{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,14]],"date-time":"2026-04-14T12:37:08Z","timestamp":1776170228746,"version":"3.50.1"},"reference-count":37,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2019,1,7]],"date-time":"2019-01-07T00:00:00Z","timestamp":1546819200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2019,1,7]],"date-time":"2019-01-07T00:00:00Z","timestamp":1546819200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["npj Digital Med"],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Low back pain (LBP) is the leading cause of disability throughout the world and is economically burdensome. The recommended first line treatment for non-specific LBP is non-invasive care. A digital care program (DCP) delivering evidence-based non-invasive treatment for LBP can aid self-management by engaging patients and scales personalized therapy for patient-specific needs. We assessed the efficacy of a 12-week DCP for LBP in a two-armed, pre-registered, randomized, controlled trial (RCT). Participants were included based on self-reported duration of LBP, but those with surgery or injury to the lower back in the previous three months were excluded. The treatment group (DCP) received the 12-week DCP, consisting of sensor-guided exercise therapy, education, cognitive behavioral therapy, team and individual behavioral coaching, activity tracking, and symptom tracking \u2013 all administered remotely via an app. The control group received three digital education articles only. All participants maintained access to treatment-as-usual. At 12 weeks, an intention-to-treat analysis showed each primary outcome\u2014Oswestry Disability Index (<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001), Korff Pain (<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001) and Korff Disability (<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001)\u2014as well as each secondary outcome improved more for participants in the DCP group compared to control group. For participants who completed the DCP (per protocol), average improvement in pain outcomes ranged 52-64% (Korff: 48.8\u201323.4, VAS: 43.6\u201316.5, VAS impact on daily life: 37.3\u201313.4; <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.01 for all) and average improvement in disability outcomes ranged 31\u201355% (Korff: 33.1\u201315, ODI: 19.7\u201313.5; <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.01 for both). Surgical interest significantly reduced in the DCP group. Participants that completed the DCP had an average engagement, each week, of 90%. Future studies will further explore the effectiveness of the DCP for long-term outcomes beyond 12 weeks and for a LBP patient population with possibly greater baseline pain and disability. In conclusion, the DCP resulted in improved LBP outcomes compared to treatment-as-usual and has potential to scale personalized evidence-based non-invasive treatment for LBP patients.<\/jats:p>","DOI":"10.1038\/s41746-018-0076-7","type":"journal-article","created":{"date-parts":[[2018,12,28]],"date-time":"2018-12-28T14:49:16Z","timestamp":1546008556000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":320,"title":["Randomized controlled trial of a 12-week digital care program in improving low back pain"],"prefix":"10.1038","volume":"2","author":[{"given":"Raad","family":"Shebib","sequence":"first","affiliation":[]},{"given":"Jeannie F","family":"Bailey","sequence":"additional","affiliation":[]},{"given":"Peter","family":"Smittenaar","sequence":"additional","affiliation":[]},{"given":"Daniel A","family":"Perez","sequence":"additional","affiliation":[]},{"given":"Gabriel","family":"Mecklenburg","sequence":"additional","affiliation":[]},{"given":"Simon","family":"Hunter","sequence":"additional","affiliation":[]}],"member":"297","published-online":{"date-parts":[[2019,1,7]]},"reference":[{"key":"76_CR1","doi-asserted-by":"crossref","unstructured":"Vos, T. et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990\u20132016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet 390, 1211\u20131259 (2017).","DOI":"10.1016\/S0140-6736(17)32154-2"},{"key":"76_CR2","doi-asserted-by":"publisher","first-page":"353","DOI":"10.1016\/j.ncl.2007.01.004","volume":"25","author":"DI Rubin","year":"2007","unstructured":"Rubin, D. I. Epidemiology and risk factors for spine pain. Neurol. Clin. 25, 353\u2013371 (2007).","journal-title":"Neurol. Clin."