meaning of the answers to questions. Interviews lasted thirty minutes to an hour and were recorded to capture all key points [34].

Trustworthiness was achieved through ensuring credibility, transferability, dependability, and confirmability [35]. Credibility was attained through prolonged engagement with participants and member checking of transcribed verbatim drafts to the respective participant and a colleague for peer review [36]. Transferability was ensured by thick description and purposive sampling techniques [37]. An audit trail consisting of the methodology, original transcript, data analysis documents and field notes provided dependability so there is transparency in the research process [36]. Confirmability was achieved through an audit trail, post-interview reflections were done by the interviewer, coding reflections and refining of themes werevaluated by all authors [38]. Direct quotations from transcripts are also provided in the discussion section to demonstrate findings are derived from the data set.

Data analysis

An independent person transcribed data from the audio-recordings verbatim to produce a manuscript. According to Hammersly [39] verbatim transcripts includes every utterance or interjection to maintain the culturally specific context imperative to health research. A summary of the data analysis process is provided in Fig. 1. A set of Transcription Instructions (Additional file 2) that included a transcription key was provided to the transcriptionist to ensure study aims and objectives were achieved. Nascimento and Steinbruch [40] affirm that the study’s aims, objectives and purpose must be discussed with the transcriptionist to improve the accuracy of the transcribed data. After transcriptions were completed, the authors reviewed them again, compared them to field notes taken during the interviews, and verified for accuracy. Thematic analysis was done on two levels: individual data and all participants. The transcribed recordings were exported to Atlas.Ti 9. Atlas.Ti 9 is a qualitative data analysis software that allows for complex coding structures while saving all quotations associated with each code. It was used to scan through the primary data to identify participants’ common terms or phrases. These terms or phrases are highlighted, organised into codes, and used to code all transcripts. Coded data were reviewed to identify patterns and relationships where similar codes were organised into categories. The coded and categorised data was interpreted to generate themes. The original process, as given by Braun and Clark [41] was followed, namely familiarisation with the data set, generation of initial codes, searching for themes, reviewing the themes, and defining and naming themes [41, 42]. The processed data was discussed amongst the authors with TS and JP having experience with thematic analysis for critique and verification of the coding, categorisation and arrangement of the themes. Our backgrounds (BP – health professional, TS and JP – lecturers and researchers) will have influenced this research process. TS and JP do have experience in reflexive analysis, which supports balancing objectivity and self-awareness to maintain a primary focus on the interview data presented. The authors of this study discussed and agreed upon the final themes.

Fig. 1.

Flow diagram summarising the data analysis of participant interviews in line with Braun and Clark [34, 35]

This study was approved by the University of the Western Cape’s (UWC) Biomedical Research Ethics Committee (BMREC) BM_8_20 and performed according to the ethical standards described in the 1964 Declaration of Helsinki and its later amendments. Participants in the qualitative phase were advised not to use names but rather their profession (nurse/doctor) or relationship (brother/employer). Deidentification was performed during the transcription of the interviews. Information obtained from the questionnaires and participants was for the study only and was handled with confidentiality.

Results

A total of six [6] one-to-one interviews were conducted with workers from the Mbombela Municipality of South Africa. There was no need for further interviews as saturation was reached. The thematic map is presented in Fig. 2.

Fig. 2.

Thematic Map

Pain attitudes and beliefs as the scaffolding of musculoskeletal disorders

Pain attitudes and beliefs are evident amongst workers and facilitate the responses and actions taken towards their pain experience. It is also clear that workers are not being questioned about their ideas or concerns regarding their symptoms during consultations with healthcare professionals that elucidate these attitudes and beliefs. These beliefs are shaped over time, but healthcare professionals behaviour appears to have immense influence, and be can be counterproductive to the intended care. The following participants demonstrate Control beliefs, which is the perceived ability to manage symptoms and the belief that their symptoms will improve.

“In a strange way it actually feels so much better when I exercise.”(E152).

“to actually keep playing because I thought that I was no going to play anymore Mm and she told me I can and I will get better with time and motivation.”(E97).

This is showing that participant E152 understands that exercise and movement can be used to manage pain and participant E97 believes that the symptoms will improve with time. These are key control traits that could facilitate recovery and prevent ideas of damage or disability. Other workers expressed the opposite of this, which prolonged suffering and held them within the fear-avoidance pathway.

“It wasn’t easy, it didn’t feel good at all you don’t know when it’s going to start.”(E2).

“I used to run a lot, you know, and do walks and all that but if I do anything and worsen this pain I might cripple myself.”(E72).

Pain-related fear is a major explanatory variable for disability and has significant prognostic value regarding the development of persistent musculoskeletal pain [43]. This loss of control, if unmanaged, will develop into worse symptoms over time and further facilitate maladaptive beliefs.

