Barriers and facilitators of activity normalisation for people with chronic low back pain in Saudi Arabia

Alotaibi, Mazyad (2019) Barriers and facilitators of activity normalisation for people with chronic low back pain in Saudi Arabia. PhD thesis, University of Nottingham.

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Low back pain (LBP) is a debilitating condition affecting 7.8 million people in the United Kingdom. A third of people with LBP develops chronic low back pain (CLBP). Individuals experiencing CLBP appear to encounter issues with managing their pain. Importantly, returning to normal activity, or normalisation, after physiotherapy has become a major concern among Saudi Arabian people experiencing CLBP. CLBP patients and healthcare professionals appear to possess various perceptions and beliefs about returning to normal activity, which may serve as barriers to or facilitators of recovery. Furthermore, the degree to which patients in Saudi Arabia achieve activity normalisation after physiotherapy interventions for CLBP is little understood and under-researched.


The aims of this study were i) to identify which psychosocial factors limit or enhance patients’ return to normal activities and/or participation; ii) to explore the experiences, attitudes, beliefs and perceptions of healthcare professionals (physiotherapists and orthopaedic surgeons) and people with CLBP in Saudi Arabia regarding the barriers and enablers to activity normalisation after physiotherapy; and iii) to investigate how beliefs about physiotherapy influence how people with CLBP in Saudi Arabia return to normal activities and participation.


This programme of research comprised three studies: (i) a systematic review of the literature investigating the psychosocial factors that affect return to normal activities and/or participation by people with CLBP; (ii) a qualitative study exploring patients’ and physicians’ views, perceptions and experiences of the barriers and enablers to normalisation after physiotherapy; and (iii) a cross-sectional survey investigating how physiotherapy beliefs influence how Saudi Arabian people with CLBP return to normal activities and participation.


The systematic review found that fear-avoidance beliefs (physical and work), kinesiophobia and catastrophising were associated with poor functional status and disability. Depression, anxiety, pain severity, widespread pain, chronic pain grade and bothersomeness were associated with disability, functional outcomes and return to work. Positive physician–patient relationships might have positively influenced patients’ health outcomes.

In the qualitative study, both patients and clinicians highlighted factors hindering recovery and activity normalisation: a lack of reassurance, encouragement, education and awareness regarding CLBP itself; fear of pain and recurrence of injury; conflicting diagnoses; ambiguous advice; and the complexity of exercises. Psychosocial support from different sources helped improve patient outcomes and recovery, as reported by both patients and clinicians. Patients and clinicians stated that the Saudi healthcare system hindered timely treatment due to a poor referral system and a lack of specialised clinics and clinical guidelines related to CLBP management.

The cross-sectional survey revealed that socioeconomic factors were negatively correlated with patients’ beliefs about fear of pain and pain coping. LBP duration, pain intensity and pain interference in normal everyday activities were positively correlated with conflicting diagnoses, patients’ beliefs about pain coping, fear of pain and the quantity and complexity of exercise. Psychosocial factors were positively correlated with conflicting diagnoses, conflicting advice, patients’ beliefs about the importance of clinical guidelines, coping with pain, fear of pain and the quantity and complexity of exercise.


Patients in Saudi Arabia require education on the fact that engaging in physical activity is unlikely to increase disability but, instead, acts to help patients better manage their condition and reduce pain. Consequently, there is a need for patients with CLBP to be informed of the benefits of sustained exercise and rehabilitation to improve their physical function. As suggested by both patients and clinicians, healthcare professionals should focus on interventions that address these beliefs during rehabilitation to improve patients’ physical functioning by offering psychosocial support, which has the potential to lead to activity normalisation and overall patient recovery. Finally, clinical guidelines and pathways should be created to guide healthcare practitioners in how to holistically address the needs of patients. With both clinicians and patients in Saudi Arabia citing communication as an issue, creating a care pathway could enhance the quality of communication between healthcare practitioners and their patients. Promoting a multidisciplinary team approach is critical to management of CLBP.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Radford, Kate
das Nair, Roshan
Keywords: Back pain; Psychosocial factors; Normal activities
Subjects: W Medicine and related subjects (NLM Classification) > WE Muscoskeletal system
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 56926
Depositing User: Al-Otaibi, Mazyad
Date Deposited: 15 Aug 2019 13:52
Last Modified: 01 Jun 2021 04:30

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