The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic

REVIEW ARTICLE

The association between health care professional attitudes andbeliefs and the attitudes and beliefs, clinical management, andoutcomes of patients with low back pain: A systematic reviewB. Darlow1,2,, B.M. Fullen3, S. Dean4, D.A. Hurley3, G.D. Baxter2, A. Dowell1

1 Department of Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South 6242, New Zealand

2 Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand

3 School of Public Health, Physiotherapy and Population Science, University College Dublin, Belfield, Dublin 4, Ireland

4 Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, Exeter EX2 4SG, United Kingdom

CorrespondenceBen Darlow

Department of Primary Health Care and

General Practice, University of Otago,

Wellington, PO Box 7343, Wellington South

6242, New Zealand.

Tel.: +64 4 385 5995;

fax: +64 4 385 5539.

E-mail: [email protected]

Funding sourcesNone

Conflicts of interestsNone declared

Accepted for publication5 June 2011

doi:10.1016/j.ejpain.2011.06.006

Abstract

Background: It has been suggested that health care professional (HCP)attitudes and beliefs may negatively influence the beliefs of patients withlow back pain (LBP), but this has not been systematically reviewed. Thisreview aimed to investigate the association between HCP attitudes andbeliefs and the attitudes and beliefs, clinical management, and outcomes ofthis patient population.Methods: Electronic databases were systematically searched for all typesof studies. Studies were selected by predefined inclusion criteria.Methodological quality was appraised and strength of evidence wasdetermined.Results: Seventeen studies from eight countries which investigatedthe attitudes and beliefs of general practitioners, physiotherapists,chiropractors, rheumatologists, orthopaedic surgeons and otherparamedical therapists were included. There is strong evidence that HCPbeliefs about back pain are associated with the beliefs of their patients.There is moderate evidence that HCPs with a biomedical orientation orelevated fear avoidance beliefs are more likely to advise patients to limitwork and physical activities, and are less likely to adhere to treatmentguidelines. There is moderate evidence that HCP attitudes and beliefs areassociated with patient education and bed rest recommendations. There ismoderate evidence that HCP fear avoidance beliefs are associated withreported sick leave prescription and that a biomedical orientation is notassociated with the number of sickness certificates issued for LBP.Conclusion: HCPs need to be aware of the association between theirattitudes and beliefs and the attitudes and beliefs and clinical managementof their patients with LBP.

Cite this article as: Ben Darlow, Brona Fullen, SarahDean, Deirdre A. Hurley, G. David Baxter, AnthonyDowell. The association between health care pro-fessional attitudes and beliefs and the attitudesand beliefs, clinical management, and outcomes ofpatients with low back pain: A systematic review.Eur J Pain 16 (2011) 3–17 [doi:10.1016/j.ejpain.2011.06.006]

1. Introduction

Low back pain (LBP) is a significant and expensivehealth condition, with direct and indirect costs repre-senting an important financial burden (Dagenais et al.,2008). LBP has been estimated to cost 2% of grossdomestic product in developed countries (van Tulderet al., 1995; Wieser et al., 2010).

3Eur J Pain 16 (2012) 3–17 © 2011 European Federation of International Association for the Study of Pain Chapters

LBP treatment guidelines acknowledge the impor-tance of psychosocial factors on the outcome of LBP(Kendall et al., 1997). A recent systematic reviewfound patient depression, psychological distress,passive coping strategies and fear avoidance beliefs tobe independently associated with poor LBP outcome(Ramond et al., 2011); other reviews have also high-lighted the importance of pain self-efficacy beliefs andcatastrophising (Main et al., 2010).

A number of tools have been developed or adaptedto assess the attitudes and beliefs of health care pro-fessionals (HCP) (Bishop et al., 2007) and it has beensuggested that HCP attitudes and beliefs may nega-tively influence the beliefs of their patients (Vlaeyenand Linton, 2006). Although factors which affectgeneral practitioner (GP) attitudes and beliefs regard-ing acute LBP management have been previouslyinvestigated (Fullen et al., 2008), the associationbetween HCP attitudes and beliefs and patient-relatedfactors has not been systematically reviewed.

Parsons et al. (2007) investigated the interactionof patients’ and primary care practitioners’ beliefsand expectations on the process of care for chronicmusculoskeletal pain. This systematic review demon-strated that HCP beliefs influenced patient manage-ment and the patient’s satisfaction with care; however,it did not specifically address LBP, was limited tochronic pain, and only included qualitative studiesrelating to GPs (Parsons et al., 2007).

The aim of this study was to systematically reviewthe evidence regarding the association between HCPattitudes and beliefs and patient-related factors forLBP of any duration. We hypothesised that therewould be an association between HCPs’ attitudes andbeliefs and (i) patient attitudes and beliefs, (ii) patientclinical management, and (iii) patient outcome.

2. Methods

2.1 Search strategy

Electronic searches of Medline, EMBASE, CINAHL,AMED, PsycINFO, and the Cochrane Central Registerof Controlled Trials (January 1990–March 2010) wereconducted in late March 2010.

The search strategy was developed in consultationwith a medical librarian and used a combination ofMeSH terms and keywords. All MeSH terms weremapped to subject headings and checked for othercontexts to ensure inclusion of all appropriate terms; aseparate strategy was developed for each database toaccount for variations in MeSH terms. The final strate-gies were independently checked by two reviewers

(BD, BF). The strategies had four components whichwere combined: (1) attitudes and beliefs, (2) healthcare professionals, (3) low back pain, and (4) patientattitudes and beliefs, management, or outcomes. Thecomplete search strategy for Medline via Ovid is avail-able online (Table S1, see the online version at10.1016/j.ejpain.2011.06.006). Hand searches for rel-evant articles were also conducted on the bibliogra-phies of identified articles and related systematicreviews.

2.2 Study selection and inclusion criteria

Studies relating to LBP (all types and categories) thatinvestigated an association between HCP attitudesand beliefs and patient attitudes and beliefs, clinicalmanagement, or outcomes were included. Originalempirical studies (both quantitative and qualitativemethodologies), written in English, publishedbetween January 1990 and March 2010 were eligible.Studies were excluded if they primarily related to HCPattitudes about outcome expectation, race/ethnicity,gender, or narcotic medications and the relationship toLBP, or to patient satisfaction as an outcome. Titles andabstracts of citations retrieved by the literature searchwere independently scrutinised for eligibility by tworeviewers (BD, BF). Full papers were retrieved andevaluated if the paper appeared to fulfil inclusion cri-teria, if eligibility was unclear based upon the contentof the abstract, or if the abstract was not available.Disagreement regarding eligibility was resolved byconsensus between the two reviewers.

