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BACKGROUND mHealth solutions are a promising method for delivering tailored self-management interventions to patients with non-specific low back pain (LBP). However, it is not clear if the effectiveness of such self-management interventions depends on patients’ initial pain characteristics. High pain intensity and long-term symptoms of LBP have been associated with an unfavorable prognosis, and current best evidence indicates that long-term LBP (lasting more than 3 months) requires a more extensive treatment approach compared to acute LBP. The artificial intelligence-based SELFBACK app supports tailored and evidence-based self-management of non-specific LBP and have been shown to reduce LBP-related disability. OBJECTIVE To explore if baseline duration and intensity of LBP modify the effectiveness of the SELFBACK intervention. METHODS In this secondary analysis of the SELFBACK randomized controlled trial (RCT), we explore if baseline duration and intensity of LBP modify the effectiveness of the SELFBACK intervention. In the RCT, 461 adults who sought care for LBP in primary care or an outpatient spine clinic were randomized to receive the SELFBACK intervention adjunct to usual care (n=232) or usual care alone (n=229). Participants were then stratified according to duration of the current LBP episode at baseline (≤12 weeks vs >12 weeks) or baseline LBP intensity (≤5 points vs >5 points) measured by a 0-10 numeric rating scale (NRS). Outcomes were LBP-related disability measured by the Roland Morris Disability Questionnaire, average LBP intensity (NRS), pain self-efficacy, and global perceived effect. RESULTS Overall, there was no clear effect modification by duration or intensity of LBP at either three or nine months follow-up. However, there was suggestive evidence that the effect of the SELFBACK intervention on LBP-related disability at three months was largely confined to people with the highest vs the lowest LBP intensity (mean difference between the intervention and control group; -1.8 [95% CI -3.0 to -0.7] vs 0.2 [95% CI -1.1 to 0.7], respectively), but that this was not sustained at 9 months. CONCLUSIONS The results suggest that intensity and duration of LBP have negligible influence on the effectiveness of the SELFBACK intervention on LBP-related disability, average LBP intensity, pain self-efficacy and global perceived effect. CLINICALTRIAL The multicenter SELFBACK RCT is registered in Clinicaltrials.gov: (NTC03798288). Registered 7 January 2019. INTERNATIONAL REGISTERED REPORT RR2-10.2196/14720

Background: The multidimensional array of clinical features and prognostic factors makes it difficult to optimize management within the heterogeneity of patients with common musculoskeletal pain. This study aimed to identify phenotypes across prognostic factors and musculoskeletal complaints. Concurrent and external validity were assessed against an established instrument and a new sample, respectively, and treatment outcome was described. Methods: We conducted a longitudinal observational study of 435 patients (aged 18–67 years) seeking treatment for nonspecific complaints in the neck, shoulder, low back or multisite/complex pain in primary health care physiotherapy in Norway. Latent class analysis was used to identify phenotypes based on 11 common prognostic factors within four biopsychosocial domains; pain, beliefs and thoughts, psychological and activity and lifestyle. Results: Five distinct phenotypes were identified. Phenotype 1 (n = 77, 17.7%) and 2 (n = 142, 32.6%) were characterized by the lowest scores across all biopsychosocial domains. Phenotype 2 showed somewhat higher levels of symptoms across the biopsychosocial domains. Phenotype 3 (n = 89, 20.5%) and 4 (n = 78, 17.9%) were more affected across all domains, but phenotype 3 and 4 had opposite patterns in the psychological and pain domains. Phenotype 5 (n = 49, 11.3%) were characterized by worse symptoms across all domains, indicating a complex phenotype. The identified phenotypes had good external and concurrent validity, also differentiating for the phenotypes in function and health-related quality of life outcome at 3-month follow-up. Conclusion: The phenotypes may inform the development of targeted interventions aimed at improving the treatment efficiency in patients with common musculoskeletal disorders. Significance: This observational prospective study identified five distinct and clinically meaningful phenotypes based on biopsychosocial prognostic factors across common musculoskeletal pain. These phenotypes were independent of primary pain location, showed good external validity, and clear variation in treatment outcome. The findings are particularly valuable as they describe the heterogeneity of patients with musculoskeletal pain and points to a need for more targeted interventions in common musculoskeletal disorders to improve treatment outcome. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®

