Disability & Rehabilitation, 2012; 34(11): 894–903

© 2012 Informa UK, Ltd.

ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.626483

RESEARCH PAPER

‘I can’t see any reason for stopping doing anything, but I might have to
do it differently’ − restoring hope to patients with persistent non-specific
low back pain − a qualitative study

Francine Toye1 & Karen Barker2

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1
Physiotherapy Research Unit, Nuffield Orthopedic Centre and 2Nuffield Orthopaedic Centre NHS Trust, Oxford, United Kingdom

Purpose: To explore the differences in narrative between Implications for Rehabilitation

patients with persistent non-specific low back pain (PLBP)
who benefited from a pain management programme, and
those who did not benefit. Method: We conducted interviews
with 20 patients attending a pain management programme;
prior to attending the programme, immediately following
the programme and at one year. Our analysis focused on
For personal use only.
• Explanatory models are likely to have an impact on
recovery following pain rehabilitation.
• Adherence to a biomedical model may have a negative
impact on recovery.
• Patients need an acceptable explanatory model that

a theoretical sample of patients who either described fits their experience.

dramatic life improvements at one year, and who described
themselves as much worse. We used the methods of grounded
theory. Results: We found that finding hope was central to
good outcome. Patients restored hope by making certain
changes; (a) deconstructing specific fears, (b) constructing an
acceptable explanatory model (c) reconstructing self identity
by making acceptable changes. Those who had not restored
hope retained fears of loss of self, remained committed to
the biomedical model and were unable to make acceptable
changes. Conclusions: Our findings may help to operationalise
the restoration of hope in patients with PLBP. Firstly, health
care professionals need to identify and resolve any specific
fears of movement. Secondly, patients need an acceptable
explanatory model that fits their experience and personal
narrative. Finally our study confirms the centrality of self
concept to recovery.
Keywords:  Grounded theory, low back pain, pain, pain
management, patient interviews
Introduction
Pain is known to have a high impact on the individual’s physi-
cal, psychological and social wellbeing [1]. Non-specific back
pain is defined as back pain ‘for which it is not possible to
identify a specific cause’ [2]. Every year, 1.6 million adults in
the United Kingdom develop persistent non-specific low back
• Defining an acceptable self concept is integral to
recovery.
pain (PLBP) that will continue for more than three months [3].
Despite considerable knowledge on psychosocial factors and
the development of pain management programmes to tackle
these factors [4,5], we still do not know why some people ben-
efit and others do not.
It is likely that a person’s perceptions regarding their pain
will have an impact on their recovery. For example, the role
of fear and anxiety is known to contribute to long term dis-
ability related to pain [6,7]. Differences in explanatory model of
disease management might also have an impact on treatment
outcome. Kleinman suggests that different cultures use specific
explanatory models to categorise, interpret and treat illness [8].
We define culture as the ‘inherited lens’ through which a per-
son sees the world; a system for ordering and categorising
experience [9]. For example, the medical model is an explana-
tory model which takes disease to be an objective biomedical
category. The way we construct illness is culturally diverse [10],
and the model used is likely to have an affect on health care
decisions. For example, if a person with back pain takes disease
to be an objective category, they are likely to continue to seek a
medical diagnosis even when none is found [10–14].
There is a growing body of qualitative research explor-
ing patient’s perceptions of long-standing pain. Qualitative

Correspondence: Dr. Francine Toye, PhD, Superintendent Physiotherapy Research, Physiotherapy Research Unit, Nuffield Orthopedic Centre,
Windmill Road, Oxford, OX3 7LD, UK. Tel: 01865 737526. E-mail: Francine.toye@noc.nhs.uk
(Accepted September 2011)

