Public perceptions about low back pain and its management: a gap between expectations and reality?

Abstract

Objective

To compare public perceptions and patient perceptions about back pain and its management with current clinical guidelines.

Design

A survey using a quota sampling technique.

Setting

On‐the‐street in South Derbyshire in the UK.

Subjects

507 members of the general population aged between 20 and 60 years, including a representative subsample of 40% who had experienced back pain in the previous year.

Survey

To test knowledge and perceptions of back pain and its best management using statements based on The Back Book which was produced in conjunction with the Royal College of General Practitioners and based on best available evidence. In addition expectations of back pain management and outcome were investigated.

Results

Forty percent of this sample had experienced back pain during the previous year, more than half of whom had consulted their GP. More than half believed the spine is one of the strongest part of the body, but nearly two thirds incorrectly believed that back pain is often due to a slipped disc or trapped nerve. Two thirds expected a GP to be able to tell them exactly what was wrong with their back, although slightly fewer among those who had consulted. Most expected to have an X‐ray, especially if they had consulted. Most recognised that the most important thing a GP can do is offer reassurance and advice. The responses were not related to age, gender or social class. Those who had consulted appeared to have slightly more misconceptions: this could be partly due to people with more severe problems or more misconceptions being more likely to consult, but also suggests either that GPs are still giving inaccurate information or at least failing to correct these misconceptions.

Conclusions

The problem of managing back pain might be reduced by closing the gap between the public’s expectations and what is recommended in the guidelines through the promotion of appropriate health education messages. Further professional education of GPs also appears to be needed to update them in the most effective approach to managing back pain.

Introduction

Over nine percent of adults in Britain now consult their family doctor each year with back pain, which accounts for just over 4% of all consultations. ¹ Von Korff & Saunders (1996) ² found that one of the main goals of consulting was to seek information about the likely course of back pain and advice on how best to deal with it. Recent clinical guidelines ^{3 , 4} emphasize that patient information should be accurate and up‐to‐date. To meet this need the RCGP (1996) guidelines were accompanied by The Back Book for patients ⁵ based on the latest available evidence.

For most patients with nonspecific low back pain, there is now strong evidence for staying active and continuing ordinary activities as normally as possible, as well as strong evidence against bed rest. ⁶ However, that is a radical shift from traditional medical advice and the public may need to be re‐educated. ⁷ Some patients may feel more cautious, and some patients still report that caution is reinforced by their doctor or therapist. ⁸ Many patients want a label to explain their problem to themselves and the outside world, they expect to have it ‘fixed’ and they feel it is the doctor’s or therapist’s responsibility to do so. ^{9 , 10} Special problems may arise in patients who have been told they have degenerative changes of the spine ¹¹ , if they then avoid physical activity. There is some evidence that patient expectations are related to outcome, and Cedraschi et al. ¹² found that patients who had realistic expectations did better in the short term. Greater congruence between the patient’s and clinician’s perception of the problem is also associated with higher patient satisfaction and patient‐rated outcome. ^{13 , 14}

If there is still a gap between the public’s perception and knowledge of back pain and its management and what is realistic, this could in part account for the size of the problem and the level of demand for health care. It could also help to explain why, despite increasing medical knowledge and resources devoted to back pain, incapacity benefits for back pain continue to rise and now account for 15.6% of all Department of Social Security incapacity benefits (DSS Data).

An awareness of the problem in South Derbyshire led to the Health Authority, local Trusts and a number of interested GPs establishing a project to improve the integration of services for low back pain patients. This included a series of interactive seminars for GPs to familiarize themselves with the clinical guidelines. The project which became part of the Kings Fund PACE (Promoting Action on Clinical Effectiveness) programme began with a ‘Search’ conference on services for back pain involving patients with longstanding back pain. The conference identified a possible conflict between patient expectation and the evidence‐based guidelines which emphasized the importance of matching consumer needs with the services provided. In a literature search of Medline, CINAHL, Psyclit and Social Science Citations Index we found over 700 papers related to patients’ perceptions and knowledge of back pain but none on public perceptions of back pain. A survey was therefore set up aiming to:

• assess the knowledge and understanding of the general public about the management of nonspecific low back pain;

• examine what expectations people have about advice, treatment or referral for back pain when they first consult their family doctor;

• to compare differences in perceptions in members of the public in: (i) those who had not had back pain; (ii) those who had back pain in the previous 12 months but had not consulted a GP; and (iii) those had back pain in the previous 12 months and had consulted a GP.

Survey design

A sample of 507 people in the South Derbyshire Health Authority area were interviewed. This sample size, which was the largest that our resources would allow, represented 0.05% of the Authority’s population. Quota sampling was used in order to include the following:

• 50% men and 50% women;

• In each sex, 50% were aged 20–35 years and 50% were aged 36–60 years, in line with the age distribution of those consulting with back pain;

• In each subgroup we selected 40% who had experienced back pain in the last year and 60% who had not, to ensure that the sample was in line with national estimates of the adult prevalence. ¹⁵ No attempt was made to identify the severity or duration of back pain experienced by our sample; and

• Three percent of the overall sample was from an ethnic minority, in line with South Derbyshire Health Authority’s population.

