Health locus of control beliefs and psychological distress as predictors for treatment outcome in low-back pain patients: results of a 3-month follow-up of a controlled intervention study How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists Occupational, Personal and Psychosocial Resources for Preventing Persistent Low Back Pain Do Physical Therapists in the United Kingdom Recognize Psychosocial Factors in Patients With Acute Low Back Pain? Physical performance, pain, pain behavior and subjective disability in patients with subacute low back pain. Delivering an Optimised Behavioural Intervention (OBI) to people with low back pain with high psychological risk; results and lessons learnt from a feasibility randomised controlled trial of Contextual Cognitive Behavioural Therapy (CCBT) vs. Physiotherapy Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement. Prognostic factors for perceived recovery or functional improvement in non-specific low back pain: secondary analyses of three randomized clinical trials Do psychological factors predict outcome in both low-back pain and shoulder pain? The Efficacy of a Short Education Program and a Short Physiotherapy Program for Treating Low Back Pain in Primary Care: A Cluster Randomized Trial Does physiotherapy management of low back pain change as a result of an evidence-based educational programme? Experiences of individuals with chronic low back pain during and after their participation in a spinal stabilisation exercise programme - a pilot qualitative study. A Prospective Study of Incidence and Risk Factors for the Onset and Persistence of Low Back Pain in Thai University Students Assessment of psychosocial risk factors for the development of non-specific chronic disabling low back pain in Japanese workers—findings from the Japan Epidemiological Research of Occupation-related Back Pain (JOB) study It's time for change with the management of non-specific chronic low back pain Active Therapy for Chronic Low Back Pain: Part 3. Factors Influencing Self-Rated Disability and Its Change Following Therapy
& NA ; Association of health locus of control beliefs ( HLC ) and psychological distress ( GHQ‐12 ) with short‐term outcome of low‐back pain ( LBP ) rehabilitation was studied in patients with chronic or recurrent LBP ( n = 459 ; aged 35–54 years ; 63 % men ) . These patients were r and omly assigned to 3 study groups , namely the inpatient , the outpatient and the control group . The results showed a significant decrease in disability due to LBP in the 2 treated groups ; in addition , the accomplishment and frequency of back exercises was significantly better in the treated groups . HLC beliefs were associated with a successful outcome ; those patients with stronger internal beliefs had gained more from the treatment , had learned their exercises better and had done the exercises more frequently during the follow‐up period . Symptoms of psychological distress were significantly associated with poorer accomplishment of back exercises & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes The aim of this prospect i ve cohort study was to identify modifiable protective factors of the progression of acute/subacute low back pain ( LBP ) to the persistent state at an early stage to reduce the socioeconomic burden of persistent LBP .  Patients attending a health practitioner for acute/subacute LBP were assessed at baseline addressing occupational , personal and psychosocial factors , and followed up over 12 weeks . Pearson correlations were calculated between these baseline factors and the presence of nonpersistent LBP at 12-week follow-up . For those factors found to be significant , multivariate logistic regression analyses were performed . The final 3-predictor model included job satisfaction , mental health and social support . The accuracy of the model was 72 % , with 81 % of nonpersistent and 60 % of persistent LBP patients correctly identified . Further research is necessary to confirm the role of different types of social support regarding their prognostic influence on the development of persistent LBP Study Design . A cross-sectional , descriptive vignette survey of practicing , musculoskeletal physical therapists . Objectives . The aim of this study was to determine if musculoskeletal physical therapists , in the United Kingdom , recognize when patients with low back pain ( LBP ) are at risk of chronicity due to psychosocial factors . A secondary aim was to explore the advice they give to patients about  work and activities .  Summary of Background Data . Psychosocial factors have been shown to be important in the progression from acute LBP to chronic disability . Early identification of individuals at risk of developing chronic disability is important to enable targeted intervention . Methods . Three vignettes were written based on acute LBP patients attending for physical therapy  and incorporated into a self-completed postal question naire sent to a simple r and om sample of musculoskeletal physical therapists in the United Kingdom ( n = 900 ) . After one reminder , 20 % of nonresponders were sent a further question naire ( n = 80 ) . Data were analyzed using the Statistical Package for the Social Sciences ( SPSS version 11 ) . Results . The response rate was 57.7 % ( n = 518 ) with 453 meeting all inclusion criteria . The sample consisted of physical therapists working in the musculoskeletal field across all practice setting s. Most correctly rated the chronicity risk of the low- and high-risk patient vignettes . Advice to restrict work and activity was common . Conclusions . Most physical therapists recognize when patients are at high risk of developing chronicity , yet many recommend the patient limit their activity levels and not work . Advice to “ not work ” is associated with more severe perceived spinal pathology , suggesting persistence of the biomedical model for LBP The aim of this paper was to study the physical performance , pain , pain behavior and disability in patients with subacute low back pain ( LBP ) . The patients were blue-collar workers and had been sick-listed for 8 weeks due to subacute low back pain . A total of 103 patients were r and omized , 51 of them to the intervention group and the other to a control group .  