The Enduring Impact of What Clinicians Say to People With Low Back Pain

Authors: Ben Darlow, Anthony Dowell, G. David Baxter, Fiona Mathieson, Meredith Perry, Sarah Dean 

AIM

This study explored how people with low back pain develop their beliefs about their back, where those beliefs come from, and how they influence subsequent behaviour. The researchers were particularly interested in the relationship between patients’ beliefs and messages received from healthcare professionals.

The aim was therefore interpretive rather than to estimate how frequently particular beliefs occur or test whether clinician communication causes particular outcomes. The researchers wanted to understand participants’ experiences and identify clinically meaningful patterns in how information about back pain was understood and carried forward. 

METHODS

This was a qualitative study using Interpretive Description, an approach designed to develop clinically useful understanding from patterns within people’s experiences. The authors explicitly worked from an interpretivist perspective: knowledge was understood as constructed through interactions between people, with researchers themselves contributing to the research process rather than acting as completely detached observers. 

The researchers interviewed 23 adults from one region of New Zealand: 12 experiencing acute low back pain of less than 6 weeks and 11 with chronic low back pain lasting more than 3 months. Purposive sampling sought variation in age, sex, ethnicity, occupation, previous back-pain experience and healthcare exposure. 

Participants completed face-to-face, semistructured interviews lasting 31 to 101 minutes. Questions explored their understanding of their back pain, concerns, previous beliefs, sources of information, healthcare experiences and thoughts about movement and management. Recruitment continued until the research team judged that additional interviews were producing no new themes or meaningful variations. 

Data collection and analysis occurred iteratively. Interviews were transcribed and analysed separately for acute and chronic pain, with emerging findings influencing subsequent interviews. An external qualitative researcher independently analysed selected material, and the wider multidisciplinary research team repeatedly discussed and reorganised the thematic framework. 

RESULTS / FINDINGS

Participants described developing their understanding of back pain through previous experiences, family and friends, media, the Internet and healthcare professionals. During acute episodes, uncertainty about what was happening and what to do prompted people to seek explanations. Clinicians were particularly influential because participants trusted their expertise and expected individualised explanations, prognosis and advice. 

Participants were not simply passive recipients of these messages. They sometimes rejected clinicians’ advice when it conflicted with their lived experience, goals or existing beliefs, or when they questioned the clinician’s competence. Nevertheless, among participants who had consulted clinicians, many could connect particular messages with subsequent ways of understanding or responding to their back pain. 

One prominent pattern concerned how clinicians explained symptoms. Participants often interpreted pathoanatomical explanations as information about the condition and vulnerability of their back. These explanations could then become a framework for interpreting future sensations. For example, one participant who had previously been told about spinal “alignment” interpreted subsequent pain as evidence that the back had become misaligned again. 

Messages about prognosis could have similarly enduring meanings. Participants described clinicians’ comments shaping expectations about future recovery, recurrence and their capacity to work. For some, a single memorable statement continued to influence how later episodes of pain were interpreted years afterwards. 

A second major theme was protecting the back. Advice about posture, strengthening particular muscles, avoiding certain movements or controlling spinal position could be interpreted as meaning that the spine was vulnerable and required protection. Participants described becoming more vigilant about their backs, avoiding activities or monitoring movement closely. When protective strategies did not produce the expected results, some described frustration or blamed themselves for failing to perform them correctly. Others experienced guilt when they did not follow the advice. 

The interviews also contained a contrasting pattern of activation and reassurance. Clear encouragement to move and reassuring messages about prognosis or safety could increase confidence and influence how participants approached both current and later episodes. One participant vividly remembered advice from six years earlier to keep moving rather than stay in bed and continued to use that message during a new episode. 

These reassuring and activating messages were reported less frequently than protective advice, and participants sometimes received both from the same clinician, creating mixed messages. 

The authors’ thematic model brings these findings together particularly clearly: clinician communication could influence symptom interpretation, prognosis, protection or activation, which participants connected with subsequent expectations, confidence, worry, vigilance and approaches to activity. 

LIMITATIONS & INTERPRETIVE CAUTIONS

The study has several methodological strengths for its purpose. Purposive sampling captured people with varied experiences, disability and fear-related beliefs; acute and chronic participants were analysed separately; data collection and analysis informed each other iteratively; and interpretation was repeatedly discussed within a multidisciplinary research team. The researchers also explicitly acknowledged their interpretivist position and reflected on how their own perspectives could shape the research process. 

The central boundary concerns what the interviews provide access to. The researchers heard participants’ recollections and interpretations of previous clinical encounters rather than observing those encounters directly. As the authors describe it, there is a “double hermeneutic”: researchers interpreted participants’ interpretations of what clinicians had said. The study therefore provides insight into the meanings that remained with participants, rather than a record of clinicians’ exact words or intentions. 

Similarly, participants connected particular clinical messages with later beliefs and behaviours during interviews. Some of these connections may have existed beforehand, while others may have become apparent through the process of reflecting during the interview. This makes the study particularly informative about how participants understood these relationships, while causal effects of particular communication strategies require other research designs. 

Finally, these were 23 English-speaking participants recruited from one New Zealand region. Interpretive Description intentionally produces contextual clinical understanding rather than population estimates, so these findings are best considered patterns that clinicians can recognise and explore rather than assumptions about how every person with back pain will interpret a particular message.

IN PRACTICE

This study makes communication itself visible as part of treatment.

An explanation about muscles, discs, alignment or posture may be intended simply to help someone understand their symptoms. What matters clinically, however, is also the meaning the person constructs from that explanation. “My muscles need strengthening” might be carried forward as “my spine currently lacks enough support.” Advice to temporarily modify an activity might become a more enduring rule that the movement is dangerous.

The same applies to reassurance. Telling someone to remain active is more than providing an instruction if they understand it as evidence that their back is safe to use. Participants’ accounts suggest that brief statements can become part of the framework through which future symptoms and decisions are interpreted.

One reasonable clinical implication is therefore to become curious about what the patient heard, rather than focusing only on what we intended to communicate. Asking questions such as “What does that explanation mean to you?”, “What do you think will happen if you bend or lift?” or “What will you take away from what we’ve discussed today?” may reveal meanings that would otherwise remain invisible.

The study also encourages some humility around patient education. People arrived with existing experiences and beliefs and actively interpreted, accepted or rejected professional explanations according to whether they fitted their lives. Communication therefore emerges less as transferring the correct information from clinician to patient and more as developing a shared understanding.

For physiotherapists, perhaps the most enduring message is that the words surrounding an intervention may matter well beyond the consultation itself. Explanations create expectations about what the body is like, what symptoms mean and what the person can safely do. This study invites us to pay attention not only to whether our explanation sounds reasonable to us, but to the understanding the patient may carry into the rest of their life.

Reference

Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine, 11(6), 527–534. https://doi.org/10.1370/afm.1518