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Abstract

Background: Lower back pain has become one of the most common complaint in the general population. Studies have shown that an estimated figure of 80 % of the general population will suffer from lower back pain at some stage in life.

Objective: The aim of this literature review is to present a synthesis of relevant research articles on people’s experiences of lower back pain and how they manage the condition without opting for surgery. This review also seeks to get an in-depth understanding of how the pain affects the individuals holistically and how they best manage it.

Methods: Online databases such as CINAHL, Google scholar, Cochrane library and NICE guidelines were used to select the most relevant pieces of literature published from 2007-2017. Two main themes emerged after critical analysis, and these were: 1. Patients experiences of lower back pain, and 2. Staying active as a management strategy for lower back pain.

Main findings: A total of sixteen studies were found to be the most relevant for this literature review. These consisted of seven qualitative studies, five systematic reviews, three quantitative studies and one mixed study. The findings showed that the experiences of lower back pain have been proven to have a negative impact as it affects the individual’s daily lives. Studies also proved that individuals suffering from lower back pain must be encouraged to stay active, exercise and to go for physiotherapy sessions to strengthen their muscles.

Conclusion: Lower back pain is a condition that has been identified to be a bothersome in many people due to several factors such as physical workload. However, individuals must be encouraged to manage in independently.

Recommendation: There is a need to create awareness to the population concerning back care and manual handling. However, it is also important to identify and tackle factors that contribute to lower back pain and find solutions to be problem.

Key words

Lower back pain*   Sciatica* “lived” experiences*  Staying active*   Management*

Contents

Introduction ……………………………..~1~

Search Strategy……………………………~1~

Main Body………………………………~2~

Discussion………………………………~11~

Recommendations…………………………~12~

Reference List……………………………~14~

Appendices:

1. Search Search Table………………………~18~
2. Summary of Studies Table…………………..~20~

Introduction

Low- back pain (LBP) is one of the most common conditions which is managed in primary care and has led to many absents in work places, and early retirements. Low-back pain or sciatica is a stressful experience for individuals who suffer from this condition. Regular physical activities, excessive physical workload which occurs in many occupations leads to musculoskeletal disorders and neurological damage. An estimate of 84 percent across the general population worldwide suffer from low-back pain disease (Lastovkaova et al. 2015). The threshold of the pain does not only affect the individual’s well-being, but it also affects their relations and daily activities. Low-back pain has proven to have a negative impact on an individual holistically, as it takes over their lives and becomes the focal point, (Dahm KT et al. 2010). Numerous studies have explored the experiences of low-back pain and how people living with the condition manage their daily lives.

The aim of this literature review is to examine and synthesise the existing literature on people’s experiences of low-back pain or sciatica. The reviewer will discuss the experiences of people living with low-back pain, and these will be categorised into two themes, patient’s experiences of lower back pain and staying active as a management strategy for lower back pain.

Search Strategy

The reviewer devised a search strategy in this literature review and a comprehensive online search of the following databases: CINAHL, Cochrane library, Google scholar and NICE guidelines. The reviewer also searched for articles on the WHO website and Orthogate website. The key search items used included: (lower back pain OR sciatica AND people’s experiences) and (lower back pain OR sciatica AND intervention AND management). The search timeframe covered 2007-2012 to retrieve the most recent journal articles in this topic. A total of 36 articles were saved and 16 were found to be the most suitable for this literature review. Due to the condition affecting most people worldwide, the reviewer included all countries but only English articles met the inclusion criteria. Several methodologies including systematic reviews and qualitative studies etc. were found appropriate in the review. The following themes emerged from the articles retrieved and were explored in detail. These include: patients experience in lower back pain, and staying active as a management strategy of lower back pain.

Main Body

Patient’s experiences of lower back pain

The aim of this theme is to explore the experiences of patients with lower back pain, how it impacts on their daily lives.

In 2011, Snelgrove et al conducted a qualitative study exploring the experiences of patients with chronic lower back pain in the United Kingdom. A total number of ten patients took part in the study, and were purposefully recruited from a consultation waiting list. Semi-structured interviews were used to obtain data from the patients, and the data transcripts were analysed using the SS guideline provided by Smith and Osborn (2003). Ethical approval was received for the study. The research findings showed that the patients described lower back pain as a threat to both physical and personal integrity. Most patients expressed how the constant pain in their back affected several aspects of their lives. One  participants emphasised on how pain had impacted on her daily activities by interrupting her sleep and causing her to be tired during the day. Participants felt that they could not participate in daily activities like other people because of back pain. In addition, several participants described how some side effects associated with lower back pain such as stiffness and numbness in the lower limbs had a negative impact on their physical appearance and self-image. Overall the patients main concern was that they felt guilty and anxious about how the condition limited the extent to which they could participate in normal activities with the partners and their families.

