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Disabil Rehabil, Early Online: 1–13
! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.913705
RESEARCH PAPER
Patterns of interaction between factors that enhance or inhibit recovery
from chronic low back pain
Vivien P. Nichols1, Frances E. Griffiths2, Shilpa Patel1, and Sarah E. Lamb3
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1
Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK, 2Social Science and Systems
in Health Research Unit, Warwick Medical School, University of Warwick, Coventry, UK, and 3Botnar Research Centre, Nuffield Department of
Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
Abstract
Keywords
Purpose: This interview study aimed to capture an account of change in low back pain over time
and understand the interaction of known bio-psychosocial risk factors. Methods: Thirty-four
participants from the Back Skills Training (BeST) UK trial, evaluating a cognitive behavioural
approach intervention for LBP, gave 61 interviews. Semi-structured interviews taken once or
twice post intervention explored participants’ experiences of LBP and the intervention received.
Initial thematic analysis of the data gave themes, which participants spoke about in an
integrated way. Rereading of whole transcripts identified interactions between themes, which
we classified as helpful or unhelpful to recovery. The team also explored whether there were
correlations with Roland and Morris Disability Questionnaire (RMDQ) scores from the main trial.
Results: Web diagrams gave a graphic representation of the interactions between factors, which
were highly individual and time specific. We identified three categories of webs; dense web
(mostly unhelpful), open web (helpful and unhelpful) and sparse web (mostly helpful). These
categories correlated with (RMDQ) scores. Conclusions: Facilitators as well as potential barriers
to recovery give added insight when considering psychosocial risk factors. Web categories
highlight patterns of interaction between psychosocial factors, which underlie levels of
disability. These patterns of interaction may help to guide clinicians in their choice of treatment
approaches.
Interview, low back pain, psychosocial
History
Received 5 July 2013
Revised 21 February 2014
Accepted 7 April 2014
Published online 30 April 2014
ä Implications for Rehabilitation
Low Back Pain
LBP is common and poor outcome is more likely in the presence of psychosocial factors and
co-morbidity.
Interaction between these factors can be helpful and/or unhelpful, reinforcing or minimising
negative or positive effects.
Identifying patterns of interaction between these factors can help clinicians to choose
appropriate treatment strategies to address these patterns.
Introduction
Low Back Pain (LBP) will be experienced by many in their
lifetime, leading to personal and societal costs both in terms of
finances and suffering [1,2]. Psychosocial risk factors for
persistent back pain are known to be potential barriers to
recovery [3]. Up until recently there has been little success in
identifying subgroups which may respond to specific treatment
approaches [4,5], although recent development of a prognostic
indicator screening tool to target three different treatment
approaches has shown a good effect [6,7]. Understanding the
Address for correspondence: Vivien P. Nichols, Research Associate,
Warwick Clinical Trials Unit, Division of Health Sciences, Warwick
Medical School, The University of Warwick, Coventry CV4 7AL, UK.
Tel: +44(0)24 76574652. Fax: +44(0)2476574647. E-mail:
v.p.nichols@warwick.ac.uk
nature and variation in the time course of LBP is important to
allow the potential classification of LBP into separate syndromes
or sub-groups [8].
The course of LBP can be self-limiting within a few weeks
(termed acute LBP) or can become chronic, defined as lasting
over twelve weeks [9]. Fluctuations are a common feature of
chronic LBP with variation in the frequency and intensity of
episodes of pain [8,10,11].
Our aim was to explore change over time for people living with
LBP taking part in the Back Skills Training (BeST) trial [12]. We
sought to add to our understanding of recovery or non-recovery
from LBP and what underlies this. Our intention was to identify
patterns of presentation that could inform the choice of clinical
approach.
Our data analysis drew on two theoretical frameworks; The
flag framework for LBP and a theory about life course and the
present time.
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2
V. P. Nichols et al.
Disabil Rehabil, Early Online: 1–13
The flag framework for back pain
Methods
Initial thematic analysis associated with change closely reflected
the well-established flag framework for the early identification
and management of psychological risk factors. This is perhaps not
surprising given the wealth of research that supports this
framework.
The flag framework has been described as ‘‘factors that
increase the risk of developing or perpetuating long – term
disability and work loss associated with low back pain’’ and
therefore possible barriers to recovery [13,9,14]. Psychological
factors such as early signs of distress and depression
and persistent fear avoidance are associated with poor recovery
[15–17]. Patient expectations may also alter outcome [18].
‘‘Yellow Flags’’, used initially as an aid to highlight a biopsychosocial model, refer to factors related to the person, their
thoughts feelings and behaviours. Further developments have
classified Blue Flags as factors concerned with the workplace and
the person’s relationship with work and Black Flags with social
and environmental factors. Although these risk factors are well
documented, physiotherapists do not always include them in their
standard assessment and screening tools that incorporate them
such as the Orebro Acute LBP Questionnaire are not routinely
used [19]. Red and orange flags will not be included in our
analysis, as these factors were exclusion criteria for the BeST
study.