“Yes,more suffering and frustration than you would ever think, there is a mental and physical part of it, the mental pain was that I would get irritable, you get angry quicker and you don’t enjoy anything.”(A1)“shock and the stress that came from it that knowing that there’s no other way I just have to go for the surgery and just has to be adjusted somehow.”(E72).

Their quality of life and performance in activities of daily living take a massive toll, as described by participant A1. Emotion is an overlooked and underestimated factor in the pain experience and can also be caused by our words’ emotive impact, which is evident in participant E72’s dialogue.

Disability beliefs are fixations that your current symptomatic experience and physical function are permanent [44]. It heavily impacts an individual’s trust in recovery and motivation to continue working despite their pain.

“can’t afford not to work and the real thing was for me and was my greatest concern that my ankle will not recover 100% that it would be like I’m just gonna walk and I would step on something uneven and there we go again we start from the beginning.”(A1).

Disability beliefs cause individuals to lose sight of the fact that pain and function are amenable to change. This belief is present in participant A1 as she has the fervent idea that she will injure herself again and that it will repeat itself.

Harm beliefs are self-constructed facts that the body is damaged, that damage will be done while engaging in a specific activity, or that something has not healed correctly [37]. These are easily identified by the language in which individuals describe their bodily areas and are often just conjecture rather than fact.

“No I just thought it’s the airbag that caused damage to my chest.”(E18).

I needed to apply for something else, something different because I just did not want to be in the Lab anymore and you stand a lot in the lab.”(E72).

Statements that are similar to participant E18 need to be quickly identified and challenged as they begin to change their lifestyle based on the idea. The central nervous system can become easily sensitised after an injury, and thorough investigations must be done to confirm or refute the presence of tissue damage [45]. Participant E72 attempted to make changes to her work to prevent further injury, which was solely based on the experience of pain.

Medical Cure is a product of the biomedical model. It is believing that something must be fixed for the pain to resolve. It has the highest financial cost to the individual and the economy as efforts are made with expensive assessments and procedures to solve the problem.

“I used to go for my sessions a lot which were helpful Mm Mm so she mentioned that, she once told me about, that maybe I should see Chiropractor to adjust my spine because she felt like there was, I don’t know what you guys call it in your health terms. Hhh I was considering doing that, just the way the pain was too SEVERE.”(E72).

Participant A1 and E72 are owned by the idea that there is another scan, procedure or treatment that will fix the musculoskeletal disorder.

Medicating is believing that only tablets or drugs can treat pain and has become an overused expense to the economy and detriment to the health of the individual.

“So that’s the only thing that would give me relief unlike panado which I don’t take, the codeine really helps.” (E2).

“I can’t remember the name of that – but I think it had 5 mg of the active ingredient Okay but then he upped the dosage to 10 because the pain was still there.”(E72).

It is evident in workers that medicating is a primary means to treating pain. The real danger exists when an individual knows exactly what they want, such as with participant E2. Healthcare professionals are facilitators of this, as seen with participant E72 where a higher dosage is needed if the first dosage did not work. It is well established that the long-term effects of medication exacerbate symptoms rather than reduce it, but this practice is still enforced [46].

Solicitude is synonymous with low self-efficacy. It is the idea that I am in pain; therefore, I need care from those within my environment, and I should do less. Society has a profound role in this as we learn to manage pain from each other and repeat the practice of the previous generation [47].

The loss of self leads to low self-efficacy, as individuals can be measured by what they can do. Solicitude results in lower activity levels and reduced work participation, as shown in the participants below [48].

“Overall I think at first I got someone to help me at my house so that I was not doing a lot of hard work just to give myself rest and manage the pain and honestly”(E72).

Psychosocial determinants of pain

Psychosocial factors are non-physical internal and external factors that affect an individual’s perception, responses, and choices regarding their pain [49]. This can include stress, anxiety/depressive disorders, various interactions with people, financial difficulties or simply their understanding of their pain experience.

This level of precision of pain based on the weather conditions described by participant E2 can be associated with central sensitisation [2].

“Winter time I SUFFER with my back and I can tell you where exactly in my spine”(E2).

The social dimension of a shared experience must not be underestimated as we constantly influence each other’s perception and beliefs of pain.

“when we approach the scene of the accident we start to get scared.”(E18).

A past experience can easily be reincarnated to a physical symptom due to the fear as a collective ‘we’ described by participant E18 could cause the individuals to influence each other’s choices and responses to their pain.

Yellow flags

Yellow flags are the barriers to recovery and are often more indicative of a long-term prognosis than objective findings alone [50]. Yellow flags present added difficulty to achieving successful outcomes within any healthcare profession and are embedded in the biopsychosocial model of health. Sorondo et al. [51] affirm that treatment of musculoskeletal disorders must involve assessing and managing yellow flags to ensure successful long-term outcomes.