894
 Restoring hope to patients with non-specific low back pain  895
studies show that even when no specific pathology is identi-
fied, patients with back pain remain committed to the medi-
cal model and continue to search for a diagnosis  [15–17].
Studies also report that patients feel that they are not
believed, [11,12,14,18–25] and may even start to doubt their
own experience of pain  [12–15,17,26]. Patients with PLBP
therefore feel it necessary to present a moral narrative  [27]
in order to legitimize their condition [19,22,23,29–31,28,16].
Although there is a large body of qualitative research explor-
ing the experiences of patients with PLBP, we did not identify
any study that specifically looked for differences in narrative
between patients who benefited from treatment and those
who did not. Studies that followed patients after treatment
suggest that being believed, feeling part of a social group and
getting a biomedical diagnosis are important to treatment
success [12,15,22,32]. We specifically wanted to explore dif-
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ferences in narratives between patients with different treat-
ment outcome. Our specific aim was to explore and identify
differences in narrative between patients who benefited from
pain management and those who did not, with a view to
developing a substantive theory that would contribute to pain
management practice.
Method
We obtained permission from the local research ethics
­council (REC) to undertake this research (REC reference 04/
For personal use only.
Q1605/99).
Sample
The sample for this study is shown in Figure 1. We sent a let-
ter of invitation to all patients with PLBP who were waiting
to attend a pain management programme at one hospital
(n = 29). Patients attending the pain management programme
have already been in contact with a wide range of health pro-
fessionals and therapists over several months or years, and
have not responded to treatments. They are referred to the
programme from various tertiary sources (for example; rheu-
matologists, orthopaedic surgeons, rehabilitation physicians,
pain clinics), having initially been referred to hospital by their
Figure 1.  Sample.
© 2012 Informa UK, Ltd.
family doctor. Each programme includes up to eight people
who attend nine sessions facilitated by a physiotherapist. The
programme adopts a biopsychosocial approach that aims to
help patients find ways of managing their pain, improve their
confidence, gain an understanding of their pain and enjoy a
better quality of life. The biopsychosocial model regards per-
sistent pain as the result of a complex relationship between
physical and psychosocial factors, and treatment aims to
change patients’ thoughts and behaviour regarding pain [33].
Patients have the option to attend either once a week for nine
weeks, or for three sessions a week over three weeks, depend-
ing on their individual circumstances. The programme con-
sists of a series of group discussions, along with exercise and
relaxation sessions. Discussions cover topics such as how to
increase activity by pacing, how to exercise safely, understand
why pain persists, relaxation, the need for a good night sleep,
medication, exploring common worries and concerns, the
role and limitations of medical investigations and planning
for possible set backs. The programmes exclude non-English
speakers who would be unable to participate in group dis-
cussions. The letter of invitation included an information
sheet giving details of the aims of the study and involvement
required. Patients were informed that they could see a copy of
their interview at any time and withdraw their permission to
use their interviews.
Twenty people agreed to take part in the study (13 women
and 7 men), and contacted us to arrange a suitable time and
place. Three people did not want to be interviewed, two did
not reply and four were unable to attend the pain management
program at that time. All 20 patients were interviewed at three
points in time; before attending the programme, immediately
after the programme and one year later. Our sample included
patients from a wide range of occupations such as office
administration, farming, cleaning, manual work, professional
and health care. All patients had suffered with persistent back
pain that had lasted from three to 23 years, and had tried
various treatments prior to attending the pain management
programme (for example, physiotherapy, acupuncture, chiro-
practic, faith-healing, transcutaneous nerve stimulation). To
provide descriptive information to assess the transferability
 896  F. Toye & K. Barker
of our interpretation, the low back pain Oswestry disability would enable participants to identify one another. Qualitative
index (ODI) was recorded for each patient (Table I). This is a research uses non-probability sampling of small groups of
measure routinely used on the programme to determine func- people to gain ‘insight into a particular experience’ [35]. There
tional limitation [34]. It is scored from 0 to 100, with higher is no specific number of interviews fundamental to qualitative
scores indicating lower function. As the sample is small, we enquiry. A sufficient number is needed for theoretical satura-
do not present specific personal or demographics details that tion [36]. This is the stage at which collecting additional data
does not add to the developing theory. The number of patients
Table I.  Patient sex, age and ODI interviewed for this study is typical for an in-depth qualitative
Sample Sex Age ODI study [35].
(a) Described condition as worse Female 35 44
Female 41 46 Interviews
Female 53 25 We conducted semi-structured interviews at three stages:
Male 29 49 prior to attending the pain management programme, imme-
(b) Described significant improvement Female 49 34 diately following the programme and at one year. FT inter-
Female 50 16 viewed patients at home so that they would feel more at ease,
Female 52 44 and so that interviews could take place at their convenience.
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Female 52 48 She made every attempt to put the person at ease and made
Female 60 49 it clear that agreeing to be interviewed would not affect their
Female 63 42 treatment. FT used an interview schedule very flexibly and
Male 33 40 only as a prompt, she encouraged patients to talk about things
Male 41 38 that they felt were significant to their experience of pain. This
Male 48 40 allowed the flexibility to follow leads opened by patients,
Male 48 25 and not to be constrained by structured questioning. This
(c) Not part of theoretical sample Female 57 44 is a useful approach in research where the aim is to explore
Female 61 56 personal meanings  [37,38]. This flexible interview schedule
Female 66 36 was developed following literature review and in collabora-
Female 67 63 tion between authors. The schedule was adapted in line with
For personal use only.