Background: Low back pain is a multifactorial disease with consequences for work ability and social participation. Improved integration of the work domain in health care management is needed. The aim of this study was to explore the relation between working conditions with outcome of low back pain treatment. Methods: Observational study of 41 patients attending physiotherapy for low back pain. Work demands, support and control were registered at baseline and work ability and disability also at baseline, with follow up after three and nine months. We used mixed-effects models to estimate the longitudinal associations between working conditions and outcome. Results: Higher work demands were related to reduced work ability (−1.1 points, 95% CI: −2.1 to −0.1) and slightly increased disability (5.6 points, 95% CI: 0.5 to 10.7). Lack of social support from colleagues was associated with reduced work ability (−2.7 points, 95% CI: −0.2 to 1.5) and disability (14.0 points, 95% CI: 4.9 to 23.1). Conclusions: This explorative study found associations between work demands and support, and work ability and disability outcome. Screening for psychosocial working conditions may influence the work ability and disability treatment outcome. The results need replication in larger samples and may indicate that patients seeking primary care management for low back pain should be screened for work demands, support and control.

Although sleep quantity and quality appear to be interrelated, most previous studies have considered sleep duration and insomnia symptoms as distinct entities. We therefore examined whether there is a joint effect of sleep duration and long-term changes in insomnia symptoms on the risk of recurrent chronic spinal pain. We performed a prospective study of 8,788 participants who participated in three surveys over ∼22 years and reported chronic spinal pain at the first, second, or both surveys. Adjusted risk ratios (RRs) were calculated for the risk of recurrent spinal pain at the last survey associated with self-reported sleep duration at the first survey and changes in insomnia symptoms between the two first surveys. Compared to participants with normal sleep duration (7-9 h) and no insomnia symptoms at the two first surveys, participants with insomnia symptoms over the same period had RRs of spinal pain of 1.33 (95% CI 1.26-1.41) in the last survey if they reported normal sleep duration and 1.50 (95% CI 1.34-1.67) if they reported short sleep (≤6 h). The corresponding RRs for spinal pain for participants who improved their sleep symptoms were 1.09 (95% CI 1.00-1.19) for those with normal sleep and 1.13 (95% CI 0.88-1.45) for those with short sleep. In conclusion, people who reported insomnia symptoms over ∼10 years in combination with short sleep had a particularly increased risk of recurrent spinal pain. Improvement in insomnia symptoms was associated with a favorable prognosis.

Research Aim/Objective:The artificial intelligence-based SELFBACK app supports tailored self-management of non-specific lowback pain (LBP) and have been shown to reduce LBP-related disability. In this secondary analysis of theSELFBACK randomized controlled trial, we explore if intensity and duration of LBP at baseline modify theeffect of the SELFBACK intervention.Research Methods:461 adults seeking care for LBP in primary care or an outpatient spine clinic were randomized to theSELFBACK intervention adjunct to usual care (n=232) or usual care alone (n=229). We classifiedparticipants based on baseline score of pain intensity the last week (≤5 points or >5 points) measured bythe 0-10 Numeric rating scale (NRS) and duration of the current LBP episode (≤12 weeks or >12 weeks).Outcomes were LBP-related disability measured by the Roland Morris Disability Questionnaire (RMDQ),average LBP intensity, pain self-efficacy, and global perceived effect. Outcomes were measured atbaseline, 6 weeks, 3, 6 and 9 months. We compared the mean difference between SELFBACK and usualcare, stratified by baseline level of LBP intensity and duration of the current LBP episode.Results:461 adults seeking care for LBP in primary care or an outpatient spine clinic were randomized to theSELFBACK intervention adjunct to usual care (n=232) or usual care alone (n=229). We classifiedparticipants based on baseline score of pain intensity the last week (≤5 points or >5 points) measured bythe 0-10 Numeric rating scale (NRS) and duration of the current LBP episode (≤12 weeks or >12 weeks).Outcomes were LBP-related disability measured by the Roland Morris Disability Questionnaire (RMDQ),average LBP intensity, pain self-efficacy, and global perceived effect. Outcomes were measured atbaseline, 6 weeks, 3, 6 and 9 months. We compared the mean difference between SELFBACK and usualcare, stratified by baseline level of LBP intensity and duration of the current LBP episode.Discussion:Although we observed an overall small favourable effect of SELFBACK for participants with the highestlevel of symptoms, there was no clear evidence of differences in the effect of a tailored app-deliveredself-management intervention in subgroups defined according to baseline level of pain intensity or painduration. Thus, our findings indicate that clinicians should not refrain from advising individually tailoredself-management support for patients with high LBP and persistent symptoms; however, this requiresfurther research.