Similarly, De Souza, L and Frank, A L conducted a qualitative study in 2011 on the emotional distress caused by lower back pain among eleven patients in United Kingdom. The participants were picked from referral letters in a rheumatology outpatient clinic. Purposeful sampling was used. Data were collected via in-depth interviews which were tape recorded and transcribed. Thematical analysis was done. Ethical approval was obtained and the findings showed that lower back pain had an impact on the victims’ relationship with their spouse and led to marital discord due to reduced sexual activities. Their partners had to deal with the changes in moods and temper contributed by the chronic pain. Although support was given to the patients by family and friends on their daily activities, some participants expressed their reluctance in discussing about the pain. On the other hand, some patients discussed their concern about work related issues, their worries about their finances relating to sickness or unemployment even though some participants believed that their back problems were due to the nature of work.

A qualitative study was conducted in Finland by Ojala in 2015 which support the above. The aim of the study was to explore the experiences of people suffering from chronic lower back pain. A total number of 34 patients participated in the study, 19 women, and the age range was from 23- 73 years. Data was collected through open ended inquiry, which were recorded and transcribed. Ethical approval was obtained from the district hospital committee in northern Finland. The study revealed that although physical and psychological pain could not be distinguished from different individuals, the patient’s complaints were the same. Most individuals suffered psychological distress, sorrow, loneliness, and loss of identity which made a significant impact on the daily living activities. The patient compared their lives before the manifestation of lower back pain. On the other hand, the fact that pain encompassed their lives daily and could not be resolved, the patients felt helpless, hopeless, and desperate thus leading to suicidal thoughts. A similar qualitative study conducted in Denmark by Ellegaard and Pedersen in 2012 exploring how stress has become dominant in patient suffering from lower back pain. A randomised control study of a total of 130 participants with the age range between 18-60 years who had been referred to The Spine Centre of Southern Denmark. Data collection was done through interviews and field notes and structural analyses was carried out. Ethical approval was received and all the participants signed an informed consent. The results of the study showed how the participants felt restricted in their everyday life which affected their self-worth and identity. A female participant expressed self-destructive tendencies of experienced loss and sorrow which were because of the pain and agony she was experiencing due to lower back pain. However in overall this study showed that stress had become dominant in most of the participants lives as a result of lower back pain. Furthermore, a quantitative randomised cluster controlled trial study was conducted by Lochting et al. (2017) in Norway with the aim to explore the perception, pain intensity and psychological distress because of lower back pain. 216 participants were randomly sampled. Data were collected through questionnaires and analysed statistically. Ethical approval was received from the Norwegian regional committee. The finding in relation to the impact of illness perception, pain, and stress due to nonspecific lower back pain revealed that it varies with individuals. Moreover, the perception based on illness being the only psychological factor that showed a significant impact on health-related quality of life.

A qualitative study supported by Rodrigues-de-Souza in 2016 was conducted in Spain and Brazil with the aim to describe the experience of patients with lower back pain and how socio-cultural factors influence it. A phenomenological approach was implemented and data was collected for 22 Spanish and 26 Brazilian patients from their respective University hospitals. The data was collected through in-depth interviews and using the researchers field notes, patients’ diaries, and notes. Purposeful sampling was used and a thematic analysis was applied and guidelines for reporting qualitative research. Ethical approval was obtained and approved by the clinical research committee. The results regarding the experience of lower back pain reported that most participants from both Spain and Brazil perceived pain as part of them. They described it as a presence as it had taken over their whole body, and it affected their lives physically, socially and psychic. Physical problems, agony and worry had become a part of their lives. A participant in Spain described the pain like being stabbed with a knife. On the other hand, most Brazilian patients were more positive regardless of how much pain they were feeling, they appeared cheerful with a positive attitude. In overall all participants stated that the pain was something nobody could understand thus it led to them to draw away from their social lives as they felt less well understood. However, some patients from both countries stated that due to the health education provided about sciatica and lumbar pain, they had become well vested with knowledge on how to find solutions and they had a better understanding on how to manage the pain. A contrasting view from some Spanish patients stated that health education on lower back pain had no impact on coping mechanism thus this proved that patients differ in their threshold for seeking care.

