Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 731–737 731

DOI 10.3233/BMR-140575
IOS Press

Beliefs about low back pain: Status quo in

Indian general population
Venus K. Pagarea,∗, Teena Dhanraja, Dhaval Thakkarb , Aarti Sareena and Tushar J. Palekara
a
Dr D.Y. Patil College of Physiotherapy, Pune, India
b
Department of Radiodiagnosis, Dr D.Y. Patil Medical College, Pune, Maharashtra, India

Abstract.
BACKGROUND: Low back pain (LBP) is a major public health problem and is the leading musculoskeletal cause of disability.
Various bio-behavioral factors which can be associated with disability due to LBP have been identified. When considering these
factors associated with LBP, beliefs that people hold are among the most important factors to consider.
OBJECTIVE: To find out the prevalence of LBP among the general population and to investigate their beliefs towards LBP.
METHODS: A cross-sectional survey of the general population was conducted. Demographic information and information on
beliefs regarding low back pain was gathered from 921 individuals. The respondents were asked to rate their agreement with 7
statements, corresponding to Deyo’s 7 myths.
RESULTS: 75% of the population reported lifetime prevalence of LBP. Regarding the beliefs about LBP, general population
exhibited diverse attitudes. Out of 7 myths explored, 3 myths were found to be dead and buried in more than 50% of the sampled
population. However, 4 out of 7 myths still exist among the population.
CONCLUSIONS: Prevalence of Low Back Pain was found to be high among the general population sampled and also myths
regarding LBP still exist among them.

Keywords: Bio-behavioral factors, bio-psychosocial model, disability, kinesiophobia, myths, low back pain

1. Introduction The traditional methods and concept of management

of low back pain are based on the biomedical model of
Low back pain (LBP) is a major public health prob- disease and pain. According to this model, direct pos-
lem all over the world. It is the leading musculoskele- itive correlation exists among pathology/disease/pain,
tal cause of disability [1–6] and is the most frequently impairment, functional limitation, and disability [11–
reported condition for which people receive outpatient 13]. Identifying the physical impairments and their
physical therapy [1–4]. In India, the occurrence of low correction can therefore have a positive effect on the
back pain (LBP) is high, with nearly 60% individu- disability [14–19]. Studies have however, identified
als having significant back pain at some or the other lack of physical factors to explain the reason for devel-
time in their lives [7,8]. The natural course of LBP is opment of chronicity in these people [20]. In addition,
self-limiting whereas an estimated 10% of patients de- in individuals with low back pain particularly those
velop chronic LBP as defined by duration of more than whose symptoms have persisted beyond a predictable
period of tissue healing, the functional limitation, de-
12 weeks [9,10]. Though this percentage is small, it
gree of pain reported and the disability is frequently
represents a high socioeconomic burden due to the as-
disproportionate to the observed pathology [12,21,22].
sociated disability.
In such patients, the traditional methods of manage-
ment are often ineffective. This proves that, in addition
∗ Corresponding author: Venus Pagare, Padmashree Dr. D.Y. Patil to the nociceptive response from injured tissues, other
College of Physiotherapy, Pune, Maharashtra, India. Tel.: +91 879 factors may be associated with patients’s perception of
3393626; E-mail: [email protected]. pain and behavioral response [23].

c 2015 – IOS Press and the authors. All rights reserved

ISSN 1053-8127/15/$35.00 
732 V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population