In the experience of participant A1, yellow flags relate to attitude, behaviour, work, emotions and family. The participant alludes that her pain experience indicates that her ankle is weak and she cannot perform her work correctly.

“When I do run after animals and pick up heavy stuff as I cannot do my job properly if my ankle is weak.”(A1).

“I would inform the guys that are in charge of the IOD’s and I struggled with him a few times I asked him for help and he said it is not his problem.”(A1).

Participant E2’s statements show higher flags relating to emotion and behaviour.

“.hhh, just any type of stress any type of anxiety Ah you know Umm (laughed) I think also a lot of anxiety contributes to everything, maybe I don’t know I’m getting anxious.”(E2).

Participant E72 displays dominant work, behaviour and attitude-related yellow flags with lesser flags of emotion and diagnosis. There is a loss of enjoyment for the work, which can be related to the pain but also shows a loss of purpose.

I: “So how did you feel about your job at that time? Was it something you really enjoyed, was it difficult, what were overall comments about your work?It, it wasn’t difficult it was pretty easy compare to what I was doing in the Lab, Ah because it was during the time when you know there was, what can I say, < retrenchments > is it) .hhh and, were taking place in my company.”(E72)

“I am now like not trying forcing myself to do what I can’t because you know so I think Umm Umm jus- < I just accepted that I’m not that old person that I was and there are things that I just need to just make a reduce doing for now until I am well.”(E72).

Pink flags

Pink flags are the opposite of yellow flags, as they facilitate disease and injury recovery. They share the same labels as yellow flags. Still, they are often missed as healthcare professionals are aware of psychosocial indicators and only assess for the ones that lead to chronicity [52]. Pink flags need to be affirmed as they can decide the participant’s overall response to their pain.

In participant A1’s remarks show a strong presence of work and family-related pink flags that can be advantageous for successful recovery.

I: “Is that where it comes from that resilience, mind over matter?Jah, Not really, my resilience is more about my work ethics. (Uttering sound was finding it difficult to say the word) My Parents brought up you know, it’s a thing from when you got work to do, even if you’ve got a toothache to work you must go no one else will do it for you. This was grained into me since I was a child.”(A1).

Environmental and social factors

The environment and society have their ways of changing that can facilitate or place undue barriers to recovery. The changes to the environment are primarily outside the control of any individual and are often a matter of circumstance.

Pain from musculoskeletal disorders is no different from any other condition, and the environment influences the experience.

Participants E18 and E72 were forced into difficult decisions due to decisions made by the employer and healthcare professionals. This may occur due to a lack of consensus on what regulations should be followed or how care should be provided. The lack of employer assistance can drive adverse attitudes and behaviours within the worker that would prolong their recovery.

“Only thing is I reported at work and they never even ask how I am feeling. They only told me that I must come to work today, I had to go to work because no work, no pay.”(E18).

“I also < felt it was, it was unfair when they told me I should use my own medical aid and do my own cash, I felt it was unfair, < it was>, < it was>. I just didn’t FEEL OKAY about this.”(E72).

Social factors are not only to the worker’s detriment but can also be supportive. The experience of participant E152 demonstrates that it can speed up recovery, but it is a matter of circumstance.

“I don’t think it really affected them that much because I just go on okay, so they never actually communicated and given some input what think about it what you should do, well my husband made appointments for me to go to the doctors to go Physio’s, well his into Rugby and he knows a lot of people so it was actually one of their Physios at the SA sevens academy In Stellenbosch so he supported me right to the end.”(E152).

Healthcare professional and the worker relationship

Workers with musculoskeletal disorders will consult with a healthcare professional and the relationship created becomes essential to the worker’s recovery. This relationship dynamics is primarily based on the healthcare professional’s approach to care and their understanding of pain and musculoskeletal disorders.

Biomedicalised healthcare

The healthcare professional in participant A1’s experience confirmed the recovery of soft tissue structures based on an x-ray. X-rays are used mainly to assess the alignment and condition of bone, confirm the position of invasive medical equipment or evaluate the lungs, making diagnostic accuracy questionable.

“He said okay I need to send you for X-Rays; he read the X-Ray and said to me there is no problem all ligaments are healing and you fine.”(A1).

The experience of participant E72 exposes the flaws of the biomedical approach in treating musculoskeletal disorders and its ‘medicalisation’ has become problematic for health consumers.