Male 61 38 developing analysis as recommended for grounded theory

Male 63 28 approaches [36]. Table II gives examples of interview prompts
Scores of Patients who: (a) Described Condition as Worse; (b) Described Significant
Improvement; (c) Were Not Part of the Theoretical Sample.
used in the interviews. A central feature of grounded theory is
ODI, Oswestry Disability Index. that analysis does not follow data collection, but is simultaneous

Table II.  Examples of interview prompts used in all interviews.

Interview 1 Can you tell me the history of your back pain since it started?
What do you think has caused your back pain?
Can you describe any changes that your pain has made to your life?
How do you see things in the future?
Can you tell me about previous treatments you have tried? Why do you think they were helpful/not helpful?
Do you know anyone else with back pain? Can you tell me about/describe them?
What do your friends/family/colleagues think about your pain?Can you tell me about any effect that your pain has had on them?
Can you give me an example of something that you have found particularly difficult about having back pain?
If you could give advice to someone else with back pain− what would you say?
If you were a health professional, what would you do to help people with back pain?
Interviews 2 and 3 Can you tell me about the pain management programme?
Can you tell me what you learned from the programme?
Was the course was what you expected?
Can you describe how things have been since the course?
How is the pain affecting your lifestyle now compared to when I saw you?
Have you changed anything about your life since the programme?
What benefits (if any) do you think people get from the programme?
Why do you think some do well on the course and others don’t?
What do you feel would help your back now?
How do you see things going from now?
If I were to say ‘here some money, go and spend it as you would like on a service for people with back pain’, what would you provide?
If you were running a course for people with back pain like yours, what would you put in it?
If you met someone else with a similar condition to yours what advice would you give them?
What do you think has caused your back pain?
What advice would you give to someone with back pain?