Furthermore, Ong, B N et al conducted a longitudinal qualitative study with the aim to have an in depth understanding of people living with chronic lower back pain. The study was done in Unite Kingdom in 2010, on 37 participants, 15 males and 22 females. Open ended interviews were tape recorded, fully transcribed and thematically analysed. Ethical approval was obtained and the findings revealed that lower back pain and its associated symptoms are frightening for patients especially if they do not understand the cause. Most participants express how the pain was intolerable and difficult to cope with. They appeared to have a higher degree of hopelessness about getting better. In conclusion, a systematic review conducted in United Kingdom by Hopayian K and Notley C in 2013 described the experience of patients living with lower back pain and sciatica in patients. The systematic review was of qualitative studies and the samples were primary studies from Medline, Cinahl, Embace and Psychoinfo databases. The findings showed that 28 articles met the inclusion criteria which revealed that though lower back pain was not curable, some people adapted to their situation with the help of care givers and coping strategies. However, if proper education is provided and support, people living with lower back pain might be able to manage their lives well.

In summary, the literature explored above on the experiences of lower back pain has proved to have a negative impact on an individual as it affects their lives daily.

Staying active as a management strategy for Lower back pain

In this theme, the reviewer will explore literature on how patients suffering from lower back pain should stay active as a management strategy.

Konstantine et al (2012) conducted a mixed study in United Kingdom. The purpose of the study was to explore the impact of the diagnosis of lower back pain and its associated symptoms, and how the patient can manage the pain. A total number of 500 participants from the age of 18 years and above were recruited through consultation lists from their general practitioner in North Staffordshire and Stroke-on-Trent in UK. A quantitative analysis software was done statistically, and a qualitative analysis was performed using a data analysis software, the data collection method was through in-depth interviews, observation, fieldnotes and audio recording whilst the study outcome was collected every four to twelve months using questioners. Ethical approval was received from South Birmingham, and the findings in relation to the management of lower back pain showed that participants who had undergone physiotherapy sessions reported that the condition had improved. Furthermore, a randomised control trial that compared surgery versus physical activity in the management of lower back pain was conducted in Australia. Fernandez et al (2015) conducted a systematic review using MEDLINE, CINAHL, EMBRACE, and PEDro databases on patients experiencing lower back pain with or without associated symptoms. An inclusion criteria of twelve trials were retrieved, data synthesis and analyses were done through a comprehensive meta-analysis software and calculated using a random effects model. However, the findings revealed that patients are encouraged to stay physically active by doing isometric exercises, and supervised exercise programmes under the supervision of a physiotherapist. These were encouraged due to positive reports from participant on how it improved the pain intensity level. A contradicting point was raised in this review which stated that physical activities as a management strategy of lower back pain depended on the severity of the condition. Patients tolerance and other factors such a lifestyle and habits also contributed to whether physiotherapy was an ideal strategy.

In 2016, Morris et al conducted a randomised trial in South Africa with the aim to investigate the efficacy of a homeopathic complex with the combination of physiotherapy. The total number of participants were 30 males and females with their ages ranging between 45 – 75 years. The method of study was a six week randomised, double blind, placebo-controlled pilot. Statistical analysis of data was processed using a software for credibility. The intervention group and control group both received a standard physiotherapy, massage and joint mobilisation in every two weeks. The finding revealed that there was a significant improvement after physiotherapy was performed on the participants although it was a short -term relief. The study limitations were that the sample size was too small and the duration of the study was rather too short, thus the longer the treatment the better it would have been to assess the outcome. In contrast, Lewis, RA et al (2015) supports the notion that physical therapy and exercise have an impact on managing lower back pain. A systematic review was conducted in Australia with the aim to perform a meta-analysis of the effectiveness of different management strategies of sciatica in adults. The search and inclusion criteria were twenty-eight electronic databases and trials from MEDLINE, EMBASE, and AMED. The exclusion criteria were of postsurgical interventions. Statistical method of meta-analysis was done and sensitivity analyses excluding non-randomised trials were done. The finding revealed that both patients and physicians reported an overall improvement of the pain intensity after physiotherapy and exercises had been done. However, health education given to patients on selfcare helped them improve their lifestyle.