Background Impaired lumbar movement has cross-sectionally been associated with low back pain (LBP); however, the consequence of impaired movement on disability and pain in persons with LBP is poorly understood. Furthermore, fear-avoidance beliefs (FAB) may influence spinal movement, but the relation between fear-avoidance and kinematics is unclear. Objectives To investigate the longitudinal associations of kinematics and FAB with disability, work ability and pain in patients with LBP. Further, to explore associations between FAB and kinematics. Design Prospective observational study. Method Kinematic measures were performed on 44 persons with LBP at baseline, three and nine months. Motion sensors identified range-of-motion and velocity during a spinal flexion/extension. FAB, disability, work ability and pain were reported at all time points using questionnaires. Results Increased range-of-motion was weakly associated with less disability (−0.14 points, 95% CI -0.22 to −0.06). Velocity was not associated with disability, work ability or pain. Higher FAB of physical activity were associated with more disability (1.50 points, 95% CI 0.51 to 2.49) and pain (0.37 points, 95% CI 0.11 to 0.62). Higher work-related FAB was associated with lower work ability (−0.37 points, 95% CI -0.68 to −0.05). Moreover, higher FAB showed weak associations with lower velocity in the initial movement phase (−3.3°/s, 95% CI -6.1 to −0.5). Conclusions Of the kinematic measures, only range-of-motion was related to disability. Higher FAB was weakly associated with all self-reported outcomes and with lower velocity only at the initial flexion phase. However, the magnitude of these associations suggest marginal clinical importance.

Background Most previous studies have relied on single measurements of body weight and physical activity and have not considered the interplay between long-term changes in body weight and physical activity in relation to mortality. The aim of the current study was therefore to examine the joint effect of changes in body weight and leisure-time physical activity over a period of ~ 10 years on all-cause and cardiovascular mortality. Methods The study population comprised 34,257 individuals who participated in the first (1984–86) and second (1995–97) waves of the HUNT Study, and were followed up through the Norwegian Cause of Death Registry until December 31st, 2013. We used Cox regression to estimate hazard ratios (HR) with 95% confidence intervals (CI) of death associated with changes in body weight and leisure-time physical activity. Results Compared to the reference group with stable weight who were long-term physically active, people who gained ≥5% of their weight had a HR for all-cause mortality of 1.54 (95% CI: 1.28–1.85) if they were long-term physically inactive; a HR of 1.23 (1.09–1.40) if they became physically active, and a HR of 1.00 (95% CI 0.94–1.06) if they were long-term physically active. The corresponding HRs for cardiovascular mortality were 1.57 (95% CI 1.17–2.12), 1.28 (95% CI 1.04–1.58) and 1.06 (95% CI 0.96–1.16), respectively. Long-term physical inactivity was associated with increased all-cause (HR 1.29; 95% CI 1.08–1.53) and cardiovascular (HR 1.37; 95% CI 1.05–1.79) mortality among those who were weight stable. Conclusions The risk of all-cause and cardiovascular mortality is particularly evident among people who gain weight while remaining inactive during a ~ 10 year period. However, participants who remained physically active had the lowest risk of premature mortality, regardless of maintenance or increase in weight. These findings suggest that there is an interplay between long-term changes in body weight and physical activity that should receive particular attention in the prevention of premature mortality. © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)

Prospective observational study pooled from two clinical cohorts.To investigate the longitudinal relation between multisite pain, psychological distress, and work ability with disability, pain, and quality of life.Knowledge of prognostic factors is essential for better management of patients with low back pain (LBP). All domains of the biopsychosocial model have shown prognostic value; however, clinical studies rarely incorporate all domains when studying treatment outcome for patients with LBP.A total of 165 patients with nonspecific LBP seeking primary care physiotherapy were included. Mixed-effects models were used to estimate longitudinal relations between the exposure variables and concurrent measures of outcomes at baseline and 3 months. Logistic regression was used to estimate odds ratios for minimal important difference in outcome.Higher work ability was associated with less disability -2.6 (95% confidence interval [CI]: -3.3, -2.0), less pain: -0.4 (95% CI: -0.5, -0.3), and higher quality of life 0.03 (95% CI: 0.02, 0.04). Higher psychological distress and number of pain sites were associated with higher disability: 10.9 (95% CI: 7.7, 14.1) and 2.3 (95% CI: 1.4, 3.2) higher pain: 1.9 (95% CI: 1.3, 2.5) and 0.4 (95% CI: 0.2, 0.5), and lower quality of life: -0.1 (95% CI: -0.2, -0.1) and -0.02 (95% CI: -0.03, -0.01), respectively. Improvement in work ability showed consistent associations with successful outcome for disability (odds ratio [OR]: 4.8, 95% CI: 1.3, 18.1), pain (OR: 3.6, 95% CI: 1.1, 12.1), and quality of life (OR: 4.5, 95% CI: 1.4, 15.1) at 3 months. Reduced psychological distress was associated with improvement in pain only (OR 4.0, 95% CI: 1.3, 12.3).More pain sites, higher psychological distress, or lower work ability showed higher disability, more pain, and lower quality of life in patients with LBP. Only improvement in work ability was consistently related to successful outcomes.2.