2.3 Data extraction

Potentially relevant papers were independently scru-tinised by two reviewers (BD, BF) using a standardiseddata extraction sheet. The categories of data extractedwere: study characteristics; study population characte-ristics; HCP attitudes and beliefs investigated; and theassociation with patients with LBP. Following dataextraction a final decision on the eligibility of paperswas made by consensus between the two reviewers.

2.4 Quality assessment

Two appraisal systems were chosen for this review; theEpidemiological Appraisal Instrument (EAI) was usedto appraise quantitative studies (Genaidy et al., 2007),and the Critical Appraisal Skills Programme (CASP)system for qualitative studies (Public Health ResourceUnit, 2006). Two reviewers independently appraisedthe articles (SD, DH); all disagreements regarding

The association between health care professional attitudes and outcomes of patients with low back pain B. Darlow et al.

4 Eur J Pain 16 (2012) 3–17 © 2011 European Federation of International Association for the Study of Pain Chapters

https://www.researchgate.net/publication/6370933_An_epidemiological_appraisal_instrument_-_A_tool_for_evaluation_of_epidemiological_studies?el=1_x_8&enrichId=rgreq-ffed61d5-69e7-4b19-9fac-99086a2e0535&enrichSource=Y292ZXJQYWdlOzUxNDU3ODI1O0FTOjEwMjgwMjUxMjY3ODkxM0AxNDAxNTIxNDM3MTQ4

https://www.researchgate.net/publication/6526436_The_Influence_of_Patients'_and_Primary_Care_Practitioners'_Beliefs_and_Expectations_About_Chronic_Musculoskeletal_Pain_on_the_Process_of_Care_A_Systematic_Review_of_Qualitative_Studies?el=1_x_8&enrichId=rgreq-ffed61d5-69e7-4b19-9fac-99086a2e0535&enrichSource=Y292ZXJQYWdlOzUxNDU3ODI1O0FTOjEwMjgwMjUxMjY3ODkxM0AxNDAxNTIxNDM3MTQ4

https://www.researchgate.net/publication/6526436_The_Influence_of_Patients'_and_Primary_Care_Practitioners'_Beliefs_and_Expectations_About_Chronic_Musculoskeletal_Pain_on_the_Process_of_Care_A_Systematic_Review_of_Qualitative_Studies?el=1_x_8&enrichId=rgreq-ffed61d5-69e7-4b19-9fac-99086a2e0535&enrichSource=Y292ZXJQYWdlOzUxNDU3ODI1O0FTOjEwMjgwMjUxMjY3ODkxM0AxNDAxNTIxNDM3MTQ4

https://www.researchgate.net/publication/5456673_Doctors'_attitudes_and_beliefs_regarding_acute_low_back_pain_management_A_systematic_review?el=1_x_8&enrichId=rgreq-ffed61d5-69e7-4b19-9fac-99086a2e0535&enrichSource=Y292ZXJQYWdlOzUxNDU3ODI1O0FTOjEwMjgwMjUxMjY3ODkxM0AxNDAxNTIxNDM3MTQ4

https://www.researchgate.net/publication/41943161_How_important_are_back_pain_beliefs_and_expectations_for_satisfactory_recovery_from_back_pain?el=1_x_8&enrichId=rgreq-ffed61d5-69e7-4b19-9fac-99086a2e0535&enrichSource=Y292ZXJQYWdlOzUxNDU3ODI1O0FTOjEwMjgwMjUxMjY3ODkxM0AxNDAxNTIxNDM3MTQ4

ratings were resolved by consensus between these tworeviewers. One article was rated by a third reviewer(DB) as SD is the first author; SD was not involved inany decision regarding this study (Dean et al., 2005).No guidelines have been developed to rate researchas of low, moderate or high quality within thesetwo systems [personal communication]. We designatedresearch fulfilling less that 50% of criteria as being oflow quality, 50–75% as being of moderate quality andmore than 75% as being of high quality. Studies of lowquality were excluded from analysis.

2.5 Synthesis of evidence

The strength of evidence according to the gradingsystem used in the Agency for Healthcare and PolicyResearch (AHCPR) guidelines was the primaryoutcome measure (Bigos et al., 1994). The quality ofevidence according to the Grading of Recommenda-tions Assessment, Development and Evaluation(GRADE) guidelines was the secondary outcomemeasure (Guyatt et al., 2008).

2.6 Thematic analysis and generalizability

Two reviewers (BD and TD) independently analysedthemes related to (i) study results and (ii) study popu-lation characteristics which might be used to assessgeneralizability, before an agreed collation by thosereviewers.

3. Results

Study identification and selection for analysis is sum-marised in Fig. 1. In total, 20 studies fulfilled the inclu-sion criteria. Results of one study were reported in twoseparate publications, which met the inclusion criteriawhen combined (Buchbinder et al., 2001a,b); this wastreated as one study in the review process. Five studieswere rated as being of high quality and 12 were ratedas moderate quality (Tables S2 and S3, see the onlineversion at 10.1016/j.ejpain.2011.06.006). Threestudies were rated as low quality (Brynhildsen et al.,1995; Rupert, 2000; Houben et al., 2004) and wereexcluded from analysis. All decisions regarding studyinclusion and quality rating were reached by consen-sus, although a third reviewer was appointed toresolve disagreements, this was not required.

Table 1 summarises the characteristics of the 17included studies, more detailed information is avail-able online (Table S4, see the online version at10.1016/j.ejpain.2011.06.006). Studies were of cross-sectional, longitudinal, concurrent cohort, and quali-

tative methodologies. They were conducted in the UK,France, the Netherlands, Australia, Germany, Norway,Sweden, and the USA. Studies were based in primarycare, secondary care, or in settings including patientsor practitioners from both primary and secondarycare. The attitudes and beliefs of GPs, physiotherapists,

1937 records identified through electronic database search

106 AMED322 CINAHL138 Cochrane905 EMBASE351 Medline115 PsychINFO

14 records identified through bibliography scan

1416 records screened for inclusion

535 duplicates removed

17 studies included for qualitative synthesis

1337 excluded on title & abstract

59 excluded after obtaining full text16 had no measure of HCP attitude or belief19 had no measure of patient attitudes & beliefs/management/outcome18 did not relate HCP attitude or belief to patient beliefs/management/outcome 2 studied attitudes to narcotics1 patient satisfaction study 1 studied students not HCPs1 was another publication from same trial 1 review article

20 studies included for quality appraisal

3 excluded following quality appraisal

79 full text articles assessed for eligibility

Figure 1 Flow of studies through the review process.