According to Engel, the scientific knowledge and beliefs, influences medical management and reduces
technology that has been developed is directed towards disability and workers’ compensation costs related to
“the body and its aberrations”, but the understanding back pain [40]. Thus, re-education can change attitudes
of “human behavior and the psychological and social and beliefs and alter patients’ expectations and behav-
aspects of illness and patient care” is very limited [24]. ior and can reverse or interrupt the rising incidence of
This led to identification of the various bio-behavioral disability from low back pain [40].
factors which can be associated with disability due to Thus, in response to increasing evidence on the role
LBP. These biobehavioral factors are a set of psycho- of psychosocial factors in the development of persis-
logical, environmental, and psycho-physiological pro- tent pain and disability, the aim of this study was to
cesses [23]. Thus, today LBP can be best explained find out the prevalence of LBP among the general pop-
from a viewpoint of bio-psychosocial model [25,26]. ulation and to investigate their beliefs towards LBP.
This model lays emphasis on interactions between bio-
logical, psychological, and social factors which are im-
plicated in persistence of pain and the development of 2. Materials and methods
disability [27,28].
A cross-sectional survey of the general population
According to Predisposing-Reinforcing-Enabling
was conducted in Pimpri region of Pune, India. The
Causes Educational Diagnosis (PRECED) model, study was approved by the institutional sub-ethics
knowledge, perception and belief are predisposing committee of Padm. Dr D.Y. Patil college of Physio-
factors necessary for changing behavior [29]. When therapy. The general population data was sampled dur-
considering the bio-behavioral factors associated with ing early 2014.
LBP, beliefs that people hold are among the most im-
portant factors to consider [30]. These can attenuate or 2.1. Participants
exacerbate the discrepancy among pathology, pain, im-
pairment, functional limitation, and disability and also Convenient sampling method was employed for this
with respect to response to treatment. The extent of prospective hospital-based survey and relatives of pa-
functional impairment that an individual experiences tients seen at the physiotherapy outpatient department
is also dictated by the extent to which the patients be- formed the study subjects. The age group was 18–
lieve that they are disabled by their pain. Cross sec- 60 years and data was collected from individuals who
tional studies have found strong association between were not related to any health care profession, irrespec-
the beliefs of people and physical dysfunction [31]. It tive of past/present history of low back pain. Of the
also determines the nature of seeking healthcare and 994 individuals who were contacted, 921 individuals
their response to the treatment [32,33]. These beliefs agreed to be involved. No incentives were offered to
that people hold are based on prior learning and so- the subjects.
cial influences, including health care provision. Var-
ious beliefs have been linked to low back pain and 2.2. Instruments
these include beliefs such as back pain is inevitably
2.2.1. Demographic information
negative, catastrophisation (hopelessness, magnifica-
Information including age, gender, Occupation,
tion and rumination regarding pain) and fear-avoidance
Qualification, Work status: part time/full time was ob-
beliefs [34–37]. Belief that the pain is stable and un- tained from survey respondents but are not considered
changeable is associated with poor compliance with at this point and will be reported in a subsequent arti-
physical and psychological treatment [38]. On the cle. To obtain data on low back pain prevalence, par-
other hand, patients who believe that they have greater ticipants were asked if they had experienced low back
control over their pain may be more likely to partici- pain at the following time points/periods; now, past
pate and benefit from rehabilitation programs [39]. 1 year or ever in lifetime. Also, they were asked to
There is an increase in evidence like staying ac- report their coping strategies and data on LBP-related
tive and continuing or resuming ordinary activities care seeking in the last month.
is more effective than rest and that early investiga-
tion and referral to a specialist are unwarranted in 2.2.2. Beliefs about back pain
most cases. Previous study has found that a popula- To gather information on beliefs of people regarding
tion based intervention regarding spreading of positive low back pain, the individuals were asked to rate their
messages about back pain can improve population’s agreement with 7 statements, corresponding to Deyo’s
 V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population 733