An insight full argument presented by Fernandez et al (2015) in Australia in the management of lower back pain which revealed small effects favouring exercise as there was no relevant patient outcome. A systematic review and meta-analysis was conducted, data was collected from several databases including CINAHL, MEDLINE and EMBASE. The studies were randomised controlled trials which compared information and advice on the management of lower back pain and the associated symptoms. Two independent reviewers collected and assessed the data for its methodological quality. The Cochrane Research Group endorsed the quality and credibility. Data analysis was done statistically and the findings revealed that supervised exercise programs contributed to patients staying active. However, it also argued that some exercises made little or no difference in pain relief as participants reported that physiotherapy sessions had not taken away the pain. These findings compliment those generated by Middlekoop et al (2010) in Netherlands. A systematic review on the effectiveness of physical and rehabilitation intervention for lower back pain was conducted. A total number of 83 randomised control trial studies were retrieved from MEDLINE, EMBACE, CINALH, and PEDro. The study population was from 18 years and above with complaints of more than 12 weeks of non-specific lower back pain. Data analysis was done statistically. The findings showed that a combination of behavioural, cognitive and physiological therapy can have an impact on reducing back pain. On the other hand, this study supports the study above by stating that no significant treatment effects of exercise were found to relieve the pain completely but rather a short-term intervention.

In a different approach, Brunzli et al. (2016) conducted a qualitative noninterventional, cross-sectional study in Australia. The aim of the study was to explore the experience of cognitive functional therapy for chronic lower back pain in Ireland and Australia. Purposeful sampling was generated based on the outcomes postintervention (n=9), and theoretical sampling (n=5). Data was obtained through semi-structured interviews which were conducted every 3- 6 months postintervention and analysed thematically. The credibility of the data was through member checks and maintaining an audit trail. A major focal in the study was that cognitive therapy does improve patients lower back pain condition. However, it depends on the individual bio-psychosocial beliefs and patient’s ability to manage their condition independently. The findings infer that individuals can return to normality if they improve their stress coping mechanism, reduce fear, and have self-efficacy. Similar findings emerged in research by Elfering et al. (2016). A population based survey in Switzerland was conducted to ascertain the beliefs of individuals with regards to lower back pain and exercises. The survey was conducted with a random selection of 2860 participants with consistent back pain. Ethical approval was received from the local Research Ethics Committee. The data collection method was through questionnaires. The data was analysed statistically, and hypotheses was tested using cross-lagged-panel models (Clegg, Jackson, and Wall, 1977). The findings place a great emphasis that pessimistic pain beliefs correspond to passive pain management as resting and staying inactive. However, inactivity according to the literature weakens the muscles and pain increases when patient resumes to their daily activities. On the contrary, in cognitive behavioural therapy, individuals participate in exercise programmes which strengthens the muscles, reduce pain, and increases self-efficacy in managing their condition.

According to the literature reviewed, it can therefore be concluded that individuals suffering from lower back pain must be encouraged to stay active. Exercises and physiotherapy sessions have been proven to have a positive impact on pain intensity although it may vary with individuals. On the other hand, with self-efficacy, individuals can manage their condition independently.

Discussion

The purpose of this literature review was to present a synthesis of the existing literature on people’s experience of lower back pain. The reviewer retrieved sixteen paper appropriate for the literature review. These included seven qualitative studies, five systematic reviews, three quantitative studies and one mixed study. During the analysis of the study, the reviewer identified two themes that constantly emerged and these were: people’s experience of lower back pain, and staying active as a management strategy for lower back pain. In exploring the literature on the experiences, the reviewer noted that most people living with this condition felt like the pain had taken over their lives. This feeling led to depression, stress, agony, and hopelessness. However regardless of the support given to these individuals, most felt the need to isolate themselves from their social lives as they felt less understood. On the other hand, staying active as a management strategy was proven that it entirely depends on an individual and their tolerance level. Evidence from the literature proved that support from orthopaedics specialists and physiotherapist to people with lower back pain condition is growing in the healthcare sector. However, it is also up to the individual to develop self-efficacy in managing their condition independently and improve their lifestyle.

In conclusion, lower back pain is a condition that most people tend to suffer from at a later stage in life due to physical activities, work overload and improper manual handling and due to other degenerative conditions. Thus, proper health education on back care is vital and should be addressed to effectively manage it.

