Learning objectives :
1. Understand beliefs about back pain, how these influence pain, movement and recovery, and ways in which these can be influenced.
2. Understand psychological and sensorimotor mechanisms through which fear and avoidance can be managed clinically
3. Understand how treatment can be adapted to support an individual to reduce their fear of movement and build their engagement in movement and activity.

General description
Low back pain (LBP) is a major global health problem with multidimensional contributing factors. Unhelpful beliefs, pain-related fear and movement avoidance have been shown to be important drivers of pain and disability in patients with LBP. Exercise-based or exposure-based interventions, together with education, have been recommended for the management of LBP and to target beliefs, pain-related fear and movement avoidance. Yet, their effects on pain and disability are only small to moderate. Recent evidence suggested that considering the interrelations between affective, cognitive and sensorimotor factors is critical to improve the care of people with LBP. Understanding and exploring individual differences in these domains is central to developing a person-centred management plan. These recent theoretical advances have brought new insights into assessment and management principles to develop beliefs that support recovery and reduce pain-related fear, and build engagement in movement and activity in patients with LBP.

Understanding and influencing beliefs about low back pain:
This section will summarise beliefs about LBP common in communities around the world and ways in which these are reinforced and perpetuated. It will discuss how patient beliefs can be explored in clinical settings through actively engaging with the person’s story. It will highlight the importance of understanding beliefs, and the evidence on which these are based, to enable the provision of effective and meaningful reassurance. It will conclude with consideration of opportunities to gather additional evidence as a mechanism to help co-construct beliefs that support recovery.

The role of spinal motor behaviour alterations in patients with low back pain:
This section will first present evidence from the biomechanical field supporting an avoidance behaviour of spinal movement in patients with LBP. It will also discuss the relationships between spinal movement avoidance, psychological factors, pain and disability. Finally, it will review evidence discussing the role of targeting spinal motor behaviour in LBP rehabilitation to summarize key rehabilitation principles for clinical practice.

Understanding discrepancies in a person's fear of movement and avoidance behaviour:
This section will focus on how to reconcile discrepancies in fear of movement and avoidance behaviour observed in the same person with LBP, and how physiotherapy management can be adapted accordingly. Aspects of fear of movement and avoidance behaviour will be discussed considering relevant theoretical models. Exposure-based therapy, as an effective treatment for patients with fear of movement and avoidance behaviour, is discussed based on the latest insights on exposure-in-vivo in general anxiety literature, and participants are guided in how to translate these insights into exposure-based treatments for persons with avoidance behaviour and related musculoskeletal pain.

Reasoning and application of interventions targeting sensorimotor, affective and cognitive mechanisms in people with low back pain:
This section will present contemporary evidence for the beneficial effects of interventions that jointly target sensorimotor, affective and cognitive mechanisms. The practical application of these interventions will be discussed, with opportunity for audience contribution. The discussion will draw on principles presented earlier in the session, and the model that underpins one of the interventions co-developed by the presenter. A secondary focus will be on practical application of clinical techniques to assess and modulate nervous system function, given emergent evidence indicates these are an important element of the contemporary interventions aforementioned.

Implications/conclusions :
Based on recent evidence from multiple perspectives, this Focused Symposia will provide musculoskeletal clinicians evidenced-based information on the management of beliefs, pain-related fear and movement avoidance in patients with LBP. It will help bridge the gap between affective, cognitive and sensorimotor domains. Guidance will be presented to develop a person-centred assessment of the patient, including actively engaging with the person’s story, using appropriate questionnaires and completing behavioural and neurophysiologic assessments. Moreover, rehabilitation principles will be described to jointly target sensorimotor, affective and cognitive mechanisms to optimize care for people with LBP.

References:
Bagg 2022 doi:10.1001/jama.2022.9930
Wand 2023 doi: 10.1093/ptj/pzac151
Darlow 2013 doi: 10.1370/afm.1518
Hasenbring 2015 doi: 10.1097/AJP.0000000000000097
Bunzli 2017 doi:10.2519/jospt.2017.7434
De Baets 2023 doi: 10.2519/jospt.2023.
Christe 2021 doi: 10.1097/j.pain.0000000000002065
Christe 2023 doi: 10.1111/papr.13191