Self-management and behaviour change in persistent LBP: Where is the science currently at?

Background

Typically, self-management behaviour change interventions for persistent low back pain (LBP) help the patient to learn and adopt a set of health behaviours that they can use to reduce or manage their symptoms. Although this may seem like a core part of treatment, the effectiveness of self-management interventions for persistent LBP to date is mixed. As part of a recent special edition on back pain in Best Practice and Research Clinical Rheumatology, we examined the existing literature within self-management interventions for persistent LBP, to establish the areas where evidence is currently lacking and how the science can be improved [1].

Evidence from four existing systematic reviews [2-5] covering 21 studies, suggested that while self-management interventions appeared to be effective overall, with some studies reporting improvements in pain and disability up to a year after the intervention, there was wide variability in the effect sizes reported by the studies. That is, some studies reported small and non-significant effects, while others reported very large, significant effects for self-management interventions on both pain and disability. While it therefore appears that there is potential for this type of intervention to be effective, it is hard to interpret the findings for use in clinical practice because of the variability in effect sizes. Sources of variability include a lack of commonality in the design of the interventions, poorly explained theoretical rationale for the interventions, the choice of outcomes, and how well the studies were reported. 

Self-management intervention design

In the four systematic reviews, common content included pain education, activity in relation to pain (i.e. that hurt does not mean harm and that activity can reduce pain), and specific strategies or resources to use in flare-ups. However, some interventions also included goal-setting, practical exercise or problem-solving sessions, or cognitive-behavioural strategies. Multiple components are often required due to the complexity of achieving behaviour change, but this makes it difficult to compare interventions and identify the components that are most effective in improving outcomes. Additional aspects of the intervention such as the frequency of contact, duration, mode of delivery, and provider, varied substantially between the included studies: for example, most intervention sessions were delivered face-to-face, but some were online or through a self-help booklet; some interventions were delivered by lay providers, others by multiple healthcare professionals; and some interventions were delivered in group sessions, some in individual sessions, and others used a combination of the two.

Theoretical rationale

Few self-management intervention studies report a theoretical rationale for their intervention. Such a rationale is important to explicitly define how your intervention will improve the outcomes of interest, and also provides guidance on which factors might be important to target during the intervention. While psychological models that are relevant to LBP development and self-management exist (e.g. the fear-avoidance model [6]) and social cognitive theory [7]), there is little guidance on how to best apply these theories practically when developing interventions. Also, a “theory” doesn’t necessarily need to be a published model – this can simply be a hypothesis of how the intervention is thought to work, based on previous evidence and clinical expertise. Work by Susan Michie and colleagues (see [8,9]) has begun to assimilate published behaviour change theories and identify key behaviour change techniques that can be applied during interventions to impact on outcome.

Choice of outcome

There are two broad categories of outcomes that are important to studies of self-management interventions: general clinical outcomes, including pain, disability and health status; and behavioural outcomes specific to the aims of the intervention, including physical activity, or mastery of a new coping or problem-solving strategy. Most self-management intervention studies focus on clinical outcomes, but arguably assessing both categories is necessary: clinical outcomes to evaluate the effectiveness of the intervention (did it work?); and behavioural outcomes to evaluate how the intervention worked and whether the aspects we were trying to change, did in fact change.

Reporting of self-management interventions

Poor reporting is a common problem, particularly in complex interventions that include multiple components and techniques [10,11].  For example, in the four reviews, information about the self-management intervention content and intervention procedures was lacking in most studies. This is problematic as without adequate intervention descriptions, replication is not possible. Guidance such as the Template for Intervention Description and Replication (TIDieR) [12], which includes 12 categories for reporting including; why (rationale), what (materials, procedures), who (providers), how (modes of delivery), where (delivery location), when and how much (dose, duration), tailoring, modifications, and intervention fidelity, may help to enhance reporting within these interventions.