Disability & Rehabilitation


to data collection. FT transcribed and analysed each interview
prior to completing the next, so that subsequent interviews
could be shaped by evolving theory. Interviews lasted for
approximately one to two hours and were tape-recorded. As
FT interviewed all patients on three occasions, there was the
opportunity to discuss and clarify evolving themes over time
with the patient.
Analysis
Because of the volume of data, we used NVivo  [39] a com-
puterised program for analysing qualitative data, to assist
in the data analysis. As we aimed to identify differences we
focused our analysis on a theoretical sample of patients who
had either shown a definite positive response to the treatment
programme (n = 10), or those who felt they had derived no
benefit from it (n = 4). Theoretical sampling is integral to
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grounded theory approaches [36]. The remaining six patients
were less polarised in their response and gained some benefit,
albeit more modest. We identified statements in the interviews
that showed (a) a definite positive response, or (b) that they
had derived no benefit.
(a)  Yesterday we had to have a new TV, and I actually helped
my husband to lift it from the floor onto the stand . . .
that is amazing for me. I haven’t lifted a tissue off the
floor for about ten years (interview 3).
(b)  To be honest I would say I am still the same, to be hon-
For personal use only.
est. I am a lot more down in myself. I can’t be bothered
as much to do things anymore (interview 3).
 All three interviews for each patient were analysed to allow
a longitudinal exploration of narratives over time. We used
the methods of constructivist grounded theory as proposed
by Charmaz, and continued analysis to the point of theoreti-
cal saturation [36]. This philosophical framework recognizes
that meaning arises out of social interaction and is modified
by interpretation. Each transcript was listened to, transcribed
verbatim and read several times to become familiar with the
accounts. Early coding began by using low inference descrip-
tors [40] to summarise each unit of meaning within the inter-
views. Low inference descriptors use patients own words or
specific actions as initial codes, and therefore avoid theoretical
interpretations too early [36,40] (Charmaz, 2006, Seale, 1999).
We also include verbatim examples of transcripts to allow the
reader to judge our chosen ‘concept indicators’ (Seale, 1999).
As the coding developed, we used constant comparison of ini-
tial codes to develop conceptual themes by making theoretical
connections. Throughout the analysis, we constantly compared
transcripts, initial codes and later conceptual codes to develop
progressively higher conceptual categories. To explore the
properties of developing categories, we kept memos in a dia-
grammatic form similar to clustering [36, p. 86], and modified
these diagrams throughout the analysis, always returning to
the initial interview data. We also used deviant-case analysis
to constantly challenge emerging theory [40, p. 75]. This is a
method that specifically looks for cases that challenge arising
themes. A deviant case is found when the data does not fit with
developing theory. Collaborative interpretation (i.e. is another
© 2012 Informa UK, Ltd.
Restoring hope to patients with non-specific low back pain  897
person involved in the analytic decisions) is also an accepted
means of ensuring rigour. This does not aim at convergence
on a particular truth, but contributes to what Seale refers to
as ‘a self-questioning methodological awareness’ inherent in
good quality research [40]. Independent researcher coding is
not always practical, nor integral to the rigour of qualitative
research [35,36]. In our study KB questioned and commented
on FT’s coding and interpretation throughout the research
process. In addition to this, as patients were interviewed on
three occasions over one year, it allowed the opportunity to
discuss and clarify evolving themes with patients.
Results
We identified several narratives that differentiated patients who
had significantly improved at one year following rehabilitation
and those who had not. An overarching theme that subsumed
these narratives of success was a restored hope for the future.
Patients’ described this as ‘like a light being switched on’.
I plan to go back to everything . . . there is nothing that I will not do
. . . I can’t see any reason for stopping doing anything. I might have