We report how our close to text analysis of interview data
about change led to similar themes to those in the flag framework.
However, our focus on change also led us to draw on a framework
for understanding individuals as they move through time,
developed from research on life course and a definition of present
time.
The data set analysed for this paper consisted of 63 interviews
from 34 participants recruited from within the BeST clinical trial
of a group cognitive behavioural approach for back pain [12]. The
interviews explored participants’ experiences of back pain, and
their participation in the trial. The data and the analysis relating to
participation in the trial are reported elsewhere [24].
The West Midlands Multi-Centred Research Ethics Committee
Birmingham UK MRC/03/7/04 provided the ethical review and
approval for BeST, including the interview study.
A life course analysis framework and the present time
Life Course Research began in the 1950s when researchers
followed cohorts over long-time trajectories [20, p. 22]. The life
course model purports that people act autonomously and will
perceive their situation differently, based upon past experiences
and beliefs. Also that they will make decisions appropriate to a
given moment in time which may be influenced by the world
around them [20]. This approach suggests the importance of
exploring the interrelation of all aspects of life and how this
changes over time. It has been suggested that this approach could
be helpful when viewing complex presentations of health over
time [21].
In order to compare the data from two different time points we
needed a definition of present time. We drew on earlier research
undertaken by one of our team members on complexity and time
in relation to health [22,23]. Rather than considering present time
in terms of calendar or clock time, we considered it in terms of the
phase of life in relation to living with back pain. There was no set
boundary; rather present time was defined by what the participant
said. For example if a participant talked about a past experience in
terms of its impact being carried into the present, perhaps
influencing how they were currently thinking, feeling and
reacting, then this was included as present time. Similarly,
where thoughts about the future were having impact in current
time, this was included.
The research questions
This study focusses on the factors known to influence recovery
from LBP. The research questions are:
How do these factors interact?
What are the patterns of interaction?
Do these patterns change over time?
The data
We approached participants in the BeST trial from two local
recruitment centres. We purposively sampled for diversity of
baseline; disability due to back pain (using the Roland and Morris
Disability Questionnaire (RMDQ) scores), fear avoidance beliefs
(using the Fear Avoidance Beliefs Questionnaire (FABQ)
scores), pain severity, age, educational attainment, gender and
ethnicity. All trial participants were recruited through GP
practices, had sub-acute or chronic LBP self-reported as moderately or very/extremely troublesome and further characteristics
are given in the results section. This study consists of
34 interviews taken at 4 months post randomisation and 29 at
12 months. Three participants declined a second interview due to
competing priorities in their lives, one because they felt they had
not received any benefit from being on the trial and one had
withdrawn. Two of the 12-month interviews did not allow for
transcription due to poor quality audio-recordings. V.N. took data
directly from the audio recordings alongside extensive field notes
and these are included in analysis.
A single researcher V.N. carried out the semi-structured
interviews, which lasted 30–45 min and all participants gave
informed consent. Interviews were audio-recorded, transcribed,
anonymised and checked for accuracy. The team used NVivo
software to manage the data (NVivo, QSR, Portsmouth, England).
Identifiers indicate the participant and time point of the interview,
e.g. Int3-1 (Interviewee 3 at first interview).or Int20-2
(Interviewee 20 at second interview.)
Our analysis team included V.N. who is a research physiotherapist, F.G. a GP and experienced qualitative researcher in
social sciences and SP a health psychologist with experience in
qualitative research. At the start of the first interview, we asked
participants about themselves in order to provide context for the
interview. Participants were encouraged to tell their own back
pain story to encourage spontaneity with as few prompts as
possible.
These stories and three specific questions elicited rich data
with regard to change, although we extracted salient text about
change from all areas of the transcripts.
The researcher drew a timeline towards the end of the
interview, and in collaboration with the participant marked key
points in their story such as episodes of pain, relevant life events,
consultations and treatments for back pain (see Figure 1). Figure 1
gives an example of how a timeline was drawn.
Whilst the researcher indicated the completed time line they
asked, ‘‘What would you say is the greatest change?’’ The
question was deliberately asked in this very open way, the only
guidance given was that it was any change they felt was important;
some participants gave more than one answer. A further question,
‘‘What would you do if you did not have back pain?’’ has been
analysed and reported elsewhere [25]. At the second interview, we
asked the same questions although referring to the time-period
since the first interview rather that the inception of their back
pain. At 12 months, we added a further question suggested by the
BeST intervention physiotherapist (ZH), ‘‘If I was watching you
Patterns of interaction in back pain recovery
DOI: 10.3109/09638288.2014.913705
Failed fireman’s
training unable to
carry person due to
back pain ‘back
went’ symptoms
subsided quickly
1975
1982
Symptoms and Events
Infrequent back pain
no real problems
playing rugby
‘Floored’ severe
pain for 1 week.
