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Low back pain (LBP) is a common cause of disability and is ranked as the most burdensome health condition globally. Self-management, including components on increased knowledge, monitoring of symptoms, and physical activity, are consistently recommended in clinical guidelines as cost-effective strategies for LBP management and there is increasing interest in the potential role of digital health.
The study aimed to synthesize and critically appraise published evidence concerning the use of interactive digital interventions to support self-management of LBP. The following specific questions were examined: (1) What are the key components of digital self-management interventions for LBP, including theoretical underpinnings? (2) What outcome measures have been used in randomized trials of digital self-management interventions in LBP and what effect, if any, did the intervention have on these? and (3) What specific characteristics or components, if any, of interventions appear to be associated with beneficial outcomes?
Bibliographic databases searched from 2000 to March 2016 included Medline, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER and TRoPHI, Social Science Citation Index, and Science Citation Index. Reference and citation searching was also undertaken. Search strategy combined the following concepts: (1) back pain, (2) digital intervention, and (3) self-management. Only randomized controlled trial (RCT) protocols or completed RCTs involving adults with LBP published in peer-reviewed journals were included. Two reviewers independently screened titles and abstracts, full-text articles, extracted data, and assessed risk of bias using Cochrane risk of bias tool. An independent third reviewer adjudicated on disagreements. Data were synthesized narratively.
Of the total 7014 references identified, 11 were included, describing 9 studies: 6 completed RCTs and 3 protocols for future RCTs. The completed RCTs included a total of 2706 participants (range of 114-1343 participants per study) and varied considerably in the nature and delivery of the interventions, the duration/definition of LBP, the outcomes measured, and the effectiveness of the interventions. Participants were generally white, middle aged, and in 5 of 6 RCT reports, the majority were female and most reported educational level as time at college or higher. Only one study reported between-group differences in favor of the digital intervention. There was considerable variation in the extent of reporting the characteristics, components, and theories underpinning each intervention. None of the studies showed evidence of harm.
The literature is extremely heterogeneous, making it difficult to understand what might work best, for whom, and in what circumstances. Participants were predominantly female, white, well educated, and middle aged, and thus the wider applicability of digital self-management interventions remains uncertain. No information on cost-effectiveness was reported. The evidence base for interactive digital interventions to support patient self-management of LBP remains weak.
The point prevalence of low back pain (LBP) is estimated to be 12% and one-month prevalence 23% across the globe [
Optimizing treatment strategies that are cost-effective, safe, and easy to administer for individuals with LBP is essential. Self-management is consistently recommended in international guidelines on the management of LBP [
A systematic review of the effectiveness of the self-management of LBP published in 2012 reports moderate quality evidence that self-management interventions have small, but clinically relevant, effects on reducing pain and disability for people with LBP when compared with minimal interventions [
Digital interventions (ie, interventions accessed via computer, mobile phone, or other handheld devices, including Web-based, desktop computer programs, or apps), providing self-management information have been proposed as a promising mode of delivery for self-management interventions. In a Cochrane Review from 2005, the use of such digital interventions was evaluated in people with chronic diseases and found to have a significant positive effect on knowledge, social support, and clinical outcomes in conditions such as diabetes and obesity [
The purpose of this systematic review was to synthesize published evidence concerning the characteristics, components, and effects of interactive digital interventions to support patient self-management of LBP. More specifically, the review aimed to address the following questions:
What are the key characteristics and components of digital self-management interventions for LBP, including theoretical underpinnings?
What outcome measures have been used in randomized trials of digital self-management interventions in LBP and what effect, if any, did the intervention have on these?
What specific characteristics or components, if any, of interventions appear to be associated with beneficial outcomes?
Participants: adults (18 years or above) with nonspecific LBP
Digital intervention:
Any intervention accessed through a computer (work or home), mobile phone, or hand-held device, and included Web-based or desktop computer programs or apps that provided self-management information or material, which is in keeping with previous reviews in this sphere [
Element of interaction between the user and digital interface: interaction was defined as patients entering data into the program or app, either by entering personal data or making choices that alter the pathways in the program and produce feedback in response to the patients’ inputted data or choices.