to do it differently, but, I can’t see any reason . . . I go to the gym, I go
swimming, I do everything that somebody that doesn’t have a bad
back does (interview 3).
In contrast, patients who were worse at one year described
a future without hope.
I thought that I was going to get better from the programme, and
I don’t feel that now. I feel I have maybe reached a point that for
whatever reason it is not going to work for me and therefore I have
to accept that . . . it will gradually get worse and eat into my life more
(interview 3)
Restoration of hope hinged upon three narratives; (a)
deconstructing fear of specific movements, (b) constructing
an acceptable explanatory model of pain and (c) reconstruct-
ing an acceptable self identity. Our conceptual model is illus-
trated in Figure 2.
(a)  ‘It’s just like a common cold’ − deconstructing fear of
specific movements
 Before attending the pain management course, all of the
patients who improved significantly at one year, had feared
that they would damage their back if they performed certain
specific movements, such as bending down or twisting.
If you bent in a certain way, and your disc slipped and you are inca-
pacitated, then you are frightened to do that again . . . because that is
something that you associate with a bad back. (interview 1)
They described the impact of fear on their lives before the
programme, and how they had wasted their lives trying to
protect themselves from damage.
I used to be just so frightened, and I’d think . . . the more I aggra-
vated it, the worse it was gonna be, so I would avoid doing things
which is completely the wrong thing to do because you just seize up.
(interview 2)
 898  F. Toye & K. Barker
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For personal use only.
Figure 2.  Conceptual model − narratives of success and failure following a pain management programme. (1) Restoration of hope related to: (a)
deconstructing specific fears, (b) constructing an explanatory model that fits and (b) reconstructing an acceptable self. (2) Hopelessness related to
(a) fear of loss of self, (b) biomedical model and (c) inability to make changes to self.
Several factors had helped them to deconstruct this fear.
Communication with the physiotherapist made patients real-
ize that there was not always an association between pain and
damage.
The physio said to me several things that transformed my entire
existence . . . they see degenerated discs in children, and they don’t
have any pain . . . so the degeneration of the disc has no bearing on
how [the pain] will be. (interview 2)
Patients often felt angry that they had not been told this
earlier.
I thought whenever my back went into spasm, I had hurt it again .
. . and just learning that I can’t have hurt it anymore, it is just that
I have overstretched or pulled it, but I haven’t actually kind of re-
hurt the injury. Nobody, but nobody had every mentioned . . . that I
hadn’t hurt it again . . . I was really really cross. (interview 2)
Many were surprised that the physiotherapist encouraged
them to do movements that they had feared.
the physios are much more laid back about a prolapsed disc than I
thought they would be like…they were talking about it like it was . . .
a common cold . . . and I mean I was terrified. (interview 2)
Being in a group with other patients who were performing
feared movements also gave them the confidence to move in
spite of fear.
I was supporting the lady who was terrified of lying down. She con-
vinced herself that if she lay on the floor, something was going to
bulge and pop and go, and we were sort of talking and we said, ‘well
how can it if you are just laying there?’ So I helped her with that and
she helped me with my bending forward . . . so we were helping one
another. (interview 2)
Finally facing fear through supervised exercise helped to
deconstruct fear. We were surprised that most of the patients
with an excellent outcome at one year described a flare-up,
during which their pain got markedly worse following unac-
customed exercise. Thus they were able to work through the
increased pain under the supervision of the physiotherapist.
By the end of the third week I had worked through the fact that I had
got more back pain . . . it was good for me to have to do the exercises
while I was in pain . . .I wouldn’t have been any further forward emo-
tionally if I hadn’t gone through that I don’t think. (interview 2)
In contrast, patients who were worse at one year did not
describe fears of specific movements, but fears related to loss
Disability & Rehabilitation