Same type of pain
as before but
lasted longer
About one episode
a year for 5-6 years
2000
Three days ago
moved 2 barrels
of beer. Severe pain
and locking’
What do you see
in the future for
your LBP?
“Switch my back
on re: liing”
“Hopeful will get
beer…Exercise
has helped”
improved
Oct2005
3
4ms
Now
Saw GP
Self treated with
painkillers and
hot/cold
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Treatment and Consultaons
4ms
GP
needed
to go
due to
severity
On to trial.
Intervenon,
aended
assessment
and 2 group
sessions
Did exs given at
assessment-improved
aer 1 week
What would you say is
the greatest change? Put
on weight when gave up
smoking in July (Sept
noced weight gain)
Figure 1. Example of a timeline for interviewee 20 at first interview (Int20-1).
one year ago compared to now, what (if anything) would I see you
doing anything differently?’’ No prompts were used only
clarification of the question where needed.
Initial thematic analysis
Initial thematic analysis gave rise to themes that were similar to
the flag framework factors that influence recovery from
back pain. From the interviews, we extracted data about the
following seven factors: Pain, Attitudes/Beliefs, Behaviours,
Diagnosis and Treatment, Emotion, Family and Work/
Compensation. As analysis progressed we added Co-morbidity,
as participants mentioned this as linked to other factors and took
out compensation as this was not mentioned in the data.
The analysis team (V.N., F.G. and S.P.) jointly examined three
interviews and agreed the definition for each factor. Examples of
definitions and examples of quotes are given in the results section
in Table 3.
Focussing the analysis on interaction between factors
influencing recovery
When analysing the data it became apparent that the factors were
often talked about together rather than always in isolation. This
then became the focus of our analysis and we returned to the raw
data. The data were coded for interaction between the factors and
the quality of interaction between factors was classified as either
helpful to recovery, unhelpful to recovery or a mixture of helpful
and unhelpful based on what the interviewee said. Each quality
could be based on any number of mentions of interaction between
factors, and although between the same factors the details of the
interactions could be different. To be classified as helpful or
unhelpful the interactions all had to be one or the other of these
categories. The mixed category was used if there was either an
interaction that the participant identified as mixed quality, or there
was more than one interaction and at least one was helpful and at
least one was unhelpful. Examples of interactions are given in the
results section in Table 4.
Diagrams were drawn for each interview representing the
interactions. At least two researchers coded each transcript to
confirm the dependability of the results. Regular meetings were
held to discuss uncertainties, clarify definitions and agree final
web diagrams, which are given in the results.
When collating the diagrams we did not count the number of
mentions of interactions as, in the data, there was no evidence that
the number of times an interaction was mentioned in any way
related to its importance in relation to back pain. For example, one
participant only once mentioned their occasional use of paracetamol to help get moving ‘‘I’m stiff in the morning but two
paracetamol and I get myself going.’’ (Int22-2) It was clear from
the data that this was an important part of their self-management.
Table 1 provides an example of the analysis of data from
Interviewee 1 at first interview (Int1-1)
This participant described her pain as constant even with
maximum pain relief. The interactions between the factors were
mostly unhelpful, reinforcing their belief that their situation was
hopeless and that nothing could be done. They described feeling
that it’s ‘‘too late for them’’ and said all health care professionals
had confirmed this. They spoke of a previous work assessment,
which labelled them as ‘‘unemployable’’. Their activities of daily
living were a struggle, requiring adaptations or help from their
children. They slept in a chair as they were unable to lie down.
Emotions of anger and frustration surround their past medical
management and their inability to work and these further
reinforced their low moods. They described their future as:
‘‘Downhill . . . I hope not but I can see it happening’’. The help
they got from their family both physically and emotionally could
be considered helpful or unhelpful depending on whether the
family were assisting them or being overprotective. Many
interactions between factors reinforced each other; they seemed
‘‘locked in’’.
Comparison of interview diagrams
The analysis team then compared all 63 diagrams and classified
them based on the density and quality of the pattern of interaction
in the diagrams. Density was judged by looking at the whole web
diagram. Where there was uncertainty, through discussion, the
team came to agreement on how to categorise each diagram. Web
diagrams were classified into one of three categories;
(1) Dense web: Multiple interactions creating a mainly unhelpful
web of interaction – five or more unhelpful interactions.
(2) Open web: Fewer unhelpful interactions than the dense web
and more mixed or helpful interactions.
(3) Sparse web of interactions: A sparse web of interaction
between factors with mostly helpful interaction – No more
than three mixed interactions, with or without one unhelpful
interaction.
4
V. P. Nichols et al.
Disabil Rehabil, Early Online: 1–13
Table 1. Diagram of interactions between factors for Int1-1 with interview extracts to illustrate the quality of the interactions.
