Is Believing Feeling? Researchers Examine Effect of Beliefs About Exercise on Low Back Pain

A new study questioned whether patients with low back pain (LBP) who believe staying active despite having pain have a better functional outcome compared to those who believe pain is a warning sign to cease activity.

Per international guidelines, healthcare professionals are expected to advise patients with LBP to stay active, the researchers note—however, this does not always occur in practice.

“The information and recommendations healthcare professionals provide about LBP to their patients may differ from what their patients perceive they have been told,” explained the study authors. “Moreover, what patients perceive to have been recommended may differ from what they actually believe will help them recover. Thus, changing patients’ beliefs is considered a crucial factor for changing actual behaviour and has the potential to impact functional outcomes. Effective delivery of information about the importance of remaining active and the patients’ role in self-management has been shown to reduce the utility of primary healthcare and reduce referrals to more expensive treatments in secondary care.”

The prospective cohort study had two aims:

• To assess if believing staying active despite feeling pain correlates with better functional outcomes among general practice patients referred to an outpatient spine clinic
• To evaluate the relationship between having received advice from a healthcare professional to stay active, patients’ pain intensity and duration, and the STarT Back Tool and functional recovery

The study was published in BMC Musculoskeletal Disorders.

Beliefs on Pain and Activity Do Not Affect Functional Outcomes

Patients with non-specific LBP were referred to the Spine Centre at Silkeborg Regional Hospital, Denmark and shared their beliefs regarding the importance of finding the cause and of diagnostic imaging, perceiving to have received advice to stay active, pain duration and intensity, and STarT Back Tool. The main explanatory analysis was the adjusted response to the statement, “An increase in pain is an indication that I should stop what I’m doing until the pain decreases”; the primary outcome was a 30% improvement in the Roland Morris Disability Questionnaire (RMDQ) score at 52 weeks.

Final analysis included 816 patients, of whom 596 (73.0%) said that they believe pain is a warning sign to stop being active. The main outcome of 30% RMDQ score after 52 weeks did not largely differ between patients who did and did not consider pain a warning signal (n=80, 43.2% vs. n=201, 41.2%; adjusted P=0.542 and unadjusted P=0.629).). Functional outcomes were poorer among STarT Back Tool high-risk patients (adjusted P=0.003 and unadjusted P=0.002). Chronic pain was a risk factor for less favorable functional outcome (adjusted P<0.001 and unadjusted P<0.001), but beliefs regarding finding the cause, diagnostic imaging, perceiving to have received advice to stay active, and pain intensity did not largely impact outcome.

The authors summarized: “Holding the single belief that pain is a warning signal to stop being active was not associated with functional outcome. However, patients characterised by having multiple psychological barriers (high-risk according to the STarT Back Tool) had a less favourable functional outcome.”