of self. For some, this fear had even increased following pain
management.
Am I going to get to a point where ten years down the line I have had
to stop doing everything that I like . . . I don’t know. I suppose that
scares me now, and it didn’t before because I hadn’t really thought
about it. (interview 3)
(b)  ‘Bringing my body back into balance’ - constructing an
acceptable explanatory model
 Central to this concept was that patients who had improved
significantly had accepted that there was a link between the
mind and body, without allowing this to challenge their legiti-
macy. Some even said that their problem was ‘more mental
than physical’.
I feel that, all these rigid things that you try and put in place to
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protect yourself, quite often are actually a problem that you have in
your mind rather than your back. So I think your mind and your
back are quite closely linked. (interview 3)
They were thus enabled to embrace psychological explana-
tions and see the benefit of treatments that aimed to ‘change
your mindset’. Stress was described as a useful construct to
explain the link between mind and body, as most patients
recognised the physical effects of stress.
I think it is all about relaxation to be honest. To a degree it might
For personal use only.
be mind over matter, it might be sort of a lot in my head . . . you
get all tense and worried that things are going wrong, and that sort
of brings on the spasm. (interview 2)
However, an important and innovative finding was that
although they accepted psychological explanations, physical
explanations were still important. In the absence of a medical
diagnosis, they constructed a complementary model, which
saw the body as out of balance rather than broken. The aim
of treatment was therefore seen ‘to identify weak spots’ and to
restore balance by teaching the correct exercises.
I am exerting too much pressure on those parts that are worn by
not standing up straight. I am slouching too much. I am not sitting
properly. So if I put into practice the things that I have been taught,
it is actually helping to . . . relieve the pressure on those parts that
are causing me the pain . . . I understand that I am bringing my body
back into balance. (interview 2)
Using this model of the body out of balance, they were able
to resolve the contradiction between needing a medical expla-
nation and receiving no explanation. Patients described how
they now realized that there was a reason for their pain, and
that it was no longer a mystery to them.
I had a new thought that it could be muscular . . . if I had a pain in
my shoulder, I wouldn’t automatically think that my arm was go-
ing to cease up completely and I wasn’t going to be able to write or
drive . . . you think, ‘must have sat in a draught’, and there is not an
expectation that it is going to go on for months . . . so I have adopted
that for my back really. (interview 3)
In contrast, patients who were worse at one year adhered
to a medical explanation for pain, insisting ‘there must be
© 2012 Informa UK, Ltd.
Restoring hope to patients with non-specific low back pain  899
something wrong’, and ‘how can exercise fix me?’ They did
not understand why the physiotherapist was teaching exer-
cises for all parts of the body, and thought that exercise should
be aimed only at the back.
I mean I was doing exercises like . . . stretching my fingers, and I
thought, ‘am I in the wrong room here?’ And I started laughing, and
I said to the physio, ‘I have got a bad back, I am actually not suffering
stiffness in my fingers. (interview 3)
(c)  ‘I need to be strict with myself now’ – making acceptable
changes to me
 Patients who had made improvements at one year perceived
no loss of self, and felt that they were ‘still me’. Paradoxically
they acknowledged that they would never be exactly the same.
Patients resolved this paradox by allowing certain accept-
able changes, thus reconstructing a positive self image. For
example, before the programme they described themselves as
a ‘perfectionist’ who ‘pushed too hard’, or for whom it was ‘all
or nothing’, whereas now they had become the sort of person
who ‘needs to be strict with themselves’. The programme had
showed them how to ‘hold themselves back’, and be more
‘disciplined’.
I am not running round like a headless chicken trying to do every-
thing at once, just taking my time and thinking about myself, and
what I am doing . . . just being much more careful . . . whether I
am gonna be disciplined and carry on with that . . . I mean, if the
sun comes out and I want to do some gardening . . . as long as I am
sensible, I think I will be alright. (interview 2)
Patients who had improved used pacing as an effective
strategy for restraining their former selves, describing pacing
as a systematic and gradual increase in activity over time. By
focusing on increased activity in the future they minimised
the impact of change on their self now.
And everyday I will just build it up. Yeah, it is just gradual. And
I will just carry on with the pacing. Like today I did five minutes.
Tomorrow I will do five minutes, ten seconds. And at that, it was
very difficult to cut off, when you are feeling really well, to stop, but
I will. (interview 2)
In contrast, patients who were worse at one year had expe-
rienced an overwhelming loss of self, describing their self as
‘sacrificed for my back’. These patients were not able to limit
activities that they saw as fundamental to their self identity.
I suppose the worry is not being independent, and that is what I am
all about. I pride myself on being independent and I enjoy doing
things for myself and other people. (interview 3)
They were not able to reconcile short-term reductions in
activity with long term improvements, and had no effective
strategy for making acceptable changes. They did not describe
pacing as a gradual increase in activity over time, but as doing
things ‘little and often’. Pacing therefore restricted self-defin-
ing activities. Similarly, they described short term goals as a
threat to their self identity. For example, one lady described
how short term goals seemed meaningless to her.
 900  F. Toye & K. Barker
I don’t want to be able to hoover . . . I want a better life . . . I want my
goals to be more interesting and exciting . . . it has been a bummer
of a life, so far, I want to pick up the good things, not hoovering.
(interview 2)
To conclude, patients restored hope for the future by mak-
ing certain changes; (a) they had deconstructed specific fears,