This randomized clinical trial examines a decision support tool that provides lower back pain information and self-management recommendations that are specific to an individual’s characteristics, symptoms, and symptom progression., Key Points Question Is selfBACK, an evidence-based, individually tailored self-management support system that is delivered through an artificial intelligence–based app and in conjunction with usual care, effective for pain-related disability in adults with lower back pain? Findings In this randomized clinical trial involving 461 participants in Denmark and Norway, those who received the selfBACK intervention had reduced pain-related disability compared with those who received usual care alone. However, the effect may be too small to be clinically meaningful. Meaning The findings of this trial and process evaluation may inform and encourage further development of the selfBACK intervention to increase its effectiveness., Importance Lower back pain (LBP) is a prevalent and challenging condition in primary care. The effectiveness of an individually tailored self-management support tool delivered via a smartphone app has not been rigorously tested. Objective To investigate the effectiveness of selfBACK, an evidence-based, individually tailored self-management support system delivered through an app as an adjunct to usual care for adults with LBP-related disability. Design, Setting, and Participants This randomized clinical trial with an intention-to-treat data analysis enrolled eligible individuals who sought care for LBP in a primary care or an outpatient spine clinic in Denmark and Norway from March 8 to December 14, 2019. Participants were 18 years or older, had nonspecific LBP, scored 6 points or higher on the Roland-Morris Disability Questionnaire (RMDQ), and had a smartphone and access to email. Interventions The selfBACK app provided weekly recommendations for physical activity, strength and flexibility exercises, and daily educational messages. Self-management recommendations were tailored to participant characteristics and symptoms. Usual care included advice or treatment offered to participants by their clinician. Main Outcomes and Measures Primary outcome was the mean difference in RMDQ scores between the intervention group and control group at 3 months. Secondary outcomes included average and worst LBP intensity levels in the preceding week as measured on the numerical rating scale, ability to cope as assessed with the Pain Self-Efficacy Questionnaire, fear-avoidance belief as assessed by the Fear-Avoidance Beliefs Questionnaire, cognitive and emotional representations of illness as assessed by the Brief Illness Perception Questionnaire, health-related quality of life as assessed by the EuroQol-5 Dimension questionnaire, physical activity level as assessed by the Saltin-Grimby Physical Activity Level Scale, and overall improvement as assessed by the Global Perceived Effect scale. Outcomes were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months. Results A total of 461 participants were included in the analysis; the population had a mean [SD] age of 47.5 [14.7] years and included 255 women (55%). Of these participants, 232 were randomized to the intervention group and 229 to the control group. By the 3-month follow-up, 399 participants (87%) had completed the trial. The adjusted mean difference in RMDQ score between the 2 groups at 3 months was 0.79 (95% CI, 0.06-1.51; P = .03), favoring the selfBACK intervention. The percentage of participants who reported a score improvement of at least 4 points on the RMDQ was 52% in the intervention group vs 39% in the control group (adjusted odds ratio, 1.76; 95% CI, 1.15-2.70; P = .01). Conclusions and Relevance Among adults who sought care for LBP in a primary care or an outpatient spine clinic, those who used the selfBACK system as an adjunct to usual care had reduced pain-related disability at 3 months. The improvement in pain-related disability was small and of uncertain clinical significance. Process evaluation may provide insights into refining the selfBACK app to increase its effectiveness. Trial Registration ClinicalTrials.gov Identifier: NCT03798288

