Brazilian Journal of Physical Therapy 25 (2021) 396 406

Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy

MASTERCLASS

Self-management at the core of back pain care: 10 key

points for clinicians
Alice Kongsteda,b,*, Inge Risa, Per Kjaera,c, Jan Hartvigsena,b

a
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
b
Chiropractic Knowledge Hub, Odense M, Denmark
c
Health Sciences Research Center, UCL University College, Odense M, Denmark

Received 14 January 2021; received in revised form 26 April 2021; accepted 6 May 2021
Available online 24 May 2021

KEYWORDS Abstract
Back pain; Background: A paradigm shift away from clinician-led management of people with chronic disor-
Behavior change; ders to people playing a key role in their own care has been advocated. At the same time, good
Delivery of health health is recognised as the ability to adapt to changing life circumstances and to self-manage.
care; Under this paradigm, successful management of persistent back pain is not mainly about clini-
Musculoskeletal cians diagnosing and curing patients, but rather about a partnership where clinicians help indi-
disease; viduals live good lives despite back pain.
Patient-centred Care; Objective: In this paper, we discuss why there is a need for clinicians to engage in supporting
Self-management self-management for people with persistent back pain and which actions clinicians can take to
integrate self-management support in their care for people with back pain.
Discussion: People with low back pain (LBP) self-manage their pain most of the time. Therefore,
clinicians and health systems should empower them to do it well and provide knowledge and
skills to make good decisions related to LBP and general health. Self-management does not
mean that people are alone and without health care, rather it empowers people to know when
to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm
and clinicians’ roles is not only challenging for individual clinicians, it requires organisational
support in clinical settings and health systems. Currently, there is no clear evidence showing
how exactly LBP self-management is most effectively supported in clinical practice, but core
elements have been identified that involve working with cognitions related to pain, behaviour
change, and patient autonomy.
© 2021 The Author(s). Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de
Pesquisa e Pós-Graduação em Fisioterapia. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

* Corresponding author at: Department of Sports Science and Clin-

Background
ical Biomechanics, University of Southern Denmark, Campusvej 55,
DK-5230 Odense M, Denmark. Across non-communicable chronic conditions, a paradigm
E-mail: akongsted@health.sdu.dk (A. Kongsted). shift away from clinician-led management towards

https://doi.org/10.1016/j.bjpt.2021.05.002
1413-3555/© 2021 The Author(s). Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de Pesquisa e Pós-Graduação em
Fisioterapia. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 Brazilian Journal of Physical Therapy 25 (2021) 396 406

management where people with chronic conditions play a often used interchangeably without clear definitions and with-
key role in their own care is advocated.1,2 At the same time, out presentation of the underlying theory.6,7 Therefore, we
good health is increasingly understood as the ability to adapt briefly introduce how we use these terms (Fig. 1).
to changing life circumstances and to self-manage in the Self-care is all the actions that people do to stay healthy
face of social, physical, and emotional challenges.3,4 In the (e.g. brushing teeth, sleeping well, eating healthy food),
case of persistent low back pain (LBP), such an approach and includes actions that aim to prevent disease, maintain
implies that successful interventions are not mainly about good health, and coping with illness and disability.8
clinicians diagnosing and curing patients, but about a part- Self-management has been defined as “the individual’s abil-
nership between individuals and clinicians that helps people ity to manage the symptoms, treatment, physical and psy-
engaging in valued activities.5 Thus, living with persistent or chological consequences, and lifestyle changes inherent in
recurrent LBP may involve care-seeking, but people manage living with a chronic condition,” and is the part of self-care
their health conditions outside the context of health care that relates to dealing with health conditions.9 11 Definitions
most of the time, and interventions for persistent LBP should of self-management emphasize the importance of interac-
enable them to do that well. tive, collaborative care between patient and healthcare pro-
In this paper, we discuss self-management in relation to fessionals allowing for patient empowerment rather than
LBP with a focus on the role of the clinician. one-way passive care from expert to patient.10 12Symptom
management is the actions initiated by the patient, a clini-
cian, or both to decrease the distress and consequences
Self-management terms caused by symptoms. It entails a collaborative relationship
between a patient and the healthcare provider to make deci-
Among clinicians and within the literature, terms like self-care, sions about for example medication or manual therapy
self-management, self-efficacy, and symptom management are interventions.9