7 myths [41]. The responders were asked to rate the 4. Discussion

statements on a 5-point likert scale (totally disagree,
disagree, neither disagrees nor agrees, agree, and to- Biological, psychological and social factors, partic-
tally agree). The 7 statements were: ularly an individual’s belief system play an impor-
1. If you have a slipped disc (also known as a her- tant role in the persistence of pain and the devel-
niated or ruptured disc), you must have surgery. opment of disability in low back pain. Irrational be-
2. Radiographs and newer imaging tests (computed liefs about back pain can lead to kinesiophobia (fear
tomography [CT] and magnetic resonance imag- of movement)/re-injury, reduction in activity, function
ing [MRI] scans) can always identify the cause and subsequently disability. The present population-
of pain. based survey was therefore, done to find out the preva-
3. If your back hurts, you should take it easy until lence of low back pain among the general population
the pain goes away. and to find out the beliefs regarding low back pain
4. Most back pain is caused by injuries or heavy lift- among them.
ing. Deyo identified 7 common myths among the peo-
5. Back pain is usually disabling. ple regarding low back pain [41]. These wrong beliefs
6. Everyone with back pain should have a spine ra- have been found to be strongly associated with and im-
diograph. plicated for maintenance or development of disability
7. Bed rest is the mainstay of therapy. due to low back pain. The results of the present sur-
The same were translated in local language (Marathi) vey showed that of these 7 myths, the beliefs of more
by experienced Marathi school teacher and were vali- than 50% of the population were in harmony with the
dated. current scientific evidence for 3 statements. The gen-
eral population showed disagreement with statement
2.3. Statistical analyses “Most back pain is caused by injuries or heavy lifting”.
In reality, over half of the people with back pain de-
Before the analysis, the responses to the myths were velop it gradually without a specific injury [41]. They
categorized into agreeing (totally agree, agree), un- also disapproved that “Back pain is usually disabling”
sure (neither agreeing nor disagreeing), and disagree- and that “Bed rest is the mainstay of therapy”. Evi-
ing (disagreeing, totally disagreeing). Frequencies of dence suggests that although the pain can sometimes
responses were calculated for the general population as be very severe, it is rarely disabling. This disability
percentages. which develops is mainly due to bio-behavioral factors
rather than physical injury associated with LBP. Also,
bed rest as a mainstay for treatment is strongly discour-
3. Results aged as it causes rapid deconditioning making a person
more susceptible to developing chronicity and perpet-
Nine hundred and twenty-one individuals partici-
uates kinesophobia [41]. This pain-kinesiophobia-pain
pated in the survey. Their median (minimum, maxi-
then forms a viscous cycle. Scientific research demon-
mum) age was 52 (21, 58) years, 557 females and 364
strates that those who remain at least active after an
males. High prevalence of back pain was reported with
a lifetime prevalence of 78%, 1 year prevalence of 53% injury do better than those who rest in bed [41].
and point prevalence (at the time of questionnaire com- Though the general population is aware of certain
pletion) of 48%. myths regarding LBP, they are not completely dead
and buried. Some of the wrong beliefs regarding LBP
3.1. Beliefs about low back pain still exist in the population sampled. People still be-
lieve that “for a slip disc (also known as a herniated
Regarding the beliefs about low back pain, the gen- or ruptured disc), surgery is a must”. This holds com-
eral population exhibited diverse attitudes. Out of the pletely wrong as 90% of all herniated discs heal with-
7 myths explored, 3 myths were found to be dead and out surgery [41]. Most of the times, LBP can be man-
buried in more than 50% of the sampled population. aged by staying active and educating people about
However, 4 out of 7 myths still exist among the popu- anatomy and physiology of pain. Surgery is generally
lation. Figure 1 shows Frequencies (%) of disagreeing, not considered until conservative measures have failed.
being unsure, and agreeing with Deyo’s 7 myths for the Also, surgery carries higher risk and also chances of
general population. failure: ‘failed back syndrome’ also exist. Surgery for
734 V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population

1. If you have a slipped disc, you must 2. Radiographs and newer imaging tests can always
have surgery idenƟfy the cause of pain
80%
80%
70%
70%
60%
60%
50% 50%
40% 40%
30% 30%
20% 20%
10% 10%
0% 0%
Disagree Unsure Agree Disagree Unsure Agree