Background Research shows that part of the variation in physical activity and sedentary behaviour may be explained by genetic factors. Identifying genetic variants associated with physical activity and sedentary behaviour can improve causal inference in physical activity research. The aim of this systematic review was to provide an updated overview of the evidence of genetic variants associated with physical activity or sedentary behaviour. Methods We performed systematic literature searches in PubMed and Embase for studies published from 1990 to April 2020 using keywords relating to “physical activity”, “exercise”, “sedentariness” and “genetics”. Physical activity phenotypes were either based on self-report (e.g., questionnaires, diaries) or objective measures (e.g., accelerometry, pedometer). We considered original studies aiming to i) identify new genetic variants associated with physical activity or sedentary behaviour (i.e., genome wide association studies [GWAS]), or ii) assess the association between known genetic variants and physical activity or sedentary behaviour (i.e., candidate gene studies). Study selection, data extraction, and critical appraisal were carried out by independent researchers, and risk of bias and methodological quality was assessed for all included studies. Results Fifty-four out of 5420 identified records met the inclusion criteria. Six of the included studies were GWAS, whereas 48 used a candidate gene approach. Only one GWAS and three candidate gene studies were considered high-quality. The six GWAS discovered up to 10 single nucleotide polymorphisms (SNPs) associated with physical activity or sedentariness that reached genome-wide significance. In total, the candidate gene studies reported 30 different genes that were associated (p

IntroductionLow back pain (LBP) and neck pain (NP) are common and costly conditions. Self-management is a key element in the care of persistent LBP and NP. Artificial intelligence can be used to support and tailor self-management interventions, but their effectiveness needs to be ascertained. The aims of this trial are (1) to evaluate the effectiveness of an individually tailored app-based self-management intervention (selfBACK) adjunct to usual care in people with LBP and/or NP in secondary care compared with usual care only, and (2) to compare the effectiveness of selfBACK with a web-based self-management intervention without individual tailoring (e-Help).Methods and analysisThis is a randomised, assessor-blind clinical trial with three parallel arms: (1) selfBACK app adjunct to usual care; (2) e-Help website adjunct to usual care and (3) usual care only. Patients referred to St Olavs Hospital, Trondheim (Norway) with LBP and/or NP and accepted for assessment/treatment at the multidisciplinary outpatient clinic for back or neck rehabilitation are invited to the study. Eligible and consenting participants are randomised to one of the three arms with equal allocation ratio. We aim to include 279 participants (93 in each arm). Outcome variables are assessed at baseline (before randomisation) and at 6-week, 3-month and 6-month follow-up. The primary outcome is musculoskeletal health measured by the Musculoskeletal Health Questionnaire at 3 months. A mixed-methods process evaluation will document patients’ and clinicians’ experiences with the interventions. A health economic evaluation will estimate the cost-effectiveness of both interventions’ adjunct to usual care.Ethics and disseminationThe trial is approved by the Regional Committee for Medical and Health Research Ethics in Central Norway (Ref. 2019/64084). The results of the trial will be published in peer-review journals and presentations at national and international conferences relevant to this topic.Trial registration numberNCT04463043.

Background Very few of the publicly available apps directed towards self-management of low back pain (LBP) have been rigorously tested and their theoretical underpinnings seldom described. The selfBACK app was developed in collaboration with end-users and clinicians and its content is supported by best evidence on self-management of LBP. The objectives of this pilot study were to investigate the basis for recruitment and screening procedures for the subsequent randomized controlled trial (RCT), to test the inclusion process in relation to questionnaires and app installation, and finally to investigate the change in primary outcome over time. Methods This single-armed pilot study enrolled 51 participants who had sought help for LBP of any duration from primary care (physiotherapy, chiropractic, or general practice) within the past 8 weeks. Participants were screened for eligibility using the PROMIS-Physical-Function-4a questionnaire. Participants were asked to use the selfBACK app for 6 weeks. The app provided weekly tailored self-management plans targeting physical activity, strength and flexibility exercises, and education. The construction of the self-management plans was achieved using case-based reasoning (CBR) methodology to capture and reuse information from previous successful cases. Participants completed the primary outcome pain-related disability (Roland-Morris Disability Questionnaire [RMDQ]) at baseline and 6-week follow-up along with a range of secondary outcomes. Metrics of app use were collected throughout the intervention period. Results Follow-up data at 6 weeks was obtained for 43 participants. The recruitment procedures were feasible, and the number needed to screen was acceptable (i.e., 1.6:1). The screening questionnaire was altered during the pilot study. The inclusion process, answering questionnaires and app installation, were feasible. The primary outcome (RMDQ) improved from 8.6 (SD 5.1) at baseline to 5.9 (SD 4.0) at 6-week follow-up (change score 1.8, 95% CI 0.7 to 2.9). Participants spent on average 134 min (range 0–889 min) using the app during the 6-week period. Conclusion The recruitment, screening, and inclusion procedures were feasible for the subsequent RCT with a small adjustment. The improvement on the RMDQ from baseline to follow-up was small. Time pattern of app usage varied considerably between the participants. Trial registration NCT03697759. Registered on August 10, 2018. https://clinicaltrials.gov/ct2/show/NCT03697759