},{"key":"76_CR3","doi-asserted-by":"publisher","first-page":"581","DOI":"10.1016\/S0140-6736(99)01312-4","volume":"354","author":"GB Andersson","year":"1999","unstructured":"Andersson, G. B. Epidemiological features of chronic low-back pain. Lancet 354, 581\u2013585 (1999).","journal-title":"Lancet"},{"key":"76_CR4","first-page":"134","volume":"17","author":"NJ Manek","year":"2005","unstructured":"Manek, N. J. & Macgregor, A. J. Epidemiology of back disorders: prevalence, risk factors, and prognosis. Curr. Opin. Rheumatol. 17, 134\u2013330 (2005).","journal-title":"Curr. Opin. Rheumatol."},{"key":"76_CR5","doi-asserted-by":"publisher","first-page":"761","DOI":"10.1053\/berh.2002.0267","volume":"16","author":"M van Tulder","year":"2002","unstructured":"van Tulder, M., Koes, B. & Bombardier, C. Low back pain. Best. Pract. & Res. Clin. Rheumatol. 16, 761\u2013775 (2002).","journal-title":"Best. Pract. & Res. Clin. Rheumatol."},{"issue":"Suppl 2","key":"76_CR6","first-page":"21","volume":"88","author":"JN Katz","year":"2006","unstructured":"Katz, J. N. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J. Bone Jt. Surg. Am. 88(Suppl 2), 21\u201324 (2006).","journal-title":"J. Bone Jt. Surg. Am."},{"key":"76_CR7","doi-asserted-by":"publisher","first-page":"3055","DOI":"10.1097\/00007632-200012010-00013","volume":"25","author":"TH Hansson","year":"2000","unstructured":"Hansson, T. H. & Hansson, E. K. The effects of common medical interventions on pain, back function, and work resumption in patients with chronic low back pain: a prospective 2-year cohort study in six countries. Spine 25, 3055 (2000).","journal-title":"Spine"},{"key":"76_CR8","doi-asserted-by":"publisher","first-page":"393","DOI":"10.3233\/BMR-150632","volume":"29","author":"L Wang","year":"2016","unstructured":"Wang, L., Guo, Q., Lu, X. & Ni, B. Surgical versus nonsurgical treatment of chronic low back pain: a meta-analysis based on current evidence. J. Back Musculoskelet. Rehabil. 29, 393\u2013401 (2016).","journal-title":"J. Back Musculoskelet. Rehabil."},{"key":"76_CR9","doi-asserted-by":"publisher","first-page":"514","DOI":"10.7326\/M16-2367","volume":"166","author":"A Qaseem","year":"2017","unstructured":"Qaseem, A., Wilt, T. J., McLean, R. M. & Forciea, M. A. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann. Intern. Med. 166, 514\u2013530 (2017).","journal-title":"Ann. Intern. Med."},{"key":"76_CR10","first-page":"1","volume":"386","author":"R Chou","year":"2018","unstructured":"Chou, R. et al. The global spine care initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low and middle-income communities. Eur. Spine J. 386, 1\u201310 (2018).","journal-title":"Eur. Spine J."},{"key":"76_CR11","doi-asserted-by":"publisher","first-page":"520","DOI":"10.1007\/s11606-011-1931-2","volume":"27","author":"J Greene","year":"2012","unstructured":"Greene, J. & Hibbard, J. H. Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J. Gen. Intern. Med. 27, 520\u2013526 (2012).","journal-title":"J. Gen. Intern. Med."},{"key":"76_CR12","doi-asserted-by":"publisher","DOI":"10.1186\/s12891-015-0533-2","volume":"16","author":"P W\u00e4lti","year":"2015","unstructured":"W\u00e4lti, P., Kool, J. & Luomajoki, H. Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial. BMC Musculoskelet. Disord. 