Across non-communicable chronic conditions, a paradigm shift away from clinician-led management towards management where people with chronic conditions play a key role in their own care is advocated.1,2 At the same time, good health is increasingly understood as the ability to adapt to changing life circumstances and to self-manage in the face of social, physical, and emotional challenges.3,4 In the case of persistent low back pain (LBP), such an approach implies that successful interventions are not mainly about clinicians diagnosing and curing patients, but about a partnership between individuals and clinicians that helps people engaging in valued activities.5 Thus, living with persistent or recurrent LBP may involve care-seeking, but people manage their health conditions outside the context of health care most of the time, and interventions for persistent LBP should enable them to do that well.

In this paper, we discuss self-management in relation to LBP with a focus on the role of the clinician.

Among clinicians and within the literature, terms like self-care, self-management, self-efficacy, and symptom management are often used interchangeably without clear definitions and without presentation of the underlying theory.6,7 Therefore, we briefly introduce how we use these terms (Fig. 1).

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 is all the actions that people do to stay healthy (e.g. brushing teeth, sleeping well, eating healthy food), and includes actions that aim to prevent disease, maintain good health, and coping with illness and disability.8Self-management has been defined as “the individual's ability to manage the symptoms, treatment, physical and psychological consequences, and lifestyle changes inherent in living with a chronic condition,” and is the part of self-care that relates to dealing with health conditions.9–11 Definitions of self-management emphasize the importance of interactive, collaborative care between patient and healthcare professionals allowing for patient empowerment rather than one-way passive care from expert to patient.10–12Symptom management is the actions initiated by the patient, a clinician, or both to decrease the distress and consequences caused by symptoms. It entails a collaborative relationship between a patient and the healthcare provider to make decisions about for example medication or manual therapy interventions.9

Self-care and self-management are concepts with ties to Orem's theory and Bandura's Social Cognitive Theory on self-efficacy.13–15Self-efficacy is people's beliefs in their ability to influence events that affect their lives. This core belief is the foundation of human motivation, performance accomplishments, and emotional wellbeing. Unless people believe they can produce desired outcomes by their actions, they have little incentive to undertake activities in the face of difficulties. Whatever factors may serve as guides and motivators, they are rooted in the core belief that one can make a difference by one's actions.

The focus of this paper is on self-management of persistent LBP where this involves the interaction and communication between the healthcare provider and the patient in a clinical encounter, and we describe the engagement of the clinician as ‘self-management support’.9 Self-management support is provided in self-management interventions defined as interventions that “aim to equip patients with skills to actively participate and take responsibility in the management of their chronic condition to function optimally.”12

Most people who experience LBP will have recurrent episodes with pain that comes and goes.16 Even patients who recover well from an episode of LBP most likely will experience new episodes, and up to 20% of those seeking care for LBP have persistent LBP that they need to manage more or less continuously.16

The impact of LBP on daily activities differs substantially between individuals for reasons that are not fully understood. However, people are more disabled from LBP when they perceive their condition as frightening and out of their control and have low pain self-efficacy.17 Also, effective interventions for persistent pain conditions work partly by influencing beliefs, catastrophising thoughts, fear, and pain self-efficacy.18–21 This includes interventions that are designed to have physical effects,22,23 implying that cognitions and emotions are not only affected by psychological interventions.

A traditional biomedical paradigm would focus on structural and degenerative changes in the spine that presumably explain the patient's symptoms. However, these do not correlate well with an individuals’ pain or activity limitations,24,25 although associated with an increased risk of LBP in populations.26 They also do not inform what treatment the patient most likely will respond to, nor do they inform the prognosis.27,28 A structural diagnosis does therefore not help patients make sense of their symptoms, and it may, in fact, add to their fear and worry, and even drive the use of ineffective treatments.29–33 Although exercises are often prescribed to improve muscle function and mobility there is little evidence that those are the mechanisms behind positive clinical effects.34–36

Clinicians should care about self-management because most people with LBP continuously manage their condition and should be enabled to do it well. Supporting self-efficacy is an important element of LBP care because people are less disabled by LBP if they trust in their ability to manage it, and effective treatments for LBP partly work by reducing fear and increasing self-efficacy.

