| FINDINGS RELEVANT ACROSS ALL INTERVENTION CLASSES |
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1
| Older people preferred treatments that were effective, credible, that they did not have concerns about and suited them as individuals (in terms of cost, access, side-effects and experience). Most older people valued treatments that maximized daily function. Knowledge from past experiences could influence this decision. [values and preferences]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of unclear reporting of sampling and reflexivity in some studies.
| Moderate concerns Explanation: moderate concerns regarding coherence owing to opaque data in some studies that needed interpretation to fit the finding.
| Minor concerns Explanation: minor concerns regarding adequacy because of thin data from one study.
| Minor concerns Explanation: minor concerns regarding relevance because of several studies where not all participants were aged over 60.
| Low confidence Explanation: minor concerns regarding methodological limitations, moderate concerns regarding coherence, minor concerns regarding adequacy, and minor concerns regarding relevance.
| Dima A et al. 2013; Hay ME & Connelly DM 2020; Igwesi-Chidobe CN et al. 2017; Igwesi-Chidobe CN et al. 2019; Kirby ER et al. 2014; Teh Carrie F et al. 2009; |
|
2
| Older people valued treatments that reduced or relieved pain temporarily and/or improved their function in the longer term. In some cases, older people valued treatments they found personally enjoyable, had a positive impact (e.g. on well-being), or were meaningful and involved social engagement. [values and preferences]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of poor reporting of sampling and reflexivity in some studies.
| Minor concerns Explanation: minor concerns regarding coherence because of variation of examples and types of treatment across the studies.
| No/very minor concerns | Minor concerns Explanation: minor concerns regarding relevance because of a few studies where not all participants were over 60.
| Moderate confidence Explanation: minor concerns regarding methodological limitations, minor concerns regarding coherence, no/very minor concerns regarding adequacy, and minor concerns regarding relevance.
| Dima A et al. 2013; Hay ME & Connelly DM 2020; Igwesi-Chidobe CN et al. 2019; Igwesi-Chidobe CN et al. 2020; Kirby ER et al. 2014; Kuss K et al. 2016; Lee TL et al. 2020; Leonhardt Corinna et al. 2017; Lilje S C et al. 2017; Makris Una E et al. 2015; Rodriguez I et al. 2019; Stensland M 2021; Teh Carrie F et al. 2009. |
|
3
| Older people generally emphasized that they valued individualized care and guidance across the different interventions, whether health practitioner- or peer-delivered. They valued care when it was person-centered. Supervision/professional guidance allowed them to feel safe. There was a preference for a collaborative communication style. [values and preferences]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of unclear reporting in some studies for sampling and data collection and unclear reporting across all studies for reflexivity.
| Moderate concerns Explanation: moderate concerns regarding coherence because participants are talking about a variety of treatments and treatment providers as well as self-initiated exercise as part of self-management.
| No/very minor concerns | Minor concerns Explanation: minor concerns regarding relevance because not all participants are aged over 60 and all are community-dwelling.
| Low confidence Explanation: minor concerns regarding methodological limitations, moderate concerns regarding coherence, no/very minor concerns regarding adequacy, and minor concerns regarding relevance.
| Cooper K et al. 2017; Dima A et al. 2013; Hay ME & Connelly DM 2020; Igwesi-Chidobe CN et al. 2019; Igwesi-Chidobe CN et al. 2020; Kuss K et al. 2016; Lee TL et al. 2020; Lin I et al. 2014; Lyons Kevin J et al. 2013. |
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4
| Some older people viewed the burden related to the intervention (financial, time and travel) as a barrier to accessing care. High cost rendered treatment inaccessible or deterred older people from trying to adjust or continue with a recommended treatment. For others who had the financial means or were accessing publicly-funded health care, cost barriers were not discussed. [resource implications]
| No/very minor concerns | No/very minor concerns | Minor concerns Explanation: minor concerns regarding adequacy because of thin data from one study.
| Minor concerns Explanation: minor concerns regarding relevance because of some participants are under the age of 60.
| Moderate confidence Explanation: no/very minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, minor concerns regarding adequacy, and minor concerns regarding relevance.
| Dima A et al. 2013; Igwesi-Chidobe CN et al. 2017; Lyons Kevin J et al. 2013; Stensland M 2021. |
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5
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Many older people preferred health workers who were located in close proximity to where they lived. For some, this was due to CPLBP limiting their ability to travel more than short distances. If services were located a considerable distance away, the services were perceived as insufficient or inaccessible, or the distance itself was seen as a barrier to care. However, some participants were willing to travel if a trusted or favoured health worker relocated, or they were exploring new treatment options. Others preferred to find a new practitioner close to where they lived.