Interactive component as an add-on to face to-face health professional contact (eg, regularly seeing doctor but reporting pain levels electronically and receiving automated messages advising on physical activity level between visits).
Control group: usual care or digital noninteractive or nondigital self-management interventions for LBP
Study design: published randomized controlled trials (RCTs) or protocols for RCTs from peer-reviewed journals
Language: studies published in English, Danish, or Norwegian
Digital intervention:
Studies that only involved sending information to a remotely located health professional and receiving advice directly from the health professional.
Study design: all non-RCT reports and protocols
The systematic literature review followed an
A systematic search of the following databases was undertaken: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Library (including Database of Abstracts of Reviews of Effects [DARE] and Health Technology Assessment [HTA] databases), Database of Promoting Health Effectiveness Reviews (DoPHER), Embase, MEDLINE, PsycINFO, Trials Register of Promoting Health Interventions (TRoPHI) and Web of Science (Social Science Citation and Science Citation Index). All databases were searched from 2000 until March 2016. Reference and citation searching were also undertaken. The searches were performed by an experienced Librarian at the Norwegian University of Science and Technology (NTNU). The search strategy included subject indexing terms and free-text terms for title, abstract, and keyword searching. The search terms were grouped into 3 concepts: (1) back pain, (2) digital interventions, and (3) self-management. The search terms were selected with reference to previous systematic reviews of interactive digital interventions for hypertension [
All identified citations from the searched databases were uploaded to Distiller software (Evidence Partners). An integrated duplication detection tool was used to identify duplicates. All suggested duplicate pairs were screened for correctness by one reviewer (LS). Title and abstract screening was performed for each article by two independent reviewers from four (LS, BN, MM, NS). Disagreement between the two reviewers resulted in inclusion of the citation to full-text screening. Full-text screening was similarly performed by two independent reviewers from four (LS, BN, MM, NS), assessing the eligibility of the citation. Any disagreement was resolved through discussion mediated by a third reviewer (PJM).
Similar to the study selection process, data extraction was performed independently by two of four reviewers (LS, BN, MM, NS) using the Distiller software. Discrepancies in data extracted were considered by LS by revisiting the original paper to adjudicate on appropriateness and discussed and finalized with BN where required. Data were systematically extracted on study settings (country, inclusion and exclusion criteria, recruitment and participation numbers); study population (baseline characteristics such as age, gender, ethnicity, duration of symptoms, comorbidities); description of the intervention (details on the key components, characteristics, and underlying theoretical concepts); and outcome measures (time-points for outcome assessment, choice of primary outcomes, included secondary outcomes and effects, if any, noted as well as attrition rates, where available).
Our primary and secondary outcomes of particular interest are outlined in
The methodological quality of all included studies was assessed using the Cochrane Collaboration tool for assessing risk of bias in randomized trials [
The study population, intervention components, outcomes, and characteristics of the included studies were narratively described. In our protocol we stated that we would conduct a meta-analysis if included studies were sufficiently homogeneous; however, due to the heterogeneity of identified studies, meta-analysis was not possible. Quantitative results from all outcomes reported in the completed RCT studies were described as either favoring the intervention group, no difference between groups, or favoring the control group. The outcomes reported in
We identified a total of 7014 citations, including 8 from searching reference lists of included studies. From these, 2316 were excluded as duplicates, and thus a total of 4698 titles were screened, resulting in the screening of 729 abstracts and 89 full-text papers. A total of 11 references concerning 9 different studies that described 5 RCT study protocols and 6 RCT reports met the inclusion criteria [
Details of outcome measures used to determine the effects of interventions for self-management of LBP pain-related disability
Pain intensity
Quality of life
Depression
Fear avoidance
Pain catastrophizing
Physical activity
Medication use
Health care utilization (eg, primary and secondary care visits, emergency department visits)
Health care costs
Knowledge of LBP
Markers of self-care
Self-efficacy
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram illustrating the screening process of papers.
Four of the 9 separate studies were undertaken in the United States [
The characteristics of the study population in each of the studies are described in
Included studies and population characteristics.