Figure 1 How self-care, self-management, symptom-management, and health care are related. Self-management of disease,
including symptom-management, is part of self-care and may be performed in collaboration with health care providers. Illustration
based on Richard and Shea.10

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Self-care and self-management are concepts with ties to How can clinicians integrate self-management
Orem’s theory and Bandura's Social Cognitive Theory on self- support in LBP management?
efficacy.13 15 Self-efficacy is people's beliefs in their ability
to influence events that affect their lives. This core belief is Clinical guidelines generally recommend advice and informa-
the foundation of human motivation, performance accom- tion, manual therapy, and supervised exercises as treatments
plishments, and emotional wellbeing. Unless people believe for persistent LBP.37-39 These interventions are effective parts
they can produce desired outcomes by their actions, they of symptom management and may prevent relapse, but do
have little incentive to undertake activities in the face of not necessarily support patient autonomy and self-manage-
difficulties. Whatever factors may serve as guides and moti- ment. Below, we outline clinical actions that help integrate
vators, they are rooted in the core belief that one can make self-management support in LBP management including
a difference by one's actions. behaviour change techniques (i.e. strategies to help patients
The focus of this paper is on self-management of persistent adopt healthy behaviours) that are frequently incorporated in
LBP where this involves the interaction and communication self-management interventions, and actions to focus on
between the healthcare provider and the patient in a clinical patient autonomy and self-efficacy (Table 1).12,40 42 These
encounter, and we describe the engagement of the clinician as actions are aligned with intervention planning, intervention
‘self-management support’.9 Self-management support is pro- delivery, and clinical evaluation (Fig. 2).
vided in self-management interventions defined as interven-
tions that “aim to equip patients with skills to actively
participate and take responsibility in the management of their Self-management: planning
chronic condition to function optimally.”12
Let patients’ value-based goals direct care

Individual goal setting, such as the ‘SMART’ (Specific Measur-

Why should clinicians care about able Achievable Realistic Time-bound) method, helps
self-management in LBP? patients identify their motivation for change, increase
adherence to their plan, and helps clinicians plan interven-
Most people who experience LBP will have recurrent epi- tions that support these goals.43 Value-based goal setting
sodes with pain that comes and goes.16 Even patients who can open the communication about people’s motivation for
recover well from an episode of LBP most likely will experi- change and can reveal what facilitates and hinders reaching
ence new episodes, and up to 20% of those seeking care for these goals.44 For example, it could be an underlying prem-
LBP have persistent LBP that they need to manage more or ise for a patient that the pain needs to be reduced for the
less continuously.16 patient to engage in valued activities. Through dialogue and
The impact of LBP on daily activities differs substantially reflections, the patient may, however, realise that pain
between individuals for reasons that are not fully understood. beliefs or emotions are more central barriers for activity
However, people are more disabled from LBP when they per- than the pain itself. Therefore, goals that relate directly to
ceive their condition as frightening and out of their control pain such as “I want to get rid of my back pain”, may lead to
and have low pain self-efficacy.17 Also, effective interven- stress and frustration instead of action and obstruct patients
tions for persistent pain conditions work partly by influencing from pursuing other and more valued goals.45
beliefs, catastrophising thoughts, fear, and pain self-
efficacy.18 21 This includes interventions that are designed to Make shared decisions
have physical effects,22,23 implying that cognitions and emo-
tions are not only affected by psychological interventions. Intervention planning and goal setting should optimally be
A traditional biomedical paradigm would focus on structural based upon a shared decision-making process between
and degenerative changes in the spine that presumably explain patient and clinician. This process aims at balancing the
the patient’s symptoms. However, these do not correlate well patients’ right to autonomy with the clinicians’ responsibil-
with an individuals’ pain or activity limitations,24,25 although ity to protect patients’ safety and ensure best-evidence
associated with an increased risk of LBP in populations.26 They care. For a shared-decision process to take place, the first
also do not inform what treatment the patient most likely will requirement is to make it explicit that a decision has to be
respond to, nor do they inform the prognosis.27,28 A structural made.46 Thus, patients should know that there are different
diagnosis does therefore not help patients make sense of their options and should be provided with best-evidence informa-
symptoms, and it may, in fact, add to their fear and worry, and tion that will help them make an informed decision on what
even drive the use of ineffective treatments.29 33 Although their preference is. Shared decision making is part of
exercises are often prescribed to improve muscle function and patient-centred care and a way to increase engagement,
mobility there is little evidence that those are the mechanisms patient satisfaction, and adherence.47 Shared decision-mak-
behind positive clinical effects.34 36 ing is, however, challenging to implement in practice and
Clinicians should care about self-management because requires that clinicians are well-informed about a patients’
most people with LBP continuously manage their condition options for care and have strong communication skills.48
and should be enabled to do it well. Supporting self-efficacy
is an important element of LBP care because people are less Define readiness to change
disabled by LBP if they trust in their ability to manage it,
and effective treatments for LBP partly work by reducing Because change does not happen at once and has to be
fear and increasing self-efficacy. driven by patient engagement, the patient’s readiness to