[resource implications]
| No/Very minor concerns | Minor concerns Explanation: minor concerns regarding coherence because of diverse specificity of findings across the studies.
| Minor concerns Explanation: minor concerns regarding adequacy because of thin data from some studies.
| Minor concerns Explanation: minor concerns regarding relevance because in some studies participants are under the age of 60.
| Moderate confidence Explanation: no/very minor concerns regarding methodological limitations, minor concerns regarding coherence, minor concerns regarding adequacy, and minor concerns regarding relevance.
| Allvin R et al. 2019; Dima A et al. 2013; Igwesi-Chidobe CN et al. 2017; Kirby ER et al. 2014; Lin I et al. 2014; Lyons Kevin J et al. 2013; Stensland M 2021. |
| MEDICINES |
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|
6
| Many older people reported that medication was often the only intervention that made a difference to the severity of their pain. However, they were apprehensive of, or dissatisfied with, medication for several reasons, often viewing it as a quick fix, temporary relief or just masking the pain. Many participants were apprehensive of taking too many medications, side-effects, addiction or did not like how the medications made them feel. Some avoided taking medications all together, did not present their prescriptions for dispensing or adjusted their treatment themselves because of this. [values and preferences]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of lack of reporting around reflexivity. We feel that the researcher’s position or role could have influenced how patients answered the question.
| No/very minor concerns | No/very minor concerns | Moderate concerns Explanation: moderate concerns regarding relevance because all except one study from USA. In two studies, some participants were under the age of 60 years.
| Moderate confidence Explanation: minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, no/very minor concerns regarding adequacy, and moderate concerns regarding relevance.
| Cummings EC et al. 2017; Dima A et al. 2013; Lyons Kevin J et al. 2013; Makris Una E et al. 2015; Stensland M 2021; Teh Carrie F et al. 2009. |
|
7
| Some older people adopted alternative forms of treatment, including traditional or herbal medicines, as a part of their self-management approach when conventional treatments failed to provide relief from their chronic LBP. Some viewed this as experimenting to find a solution. Often older people did not inform their health care provider about taking this type of treatment. [values and preferences]
| No/very minor concerns | No/very minor concerns | Serious concerns Explanation: serious concerns regarding adequacy because of thin data from two studies.
| Serious concerns Explanation: serious concerns regarding (global) relevance because of studies from two different contexts (United States of America, Nigeria) and several participants in one study were under the age of 60 years.
| Low confidence Explanation: no/very minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, serious concerns regarding adequacy, and serious concerns regarding relevance.
| Igwesi-Chidobe CN et al. 2017; Teh Carrie F et al. 2009. |
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8
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In one study conducted in rural Nigeria, older people considered medicines as a legitimate form of treatment (a cultural norm where disease was treated and “cured” with medication) and depended on medicines to be able to perform daily tasks. Other treatments were looked down on or stigmatized, such as exercise. Some older people took medication only to comply with this cultural norm. However, there was a constant struggle to be able to afford the medicines on which they depended to function normally.
[resource implications]
| No/very minor concerns | No/very minor concerns | Serious concerns Explanation: Serious concerns regarding adequacy because of thin data from one study.
| Moderate concerns Explanation: moderate concerns regarding relevance since there was only one study available with participants sampled from one rural area in Nigeria, representing a subpopulation from a broader Nigerian population.
| Low confidence Explanation: no/very minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, serious concerns regarding adequacy, and moderate concerns regarding relevance.
| Igwesi-Chidobe CN et al. 2017. |
|
9
| Many older people expressed fear of addiction to medication, especially to opioids. This led them to not present prescriptions for dispensing, adjust the dosage or stop taking the medication often without consulting their health worker. In one case, the fear of addiction stemmed from the health care worker who refused to provide the prescription requested. [acceptability]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of lack of reporting of reflexivity.
| No/very minor concerns | Minor concerns Explanation: minor concerns regarding adequacy because of some thin data, although addressing a very specific topic.
| Moderate concerns Explanation: moderate concerns regarding relevance because all but one study from the USA and one study had some participants under the age of 60.
| Moderate confidence Explanation: minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, minor concerns regarding adequacy, and moderate concerns regarding relevance.
| Dima A et al. 2013; Lyons Kevin J et al. 2013; Makris Una E et al. 2015; Stensland M 2021; Teh Carrie F et al. 2009. |
|
10
| In a study in rural Nigeria, some older people reported that when the locally manufactured medicines failed to relieve symptoms, they believed that they were fake or substandard. These older people thought that imported medicines were stronger and more likely to lead to a cure. [acceptability]
| No/very minor concerns | No/very minor concerns | Serious concerns Explanation: Serious concerns regarding adequacy because of very thin data from one study.
| Moderate concerns Explanation: moderate concerns regarding relevance because only one rural area considered in a subpopulation (farmers).
| Low confidence Explanation: no/very minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, serious concerns regarding adequacy, and moderate concerns regarding relevance.