B. Darlow et al. The association between health care professional attitudes and outcomes of patients with low back pain


https://www.researchgate.net/publication/7724677_Managing_time_An_interpretative_phenomenological_analysis_of_patients'_and_physiotherapists'_perceptions_of_adherence_to_therapeutic_exercise_for_low_back_pain?el=1_x_8&enrichId=rgreq-ffed61d5-69e7-4b19-9fac-99086a2e0535&enrichSource=Y292ZXJQYWdlOzUxNDU3ODI1O0FTOjEwMjgwMjUxMjY3ODkxM0AxNDAxNTIxNDM3MTQ4

https://www.researchgate.net/publication/5415859_Guyatt_GH_Oxman_AD_Vist_GE_et_al_GRADE_Working_Group_GRADE_An_emerging_consensus_on_rating_quality_of_evidence_and_strength_of_recommendations?el=1_x_8&enrichId=rgreq-ffed61d5-69e7-4b19-9fac-99086a2e0535&enrichSource=Y292ZXJQYWdlOzUxNDU3ODI1O0FTOjEwMjgwMjUxMjY3ODkxM0AxNDAxNTIxNDM3MTQ4

Tab

le1

Sum

mar

yof

incl

uded

stud

ies.

Stud

yTy

pe

Cou

ntry

Sett

ing

HC

Psp

ecia

lity

Patie

ntty

pe

Res

ults

Pap

er

qua

lity

Att

itud

e/b

elie

fofH

CP

(sca

le)

Ass

ocia

tion

with

pat

ient

-rel

ated

fact

or

Bis

hop

and

Fost

er(2

005)

C-S

UK

Maj

ority

2°ca

reP

T(n

=45

3)

inM

/Sfie

ld

Thre

evi

gnet

tes

with

acut

eN

SLB

PB

iom

edic

alvs

bio

psy

cho

soci

alo

rien

tati

on

Pati

ent

man

agem

ent

Wo

rkre

com

men

da

tio

ns:

bas

ed

upon

BM

view

–th

egr

eate

rth

e

per

ceiv

edp

atho

logy

the

mor

e

likel

yth

ere

com

men

dat

ion

not

to

wor

k

M

Bis

hop

etal

.

(200

8)

C-S

UK

Maj

ority

1°ca

reG

P(n

=44

2)

PT

(n=

580)

Vig

nett

ew

ithac

ute

NSL

BP

Bio

med

ical

vsb

iop

sych

oso

cial

ori

enta

tio

n(P

AB

S)

Pati

ent

man

agem

ent

Wo

rkre

com

men

da

tio

ns:

advi

ceto

rem

ain

offw

ork

asso

ciat

edw

ith

high

erB

Msc

ores

&lo

wer

BP

S

scor

es

Gu

idel

ine

ad

her

ence

:su

bgr

oup

with

high

BM

/low

BP

Ssc

ores

mor

e

likel

yto

pro

vid

ere

com

men

dat

ions

not

alig

ned

with

guid

elin

es

M

Buc

hbin

der

etal

.

(200

1a,b

)

C-C

Aus

tral

ia1°

care

GP

(n=

2556

)Tw

ovi

gnet

tes

with

acut

e/su

b-a

cute

NSL

BP

Att

itu

des

toLB

Pp

atie

nts

&m

anag

emen

tA

ttitu

des

follo

win

gm

edia

inte

rven

tion

Pati

ent

man

agem

ent

Gu

idel

ine

ad

her

ence

:in

terv

entio

n

grou

pm

ore

likel

yto

be

alig

ned

with

guid

elin

es

M

Cou

dey

reet

al.

(200

6)

C-S

Fran

ce1°

care

GP

(n=

887)

Rep

orte

db

ehav

iour

with

acut

e/ch

roni

cLB

P

Fear

avo

idan

ceb

elie

fs(F

AB

Q)

Pati

ent

man

agem

ent

Hig

hG

PFA

BQ

Phy

sas

soci

ated

with

mor

esi

ckle

ave

pre

scri

ptio

n&

mor

ere

stri

ctiv

eac

tivity

advi

ce;l

ow

GP

FAB

QP

hys

asso

ciat

edw

ith

pro

vid

ing

mor

esp

ecifi

cLB

P

info

rmat

ion

&re

ferr

alto

spin

e

spec

ialis

t/b

ack

scho

ol

Gu

idel

ine

ad

her

ence

:hig

hG

PFA

BQ

scor

esne

gativ

ely

asso

ciat

edw

ith

follo

win

ggu

idel

ines

for

phy

sica

l&

occu

pat

iona

lact

iviti

es

H

Cou

dey

reet

al.

(200

7)

C-S

Fran

ce1°

care

GP

(n=

709)

Patie

nts

with

acut

eN

SLB

P(n

=27

27)

Fear

avo

idan

ceb

elie

fs(F

AB

Q)

Pati

ent

atti

tud

es&

bel

iefs

Wea

kco

rrel

atio

nb

etw

een

GP

s’&

pat

ient

s’fe

arav

oid

ance

bel

iefs

M



Tab

le1

(co

nti

nu

ed)

Stud

yTy

pe

Cou

ntry

Sett

ing

HC

Psp

ecia

lity

Patie

ntty

pe

Res

ults

Pap

er

qua

lity

Att

itud

e/b

elie

fofH

CP

(sca

le)

Ass

ocia

tion

with

pat

ient

-rel

ated

fact

or

Day

kin

and

Ric

hard

son

(200

4)

SSI

UK

2°ca

reP

T(n

=6)

in

NH

S

outp

atie

nts

Patie

nts

with

chro

nic

NSL

BP

(n=

12)

Att

itu

des

toLB

Pp

atie

nts

&m

anag

emen

tB

elie

fsab

out

&p

erce

ptio

nsof

chro

nic

LBP

Pati

ent

atti

tud

es&

bel

iefs

Bel

iefs

ab

ou

tb

ack

pa

in:

exp

lana

tions

may

chan

gep

atie

nt

bel

iefs

H

Pati

ent

man

agem

ent

Edu

cati

on

&g

uid

elin

ea

dh

eren

ce:

BM

view

refle

cted

inst

ruct

ure

orie

ntat

edp

ain

attr

ibut

ions

,

exp

lana

tions

&tr

eatm

ent

stra

tegi

es

Dea

net

al.

(200

5)

SSI

UK

2°ca

reP

T(n

=8)

in

NH

S

outp

atie

nts

Patie

nts

with

acut

e/su

b-a

cute

NSL

BP

(n=

9)

Att

itu

des

toLB

Pp

atie

nts

&m

anag

emen

tA

ttitu

des

to

ther

apeu

ticex

erci

se

Pati

ent

atti

tud

es&

bel

iefs

PTs

try

&ch

ange

pat

ient

s’b

elie

fsto

pro

mot

ead

here

nce

toan

exer

cise

regi

me.

Patie

nts

acce

pt

thei

rla

ck

ofad

here

nce

asre

ason

for

not

imp

rovi

ng

H

Hou

ben

etal

.