“but one thing was Mmm with the Orthopaedic Surgeon that I saw at first he on the report pointed out on my 1st appointment that < I, I > have mild, Ah, What do you call this: scoliosis, is it scoliosis?”(E72)

“I think the Orthopaedic Surgeon that recommended (hiccupped) Sorry that recommended the surgery, was the one that told me the pain was from the pinched nerve.” (E72)

Healthcare professional and worker knowledge of pain

The worker and the healthcare professional are knowledgeable about pain, the healthcare professional on the pathology, and the worker on their experience. There should be a shared understanding of each other’s expertise, but even unintentionally providing misinformation can adversely affect the relationship. The healthcare professional’s responsible for ensuring that all the information received is complete and accurate and for providing accurate information in response.

The statement of participant A1 displays how the healthcare professionals’ knowledge of the pathology, lack of understanding of pain, and lack of respect for the worker’s experience degrade the relationship.

Firstly, the participant had a misconception about pain that bodily tissues have the highest association with pain.

“I also realised that the ligaments were also part of my pain and I know if you read about them, it’s says ligaments do not have pain. But I do believe there is some pain connected to ligaments.”(A1).

The participant had concerns and disagreed with the healthcare professional’s findings, but the symptomatic experience is not enough to confirm its stability. This displays inadequate knowledge of pain from both sides of the relationship, but the lack of validation of concerns impeded clear communication between them.

“No, deep down I did not agree as I could feel on my foot there wasn’t no stability.”(A1).

The contrast in approaches between the physiotherapist and the doctor demonstrates a different understanding of pain.

Further, she provides insight into a potential problem: healthcare professionals who are ‘higher ranked’ may not adequately address expectations.

“Then I kept on coming to my Physio, and he could see and feel that my foot is still not in a good condition and that there is something is not, I don’t think something is lekker there still seriously wrong with my foot.”(A1).

“Doctors are put on pedestals like the second guy and I was told that he is the best in the country. This expectation of people like you are going to help them like you are a priority for them.”(A1).

Healthcare professionals are allowing their knowledge to undermine and disrespect what their patients have. There may not be equal knowledge of the pathology, but even the participant in this scenario understood what she was experiencing more than anyone. Healthcare professionals may have knowledge gaps that they are unaware of, leading to dysfunctional patient relationships. A systematic review by Emerson et al. [53] emphasises that healthcare professionals with authority on clinical-decision making are prey to their implicit biases that facilitate improper care of persistent musculoskeletal pain.

Participant E72’s understanding of ‘well’ is paradoxical as the first rule of pain is that there is no such thing as pain-free. Her complete response highlights a trust issue that may have developed in her consultations with healthcare professionals. Carroll et al. [54] affirm this as expectations of recovery is a dynamic cognitive process, and goal setting is included so that there is a clear understanding of recovery from musculoskeletal disorders.

1: “What do you mean by well?< (…) Pain free if I ever will be>.”(E72).

Communication is key

Communication is the heart of the relationship between healthcare professionals and their patients. It is a clinical skill and treatment modality simultaneously as it helps understand the complaints and beliefs of the patient and shift them if necessary.

Participant E72 experienced a significant change in her relationship by being allowed to tell her story. Her confidence and trust improved from being listened to but it is not always this simple. healthcare professional

1: “So what was the reasons behind that trust being better? What do you feel was different compared to the 1st one? < I think our 1st session she allowed me to tell her exactly how I’m feeling, what went down and like what happened until I got where I was.> Right and then she, I didn’t know how long she has been practicing but from our first session I felt like she was more experienced. Okay, yah and I think with her I got that she understands and she is more experienced.” (E72).

The interactions that participant E72 has with healthcare professionals continue to show her concerns being ignored. Healthcare professionals underestimate their authority and how easily they can inadvertently make massive life decisions for their patients without exploring all options, risks and outcomes.

“It came as some kind of a shock (laughed/giggled); just knowing that I had to go to surgery which I thought that they will say there is another, okay this how we are going to solve it.”(E72).

A study by Vangronsveld and Linton 2012 [55] showed that validation of an individual’s experience is a treatment for the psychological drivers of pain as people feel they have been seen and heard, and invalidation reverses this effect. This is an act that society can perform efficiently, but healthcare professionals are more pressed to use it to achieve effective communication within the relationships with their patients.

“No there was no communication. They just said I must go to the other side.”(E18).

“It felt like I was not welcomed.”(E18).

“Even if I feel more pain I was going to tell them at Physio certain things the pain SEVERE. The Physio always told me what to do.”(E18).

The following accounts of participants A1 and E18 demonstrate the effect of a therapeutic alliance that addresses the concerns of the individual.

“ER doctor came in he said to me you don’t look comfortable what else is wrong with you, can you tell me what you feeling.”(A1)

“He also asked me the whole story around the injury, which she did not do. He asked me the whole story around the story.”(A1).

