Reflections of rehabilitation professional: thoughts from the back pain clinic and some memorable patients

It was in December 1973 that my wife and I travelled to Kuala Lumpur so I could take up the post of lecturer in medicine at the University of Malaya. Apart from the blazing wet heat that met us at the top of the steps leading from the aircraft, my next memory is of the discussion I had with the young doctor from the University Hospital who had the chore of picking us up from the airport and taking us to our hotel. I noticed that he did not put on his seatbelt in the car. I commented on this as I had obviously put on my seatbelt and he replied:

“what for to put on the seatbelt – if you are going to die then you will die”.

In other words he said “that’s fate”.

That was my introduction to fatalism which is prominent in the East – even in western-trained individuals such as this young doctor. Later in my career when I was sitting in low back pain clinics (LBP) and thinking about this subject, that I met the writing of Walston and Walston [1]. This has considerable implications particularly for those for those who practice where there are large immigrant communities. We did some research into this and found the Praying and Hoping subscale of the Coping Strategies Questionnaire [2] lacked the ability to discriminate between those who prayed to God to take away their pain (unhelpful response to pain) and those who prayed to God to give them the strength to cope with their pain (helpful to adjustment?). However, a major implication for further study is the relationship of belief – that may be religious – to the experience of LBP. Thus patients in north-west London ‘born in South Asia, or who were Hindu or Muslim’, appeared to experience LBP significantly worse than British, British-born or Christian low back pain patients’ [3].

It later dawned on me that the difficulties in helping ‘internal believers’ was that they had already adopted all the strategies that I was likely to recommend e.g. no smoking, obtain ideal weight, relaxation, regular exercise, work-life balance etc.

Another memorable patient was a young man probably in his early thirties who presented with LBP. He was born in South Asia and had been in the UK for many years – he spoke fluent English. It transpired that he had been a bus conductor but he had been assaulted on three separate occasions and this had resulted in his losing his job. However, he had been very proud of his uniform and was unable to discuss the loss of his job with his family, Every morning he got up to go to work wearing his uniform and only came home after the equivalent time of a full day’s work! Eventually, we got around to asking why his trade union had not helped him in his relationship with his employer. It transpired that they had given him many forms to complete and he had been too proud to admit that he was illiterate and thus he had not persisted in getting help from his union!

The only other patient that I recognised as being illiterate was a trader from the east end of London who was quite successful from memory. I was a medical registrar in about 1972-3 on the renal unit of the Royal London Hospital. No one could quite understand the difficulties that this man was having following the instructions of his dialysis machine until one day he confided that he was unable to read the instructions he had been given!


  • An individual’s beliefs may impact on their rehabilitation.
  • Literacy cannot always be taken for granted even in those with great oral fluency.

I am happy to discuss any of the issues raised in these reflections with colleagues who can email me andrew.frank1 AT (remove spam filter) and head the email VRA – professional reflections.

Andrew Frank

Trustee and Past-Chair, VRA


  1. Wallston, B., et al., Development and validation of the Health Locus of Control (HLC) Scale. J Consult and Clin Psychol, 1976. 44(4): p. 580-585.
  2. Rosenstiel, A.K., FJ., The use of coping stragies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain, 1983. 17: p. 33-44.
  3. McAuley, J., Cultural influences on low back pain: extending the biopsychosocial model. 2001, PhD thesis, Brunel University London.