"Our training left us unprepared"- two physiotherapists' reflections after working with women with low back pain in a rural Zulu community in South Africa

  • Victoria Madden
  • Peter O'Sullivan
  • Julia Fisher
  • Busisiwe Malambule


Low back pain (LBP) is a major health disorder that has been researched thoroughly in the western world context, but poorly in the developing world. Back pain beliefs, assessment, and management strategies developed for the western world may have limited relevance for the developing world. This paper reflects on the experiences of two recent physiotherapy graduates working in a rural Zulu community in South Africa. It highlights the socioeconomic, lifestyle, and cultural influences on women who presented with LBP. The authors discuss the challenges they faced in adjusting from a largely western biomedical understanding of LBP to the rural Zulu context. The authors propose the need for a greater bio psychosocial understanding of LBP in a cultural socioeconomic context. Enhanced clinical skills are required to adapt across cultural beliefs, language and lifestyle contexts, for better management of LBP.


Abenhaim, L., Rossignol, M., Valat, J., Nordin, M., Avouac, B., Blotman, F., et al. (2000). The role of activity in the therapeutic management of back pain: Report of the international paris task force on back pain. Spine, 25(4S) (Supplement), 1S-33S. Retrieved from http://ovidsp.ovid.com/ov idweb.cgi?T=JS

&NEWS=N&PAGE=fulltext&AN=0000763 2-200002151-


Adams, M.A., Mannion, A F., & Dolan, P. (1999).Personal risk factors for first-time low back pain.Spine, 24(23), 2497. Retrieved from http://ovidsp.ovid.com.ezproxy.uct.ac.za/ ovidweb.cgi?T=JS&NEWS =N&PAGE=fulltext&AN=0000763 2-199912010-00012&D=ovftd

Andersson, G. B. (1999). Epidemiological features of chronic low­ back pain. The Lancet, 354(9178), 581-585. doi:DOI10.1016/S0140-6736(99)01312-4

Bagnall,D. L. (2010).Physiatry: What's the end game? Physical

Medicine and Rehabilitation, 2, 3-3-5.

Battie, M. C., Videman, T., Kaprio, J., Gibbons, L. E.• Gill, K..

Manninen, H., et al. (2009). The twin spine study : Contributions to a changing view of disc degeneration. The Spine Journal : Official Journal of the North American Spine Society, 9(1). 47-59. doi:10.1016/j.spinee.2008.11.011

Bezuidenhout,M. (2011}.Interview.Unpublished.

Blumenstiel, K. (2011). Quantitative sensory testing profiles in chronic back pain are distinct from those in fibromyalgia. The Clinical Journal of Pain, 27(8) , 682. doi:10.1097/AJP.Ob013e3182177654

Boersma, K. & Linton, S. J. (2005). Screening to identify patients at risk: Profiles of psychological risk factors for early intervention. Clinical Journal of Pain.Special Topic Series: Cognitive-Behavioral Treatment for Chronic Pain, 21(1},38-

Retrieved from

http://ovidsp.ovid.com.ezproxy.uct.ac.za/ovidweb.cgi?T=JS& NEWS= N& PAGE=fulltext&AN =00002508-20050 1000-


Briggs, A . M. (2010). Health literacy and beliefs among a community cohort with and without chronic low back pain.Pain, 150(2),275.

Burton, A. K. Balagu, F.,Cardon, G.,Eriksen. H.R., Henrotin. Y., Lahad, A., et al. (2006). Chapter 2. European guidelines for prevention inlow back pain :November 2004.European Spine Journal,15Suppi2,S136.

Burton, A. K., Tillotson, K. M., Main, C. J., & Hollis, S. (1995).

Psychosocial predictors of outcome in acute and subchronic

low back trouble .Spine, 20(6),722-728.

Cassidy, J. D..Carroll, L. J., & Cote, P. (1998). The saskatchewan health and back pain survey. the prevalence of low back pain and related disability in saskatchewan adults.Spine,23(17), 1860-6;discussion 1867.