“I said my score is 100. I was informed by my physiotherapist that recovery would take place within 8 weeks but with my positive mind-set I followed all my instructions from my physio and I was already feeling better in 8 days.”(E18).

Assessment and treatment of musculoskeletal disorders

The general approach to musculoskeletal pain has always been met with controversy due to poor assessment choices and unnecessary treatments that did not resolve the patient’s problem [7]. In the biomedical world, assessment and treatment lie entirely within the healthcare professional, who overlooks the concerns and expectations of the individual. If relief is not found within the treatment directed by the healthcare professional, the individual might consider exploring alternative options.

Participant E18 experienced a direct deferral in care from the healthcare professionals he encountered. This sets a strong precedent for what he is perceived as and makes subsequent care arduous.

“They said we are not going to give you anything we are not even going to attend you that no doctor will see to me until they received the approval of the paperwork from my company. They said that I will not even get a meal.”(E18).

“At Medic-Clinic on the 11th Feb they just give us put us on the drips and give us the pills okay Mm and then drink those pills but still there was those pains.”(E18).

Participant E72 decided to learn unsupervised exercises based on a diagnosis that may not be accurate. Lin et al. [7] advise that healthcare professionals educate patients about their condition and management options. Healthcare professionals may not be taking care of the words or diagnoses used with their patients, as this can send them off seeking treatment that is not tailored to them.

on my side and stretching the stretches you know, from your head, let me just stretch my back up. I went onto “You Tube” and follow people that speak about Sciatic Nerve.”(E72).

“I started the massages and I was I told about the Sciatica Nerve so started researching about it, so even on You Tube I started following people that talk about it, the sciatic nerve and pain relief and stuff like that. So there were exercises some exercises that I would feel comfortable doing that were recommended in those videos but because they were not for me it was just a general information out there.”(E72).

The worker is always right?

The person with the musculoskeletal disorder is the expert on their associated pain experience, but that expertise is not being used in their assessment and treatment. Optimal outcomes in musculoskeletal care are based on a trusting, therapeutic alliance that enables the patient to self-manage successfully based on the knowledge obtained during their consultations with a healthcare professional [56]. The sub-themes explore the worker’s experience of their musculoskeletal disorders, the treatment received, and knowledge their healthcare professional may not have been privy to.

Worker experience with pain

The worker’s experience with pain starts from their first consultation, and first impressions can make a difference, as indicated by participant A1. Poor experiences with healthcare professionals can alter the health consumer’s self-perception of pain.

I: “How did you feel about the treatment you received?Well, Ah! The the female doctor” wasn’t very sympathetic but Aah the male doctor that is head of the ER department, he - brilliant, it is not the first time I seen him. He helped me when the dog bitten I on my elbow a few years back.”(A1).

There may be pre-existing internal struggles that may have developed before the onset of symptoms, such as with participant E2. She is even uncertain about the cause of the anxiety because it may be facilitating her pain experience. Past, present, and future are relevant to the person and will impact their pain. The pain does not have a chronological state, and persistent pain is the body’s inability to return to normal.

“.hhh, Just any type of stress any type of anxiety Ah you know Umm (laughed) I think also a lot of anxiety contributes to everything, maybe I don’t know I’m getting anxious Ah but my body feels it jah.I: Have you suffered with anxiety for a long time or is it also a new thing?Not really hey it’s also quite a new thing I haven’t had like… Mm or maybe in my pain just didn’t know (laughed) jah what it feels like I’d be anxious.”(E2).

Impact of pain on the worker

Understanding the impact of pain on the worker is crucial to understanding their unique experience. It is possible to encounter the same musculoskeletal disorders in many persons, but each has their own unique experience. A systematic review by Langberg et al. [57] defined person-centredness as understanding the person’s experience as one of the primary dimensions.

Participant E72 was having side effects of her treatment, and an example of how caution must be applied when making treatment choices.

“I was also feeling drowsy whilst I had to work shifts and do stuff like that.”(E72).

She also reduced her activity level to match her symptomatic experience. Her pain began to dictate what level of activity she could have. There is a clear emotional impact due to her limitations and pain.

“So I-I avoided exercising and if it was very uncomfortable I would most of the time just walk, take light walks.”(E72)”.

“There were some where I just feel like, umm, if it causes more pain or if I feel uncomfortable about it. I also think it was an emotional issue I would feel tired Hmm when the pain does not get any better.”(E72)”.

Ideas, concerns and expectations

Ideas, Concerns and Expectations (ICE) reveal to healthcare professionals the understanding individuals have with presenting problems and what they expect the healthcare professional to do about it. De Haes and Bensing [58] emphasised the importance of understanding what the patient thinks is the problem (Ideas), what it means for them (Concerns) and what they are looking for (Expectations) as medical communication and is the foundation in formulating a treatment plan.