(200

5)

C-S

NL

Mix

edPa

ram

edic

al

ther

apis

ts

inP

P

(n=

295)

Thre

evi

gnet

tes

with

chro

nic

NSL

BP

aB

iom

edic

alvs

bio

psy

cho

soci

alo

rien

tati

on

(PA

BS)

Pati

ent

man

agem

ent

Wo

rk&

act

ivit

yre

com

men

da

tio

ns:

BM

orie

ntat

ed

ther

apis

tsvi

ewed

activ

ities

as

mor

eha

rmfu

l&ad

vise

dp

atie

nts

to

limit

dai

lyac

tivity

&w

ork

M

Laek

eman

etal

.

(200

8)

C-S

Ger

man

yM

ixed

PT

(n=

220)

bTh

ree

vign

ette

sw

ithch

roni

cN

SLB

Pa

Bio

med

ical

vsb

iop

sych

oso

cial

ori

enta

tio

n(P

AB

S)

Pati

ent

man

agem

ent

Wo

rk&

act

ivit

yre

com

men

da

tio

ns:

Cor

rela

ted

with

BM

orie

ntat

ion

M

Lint

onet

al.

(200

2)

C-S

Swed

enM

ixed

GP

(n=

60)P

T

(n=

71)

Rep

orte

db

ehav

iour

Fear

avo

idan

ceb

elie

fs(it

ems

from

TSK

,FA

BQ

,PA

IRS)

Pati

ent

man

agem

ent

Wo

rk&

act

ivit

yre

com

men

da

tio

ns:

thos

ew

ith

high

leve

lsof

fear

avoi

dan

ceb

elie

fs

pro

vid

edle

ssin

stru

ctio

nsab

out

activ

ities

M

Sic

knes

sce

rtifi

cati

on

:tho

sew

ith

high

leve

lsof

fear

avoi

dan

ceb

elie

fs

rep

orte

dsi

ckce

rtifi

cate

sto

be

a

good

trea

tmen

t



Tab

le1

(co

nti

nu

ed)

Stud

yTy

pe

Cou

ntry

Sett

ing

HC

Psp

ecia

lity

Patie

ntty

pe

Res

ults

Pap

er

qua

lity

Att

itud

e/b

elie

fofH

CP

(sca

le)

Ass

ocia

tion

with

pat

ient

-rel

ated

fact

or

McI

ntos

han

d

Shaw

(200

3)

SSI & FG

UK

1°ca

reG

P(n

=15

)Pa

tient

sw

ithLB

P(n

=37

)A

ttit

ud

esto

LBP

pat

ien

ts&

man

agem

ent

Info

rmat

ion

pro

visi

on&

The

Bac

kB

ook

Pati

ent

man

agem

ent

Edu

cati

on

:som

eG

Ps

relu

ctan

tto

dis

trib

ute

info

rmat

ion

mat

eria

ls

resu

lting

inin

equa

litie

sfo

rp

atie

nts

inte

rms

ofw

hat

mat

eria

lsth

ey

rece

ive.

Patie

nts

rep

orte

dre

ceiv

ing

little

orno

info

rmat

ion

from

thei

r

GP

s

H

Poir

aud

eau

etal

.

(200

6a)

C-S

Fran

ce2°

care

RH

(n=

266)

Patie

nts

with

acut

e/su

b-a

cute

LBP

(n=

443)

Fear

avo

idan

ceb

elie

fs(F

AB

Q)

Pati

ent

atti

tud

es&

bel

iefs

Fea

ra

void

an

ceb

elie

fs:

high

RH

FAB

QP

hys

scor

esi

gnifi

cant

ly

incr

ease

dri

skof

the

pat

ient

havi

ng

high

FAB

QP

hys

M

Poir

aud

eau

etal

.

(200

6a)

LFr

ance

2°ca

reR

H(n

=26

6)R

epor

ted

beh

avio

urac

ute/

chro

nic

LBP

Patie

nts

with

acut

e/su

b-a

cute

LBP

(n=

440)

Fear

avo

idan

ceb

elie

fs(F

AB

Q)

Pati

ent

man

agem

ent

Hig

hR

HFA

BQ

Phy

sas

soci

ated

with

mor

eb

edre

stp

resc

rip

tion

and

mor

ere

stri

ctiv

ew

ork

&ac

tivity

reco

mm

end

atio

ns;l

ess

likel

yto

cons

ider

mai

nob

ject

ive

of

phy

siot

hera

pyfo

rLB

Pw

asto

rein

forc

em

uscl

est

reng

thor

end

uran

ce;d

idno

td

iffer

inp

atie

nt

refe

rral

orsi

ckle

ave

pre

scri

ptio

n

Pati

ent

ou

tco

me

No

asso

ciat

ion

bet

wee

nR

HFA

BQ

scor

e&

pai

np

ersi

sten

ceat

3

mon

ths

M

Rai

nvill

eet

al.

(200

0)

C-S

USA

Mix

edG

P(n

=41

)

OS

(n=

41)

Thre

evi

gnet

tes

with

chro

nic

NSL

BP

aFe

arav

oid

ance

bel

iefs

(PA

IRS)

Pati

ent

man

agem

ent

Wo

rk&

act

ivit

yre

com

men

da

tio

ns:

corr

elat

ed

with

PAIR

Ssc

ores

M



Tab

le1

(co

nti

nu

ed)

Stud

yTy

pe

Cou

ntry

Sett

ing

HC

Psp

ecia

lity

Patie

ntty

pe

Res

ults

Pap

er

qua

lity

Att

itud

e/b

elie

fofH

CP

(sca

le)

Ass

ocia

tion

with

pat

ient

-rel

ated

fact

or

Sieb

enet

al.

(200

9)

LN

L1

care

GP

(n=

42)

3vi

gnet

tes

with

chro

nic

NSL

BP

a22

2

pat

ient

sw

ithac

ute

NSL

BP

Fear

avo

idan

ceb

elie

fs(P

AIR

S

&TS

K)

Pati

ent

man

agem

ent

Wo

rk&

act

ivit

yre

com

men

da

tio

ns:

(vig

nett

e)

high

erPA

IRS

&TS

Ksc

ores

asso

ciat

edw

ithre

stri

ctiv

eac

tivity

reco

mm

end

atio

ns

Ref

erra

l:(a

ctua

l)no

asso

ciat

ion

bet

wee

nPA

IRS/

TSK

scor

es&

trea

tmen

tb

ehav

iour

(dia

gnos

tic

test

s,d

rug

pre

scri

ptio

n,re

ferr

als)

Pati

ent

ou

tco

me

No

asso

ciat

ion

bet

wee

nG

P

PAIR

S/TS

Ksc

ores

&lo

ng-t

erm

(mea

n1.

9ye

ars)

pat

ient

pai

n/d

isab

ility

M

Wat

son

etal

.

