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Doctors’ attitudes and beliefs regarding acute low back pain management: A systematic review

Fullen, B. M.a,*; Baxter, G. D.b; O’Donovan, B. G.G.c; Doody, C.a; Daly, L.d; Hurley, D. A.a

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doi: 10.1016/j.pain.2008.01.003
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1. Introduction

Low back pain (LBP) is widely recognised as a major medical and social problem and represents a considerable burden to healthcare [48]. It also has a significant economic impact: LBP costs are comparable to those associated with coronary heart disease, diabetes or depression; therefore reducing costs is a major public health issue [11]. The mechanisms by which patients cope with non-specific LBP are frequently determined by factors not related to physical pathology or pain severity. In particular, patients’ attitudes and beliefs to LBP are influenced by many factors, including past pain experience [14], culture [38], and social and economic factors [23,46]. Their attitudes and beliefs may also be reinforced or challenged by their doctor. Projected beliefs of doctors have recently gained the attention of the scientific community as contributing to poor adherence to established guidelines and influencing patients’ beliefs [45]. Doctors’ beliefs could contribute to the development of chronic spinal disability through their over- or undertreating, failing to use effective pain control or reactivation strategies, and reinforcing patients’ unhelpful illness perceptions by advising increased spinal vigilance and restricting normal activities [33]. A relationship has been shown to exist between beliefs and behaviour. Beliefs influence behaviour, and furthermore the consequence of the behaviour can also feed back to influence beliefs [9]; this applies to both the doctor managing the pain and the patient experiencing it [29].

There is some evidence in the literature of attempts to quantify doctors’ attitudes to LBP management with studies using questionnaires adapted from those originally developed for and with patients [33]. Physicians’ beliefs about fear of movement have previously been explored [26,34]. The literature has also identified several factors which combine to influence doctors’ decision-making processes in formulating a treatment plan for a patient including past experience, undergraduate and postgraduate education, individual clinical reasoning, knowledge of the evidence base, and time and personal beliefs [18,26].

Whilst patients’ beliefs about LBP have been extensively described in the literature, including a review of 39 prospective studies that found strong evidence that patients’ beliefs were related to future pain and disability [25], a systematic review regarding doctors’ attitudes and beliefs to acute LBP, or the factors that influence these, has not been previously undertaken. This paper reports on a review of the literature, which highlights those attitudes and beliefs which have important health and financial implications for both the patient, the practitioner, and the health service.

2. Aim of review

The aim of this study was to systematically review the literature to determine doctors’ attitudes and beliefs to acute LBP management and the factors that influence them.

3. Methodology

3.1. Overview

The review comprised three phases. Phase 1 involved a systematic search of the literature using devised criteria and a search strategy of key words. Phase 2 involved the initial screening of appropriate abstracts and subsequently full papers by two independent reviewers (B.F., D.H.). Phase 3 involved classifying the internal validity of the included papers, and grading the strength of the evidence using established and validated tools: for quantitative papers, the Thomas Test [43], and for qualitative papers, the Critical Appraisal Skills Programme [CASP, 35]. The strength of the evidence was graded using an adapted version of the Agency for Healthcare Research and Policy (AHCPR) guidelines [4].

3.2. Search strategy

3.2.1. Phase 1 data base search

Electronic searches of Medline (January 1990–May 2006), EMBASE (January 1990–May 2006), CINAHL (January 1990–May 2006), Psychinfo (January 1990–May 2006), BIOSIS (January 1990–May 2006), Science Citation Index (January 1990–May 2006), and the Cochrane Central Register of Controlled Trials (Central) were carried out in May 2006.

On advice from a medical librarian, two searches on each database were undertaken using a combination of key words, and using each data base thesaurus and the key words. The following key words were used: back pain, low back pain, acute low back pain, thoracolumbar pain, sciatica, backache, medical profession, health care provider, physician, doctor, general practitioner, rheumatologist, pain consultant, orthopaedic, surgeon, medical practitioner, attitude, belief, behaviour, education, knowledge, and recommendations. Hand-searches were also conducted on the bibliographies of identified articles for relevant papers.