Participant E2 indicated that her previous procedures and the weather are causing her pain. This provides an incomplete, plain biomedical explanation of symptoms.

“I think the epidurals and you know.” (E2).

“…because I had a C-Section okay for both of them okay so that impacted (Inaudible text segment) the pain in the back.” (E2).

I:“And why do you think that is only in winter the pain increases? E2: I don’t know I think the cold gets into my bones (kind of laughter) jah okay.” (E2).

Participant E18 demonstrates a direct link of pain to damage.

“No I just thought it’s the airbag that caused damage to my chest.”(E18).

Participants E18 and E72 expressed concern over their employer’s apathy for them. They expected more support during their recovery. This information is relevant to healthcare professionals because best practice for musculoskeletal care advises engaging with employers to facilitate return-to-work.

“The only thing I saw it is difficult, it means all that the employer was more concerned about was their own belongings, properties, their job.”(E18).

“If you are injured it’s your own problem and if you are dead they can employ other people.”(E18).

“It was just frustrating and I think at that time I was I just wanted it to be over and I didn’t want to explain a lot things- (laughed) I was just I don’t know- but < I think > if they have taken me seriously and everything that I’ve said and everything my doctor have said it wouldn’t of dragged for so long.”(E72).

Response to care

The effectiveness of care provided by healthcare professionals directly affects outcomes and return-to-work timelines. The participant’s attitudes and beliefs about the care they receive can be congruent with that towards pain. The critical aspect of care in musculoskeletal health and musculoskeletal disorders must correlate with best practices and be person-centred.

Participant A1 disagreed with one of the treatment options she received, and it seems as if medicating the problem was being used as a repeated treatment but yielding no results. Healthcare professionals may not fully understand medication’s pharmacological action in treating musculoskeletal disorders’ pain.

I: “Was that something that you wanted to be doing with all this medication?No, I did not because it’s not healthy Umm for (murmurs) your stomach that (stutters) anti-inflammatory medicine thins your blood so I started to get so many bruises so easily and I realise it was due to these inflammatory medicine.”(A1).

Participant E72 hints at the possibility that she was discharged from care but was still experiencing symptoms. The healthcare professional advised her to continue the exercises, an active treatment aligned with best practices for musculoskeletal disorders. This demonstrates what good coaching can do during consultations by giving the patient the tools and confidence to self-manage.

“She didn’t necessarily tell me how long it will take for me to be well but felt that if I continue with the exercises she gave me then it will be fine or it will be better than what it is now. Which by the way it’s much better than when it started Umm so I don’t know how long it will take. Jah but I am positive that I will be fine.”(E72).

Autonomy and shared decision-making

Autonomy and shared decision-making provide structure to the patient-centred approach to care. One of the pillars of healthcare ethics that places healthcare consumers in more control from the assessment to their recovery or desired outcome. The healthcare professional is responsible for guiding and advising based on the best scientific evidence for individual’s presenting problem.

Participant E18 experienced more open channels of communication with his healthcare professional.

“Even if I feel more pain I was going to tell them at Physio certain things the pain SEVERE. The Physio always told me what to do.” (E18).

Participant E97 experienced a textbook example of autonomy and shared decision-making. If there is an explanation for treatment choices where the individual understands the purpose of it, it becomes an informed treatment choice.

“The physio helped me more than the other’s, it helped me a lot, he made me understand more cos he did not just do the activities, like the needles, he explained to me why he was doing it and this made Mm me fully understand more.”(E97).

Recommendations

Healthcare is a learning process and treating musculoskeletal disorders is no exception. The health consumers are the only ones who can identify where the healthcare system succeeded and failed. It also assists all people experiencing a similar problem and the best treatment approach. This information will help prevent the same errors from being repeated and support improved outcomes and faster recoveries. The only way to obtain this data is to ask the question.

Participant A1 advises listening to the story as not every injury is the same. She also alluded that not listening results in missed information that would make healthcare professionals more accurate with their assessment and treatment.

“I, I think listening is a very important story, don’t just zone out people just because you’ve seen this injury before.” (A1).

“The thing is we learn in our books, this is what it should look like but humans aren’t in boxes, it doesn’t work like that. We all at different levels and we all experience everything differently, you understand.”(A1).

Participant E72 suggested communication, support, and consideration during treatment. This is an indication to healthcare professionals that workers are also people who are looking to recover.

“Okay, I think Hmm (unintelligible segment) maybe approaching people with the same condition that I have, try to be more considerate and listen to them. I don’t know why people can like, think like a person can just lie about pain right Mm < but just be considerate and listen.”(E72).