3. If your back hurts, you should take it easy unƟl 4. Most back pain is caused by injuries or
the pain goes away heavy liŌing
90% 90%
80% 80%
70% 70%
60% 60%
50% 50%
40% 40%
30% 30%
20% 20%
10% 10%
0% 0%
Disagree Unsure Agree Disagree Unsure Agree

5. Back pain is usually disabling

80%
70%
60%
50%
40%

30%
20%
10%
0%
Disagree Unsure Agree

6. Everyone with back pain should have a spine radiograph 7. Bed rest is the mainstay of therapy
80% 70%
70% 60%
60%
50%
50%
40%
40%
30%
30%
20%
20%
10% 10%

0% 0%
Disagree Unsure Agree Disagree Unsure Agree

Fig. 1. Shows Frequencies (%) of disagreeing, being unsure, and agreeing with Deyo’s 7 myths for the general population.

LBP is therefore reserved for those with high severity and magnetic resonance imaging [MRI] scans) can al-
or associated complications. ways identify the cause of pain” and that “Everyone
Another common myth which was found to be with back pain should have a spine radiograph”. This
prevalent in Indian population was that “Radiographs shows misconception among the general population re-
and newer imaging tests (computed tomography [CT] garding use of investigative procedures for low back
 V.K. Pagare et al. / Beliefs about low back pain: Status quo in Indian general population 735

pain. Firstly, according to evidence based guidelines rant concerns regarding the activities which are consid-
only 15% of patients with low back pain (LBP) are ered to cause (re) injury. These beliefs become signifi-
given specific diagnosis, the remaining 85% are diag- cant when it leads to behavioral changes in individuals
nosed as ‘non-specific low back pain (NSLBP)’ [42] (fear-avoidance behavior), the restriction of activity by
The term ‘non-specific’ is used to describe an en- the ‘avoiders’, escape and hyper-vigilance being of ut-
tity whose pathoanatomical etiology is unknown [42]. most importance. This is believed to predispose them
Therefore, in most cases of LBP, X-rays or other inves- towards reducing fitness (disuse), depression, persist-
tigations are not needed. Even when indicated, these ing pain and increasing disability [59].
investigations may not identify the cause or source of Thus, the results of the study showed that for this
LBP, with not much contribution to better manage- highly prevalent condition of low back pain, the public
ment [43–45]. Secondly, some of the changes such back pain beliefs sampled were not in harmony with
as ‘disc bulge or degenerative changes’ identified by current scientific evidence. Due to this mismatch, there
these investigations may only be incidental which may is a need to disseminate corrected information to the
even be present in the age and gender matched pop- general population. Thus, strategies for re-educating
ulation without low back pain [46–48]. Thirdly, diag- the public with focus on changing their attitudes and
nostic scans are not reassuring for the patients [49]. promoting their perception so as to create more ade-
A recent study in the USA demonstrated that disabil- quate expectations and behavior are required.
ity was high among the patients who were sent for an
early MRI as compared to those who did not have an
MRI scan [50]. Lastly, these investigations also carry 5. Conclusion
a potential hazard of exposure to radiation. Thus, it is
highly recommended to reserve these expensive inves- Prevalence of Low Back Pain was found to be high
tigations for those with signs of serious pathology who among the general population sampled and also the
myths regarding LBP still exist among them.
can easily be identified by appropriate history taking
and systematic clinical examination.
The last myth reported in high proportion of popu-
Acknowledgements
lation was “If your back hurts, you should take it easy
until the pain goes away”. This completely contrasts We would like to thank all the participants, Dr.
the current scientific evidence according to which, af- (Brig) Amarjit Singh, Dean for his support, Dr. Soumik
ter an initial back injury, it is advisable to avoid ag- Basu and Mr. Karan Udasi for their help in data collec-
gravating or causative activities/movements. However, tion.
there is very strong evidence that keeping active and
returning to all usual activities is important in recov-
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