The survey was carried out in brief, structured interviews on‐the‐street. Fifty pilot interviews were carried out, and as no major problems were encountered, these 50 were included in the total sample. The interviews were carried out during November and December 1996.

Data was collected on age, sex and occupation, which was used as a proxy for social class. The first section of the interview then asked about experience of low back pain in the previous year and about treatment received. The second section tested knowledge and understanding of back pain. The third section asked about expectations of a hypothetical consultation with their family doctor for back pain. Sections 2 and 3 were based on The Back Book. In section 2, eight statements about back pain taken directly from The Back Book had to be answered true, false or don’t know. For clarity only the percentage of statements in agreement with The Back Book are displayed on Table 1, and compared with traditional advice. In section 3, three possible expectations (Table 2) based on information in The Back Book had to be answered yes or no.

Table 1.

 Knowledge of back pain: comparing information provided in The Back Book and traditional medical advice with public perceptions categorized by previous experience

Table 2.

 Expectations of GP consultation – statements in agreement with statements derived from The Back Book

Results

As planned, the quota sample included exactly equal numbers of men and women, with 49.7% aged 20–35 years and 50.3% aged 36–60 years. The breakdown by social class was A/B–10.6%, C1–44.0%, C2–16.8%, D–12.8%, and E–15.8%, which is similar to that of the South Derbyshire Health Authority’s population.

Previous experience of back pain and treatment

Of the total sample, 302 had not experienced back pain in the past year and 205 (40%) had. Of those experiencing low back pain, 87 (42%) had consulted their family doctor, evenly divided by sex and age group. Of those who consulted their family doctor, 42 (49%) were referred to other services: 26 to physiotherapy, four to orthopaedic outpatients and four to rheumatology out‐patient clinics, and eight to various other services. Of those patients referred to other services, seven were referred to two different services, and two were referred to three services.

Of the 118 people with back pain who did not consult their GP, 15 (13%) saw some other health professional. Seven saw a chiropractor, five saw an osteopath, one saw a physiotherapist and two did not provide details. All 15 who sought alternative care were from social classes A–C.

Knowledge and understanding of the management of back pain

Table 1 shows the responses of the public to the eight statements about back pain derived from The Back Book. These responses are compared with the latest evidence as presented in The Back Book and with traditional medical advice about back pain. ¹⁶ Traditional information and advice about back pain given by family doctors, physiotherapists and hospital specialists is probably very variable. The information and advice in current guidelines and The Back Book now have multidisciplinary agreement. ^{17 , 18}

The public responses are categorized into three separate groups: (i) those who had not had back pain; (ii) those who had back pain in the previous 12 months but not seen a GP; and (iii) those who have had back pain in the past 12 months and consulted a GP.

The figures show that public perceptions and knowledge of back pain differ somewhat depending on the individual’s previous experience. Those who have not experienced back pain are more likely to believe that the spine is strong (67%). People who have had back pain are less sure this is true (49%) and it makes no difference if they have seen a GP.

Most people who have not experienced back pain believe that those who are physically fit are less likely to get back pain and recover faster. A small majority across the board believe that back pain is not due to any serious disease. Interestingly most people still believe back pain is often due to a slipped disc or a trapped nerve. Those who had consulted their GP were slightly more likely to believe this. The response to the statement that most back pain settles quickly at least enough to get on with normal activities was apparently influenced by experience: A large minority of those who had no back pain agreed. Fewer agreed if they had consulted their GP with back pain. Of those with back pain who had not consulted, however, mostly did agree. Few people in all three categories agreed with the statement that if you have back pain you should avoid exercise. Fewer still agreed with the statement that when you have backache it is helpful to sit for long periods in a soft chair. A small majority agreed that if you have backache bed rest for more than one or two days is not a good idea.

Overall 58 percent answered five or more questions in agreement with The Back Book. Thirty‐two percent of people answered six or more of the eight questions in agreement with The Back Book. Those in the older age group and those in social classes A–C were slightly more likely to agree with The Back Book.

Expectations from GP consultations

Table 2 shows the respondents’ expectations of a consultation with their GP if they presented with back pain, comparing responses of those who had consulted a GP with those who had not. Two thirds recognized that their doctor would probably not be able to tell them exactly what was wrong with their back. Of those who had back pain, perhaps as one would expect, those who didn’t consult were more likely to believe this to be the case compared with those who felt the need to consult. Overall, two thirds did expect to be sent for an X‐ray. Almost half of those who had back pain and didn’t consult would expect to have an X‐ray, and nearly three quarters of those who consulted a GP said they would expect an X‐ray. It cannot be deduced from our data as to whether this is because they were given an X‐ray or because they thought they should have had one. The large majority recognized that the most important thing the GP could do was to offer reassurance and advice. Age, sex and social class bore no relationship to these expectations.