Clinical guidelines generally recommend advice and information, manual therapy, and supervised exercises as treatments for persistent LBP.37-39 These interventions are effective parts of symptom management and may prevent relapse, but do not necessarily support patient autonomy and self-management. Below, we outline clinical actions that help integrate self-management support in LBP management including behaviour change techniques (i.e. strategies to help patients adopt healthy behaviours) that are frequently incorporated in self-management interventions, and actions to focus on patient autonomy and self-efficacy (Table 1).12,40–42 These actions are aligned with intervention planning, intervention delivery, and clinical evaluation (Fig. 2).

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.

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Systematic reviews summarizing the evidence for the effectiveness of self-management interventions in people with persistent LBP report that there is considerable heterogeneity between studies and that the methodological quality is generally low to moderate. Nonetheless, across randomized clinical trials, interventions to promote self-management are generally found to have small to moderate effects on key clinical outcomes such as pain intensity, back-related disability, and self-efficacy at least up to one year post-intervention.40,75–77

Du et al.40 identified core elements of self-management interventions across trials that included problem-solving skills, decision making, resource utilization, a focus on the patient-clinician relationship, goal setting, and activity planning. They further found that generally, self-management interventions based on a theory, for example, the fear-avoidance theory, or delivered according to a theory, for example, cognitive behavioural therapy or social cognitive theory, were more effective than interventions that were not based on or delivered according to a theoretical framework; that interventions of shorter duration (<6 weeks40 or ≤8 weeks78) tended to be more effective than longer-lasting interventions; and that interventions where the whole or parts of the intervention was delivered over the internet or other eHealth platform were as effective as interventions delivered in person.40 Interventions delivered over mobile devices seemed superior to interventions delivered over the internet via web-pages, but these types of delivery had not been directly compared. There were also no trials directly comparing eHealth delivery to person delivery of identical self-management interventions.78 There is a lack of evidence to tell if self-management is best supported by individual or group-based interventions. A systematic review found group-based interventions for LBP to be more effective than other types of care for pain relief,79 whereas individual cognitive functional therapy for people with chronic LBP was more effective in reducing disability than group-based exercise and education in a recent trial.80

Despite a growing body of literature, most interventions aiming to promote self-management in people with LBP are not well described in reports. These interventions are often multifaceted and complex, so standardised reporting, for example according to the Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare (CReDECI), should be adopted.81 In addition, authors generally report on clinical outcomes such as pain intensity and back-related disability, but less often on behaviour related outcomes such as self-management skills, learning, and knowledge, which are more related to the 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 LBP are hampered by a lack of theoretical frameworks and interventions are often poorly described. Still, the existing evidence suggests positive effects on a range of key outcomes and that eHealth may have an important role to play.

Health care is just one component in a person's strategies to manage their health, and people with persistent LBP very often have multiple chronic conditions.83 Therefore, self-management skills beyond coping with LBP are often needed to maintain a healthy life.

Results from 53 qualitative studies investigating patients’ perspectives on self-management of chronic diseases demonstrated that personal factors (e.g. knowledge, beliefs, and motivation), health status (including symptom severity and general health), available resources, social context (work, family, community), and health care systems all affect a person's ability to self-manage.84 Another synthesis of qualitative studies demonstrated that it can be an exhausting effort to maintain ongoing self-management of LBP, and the success of this sustained process depends on individual personal factors as well as support from clinicians, family, and friends.85 Thus health care does not act in isolation, and self-management strategies must be based on individual needs and care must be person-centred. Four principles of person-centred care have been described by The UK Health Foundation as: (1) affording people dignity, compassion, and respect; (2) offering coordinated care; (3) offering personalised care, and; (4) supporting people to recognise and develop their strengths and abilities to enable them to live an independent and fulfilling life.86

Self-management interventions should support people's self-efficacy and autonomy not only as a tool for managing pain but rather support the ability to maintain good overall physical and mental health. People manage very different life situations and individual resources and contexts must be met with compassion and respect.

People with 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 (Table 3). 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.