The main finding of our analysis was that the content on most of the websites were ambiguous and not in concordance with current research. There is a lot of nocebic information presented on most of the websites explored. Information presented on websites are biomedically oriented with back pain being depicted as a structural problem with disc related injuries as the most common cause. Bulk of the information highlights pathoanatomical causes of LBP and biomechanical influences on lumbar anatomy.
The causes varied a lot with information showing reliance on disc, posture, and lifting mechanics as the source of LBP. The disc was discussed by almost all the websites and the descriptors used for it were vague and imprecise. All of the websites specifically refer to lumbar intervertebral disc and arthritis-related disorders as possible causes of LBP. Very few of the websites acknowledged the impact of a person's beliefs, feelings, and behaviors on their LBP experience, and even fewer discussed social determinants. The obvious focus on pathoanatomical info as a cause of LBP suggests a widespread belief in the importance of educating the masses about the wide range of illness processes that may influence LBP.
Intervertebral discs and lumbar pathologies may be a source of nociception in some individuals with LBP [18]. The majority of LBP clinical diagnoses, on the other hand, are non-specific, and the evidence suggest that there is no link between lumbar structural abnormalities and pain [4, 19, 20]. This suggests that focus on biomechanical or structural abnormalities alone may be misleading. The limited psychosocial representation found by us emphasizes similar findings by ‘International forum for primary care research on low back pain’ that the biopsychosocial model has not been adequately adopted in investigating LBP [21].
Despite the lack of representation for biopsychosocial factors, the therapeutic use of openly stating within public information that fear and catastrophizing are contributors to LBP is unknown [22]. However, it is shown that a focus on tissue pathology may promote the maladaptive attitudes, emotions and behaviors that contribute to pain and disability [23]. Encouragingly, LBP is described as a natural and common phenomenon by majority of websites, this approach has been suggested to help prevent the development of maladaptive reactions contributing to LBP [24]. Concisely, the information presented is unidirectional for such a complex problem.
A variety of diagnostic tools were mentioned on the websites. We found that sites recommended diagnostic imaging specifically for those individuals who presents with red flags or those who failed to respond to the conservative care, as suggested by the NICE guidelines [25]. Despite this imaging is presented as a prime solution to find the cause which may result in clients perceived need for imaging during their consultations with Health care providers (HCPs) [26].
With regard to the treatment options a wide variety of strategies were mentioned on the websites (Fig. 4). All of the web pages suggested physiotherapy, osteopathy, and chiropractic (musculoskeletal practitioners) as a treatment option. Encouragingly conservative approach was suggested as first line of care followed by surgical options. This recommendation is as per the recent CPGs [25, 27]. In terms of pharmacological advice, drugs like acetaminophen, NSAIDS, opioids, and muscle relaxants were recommended for management of LBP. The suggestion of acetaminophen as drug is contrary to the published literature which suggests that it is no better than placebo for people with LBP [28]. Selective serotonin reuptake inhibitors (SSRIs) and anti-convulsant were also mentioned by few websites which is again against the NICE recommendations [25].
Apart from the pharmacologic management, websites also recommended ergonomic options like posture corrections, sleeping in a particular position, and lifting in a particular way, and these treatment advice are not in line with the recent evidence [29]. These findings suggest that treatment recommendations made by websites were either incorrect or ambiguous, putting the public at danger of being misled. It also reflects that people cannot get accurate information regarding LBP on the internet [30]. Furthermore, research conducted among the common people indicates that looking for health-related information on the internet is linked to higher health-care utilization [31, 32]. Considering the fact that individual seeks health information on the Internet for LBP. This added to the current findings that the enormous amount of erroneous and unclear content available on these websites, may be leading them to seek unneeded or ineffective treatment [33].
Given that this is the current state of affairs, one may ask what the solution is to the spread of unhelpful information? How may we better suit the needs of the general population searching for accurate evidence-based information on back pain and its treatment. We are living in an age where “Dr Google” is the main initial source of medical information for the common people. As clinicians, this can be a challenge when the information is at best out of date and at worst out of step with the evidence and the guidelines on best management. It is a daily struggle to re-educate our patients when they arrive to our clinics with preconceived notions gleamed from Google that cause loss of self-efficacy, fear avoidance, and catastrophizing. Th findings highlight the need for development of online content that is more in adherence with the research. The content must also be easy, comprehensive and avoid overt medical jargons.
Comparison with previous work
Our results extend previous research which highlighted that back pain-related online content lacks credibility, accuracy and is not as per the recently published literature [33,34,35,36,37]. Hendrick and colleagues showed that current back pain management content accessible on the Internet is not always aligned with existing evidence. They had only looked into the veracity of information for one type of LBP (acute LBP) [37]. Samanci et al. only observed online content related to “lumbar disc herniation (LDH) treatment”, “lumbar spinal stenosis (LSS) treatment,” and “lumbar spondylolisthesis (LSL) treatment” [35]. The other similar studies only used a limited number of websites and were conducted almost a decade back [34, 36]. Ferreira et al. in their study only looked at web pages from government agencies, health care organizations, and universities [33].
Our study extends the scope of previously published literature providing an overview of the content presented on different web pages and recognizing the broad themes around which these websites are developed. In contrast to the previous studies, the authors of the present study made sure that the search strategies reflected the real-life searches conducted by the common people. The content analysis was also done according to the information needs of people with low back pain from the online resources [17].