Study | Definition of LBPa | Number | Age, mean (SD)b | Sex (%) | Ethnicity (%) | Comorbid (%) | SES (%)c |
Chiauzzi et al [ |
LBP ≥10 days/month for at least 3 consecutive months |
N=209 |
I=47.3 (12.2) |
I=Ff |
White |
N/Rg | Education |
Simon et al [ |
Acute LBP (<3 months) | N=1343 |
I=45.8 (12.7)h |
F (82)h | N/R | N/R | Education |
Carpenter et al [ |
Noncancer LBP ≥6 months | N=141 |
42.5 (10.3) |
F (83) | White (77) | N/R | Education |
Krein et al [ |
Patients with ≥2 outpatient encounters within the past 12 months with a diagnosis of back pain with no neurologic findings (ICD-9-CM codes 724.2, 724.5, 846.0-846.9) |
N=229h |
I=51.2 (12.5) |
I=F (11%) |
White |
N/R | Education |
Irvine et al [ |
Nonspecific LBP within the past 3 months | N=398 |
N/R | I=F (58%) |
White |
N/R | Education |
Weymann et al [ |
Chronic LBP: pain almost every day for >12 weeks | N=368h |
I=52.2 (13.1)h |
I=F, 162 (59)h |
N/R | N/R | Educationh |
Geraghty et al [ |
LBP in the past 3 months recorded in General Practitioner records and current LBP (or within the past 2 weeks) at the time of screening | 20-30/group | - | - | - | - | - |
Valenzuela-Pascual et al [ |
Chronic LBP >6 months, confirmed by clinician | 29/group | - | - | - | - | - |
Amorim et al [ |
Chronic LBP persisting for |
34/group | - | - | - | - | - |
aLBP: low back pain.
bSD: standard deviation.
cSES: socioeconomic status.
dI: intervention group.
eC: control group.
fF: female.
gN/R: not reported.
hPopulation comprising more conditions than LBP, numbers refer to the general population and were not available for LBP group only.
iProtocol paper, no data available unless reported alongside the RCT results paper.
jPlanned number to recruit based on protocol paper.
Results for the 7 items of the Cochrane Risk of Bias tool for the 6 completed RCTs are reported in
The extent of descriptions of the intervention content varied across studies (
Quality assessment: risk of bias assessment with Cochrane Risk of Bias tool (low risk of bias, unclear risk of bias, high risk of bias).
Study | Random sequence generation | Allocation concealment | Blinding | Incomplete data | Selective reporting | Other biases | ||||
Patients/personnel | Assessor | |||||||||
Chiauzzi et al [ |
Low | Unclear | Unclear | Low | Low | Unclear | Unclear | |||
Simon et al [ |
Low | Low | Unclear | Low | High | Low | Low | |||
Carpenter et al [ |
Low | Unclear | Unclear | Low | Low | High | Unclear | |||
Krein et al [ |
Low | Low | Low | Low | Low | Low | Low | |||
Irvine et al [ |
Unclear | Unclear | Unclear | Low | Low | High | Unclear | |||
Weymann et al [ |
Low | Low | Low | Low | Low | Low | High |
Four of the 9 studies reported a theoretical underpinning to their intervention development (
Intervention components and theoretical underpinnings.
Study | Content | Theoretical underpinning of content |
Chiauzzi et al [ |
Educational material: content not more specifically described |
Cognitive behavior theory |
Simon et al [ |
Condition-specific information: epidemiology, etiology, diagnostics, treatment options | N/Ra |
Carpenter et al [ |
Educational chapters: all about pain, thoughts and pain, stress and relaxation, getting active |
Cognitive therapy, behavioral activation |
Krein et al [ |
Educational material: Handouts about topics (body mechanics, use of cold packs, lumbar rolls, and good posture); videos demonstrating specific strengthening and stretching exercises |
Social cognitive theoryb |
Irvine et al [ |
Education and behavioral strategies to manage and prevent pain: thirty 1-4 min videos on pain management, cognitive, and behavioral strategies; videos gain-framed messages with animated whiteboard-style coach; videos of ergonomics and exercises | Social cognitive theory |
Weymann et al [ |
Educational information: physiology of pain, acute versus chronic pain; “chronification”; epidemiology; psychological aspects; coping and pain management |
N/R |
Geraghty et alc[ |
Educational information: goal review; feedback on achievements; sessions on sleep, pain relief, flare-up, work, mood daily living. |
N/R |
Valenzuela-Pascual et alc [ |
Content not yet developed, but will be based on qualitative study including interviews with patients | N/R |
Amorim et alc [ |
Educational material: “make your move—sit less, be active for life!” |
N/R |
aN/R: not reported.
bInformation given in the protocol but not stated in the randomized controlled trial report.
cProtocol paper.