3.2.2. Phase 2 screening process and data extraction

Potentially relevant articles were identified from the titles, abstracts and key words of the references retrieved by the literature search, and scrutinised by two researchers (B.F., D.H.) for inclusion/exclusion criteria. The full papers of accepted abstracts were retrieved and independently scrutinised by the two researchers using a detailed proforma developed to capture, and subsequently categorise the methodology and results of each paper. Inclusion criteria are summarised in Table 1. Doctors’ attitudes and beliefs were determined as well as four factors that influenced their attitudes and beliefs: specialty, demographic factors, personal beliefs and education. Accepted papers were re-categorised into the themes by an academic general practitioner (B. O’D.) to increase face validity.

Table 1:
Inclusion criteria

3.2.3. Phase 3 internal validity and strength of evidence

A critical appraisal tool for non-RCTs is not currently available (Reeves B, Cochrane non-randomised study methods group, personal communication). Due to this absence, and for the purpose of this systematic review, two appraisal systems were chosen. First, the Thomas Test [43] was used for quantitative studies, as a review of the literature [10] identified this tool as one of the most appropriate for assessing non-randomised studies as well as RCTs and it has been used in 29 previous systematic reviews [35]. Second, the CASP system [35] was used to appraise qualitative studies: this system has been used in other recent, similar systematic reviews [32]. It consists of 10 questions that address the rigour of the research methodology, the credibility of the findings (are they well presented and meaningful), and the relevance of the findings. Each section is scored as ‘yes’, ‘can’t tell’ or ‘no’. No rating scale for this system is available [(PHRU), personal communication]; therefore, for the purpose of this review, a similar rating system to the Thomas test was devised: i.e. if two-thirds of the sections in the CASP system scored ‘yes’, it was rated as ‘strong’, between four and six ‘yes’ scores was rated as ‘moderate’, and if greater than two-thirds of scores were rated as ‘no’, the paper was scored as ‘poor’ quality.

The strength of the evidence was graded according to the grading system used in the AHCRP guidelines [4], and most recently for rating the evidence for the COST ACTION B13 European guidelines for LBP [44]. Minor amendments were made to include a level B category for trials of moderate quality (Table 2).

Table 2:
Levels of evidence

4. Results

In total, 15 papers of various methodologies were included in the review: cross-sectional studies (n=10), RCT (n=1), qualitative studies (n=3), and longitudinal design (n=1). For included studies, study design, internal validity rating, and strength of evidence are represented in Fig. 1, and the results summarised in Table 3.

Fig. 1:
Factors influencing doctors’ attitudes and beliefs.
Table 3:
Summary of included studies
Table 3:

4.1. Doctors’ attitudes and beliefs to acute LBP management

There was consistent evidence (level B) from two papers that GPs held a biomedical approach to acute LBP management, reporting difficulty in predicting patients at risk of chronicity, and having a negative attitude to LBP management due to the small number of patients they believed were malingerers, and fearing they may be legitimising this behaviour [20,30]. They also did not believe that physiotherapy was of benefit to patients with acute LBP [39]. Some physicians believed that LBP recovered spontaneously, and that it was irrespective of treatment [49], which differed significantly from those of chiropractors who did not believe this, although the latter’s active intervention strategies were not reported.

4.2. Factors impacting attitudes and beliefs

4.2.1. Specialty

There was consistent evidence (level B) from eight papers that doctors’ specialty impacted their attitudes to acute LBP management options: doctors who specialised in rehabilitation medicine (physiatrists) advocated bed rest for more than three days, corsets, and epidurals [37], whilst family physicians did not believe these treatments to be effective or appropriate for the management of acute LBP [8]. Physiatrists also valued the use of electrotherapy modalities (e.g. ultrasound, interferential, transcutaneous electrical nerve stimulation) significantly more than rheumatologists [37]. Reasons for such differences included a desire to maintain the doctor–patient relationship, doctors’ personal beliefs, and beliefs about the efficacy of treatments.

Physicians differed significantly in their belief that patients with disc herniation in most cases required surgery, compared with chiropractors, who did not agree with this statement [49].

Some doctors held beliefs regarding their colleagues’ management of acute LBP: occupational physicians believed that general physicians focused on the diagnosis and localised treatment of LBP, rather than concentrating on strategies to limit the patients’ overall level of dysfunction [1]. Neurosurgeons also believed that GPs were unable to accurately perform neurological examinations of the lumbar spine [27].

