Barriers and Facilitators to Self-management in People With Back-related Leg Pain

Background:   Back related leg pain (BRLP) is a problematic subset of low back pain, leading to greater pain, loss of function and health related care costs. While evidence suggests self-management is effective, patient implementation can be sub-optimal. The purpose of this study is to identify barriers and facilitators to self-management for persons experiencing BRLP within the context of a controlled clinical trial and to map these to theory-informed intervention elements that can be addressed by front-line healthcare providers, informing the design and implementation of future theory-driven self-management interventions for this population.

Methods:   This study was a qualitative secondary analysis of a 2-site, pragmatic, parallel group, randomized clinical trial (participants enrolled 2007-10) of spinal manipulative therapy (SMT) and home exercise and advice (HEA) compared to HEA alone for persons with subacute or chronic BRLP. We used deductive and inductive content analysis, to describe self-management facilitators and barriers among trial participants, map these to behavior change elements in the Behavior Change Wheel (BCW) Framework, and identify potentially modifiable, theory-intervention elements which may be addressed with guidance by healthcare providers. Baseline characteristics of participants were descriptively analyzed using SAS (University Edition).

Results:   Of 40 participants, the majority identified as white (n = 24, 85%) and of non-Hispanic or Latino ethnicity (n = 38, 95%). Average participant age was 57 years old (range 29-80). Frequent facilitators included ease of exercises, knowing how to manage condition, atmosphere created by staff, therapeutic alliance, effectiveness of exercises or treatment, goal of reducing pain, and intentions of continuing exercises. Frequent barriers included time constraints, pain, and lacking confidence in treatment. Barriers were mapped to all 9 Intervention Functions, most common being modelling and education. Frequently identified Behavior Change Techniques included information, feedback, self-monitoring, graded tasks, restructuring, social support, goal setting, reviewing goals, and action planning.

Conclusion:   This study identified barriers and facilitators to engaging in self-management for participants in a pragmatic, randomized clinical trial. A rigorous systematic intervention mapping process utilizing the BCW was used for describing what participants need and how their needs may be met. These findings may support the design of future self-management interventions for persons experiencing BRLP.

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Keywords:   Back pain; Behavior change; Self-management; Spinal manipulation.

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Introduction

People with chronic low back pain (LBP) experience a myriad of disruptions to multiple facets of their lives, including health, social activity, employment, and identity. LBP is a leading cause of disability [1–4], leading many people to weave together a patchwork of pharmacological, nonpharmacological, and self-management strategies to cope with their pain and symptoms. [5, 6] This is especially true for patients with back-related leg pain (BRLP), a more complicated variation of LBP with symptoms that can be more difficult to self-manage than back pain alone. [7–10] Persons experiencing BRLP pain face greater levels of disability, pain intensity, activity limitations, higher frequency of psychological risk factors, and poorer quality of life than those with uncomplicated LBP. [8, 9, 11–13]

Self-management can be defined as an “individual’s ability to manage symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition”. [14] Clinical practice guidelines (CPGs) consistently recommend patient education, exercise, and self-management as first-line treatments for BRLP due to the impact of these strategies on patient outcomes. [15–19] For example, patients who engage in home exercise programs to manage chronic health conditions may experience a sense of empowerment and reduced dependence on healthcare professionals for treatment. [14, 20] Effective self-management however is hard and implementing new self-management strategies on a consistent basis requires behavior change [21, 22], not only on the part of the patient, but also among their clinicians. Healthcare professionals can play a key role in fostering effective BRLP self-management among patients through partnership, support, education, and supervision, and promoting self-efficacy. [20, 23–25]

However, health professionals’ practice conventions are often misaligned with guideline recommendations. For example, clinicians prescribe exercise to only half of their patients who might benefit [26] and rarely offer self-care education [27], rather continuing to advocate for rest over active care, and poorly advising patients on the psychological and social dimensions of their experience. [26] Even when health professionals do implement CPG recommendations, patient adherence to exercise and other self-management strategies is sub-optimal. [25, 28] These gaps between ideal and actual treatments necessitate further investigation into how patients and providers understand, recommend, or adopt self-management strategies for BRLP.

Self-management interventions, a type of behavioral change intervention, are those that promote the “active involvement of the patient in managing their condition”, and can help the individual learn about and implement health behaviors in their daily lives. [29] However, implementing such interventions can be tenuous. [29] Behavioral change models, for example, Michie and colleagues’ Behavior Change Wheel, highlight sustained behavioral change requires sufficient capability, opportunity, and motivation. [30] The absence of, or barriers within any of these three realms may prevent an individual from engaging in new health behaviors regularly and effectively [21] while facilitating them may support long-term adoption. [31–35]

A theory-informed approach to behavior change may allow patients and providers to move from identifying self-management barriers and facilitators to establishing a behavior change diagnosis with its accompanying interventions and expected outcomes. [30, 36] Not all behavior change frameworks are comprehensive, which may lend to heterogeneity among developing and implementing self-management interventions. [21, 36] The Michie and colleagues’ behavior change wheel (BCW) was developed from a systematic review of 19 frameworks of behavior change including nine intervention functions and seven policy categories resulting in a “behavior system” applicable to range of behavior change interventions. [21] Eilayyan et al., and Hurley et al. have undertaken studies to develop LBP self-management interventions utilizing the BCW. [31, 34, 37]

However, these studies focused on spinal back pain rather than BRLP, a more complicated and disabling variant of back pain. [8, 9, 11] To further expand the BCW knowledge base, our team undertook a theory-informed evaluation of BRLP self-management interventions. The purpose of our study was to identify barriers and facilitators to self-management for persons experiencing BRLP within the context of a controlled clinical trial and to map these to theory-informed intervention elements that can be addressed by front-line healthcare providers. Our goal was to provide research-based information to improve the design and implementation of future theory-informed self-management interventions for persons experiencing BRLP.

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