(200

8)

C-S

UK

1°ca

reG

P(n

=83

)Pa

tient

sw

ithN

SLB

PB

iom

edic

alvs

bio

psy

cho

soci

alo

rien

tati

on

(PA

BS)

Pati

ent

man

agem

ent

Sic

knes

sce

rtifi

cati

on

:no

rela

tions

hip

bet

wee

nth

eB

Mor

BP

Ssc

ore

&th

enu

mb

erof

cert

ifica

tes

issu

edfo

rN

SLB

P

H

Wer

ner

etal

.

(200

5)

C-S

Nor

way

Mix

edG

P(n

=19

3)

PT

(n=

255)

CP

(n=

21)

Mem

ber

sof

the

gene

ralp

ublic

(n=

1502

)

Att

itu

des

toLB

Pp

atie

nts

&m

anag

emen

tB

elie

fsab

out

bac

kp

ain

reco

very

&su

rger

yam

ongs

tG

Ps,

PTs

&

CP

s

Pati

ent

atti

tud

es&

bel

iefs

Bel

iefs

ab

ou

tb

ack

pa

in:

pat

ient

bel

iefs

abou

tb

ack

pai

nre

cove

ry

corr

elat

edw

ithb

elie

fsof

the

HC

P

grou

pw

ithw

hom

they

had

cons

ulte

d

Key:

1,p

rim

ary;

2,se

cond

ary;

HC

P,he

alth

care

pro

fess

iona

l;C

-Cco

ncur

rent

coho

rt;C

-S,c

ross

-sec

tiona

l;FG

,foc

usgr

oup

s;L,

long

itud

inal

;SSI

,sem

i-str

uctu

red

inte

rvie

ws;

NL,

The

Net

herl

and

s;U

K,U

nite

d

King

dom

;U

SA,

Uni

ted

Stat

esof

Am

eric

a;C

P,ch

irop

ract

or;

GP,

gene

ral

pra

ctiti

oner

;M

/S,

mus

culo

skel

etal

;N

HS,

Bri

tish

Nat

iona

lH

ealth

Serv

ice;

OS,

orth

opae

dic

surg

eon;

PT,

phy

siot

hera

pis

t;

RH

,rhe

umat

olog

ist;

LBP,

low

bac

kp

ain;

NSL

BP,

non-

spec

ific

low

bac

kp

ain;

CLB

P,ch

roni

clo

wb

ack

pai

n;B

M,b

iom

edic

al;B

PS,

bio

psy

chos

ocia

l;FA

BQ

,Fea

rA

void

ance

Bel

iefs

Que

stio

nnai

re–

Phy

s,p

hysi

cal

sub

scal

e;PA

BS,

Pain

Att

itud

es&

Bel

iefs

Scal

e;PA

IRS,

Pain

&Im

pai

rmen

tR

elat

ions

hip

Scal

e;TS

K,T

amp

aSc

ale

for

Kine

siop

hob

ia;H

,hig

h;M

,mod

erat

e;L,

low

.a Id

entic

alse

tof

vign

ette

sd

evel

oped

by

Rai

nvill

eet

al.(

2000

).bTh

isst

udy

also

incl

uded

60p

hysi

othe

rapy

stud

ents

,thi

sis

not

rep

orte

das

this

revi

ewon

lyre

late

dto

qua

lified

heal

thca

rep

rofe

ssio

nals

.



chiropractors, rheumatologists, orthopaedic surgeons,and other paramedical therapists were investigated.These included biomedical vs biopsychosocial treat-ment orientation, fear avoidance beliefs, and attitudesto LBP patients and their management.

The association between HCP attitudes and beliefsand patientrelated factors was investigated using HCPself-reported behaviour, patient vignettes, patientquestionnaires or interviews, treatment observation oraudit, or a combination of measures. The studiesincluded acute, sub-acute and chronic LBP, as well asparticipants from the general population with previ-ous experiences of LBP. No specific LBP diagnosis wasreported by any study.

Results are described relating to the associationbetween HCP attitudes and beliefs and (i) patients’attitudes and beliefs, (ii) patient clinical management,and (iii) patient outcomes (Table 2). Strength of evi-dence is reported according to the AHCPR system(Bigos et al., 1994) (GRADE quality of evidence ratingin brackets (Guyatt et al., 2008)). Key findings aresummarised in Fig. 2.

3.1 Patient attitudes and beliefs

There is strong evidence (GRADE low quality) thatHCP beliefs about back pain are associated with thebeliefs of their patients (Daykin and Richardson, 2004;Dean et al., 2005; Werner et al., 2005), and moderateevidence (GRADE high quality) that high levels of fearavoidance beliefs in HCPs are associated with highlevels of fear avoidance beliefs in their patients(Poiraudeau et al., 2006a; Coudeyre et al., 2007).

3.2 Patient management

3.2.1 Education

There is moderate evidence (GRADE low quality) thatHCP attitudes and beliefs are associated with the typeand content of education provided to patients (McIn-tosh and Shaw, 2003; Daykin and Richardson, 2004;Coudeyre et al., 2006).

3.2.2 Work and activity recommendations

There is moderate evidence (GRADE moderatequality) that HCPs with a biomedical orientation(Bishop and Foster, 2005; Houben et al., 2005; Bishopet al., 2008; Laekeman et al., 2008) or high fear avoid-ance beliefs (Rainville et al., 2000; Coudeyre et al.,2006; Poiraudeau et al., 2006b; Sieben et al., 2009)

are more likely to advise patients with acute andchronic LBP to limit work and physical activities.

There is moderate evidence (GRADE moderatequality) that HCPs with high fear avoidance beliefs aremore likely to recommend bed rest during sick leavefor acute LBP (Coudeyre et al., 2006; Poiraudeauet al., 2006b), and that a change in HCP beliefs follow-ing a media campaign is associated with them beingless likely to prescribe bed rest (Buchbinder et al.,2001a, b).

There is moderate evidence (GRADE moderatequality) that high HCP fear avoidance beliefs are asso-ciated with increased reported sick leave prescriptionfor acute and chronic LBP (Linton et al., 2002;Coudeyre et al., 2006). There is moderate evidence(GRADE low quality) that a biomedical orientation isnot associated with the number of sickness certificatesprescribed (Watson et al., 2008).

3.2.3 Referral

There is inconsistent evidence regarding the associa-tion between HCP attitudes and beliefs and patientreferral, as outlined in Table 2 (Coudeyre et al., 2006;Poiraudeau et al., 2006b).

3.2.4 Guideline adherence

There is moderate evidence (GRADE low quality) thatHCPs with a biomedical orientation (Daykin andRichardson, 2004) or high levels of fear avoidancebeliefs (Coudeyre et al., 2006; Poiraudeau et al.,2006b) are less likely to adhere to LBP treatmentguidelines.

3.3 Patient outcome

There is limited evidence (GRADE low quality) thatHCP fear avoidance beliefs are not associated with thepersistence of LBP at three months (Poiraudeau et al.,2006b) or long-term pain/disability (Sieben et al.,2009).

