Where to start with education and advice for people with low back pain?

Where to start with education and advice for people with low back pain?

Where to start with education and advice for people with low back pain?

Where to start with education and advice for people with low back pain?

A new questionnaire could enable clinicians to tailor the education and advice they provide to align with patients’ attitudes, which, writes Edel O’Hagan, may lead to more efficient delivery of first-line care and potentially improve patient outcomes.

The first-line care consistently recommended for people with low back pain includes patient education and advice.

Regardless of the duration of low back pain, clinicians should provide education on the benign nature of low back pain, reassurance about the absence of a serious medical condition and advice to remain active.

Systematic reviews have highlighted a gap between clinical practice guideline recommendations for first-line care and the care that is usually provided to people with low back pain.

Short consultation times and a desire to maintain a harmonious relationship with patients are reported barriers to providing education and advice to people with low back pain.

Time constraints may manifest as a consultation feeling rushed, which may hinder uptake of patient education and advice and reduce their effectiveness.

The Attitude toward Education and advice for Low back pain Questionnaire (AxEL-Q) is a new questionnaire designed to enable clinicians to provide more efficient consultations within the time constraints of clinical practice.

Development and evaluation

We used guidance from the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) consortium to develop the questionnaire and evaluated it in a sample of people with low back pain of any duration.

Participants were recruited from the community, were over 18 years of age and were fluent in English.

A recent Delphi survey that included a panel of expert researchers, clinicians and consumers with low back pain reached a consensus on a set of evidence-based key statements for people with low back pain.

Semantic scales were used to measure attitude towards these statements.

These items were combined to develop the questionnaire draft.

Edel O'Hagan and colleagues have designed and evaluated a questionnaire on attitudes to education and advice among patients with low back pain. 

Construct validity was evaluated with exploratory factor analysis and hypotheses testing, comparing to the Back Beliefs Questionnaire and modified Pain Self-Efficacy Questionnaire.

Reliability was evaluated, and floor and ceiling effects calculated.

The questionnaire was evaluated in 313 participants.

The questionnaire draft was reduced to a three-factor questionnaire through exploratory factor analysis: Factor 1—Attitude toward staying active—consists of nine items, with a score range from 0 to 54 and higher scores indicating a more positive attitude; Factor 2—Attitude toward low back pain being rarely caused by a serious health problem—consists of four items, with a score range from 0 to 24 and higher scores indicating a more positive attitude; Factor 3—Attitude toward not needing to know the cause of back pain to manage it effectively—consists of four items, with a score range from 0 to 24 and higher scores indicating a more positive attitude.

There was a strong inverse association between each factor and the Back Beliefs Questionnaire and a moderate positive association with the modified Pain Self-Efficacy Questionnaire.

Each independent factor demonstrated acceptable internal consistency: Cronbach a Factor 1=0.92, Factor 2=0.91, Factor 3=0.90 and adequate interclass correlation coefficients: Factor 1=0.71, Factor 2=0.73, Factor 3=0.79.

Each subscale could be used independently to understand attitudes toward distinct aspects of education and advice for people with low back pain.

Clinical applications

The AxEL-Q could be integrated into clinical practice in two ways.

Firstly, the AxEL-Q could provide a starting point to guide clinical consultations.

For example, a negative attitude toward a message of education that low back pain is rarely caused by a serious health problem could lead a clinician to target that message, and begin a conversation with questions such as, ‘Why did you answer that way?’ or ‘What does this statement mean to you?’

Conversely, a positive attitude toward a message about advice to stay active might suggest that the clinician should not focus on re-enforcing that message.

Secondly, the AxEL-Q could be used as a triage tool to identify people whose pain could be managed remotely using telehealth.

The COVID-19 pandemic has seen the rapid adoption of telehealth in the management of people with musculoskeletal pain.

Current guidance on who to triage to telehealth is based on several clinical judgements.

The AxEL-Q could provide clinicians with reassurance and insight to identify patients who are likely to adhere to education and advice and may be suitable for telehealth management; for example, if a patient has a positive attitude toward all factors, the clinician may consider telehealth management appropriate.

A tool that identifies people who would benefit equally from remote management could generate significant savings for individuals and health services.

Whether the use of the questionnaire leads to improved patient outcomes would need to be tested in future research.

>> Edel O’Hagan APAM is an experienced clinical physiotherapist and early career researcher. Edel’s clinical career over 15 years has included roles in the public and private settings in Ireland, New Zealand and Australia. She completed her research master’s at Neuroscience Research Australia in 2016 and is currently a PhD candidate.


O’Hagan, E.T., Skinner, I.W., Jones, M.D. et al. 'Development and measurement properties of the AxEL (attitude toward education and advice for low-back-pain) questionnaire.' Health Qual Life Outcomes 20, 4 (2022). https://doi.org/10.1186/s12955-021-01908-4 (Open Access)




© Copyright 2018 by Australian Physiotherapy Association. All rights reserved.