Last time I wrote about our beliefs on back pain and how psychological variables can contribute to the development of lower back pain.

Lots of studies look into the situations, activities, and anatomic structures to be responsible for people’s lower back pain but never get into how and why these beliefs develop. If we can understand the underlying beliefs of a patient then we can improve management.

A study interviewed New Zealanders with back pain – 12 with acute back pain and 11 with chronic pain (Darlow, 2015).

It seems as though people with low back pain pull their information from multiple sources. They reported they relied on the media, the internet, family and friends, previous experiences, and health care professionals as the main contributors to influencing their beliefs. Advice from a clinician seems to carry the most weight.

Patients trust health care professionals know what they’re talking about so they place their trust in their advice. Many people seek advice in the face of uncertainty. They want to know what’s going on and exactly what to do in the event of a back pain episode. Naturally, they seek more knowledge about the problem, prognosis (likely events, how long will it take to feel better), and management and prevention of recurring episodes.

Interestingly enough, lots of folks use the Internet (aka Dr Google) for more information but tend to value people in their circles with back pain experience more.

Most of these participants received a biomedical explanation of their back pain. In other words, it was something structural, anatomical, or biomechanical that was the issue. By interpreting it this way, patients viewed their backs as vulnerable and they needed to adapt lifting techniques, postural control, and protective strategies such as strengthening a ‘weak’ core in order to avoid future episodes. The biomedical message can reinforce negative beliefs about the frailty of the spine creating more vigilance and protection. One can’t help to think these negative beliefs guide our behavior in response to pain and create a vicious pain cycle.

As I’ve mentioned before, our clinical message has staying power with patients. One participant reported her doctor emphasized the importance of activity and movement and reassured her about the prognosis or the likely course of her back pain. This restores hope and confidence in the patient and totally alters the pain trajectory in a positive way.

That’s a message I can get behind. Surely we can do better than blame a structural cause for back pain!

Patient Views about the Back

Another study by Darlow (2015) interviewed 12 participants with acute back pain and 11 participants with persisting lower back pain just to see the range of perspectives they’d get from them. It was a diverse bunch all with different occupations, back pain experiences, impairment levels, and fear avoidance beliefs.

Five themes emerged: 1) the vulnerability of the back; 2) the special nature of back pain; 3) the prognosis of back pain; 4) activity and back pain; and 5) influences on beliefs.

I’ll get into detail for the first 3 themes. I covered the details on influences on beliefs above.

I. Vulnerability of the back

All participants thought their LBP (lower back pain) was due to some injury, damage or dysfunction. Because their back pain started after a trivial event, this contributed to their perception of how vulnerable their backs are and also that they could ‘damage their backs’ without even being aware of it.

They wanted to know what exactly was wrong so it would inform management and prevention of recurrence.

In general, they believed the more severe the pain, the more damage would exist in the back.

The participants believed the back was vulnerable because the way it was used, how it’s designed, and personal factors. They thought the back was at risk for ‘overuse’ because it’s used for ‘everything’ in daily life. They also thought it was poorly designed or maladapted for modern life. Personal physical traits such as height and weight and lifestyle factors such as diet and posture can cause pain down the line.

Participants with chronic pain viewed their backs as ‘degenerative’ associated with the ideas of ‘falling apart.’

Activities which place load on the back such as lifting, bending, twisting, and sitting were viewed as dangerous.

I.I  Protection of the back

Participants often blamed themselves for not protecting their backs enough. Their pain experience reinforced the belief of vulnerability in the back and that they needed to be extra careful in usage in the future.

Their guidelines to protect the back were to: rest, be careful and avoidant of dangerous activities, strengthen the area, and lifting with ‘correct’ posture and lifting techniques.

III. The Special Nature of the Back

Back pain was viewed as special and viewed as different from many other physical pains. This was because of the nature and the complexity of the pain.

Also, they felt back pain is difficult to understand and relate to without experiencing it. There’s a stigma involved because of the inability to see what is/was wrong with the back.

The back was characterized as its own entity that’s beyond the control of anyone. It was generally viewed as unpredictable and uncontrollable and to adhere to protective strategies to avoid and manage future episodes.

What’s interesting is how only few of the participants recognized how psychological factors impacted their pain, but nearly all reported how impactful the pain was on their psychological wellbeing. A common report was that they felt depressed, old, irritable and how this can negatively affect their relationships.

III. Prognosis of the back

Many had a gloomy outlook on their back pain. Their perception of a bad outcome seemed to be very real. It was punctuated by the importance of the back, its vulnerability, uncertainty about its healing capacity, and how disruptive it can be in people’s lives.

Those with chronic LBP had gloomy views as well about the future. Though they may feel positive about healing the area, the failure of the pain to fully resolve still tells them it’s not completely healed.

Many of these participants dissociated the self from their painful body part. They regarded the back as untrustworthy, unpredictable, and ‘acting outside of their best interests.’

I hope this provides a glimpse into why we think what we think about the ‘how and why’ of back pain. If we tend to believe that the back is vulnerable because of its inherent design, its special nature, invisible to those who haven’t experienced it, and they expect to be doomed forever, then these representations of the back have a huge influence on how we deal and respond to back pain events.

n.If we understand a person’s attitudes, beliefs, and cognitions on back pain, we can address them more positively and with more accurate information. Accurate knowledge can provide safety in a person in an otherwise precarious pain situation.


1. Darlow, B., Dowell, A., Baxter, GD., Mathieson, F., Perry, M., Dean S. (2013). The Enduring Impact of What Clinicians Say to People with Low Back Pain. Ann Fam Med, 527-534. doi:10.1370/afm.1518.

2. Darlow, B., Dean, S., Perry, M., Mathieson, F., Baxter GD., Dowell, A. (2015). Easy to harm, hard to heal: patient views about the back. Spine (Phila Pa 1976), Jun 1;40(11):842-50. doi: 10.1097/BRS.0000000000000901.

3. Photo credit –


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