Background & Aims
Chronic low back pain (CLBP) is a common condition, which continues to be the leading cause of disability globally (Global Burden of Disease, 2023). The societal costs of CLBP are profound across high-, middle- and low-income countries, largely reflecting loss of work participation and care-seeking (Fatoye et al., 2023; Gaskin & Richard, 2012; Hartvigsen et al., 2018). The individual multi-dimensional factors that contribute to a person developing CLBP are well documented and include: psychological factors such as negative pain beliefs, pain catastrophising, low self-efficacy, pain-related fear, depression, anxiety; passive behavioural coping including avoidance of movement and activity; and social factors such as lower socioeconomic status (Chen et al., 2018) However, exploration of the treatment process from the patients’ perspective, including the process of gaining control and agency over CLBP, is relatively understudied.
Methods
This qualitative narrative inquiry was embedded within the RESTORE trial testing treatment effectiveness and efficiency of cognitive functional therapy for disabling chronic CLBP (Kent et al., 2023). A purposive sample of 12 participants from the RESTORE trial were selected based on representation of different ages, genders, and high pain related disability (>13 on Roland Morris Disability Questionnaire), and then consented to be interviewed. Interviews were conducted separately to CFT treatment and took place at baseline (prior to commencement of CFT; interview 1), at week 6 (mid-way through CFT treatment; interview 2), at week 13 (end of the CFT treatment; interview 3), and at week 52 (12-month follow-up from the baseline interview; interview 4). Interviews explored how participants’ understandings of, and approaches to, CLBP evolved over the course of a year that involved 3-months of CFT treatment and 9 months integrating this into ongoing self-management.
Results
Participants’ ages ranged from 46 to 87, and the duration of their back pain ranged from 3 months to 36 years at the time of inclusion in the study, with the average Rolland Morris Disability Questionnaire score of 16.13 at time of inclusion. Findings described the overarching narrative themes of ‘The Journey to Self-Management’. Within this overarching narrative four distinct narratives were identified, beginning with ‘Left High and Dry’ capturing the experience of isolation and abandonment with CLBP before commencing CFT; and concluding with three narratives of the experience of CFT from the start of treatment through to the 12-month follow-up. These included, ‘Plain, Smooth Sailing’ describing a journey of relative ease and lack of obstacles; ‘Learning the Ropes and Gaining Sea Legs’ capturing an iterative process of learning and negotiating setbacks; and ‘Sailing Through Headwinds’, describing the experience of struggle to gain agency and control over CLBP through CFT.
Conclusions
In exploring CLBP self-management using CFT, the findings of this study emphasised the importance of linking body and pain awareness, reconceptualising and reducing the threat of pain, gaining control, and resuming essential and valued activities. This was enabled through sense-making processes and successful exposure to movement and activity, underpinned by a strong therapeutic relationship. Those who experienced ‘headwinds’ in their journey reported lacking confidence or a comprehensive understanding of their body and pain. Clinicians treating individuals with CLBP can use these insights to facilitate the CFT treatment journey more effectively, including the journey towards ongoing self-management.
References
Global Burden of Disease 2021. (2023). Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatology, 5(6), 2665-9913.
Fatoye, F., Gebrye, T., Mbada, C. E., & Useh, U. (2023). Clinical and economic burden of low back pain in low- and middle-income countries: a systematic review. BMJ Open, 13(4), e064119. https://doi.org/10.1136/bmjopen-2022-064119
Gaskin, D. J., & Richard, P. (2012). The economic costs of pain in the United States. Journal of Pain, 13(8), 715-724. https://doi.org/10.1016/j.jpain.2012.03.009
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., Underwood, M., & Lancet Low Back Pain Series Working Group (2018). What low back pain is and why we need to pay attention. Lancet (London, England), 391(10137), 2356–2367. https://doi.org/10.1016/S0140-6736(18)30480-X
Chen, Y., Campbell, P., Strauss, V. Y., Foster, N. E., Jordan, K. P., & Dunn, K. M. (2018). Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. (1872-6623).
Kent, P., T. Haines, P. O’Sullivan, A. Smith, A. Campbell, R. Schutze, S. Attwell, J. P. Caneiro, R. Laird, K. O’Sullivan, A. McGregor, J. Hartvigsen, D. A. Lee, A. Vickery, M. Hancock and R. t. team (2023). “Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial.” Lancet 401(10391): 1866-1877.