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 Brazilian Journal of Physical Therapy 25 (2021) 396 406

Table 1 Actions to place self-management at the core of back pain care.

Clinical process Self-management How? Why?
component
Planning Let patient value- Discuss specific patient value-based goals To help patients identify their
based goals guide using for example the SMART framework. motivation for change and what
management. facilitates and hinders engaging
in valued activities.
To reduce focus on pain-goals.
Make shared decisions Exchange information about treatment To enhance patient-centred
about the plan. options. care and increase patients’ sat-
Include patients’ values and preferences. isfaction, engagement, and
Affirm the decision. adherence.
Define readiness to Identify resources and knowledge to To understand elements of
change. make a lasting change successfully. change, the stages of change,
Identify barriers to change. and ways to address each stage
Identify challenges to maintain new to achieve goals.
behaviour.
Delivery Help patients make Deliver knowledge to reduce fear and To avoid restrictions in patient-
sense of their address misconceptions. valued activities and low sense
symptoms. Direct patients to useful sources of of control due to misbeliefs and
information. fears.

Teach skills to solve Use exercises as a tool to train problem- To avoid dependency on the cli-
everyday problems. solving skills by patients exploring move- nician, as being the one know-
ment instead of being told what to do. ing what correct movement/
Encourage patients to try out a variety of posture is.
movements and activities. To enable patients to cope with
Help patients come up with solutions to everyday situations on their
everyday problems. own
To increase self-efficacy by
using operant conditioning, pos-
itive reinforcement and positive
experiences.
Set patients up for Use exposure to new/feared activities to To help patients reframe their
successful provide the experience of success. perspectives on low back pain.
experiences Discuss alternative perspectives on To challenge overly negative
feared activities or movements. beliefs.
To change thoughts or emotions
related to an activity.
Provide tools for man- Teach pain strategies as distraction, To support planning of active
agement of pain and breathing exercises, or mindfulness. behaviour with relapses and
emotions flare ups.
To enhance feeling of control.
Evaluation Evaluate and discuss Ask if the patient-valued goals have been To keep focusing on value-based
adjustments of goals achieved: goals and motivate for main-
Partly: “What went well?” tained engagement.
Not at all: “What are the barriers?”
Evaluate patients’ Ask questions about patients’ beliefs To raise awareness of more
understanding of back related to pain and what forms those appropriate back pain beliefs.
pain beliefs: “What do you think happens
when your back hurts?”
Assist patients in Discuss active tools to maintain self-man- To help patients sustain good
action planning aging of back problems. habits and prepare for relapses.
Prompt detailed planning of actions to
take when perusing goals is challenged
“How will you react when you back relap-
ses/has flare ups?”
“When will you need help from health
care and why?”