Discussion

The present study explored themes relating to the belief systems of workers and how external influences modelled it. The workers who deliberated their experience and management found themselves in uncertainty. As discussed, it is becoming the norm as healthcare systems do not agree on using a biomedical or biopsychosocial model of care [59]. The significant association of emotion with absenteeism stems from an understanding that influences decision-making that treatment, as Vanhaudenhuyse et al. [60] stated, is effective in changing the pain attitudes and beliefs of the individual. The pain attitudes and beliefs were found intertwined with the locus of control over symptoms, which determined the level of perceived disability, self-efficacy and emotional predisposition [61]. The work environment was a key factor in the participant’s control, mainly their perspective and is often missed in treating musculoskeletal disorders [62]. Healthcare professional’s understanding of pain attitudes and beliefs appears limited or is not being applied to provide cognitive reassurance. These attitudes and beliefs are predisposing factors to developing Fear-Avoidance Behaviour (FAB), catastrophic thinking, low self-efficacy and long-term sickness absence [63]. In the instances where participants were heard and supported just by communication, the perception of their musculoskeletal disorder changed.

The participants presented with beliefs that significant risk factors for absenteeism indicate a need for screening them to mitigate that risk [64]. The actions of healthcare professionals played a role in developing the participants’ beliefs, but some in the journey began to challenge them, which is not a common occurrence. They could deviate from the biomedical model, albeit with influence from healthcare professionals they encountered and their social circles [65]. According to Yu et al. [66] this phenomenon differs between societal and cultural contexts where psychological and social support is seen as more effective in treatment, and pharmacological treatments are a modality heavily imposed by the healthcare system. This demonstrates if strides are made to pursue a biopsychosocial model of treatment for musculoskeletal disorders, these will become the norm among workers. It is shown within multiple themes of the qualitative results where healthcare professionals adopting a pure biomedical approach developed more dependency on the healthcare system for all their needs which creates workers with low self-efficacy. A similar study by De Sola et al. [67] demonstrated how the biomedicalisation of healthcare facilitated maladaptive beliefs among persons with musculoskeletal disorders from low and middle-income households due to the difficulty of obtaining a ‘higher level’ of care involving non-pharmacological treatment modalities.

In previous studies, self-efficacy was consistent with the response and recovery from musculoskeletal disorders attributed to the individual’s social environment [68]. Self-efficacy beliefs are also a well-established predictor of absenteeism from work and return-to-work timelines in workers with musculoskeletal disorders [69]. In a recent review by Martinez-Calderon et al. [70], the pattern continues due to the complex multifactorial nature of pain associated with musculoskeletal disorders and self-efficacy. It is directly related to physical function, activity and work participation, health status, lower pain intensity and perceived disability. The workers who showed a high self-efficacy in their ability to work and perform activities of daily living despite having faster return-to-work had receding symptoms and lowered expectations of threat from the injury. Early screening of solicitude beliefs or self-efficacy by healthcare professionals in workers with musculoskeletal disorders is necessary to improve return-to-work timelines and prevent prolonged absenteeism from work [71].

The first central theme provided an overview of how pain attitudes and beliefs must be extracted and analysed in consultation. A clear facilitator to recovery and the development of adaptive beliefs by workers that showed recovery seem to be attributed to education. A study by Lacey et al. [72] proved the importance of health literacy for improved outcomes from musculoskeletal pain. The second central theme explored psychosocial determinants of pain, such as yellow flags, pink flags, and environmental and social factors. Yellow flags and environmental and social factors are commonly known as psychosocial factors and facilitate ongoing pain and impact recovery times, but is also not regularly assessed in persons with musculoskeletal disorders [73, 74]. The workers demonstrated influences from their family, continuing stress and anxiety, disputes with their employer and difficulty understanding their diagnosis. All these factors are known to be associated with worker absenteeism presenting with musculoskeletal disorders, which indicates a need for psychosocial screening in workers to predict recovery and return-to-work timelines [75]. This resonates with Schultz et al. [76] who state that assessments of psychosocial factors in workers with musculoskeletal disorders must be standardised to establish optimal return-to-work and reduce unnecessary absenteeism. The converse of this would be resilience factors or pink flags that enable continued work attendance while recovering. Workers expressed the influence of a work ethic inspired by their family and healthcare professionals that motivated them to continue working during their recovery. Kent et al. [77] explored a biopsychosocial model of goal-directed resilience training that was effective in pain, based on developing motivation, emotion regulation and well-being within the individual.