(b) they had constructed an acceptable explanatory model of
pain and (c) they had reconstructed their self identity by mak-
ing acceptable changes to their activity levels; in particular by
conceptualising pacing as a means of making incremental
increases to their activity. Those who had not restored hope
retained fears of loss of self, remained committed to the bio-
medical model and were unable to make acceptable changes
to their self.
Discussion
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The aim of this study was to identify narratives that differ-
entiate a group of patients who achieved excellent results
following pain management from a group who perceived no
benefit. A narrative of hope was central to our findings and
divided the groups. Hope is a multidimensional concept that
can be difficult to define [41]. In healthcare it implies a more
positive orientation towards the future in spite of illness; an
‘internal psychological process that individuals undertake
or work towards, to create new, positive perspectives for the
future’ [42]. It is likely that hope is linked to rehabilitation and
For personal use only.
recovery [42]. This is supported by our finding that patients
who had no hope had made no recovery at one year. Loss of
hope is not surprising in view of the ongoing struggle between
hope and despair described by patients with persistent
pain [43]. We found that patients with a positive outcome had
restored hope for a brighter future. This restoration of hope
hinged upon three core narratives: deconstruction of fear,
construction of an acceptable explanatory model and recon-
struction of self. These findings may help to operationalise the
restoration of hope for patients with PLBP.
Our research support findings that fear-avoidance is one
of the central mechanisms explaining the persistence of pain
and disability in some patients with back pain, [6,7,44,45] and
that exposure to feared activities can be beneficial [46]. All of
the patients with an excellent outcome at one year described
fear of a specific activity that had first caused their pain. We
identified three factors that helped patients overcome their
fear. First, all patients thought that it was important to have a
qualified physiotherapist giving advice and supervising exer-
cise. Importantly, their advice helped patients to know that
symptoms and outcome was not necessarily related to specific
medical findings. Second, being part of a group of similar
people who also feared movement, particularly different
movements. This empowered patients to challenge the medi-
cal model; if other patients were not afraid of the same move-
ments this raised the possibility that their own disability was
maintained by factors such as fear. Our findings also support
research suggesting that being part of a group is important in
establishing credibility and giving a person a sense of com-
munity  [12,15,22]. Finally, exposure to feared activities and
experiencing a flare-up was instrumental in deconstructing
fear. Vlaeyen and Linton  [44] suggest that a programme
of graded exposed to a specific feared activity would help
patients deconstruct their fear. In addition to this, our com-
parative analysis suggested that fear of specific activities was
not instrumental in maintaining disability in those patients
whose fears were related to loss of self. This suggests that tack-
ling specific fears is only one strategy towards recovery that is
relevant to a group of patients with specific identified fears.
Our research also highlights the importance to recovery
of constructing an acceptable explanatory model  [8]. The
biomedical model has characteristics that are fundamentally
antagonistic to the experience of those with PLBP: the dual-
ism of mind and body; specific aetiology beyond morality;
curability of disease [47–50]. Importantly, guidelines recom-
mending that doctors do not routinely offer x-rays and mag-
netic resonance imaging scans for PLBP [2] conflict with the
biomedical model where medical tests have become related to
the legitimacy of symptoms [51–53]. We know that patients
with persistent back pain remain committed to a biomedical
model of pain [11,12,14,16,21,43,54], and continue to strive
for an organic explanation  [10–14]. Kugelman  [20] argues
that the dialogue between two opposing explanatory models
(biomedical and psychological) is problematic for patients
with unexplained pain because of the associated cultural
polarity between reality (body, medical, rational, fact, visible),
and unreality (mind, psychosocial, irrational, belief, invis-
ible). This polarity is explored by Byron Good - the patients
believes; the doctor knows [53]. In this dichotomous cultural
context, we could argue that a danger of embracing a psycho-
logical model is that it forces the person to admit that pain is
‘in your head’ [55]. An innovative finding in our study is that
although successful patients embraced a psychological model,
they also constructed a model which emphasised the physi-
cality of their condition. They described the body as out of
balance rather than broken, and this enabled them to resolve
the paradox inherent in the biomedical model [56]. A patient’s
explanatory model is likely to be related to expectancy from
treatment and the perceived credibility of their symptoms. In
this case, if a person is seeking a biomedical explanation then
they are not likely to think a psychosocial explanation is cred-
ible. Importantly, our study also shows that although prevail-
ing explanatory models are inherently difficult to challenge,
they are not necessarily static [8,57], and can hide underlying
tension  [58]. Contradiction and ensuing struggle need not
necessarily be seen as negative, but may allow the opportunity
for positive change [59,60]. Unresolved tension may help the
patient to move towards a biopsychosocial explanatory model.
In this study, stress was a useful model for understanding and
embracing the link between mind and body.
Finally, our research shows the importance to recovery of
retaining a positive self identity in the face of ill health. We
found that although patients who had recovered had made
adaptations to their lives, they no longer perceived a loss of
self. Our findings support the suggestion made by Morley and
Eccleston that a threat to a persons identity is a key ‘object
of fear’ in persistent pain [61]. The loss of ideal self and the
complexity of reconciling this loss with acceptance is central
to the experience of those with persistent pain [62]. However,
Disability & Rehabilitation