BACKGROUND Self-management is the key recommendation for managing nonspecific low back pain (LBP). However, there are well-documented barriers to self-management; therefore, methods of facilitating adherence are required. Smartphone apps are increasingly being used to support self-management of long-term conditions such as LBP. OBJECTIVE The aim of this study was to assess the usability and acceptability of the SELFBACK smartphone app, designed to support and facilitate self-management of non-specific LBP. The app provides weekly self-management plans, comprising physical activity, strength and flexibility exercises, and patient education. The plans are tailored to the patient’s characteristics and symptom progress by using case-based reasoning methodology. METHODS The study was carried out in 2 stages using a mixed-methods approach. All participants undertook surveys, and semistructured telephone interviews were conducted with a subgroup of participants. Stage 1 assessed an app version with only the physical activity component and a web questionnaire that collects information necessary for tailoring the self-management plans. The physical activity component included monitoring of steps recorded by a wristband, goal setting, and a scheme for sending personalized, timely, and motivational notifications to the user’s smartphone. Findings from Stage 1 were used to refine the app and inform further development. Stage 2 investigated an app version that incorporated 3 self-management components (physical activity, exercises, and education). A total of 16 participants (age range 23-71 years) with ongoing or chronic nonspecific LBP were included in Stage 1, and 11 participants (age range 32-56 years) were included in Stage 2. RESULTS In Stage 1, 15 of 16 participants reported that the baseline questionnaire was easy to answer, and 84% (13/16) found the completion time to be acceptable. Overall, participants were positive about the usability of the physical activity component but only 31% (5/16) found the app functions to be well integrated. Of the participants, 90% (14/16) were satisfied with the notifications, and they were perceived as being personalized (12/16, 80%). In Stage 2, all participants reported that the web questionnaire was easy to answer and the completion time acceptable. The physical activity and exercise components were rated useful by 80% (8/10), while 60% (6/10) rated the educational component useful. Overall, participants were satisfied with the usability of the app; however, only 50% (5/10) found the functions to be well integrated, and 20% (2/10) found them to be inconsistent. Overall, 80% (8/10) of participants reported it to be useful for self-management. The interviews largely reinforced the survey findings in both stages. CONCLUSIONS This study has demonstrated that participants considered the SELFBACK app to be acceptable and usable and that they thought it would be useful for supporting self-management of LBP. However, we identified some limitations and suggestions useful to guide further development of the SELFBACK app and other mobile health interventions.

Background: Self-management is the key recommendation for managing nonspecific low back pain (LBP). However, there are well-documented barriers to self-management; therefore, methods of facilitating adherence are required. Smartphone apps are increasingly being used to support self-management of long-term conditions such as LBP. Objective: The aim of this study was to assess the usability and acceptability of the SELFBACK smartphone app, designed to support and facilitate self-management of non-specific LBP. The app provides weekly self-management plans, comprising physical activity, strength and flexibility exercises, and patient education. The plans are tailored to the patient’s characteristics and symptom progress by using case-based reasoning methodology. Methods: The study was carried out in 2 stages using a mixed-methods approach. All participants undertook surveys, and semistructured telephone interviews were conducted with a subgroup of participants. Stage 1 assessed an app version with only the physical activity component and a web questionnaire that collects information necessary for tailoring the self-management plans. The physical activity component included monitoring of steps recorded by a wristband, goal setting, and a scheme for sending personalized, timely, and motivational notifications to the user’s smartphone. Findings from Stage 1 were used to refine the app and inform further development. Stage 2 investigated an app version that incorporated 3 self-management components (physical activity, exercises, and education). A total of 16 participants (age range 23-71 years) with ongoing or chronic nonspecific LBP were included in Stage 1, and 11 participants (age range 32-56 years) were included in Stage 2. Results: In Stage 1, 15 of 16 participants reported that the baseline questionnaire was easy to answer, and 84% (13/16) found the completion time to be acceptable. Overall, participants were positive about the usability of the physical activity component but only 31% (5/16) found the app functions to be well integrated. Of the participants, 90% (14/16) were satisfied with the notifications, and they were perceived as being personalized (12/16, 80%). In Stage 2, all participants reported that the web questionnaire was easy to answer and the completion time acceptable. The physical activity and exercise components were rated useful by 80% (8/10), while 60% (6/10) rated the educational component useful. Overall, participants were satisfied with the usability of the app; however, only 50% (5/10) found the functions to be well integrated, and 20% (2/10) found them to be inconsistent. Overall, 80% (8/10) of participants reported it to be useful for self-management. The interviews largely reinforced the survey findings in both stages. Conclusions: This study has demonstrated that participants considered the SELFBACK app to be acceptable and usable and that they thought it would be useful for supporting self-management of LBP. However, we identified some limitations and suggestions useful to guide further development of the SELFBACK app and other mobile health interventions. ©Anne Lovise Nordstoga, Kerstin Bach, Sadiq Sani, Nirmalie Wiratunga, Paul Jarle Mork, Morten Villumsen, Kay Cooper. Originally published in JMIR Rehabilitation and Assistive Technology (http://rehab.jmir.org), 09.09.2020. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Rehabilitation and Assistive Technology, is properly cited. The complete bibliographic information, a link to the original publication on http://rehab.jmir.org/, as well as this copyright and license information must be included.