The third theme evaluated workers’ relationship with their healthcare professionals based on the healthcare approach, knowledge of contemporary pain science and communication. The relationship quality is highly predictive of positive outcomes during recovery of musculoskeletal disorders but requires a person-centred approach and is paramount to the recovery experience of workers [78, 79]. Healthcare professionals adopt a biomedical approach, which is evident in the reasoning of pain solely to pathoanatomical structures, whether the pain experience is less than three months or over twenty years. This concern previously presented by Malik et al. [80] preserves pain as biomedical certainty, leading to mismanagement of musculoskeletal disorders, resulting in poor outcomes from treatment and wasteful expenditure of financial and medical resources. Workers who have been given a biomedical diagnosis now fervently search for a ‘fix’ to their pain, develop maladaptive pain beliefs and become at risk for absenteeism from work. Similar findings were echoed by Blanchette et al. [81] and Hudon et al. [82], who investigated the impact of the first healthcare provider in establishing pain attitudes and beliefs in persons with musculoskeletal disorders. However, further qualitative investigations are necessary to understand it completely. The findings from the third theme was modelled into the fourth theme through the assessment and treatment of musculoskeletal disorders. The workers predominantly received an assessment involving radiological investigations that may not be justifiable in all their injuries treatment, including medication and passive approaches such as massage. One worker did describe exercises, but these were found on her own and were not tailored to address her presentation. Management of musculoskeletal disorders requires an individualised approach with sound clinical communication skills, shared decision-making on treatment and education relevant to the presenting concerns [83]. Furthermore, active approaches are needed to address lifestyle concerns psychosocial barriers to recovery and return-to-work, empower workers to be responsible for their health, and reduce the ongoing low-value care derived from the biomedicalisation of healthcare [84, 85].

Strengths and limitations

A strength of this study was that it explored the entire history of each worker’s experience of seeking care in an environment where challenges are numerous and access to care may not be equal for each individual. The interview participants had already been involved in another study by the same authors that assessed their pain attitudes and beliefs. The literature exploring the experience of workers seeking care from a lens of pain attitudes and beliefs has hitherto been lacking. The musculoskeletal disorders experienced by workers were of different types and included both acute and persistent pain experiences.

We acknowledge the influence of the researcher’s role during the data analysis phase and the selection of themes for presentation. Reflexivity is an essential tool used to analyse this influence [86].

The participants’ sample was purposeful and not representative, so the results cannot be translated into the whole population. It is also a small sample of participants, though saturation was reached, its still a limitation. The full profile of health workers was not elaborated on directly, but individual workers are alluded to in quotations. This limitation excludes necessary information for the treatment of musculoskeletal disorders.

Conclusions

In this study, the biomedical approach was the dominant method experienced by the participants seeking care for pain due to musculoskeletal disorders. Psychosocial factors were more prevalent contributors to pain experienced by the participants, such as yellow flags, work environment and their relationship with healthcare professionals. These factors were more evident as pain persisted, particularly in self-efficacy and the strength of the relationship between the participant and their healthcare professional. Contributors to improved outcomes included effective communication, relationship building and education on the meaning behind symptoms that followed the biopsychosocial approach. Healthcare professionals, employers, and, in some cases, insurers are involved in caring for workers recovering from musculoskeletal disorders. Improving the approach to addressing musculoskeletal disorders may improve return-to-work and prevent persistent symptoms in workers and the associated risk of absenteeism. The system may need to change its beliefs by updating the general publics knowledge on a contemporary understanding of pain [87, 88]. A biopsychosocial informed practice that extends further than service-level healthcare is needed to curb the burden that musculoskeletal disorders placed on workers. Workers seek to understand the cause of their pain, and maintaining musculoskeletal disorders as an enigma may only preserve maladaptive and catastrophic thinking [89]. Poor communication between the worker and relevant stakeholders as a causal factor in work disability and long-term absenteeism. Change is needed to resolve unnecessary absenteeism, workers negative experiences and maladaptive beliefs associated with pain attributed to musculoskeletal disorders at all healthcare system levels [90]. Healthcare professionals must move to the stage where establishing the worker’s context becomes the norm to provide holistic healthcare that serves the person’s needs.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

BP, TS and JP designed the study. BP performed data collection. BP analysed the data with support from TS. Final coding and derived themes were evaluated by JP. BP, TS and JP compiled the manuscript, read and approved the final manuscript.

Funding

BP received funding from the Hillensberg Trust. The funder did not influence the design of this study.

Data availability

The datasets created and/or analysed during the current study cannot be made publicly available as permissions were only available for anonymised summaries and quotations presented. Data from the analysis of transcripts can be provided on reasonable request. Full transcripts cannot be provided due to the risk of identifying participants of the study. The request can be directed to BP at 3219668@uwc.ac.za.

Declarations

Ethics approval and consent to participate

The study was submitted to and approved by the Biomedical Research Ethics Committee of the University of the Western Cape with reference number BM_8_20. All procedures followed were in accordance with the Ethics Committee and with the Helsinki Declaration of 1975 and subsequent revisions. Written informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Clinical trial number

Not applicable.

Competing interests

The authors declare no competing interests.