There was inconsistent evidence (level D) from three papers regarding doctors’ beliefs about return to work as part of acute LBP management. Physicians believe that patients should continue to work, or return to work as soon as possible [49]. This contrasted with GPs who believed that pain reduction was needed prior to return to work [26], and with occupational physicians who believed return to work was delayed by GPs’ beliefs that pain reduction was required prior to patients’ returning to work [1].

Doctors’ beliefs about LBP guidelines were also identified as a factor impacting on doctors’ attitudes and beliefs. There was consistent evidence (level B) in three papers from two studies that negative beliefs accounted for doctors’ lack of adherence to LBP guidelines: neurosurgeons believed that guidelines were both outdated and inaccurate, therefore, they did not adhere to them [27,28]. They disputed the continued use of neurophysiological examinations in providing additional information about the location and severity of nerve root damage, as new evidence no longer supported its use. They also highlighted that there was sufficient evidence that conservative treatments (bed rest, traction, and psychotherapy) were not useful in the management of acute LBP, rather than stating that they had not been sufficiently investigated. A study involving GPs reported that lack of self-efficacy (due to lack of education) in managing patients according to evidence-based guidelines accounted for the overuse of X-rays, and deviation from established guidelines [12].

4.2.2. Demographic factors

There was inconsistent evidence (level D) from four papers that the number of years in practice impacted doctors’ attitudes and beliefs: two papers reported no significant difference in terms of doctors’ attitudes to managing LBP [6], or their attitudes towards the use of electrotherapy modalities as a treatment [37]. Two other papers did report a significant difference in that older doctors (>55 years) were more cautious with recommendations for activity and recommended bed rest [8], and were influenced more by their personal fear avoidance beliefs regarding activity with LBP, and were less likely to maximise physical activity in patients with acute LBP [34].

One paper reported that gender impacted doctors’ beliefs: female GPs were more concerned about patients’ pain and levels of activity, and more likely to believe that patients should avoid lifting. They were also better able to determine patients at risk of chronicity [26].

4.2.3. Education

There was inconsistent evidence (level D) from three papers that education impacted doctors’ attitudes and beliefs: one paper reported no difference in attitudes and beliefs between doctors in clinical practice and academia [37]. However, attitudes and beliefs of doctors who had not undertaken LBP education in the past three years negatively impacted their adherence to established guidelines [34]. Similarly, a third paper reported significant positive changes in GPs’ attitudes and beliefs (as measured by the Pain Attitudes and Beliefs Scale) following an educational interventional strategy. General practitioners had a significantly less biomedical attitude to LBP management: although of note, improvement in behavioural attitude did not improve significantly [24].

4.2.4. Personal beliefs and history of LBP

There was consistent evidence from two papers (Level B) that doctors’ personal beliefs impacted acute LBP management: doctors with high fear avoidance beliefs (as measured by the Fear Avoidance Beliefs Questionnaire) were less likely to give advice regarding activity to follow established guidelines (including referral to physiotherapy for appropriate functional rehabilitation), and more likely to recommend sick leave, than those who did not have high fear avoidance beliefs [26,34].

There was inconsistent evidence (level D) from two papers that doctors’ personal history of LBP influenced management; a personal history of LBP caused GPs to be cautious when treating patients and to scrutinise their motives (fearing that they may legitimise malingerers), leading them to have mixed feelings regarding their management [30]. This contrasted with the second paper which reported that a personal history of LBP did not influence management [34].

5. Discussion

This systematic review has established for the first time doctors’ attitudes and beliefs to the management of acute LBP and the factors that influence these attitudes and beliefs. Results were based on 15 studies that included both qualitative and quantitative methods. All studies were reported as either moderate or high quality.

Both qualitative and quantitative studies were included in this review. While there is less agreement on critical appraisal tools for the evaluation of non-RCT studies, compared to RCT studies, two methods that have been published were used in this review: the Thomas Test (quantitative studies), and the CASP system (qualitative studies). The results of this systematic review should be considered in the light of the following limitations. Studies were only included if written in English and published from 1990 onwards. These decisions were taken because the overwhelming majority of studies were written in English, and as established clinical guidelines first appeared in the 1990s it was deemed suitable to choose these parameters.