Background Low back pain (LBP) is prevalent across all social classes, in all age groups, and across industrialized and developing countries. From a global perspective, LBP is considered the leading cause of disability and negatively impacts everyday life and well-being. Self-management is a recommended first-line treatment, and mobile apps are a promising platform to support self-management of conditions like LBP. In the selfBACK project, we have developed a digital decision support system made available for the user via an app intended to support tailored self-management of nonspecific LBP. Objective The trial aims to evaluate the effectiveness of using the selfBACK app to support self-management in addition to usual care (intervention group) versus usual care only (control group) in people with nonspecific LBP. Methods This is a single-blinded, randomized controlled trial (RCT) with two parallel arms. The selfBACK app provides tailored self-management plans consisting of advice on physical activity, physical exercises, and educational content. Tailoring of plans is achieved by using case-based reasoning (CBR) methodology, which is a branch of artificial intelligence. The core of the CBR methodology is to use data about the current case (participant) along with knowledge about previous and similar cases to tailor the self-management plan to the current case. This enables a person-centered intervention based on what has and has not been successful in previous cases. Participants in the RCT are people with LBP who consulted a health care professional in primary care within the preceding 8 weeks. Participants are randomized to using the selfBACK app in addition to usual care versus usual care only. We aim to include a total of 350 participants (175 participants in each arm). Outcomes are collected at baseline, 6 weeks, and 3, 6, and 9 months. The primary end point is difference in pain-related disability between the intervention group and the control group assessed by the Roland-Morris Disability Questionnaire at 3 months. Results The trial opened for recruitment in February 2019. Data collection is expected to be complete by fall 2020, and the results for the primary outcome are expected to be published in fall 2020. Conclusions This RCT will provide insights regarding the benefits of supporting tailored self-management of LBP through an app available at times convenient for the user. If successful, the intervention has the potential to become a model for the provision of tailored self-management support to people with nonspecific LBP and inform future interventions for other painful musculoskeletal conditions. Trial Registration ClinicalTrial.gov NCT03798288; https://clinicaltrials.gov/ct2/show/NCT03798288 International Registered Report Identifier (IRRID) DERR1-10.2196/14720

BackgroundWe investigated the influence of sleeplessness and number of insomnia symptoms on the probability of recovery from chronic low back pain (LBP), and the possible interplay between sleeplessness and co-occurring musculoskeletal pain on this association.MethodsThe study comprised data on 3712 women and 2488 men in the Norwegian HUNT study who reported chronic LBP at baseline in 1995–1997. A modified Poisson regression model was used to calculate adjusted risk ratios (RRs) for the probability of recovery from chronic LBP at follow-up in 2006–2008, associated with sleep problems and co-occurring musculoskeletal pain at baseline.ResultsCompared with persons without sleeplessness, persons who often/always experienced sleeplessness had a lower probability of recovery from chronic LBP (RR 0.65, 95% CI 0.57 to 0.74 in women and RR 0.81, 95% CI 0.69 to 0.95 in men). Although there was no clear evidence of statistical interaction between sleeplessness and co-occurring musculoskeletal pain, women and men who often/always experienced sleeplessness and had ≥5 additional chronic pain sites had RRs of recovery of 0.40 (95% CI 0.33 to 0.48) and 0.59 (95% CI 0.45 to 0.78), respectively, compared with persons without sleeplessness and 1–2 chronic pain sites.ConclusionThese findings suggest that preventing or reducing sleep problems among people with chronic LBP may have the potential of improving the long-term prognosis of this condition, also among those with several additional pain sites.