A wide range of outcomes were included in the RCTs (
Pain-related disability was considered as the primary outcome in 4 of the 9 studies. The Roland-Morris Disability Questionnaire (RMDQ) was used in 2 of the 6 completed RCTs [
A large variety of secondary outcome measures were described (
Pain intensity measured with either an 11-point Numerical Rating Scale (NRS) or a 100-mm Visual Analogue Scale (VAS) was reported in 3 of 6 RCT reports [
Health-related quality of life was reported in 2 studies using the Dartmouth Primary Care Cooperative Information Project (CO-OP) [
Depression was reported in 3 of the 6 RCT reports [
Three studies reported fear of movement with the Fear Avoidance Belief Questionnaire (FABQ) [
The PCS questionnaire was used in 2 RCT reports [
Only one of the completed RCTs assessed physical activity outcomes and observed no difference in daily steps achieved between the control and intervention group [
No studies reported medication use.
No studies reported details of health care utilization (eg, primary and secondary care visits, emergency department visits).
No studies reported on health care costs or cost-effectiveness.
Three of the RCT reports used participants’ knowledge of LBP as an outcome measure [
In total, 14 different outcomes were identified as markers of self-care, such as the Decision Conflict Scale [
Four different measures of self-efficacy were reported in 4 RCT reports. The Self-Efficacy for Exercise Scale was used by Carpenter et al, who found an effect on self-efficacy in favor of the digital intervention group as compared with the waiting list control [
Ten outcomes could not be classified within our
Key characteristics of the digital interventions are summarized in
Eight of the 9 studies aimed to investigate the effectiveness of the digital intervention in relation to pain intensity, attitudes toward pain, or pain-related disability by comparison with a control group (usual care or a nondigital intervention; as summarized in
Seven of 9 studies assessed digital interventions that were accessed over the Internet and by use of a computer [
Large variation was seen in the reported frequency and duration of use of the digital interventions. Six studies reported unlimited access to the programs with no report of recommendations given regarding frequency of use [
The interactive elements reported in the studies included (1) keeping a log or journal of use of the intervention [
Study aim, available outcomes, and main results.
Study | Aim | Primary analysis | Secondary outcomes | Main result | Control condition | |
Outcomes | Measurement Times | |||||
Chiauzzi et al [ |
Compare interactive self-management website for chronic LBP to standard text-based materials; hypothesized improved emotional management, coping, self-efficacy to manage pain, pain levels, and physical functioning | BPI (Brief Pain Inventory) |
Baseline, post-intervention (4 weeks), 3 months, 6 months | PCS (Pain Catastrophizing Scale) |
Hypothesis not supported |
Educational material: “A back pain guide” |
Simon et al [ |
Whether insurees with depression or LBP experienced more favorable decision-related outcomes after using a Web-based tailored decision aid compared with non-tailored, static patient information | DCS (Decisional Conflict Scale) | Baseline, post-intervention, 3 months | Preparation for decision-making scale |
Intervention effective in short term |
Same information as intervention, website, but no tailoring to the individual user |
Carpenter et al [ |
Efficacy of a pilot version of a Web-based CBT (cognitive behavioral therapy) intervention for chronic LBP | SOPA (Survey of Pain Attitudes) | Baseline, 3 weeks, 6 weeks | FABQ |
Difference in favor of the intervention group on all SOPA subscales in the SOPA questionnaire except “medical cure” |
Wait list, received no care for 3 weeks, then access to website |
Krein et al [ |
Whether a pedometer-based, Internet-mediated intervention would reduce pain-related disability and functional interference in chronic LBP | RMDQ (Roland-Morris Disability Questionnaire) |
Baseline, 6 months, 12 months | Pain intensity (NRS, numerical rating scale) |
No between-group difference reported at any time-points |