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Figure 2 Clinical actions in self-management support. Self-management support includes actions related to intervention planning,
delivery, and evaluation, and places demands on clinicians and organisations.

change their behaviour needs consideration to define education resources directed at clinicians and people with
achievable and realistic goals and action plans. For this pur- pain (see references for suggested readings, videos, podcasts
pose, five stages of behavioural change have been proposed: and web sites52 63), however, there is also a lot of misinfor-
Precontemplation (unawareness or denial with no intention mation about LBP.64 Therefore, clinicians should direct
of changing behaviours), Contemplation (ambivalent about patients to suitable sources of information where inappropri-
possibilities to change), Preparation (action planning, start ate messages and pain education using terminology relating
changing behaviour), Action (changing behaviours, using to spinal instability, postural abnormalities, wear and tear,
self-management strategies but not adopted as a new discs “popping” in and out, or restrictions on what patients
habit), and Maintenance (consolidating new behaviour and are ‘allowed’ to do or not are avoided.
self-management strategies in everyday life).47,48 Patients
in the first 2 or 3 stages may need more information and edu- Teach problem-solving skills
cation, whereas those in the last stages may need reassur-
ance and positive feedback. Supervised exercises can be used as a tool to practice prob-
Self-management support can be integrated into inter- lem-solving skills.65,66 When patients experience pain
vention planning by letting patient value-based goals and a during an exercise, difficulties in performing desired move-
focus on behaviour change direct management while shift- ments, or fear about their consequences, the clinician has
ing focus away from structure, pain, and impairments. an opportunity to explore their thoughts about causes and
consequences by encouraging patients to experiment with
moving in different ways. Exercises then become behaviou-
Self-management: delivery ral experiments that help patients reframe their beliefs and
emotions related to activity. Traditionally, however, clini-
Help patients make sense of their symptoms cians often correct patients when they perform exercises,
based on the assumption that benefits of exercises depend
Although empirical evidence is sparse, changing LBP on performing movements in very specific ways, when in
related behaviours seems intimately related to changing fact there is little evidence to support that the way exer-
beliefs.49 51 Patients perceive LBP as unpredictable and cises are performed relates to outcomes. Importantly, cor-
uncontrollable and difficult to make sense of, which hampers recting patients carry a risk of decreasing self-management
their ability to deal with it in an expedient way.31 Educating skills by communicating that exercising is difficult and
patients about pain mechanisms and management may there- potentially unsafe to do on your own. Thus patients may lose
fore prevent them from restricting their valued activities autonomy and self-efficacy and become fearful of doing
because of misbeliefs and fears. There are many useful pain something “wrong” or potentially harm themselves.

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Table 2 Turning clinical activities and treatment into self-management support.

Do. . . Don’t. . .
Planning Defining success Support and guide patients towards Communicate that cure of symptoms is
their individual value-based goals. the ultimate goal of treatment.
Clinical assessment Assess (pain) behaviours, impair- Emphasize a structural diagnosis that
ments, thoughts, and feelings that does not inform choice of treatment and
facilitate and hinder valued goals. prognosis, or understanding of pain.
Intervention plan Provide evidence-based knowledge Decide what is best for a patient or make
to help patients make informed them believe that their pain will be cured
decisions about their care. and never return.
Delivery Patient education Focus on the benign aspect of low Focus on structural injury as an explana-
back pain. tion of non-specific low back pain.
Manual therapy Include manual therapy in symp- Tell patients that their back pain cannot
tom management if valued by improve without manual therapy, that
patients and helpful for achieving something is out of place or that manual
patient-valued goals. treatment corrects spinal abnormalities.
Exercise supervision Use exercises to help people Tell patients that their back pain cannot
become confident with natural and improve without specific exercises, and
varied movements and use exer- don’t make movement difficult by cor-
cises to develop problem-solving recting them to achieve a ‘neutral pos-
skills. ture’, ‘alignment’, or other clinician
determined criteria for moving correctly.
Evaluation Define success of intervention Use patient-centred goals to define Use pain measurements to define results
results of the intervention. of the intervention.