E
H
SC
PA
W
C
AB
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Int1-1D
Pain
P
AB
‘‘ . . . basically if you’ve got a bad back it’s controlling everything isn’t it?’’
P
PA
P
H
P
E
E
SC
‘‘I try to vac up but it’s all done sitting down you know um . . . but . . . I mean I do try and keep as sort of active as I
can but I really struggle’’
‘‘ . . . because I have my ordinary pain killers and then I’ve got Tramadol but I can only take them . . . every, one
every few days, because um . . . I’ve been on them quite a while and they’ve told me that if I keep taking them
everyday like I have been, then my liver will pack up within two years because of my other tablets I take, so I just
take sort of them when it gets really bad and I’m not coping very well, or if I’ve got to go out somewhere, you
know, and then I know that extra tablet will sort of get me through.’’
‘‘Well, you do get depressed and you get low but no, my daughter’s learned . . . like a carer and she kicks you back
into gear sort of thing, she doesn’t let you get sort of, you know, too out of hand.’’
AB
H
AB
W
PA
P
SC
SC
H
E
E
SC
E
W
PA
H
PA
C
AB
PA
AB
E
‘‘Yes I’ve seen them all and they’ve all said the same and they’ve got . . . I had loads of tests and on the printed scans,
all sorts you know, and the x-rays that they go through, your bones . . . but they’ve all came up with the same thing
- that there’s too much damage.’’
‘‘I do get very angry and frustrated of it because I thought I could return to work . . . . . . Basically, they’re saying that
nobody would employ me so that didn’t go down well.’’
‘‘I try to do what a lot of parents do in the house, but there is a limit that I can only do and like I say, luckily my
children are there and they, you know, sort of help with that, but I mean they know when I’m having a bad time
because, you know, they’re there with the tablets and water on the ready, or if I want hot drinks or anything . . . ’’
‘‘I’ve had scans, lumbar punctures everything but they said there was too much damage there. It’s gone too far so
basically you learn to live with it, but I’m angry because mainly if they’d have picked it up years ago then you
know they might have been able to have done more . . .’’
‘‘Well, you do get depressed and you get low but no, my daughter’s learned . . . like a carer and she kicks you back
into gear sort of thing, she doesn’t let you get sort of, you know, too out of hand.’’
‘‘I went to somebody, somebody at the job centre for the disabled but nobody will employ me now (inaudible) stated
that, you know, and they couldn’t understand why I wanted to return to work, but it’s self-respect and everything
isn’t it?’’
‘‘Oh I was seeing a physio not so long back because I’ve been trying to lose weight for ages because that doesn’t
help with being overweight, but then again, I can’t do the exercise and I thought you know maybe if they could
show me to do a few exercises I might be able to get the weight down but he wouldn’t even touch me.’’
‘‘. . . I mean standing up that is the main problem and then when I first wake up in the morning I have big problems
because . . . probably because I slept awkward and moving about. Everyday things . . . I have a lot of problems
with . . . you know, dealing with . . . It’s just anything really that can trigger it, you know, if I move wrong or
something.’’
‘‘Um . . . It’s not very good today because it’s cold and the cold affects it really bad and I’ve . . . you know, I took a
few tablets but I can’t see there ever being an improvement. If I say there is I’m kidding myself. I can see it
getting from bad to worse really.’’
For presentation of the results we have given each participant;
an identification number, Interviewee (Int) 1–34, an indication of
the first/second interview 1 or 2 and a diagram category, Dense D,
Open O or Sparse S. For example, Int 22-1-D.
Testing the correlation between web density and the
Roland and Morris Disability Questionnaire (RMDQ)
The BeST trial used the RMDQ as its primary outcome measure
and results showed that the intervention gave a moderate effect,
which was sustained over the 12-month trial period. We
hypothesized that the web diagrams may, in some way, correlate
to their RMDQ scores and we tested this hypothesis using nonparametric methods.
Results
Participants
The patient characteristics of the participants and the trial
population from which they were sampled are illustrated in Table 2.
The range of RMDQ scores (2–19), FABQ scores (0–24) and
pain severity scores of moderate/very extremely (15/19) were
similar to the clinical trial sample, as was the proportion of males
(16) and females (18) and the number of people from ethnic
minorities (3). There was a wide age range among the interviewees (19–76 years). In comparison to the trial, a greater
proportion of interviewees left school at 16 years or less
suggesting that we were successful in accessing those of lower
educational attainment.
Patterns of interaction in back pain recovery
DOI: 10.3109/09638288.2014.913705
Table 2. Interviewees’ characteristics.