3.4 Generalizability

Table S5, see the online version at 10.1016/j.ejpain.2011.06.006 summarises study design andpopulation characteristics related to each finding.

4. Discussion

This systematic review demonstrates strong evidencethat the attitudes and beliefs of patients with LBP are



Tab

le2

Sum

mar

yof

evid

ence

.

Hyp

othe

sis

Them

eEv

iden

ce

Stre

ngth

of

evid

ence

a

Qua

lity

of

evid

ence

bSt

udie

s

Patie

ntat

titud

es

and

bel

iefs

Fear

avoi

dan

ceb

elie

fs•

Hig

hle

vels

ofFA

Bs

inH

CP

sas

soci

ated

with

high

leve

ls

ofFA

Bs

inth

eir

pat

ient

s

Mod

erat

eH

ighe

Cou

dey

reet

al.(

2007

),Po

irau

dea

uet

al.(

2006

a)

Bel

iefs

abou

tb

ack

pai

n•

HC

Pb

elie

fsab

out

bac

kp

ain

are

asso

ciat

edw

ithth

e

bel

iefs

ofth

eir

pat

ient

s

Stro

ngLo

wD

ayki

nan

dR

icha

rdso

n(2

004)

,Dea

net

al.(

2005

),W

erne

r

etal

.(20

05)

Patie

nt

man

agem

ent

Educ

atio

nre

ceiv

edb

yp

atie

nt•

HC

Ps’

BM

orie

ntat

ion

istr

ansl

ated

into

the

exp

lana

tion

give

nto

pat

ient

sab

out

the

sour

ceof

LBP

Mod

erat

eLo

wD

ayki

nan

dR

icha

rdso

n(2

004)

•H

CP

sw

ithlo

wle

vels

ofFA

Bs

mor

elik

ely

top

rovi

de

spec

ific

LBP

info

rmat

ion

Mod

erat

eLo

wC

oud

eyre

etal

.(20

06)

•H

CP

s’ne

gativ

eat

titud

eto

info

rmat

ion

mat

eria

ls

resu

ltsin

pat

ient

sno

tre

ceiv

ing

adeq

uate

info

rmat

ion

&b

eing

frus

trat

edb

yth

is

Mod

erat

eLo

wM

cInt

osh

and

Shaw

(200

3)

Wor

kan

dac

tivity

reco

mm

end

atio

ns•

HC

Ps

with

aB

Mor

ient

atio

nap

pra

ise

mov

emen

tas

bei

ngm

ore

harm

ful

Lim

ited

Low

Hou

ben

etal

.(20

05)

•H

CP

sw

ithhi

ghle

vels

ofFA

Bs

app

rais

em

ovem

ent

as

bei

ngm

ore

harm

ful

Lim

ited

Low

Sieb

enet

al.(

2009

)

•H

CP

sw

ithB

Mor

ient

atio

nad

vise

pat

ient

sto

limit

wor

k

&p

hysi

cala

ctiv

ities

Mod

erat

eM

oder

atec

Bis

hop

and

Fost

er(2

005)

,Bis

hop

etal

.(20

08),

Hou

ben

etal

.(20

05),

Laek

eman

etal

.(20

08)

•H

CP

sw

ithhi

ghle

vels

ofFA

Bs

advi

sep

atie

nts

tolim

it

wor

k&

phy

sica

lact

iviti

es

Mod

erat

eM

oder

atec

Cou

dey

reet

al.(

2006

),Po

irau

dea

uet

al.(

2006

b),

Rai

nvill

eet

al.(

2000

),Si

eben

etal

.(20

09)

•H

CP

BM

orie

ntat

ion

not

corr

elat

edw

ithnu

mb

erof

sick

ness

cert

ifica

tes

issu

ed

Mod

erat

eLo

wW

atso

net

al.(

2008

)

•H

CP

sw

ithhi

ghle

vels

ofFA

Bs

rep

ort

issu

ing

mor

e

sick

ness

cert

ifica

tes

(ass

ocia

tion

not

foun

db

yon

e

stud

y)

Mod

erat

eM

oder

ated

Lint

onet

al.(

2002

),C

oud

eyre

etal

.(20

06),

(Poi

raud

eau

etal

.,20

06b

)

•H

CP

sw

ithhi

ghle

vels

ofFA

Bs

mor

elik

ely

to

reco

mm

end

bed

rest

dur

ing

sick

leav

efo

rac

ute

LBP

Mod

erat

eLo

wC

oud

eyre

etal

.(20

06),

Poir

aud

eau

etal

.(20

06b

)

•A

chan

gein

HC

Pb

elie

fsfo

llow

ing

am

edia

cam

pai

gnis

asso

ciat

edw

ithb

eing

less

likel

yto

pre

scri

be

bed

rest

Mod

erat

eM

oder

ated

Buc

hbin

der

etal

.(20

01a,

b)

•H

CP

sw

ithhi

ghle

vels

ofFA

Bs

pro

vid

ele

ssin

stru

ctio

ns

abou

tac

tiviti

es

Lim

ited

Low

Lint

onet

al.(

2002

)



Tab

le2

(co

nti

nu

ed)

Hyp

othe

sis

Them

eEv

iden

ce

Stre

ngth

of

evid

ence

a

Qua

lity

of

evid

ence

bSt

udie

s

Ref

erra

l•

HC

PFA

Bs

are

not

asso

ciat

edw

ithac

tual

pat

ient

refe

rral

for

dia

gnos

ticte

sts

/the

rapy

/sp

ecia

lists

Lim

ited

Low

Sieb

enet

al.(

2009

)

•H

CP

sw

ithlo

wle

vels

ofFA

Bs

rep

orte

db

eing

mor

e

likel

yto

refe

rch

roni

cLB

Pp

atie

nts

tosp

ecia

lists

or

bac

ksc

hool

inon

est

udy,

but

HC

Ps

with

high

leve

lsof

FAB

sd

idno

tre

por

tin

crea

sed

refe

rral

inan

othe

r

Inco

nsis

tent

Ver

ylo

wC

oud

eyre

etal

.(20

06),

Poir

aud

eau

etal

.,20

06b

•A

chan

gein

bel

iefs

follo

win

ga

med

iaed

ucat

ion

cam

pai

gnis

asso

ciat

edw

ithd

ecre

ased

rep

orte

d

pat

ient

refe

rral

for

test

s/im

agin

g/sp

ecia

lists

for

acut

e/su

b-a

cute

LBP

&in

crea

sed

rep

orte

dre

ferr

alto

phy

siot

hera

pyfo

rsu

b-a

cute

LBP

Lim

ited

Mod

erat

edB

uchb

ind

eret

al.(

2001

a,b

)

Gui

del

ine

adhe

renc

e•

HC

PB

Mor

ient

atio

nas

soci

ated

with

not

adhe

ring

to

guid

elin

es

Mod

erat

eLo

wD

ayki

nan

dR

icha

rdso

n(2

004)