Set patients up for successful experiences Self-management: evaluation

Re-engaging in valued activities may involve exposure to Evaluate goals and patients’ understanding of
movements and activities that have been avoided. Here, back pain
graded exposure ensuring that progression feels safe or to
gradually increase physical performance can be helpful. If Re-assessment and reflection are necessary to evaluate
exposure is a tool to reframe beliefs about consequences, it treatment outcomes and for clinicians’ ongoing learning pro-
should include exposures to tasks, postures, or movements cess, and therefore an integrated part of health care. Evalu-
that have been avoided.51 This exposure is an opportunity to ation of patients’ progress must be aligned with the
provide a positive experience and increase the patient’s intention of care, so the evaluation of self-management
beliefs in their ability to move and be active. Operant condi- interventions should include assessment of patients’ under-
tioning principles, stating that pain behaviour is reinforced standing of their symptoms as well as achievements of
if these behaviours result in pain reduction or positive atten- patients’ individual goals and discussion about strategies
tion from others, can also be used to reinforce healthy and needs for adjusting these.
behaviour by increasing activity gradually in a time-contin-
gent manner.67 69 Using operant conditioning, activity, or Assist patients in action planning
exercises should not be directed by pain as this would rein-
force withdrawal from activity. The patient should be encouraged to make an action plan for
dealing with future challenges and relapses. Here, patients’
stage of change of behaviour should be evaluated and the
Provide tools to manage pain and emotions action planning related to this.
Clinicians support self-management by evaluating
Living with LBP invariably involves episodes of flare-ups and patient valued goals, action plans, and phase of change
situations with increased pain. Therefore, patients need a instead of defining success as a cure of symptoms.
‘toolbox’ for managing pain and related fears or other emo-
tions which includes tools such as distraction and breathing Pre-requisites
exercises,70 mindfulness techniques,71,72 or walking.72
Self-management support is integrated into the delivery Integrating self-management support into routine care
of the intervention when clinicians help patients making requires organisational support (Fig. 2). First, clinicians need
sense of their symptoms, discuss pain behaviours, and avoid training in communication skills, behavioural change techni-
supporting negative beliefs. Clinicians can use active inter- ques, and in working with patient-centred care as this is
ventions to teach problem-solving skills and provide often not a part of their basic training.73 Then, there is a
patients with insights and tools to better manage their pain need for a practical clinical set-up that allows for self-man-
and overcome obstacles encountered in everyday life. agement support including having sufficient time for dialogue