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BeST Trial participants
N
701
RMDQ baseline scores: 0–24
Mean
8.7
Range
0–23
Missing
1
FABQ baseline scores: 0–24
Mean
13.8
Range
0–24
Missing
39
Gender:
Male
284 (40.5)
Female
415 (59.2)
Missing
2 (0.3)
Severity of back pain:
Very/extremely
319 (45.5)
Moderate
382 (54.5)
Age range (years);
18–85
Missing
2 (0.3)
Ethnicity:
White
618 (88.2)
Mixed
7 (1)
Asian
29 (4.2)
Black
11 (1.6)
Chinese
2 (0.3)
Missing
34 (4.9)
Age left Education:
Still in
3 (0.4)
16 or less
387 (55.21)
17 to 19
165 (23.5)
20 or over
113 (16.1)
Missing
33 (4.7)
5
Factors influencing recovery from low back pain
Interview participants
Individual factors that could influence recovery are given with
illustrative quotes in Table 3.
34
8.7
2–19
0
14.2
0–24
1
16 (47.06)
18 (52.9)
0 (0)
15 (44.1)
19 (55.9)
19–76
0 (0)
31
1
2
0
0
0
(91.2)
(2.94)
(5.9)
(0)
(0)
(0)
1
19
9
5
0
(2.9)
(55.9)
(26.5)
(14.7)
(0)
RMDQ, Roland and Morris Disability Questionnaire FABQ Fear
Avoidance Beliefs Questionnaire.
Quality of interaction of factors influencing recovery
Participants spoke about factors together and lines between the
factors were drawn on a diagram to indicate the quality of the
interaction between factors described in the interview. These were
classified as helpful, unhelpful or mixed examples are given in
Table 4.
The quality of interaction between two factors was sometimes
surprisingly different for people in apparently similar situations.
For example, Int22-2S and Int23-2D had both recently experience
their spouse being in hospital. For Int22-2S, regular visits to the
hospital involved a walk to and from the bus stop with a bus
journey twice a day, something the participant did not think they
would manage.
‘‘. . . when I look back now I think ‘how have I managed for six
weeks to run up there twice a day?’ and you’re sitting
out . . . but that did get me a couple of times and I’ve thought to
myself when I’m sitting at his bedside so I get up and move
around . . . so it just shows you that you can do it if you’ve got
to do it . . .’’ Int22-2S
However, they were pleasantly surprised when their back
improved with the walk which gave them confidence to further
increase their activity. However, Int23-2D undertook the journeys
to hospital by car and sat for long periods at the beside, both of
which they found uncomfortable.
Table 3. Definitions of factors with examples.
Factor
Definition
Pain P
All descriptions of back pain.
Attitudes or
Beliefs AB
All attitudes or beliefs regarding back pain e.g. confidence,
self-efficacy, avoidance, negative/positive thoughts and
feelings.
All physical activity behaviours (or absence of) described
with regard to back pain. Include activities of daily
living, housework, sport and posture.
Physical
Activity PA
Healthcare H
Emotion E
Social Context SC
Co-morbidity C
Work/Employment W
All sentiments or experiences to do with process of
diagnosis or treatment. Includes of all types including
pain relief, contact with health professionals, selfmanagement and prescribed exercise. Also includes
what a participant reports a health professional telling
them about their back.
All emotions described or emotional terms used with regard
to their back pain experience e.g. ‘gets depressed with
the pain’, frustrated, worried, lack of worry, pleased,
confident, frightened, angry. Stress and depression is
included here rather than with co-morbidities.
All descriptions of interaction between themselves and
friends, family or acquaintances with regard to their back
pain. Also other impacting life events e.g. spouses
illness, moving house.
Any other health problems or its treatment which the
participant links to their back pain e.g. increasing
exercise due to recent diagnosis of high blood pressure,
other joint pain, diseases, being overweight.
Any description of work (paid, voluntary or charity) which
the participant links to their back pain (not housework).
Example
‘‘. . . it’s like somebody’s got a cigarette burning in
my back.’’
Int2-1
‘‘I don’t think . . . ‘Oh well, I can’t do this and I can’t
do that’’’
Int31-1
‘‘I’m not a natural exerciser so it’s very hard to go
from doing absolutely nothing to doing something you know on a regular basis and then you
just . . . as I say before you know it it’s next week
and you haven’t done anything.’’
Int25-1
‘‘So, I presume they don’t have the cure they don’t
know what to do either . . .’’
Int4-1
‘‘. . . I do worry that it is getting worse and I just
don’t know what to do about it . . .’’
Int14-1
‘‘Well he doesn’t want to hear about my troubles. He
just wants his meal on the table when he comes
home . . .’’
Int32-1
‘‘. . . I’m diabetic, I’ve had a triple bypass and I’ve
had a replacement knee and none of those things
have helped.’’
Int9-1
‘‘ . . .there’s only twice that I’ve had time off work
with it in seven years so . . . I know my job isn’t
ideal for my back . . .’’
Int15-1
6
V. P. Nichols et al.
Disabil Rehabil, Early Online: 1–13
Table 4. Quality of interactions.
Helpful to recovery
AB
Unhelpful to recovery
P
Mixture of helpful and unhelpful
W
AB
H
This man was concerned that his pain was not improving
and this was affecting his work. He was self-employed.