| Igwesi-Chidobe CN et al. 2017. |
| PHYSICAL INTERVENTIONS |
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|
11
| Needling therapies were valued as effective by the few participants who talked about it. However, it was viewed as providing temporary relief and being expensive. [values and preferences]
| No/very minor concerns | No/very minor concerns | Serious concerns Explanation: serious concerns regarding adequacy because of thin data from a limited number of studies.
| Serious concerns Explanation: Serious concerns regarding relevance owing to exclusively high-income contexts and some participants under the age of 60 years.
| Low confidence Explanation: no/very minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, serious concerns regarding adequacy, and serious concerns regarding relevance.
| Dima A et al. 2013; Stensland M 2021. |
|
12
| Older people emphasized the importance of continuity of physical exercises to maintain mobility and reduce pain. A lack of continuity of physical exercise and instruction could have adverse effects. [values and preferences]
| No/very minor concerns | Moderate concerns Explanation: moderate concerns regarding coherence because not all studies reflect both parts of the findings.
| Minor concerns Explanation: minor concerns regarding adequacy because thin data from some of the included studies.
| Minor concerns Explanation: minor concerns regarding relevance because of one study where participants were not all aged over 60 years and all were community-dwelling.
| Low confidence Explanation: no/very minor concerns regarding methodological limitations, moderate concerns regarding coherence, minor concerns regarding adequacy, and minor concerns regarding relevance.
| Hay ME & Connelly DM 2020; Igwesi-Chidobe CN et al. 2017; Igwesi-Chidobe CN et al. 2019; Lilje SC et al. 2017; Teh Carrie F et al. 2009. |
|
13
| Older people also valued educational materials to accompany exercise programmes, such as drawings and descriptions of the exercises. [values and preferences]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of unclear reporting of sampling in a few studies and unclear reporting of reflexivity across all studies.
| No/very minor concerns | Serious concerns Explanation: serious concerns regarding adequacy because of thin data and small number of studies.
| Serious concerns Explanation: serious concerns regarding relevance because of studies from only two countries and one study where not all participants were aged over 60 years.
| Low confidence Explanation: minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, serious concerns regarding adequacy, and serious concerns regarding relevance.
| Dima A et al. 2013; Igwesi-Chidobe CN et al. 2019; Igwesi-Chidobe CN et al. 2020; Kuss K et al. 2016; Leonhardt Corinna et al. 2017. |
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14
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Older people saw that there is a need to reduce the stigma associated with doing exercise as treatment for LBP since it is not regarded as a legitimate treatment in rural Nigeria. They suggested that changes at the community level such as increasing awareness about the benefits of exercise could change negative community beliefs and legitimize exercise as a treatment for back pain, thereby reducing the stigma currently associated with it.
[equity and human rights]
| No/very minor concerns | No/very minor concerns | Serious concerns Explanation: serious concerns regarding adequacy because of thin data from only one study.
| Moderate concerns Explanation: moderate concerns regarding relevance because study was only in one rural area of Nigeria with a subpopulation of farmers.
| Low confidence Explanation: no/very minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, serious concerns regarding adequacy, and moderate concerns regarding relevance.
| Igwesi-Chidobe CN et al. 2017; Igwesi-Chidobe CN et al. 2019; Igwesi-Chidobe CN et al. 2020. |
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15
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Many older people liked a group format for physical exercise classes as this facilitated social support, collaborative learning and social activities, all of which encouraged increased attendance.
[acceptability]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of poor reporting of sampling and reflexivity in some studies.
| Minor concerns Explanation: minor concerns regarding coherence because of one participant whose opinion opposed the finding.
| Minor concerns Explanation: minor concerns regarding adequacy because of thin data from two studies.
| Minor concerns Explanation: minor concerns regarding relevance because of the age of participants in one study and because all participants were community-dwelling adults.
| Moderate confidence Explanation: minor concerns regarding methodological limitations, minor concerns regarding coherence, minor concerns regarding adequacy, and minor concerns regarding relevance.
| Hay ME & Connelly DM 2020; Igwesi-Chidobe CN et al. 2019; Kuss K et al. 2016; Lee TL et al. 2020. |
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16
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Some older people adopted physical exercise or assistive products as a part of their self-management approach to supplement conventional treatments, or when conventional treatments failed or proved to be insufficient. Some viewed this as experimenting to find a solution.