Usual care (attending Back Class) and uploading pedometer data after receiving monthly email reminders to upload; no goal-setting or feedback received; no access to website |
Irvine et al [ |
Test FitBack for adults at increased risk for chronic LBP due to a recent episode of NLBP |
Baseline, 8 weeks, 16 weeks | Pain: level, frequency, intensity and duration |
Usual care, emails to request completion of questionnaire |
||
Weymann et al [ |
Investigate effectiveness of a Web-based, tailored, fully automated intervention for patients with type-2 diabetes or chronic LBP against a standard website with identical content without tailoring | Knowledge (post-intervention) |
Baseline, post-intervention, 3 months | DCS |
The tailored intervention had no effect on the total study population |
Same website material as intervention but not tailored; not presented in a dialogue format; no guidance through the content |
Geraghty et al [ |
Explore feasibility of providing an Internet intervention for patients with LBP in primary care, with and without physiotherapist telephone support (in addition to usual care), compared with usual care alone | Feasibility outcome |
Baseline, 3 months | Pain: days, duration, intensity |
- | Usual care from their general practitioner; this may consist of education and self-management advice, including advice to stay active |
Valenzuela-Pascual et al [ |
Evaluate effect of a biopsychosocial Web-based, educational intervention for chronic LBP based on pain intensity compared with normal care | Pain intensity (100-mm VAS [visual analogue scale] scale) | Baseline, 2 weeks | FABQ |
- | No intervention; asked to return to webpage to complete questionnaire at 2 weeks |
Amorim et al [ |
Investigate effect of a patient-centered PA intervention supported by health coaching and technology in chronic LBP | Care-seeking |
Baseline, weekly during intervention, 6 months, 12 months | IPAQ |
- | Educational material same as intervention: “Make your move—Sit less, be active for life!”; advice to work toward increasing PA and achieving long-term goals |
aProtocol paper, no data available.
bDifference between the protocol paper and RCT report.
Two of the 9 studies did not report any tailoring element to the content of their digital intervention [
Intervention characteristics.
Study | Mode of delivery | Recommended frequency | Recommended duration of visit | Interactive element | Tailoring |
Intervention |
Chiauzzi et al [ |
Website | 2 times/week for 4 weeks, then unlimited | <20 min/session | Log of activities and content viewed during sessions | Yes |
4 week intervention period, access for 6 months |
Simon et al [ |
Website |
Unlimited access but no required frequency | N/Rc | Simulated dialogue between user and system |
Yes |
One-time use required, access for 3 months |
Carpenter et al [ |
Website |
Two times/week, email reminders | 1-1.5 hour/log-in | Reflective and interactive exercises | No |
3-week intervention period |
Krein et al [ |
Website |
Unlimited access with weekly reminders to upload data | N/Rc | Pedometer data, used to create weekly PAegoals and track progress |
Yes |
12-month intervention period |
Irvine et al [ |
Web app, accessible from Internet and mobile |
Unlimited access, weekly reminders to visit app | N/Rc | Pain and PAeself-monitoring tool |
Yes |
8-week intervention period, access for 16 weeks |
Weymann et al [ |
Website |
Unlimited access, designed to be used in 1 sitting | N/Rc | Simulated dialogue between user and system |
Yes |
3-month intervention period |
Geraghty et al [ |
Website | One session/week | N/Rc | User selects PAe, system generates activity goals |
Yes |
3-month intervention period |
Valenzuela-Pascual et al [ |
Website |
Unlimited access | N/Rc | N/Rc |
Yes |
2-week intervention period |
Amorim et al [ |
App, accessed via computer or smartphone | Unlimited access, no recommendations on frequency or duration | N/Rc | User reports PAelevels, pain intensity, and disability |
No |
6-month intervention period |
aC: control group.
bI: intervention group.
cN/R: not reported.
dProtocol paper, no data available.
ePA: physical activity.
fInformation given in the protocol but not stated in the RCT report.
gAttrition rates reported as number of completed cases in relation to the total number of participants randomized to the group.