He had not discussed his back pain with his doctor in any
detail. He gave priority to his other health problems
(diabetes and leg ulcers). He used medication and rest to
cope with his back pain. He wanted to know what caused
the pain and why it changed so much day to day.
He downplayed any emotion. He said he did not want to
complain or grumble but “some days I does get me down
you know, plus with the back pain the pain I’ve got in my
leg as well it …does get very depressing…”
E
SC
H
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PA
W
AB
C
Int33-1D
P
Dense
E
H
SC
PA
W
C
AB
P
Int20-1O
This man had a dull ache and stiffness with occasional
severe bouts of back pain usually precipitated by heavy
lifting. Most of the interaction between factors was
helpful. He used exercise to prevent pain and rest when in
pain. He had an episode a few days before the interview
which left him wondering how quickly it would clear. His
self-help strategies also included local cold packs, buying
a new mattress and visits to the GP for pain medication.
He avoided lifting and felt his recent weight gain had not
helped his back. He was trying to increase his activity by
walking more.
Open
E
H
SC
PA
W
C
AB
Int21-1S
‘‘. . . but I feel more confident that I’ll be able to . . . if I do get it bad, get over
it with the exercises . . .’’
Int20-1
‘‘Well it stops me doing my work; it just stops me doing practically
everything really.’’
Int33-2
‘‘I think that the management I’ve had from the GP has been of very little
value really. You know, I’ve had useful advice from physios and the
consultant I saw at [Hospital] was I feel, fairly useless as well.’’
Int13-2
PA
P
This man talked about conflicting advice from specialists.
One suggested a shoe raise which didn’t help “he didn’t
leave me in any sort of good mental state.” The other said,
“…’it’s just wear and tear’… and gave an exercise regime
…he was much more positive and I’d never had it
explained to me like that before.” He did not have a lot of
confidence in their GP due to failure to diagnose other
conditions. He felt more confident using graded exercises
given by the consultant and reinforced by the BeST
intervention and has a positive outlook on how he’ll
manage his back pain should it reoccur. He was physically
active and does a lot for family members.
Sparse
Figure 2. Vignettes for each web diagram category of Dense (D) Open (O) and Sparse (S).
‘‘. . . exercise is walking to the hospital, walking back . . . not
walking but walking from the car and back and I have to sit a
lot longer because I’m sitting with my husband . . . So I have
that there all the time but solely I’m sitting a lot more than I
used to which isn’t helping my back at all and I’m doing a lot
more driving.’’ Int23-2D
their spouse so ill but also by their seemingly uncontrolled back
pain.
Some participants described both helpful and unhelpful
interactions between the same two factors. For example,
Int15-1D talked about their fear of doing exercise but also their
commitment to doing more exercise;
They felt unable to do the exercises, interspersed with
periods of rest, which usually helped their back, due to the
upheaval in their routine. They were distressed at seeing
‘‘I’ve read everything that says you can’t do more damage but
I’m still like, ‘oh it hurts I’m a bit scared . . . . . . I know I’ve got
to stay active.’’ Int15-1D
Patterns of interaction in back pain recovery
DOI: 10.3109/09638288.2014.913705
Comparison of web diagram categories
Whole web diagrams for each interview were compared and
categorised into Dense, Open or Sparse. Figure 2 illustrates each
category with vignettes. These illustrate very different patterns
and qualities of interactions between factors that enhance or
inhibit recovery from back pain. Appendix 1 shows the diagrams
for all participants and their categories.
Table 5. Classification of interviews.
Interview
time point
Dense
Open
Sparse
Total number
interaction interaction interaction of interviews
First interview
17
10
7
34
Second interview
10
7
12
29
Totals
27
17
19
63
Changes of category between first and second interviews (n ¼ 29)
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Category of first interview
Dense
Open
Sparse
Total
D to O
O to S
D to S
Total
S to O
O to D
S to D
Total
Number of participants with no
change of category between
first and second interview
9
3
6
18
Changed groups towards a
decrease in density
3
4
2
9
Changed groups towards an
increase in density
1
1
0
2
7
In Table 5, we summarise the classification of interviews and
whether or not there was change in the category of a participant’s
interview between first and second interviews. Those participants
with interviews classified as dense were in the majority at first
interview. Over half did not change category 18/29.
Of those which did change most changed to a less dense
category, e.g. Int12 (Dense to Open), Int18 (Open to Sparse) and
Int22 (Dense to Sparse). Only two participants changed to a more
dense presentation (Sparse to Open), e.g. Int5.
Comparisons between the Roland and Morris Disability
Questionnaire scores and the web diagrams
The RMDQ score distribution was normal using a one sample
Kolmogorov–Smirnov (0.240 at 3 months and 0.438 at
12 months; Figure 3). However, the frequency histograms did
not appear normally distributed, and due to the Kolmogorov–
Smirnov test being less robust on small samples, we decided to
use non-parametric methods.