[feasibility]
| Minor concerns Explanation: minor concerns regarding methodological limitations because of unclear reporting of sampling and reflexivity.
| No/very minor concerns | No/very minor concerns | Minor concerns Explanation: minor concerns regarding relevance because of some studies in which not all participants were aged over 60 years.
| Moderate confidence Explanation: minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, no/very minor concerns regarding adequacy, and minor concerns regarding relevance.
| Cooper K et al. 2017; Hay ME & Connelly DM 2020; Igwesi-Chidobe CN et al. 2019; Lyons Kevin J et al. 2013; MacKichan F et al. 2013; Rodriguez I et al. 2019; Stensland M 2021. |
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17
| Older people requested shorter sessions of physical exercises on specific days to fit in with their daily schedule. [feasibility]
| No/very minor concerns | Moderate concerns Explanation: moderate concerns regarding coherence because of vague data.
| Serious concerns Explanation: serious concerns regarding adequacy because of thin data from a small number of studies.
| Serious concerns Explanation: serious concerns regarding relevance because of studies from a limited number of settings and two of three studies in which not all participants were aged over 60 years.
| Very low confidence Explanation: no/very minor concerns regarding methodological limitations, moderate concerns regarding coherence, serious concerns regarding adequacy, and serious concerns regarding relevance.
| Dima A et al. 2013; Hay ME & Connelly DM 2020; Igwesi-Chidobe CN et al. 2019; Igwesi-Chidobe CN et al. 2020. |
| PSYCHOLOGICAL INTERVENTIONS |
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18
| Mindfulness and meditation allowed some older people to increase their body awareness in relation to, for example, breathing, posture, cognition and pain. In some cases, this allowed for early recognition of pain. [values and preferences]
| Minor concerns Explanation: minor concerns regarding methodological limitations due to unclear reporting of sampling and lack of evidence of reflexivity.
| No/very minor concerns | Serious concerns Explanation: serious concerns regarding adequacy because of relatively thin data from two studies and very thin data from one study.
| Serious concerns Explanation: serious concerns regarding relevance because all three studies are from the same context (USA), were conducted as part of trials and all subjects were community-dwelling adults.
| Very low confidence Explanation: minor concerns regarding methodological limitations, no/very minor concerns regarding coherence, serious concerns regarding adequacy, and serious concerns regarding relevance.
| Lee TL et al. 2020; Luiggi-Hernandez JG et al. 2018; Morone NE et al. 2008. |
|
19
| Mindfulness and meditation allowed older people to examine, assess, understand and accept their pain rather than avoid it. For some people, this lessened the significance or power of the pain experience, allowed them to gain a sense of control over their lives and increase their ability to relax and respond to stress, with improved sleep, attention, well-being and general quality of life. [values and preferences]
| Moderate concerns Explanation: moderate concerns regarding methodological limitations because of unclear reporting of sampling and lack of reporting of reflexivity.
| No/very minor concerns | Minor concerns Explanation: minor concerns regarding adequacy because of thin data from one study.
| Serious concerns Explanation: serious concerns regarding relevance because all three studies are from the same context.
| Low confidence Explanation: moderate concerns regarding methodological limitations, no/very minor concerns regarding coherence, minor concerns regarding adequacy, and serious concerns regarding relevance.
| Lee TL et al. 2020; Luiggi-Hernandez JG et al. 2018; Morone NE et al. 2008. |
|
20
| Some older people were able to use mindfulness and meditation for pain management and coping to varying degrees. Some older people experienced no relief, while others experienced some or short-term relief, and a few were able to eliminate feelings of pain. [values and preferences]
| Serious concerns Explanation: serious concerns regarding methodological limitations because of unclear description of sampling and lack of reporting on reflexivity.
| No/very minor concerns | Minor concerns Explanation: minor concerns regarding adequacy because of very thin data from one study.
| Serious concerns Explanation: serious concerns regarding relevance because all three studies are from the same context (USA).
| Low confidence Explanation: serious concerns regarding methodological limitations, no/very minor concerns regarding coherence, minor concerns regarding adequacy, and serious concerns regarding relevance.
| Lee TL et al. 2020; Luiggi-Hernandez JG et al. 2018; Morone NE et al. 2008. |
| EDUCATION INTERVENTIONS |
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21
| Older people broadly had positive views of peer support although they found it was difficult to access and did not know of support groups in their area. Empathy and “being believed” through common experience were the most important attributes in a peer supporter. Older people considered it would be helpful to share information and receive or exchange support and advice. [acceptability]
| Moderate concerns Explanation: moderate concerns regarding methodological limitations because of lack of reporting of sampling, context and reflexivity in some studies.
| Minor concerns Explanation: minor concerns regarding coherence because of the indirect nature of some of the data that needed to be interpreted.
| Minor concerns Explanation: minor concerns regarding adequacy because of thinner data from some studies.
| Moderate concerns Explanation: moderate concerns regarding relevance because of the studies being limited to HIC contexts and several studies in which not all participants were aged over 60 years.
| Low confidence Explanation: moderate concerns regarding methodological limitations, minor concerns regarding coherence, minor concerns regarding adequacy, and moderate concerns regarding relevance.
| Cooper K et al. 2017; Cummings EC et al. 2017; Hay ME & Connelly DM 2020; MacKichan F et al. 2013; Teh Carrie F et al. 2009.
|