Research Review By Dr. Kent Stuber©


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Date Posted:

November 2020

Study Title:

“I stay in bed, sometimes all day.” A qualitative study exploring lived experiences of persons with disabling low back pain


Esson SA, Côté P, Weaver R, Aartun E & Mior S

Author's Affiliations:

Centre for Disability Prevention and Rehabilitation at Ontario Tech University and Canadian Memorial Chiropractic College, Toronto, Canada; Faculty of Health Sciences, Ontario Tech University, Toronto, Canada; Department of Health and Exercise Science & Department of Medicine – Rowan University; Department of Research, Canadian Memorial Chiropractic College, Toronto, Canada.

Publication Information:

Journal of the Canadian Chiropractic Association 2020; 64(1): 16-31.

Background Information:

The high prevalence and recurrence rates of low back pain and the resulting disability and disease impact have been studied and cited ad nauseam. What frequently gets lost in all of the numbers that we can so faithfully recite to our patients is what this actually means to the individual who is dealing with back pain, whether as a new injury or something that is more long-standing. Low back pain has a multi-faceted impact on the lives of our patients, and it is important to remember this whether you are seeing a patient with back pain for the first time or the tenth. Qualitative studies such as this one are important, as they explore what patients go through as they deal with their condition and the impacts that it has on their lives as the voices of patients can at times be lost in other study designs.

In this study, the authors employed the International Classification of Functioning, Disability, and Health (ICF) framework to help ground their study and data collection and analysis in the multifactorial (i.e. biopsychosocial) nature of low back pain. The ICF is an important and commonly used means of classifying function and disability with respect to a health condition, used by the World Health Organization among other bodies. The ICF places health and disability on a continuum that considers the biopsychosocial model and consists of 4 multidimensional, interactive concepts of function and disability: body function and structures, activities, participation or involvement in different areas of life, and environmental factors (see figure below, personal factors are not actually part of the model). In the ICF model, function is seen as an interaction between personal and environmental factors and a person’s health or health conditions.

Domains of the International Classification of Function, Disability and Health Model and related emergent sub-categories:
ICF Framework
Guided by this framework, these authors conducted a qualitative study using focus group methodology to explore the lived experiences of people with low back pain.

Pertinent Results:

The authors conducted 3 focus group interviews with a total of 12 patients. Two of the groups had patients with low disability due to back pain (n = 9) and one had patients with high levels of disability (n = 3), as indicated by the WHODAS (World Health Organization Disability Assessment Schedule). Interviews were coded into the 5 domains of the ICF (International Classification of Functioning, Disability and Health) framework. From there, the authors identified 4 interrelated themes found among the ICF domains that arose from those discussions:
  1. Invisibility: Low back pain cannot be seen and thus it is often left unacknowledged or appreciated by non-sufferers, including family and other members of the public. Back pain sufferers worry about others viewing their condition as lacking legitimacy because they can’t see it with their own eyes.
  2. Ambivalence: Back pain sufferers with high levels of disability appear to be ambivalent as to how they deal with their back pain, not being sure as to whether they should accept the changes in their capabilities and not wanting to appear disabled to others.
  3. Social isolation: Back pain sufferers feel that their condition is draining, it can negatively affect their behaviour including their self-esteem, and hinders their motivation to perform daily activities. When that coincides with symptoms of depression, it can lead to social withdrawal. The effect on a back pain sufferers’ social interaction with others seemed to be more pronounced among those with higher levels of disability.
  4. Stigmatization and marginalization: Those with jobs and lower levels of disability from their back pain attempted to self-select their positions based on their capabilities and limitations. Employment opportunities were more limited for those with higher levels of disability, as they were all unemployed at the time, and concerned about the reactions of prospective employers to their condition. Patients felt marginalized when they felt that their family members did not want to discuss their low back pain.
Those with higher levels of disability face greater challenges in terms of their physical abilities and emotional symptoms. Depressive symptoms and social isolation were more common among those with higher levels of disability.

Interestingly, many of the involved patients had poor experiences as passengers on public transit and the discomfort and aggravation of symptoms it could create (the interviews took place in the Greater Toronto Area, where public transit is well used and important for many residents).

Clinical Application & Conclusions:

As per the ICF framework, some of these issues are personal ones for back pain sufferers, while others are more environmental. It is important for clinicians to recognize that at least one of the themes identified might be present for patients with back pain and have patient-centred solutions to help them address these issues. Disability from back pain can be physical, emotional, social, and economic and each of these forms of disability are important to patients (in varying degrees, depending on the individual). Asking about and encouraging patients to discuss their concerns or problems that they are encountering while dealing with their back pain is important, as is patient education, and possibly referrals to community support organizations and other health professionals.

Study Methods:

This was a qualitative study that used stratified focus group interviews of patients with low back pain to learn about the everyday experience of having back pain. The WHODAS (World Health Organization Disability Assessment Schedule) was used to stratify the groups into low disability (2 groups) and high disability (1 group). Participants were adults (20-65 years old) with low back pain, recruited from CMCC teaching clinics. The interview schedule was based on the ICF (International Classification of Functioning, Disability and Health) framework and the analysis was organized around the ICF using thematic analysis.

Study Strengths / Weaknesses:

The authors cite their use of the ICF framework as a major strength of the study, along with their recruitment of patients with differing levels of disability. The main limitation was the small sample size and how it limited the representativeness of the data, as several subgroups were at least somewhat underrepresented (such as employed patients, those with high levels of disability, limited age distribution, and those who do not seek treatment).

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