There was a significant correlation between the medians of the
RMDQ for each web diagram category at both time points
(Spearman’s rho test 0.1 at 3 and 12 months).
An independent-samples median test showed a statistically
significant difference in the medians of the RMDQ scores of
the web diagram category (0.000 at 3 months and 0.031 at
12 months). The distribution of the RMDQ was also statistically
different for each web diagram category (Independent-samples
Kruskal–Wallis 0.001 at 3 months and 0.013 at 12 months).
Discussion
This analysis has identified patterns of interaction of psychological
factors that underlie levels of disability due to LBP and change over
time. Our initial thematic analysis revealed psychosocial factors
very similar to those found by other research. However, we were
able to move beyond this to identify patterns of interaction between
these factors. We found that there were three categories of pattern
of interaction; dense, open and sparse webs. These categories
Figure 3. Box plot graph of the RMDQ medians for the web diagram categories (not link groups) at two time points.
Disabil Rehabil Downloaded from informahealthcare.com by 137.205.161.96 on 06/10/14
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8
V. P. Nichols et al.
correlated with levels of disability as measured by the RMDQ
scores. Across the two time points most participants stayed in the
same category but a third moved to a more open category.
The diverse expertise of three researchers analysing the data
added to the depth and rigor of the analysis. Timelines gave a
graphic representation of LBP over time and helped to elicit rich
data about change from participants. They also aided the team to
understand the participants’ journeys chronologically using time
anchors.
When designing data collection we did not plan to focus on
interactions as this emerged during data analysis. Further depth of
understanding of interaction may have been gained if we had
prompted for this during interview. Second interviews may
contain no data about those interactions continuing since the first
interview as the interview focussed on what had changed.
Although the analysis team reached consensus on analysis tasks,
this was not always reached easily. It was not always clear how to
classify interactions – helpful, unhelpful or mixed – or how to
classify the patterns of interaction – dense, open, or sparse.
However, it was clear from the data that the interactions between
factors were important and that there were very different patterns
of interaction.
Most research on psychosocial factors related to back pain
examines the impact of single risk factors rather than the impact
of the interrelation between factors. However, a recent study by
Bergbom et al. in 2011 has looked at pain catastrophising and
depressed mood together, finding that high levels of both resulted
in poor outcomes, the authors concluding that that treatments
should match patterns of prognostic factors [26].
There is research evidence that suggests that physiotherapists
have difficulty embracing a true psychosocial approach
[19,27,28]. Physiotherapists regularly use positive reinforcement
and motivation and it could be hypothesized that focussing solely
on identifying barriers to recovery may not be a preferred clinical
approach. Louis Gifford in 2005 did consider pink flags that were
facilitators to recovery in a Physiotherapy Pain Association article
although to our knowledge this has not been explored further [29].
Our results suggest a combined approach, looking at both
facilitators and barriers to recovery. Von Korff and Lin (2007)
studied the service use of people with chronic pain and concluded
that clinicians tended to consider each therapeutic encounter in
isolation rather than the continuum of LBP [30]. This study gave
us the opportunity to explore LBP at two time points but also the
trajectory of participants’ LBP experiences over time by using
timelines.
Web categories represent a complex pattern of interactions.
Dense webs suggest a ‘‘locked in’’ state, with interaction between
risk factors preventing change. Clinically these people may be
challenging to treat as the clinician may have difficulty finding a
possible ‘‘way in’’ to aid recovery. People in the open web
category may have some strategies in place to address their back
pain. Clinicians could then reinforce the positive aspects and
address those interactions that had an unhelpful component.
Those with a sparse web appeared to be managing their pain
successfully.
Web categories serve to highlight the complex nature of
the relationships between multiple psychosocial manifestations
of an individual’s LBP experience. Interactions between
risk factors may give differing clinical presentations and it
may be useful for clinicians to consider facilitators as well as
potential barriers to recovery when assessing and treating LBP.
Conclusion
The potentially complex nature of LBP poses a challenge for the
individual clinician. Identifying patterns of interaction through
Disabil Rehabil, Early Online: 1–13
exploring interactions between psychosocial influences on LBP
may assist clinician and patient treatment choices. Clinicians need
to listen to the patient’s narrative for patterns of interaction and
identify those interactions that are helpful in order to build on
them, and identify unhelpful interactions in order to address them.
Some of the interactions may be outside the remit or scope of a
single clinician’s practice. However, identifying interactions and
their potential influence on LBP recovery may steer clinicians
towards specific treatment strategies or referral to other
disciplines.
Acknowledgements
We would like to thank Zara Hansen the intervention Clinical
Research Fellow on the BeST study, for their help in developing
the interview schedule.
Declaration of interest
This interview study was part of the BeST UK trial, which was
funded by the NIHR Health Technology Assessment programme Project reference 01/75/01.
