Misconceptions about the safety of bending with low back pain exist among professionals and are more common in medical students and general practitioners
This means that medical professionals have another belief regarding the safety of lifting a light load than (student) physiotherapists
Qualified physiotherapists who followed a pain education course had higher Back-PAQ scores and thus, fewer misconceptions about low back pain
People with low back pain often present to physical therapy. Many of these people believe that their back is (or has) become vulnerable to injury. Media, family and friends, and previous experiences often drive these misconceptions. The spine is a solid structure, and, contrary to common belief, flexing it does not harm! How we educate people with low back pain is very important. However, you’ll get confronted with patients whose doctor told them not to bend the spine. Or who received that advice from another physiotherapist. The way we, as healthcare providers, communicate about low back pain is crucial. Our wording can have a lot of impact on the pain experience and its evolution. Think about nocebo as an example. Healthcare providers should ideally spread the same message about bending the spine to people with low back pain. This study gauged the attitudes and beliefs of healthcare providers from different professions regarding the safety of bending with low back pain to lift a light load.
This research review covers the study results from a cross-sectional survey conducted among qualified physical therapists, qualified general practitioners, and students of both professions. The survey was held in Belgium and France but was only spread to French-speaking individuals.
The questionnaire gauged perceptions about the safety of 8 different techniques for lifting a light load off the floor.
The two most important questions asked were:
Further, the short version of the Back pain attitudes questionnaire (Back-PAQ) was filled to probe for the beliefs and attitudes of back vulnerability, the relationship between back pain and injury, participation in activities during back pain, the psychological influences of back pain, and the prognosis of back pain. More negative scores indicate more significant misconceptions about low back pain.
Qualified physical therapists, general practitioners, and students of both professions were asked about the safety of bending with low back pain. The questionnaire was spread to students in 21 French and French-speaking Belgian physical therapy schools. In total, 417 physical therapy students responded. 395 qualified physical therapists filled out the questionnaire. They had on average 7 years of experience. They reported seeing 12 (+/- 10) patients with low back pain weekly. 108 general practitioners and 85 medical students completed the questionnaire. The general practitioners reported seeing 7 (+/- 12) patients with low back pain per week.
Considering the question of what movement strategies were considered harmful for asymptomatic people with a history of low back pain, on average 1.9 (+/- 2.08) photos were selected. The second question about movement strategies revealed that a mean of 2.54 (+/- 2.36) photos were considered harmful for people with chronic low back pain.
There was a significant difference in the number of photos selected to be harmful among the different professions. The qualified physiotherapists picked the lowest number of photos, followed by the physical therapy students. There was no difference between medical students and general practitioners.
The Back-PAQ scores revealed higher scores for qualified physical therapists, followed by physical therapy students. The scores of the general practitioners and medical students were lower than the scores of physical therapy students and qualified physical therapists, meaning they had more misconceptions about low back pain.
Whereas the majority of qualified physiotherapists were aware that none of the strategies depicted were unsafe, more than 90% of the medical students and general practitioners believed that at least one method should not be recommended. Where does that difference between the professions of physiotherapy and general practitioners come from? Most likely, from the education they received. Where the physiotherapist is schooled with a biopsychosocial model of pain, medical professionals are generally taught a more biomedical approach.
Bending the spine for picking up a light load when having (had) low back pain is not dangerous or harmful. The safety of bending with low back pain is under debate but, reassurance and positive beliefs towards low back pain and movement have even been shown to promote recovery. In healthy participants, evidence showed that lifting a heavy load with a bent spine was even more efficient as it reduced paraspinal muscle activity and increased strength. To learn more about this, I recommend you to read the research review we published about this finding: https://www.physiotutors.com/research/lifting-with-a-flexed-back/.
“Qualified physiotherapists who followed a pain education course had higher Back-PAQ scores and thus, fewer misconceptions about low back pain.”
The movement strategies in the 8 pictures were developed from field observations, literature, and a previous preliminary study. According to the literature, none of these strategies would be harmful if used to lift a light load from the floor. Twelve experts were contacted to determine the validity of the 8 strategies. They agreed that these movements were not harmful and were probably the most used by the general population, suggesting good face validity.
Two subgroup analyses were performed to see whether they changed the results. Among the responders, it was asked whether they were affected by low back pain. Those with low back pain selected slightly more pictures for question 1 than respondents without low back pain. The second subgroup analysis revealed that qualified physiotherapists who had attended a pain education course had higher Back-PAQ scores, and thus, fewer misconceptions about low back pain. They also selected fewer photographs for both questions.
It seems that the movement strategies depicted in photos 6, 7, and 8 were considered most safe for asymptomatic people with a low back pain history and people with chronic low back pain. Importantly, approximately 70% and 60% of qualified physiotherapists indicated that none of the strategies were harmful to both asymptomatic with a history of low back pain and symptomatic people with low back pain.
Misconceptions about the safety of bending with low back pain exist among professionals and are more common among medical students and general practitioners. They chose more movement strategies to be harmful in both asymptomatic and symptomatic people. This may imply that they would instead recommend avoiding such activities to their low back pain patients. Despite their good intentions, there is no evidence suggesting that flexing the lumbar spine while lifting a light load is harmful. By believing there are harmful or unsafe strategies for lifting a light load, they may communicate a nocebo, which in turn can lead to fear avoidance and maladaptive movement strategies. These can negatively affect the pain experience and further lead to chronic low back pain. On the contrary, physiotherapists and physiotherapy students selected fewer movement strategies to be harmful. Seventy and sixty percent of qualified physiotherapists even indicated that none of these movement strategies were dangerous in those with a history of and in those having chronic low back pain. This means that medical professionals have another belief regarding the safety of lifting a light load than (student) physiotherapists and that different messages are potentially spread out to patients. This may confuse patients confronted with low back pain.
“The perceived vulnerability of the spine is a well-known risk factor for chronic low back pain and should be countered by education that helps patients to understand that their spine is a strong structure, rather than advice to be cautious when bending the back.”
Rialet-Micoulau J, Lucas V, Demoulin C, Pitance L. Misconceptions of physical therapists and medical doctors regarding the impact of lifting a light load on low back pain. Braz J Phys Ther. 2022 Jan-Feb;26(1):100385. doi: 10.1016/j.bjpt.2021.100385. Epub 2022 Jan 2. PMID: 35063698; PMCID: PMC8784290. https://pubmed.ncbi.nlm.nih.gov/35063698/