•H

CP

sw

ithhi

ghle

vels

ofFA

Bs

are

less

likel

yto

adhe

re

togu

idel

ines

Mod

erat

eLo

wC

oud

eyre

etal

.(20

06),

Poir

aud

eau

etal

.(20

06b

)

•A

chan

gein

bel

iefs

follo

win

ga

med

iaed

ucat

ion

cam

pai

gnis

asso

ciat

edw

ithb

eing

mor

elik

ely

to

adhe

reto

guid

elin

es

Lim

ited

Low

Buc

hbin

der

etal

.(20

01a,

b)

Patie

nt

outc

ome

•H

CP

FAB

sar

eno

tas

soci

ated

with

pai

np

ersi

sten

ceat

thre

em

onth

s

Lim

ited

Lim

ited

Low

Low

Poir

aud

eau

etal

.(20

06b

)Sie

ben

etal

.(20

09)

•H

CP

FAB

sno

tas

soci

ated

with

long

-ter

mp

ain/

dis

abili

ty

per

sist

ence

Key:

BM

,bio

med

ical

;FA

B,f

ear

avoi

dan

ceb

elie

f;H

CP,

heal

thca

rep

rofe

ssio

nal;

LBP,

low

bac

kp

ain.

a Age

ncy

for

Hea

lthca

rean

dPo

licy

Res

earc

hra

ting.

bG

rad

ing

ofR

ecom

men

dat

ions

Ass

essm

ent,

Dev

elop

men

tan

dEv

alua

tion

ratin

g.c D

ose–

resp

onse

rela

tions

hip

.dO

dd

sra

tioP

�2.

0(�

0.5)

.e O

dd

sra

tioP

�5.

0(�

0.2)

.



associated with the attitudes and beliefs of the HCPwith whom they have consulted. This finding comesfrom consistent evidence from varied research meth-odologies, primary and secondary care, and a range ofspecialities, geographical locations, and cultures. It isdemonstrated in participants with acute, sub-acute,chronic, and previous experiences of LBP.

There is also moderate evidence that patient educa-tion, work and activity recommendations (includingbed rest), and guideline adherence are associated withHCP attitudes and beliefs. Finally, there is moderateevidence that HCP fear avoidance beliefs are associ-ated with reported sick leave prescription, whereasHCP biomedical orientation is not associated with thenumber of sickness certificates issued to patients withLBP.

Parsons et al. (2007) found that GPs providedpathology-based explanations for patients’ chronicmusculoskeletal pain which were grounded in a bio-medical model, and that the education provided topatients was influenced by the beliefs of the GP. Thecurrent study demonstrates similar influences on theeducation provided to LBP patients and that theseinfluences are consistent across HCP disciplines.

Studies included in this review demonstrate thatmany HCPs hold elevated fear avoidance beliefs(Linton et al., 2002; Coudeyre et al., 2006; Poiraudeau

et al., 2006b; Sieben et al., 2009), and that these beliefsare associated with higher levels of fear avoidancebeliefs in their patients, but not persistent pain anddisability. A systematic review has found patient fearavoidance beliefs to be independently associated withpersistent disability, but not pain (Ramond et al.,2011). Poiraudeau et al. (2006b) investigated only painpersistence, while Sieben et al., 2009 investigated painand disability persistence as a unidimensional con-struct. It must also be noted that Sieben et al., (2009)exluded 25 patients with the highest fear-avoidancescores and calculated Graded Chronic Pain Scale scoresbased on other measures taken at baseline, rather thanusing the scale itself (Sieben et al., 2005). This raisesquestions about the suitability of the outcome measure,especially as it is designed and validated in populationswith chronic pain (Underwood et al., 1999; Elliot et al.,2000), as opposed to their very acute sample. It is alsopossible that HCP fear avoidance beliefs may influencethe degree of these beliefs in their patients, but thestrength of this association may not be sufficient toproduce a significant effect on patient outcome, or thatsuch an association does not exist.

The contrasting findings with regards to sicknesscertification may be due to this behaviour being asso-ciated with fear avoidance beliefs rather than a bio-medical treatment orientation, or a difference between

Low quality evidence of NO association

Moderate quality evidence of associationModerate evidence of association

Strong evidence of association

Moderate evidence of NO association X

AHCPR assessment of strength of evidence

Low quality evidence of association

High quality evidence of association

GRADE assessment of quality of evidence

Health Care Professional Attitudes and Beliefs

Biomedical orientation High fear avoidance beliefs

Beliefs about back painNegative attitude to

information materialsPatient beliefs about

back painPatients less likely to receive information

Structure orientated LBP explanations

Bed rest recommended during acute LBP

High patient fear avoidance beliefs

X

Guideline non-adherence

Increased reportedsickness certification

Number of sickness certificates issued

Advice to limit work and physical activities

Figure 2 Summary of strong and moderate evidence of the association between HCP attitudes and beliefs and patient-related factors for LBP.



reported and actual behaviour. Actual treatmentbehaviour may be influenced by case specific factors,such as patient preferences, relationship maintenance,time pressure, and funding issues, or the GP’s generalpropensity to issue sickness certificates, thus maskingany association with HCP attitudes and beliefs(Watson et al., 2008; Sieben et al., 2009).

4.1 Strengths and limitations

A strength of this study is that it included studies ofboth quantitative and qualitative methodologies. Thisapproach provided a much richer perspective, and haspreviously been used in a related systematic review(Fullen et al., 2008). High quality quantitative andqualitative studies were considered to contributeequally to the evidence (Tomlin and Borgetto, 2011).The two methodologies produced consistent conclu-sions, and therefore strengthened the study’s conclu-sions. Although qualitative research is often notperformed with the aim of generalising to other popu-lations, by reporting the characteristics of study popu-lations and setting, judgements can be made as towhether the findings are applicable to another setting(Lincoln and Guba, 1985). Similar to the findings ofFullen et al. (2008), the majority of the quantitativestudies included were only of moderate methodologi-cal quality. In general the findings were consistentacross studies of different quality, however, thestrength of evidence generated was diminished by themodest overall quality. Three studies were excludedbased upon their low quality rating; these studies didnot contradict the review’s conclusions and had lowexternal validity.

This review used the AHCPR strength of evidenceassessment as the primary outcome measure as itallowed the integration of quantitative and qualitativeresearch evidence (Bigos et al., 1994). This gradingsystem has also been utilised in three recent LBP sys-tematic reviews (Fullen et al., 2008; Bigos et al., 2009;Kelly et al., 2011). The GRADE quality of evidenceassessment was used as a secondary outcome measureto provide consistency with Cochrane reviews (Guyattet al., 2008). The GRADE rating was generally lowerthan the AHCPR rating due to there not being amechanism to increase the GRADE based upon con-sistent findings across multiple high quality observa-tional studies.