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Disabil Rehabil, Early Online: 1–13
Appendix
Categorised web diagrams
Legend:
Int5 ¼ ID
1 ¼ 1st interview
2 ¼ 2nd interview
D ¼ Dense web
O ¼ Open web
S ¼ Sparse web
P ¼ Pain
AB ¼ Attitudes and beliefs
PA ¼ Physical Activity
H ¼ Healthcare
E ¼ Emotion
SC ¼ Social context
W ¼ Work/Employment
C ¼ Co-morbidities
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Dense Web
H
SC
PA
W
H
SC
PA
H
SC
SC
PA
W
AB
AB
E
E
E
E
H
PA
W
W
AB
C
AB
C
C
C
P
P
P
P
Int1-1 D
H
SC
PA
W
AB
H
SC
PA
C
W
AB
E
SC
H
PA
W
AB
C
C
P
W
AB
E
H
PA
H
W
AB
C
H
SC
PA
H
PA
W
AB
C
W
AB
P
C
E
SC
PA
H
W
AB
C
Int17-2 D
SC
PA
W
AB
P
P
Int17-1 D
C
Int14-2 D
H
SC
PA
P
W
E
E
SC
PA
P
Int14-1 D
H
SC
AB
C
P
Int12-1 D
E
H
W
AB
C
P
E
SC
PA
W
AB
Int11-2 D
P
E
E
SC
C
Int11-1 D
Int9-2 D
Int9-1 D
SC
PA
P
P
Int7-2 D
Int15-1 D
E
E
E
H
Int4-2 D
Int4-1 D
Int1-2 D
C
P
Int22-1 D
Patterns of interaction in back pain recovery
DOI: 10.3109/09638288.2014.913705
E
E
H
H
SC
P
W
AB
W
AB
PA
W
AB
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H
C
P
Int33-1 D
PA
H
W
C
P
W
C
P
Int8-1 D
P
SC
PA
W
AB
C
P
Int30-1 D
PA
Int33-2
E
PA
SC
W
AB
C
H
SC
AB
H
W
E
SC
AB
PA
P
E
P
SC
AB
Int32-1 D
H
C
E
H
W
AB
Int27-2 D
AB
E
SC
PA
C
W
Int27-1 D
Int24-1 D
E
SC
C
SC
PA
P
P
E
W
AB
Int23-2 D
H
H
SC
PA
C
P
Int23-1 D
Int6-1 D
H
P
C
E
E
SC
C
P
11
12
V. P. Nichols et al.
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Open Web
E
H
H
PA
W
AB
H
SC
PA
C
W
AB
H
PA
W
AB
W
AB
W
PA
C
P
E
W
C
H
PA
W
AB
C
PA
C
Int31-2 O
E
SC
PA
W
C
P
P
E
SC
H
W
AB
Int32-2 O
C
P
PA
P
Int31-1 O
AB
Int28-2 O
H
W
A
W
E
SC
SC
PA
P
Int28-1 O
E
SC
H
PA
P
Int25-1 O
Int20-1 O
E
SC
AB
C
C
P
E
W
AB
W
Int18-1 O
H
SC
PA
W
P
P
E
SC
AB
C
Int19-1 O
H
SC
E
H
PA
AB
C
Int15-2 O
E
Int29-1 O
C
P
SC
P
Int13-2 O
AB
AB
Int13-1 O
H
SC
P
H
W
E
PA
C
H
PA
C
Int12-2 O
E
SC
AB
SC
P
P
E
H
H
W
AB
Int7-1 O
H
E
SC
PA
C
P
Int5-2 O
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E
E
SC
C
SC
PA
W
AB
P
Int10-1 O
C
P
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Sparse Web
E
H
H
PA
W
AB
W
AB
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PA
W
AB
SC
W
AB
C
C
W
AB
AB
AB
W
AB
W
E
W
C
P
H
SC
W
PA
E
SC
W
AB
W
C
AB
P
P
Int26-2 S
Int34-1 S
C
P
Int34-2 S
C
P
PA
C
W
AB
Int26-1 S
H
SC
PA
P
Int25-2 S
E
SC
AB
H
SC
A
Int24-2 S
PA
P
PA
C
E
C
Int21-2
H
PA
P
Int22-2 S
A
E
SC
AB
C
W
P
E
PA
SC
P
C
Int21-1 S
H
SC
H
W
P
E
H
H
SC
PA
C
Int19-2 S
Int18-2 S
E
E
W
P
P
Int16-2 S
H
SC
PA
C
C
P
H
PA
W
AB
Int16-1 S
E
SC
SC
PA
W
AB
Int20-2 S
E
H
H
SC
PA
P
P
E
H
PA
C
P
Int3-2 S
E
H
SC
C
P
Int3-1 S
E
E
W
AB
C
P
SC
PA
W
AB
Int2-2 S
H
H
S
PA
C
P
Int2-1 S
Int5-1 S
H
S
PA
C
E
E
E
SC
13