BACKGROUND Low back pain (LBP) is prevalent across all social classes, in all age groups, and across industrialized and developing countries. From a global perspective, LBP is considered the leading cause of disability and negatively impacts everyday life and well-being. Self-management is a recommended first-line treatment, and mobile apps are a promising platform to support self-management of conditions like LBP. In the selfBACK project, we have developed a digital decision support system made available for the user via an app intended to support tailored self-management of nonspecific LBP. OBJECTIVE The trial aims to evaluate the effectiveness of using the selfBACK app to support self-management in addition to usual care (intervention group) versus usual care only (control group) in people with nonspecific LBP. METHODS This is a single-blinded, randomized controlled trial (RCT) with two parallel arms. The selfBACK app provides tailored self-management plans consisting of advice on physical activity, physical exercises, and educational content. Tailoring of plans is achieved by using case-based reasoning (CBR) methodology, which is a branch of artificial intelligence. The core of the CBR methodology is to use data about the current case (participant) along with knowledge about previous and similar cases to tailor the self-management plan to the current case. This enables a person-centered intervention based on what has and has not been successful in previous cases. Participants in the RCT are people with LBP who consulted a health care professional in primary care within the preceding 8 weeks. Participants are randomized to using the selfBACK app in addition to usual care versus usual care only. We aim to include a total of 350 participants (175 participants in each arm). Outcomes are collected at baseline, 6 weeks, and 3, 6, and 9 months. The primary end point is difference in pain-related disability between the intervention group and the control group assessed by the Roland-Morris Disability Questionnaire at 3 months. RESULTS The trial opened for recruitment in February 2019. Data collection is expected to be complete by fall 2020, and the results for the primary outcome are expected to be published in fall 2020. CONCLUSIONS This RCT will provide insights regarding the benefits of supporting tailored self-management of LBP through an app available at times convenient for the user. If successful, the intervention has the potential to become a model for the provision of tailored self-management support to people with nonspecific LBP and inform future interventions for other painful musculoskeletal conditions. CLINICALTRIAL ClinicalTrial.gov NCT03798288; https://clinicaltrials.gov/ct2/show/NCT03798288 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/14720

Background Various occupational inpatient rehabilitation programs are established in Norway. This study aimed to assess change in cardiorespiratory fitness, pain, anxiety, depression, and quality of life in persons on long-term sick leave due to musculoskeletal-, mental or unspecific disorders after participation in multicomponent inpatient occupational rehabilitation. Methods Twenty-five women and five men (mean age 45.2 years, SD 6.7, range 30–57) volunteered to participate in the study. The participants attended either 8 or 17 full days of occupational multicomponent rehabilitation including physical exercise, cognitive behavioral therapy in the form of acceptance and commitment therapy (ACT), and development of a tailored plan for return to work. Cardiorespiratory fitness was assessed by the Åstrand/Ryhming cycle test at the start and end of rehabilitation program, and at one-year follow-up. Changes in somatic and mental health were measured by questionnaires up to 4 months after start of the program. Results Linear mixed models showed that the maximal oxygen uptake increased by 1.1 mL°kg-1°min− 1 during the rehabilitation program and by 3.7 mL°kg-1°min− 1 at one-year follow-up. There were minor improvements in somatic and mental health, and quality of life. Conclusions This study indicates that occupational inpatient multicomponent rehabilitation including physical exercise and ACT may promote a long-term increase in physical exercise that is sufficient to induce a significant increase in cardiorespiratory fitness. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated

Objectives: This study aimed to investigate the prospective influence of multisite pain, depression, anxiety, self-rated health and pain-related disability on recovery from chronic low back pain (LBP). Setting: The data is derived from the second (1995–1997) and third (2006–2008) wave of the Nord-Trøndelag Health Study (HUNT) in Norway. Participants: The study population comprises 4484 women and 3039 men in the Norwegian HUNT Study who reported chronic LBP at baseline in 1995–1997. Primary outcome measures: The primary outcome was recovery from chronic LBP at the 11-year follow-up. Persons not reporting pain and/or stiffness for at least three consecutive months during the last year were defined as recovered. A Poisson regression model was used to estimate adjusted risk ratios (RRs) with 95% CIs. Results: At follow-up, 1822 (40.6%) women and 1578 (51.9%) men reported recovery from chronic LBP. The probability of recovery was inversely associated with number of pain sites (P-trend