Back pain is everywhere.

For most people, it settles or becomes managed.

But for some, pain remains a big problem and people understandably look for big solutions.

Spinal surgery feels like one of them—a logical physical solution to what may be understood as a physical problem.

Elective back surgery remains very common in Australia despite its omission from guideline-based care (except in very specific circumstances such as significant neural compromise). 

In fact, spinal fusions in New South Wales alone have jumped more than 300 per cent in the past two decades (Tran et al 2023). 

That’s a huge number—and a huge cost burden—and it is likely that many of these patients have not had the opportunity to fully engage in conservative, multidisciplinary rehabilitation, which evidence suggests is more cost-effective and less risky.

Understanding why people make the choice to pursue surgery is important for physiotherapists, who can play a key role in steering people toward conservative solutions and screening those who may truly benefit from or require surgery.

Our recent research (Harvie et al 2025) shows that surgery seeking isn’t driven by pain alone.

It’s strongly influenced by pain-related beliefs.

Dr Daniel Harvie FACP

And not just any beliefs, but the very beliefs that physiotherapists can help shift through education, movement and psychologically informed approaches, especially within the context of multidisciplinary care.

With stronger buy-in and improved access to these approaches, we could meaningfully change treatment trajectories and outcomes for people with persistent pain.

In our study of privately insured Australians with chronic back pain, one of the strongest predictors of willingness to undergo spinal surgery wasn’t imaging findings or disability level.

It was negative pain beliefs such as fear that the pain will never improve, belief that pain signals serious damage and reduced confidence in being able to live or function with pain.

This is where physiotherapists have a unique opportunity and responsibility.

Physiotherapists aren’t just treating pain; we’re treating interpretations of pain and guiding behavioural and protective responses to pain.

Patients make decisions based on meaning, not sensation.

Two people with the same pain intensity can make completely different choices.

One might think ‘This hurts but it’s manageable’ and the other ‘This pain means I’m damaging my spine—I need surgery’.

Same stimulus, different narrative—different decision path.

As physiotherapists, we routinely assess tissue loading, movement sensitivity and impairments but we should equally be assessing expectations, beliefs, self-efficacy and pain-related anxiety.

These cognitive-affective variables may be as clinically relevant as range of motion or straight leg raise, perhaps even more so.

Pain undoubtedly drives an imperative to seek pain relief as soon as possible, while conservative approaches usually involve the hard slog of rehabilitation for longterm gain.

As such, coping strategies and short-term pain relief and management also matter, even if they don’t cure the problem, and we can’t forget our skills in managing symptoms in the short term.

Short-term relief does more than reduce pain—it reduces urgency and allows people to attend to the strategies that build resilience and reduce sensitivity over a longer timeframe.

Combined with approaches that restore positive pain beliefs, better short-term pain management means less internal pressure to pursue surgery.

It creates psychological breathing room, allowing time for rational decision-making and long-term planning.

The key things to think about as part of long-term care are education, reassurance, pacing, positioning, graded activity, behavioural support, realistic expectations and emotional regulation.

The research shows that unnecessary surgery is wildly expensive, while conservative and multidisciplinary care is far cheaper (Mannion et al 2013, Chowdhury et al 2022).

That’s not just good medicine; it’s good economics.

So, what should we be asking patients?

Informative questions include ‘What do you think is causing your pain?’ ‘What does the pain mean to you?’ ‘How worried are you that this will never improve?’ ‘Do you feel you can live a good life even with some pain?’ and ‘What are your expectations for recovery?’

These take only a few minutes but can provide a basis for discussion and for gently guiding optimistic cognitions and approaches. 

We also need to make sure, by broadening our expertise and clinical referral networks, that people have access to persistent-pain-specific expertise and multidisciplinary support where necessary.

This research was commissioned by MoreGoodDays (moregooddays.com), a company that aims to bridge the gap between community-based care and formal multidisciplinary pain programs, with a particular interest in how such interventions may shape surgical decision-making.

Online programs like this can complement the work of community physiotherapists by providing accessible, pain-specific psychological and physiotherapy support, education and self-management training via telehealth—helping to overcome the typical barriers to multidisciplinary pain care.

Physiotherapists do incredibly costeffective and important work in addressing low back pain and shaping treatment decisions.

If you are already assessing and addressing beliefs early, you may well be having a greater impact than you realise on reducing unnecessary surgical care—saving the healthcare system money, preserving patient agency and confidence, and supporting better long-term recovery trajectories.

We need more quality pain coaching and physiotherapy is uniquely positioned to deliver it and to direct people to it.

Research conclusions Surgery seeking is strongly shaped by negative pain beliefs, low expectation of recovery, low self-efficacy and catastrophic interpretations.

These beliefs about pain and its meaning appear to be better predictors of willingness to pursue surgery than imaging history, pain or functional impairment.

Practical implications for physiotherapists include the following.

1. Assess beliefs as routinely as movement: 

• ask about expectations, worries, perceived meaning of pain and confidence managing life with pain. 

2. Shape helpful pain beliefs early: 

• provide clear education that reframes pain as a modifiable protective response rather than structural damage 
• mould negative beliefs through discussion before they drive surgical decisions. 

3. Offer short-term symptom relief to reduce urgency: 

• draw on reassurance, pacing, positioning, early coping strategies, manual therapy, at-home hot/cold therapy and careful analgesic use to help people feel safer, keep active and slow the drive toward surgery. 

4. Prioritise active strategies to build confidence: 

• use active strategies like exercise, graded exposure, pacing and goal setting to rebuild confidence and self-efficacy 
• support emotional regulation and practical pain management 
• be aware of the need for positive suggestion. 

5. Screen for those who may truly need surgical assessment: 

• understand red flags and indicators for referral (eg, significant or progressive neural compromise). 

6. Use high-value questions that reveal surgical drivers: 

• What do you think is causing your pain? 
• What does this pain mean to you? 
• How worried are you that this won’t improve? 
• Do you feel you can live well even if some pain remains? 

7. Strengthen referral pathways to multidisciplinary care: 

• be aware of funding models that help clients subsidise multidisciplinary services, eg, some private health insurers cover the total cost of the MoreGoodDays program for eligible members and GP mental health treatment plans can subsidise costs of psychology sessions 
• develop networks with pain specialists, psychologists and programs designed to provide pain-specific coaching and education 
• be aware of pain services in your area and how to access them. If you’re not sure, reach out to colleagues in the field. 

8. Recognise and be proud of your role and impact on individuals and the healthcare system: 

• consider that by addressing beliefs and promoting high-value care, physiotherapists help reduce unnecessary surgeries, healthcare costs and long-term disability 
• look after yourself so you can keep caring for others; working in this area can be emotionally and energetically taxing. 

>>Dr Daniel Harvie FACP is a clinical pain scientist, physiotherapist and program director of the Master of Advanced Clinical Physiotherapy in the School of Allied Health and Human Performance, Adelaide University. Daniel is a Specialist Research Physiotherapist (as awarded by the Australian College of Physiotherapists in 2025) and co-author of Pain and perception: a closer look at why we hurt.

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