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and facilities that protect patient confidentiality when dis- patient-clinician relationship, goal setting, and activity
cussing personal matters. Finally, health systems need to planning. They further found that generally, self-manage-
support clinicians by providing reimbursement for time spent ment interventions based on a theory, for example, the
on patient education and on promoting behaviour change.74 fear-avoidance theory, or delivered according to a theory,
Notably, shifting the paradigm of care requires that clini- for example, cognitive behavioural therapy or social cogni-
cians are open to thinking differently about LBP care tive theory, were more effective than interventions that
throughout the clinical encounter. Table 2 lists some “dos were not based on or delivered according to a theoretical
and don’ts” illustrating that translating treatment into self- framework; that interventions of shorter duration (<6
management support may require profound shifts in clinical weeks40 or 8 weeks78) tended to be more effective than
cognition and habits. longer-lasting interventions; and that interventions where
Self-management support requires organisational change the whole or parts of the intervention was delivered over
and support from payers, educators, and clinic owners. the internet or other eHealth platform were as effective as
interventions delivered in person.40 Interventions delivered
over mobile devices seemed superior to interventions deliv-
ered over the internet via web-pages, but these types of
What is the evidence for self-management delivery had not been directly compared. There were also
interventions in people with LBP? no trials directly comparing eHealth delivery to person deliv-
ery of identical self-management interventions.78 There is a
Systematic reviews summarizing the evidence for the effec- lack of evidence to tell if self-management is best supported
tiveness of self-management interventions in people with per- by individual or group-based interventions. A systematic
sistent LBP report that there is considerable heterogeneity review found group-based interventions for LBP to be more
between studies and that the methodological quality is gener- effective than other types of care for pain relief,79 whereas
ally low to moderate. Nonetheless, across randomized clinical individual cognitive functional therapy for people with
trials, interventions to promote self-management are gener- chronic LBP was more effective in reducing disability than
ally found to have small to moderate effects on key clinical group-based exercise and education in a recent trial.80
outcomes such as pain intensity, back-related disability, and Despite a growing body of literature, most interventions
self-efficacy at least up to one year post-intervention.40,75 77 aiming to promote self-management in people with LBP are
Du et al.40 identified core elements of self-management not well described in reports. These interventions are often
interventions across trials that included problem-solving multifaceted and complex, so standardised reporting, for
skills, decision making, resource utilization, a focus on the example according to the Criteria for Reporting the

Table 3 Summary of key aspects of self-management support.

Principles
People self-manage most of the time
Enable them to do it well
Support patient autonomy
Act as a partner, be person-centred, avoid strong clinician control
Help patients develop self-efficacy
Provide and reinforce positive experiences
It is not only about back pain
Helping people to manage their pain in daily life supports their ability to maintain
good physical and mental health
Working with self-management requires the right setting
Trained clinicians, time for dialogue, and room for confidentiality are pre-requisites for self-management support

Clinical actions
Let patient value-based goals guide management
Focus on patient valued goals and shared decision making rather than on pain and dysfunction
Help patients make sense of their symptoms
Educate people about pain and pain behaviour and help them reframe negative perspectives
Teach skills to solve everyday problems
Give patients insights to help them overcome obstacles in everyday life
Provide tools for pain management
Focus on proactive pain behaviour techniques
Evaluate patient valued goals, action plans, and patients’ understanding of back pain
Move focus away from defining success as curing pain forever

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Development and Evaluation of Complex Interventions in requires organisational support in clinical settings and
healthcare (CReDECI), should be adopted.81 In addition, health systems. Currently, there is no clear evidence show-
authors generally report on clinical outcomes such as pain ing how exactly LBP self-management is most effectively
intensity and back-related disability, but less often on supported in clinical practice, but core elements have been
behaviour related outcomes such as self-management skills, identified that involve working with cognitions related to
learning, and knowledge, which are more related to the pain, behaviour change, and patient autonomy.
goals of these interventions.40,75,82 One reason for this is the
lack of valid measurements tool to capture the complexity
of being able to self-manage.
Current evidence on self-management interventions for Declaration of Competing Interest
LBP are hampered by a lack of theoretical frameworks and
The authors have no conflict of interest to declare. AK’s
interventions are often poorly described. Still, the existing
position at University of Southern Denmark is partly funded
evidence suggests positive effects on a range of key out-
by the Foundation for Chiropractic Research and Post-gradu-
comes and that eHealth may have an important role to play.
ate Education. IRH’s position is financially supported by
income from clinician training in GLA:D Back.

LBP care does not work in isolation

Health care is just one component in a person’s strategies to Funding
manage their health, and people with persistent LBP very
often have multiple chronic conditions.83 Therefore, self- This research did not receive any specific grant from funding
management skills beyond coping with LBP are often needed agencies in the public, commercial, or not-for-profit sectors.
to maintain a healthy life.
Results from 53 qualitative studies investigating patients’
perspectives on self-management of chronic diseases dem-
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