We have systematically searched and reviewed the literature pertaining to interactive, digital interventions for self-management of LBP. The effectiveness of interventions was mixed, with only 1 study reporting a positive effect on their primary outcome [
Despite international recommendations for reporting core outcome domains (physical functioning, pain intensity, and health-related quality of life) in LBP studies [
This systematic review was undertaken by a team with extensive experience in conducting such reviews. We used multiple databases, and a thorough search strategy that was designed iteratively by the research team and an information specialist to account for the 3 different dimensions of the search (back pain, digital interventions, and self-management). The methodological assessment tool used in our systematic review has been specifically developed to assess the risk of bias in RCTs [
The primary limitation of this systematic review is the sparse literature related to our objectives. Due to the sparsity and heterogeneity of the data, a formal meta-analysis was not possible. Additionally, our search was limited to studies published in English, Danish, or Norwegian, which could be construed as a limitation, although there is increasing evidence that this is not a particular problem [
To the best of our knowledge this is the first systematic review of RCTs of interactive digital interventions for self-management of LBP. However, systematic reviews of Web-based interventions for LBP (not specifically self-management) [
The populations within the identified studies were predominantly female, white, well-educated, and middle-aged, and thus the wider applicability of digital self-management interventions remains uncertain and therefore further investigation including a broader range of participants is merited. Seven of the 9 included studies specifically aimed to address the self-management of chronic LBP, and thus the usefulness of supporting self-management for acute LBP using digital tools remains underinvestigated; any such interventions for acute LBP would possibly require different advice and support to that offered for chronic LBP, as directed in clinical guidelines [
Our review has highlighted that the published literature is extremely heterogeneous and that digital intervention studies for LBP are generally poorly described. The literature provides insufficient detail regarding target and participating populations, and intervention components, theoretical underpinnings, and the rationale for the wide variety of outcome measures used. This makes it difficult to gain a clear impression of what might work best, for whom and in what circumstances. It is clear that the existing evidence has not yet proven the wider utility of digital interventions for self-management of LBP for the population at large, a knowledge gap that future research should address by better characterizing participants and interventions in a way that would allow replication and by providing clear rationales for intervention components and outcome measure selection.
MEDLINE search strategy.
Overview of all outcome measures included.
Brief Pain Inventory
cognitive behavioral therapy
Cochrane Database of Systematic Reviews
Cochrane Central Register of Controlled Trials
Credibility and Expectancy Questionnaire
Centre for Epidemiologic Studies Depression Scale
Cumulative Index to Nursing and Allied Health Literature
Primary Care Cooperative Information Project
Chronic Pain Coping Inventory
Database of Abstracts of Reviews of Effects
Depression/Anxiety and Stress Scale
Decisional Conflict Scale
Database of Promoting Health Effectiveness Reviews
Fear Avoidance Belief Questionnaire
Goal Attainment Scale
Health Education Impact Questionnaire
Health Technology Assessment
International Physical Activity Questionnaire
low back pain
Multidimensional Pain Inventory Interference Scale
Negative Mood Regulation scale
Numerical Rating Scale
Norwegian University of Science and Technology
Oswestry Disability Questionnaire
Oswestry Disability Index
physical activity
Patient Activation Measures
Pain Catastrophizing Scale
Preparation for Decision Making Scale
Patient Enablement Instrument
Problematic Experiences of Therapy Scale
Patient Global Impression of Change
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Pain Self-Efficacy Scale
randomized controlled trial
Roland-Morris Disability Questionnaire
standard deviation
socioeconomic status
Survey of Pain Attitudes
Stanford Presenteeism Scale
Tampa Scale of Kinesiophobia
Trials Register of Promoting Health Interventions
Tampa Scale of Kinesiophobia
visual analogue scale
Work Limitations Questionnaire
We would like to thank our librarian adviser Ingrid Ingeborg Riphagen, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU). This project has received funding from the European Union Horizon 2020 research and innovation program under grant agreement no. 689043.
BN, LS, MS, OV, JH, PM, PK, KS, and FM contributed to the design of the study. LS and BN managed the review process. LS, MM, NS, BN, PJM, and PK were involved in one or more of the following stages of the review: screening, data extraction, quality appraisal, or resolution of conflicts. LS led on data synthesis with input from BN, FM, JH, PK, and KS. BN and LS drafted the manuscript. FM oversaw manuscript preparation.
None declared.