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Title: Complexity and low back pain.

Authors and affiliation: Frances Griffiths, Institute of Health Sciences, University of Warwick; Jeffrey Borkan, Department of Family Medicine, Brown Medical School; Sally Lamb, Institute of Health Sciences, University of Warwick; Uzma Manazar, Institute of Health Sciences, University of Warwick; Shmuel Reis, Department of Family Medicine, R&B Faculty of Medicine, Technion- Israel institute of technology, Haifa, Israel.

Email address: Reis@netvision.net.il

Introduction: There is research evidence about how to prevent and improve back pain, and widely used guidelines for sufferers. Despite this, back pain is still a major health issue / The back pain research enterprise seems to have reached an impasse. The framing of research limits the evidence it can produce. There is increasing interest in using the framework of complexity sciences for research to extend our evidence base in health research. A complex system displays non- linear dynamics, co-evolves with its context and relationships and is characterized by its emergent behavior which cannot be fully explained through understanding the components of the system. This contrasts with mechanical systems with linear dynamics that do not adapt to their context and can be understood through taking them apart  This contrast of understanding mechanical and complex systems resonates with back pain where the embodied experience of back pain is mechanical yet there is usually no identifiable pathophysiologial process.

Objectives: To explore the use of complexity as analytical framework for back pain narratives.

Methods: Narrative accounts of low back pain were collected from individuals with long term back pain, and their carers, in the UK and the US. The UK study recruited 12 individuals with >6 weeks pain for a series of interviews over 12 months and interviews with family members. The US study recruited 15 individuals with many years of back pain, interviewing each individual and their usual health care professional. The research team developed analytical questions for the data to examine whether back pain narratives are complex adaptive systems or not and how narratives may change from complex to linear and vice versa.

Results: Initial analysis indicates that patients’ back pain narratives loose their complexity and adaptability and become more mechanical and linear, sometimes very early in the back pain experience and this non-complex narrative may remain unchallenged. Carers co-evolve to support this non-complex narrative, but may retain elements of complexity in their stories and their approach to patients.

Conclusion: From initial analysis the team are developing further interview questions for project participants exploring their awareness of positive and negative feedback, their need for certainty in controlling their symptoms and potential for change for themselves and their context. This should help us understand whether ‘complexifying’ back pain may be a way forward.