Beliefs about chronic back pain and its management among patients and healthcare professionals in Kuwait

Background: Chronic back pain (CBP) is a multifactorial musculoskeletal problem that affects many people annually. However, due to the lack of back pain-related research in Kuwait, the exact incidence is unknown. It can be caused by physical or psychosocial factors, leading to multidimensional problems, such as psychosocial and economic consequences; therefore, a multidisciplinary approach is required to manage the problem. Cognitive behavioural therapy (CBT) is an effective psychological approach, which aims to change maladaptive beliefs and behaviour in patients with chronic illness. It has been found that CBT is best tailored according to the patient’s symptoms, culture and beliefs about their condition. Furthermore, CBT would provide better outcomes when it is interactive and adapts to changes in a patient’s day-to-day symptoms, meaning that the content and intensity of the programme could be modified accordingly. Thesis aim: The aim of the thesis was to investigate the impact of physiotherapists’ and patients’ beliefs and perceptions about chronic back pain on the illness and its management, as well as the acceptability of cognitive behavioural therapy as a treatment for the CBP. This was approached through four studies: Study One was a systematic review, examining the effect of CBT dose and deliverer of the intervention on the outcomes; study two was a questionnaire study exploring chronic back pain risk factors and predictors in Kuwait; Study Three was a qualitative study exploring the beliefs and perceptions of Kuwaiti chronic back pain patients about their illness; and study four was a qualitative study, exploring physiotherapists’ beliefs, knowledge and experience on the management of chronic back pain in Kuwait. Result: In Kuwait, walking, sedentary life style and current back episode of pain were found to be risk factors for chronic back pain. Moreover, illness perception was found to predict pain intensity, disability and mood (anxiety), whereas the level of insomnia was found to predict anxiety and disability, which could also be predicted by a coping strategy. Patients’ beliefs and cultural norms have a strong impact upon the illness behaviour and coping strategies. Additionally, a therapist’s poor communication skills and a patient’s unhealthy beliefs were found to reduce the level of adherence. Similarly, a therapist’s beliefs and attitudes were found to have a significant impact upon the effectiveness of the management. Physiotherapists in Kuwait acknowledged that a patient’s psychosocial factors have a strong impact upon the illness and treatment; however, they were resisting the idea of implementing CBT in physiotherapy treatment. Conclusion: CBP is a common multifactorial musculoskeletal problem that has psychological, emotional and sociocultural consequences. In Kuwait, CBP is commonly treated with medication and physiotherapy, but studies report only poor to moderate effects for these treatments, with high rates of relapse. CBT is suggested as an option to improve outcomes. It has been shown to be effective for the management of CBP and the co-morbid disability and mood disturbance. Due to the nature of CBP symptoms, CBT programmes must be flexible, adaptive and interactive with patients’ symptoms, rather than using a fixed dose and content. Programmes for Kuwaiti patients with CBP must also be sensitive to cultural beliefs and to religion. Kuwaiti patients with CBP have demonstrated awareness of the relationship between their beliefs, emotions and the symptoms; however, they are unaware of CBT or the role of psychological therapies as a treatment option for CBP. Patients also reported poor communication with and negative attitudes from therapists, which discouraged them from adhering to recommendations. Physiotherapists in Kuwait also reported that a patient’s beliefs and psychological status might affect the outcomes. However, they are resistant to the idea of implementing CBT for the management of CBP for reasons such as lack of time and high workload. In Kuwait, the lack of activity and poor lifestyle are correlated with the incidence of CBP. Therefore, a major step towards reducing the prevalence of CBP in Kuwait is to improve the lifestyle by changing health beliefs and associated behaviours. Culturally sensitive CBT programmes are recommended for the management of CBP in Kuwait, with a strong emphasis on the inclusion of religious and spiritual content, especially for the older population. Digital format CBT could be an option for younger patients in Kuwait, many of whom use social media daily