Discussion

This study has strengths and weaknesses. It was a relatively small sample in one Health Authority area, using a basic quota sampling technique. It was a simple and unsophisticated interview, carried out by nonspecialist interviewers on the street. People with an acute episode or those with severe, chronic disability might be less likely to be in the street and unrepresented in the sample. Nevertheless, it is the only such survey available of public perceptions of back pain in more than 500 adults, with typical demographic distribution and experience of back pain. Prior to this survey there had been no special effort to educate the population of South Derbyshire about back pain, and there is no particular reason to believe that they had any different knowledge or expectations from other parts of UK. The questionnaire started from the assumption that The Back Book offers the best current information and advice. On most issues it probably is closest to current guidelines, although the present results raise one important exception discussed further below.

This survey shows that current public knowledge and understanding of back pain falls between traditional and current medical information and advice. The responses to statements 1, 2, and 7 shown in Table 1 suggest that a small majority of around 50–60% do now believe that the spine is one of the strongest parts of the body, and that most back pain is not due to any serious disease. However, those who have had back pain are less ready to endorse these statements and those who have consulted are apparently not reassured by their GP consultation. Overall, around 60 per cent still believe that back pain is often due to a slipped disc or trapped nerve, although disc prolapse or true nerve root pain probably actually accounts for less than 5% of all episodes of back trouble. ¹⁹ Significant differences were obtained according to previous experience of back pain in response to the statement Most back pain settles quickly…. Forty percent of those who had not experienced back pain endorsed this statement, but 61% of those who had back pain without needing to consult agreed, whereas only 35% of those who did consult agreed (chi‐squared, P < 0.001). This implies that these two latter groups may have experienced different types of back pain but many other factors may also have influenced their different responses. It seems however, that they are not always receiving (or accepting) the reassurance that might have speeded up recovery. The message about physical fitness and staying active does seem to be getting through, although people who had consulted their GP with back pain were less likely to agree that physical fitness was important. A large minority of about one third still believe in longer periods of bed rest, with the largest percentage being the individuals who had consulted. It appears from this data that a large minority of about 40% who are uncertain or overcautious in their attitude to managing back pain.

Expectations about GP consultations show the same split. A large majority of 86% are very realistic that as far as back pain is concerned a doctor’s most useful function is to provide reassurance and advice. This is strongly recommended by current guidelines but has not always been carried out by GPs. ^{20 , 21} This survey shows that:

• One third are likely to be disappointed in their expectation that their doctor will be able to tell them exactly what is wrong. Those who didn’t consult with their back pain accepted mostly that this is not possible, whereas expectations were greater in those who had consulted.

• Two thirds also expect to have an X‐ray, even though all guidelines now emphasize that plain X‐rays provide little information about nonspecific low back pain and are not indicated at the acute stage unless there are any red flags. Again, those who did not consult with back pain were slightly more realistic with half of them expecting an X‐ray compared with almost twice as many expecting an X‐ray if they had consulted.

• Those who had consulted their GP seem to have more misconceptions compared with those who had not consulted. Those who consult are self‐selected and it is possible that they may have longer standing or more severe back pain. One of the reasons for consulting may be that that they start with more misconceptions about back pain. Evidently, the consultation did not manage to correct these misconceptions. In some cases the consultation may actually have contributed to their misconceptions.

This survey highlights the need to improve information about the likely natural history of back pain. It is frequently stated that 90% of acute attacks presenting to a GP will recover in 6 weeks. However, many recent epidemiological studies show that this can be misleading. For example, Croft ²² showed that 90% may stop consulting and return to work within that period, but 60% or more will still have some symptoms a year later. The authors of The Back Book ⁵ were well aware of that epidemiology but wanted to present a positive and encouraging message that the best management for back pain is to stay active, so they qualified their statement that Most back pain  should  settle quickly, at least enough to get on with your normal life. We still believe that is strictly accurate, but this survey shows that 40% of the public remain unconvinced. They still believe, and the epidemiology confirms, that in practice (at least under traditional management) back pain often persists and may become a recurrent or even chronic problem. People who consulted their GP were less likely to believe that back pain settles quickly. That highlights two issues. Firstly, that back pain is very variable in its presentation and individuals will cope in differing ways. Von Korff & Saunders ² and Waddell ²³ suggest patients may now want and need more detailed and sophisticated medical information (Table 3). Secondly, better management of acute attacks should lead to improved results, which is the aim of current clinical guidelines and better advice to patients.

Table 3.

 Information and advice about the natural history of nonspecific low back pain ^{2 , 23}

The overall aim should be to empower the individual at least in the longer term to feel less dependent on health professionals. If Health Authorities are seeking to change clinical practice through implementation of the guidelines, they may need to address the misconceptions held by the public. These can lead to pressure being placed on the GPs and other health professionals which are contrary to the guidelines. At the same time it is important that every GP should feel confident in carrying out a diagnostic triage to eliminate any red flags which could be associated with a potentially serious pathology. In the remaining 90 percent or more, they would then be able to provide the patient with the necessary reassurance and be able to encourage them to return to normal activities as soon as possible.

Acknowledgements

This research was funded by the Kings Fund PACE (Promoting Action on Clinical Effectiveness) programme. Thanks are due to Karen Ray for her assistance with the survey, and many other individuals who worked closely with South Derbyshire Health Authority and the University of York, including members of the public who took part in the Search conference and also those who provided the data for the survey.