Croft, P. R., Papageorgiou ,A. C., Ferry, S., Thomas, E.. Jayson , M., & Silman,A. J. (1995). Psychologic distress and low back pain.evidence from a prospective study in the general population. Spine ,20(24},2731-2737.

Deyo, R.A. (2009).Overtreating chronic back pain: Time to back off? The Journal of the American Board of Family Practice,22(1), 62.doi:10.3122/jabfm .2009.01.080102

Deyo, R. A. , & Weinstein,J. N. (2001).Low back pain. The New England Journal of Medic ine, 344(5), 363-370. doi: 10.1056/NEJM200102013440508

Dionne, C.E., Koepsell, T.D., Von Korff,M.,Deyo, R.A., Barlow, W.E.,& Checkoway,H.(1997).Predicting long-term functiona l limitations among back painpatients in primary care settings. Journal ofGiiAieai-EJ: idemiology ,50(1),31-43.

Foster, N. E.(2011).Embedding psychosocial perspectives within clinical management of low back pain: Integration of psychosocially informed management principles into physical therapist practice-challenges and opportunities .Physical Therapy, 91(5),790.doi:10.2522/ptj.20100326

Frank, J. W. (1996). Disability resulting from occupational low back pain:Part 1:What do we know about primary prevention? A review of the scientific evidence on prevention before disability begins.Spine (Philadelphia. Pa.1976), 21(24), 2908.

Frank, J., Sinclair, S., Hogg-Johnson, S., Shannon, H., Bombardier, C.,Beaton, D.,et al. (1998).Preventing disability from work-related low back pain. Canadian Medical Association Journal, 158(12}, 1625-31.

Fredlund, V.(2011). HIV prevalence. Unpublished.

Futter, M.J. (2003). Developing a curriculum module to prepare students for community-based physiotherapy rehabilitation in South Africa .Physiotherapy, 89(1), 13.doi:10.1016/S0031 - 9406(05)60665-7

Gatchel,R. J.,Peng,Y.B.,Peters,M. L., Fuchs, P. N.,&Turk, D.C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin,133(4), 581-624. doi:10.1037/0033-2909.133.4.581

Gumede,S.(2009).Personalcommunication. Unpublished.

Hartvigsen, J., Lauritzen, S., Lings, S., & Lauritzen, T. (2005).

Intensive education combined with low tech ergonomic intervention does not prevent low back pain in nurses. Occupational and Environmental Medicine, 62(1), 13-17. doi:10.1136/oem.2003.010843

Health Systems Trust. (2005). The district health barometer Health Systems Trust.

Horne, R. (2004). Medicine in a multi-cultural society: The effect of cultural background on beliefs about medications. Social Science Medicine,59(6), 1307

lgumbor, E. (2011). Pain as a reason for primary care visits:Cross­ sectional surveys in a rural and a peri-urban health clinic inthe Eastern Capeprovin e. 4th Pan African Pain Congress.

Kent, P. M., Keating, J. l., & Taylor, N. F. (2009). Primary care clinicians use variable methods to assess acute nonspecific low back pain and usually focus on impairments. Manual Therapy,1-4t1 ),88-100. doi:10.1016/j.math.2007.12.006

Krismer, M. (2007).Low back pain (non-specific). Bailliere's Best Practice Research.Ciinical Rheumatology,21(1), 77.

Lin,l. B.,O'Sullivan, P. B., Coffin, J.A.,Mak,D.B., Toussaint, S.,& Straker, L.M. (2012). 'I am absolutely shattered': The impact of chronic low back pain on australian aboriginal people. European JOurnal of Pain, doi:10.1002/j.1532- 2149.2012.00128.x

Linton, S. J. (2000). A review of psychological risk factors in back and neck pain. Spine, 25(9), 1148-1156.

Loney, P. L. (1999). The prevalence of low back pain in adults: A methodological review of the literature.Physical Therapy, 79(4), 384.