Overall, there was limited evidence regarding doctors’ attitudes and beliefs regarding acute LBP, and the factors that influence them. There was consistent evidence that doctors’ specialty impacted on their attitudes and beliefs: lack of consensus regarding the natural history of LBP, around treatment options, and issues regarding work. These differences may reflect the large inconsistencies found in pain management education at both undergraduate and postgraduate education levels in the Republic of Ireland [15]. Differences in beliefs among specialties may in part contribute to the frustration many patients with LBP express after visiting more than one doctor, where conflicting diagnoses and treatment recommendations may contribute to the development of chronic LBP [29].

The conflicting evidence regarding doctors’ beliefs about return to work is of concern. In the UK, once patients are off work for six months, they have a 50% chance of returning to work, but only a 2% chance if off work for two years [47]. Similarly in Ireland, once a patient is off work for 4–12 weeks, they have a 10–40% risk of still being off work at one year, while after one to two years’ absence it was unlikely that they would return to any form of work in the foreseeable future, irrespective of future treatment [24]. The impact of worklessness (not being able to work due to pain, rather than being unemployed) is one of the greatest known risks to public health, with decreased life expectancy greater than for many “killer diseases” [47]. Suicide in young men who have been out of work for more than six months is increased 40 times [49], and in the general population is increased sixfold [2]. Worklessness has similar health risks as smoking 10 packs of cigarettes per day [36]. Thus, as well as the cost to the patient, the economic cost of sickness certification is significant. Wage replacement costs accounted for two thirds of the total cost of acute LBP management [15]. Guidelines for acute LBP have been disseminated in 11 countries [22], and the benefits of education in acute LBP management (i.e. using evidence-based guidelines) have been established in terms of cost-effective treatment, significantly more positive patient feedback, significantly less need for continuing treatments, improvements in reported health, lower levels of disability, and lower healthcare costs [13,31].

Despite this, there was evidence that doctors did not adhere to established guidelines because they believed them to be outdated. This concurs with the results of a systematic review of guideline adherence [7]. Barriers to adherence were categorised into three areas – knowledge (lack of awareness and familiarity), attitudes (lack of agreement and self-efficacy, lack of outcome expectancy or the inertia of previous practice) and behavioural (external barriers) framework. This framework maintained that before guidelines could affect patient outcomes, they first had to affect doctors’ knowledge, then attitudes, and finally practice behaviour [7,50].

There was conflicting evidence, however, in the current review that education positively affected doctors’ attitudes and beliefs, and further research is needed in this area. For now, there is evidence that guidelines need to be ‘patient-driven’, and that guideline developers should focus on the needs of the physician, and provide clear statements, decision aids, patient education materials and practical tools to manage difficult problems in practice [17]. Regular reviews and updates of the established guidelines are therefore necessary. Guidelines are expensive – the cost of producing a single guideline may range from $50 to $500,000, not including the substantial donated time from many contributors [5]. Similar factors to those found in the current review were reported in a study involving physiotherapists, where examination of physiotherapists’ management of LBP highlighted a gap between clinical practice and evidence-based guidelines [16,41], with adherence as low as 27% [3]. Reasons for non-adherence included lack of skills, the culture within practice settings, financial barriers, and the miss-fitting of guidelines on practice i.e. patients with acute problems might have severe problems that cannot be solved in one or two sessions. Updating guidelines and disseminating them should include the use of the internet, as it is considered to hold great or very great potential for guideline dissemination [19,42].

In conclusion, to date, only the attitudes and beliefs of GPs to acute LBP management have been determined by this review. Several factors were found to impact doctors’ attitudes and beliefs. The impact of doctors’ specialty, level of specific LBP, and beliefs about guidelines were common themes. These areas require further investigation as they affect clinical decision-making, and result in deviation from evidence-based care. Further research, however, is needed into the impact of some of the factors identified as the validity and strength of the evidence is limited.


This study was supported by a project grant from the Health Research Board, Ireland Research Project Grant 2005/297.


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Low back pain; Doctors’ attitudes and beliefs; Systematic review

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