Cause of CLBP attributed to physical and structural/anatomical factors

All participants held similar biomedical CLBP beliefs. Common causal beliefs attributed CLBP to physical and structural/anatomical factors. These mainly included bending and lifting strains, for example:

I basically bent down to pick up a pen or something and it clicked and I couldn’t straighten myself up. (S6)

Consistent with these beliefs, in cases where a physical causal mechanism could not be recalled, participants self-diagnosed a structural/anatomical cause for their CLBP. The most frequently expressed labels included: ‘slipped disc’ (n=5), ‘wear and tear’ (n=3) and ‘trapped nerve’ (n=3).

Recalling HCPs’ biomedical diagnosis and the biomedical beliefs adopted

Most participants recalled a diagnostic label derived from HCPs embedded within the biomedical model, consistent with their own beliefs. Nonetheless, some interpreted this information negatively. Following a consultation with a chiropractor, one participant perceived his back ‘… was out of place’ (S7).

Biomedical CLBP beliefs were influenced by manual-handling training and by participants’ occupation. A HCP working in a hospital believed the repetitive nature of manual handling in ward settings to be a cause of his CLBP. Subsequently, participants’ adopted the belief their spine needed protecting when bending and lifting:

I suppose if you lift incorrectly it will cause back pain. I mean we have all had it drummed in to us (manual-handling training), how to bend our knees and how to do all that malarkey. (S2)

Vulnerability of the spine

Many viewed their spine as vulnerable, central to function and critical to one’s well-being. Given participants had ‘one back’, which was hard to see, combined with a feeling of weakness, the back was commonly described as ‘precious’ and, when compared with an ankle sprain, required more protection:

It just feels as though the spine controls so much of your function in your legs and everything, that if you injure it, it’s much more serious than perhaps injuring your ankle. (S2)

Consistent with higher levels of disability, participants’ fear-avoidance beliefs suggested they believed pain indicated harm and was a warning signal from the back:

Your back is trying to tell you something. It’s trying to tell you to stop doing whatever you’re doing if it’s hurting…because you are making it worse. (S3)

Future outlook

Participants tried to maintain a positive future outlook; this was mainly based on prior pain experiences and individual personalities.

I even think now that I will wake up and it will all go away and it maybe will. (S2)

Despite this, there was an overriding feeling of uncertainty:

I don’t want to think about that because I don’t know how I’m going to be. (S5)

For some Punjabi participants, religion was expressed as a key part of their lives and interlinked with their positive outlook on pain. One participant described a hand injury whereby his fingers were amputated as ‘God’s will’ and expressed his positive outlook in the context of his religious beliefs:

Someone up there wanted them so they were gone…my sin plate was wiped clean on that day and we start again. (S1)

Active coping strategies

White British participants predominantly demonstrated active coping ‘self-help’ strategies based on prior CLBP experiences and searching online for knowledge and understanding:

I went onto NHS choices and typed in sciatica - just that word and a whole load of stuff comes up and there is one big sentence and it says ‘keep active…’. (S2)

Among the white British group, exercise strategies such as stretching, yoga and football were used. They commonly shared the narrative ‘confronting pain and battling on’. Influenced by a need to avoid interference in one’s life, fulfil family and parental duties and avoid burdening others, this often meant enduring pain.

All I was bothered about was getting things better for him (disabled child) because he literally couldn’t do anything. (S4)

Reliance on HCPs and biomedical interventions

A lack of understanding and control over pain led some participants to rely on HCPs in an unrelenting search for a diagnostic label, while others sought reassurance via scans:

I wanted to have a scan just to see if there was anything major wrong. (S9)

Both groups expressed varying levels of reliance on medication, ranging from daily use to situations of desperation where they felt ‘physically stuck’ or to prevent pain intensifying.

In contrast to white British participants, Punjabi participants demonstrated a passive reliance on HCPs to provide ‘quick fix’ interventions including acupuncture, massage and most frequently manual therapies:

You go there (manual therapist) for a quick fix. (S6)

Protective and avoidance coping strategies

In terms of bending, lifting and heavy physical tasks, many participants used protective and avoidance strategies. Meanwhile, experiencing exercise-related pain increased fear avoidance around exercise, which promoted resting behaviours. Uncertainty about the cause of pain increased hypervigilance to the threat of pain and adherence to manual handling advice to protect the back reflecting a belief of spinal vulnerability:

I think a bit more…. if I have a task that it would probably involve lifting a box or whatever, I will now consciously think, make sure you bend your knees and you keep your back straight if you’re lifting something or whatever. Whereas previously you think you are fine, it doesn’t matter, nothing is going to happen …. (S1)

Coping transition

An interesting difference emerged in the coping trajectories of white British and Punjabi participants. Although it was not clear how this transition took place, all Punjabi participants reported a transition from a passive reliance on HCPs for a ‘quick fix’ to more active coping strategies such as self-searching the internet, as well as replacing rest with increased physical and social activities in order to resume normal life:

Instead of relax it…. I’d just go back to my normal routine. (S6)

Psychological and emotional consequences

Across both groups, a number of negative psychological and emotional dimensions of CLBP were expressed. Those with more disabling CLBP most frequently reported depressed mood, hopelessness, frustration, catastrophising thoughts and uncertainty about pain and lack of control over it.

Depressed mood was most often expressed in relation to the persistence of CLBP and as a consequence of failed interventions, disruption to sleep and engagement in meaningful activities. Some attributed disabling CLBP to weight gain resulting in depressed mood:

Because I put on a lot of weight when I was bed bound that got me really down. (S5)

Hopelessness was attributed to a lack of control over pain and a lack of support from HCPs who, in some cases, painted a pessimistic outlook:

No I mean they just said it’s just down to wear and tear basically and you’ve got to live with it. (S9)

Frustration was repeatedly expressed in relation to a lack of understanding of the cause of pain and the interference with daily life and, in some cases, the desire to exercise and lose weight. Participants with more disabling pain held catastrophic CLBP thoughts. Similar to depressed mood and frustration, this was associated with diagnostic uncertainty and a lack of control over pain, resulting in catastrophising about the future:

I might not walk again. (S5)

Catastrophic nature of pain flare-ups

Often participants used catastrophic language to portray the unpredictable, fluctuating and uncontrollable disabling impact of flare-ups, for example:

I would say at it’s very worst point it feels like a ball of fire. It’s debilitating to the point where I want to cut my left-side off. It’s awful and the longer the pain continues the worse it seems to spread. (S4)

For some, this entailed a physical and emotional struggle. However, only a few seemed to form a link between their thoughts and CLBP:

When I have got a project or something… I am not thinking about my back at all. I am just cracking on. I’m noticing it more because I have got time on my hands. (S4)

Threat to self-identity

Cross-cultural comparisons highlighted that CLBP posed a major threat to participants’ ‘self’ and their identity. Some described negative consequences of CLBP such as low self-esteem, reduced independence and disempowerment. One participant expressed disabling CLBP as a major loss:

Everything is just gone now like dignity, confidence. I had a stick but I would only use that sometimes if I was going out. (S5)

During flare-ups, a small number expressed difficulties carrying out daily functional activities. The greatest impact seemed to be on bending-related tasks such as putting on socks and hoovering. This led to dependency on family members and changing roles in their relationships, which negatively impacted participants’ psychological and emotional well-being.

Threat to family/friend relationships and social life

Mostly expressed by white British participants, the interference of CLBP on family relationships and fulfilling parental roles was described as ‘restrictive’ on their spouse/partner, often eliciting negative emotions in family members. One participant identified her coping strategies as a potential cause of frustration:

My husband also gets frustrated with me. He says ‘what you being a legend for, why don’t you just sit down and do it later’. I don’t know… he still thinks I have OCD. (S4)

CLBP inhibited social interactions across both groups. Social isolation was the consequence for some previously sociable participants with more disabling pain:

Just walking round town I have to stop and go in a café and have a coffee just to sit down to rest my back. I stay at home now. (S9)

Work impact

Disrupting work roles, those sitting at work constantly fidgeted and had move in an attempt to control pain. Participants also commented how CLBP impacted on colleagues. Sickness absence was discussed by most with varied views, while some cited having time off work due to a flare-up:

I did have time off ‘cos my back was hurting too much. (S7)

The impact of CLBP on cultural and religious well-being

CLBP negatively impacted cultural-religious well-being of Punjabi participants, consistently impeding meditation, particularly as this involved sitting cross-legged on a floor for long periods:

I do sit down crossed legs on the floor when we pray and meditate and maybe that has slight impact on it, you know when it maybe gets tired. (S6)

This impact varied from ‘the hips and back locking’ to an inability to sit, leaving one participant secluding herself from religious rituals that involved sitting:

(Referring to sitting in the temple) I’ll just go when it’s quiet y’know, ermmm do my praying and then come back out and then just go downstairs where there’s chairs or… I can just hang around somewhere else…I feel excluded sometimes because y’know people tend to like wanna sit upstairs and I have to like go just downstairs. (S10)

Cultural roles and obligations were impacted. In this context, one Punjabi female described the ‘perceived’ female cultural role and how CLBP disrupted her ability to carry out household duties including cooking. Viewed as essential to the female role among Punjabis, difficulties with or an inability to carry out these duties had far-reaching consequences such as finding a marriage partner:

With the Asian culture a girl has to do housework - she has to get prepared for her married life, so she has to learn how to cook, she has to learn how to do housework, look after her husband and when you can’t do that, you’re you know not suitable anymore. (S10)

The response of family, friends and wider community to CLBP

Participants reported experiencing varied responses from friends and family members to their CLBP. These included feeling pushed to seek healthcare to ‘get it fixed’, feeling supported in some cases and oversupported in others. In contrast, one Punjabi participant experienced very little empathy and support:

My family don’t take me seriously anymore because they’re just sick of hearing about it and my friends just don’t understand. (S10)

Some Punjabi participants felt stigmatised, with cultural comparisons indicating a perceived lack of empathy and understanding from people within the Punjabi community:

In other cultures… they tend to be a bit more understanding. (S10)

CLBP advice from Punjabi community members, the self-acclaimed ‘back pain experts’, left one participant frustrated:

Unfortunately we live in a community that everyone thinks they are a qualified doctor. You know, don’t do this, do this sort of a thing. (S1)

Recalling family experiences of CLBP

Participants recalled back pain experiences of family members with regards to their coping strategies, levels of disability and interactions with HCPs. Some family members reluctantly relied on medication, while others adopted active coping strategies and demonstrated self-efficacy. However, participants did not consistently adopt the coping strategies observed. For example, one Punjabi participant initially used passive interventions (including massage) in contrast to his father:

He has not let it really impact him to be honest because he still goes to the gym, he still lifts weights, just does everything. Before every now and again his back hurts a little bit. He does what he does - he hasn’t changed anything. (S6)

Varying quality of therapeutic alliance

Reflecting on previous HCP interactions, many experienced variations in therapeutic alliance, with mostly negative interactions. Strong therapeutic alliance was associated with HCPs providing clear communication. This included a clear explanation about the cause of pain, as well as reassurance, collaborative compassionate care with ongoing support and guidance. This increased adherence to treatment, built empowerment and trust in their HCPs:

I’ve great faith in the physio. (S2)

In contrast, several factors were attributed to weak therapeutic alliance. Some depicted a power struggle, where the HCP was in control and access to investigations such as MRI scans was rejected, while others reported a lack of individualised holistic care. However, most cited HCPs communication as a major problem, particularly not being given time, not being taken seriously, not feeling understood nor listened to. One participant reported feeling disrespected:

It really did upset me when I went to see a consultant - I felt very belittled by how he approached me. (S9)

Expectations were often unmet, where participants did not receive investigations, a clear diagnosis, a physical examination or manual therapy while enduring unexpected pain flare-ups. A perceived lack of guidance and support from HCPs was also cited, in some cases resulting in feelings of helplessness and low mood.

Interpreting the HCP explanation

Iatrogenic language used by HCPs was fear-inducing for some participants. Interpretations of HCPs explanations led to a sense of vulnerability around the spine and a need to adopt caution. One participant in his 30s recalled his interpretation of ‘wear and tear’:

It makes you think that you’ve got something permanent and you’re basically going to have to live with it. (S6)

However, uncertainty about the actual cause of their pain was most common, partly due to mixed messages conveyed by HCPs and inconclusive radiological investigations.

Appraising interventions and ability to control CLBP

Reflecting on prior CLBP management, this was embedded within the biomedical model for the majority. Treatment interventions were appraised in relation to their therapeutic effect and the participant’s ability to control their pain. Medications, despite being taken for long periods, were deemed largely ineffective by many, as was acupuncture. In addition, a reliance on manual therapies offered minimal long-term effect:

If I’m honest - at the time it’s a psychological plaster. (S4)

Expectations of future management

Interestingly, when exploring cross-cultural expectations of future management, all participants’ sought an individualised, mind–body approach, which involved a physical ‘hands on’ examination. Many expressed the need for HCPs to possess strong communication skills that include: empathy, active listening skills, providing time, clear communication and to:

Explain things thoroughly, don’t frighten the patient, and just generally be welcoming. (S3)