Recommendations

Future researcher need to be empowered to continue conducting research amongst the vital population on low back pain and its management. There is a need to create awareness to the population concerning back care, and manual handling. However, it is important to identify and tackle factors that contribute to lower back pain such as physical workload, and other occupations that may cause or worsen lower back pain disease and come up with solutions.

References

 Bunzli, S., McEvoy, S., Dankaerts, W., O’Sullivan, P. and O’Sullivan, K. (2016). Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain. Physical Therapy, 96(9), pp.1397-1407.

De Souza, L. and Oliver Frank, A. (2010). Patients’ experiences of the impact of chronic back pain on family life and work. Disability and Rehabilitation, 33(4), pp.310-318.

 Elfering, A., Müller, U., Rolli Salathé, C., Tamcan, Ö. and Mannion, A. (2015). Pessimistic back beliefs and lack of exercise: a longitudinal risk study in relation to shoulder, neck, and back pain. Psychology, Health & Medicine, 20(7), pp.767-780.

 Ellegaard, H. and Pedersen, B. (2012). Stress is dominant in patients with depression and chronic low back pain. A qualitative study of psychotherapeutic interventions for patients with non-specific low back pain of 3–12 months’ duration. BMC Musculoskeletal Disorders, 13(1).

Fernandez, M., Ferreira, M., Refshauge, K., Hartvigsen, J., Silva, I., Maher, C., Koes, B. and Ferreira, P. (2015). Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis. European Spine Journal, 25(11), pp.3495-3512.

 Fernandez, M., Hartvigsen, J., Ferreira, M., Refshauge, K., Machado, A., Lemes, Í., Maher, C. and Ferreira, P. (2015). Advice to Stay Active or Structured Exercise in the Management of Sciatica. Spine, 40(18), pp.1457-1466.

 Hopayian, K. and Notley, C. (2014). A systematic review of low back pain and sciatica patients’ expectations and experiences of health care. The Spine Journal, 14(8), pp.1769-1780.

 Konstantinou, K., Beardmore, R., Dunn, K., Lewis, M., Hider, S., Sanders, T., Jowett, S., Somerville, S., Stynes, S., van der Windt, D., Vogel, S. and Hay, E. (2012). Clinical course, characteristics and prognostic indicators in patients presenting with back and leg pain in primary care. The ATLAS study protocol. BMC Musculoskeletal Disorders, 13(1).

Løchting, I., Garratt, A., Storheim, K., Werner, E. and Grotle, M. (2017). The impact of psychological factors on condition-specific, generic and individualized patient reported outcomes in low back pain. Health and Quality of Life Outcomes, 15(1).

Lewis, R., Williams, N., Sutton, A., Burton, K., Din, N., Matar, H., Hendry, M., Phillips, C., Nafees, S., Fitzsimmons, D., Rickard, I. and Wilkinson, C. (2015). Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal, 15(6), pp.1461-1477.

Morris, M, Pellow, J, Solomon, E M, Tsele-Tebakang, T. (2016). Physiotherapy and a homeopathic complex for chronic low-back pain due to osteoarthritis. A randomised controlled pilot study.

Ojala, T. (2016). The essence of the experience of chronic pain. Manual Therapy, 25, p.e160.

Ong, B., Konstantinou, K., Corbett, M. and Hay, E. (2011). Patientsʼ Own Accounts of Sciatica. Spine, 36(15), pp.1251-1256.

Poquet, N. and Lin, C. (2015). Management strategies for sciatica (PEDro synthesis). British Journal of Sports Medicine, 50(4), pp.253-254.

 Rodrigues-de-Souza, D., Palacios-Ceña, D., Moro-Gutiérrez, L., Camargo, P., Salvini, T. and Alburquerque-Sendín, F. (2016). Socio-Cultural Factors and Experience of Chronic Low Back Pain: a Spanish and Brazilian Patients’ Perspective. A Qualitative Study. PLOS ONE, 11(7), p.e0159554.

 Snelgrove, S., Edwards, S. and Liossi, C. (2013). A longitudinal study of patients’ experiences of chronic low back pain using interpretative phenomenological analysis: Changes and consistencies. Psychology & Health, 28(2), pp.121-138.

 van Middelkoop, M., Rubinstein, S., Kuijpers, T., Verhagen, A., Ostelo, R., Koes, B. and van Tulder, M. (2010). A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal, 20(1), pp.19-39.

Appendix 1: Search Strategy Table