Recordings of physical performance and complaints of LBP were done before and after treatment in the intervention group . The proportion of patients with no complaints of LBP was significantly greater in the intervention group than in the control group at the one-year follow-up . The patients who intra-individually improved their physical performance also intra-individually decreased their complaints of LBP . The intra-individual improvements were suggested to be important for the individual return to work Background Low Back Pain ( LBP ) remains a common and costly problem . Psychological obstacles to recovery have been identified , but psychological and behavioural interventions have produced only moderate improvements . Review s of trials have suggested that the interventions lack clear theoretical basis , are often compromised by low dose , lack of fidelity , and delivery by non-experts . In addition , interventions do not directly target known risk mechanisms . We identified a theory driven intervention ( Contexual Cognitive Behavioural Therapy , CCBT ) that directly targets an evidence -based risk mechanism ( avoidance and ensured dose and delivery were optimised . This feasibility study was design ed to test the credibility and acceptability of optimised CCBT against physiotherapy for avoidant LBP patients , and to test recruitment , delivery of the intervention and response rates prior to moving to a full definitive trial . Methods A r and omised controlled feasibility trial with patients r and omised to receive CCBT or physiotherapy . CCBT was delivered by trained supervised psychologists on a one to one basis and comprised up to 8 one-hour sessions . Physiotherapy comprised back to fitness group exercises with at least 60 % of content exercise-based .  Patients were eligible to take part if they had back pain for more than 3 months , and scored above a threshold indicating fear avoidance , catastrophic beliefs and distress . Results 89 patients were recruited .  Uptake rates were above those predicted . Scores for credibility and acceptability of the interventions met the set criteria . Response rates at three and six months fell short of the 75 % target . Problems associated with poor response rates were identified and successfully resolved , rates increased to 77 % at 3 months , and 68 % at 6 months . Independent ratings of treatment sessions indicated that CCBT was delivered to fidelity . Numbers were too small for formal analysis . Although average scores for acceptance were higher in the CCBT group than in the group attending physiotherapy ( increase of 7.9 versus 5.1 ) and change in disability and pain from baseline to 6 months were greater in the CCBT group than in the physiotherapy group , these findings should be interpreted with caution . Conclusions CCBT is a credible and acceptable intervention for LBP patients who exhibit psychological obstacles to recovery . Trial registration IS RCT N43733490 , registered 15/12/2010 BACKGROUND CONTEXT A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain ( LBP ) illness . Although the relative contributions of structural and psychosocial variables are intensely debated , the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects . These factors dictate the requirement for large sample sizes , extensive structural imaging and extended longitudinal study . Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline . PURPOSE To establish , using a strict patient sample design , the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness . STUDY DESIGN / SETTING A prospect i ve , longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics . PATIENT SAMPLE One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic ( non-lumbar ) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease , to undergo baseline examination , testing and 5-year follow-up . OUTCOME MEASURES Observations were made at 6-month intervals over 4 to 6 years ( mean , 5.3 ) for the after primary outcomes measures : episodes of serious back pain ( visual analogue scale [ VAS ] > or = 6 ) , episodes of occupational disability less than 1 week , episodes of occupational disability for 1 week , remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment . METHODS Lumbar magnetic resonance imaging ( MRI ) , lumbar provocative discography ( in psychometrically normal subjects ) , physical examinations , medical and work histories and psychometric testing were performed at baseline . Imaging and psychometric testing were grade d by blinded examiners . A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data . The interview covered interval medical , occupational and accident or injury histories . RESULTS Psychosocial variables strongly predicted both long- and short-term disability events , duration and health-care visits for LBP problems ( p<0.0001 - 0.004 ) . The likelihood of a sustained remission from the baseline persistent ( sub clinical ) LBP appeared to be linked to occupation factors ( leaving a heavy labor occupation ; p=0.0001 ) , neurophysiologic variables ( chronic nonlumbar pain ; p=0.0002 ) and psychometric profiles at baseline ( DRAM and FABQ-PA ; p=0.003 - 0.002 ) . Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome . A positive provocative discogram at baseline did not predict any future adverse event . CONCLUSION The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables . Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing The objective of this study was to report on secondary analyses of a merged trial data set aim ed at exploring the potential importance of patient factors associated with clinical ly relevant improvements in non-acute , non-specific low back pain ( LBP ) . From 273 predominantly male army workers ( mean age 39 ± 10.5 years , range 20–56 years , 4 women ) with LBP who were recruited in three r and omized clinical trials , baseline individual patient factors , pain-related factors , work-related psychosocial factors , and psychological factors were evaluated as potential prognostic variables in a short-term ( post-treatment ) and a long-term logistic regression model ( 6 months after treatment ) . We found one dominant prognostic factor for improvement directly after treatment as well as 6 months later : baseline functional disability , expressed in Rol and –Morris Disability Question naire scores . Baseline fear of movement , expressed in Tampa Scale for Kinesiophobia scores , had also significant prognostic value for long-term improvement . Less strongly associated with the outcome , but also included in our final models , were supervisor social support and duration of complaints ( short-term model ) , and co-worker social support and pain radiation ( long-term model ) . Information about initial levels of functional disability and fear-avoidance behaviour can be of value in the treatment of patient population s with characteristics comparable to the current army study population ( e.g. , predominantly male , physically active , working , moderate but chronic back problems ) . Individuals at risk for poor long-term LBP recovery , i.e. , individuals with high initial level of disability and prominent fear-avoidance behaviour , can be distinguished that may need additional cognitive-behavioural treatment Background and Objective : Psychological factors are assumed to predict persistent or recurrent musculoskeletal pain . The influence of psychological factors in patients with low-back pain ( LBP ) or shoulder pain was explored to study whether there is similarity regarding the factors that predict persisting pain and disability . Methods : Patients presenting in primary care with a new episode of shoulder pain or non-specific (sub)acute low back pain ( LBP ) were enrolled in a prospect i ve study . In both patient groups ,  pain catastrophising , distress , somatisation and fear-avoidance beliefs  were measured at baseline . Primary outcome measures at 3 months were ( 1 ) persistent symptoms , and ( 2 ) < 30 % reduction in functional disability .  Multivariate logistic regression analysis was used to study the associations between psychological factors and outcome . Results : A total of 587 patients with shoulder pain and 171 patients with LBP were enrolled in the study . In patients with shoulder pain , most associations of psychological factors with outcome were weak and not significant . Only in patients with longer symptom duration at baseline ( ⩾3 months ) were higher scores on catastrophising significantly associated with persistent symptoms ( p = 0.04 ) . In patients with LBP , psychological factors were more strongly associated with poor outcome , although most associations were not significant . Conclusion : Psychological factors , with the exception of fear-avoidance beliefs , are more strongly associated with persistent pain and disability in patients with LBP than in those with shoulder pain . This seems to indicate that in a primary care population the influence of psychological factors on outcome may vary across patients with different types of pain Study Design . Cluster r and omized clinical trial . Objective . To assess the efficacy of a short education program and short physiotherapy program for treating low back pain ( LBP ) in primary care . Summary of Background Data . There is sparse evidence on the effectiveness of education and physiotherapy programs that are short enough to be feasible in primary care . Methods . Sixty-nine primary care physicians were r and omly assigned to 3 groups and recruited 348 patients consulting for LBP ; 265 ( 79.8 % ) were chronic . All patients received usual care , were given a booklet and received a consistent 15 minutes group talk on health education , which focused on healthy nutrition habits in the control group , and on active management for LBP in the “ education ” and “ education + physiotherapy ” groups . Additionally , in the “ education + physiotherapy ” group , patients were given a second booklet and a 15-minute group talk on postural hygiene , and 4 one-hour physiotherapy sessions of exercise and stretching which they were encouraged to keep practicing at home . The main outcome measure was improvement of LBP-related disability at 6 months . Patients ' assessment and data analyses were blinded . Results . During the 6-month follow-up period , improvement in the “ control ” group was negligible . Additional improvement in the “ education ” and “ education + physiotherapy ” groups was found for disability ( 2.0 and 2.2 Rol and Morris Question naire points , respectively ) , LBP ( 1.8 and 2.10 Visual Analogue Scale points ) , referred pain ( 1.3 and 1.6 Visual Analogue Scale points ) , catastrophizing ( 1.6 and 1.8 Coping Strategies Question naire points ) , physical quality of life ( 2.9 and 2.9 SF-12 points ) , and mental quality of life ( 3.7 and 5.1 SF-12 points ) . Conclusion . The addition of a short education program on active management to usual care in primary care leads to small but consistent improvements in disability , pain , and quality of life . The addition of a short physiotherapy program composed of education on postural hygiene and exercise intended to be continued at home , increases those improvements , although the magnitude of that increase is clinical ly irrelevant RATIONALE The concept of evidence -based medicine is important in providing efficient health care . The process uses research findings as the basis for clinical decision making . Evidence -based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide . Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence . The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed . AIMS The aim of this study was to investigate if physiotherapists ' clinical management of patients with low back pain would change following an evidence -based education package , which utilized local opinion leaders and delivered the best evidence . METHOD Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster r and omized by location of work , to two groups . The intervention group received an evidence -based programme on the management of low back pain , including advice regarding increasing activity levels and return to normal activity and challenging patients ' fears and beliefs about their pain . The control group received a st and ard in-service training package on the management of common knee pathologies . The physiotherapists ' clinical management of patients with low back pain was measured prior to training and 6 months post training . Outcome measures were based on physiotherapists completing ' discharge summary ' question naires , which included information relating to the use and importance of therapies for treating their low back pain patients . RESULTS There were few significant differences in treatment options between the intervention and control groups post training . Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain , there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention . CONCLUSIONS Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain . This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice . Whilst there were some limitations in the overall size of the study , the results help to give an insight into the challenges faced by the health care system and research ers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care Spinal stabilisation exercises are commonly used in the management of low back pain ( LBP ) . There is limited evidence relating to patients ' experiences of their involvement in such programmes . The aim of this study was to explore the experiences of a sample of individuals with chronic LBP who participated in a r and omised controlled trial ( RCT ) investigating the most efficacious dosage and frequency of spinal stabilisation exercises .  The qualitative study involved nine participants who took part in focus group discussion s. The data were analysed using thematic content analysis and provided insights into the experiences of the participants . Four themes emerged : Physical dimensions of the LBP experience , emotional and psychological dimensions of the LBP experience and perceived effects of the programme and lastly , the impact of the treatment programme on participants ' knowledge , underst and ing and adherence . In conclusion participants ' experiences were not limited to the positive effects of stabilisation exercises on pain , functional disability and quality of life , but also reflected increases in confidence , the formulation of self help strategies and the ability to exert better control over their LBP . The findings highlight the importance of well planned associated educational support packages in the treatment of LBP paving the way for future qualitative research This study aim ed to examine the 12-month incidence and risk factors for the onset and persistence of low back pain ( LBP ) in undergraduate students . A 1-year prospect i ve study was carried out among 684 healthy students in a large public university in Thail and . Data were collected using a self-administered question naire and a physical examination . Follow-up data were collected every 3 months . A total of 524 ( 77 % ) students were followed for 1 year . A total of 31 % reported a new onset of LBP , of whom 31 % reported persistent LBP . Having no low back support during computer work was a significant predictor for the onset and persistence of LBP . The onset of LBP was also associated with quadriceps muscle tightness . LBP is common among undergraduate students , and many of them may have persistent symptoms . Physical risk factor plays a significant role for the onset and persistence of LBP among the study population To investigate the associations between psychosocial factors and the development of  chronic disabling low back pain ( LBP ) in Japanese workers . A 1 yr prospect i ve cohort of the Japan Epidemiological Research of Occupation-related Back Pain ( JOB ) study was used . The participants were office workers , nurses , sales/marketing personnel , and manufacturing engineers . Self-administered question naires were distributed twice : at baseline and 1 yr after baseline . The outcome of interest was the development of chronic disabling LBP during the 1 yr follow-up period . Incidence was calculated for the participants who experienced disabling LBP during the month prior to baseline . Logistic regression was used to assess risk factors for chronic disabling LBP . Of 5,310 participants responding at baseline ( response rate : 86.5 % ) , 3,811 completed the question naire at follow-up . Among 171 eligible participants who experienced disabling back pain during the month prior to baseline , 29 ( 17.0 % ) developed chronic disabling LBP during the follow-up period . Multivariate logistic regression analysis implied reward to work ( not feeling rewarded , OR : 3.62 , 95%CI : 1.17–11.19 ) , anxiety ( anxious , OR : 2.89 , 95%CI : 0.97–8.57 ) , and daily-life satisfaction ( not satisfied , ORs : 4.14 , 95%CI : 1.18–14.58 ) were significant . Psychosocial factors are key to the development of chronic disabling LBP in Japanese workers .  