We took several steps to minimise potential sourcesof bias in this review. We explicitly stated our hypo-theses at the outset, allowing the influence of anypossible preconceptions to be evaluated. Two review-ers independently completed each stage of the review

process, notably article screening, data extraction,quality appraisal, and thematic analysis. This reviewwas also conducted by a collaboration of reviewersfrom a number of institutions, countries, and back-grounds with different research interests, experience,and funding sources.

In this review we combined findings from studiesusing the Fear Avoidance Beliefs Questionnaire(FABQ), Tampa Scale of Kinesiophobia (TSK) and Painand Impairment Relationship Scale (PAIRS) into thecategory of Fear Avoidance Beliefs. This is analogousto the composite survey tool created by Linton et al.(2002). This allowed us to combine several relatedstudies when making strength of evidence assess-ments. These instruments provided consistent findingswhile measuring slightly different aspects of the sameconstruct, thereby increasing the external validity ofthe review’s conclusions.

Studies included in this review used a variety ofmethods to measure the association between HCP atti-tudes and beliefs and patient-related factors. Theseranged from HCP reported behaviour, to patientvignettes, measures taken directly from patients ortheir notes, and direct observation of the treatmentinteraction. Patient vignettes are easy to manipulate,and there is a reduced impact of social desirability,observer bias and Hawthorne effect; however, theymay elicit attitudes and opinions rather than actualbehaviour in real situations (Bishop and Foster, 2005).Measures taken directly from patients may be morerelevant to clinical situations; however, as patientswere recruited by participating HCPs in the studies ofpatient outcome, this may have introduced a source ofbias. A major limitation of this review is that althoughit demonstrates a strong association between the atti-tudes and beliefs of patients with LBP and those of theHCP with whom they have consulted, a causal linkcannot be implied due to the observational nature ofthe majority of studies included. An alternate expla-nation may be that patients choose their HCP accord-ing to beliefs they have already (Werner et al., 2005).

4.2 Practice and research implications

The biopsychosocial model was proposed over 30years ago (Engel, 1977), and is the basis of many LBPtreatment guidelines (Koes et al., 2001), however, anumber of relatively recent studies found that manyHCPs continue to manage their patients within a bio-medical framework. A biomedical orientation has anegative association with patient education, adher-ence to treatment guidelines, and reported work andactivity recommendations. Physiotherapists often



recommend activity and exercise programmes that fitwell within the biopsychosocial model; however, theyjustify these recommendations using a tissue-based(biomedical) explanatory model (Daykin and Richard-son, 2004; Dean et al., 2005). GPs acknowledge theimportance of psychosocial factors, but feel they mustprioritise screening for medical pathology, and thatthey lack the time and training to integrate psychoso-cial assessment (Crawford et al., 2007; Parsons et al.,2007). It appears that biomedical and psychosocialfactors are often viewed as being from separateschema, rather than being part of the same model.Patients experience similar difficulties to HCPs in rec-onciling the two explanatory models; they desire amedical diagnosis despite understanding that psycho-social factors influence their pain (McIntosh andShaw, 2003; Toye and Barker, 2010). Pain of psycho-social origin is often seen as being not real or thepatient’s fault (Toye and Barker, 2010). The challengeis to make the biopsychosocial model more relevant toHCPs, and less stigmatising to patients, withoutunhelpfully reinforcing the already strong biomedicalbeliefs and related behaviours of HCPs. One waywould be to place more emphasis on the bio-component of the model and the biological (neuro-physiological) processes by which psychosocial factorsinfluence pain perception and disability.

The finding that HCPs with a biomedical orientationare less likely to adhere to treatment guidelines maybe unsurprising given their biopsychosocial basis(Koes et al., 2001). The finding that HCPs withelevated fear avoidance beliefs are less likely to adhereto these guidelines is more novel and important. HCPbehaviour is often inconsistent with LBP treatmentguidelines (Foster et al., 1999; Swinkels et al., 2005;Somerville et al., 2008) despite evidence that guide-line adherence improves outcomes and decreaseshealth care utilisation (Rutten et al., 2010). ChangingHCP behaviour is a difficult and complex task; theassociation between attitudes and beliefs and behav-iour demonstrated by this review may provide afoundation for the development of complex cognitive-behaviour interventions for HCPs, similar to thosebeing developed for patients with LBP (Ammendoliaet al., 2009). Given the association between HCP atti-tudes and beliefs and patient attitudes and beliefs,such interventions may have a double benefit of opti-mising management of patients with LBP as well aspositively influencing the attitudes and beliefs of thesepatients.

The two higher quality quantitative studies includedin this review were differentiated from the otherstudies by the participation rates they achieved, their

consideration of losses and unavailable records duringanalysis, their reporting of outcomes relative to expo-sure level and the applicability of their findings(Table S2). We recommend that further longitudinalstudies be performed to investigate the associationbetween HCP attitudes and beliefs and persistent LBPdisability, using appropriate standardised outcomemeasures and researcher recruitment of patient par-ticipants. Developing a causal model for such an asso-ciation would be challenging, although it may bepossible to pre-screen HCPs for attitudes and beliefs,and then randomly allocate patients. Further qualita-tive research may also be useful to investigate causallinks.

4.3 Conclusions

This review demonstrates that HCP attitudes andbeliefs are associated with those of their patients, aswell as their clinical management of patients withLBP; HCPs need to be cognisant of this during consul-tations. The findings of this review may help informthe development of cognitive-behaviour change inter-ventions for HCPs involved in the management of LBP.

Funding

This study received no external funding. All authorshad full access to all of the data (including statisticalreports and tables) in the study and can take respon-sibility for the integrity of the data and the accuracy ofthe data analysis. Dr Sarah Dean’s time is supported byfunding from the National Institute for HealthResearch UK, in connection with her role within thePeninsula Collaboration for Leadership in AppliedHealth Research and Care.

Acknowledgements

We gratefully acknowledge the assistance of RachelEsson, Head of Research and Learning, Victoria Uni-versity of Wellington, NZ in developing the databasesearch strategies.

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Supporting information

Additional Supporting Information may be found inthe online version of this article:

Table S1 Medline via Ovid Search Strategy.Table S2 Quality appraisal of quantitative studiesusing the Epidemiological appraisal Instrument(Genaidy et al., 2007).Table S3 Quality appraisal of qualitative studies usingthe Critical Appraisal Skills Programme (CASP) system(Public Health Resource Unit, 2006).Table S4 Extended summary of included studies.Table S5 Summary of findings including externalvalidity information.

Please note: Wiley-Blackwell are not responsible forthe content or functionality of any supporting mate-rials supplied by the authors. Any queries (other thanmissing material) should be directed to the corre-sponding author for the article.



The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic

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