the relationship between acceptance and good outcome is
not clear [63]. We support the suggestion that central to the
construct of acceptance of pain is the person’s perception that
they can still be themselves in spite to pain [64]. It might be
that to some, the term acceptance implies an act or ‘resigna-
tion or quitting’ [64], and therefore does not fit with a person’s
positive self-narrative. The enmeshment model developed by
Pincus and Morley [65] proposes that the enmeshment of the
self with the presence of pain determines the degree of depres-
sion or acceptance. In other words, if a patient regards their
hoped-for self as unobtainable in the presence of pain, they
are less likely to accept and recover  [66]. This is supported
by qualitative studies that show the importance of retaining
a positive self identity, whilst accepting that certain changes
to identity are necessary [21,22,67]. Miles et al. [29] suggest
that patients with persistent pain can use several strategies; re-
Disabil Rehabil Downloaded from informahealthcare.com by Northeastern University on 12/02/14
conceptualise normal life and accept that they can no longer
do certain things (accommodate); appear normal by avoid-
ing certain situations (subversion); ignore pain and carry on
with normal activities for as long as possible in spite of pain
(confrontation). Although avoiding situations and ignoring
pain might minimise the emotional impact of pain, in the
long term, it might be related to poor outcome as behavioural
adaptations are not made [68]. In our study, successful patients
managed to accommodate their pain with no perceived loss to
self. It could be argued that this is linked to the concept of
‘psychological flexibility’ defined by Vowles and McCracken
For personal use only.
as the ‘ability to . . . contact experiences in the present moment
and persist or change behaviour according to what the situa-
tion affords and ones personal goals and values’ [69].
Another innovative finding in our study was that patients
conceptualised pacing as an important strategy to enable
them to reconstruct their self in an acceptable way that did
not threaten their self narrative. Pacing allowed the person
to restrict former behaviours (‘not running round like a
headless chicken’) and replace them with new behaviours
(‘being strict with myself ’) in a way that was not challeng-
ing to self. Importantly, pacing was constructed as activity
enhancing rather than limiting. Pacing in persistent pain
patients is poorly understood [70], and there is currently no
accepted definition  [71–73]. Some authors define pacing as
a method used to ‘budget energy’ by breaking down activi-
ties into smaller parts, and others emphasise the importance
of an incremental increase in activity over time. McCracken
and Samuel [70] found that pacing was related to increasing
disability in patients with persistent pain. This is not surpris-
ing if pacing is described in terms of activity reduction. No
research has examined patients’ perceptions of pacing. Ours
is the first study to describe patients’ perceptions of pacing
and identify differences. We found a difference in the defini-
tion of pacing that distinguished the two groups. This finding
could explain why pacing sometimes improves outcome and
sometimes does not. It might be that if patients (and profes-
sionals) understand pacing as a means of limiting activity to
avoid pain, this cannot be reconciled with a hoped-for self.
To fully understand the impact of pacing, more research is
needed to explore the meaning of pacing for patients and
health care professionals.
© 2012 Informa UK, Ltd.
Restoring hope to patients with non-specific low back pain  901
Although we used recognized methods of ensuring the
rigour of our theoretical interpretation, we know that this is
one interpretation. A reflexive approach that considers the
impact of the researcher’s perspective on the interpretation is
recognized as a facet of interpretive rigour and is reflected in
tools developed for appraising quality [40,74]. FT has a mas-
ter’s degree in Anthropology and has a particular interest in
explanatory models which may have influenced her concep-
tual interpretation. Also FT and KB are both physiotherapists
with experience in treating patients with PLBP. Although nei-
ther was involved in delivering the treatment program, this
may have had an impact on their interpretation.
Grounded Theory approaches do not aim at reproducibility
but aim to offer a theoretical insight into experience of a par-
ticular phenomenon that is transferable beyond the particular
setting  [36]. We identified several narratives that differenti-
ated those who benefited from those who did not. Central to
these narratives was restoration of hope that a person could
still be themselves in spite of pain. All the patients in this
study were from one particular pain management program
and the results might not be transferable to other settings.
Further studies are needed to see if this particular theoretical
interpretation helps to makes sense of differential outcomes
in other clinical settings. In particular research to further
explore narratives of self and the persistence of hope in the
face of illness might help to improve patients’ outcome from
rehabilitation. Intervention studies are needed to determine
whether hope and its three related factors (deconstruction
of fear, construction of an acceptable explanatory model and
reconstruction of self) are modifiable and what interventions
would be best to modify these factors.
Our study presents innovative findings that may help to
operationalise the restoration of hope in patients with PLBP.
Firstly, health care professionals need to identify and resolve any
specific fears of movement. Secondly, patients need an accept-
able explanatory model that fits experience but that also con-
firms a person’s self concept. Although patients recognized the
link between mind and body, to be successful they constructed
a model that emphasised the physicality of their illness. They
described the body as ‘out of balance’ rather than ‘broken. Finally
our study confirms the centrality of self concept to the experi-
ence of pain and recovery. In particular, pacing was used as a
means of confirming self and moving forward to the future.
Declaration of Interest:  This research was supported by a grant
from Oxfordshire Health Services Research Committee.
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