Biomedical Dogmas Still Influence the Delivery of Exercise Therapy in Chronic Low Back Pain Management: Mixed-Methods Study

Abstract

Purpose

Non-specific, chronic low back pain (NSCLBP) is a leading cause of disability, prompting long-term rehabilitation. Positive patient beliefs and expectations towards lasting exercise engagement play a crucial role for a successful management of this condition. The aim was to investigate beliefs, unmet needs and expectations of NSCLBP patients for exercise-related health behaviour change in the context of rehabilitative care.

Patients and Methods

In a mono-centric mixed-methods study, we conducted semi-structured interviews with NSCLBP patients and care providers. We recruited in a rehabilitation clinic which is specialized in orthopaedics and internal medicine. Interviews were analysed deductively by combining health behaviour change theories with Donabedian’s quality model of care. In a patient survey, disability (RMDQ), exercise behaviours, fear avoidance beliefs (FABQ), self-efficacy in chronic disease management (SES6G), process- and outcome-expectations (OEE-2) were queried and analysed descriptively.

Results

Twenty-two interviews were conducted and 40 questionnaires completed. Qualitative results revealed that NSCLBP patients had persistent biomedical perspectives on their health condition, marked by strong preferences for biomedical diagnostics and beliefs in the superiority of specific exercise regimes. Based on met expectations and positive movement experiences, patients’ motivation was successfully fostered in the motivational phase of health behavior change. In the volitional phase, the postulated desire to receive self-management strategies was largely unmet. Psychosocial aspects of care were not widely accepted. The survey study sample showed a disability score (RMDQ) of M = 6.8 (±4.6). Mean scores of validated scales reflecting on attitudes, beliefs and expectations of chronic NSCLBP management were at FABQ-pa M = 15.4 (±6.0), FABQ-w M = 24.0 (±12.1), SES6G M = 6.4 (±2.3), and OEE-2 M = 2.7 (±0.5).

Conclusion

In this sample, patients’ understanding of NSCLBP was still dominated by biomedical dogmas and perspectives. Inpatient rehabilitation predominantly addressed expectations towards the motivational phase of exercise-related health behaviour change.

Keywords:

• behaviour change
• exercise
• patient needs
• musculoskeletal disorders
• self-management

Abbreviations

EBS, Exercise Behaviours Scale; FABQ-pa, Fear Avoidance Beliefs Questionnaire – physical activity; FABQ-w, Fear Avoidance Beliefs Questionnaire – work; HAPA, Health Action Process Approach; HSU, Health Services Utilization Scale; ITHBC, Integrated Theory of Health Behaviour Change; NSCLBP, Non-specific, chronic low back pain; OEE-2, Outcome expectancies scale – Version 2; PES, Process expectations scale.

Data Sharing Statement

Due to German data protection standards, pseudonymized interview data cannot be made publicly available. Anonymized survey data can be accessed on reasonable request by contacting LK (corresponding author).

Ethics Approval and Informed Consent

For this study, ethical approval was provided by the Ethics Committee of the Brandenburg Medical School (E-03-20220322). All study participants of the interview study signed informed consent prior to participation. For the survey study, informed consent was given by confirming a checkbox prior to beginning the survey. The survey was held anonymously at any point in time. Informed consent of qualitative and quantitative study participants included the consent for publication of anonymized responses. This study complies with the Declaration of Helsinki (Fortaleza, Brazil, October 2013).

Consent for Publication

All interview participants gave informed and written consent prior to study participation. All authors have read and accepted the final manuscript version.

Acknowledgments

We would like to thank our clinical partners for organizing and supporting the recruitment of the ExBackTation study. We also express our gratitude to the Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany, for making the SES6G available for this study.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article, gave final approval of the version to be published, have agreed on the journal to which the article has been submitted, and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

The ExBackTation study was funded by the internal research funding of the Brandenburg Medical School. The authors also report general funding by the German Pension Insurance Berlin-Brandenburg. However, the funders have no influence on research activities.