Psychosocial interventions may reduce the impact of LBP in the workplace Low back pain ( LBP ) is the second greatest cause of disability in the USA.1 USA data supports that in spite of an enormous increase in the health re sources spent on LBP disorders , the disability relating to them continues to increase.2 The management of LBP is underpinned by the exponential increase in the use of physical therapies , opiod medications , spinal injections as well as disc replacement and fusion surgery.2 This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model.1 This is in spite of calls over a number of years to adopt a bio-psycho-social approach , and evidence that only 8–15 % of patients with LBP have an identified patho-anatomical diagnosis , result ing in the majority being diagnosed as having non-specific LBP.3 Of this population , a small but significant group becomes chronic and disabled , labelled non-specific chronic low back pain ( NSCLBP ) , consuming a disproportionate amount of healthcare re sources .4 1 . Over the past decade , the traditional biomedical view of LBP has been greatly challenged . This is a result of : the failure of simplistic single-dimensional therapies to show large effects in patients with NSCLBP5–8 ; 2 . the results of clinical trials testing commonly prescribed interventions demonstrating that no management approaches are clearly superior5–7 9 ; 3 . the stories of NSCLBP patients relating their own ongoing pain experiences of multiple failed treatments , conflicting diagnoses , lost hope and ongoing suffering10 ; 4 . the indisputable evidence supporting the multidimensional nature of NSCLBP as a disorder , where disability levels are more closely associated with cognitive and behavioural aspects of pain rather than sensory and biomedical ones11 12 ; 5 . positive outcomes in r and omised controlled trials ( RCTs ) are best predicted by changes in psychological distress , fear avoidance beliefs , self-efficacy in Design . Cross-sectional analysis of the factors influencing  self-rated disability associated with chronic low back pain and prospect i ve study of the relationship between changes in each of these factors and in disability following active therapy . Objectives . To examine the relative influences of pain , psychological factors , and physiological factors on self-rated disability . Summary of Background Data . In chronic LBP , the interrelationship between physical impairment , pain , and disability is particularly complicated , due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment . Investigations using new “ belief ” question naires and “ sophisticated ” performance tests , which have shown promise as discriminating measures of impairment , may assist in clarifying the situation . Previous studies have rarely investigated all these factors simultaneously . Methods . One hundred forty-eight patients with cLBP completed question naires and underwent tests of mobility , strength , muscle activation , and fatigability , and ( in a subgroup ) erector spinae size and fiber size/type distribution . All measures were repeated after 3 months active therapy . Relationships between each factor and self-rated disability ( Rol and and Morris question naire ) at baseline , and between the changes in each factor and changes in disability following therapy , were examined . Results . Stepwise linear regression showed that the most significant predictors of disability at baseline were , in decreasing order of importance : pain ; psychological distress ; fear-avoidance beliefs ; muscle activation levels ; lumbar range of motion ; gender . Only changes in pain , psychological distress , and fear-avoidance beliefs significantly accounted for the changes in disability following therapy . Conclusion . A combination of pain , psychological and physiological factors was best able to predict baseline disability , although its decrease following therapy was determined only by reductions in pain and psychological variables . The active therapy programm — in addition to improving physical function — appeared capable of modifying important psychological factors , possibly as a result of the positive experience of completing the prescribed exercises without undue harm
Physiotherapists partially recognised cognitive , psychological and social factors in people with LBP .
Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP , and some stigmatised the behaviours suggestive of cognitive , psychological and social contributions to LBP .
Physiotherapists perceived that neither their initial training , nor currently available professional development training , instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP .
QUESTION What are physiotherapists ' perceptions about identifying and managing the cognitive , psychological and social factors that may act as barriers to recovery for people with low back pain ( LBP ) ?