Conclusion

In conclusion, we suggest the following for future self-management intervention studies:

  • A clear definition of self-management, with detailed information on what components will be included, to allow comparison of interventions.
  • A theoretical rationale for the intervention, based on previous evidence and/or clinical and patient expert knowledge. The use of a logic model [13] would help to make any assumptions explicit.
  • Inclusion of both clinical and behavioural outcomes in order to assess both if, and how, the intervention worked.
  • Use of a reporting guideline (e.g. TIDieR) to provide enough information about intervention content and processes.

About the authors

 Gemma Mansell

Dr Gemma Mansell works as a post-doc Research Associate at the Research Institute for Primary Care Sciences, Keele University, UK. Her main research interests are around behavioural interventions and specifically investigating how they work through conducting mediation analysis, which was the focus of her PhD. She plans to continue with this work to help improve the design of trials to better allow for the evaluation of mediating effects. Most of her spare time and money is spent on music, going to gigs and consuming more coffee than is probably healthy.

Amanda Hall

Dr Amanda Hall is an Assistant Professor with the Primary Healthcare Research Unit in the Faculty of Medicine at Memorial University in Newfoundland, Canada. She has a clinical background in exercise and multidisciplinary treatments for Chronic Pain Management and has published over 30 academic papers in this area. Her research focuses on evaluating and implementing of self-management interventions for chronic pain such as arthritis and back pain. Her most recent work revolves around using e-health and decision support to achieve a broader goal of designing and evaluating behavior change interventions to support the implementation and successful adoption of best available evidence into routine clinical practice. Her methods include using innovative clinical trials, systematic reviews and mixed methods designs.

Elaine Toomey

Dr Elaine Toomey is a Health Research Board (HRB) Interdisciplinary Capacity Enhancement (ICE) post-doctoral research fellow, and a chartered physiotherapist with the Health Behaviour Change Research Group based in the National University of Ireland Galway. Her research interests include implementation science and knowledge translation, trials methodology, complex interventions and health behaviour change in areas such as chronic pain, childhood obesity and physical activity. In her free time (whatever that is) she enjoys food, travelling, sports, and being outdoors – preferably in, on or near water. Researchgate profile: https://www.researchgate.net/profile/Elaine_Toomey2 

References

[1] Mansell G, Hall A, Toomey E. Behaviour change and self-management interventions in persistent low back pain. Best Pract Res Clin Rheumatol 2017;30(6):994-1002.

[2] Oliveira VC, Ferreira PH, Maher G, et al. Effectiveness of self-management of low back pain: systematic review with meta analysis. Arthritis Care Res 2012;64(11):1739e48.

[3] Du S, Hu L, Dong J, et al. Self-management program for chronic low back pain: a systematic review and meta-analysis. Patient Educ Couns 2017;100(1):37e49.

[4] Carnes D, Homer KE, Miles CL, et al. Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain. A systematic literature review. Clin J Pain 2012;28(4):344e54.

[5] Toomey E, Currie-Murphy L, Matthews J, Hurley DA. The effectiveness of physiotherapist-delivered group education and exercise interventions to promote self-management for people with osteoarthritis and chronic low back pain: a rapid review part I. Man Ther 2015;20(2):265e86.

[6] Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85(3):317e32.

[7] Bandura A. Human agency in social cognitive theory. Am Psychol 1989;44(9):1175e84.

[8] Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 2012;7:37.

[9] Michie S, Richardson M, Johnston M, et al. The behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behaviour change interventions. Ann Behav Med 2013;46(1):81e95.

[10] Glasziou P, Meats E, Heneghan C. What is missing from descriptions of treatment in trials and reviews? BMJ 2008;336(7659):1472e4.

[11] Hall A, Richmond H, Copsey B, et al. Physiotherapist-delivered cognitive-behavioural interventions are effective for low back pain, but can they be replicated in clinical practice? A systematic review. Disabil Rehabil 2018: 40(1):1-9.

[12] Hoffman TC, Glasziou PP, Milne R, et al. Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014:348.

[13] Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new medical research council guidance. BMJ 2008;337. a1655.