Louw, Q., Morris, L., & Grimmer-Somers , K. (2007). The prevalence oflow back pain in africa: Asystematic review.BMC Musculoskeletal Disorders, 8(1), 105. Retrieved from http://www.biomedcentral.com/1471-247 4/8/105

Malambule, B.(2009).Personal communication. Unpublished.

Malambule, B. (201O). Personal communication. Unpublished.

Martel, M. 0., Thibault,P., & Sullivan, M. J . L. (2010). The persistence of pain behaviors in patients with chronic back pain is independent of pain and psychological factors.Pain , 151(2), 330-331-336 .

Martin,B.1., Deyo, R. A., Mirza, S.K.,Turner, J.A., Comstock, B. A., Hollingworth, W., et al. (2008). Expenditures and health status among adults with back and neck problems. JAMA: The Journal of the American Medical Association, 299(6), 656-664. doi:10.1001/jama.299.6.656

Naidoo, S. (2009). Musculoskeletal pain in women working in small-scale agriculture in South Africa. American Journal of Industrial Medicine, 52(3), 202.

O'Sullivan,P. (2011). It's time for change with the management of non-specific chronic low back pain. British Journal of Sports Medicine, doi:10.1136/bjsm.2010.081638

Ross._S. (2004) . Patient compliance in hypertension: Role of illness perceptions and treatment beliefs.Journal of Human Hypertension, 18(9),607.

Rumsey, C. A. (2012). Culture, abstinence, and human rights: Zulu use of virginity -testing in south Africa's battle against AIDS. University of Ottowa).

Statistics South Africa. Census 2001

Statistics South Africa. (2007). Community survey.Unpublished manuscript.

Stats SA Library Cataloguing-in-Publication (CIP) Data. (2003). Census 2001: Investigation into appropriate definitions of urban and rural areas fo r south africa: Discussion document No. 03-02-20 (2001)]). Pretoria: Statistics SouthAfrica.

Umkhanyakude Municipality IDP.(2005). Health and related indicators. Umkhanyakude Municipality IDP: KZN Department of Health.

Vaughan Williams, C. H. (2010). Personal communication Unpublished.

Vieira. E. R. (2006). Cut-points to prevent low back injury due to force exertion at work.Work, 27(1), 75.

Vingard, E., Mortimer, M., Wiktorin, C., Pernold RPT, G., Fredriksson, K.,Nemeth,G., et al. (2002).Seeking care for low back pain in the general population: A two-year follow-up study: Results from the MUSIC-norrta lje study. Spine, 27(19), 2159-2165. Retrieved from http://ovidsp.ovid .com/ovidweb .cgi?T=JS&NEWS=N&PAGE

=fulltext&AN=00007632-20021 0010-00016&D=ovftf

Volinn,E.(1997).The epidemiology of low back pain in the rest of the worfd.A review of surveys in low- and middle-income countries.Spine, 22,1747-54.

Waddell, G. (2004). The back pain revolution (Second ed.).

Edinburgh: Churchill Livingstone.

Walker, B., Muller, R., & Grant, W. (2004). Low back pain in Australian adults. prevalence and associated disability.Journal of Manipulative and Physiological Therapeutics, 27,238-44.

Washington , K. (2010).Zulu traditional healing, afrikan worldview and the practice of ubuntu: Deep thought for Afrikan/Biack psychology.The Journal of PanAfrican Studies, 3(8), 24.

Williams, D. A. (1989). An empirical assessment of pain

beliefs. Pain,36(3),351.

Williams, D.A. (1998). Health care and indemnity costs across the natural history of disability inoc upationallow back pain.Spine (Philadelphia, P.a,1976),.23(21),2329.

Woolf,A. D.,& Pfleger,B.(2003). Burden of major musculoskeletal conditions. Bulletin of the World Health Organization, 81(9), 646-656.

Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain.Pain , 152(3), S2. doi:10.1016/j.pain.2010.09.030

Yassi, A., Cooper, J.E., Tate, R. B., Gerlach, S., Muir, M.,Trottier, J., et al. (2001).A randomized controlled trial to prevent patient lift and transfer injuries of health care workers.Spine, 26(16), 1739-1746.