16, 83 (2015).","journal-title":"BMC Musculoskelet. Disord."},{"key":"76_CR13","first-page":"85","volume-title":"Ment Health Fam Med","author":"DL Frank","year":"2010","unstructured":"Frank, D. L., Khorshid, L., Kiffer, J. F., Moravec, C. S. & McKee, M. G. Biofeedback in medicine: who, when, why and how? Ment Health Fam Med 7, (85\u201391 (2010)."},{"key":"76_CR14","doi-asserted-by":"publisher","DOI":"10.2196\/jmir.7290","volume":"19","author":"BI Nicholl","year":"2017","unstructured":"Nicholl, B. I. et al. Digital support interventions for the self-management of low back pain: a systematic review. J. Med. Internet Res. 19, e179 (2017).","journal-title":"J. Med. Internet Res."},{"key":"76_CR15","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1097\/AJP.0b013e31822363db","volume":"28","author":"KM Carpenter","year":"2012","unstructured":"Carpenter, K. M., Stoner, S. A., Mundt, J. M. & Stoelb, B. An online self-help CBT intervention for chronic lower back pain. Clin. J. Pain. 28, 14\u201322 (2012).","journal-title":"Clin. J. Pain."},{"key":"76_CR16","doi-asserted-by":"publisher","DOI":"10.2196\/rehab.7258","volume":"4","author":"P Smittenaar","year":"2017","unstructured":"Smittenaar, P. et al. Translating comprehensive conservative care for chronic knee pain into a digital care pathway: 12-week and 6-month outcomes for the Hinge Health Program. JMIR Rehabil. Assist. Technol. 4, e4 (2017).","journal-title":"JMIR Rehabil. Assist. Technol."},{"key":"76_CR17","doi-asserted-by":"publisher","DOI":"10.2196\/jmir.9667","volume":"20","author":"G Mecklenburg","year":"2018","unstructured":"Mecklenburg, G. Effects of a 12-week digital care program for chronic knee pain on pain, mobility, and surgery risk: randomized controlled trial. J. Med. Internet Res. 20, e156 (2018).","journal-title":"J. Med. Internet Res."},{"key":"76_CR18","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3310\/hta14410","volume":"14","author":"SE Lamb","year":"2010","unstructured":"Lamb, S. E., Lall, R. & Technol, Z. H. H. A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial. Health Technol. Assess. 14, 1\u2013253 (2010).","journal-title":"Health Technol. Assess."},{"key":"76_CR19","doi-asserted-by":"publisher","first-page":"1155","DOI":"10.1177\/0269215515570379","volume":"29","author":"A Searle","year":"2015","unstructured":"Searle, A., Spink, M., Ho, A. & Chuter, V. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin. Rehabil. 29, 1155\u20131167 (2015).","journal-title":"Clin. Rehabil."},{"key":"76_CR20","doi-asserted-by":"publisher","DOI":"10.1186\/s12891-016-1371-6","volume":"18","author":"T Haines","year":"2017","unstructured":"Haines, T. & Bowles, K.-A. Cost-effectiveness of using a motion-sensor biofeedback treatment approach for the management of sub-acute or chronic low back pain: economic evaluation alongside a randomised trial. BMC Musculoskelet. Disord. 18, 18 (2017).","journal-title":"BMC Musculoskelet. Disord."},{"key":"76_CR21","doi-asserted-by":"publisher","first-page":"1093","DOI":"10.1093\/aje\/kwx337","volume":"187","author":"R Shiri","year":"2018","unstructured":"Shiri, R. & of, D. C. A. J. Exercise for the prevention of low back pain: systematic review and meta-analysis of controlled trials. Am. J. Epidemiol. 187, 1093\u20131101 (2018).","journal-title":"Am. J. Epidemiol."},{"key":"76_CR22","first-page":"30489","volume":"18","author":"NE Foster","year":"2018","unstructured":"Foster, N. E. et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 18, 30489\u201330486 (2018).","journal-title":"Lancet"},{"key":"76_CR23","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1097\/BRS.0b013e31815e3a10","volume":"33","author":"RWJG Ostelo","year":"2008","unstructured":"Ostelo, R. W. J. G. et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine 33, 90\u201394 (2008).","journal-title":"Spine"},{"key":"76_CR24","doi-asserted-by":"publisher","first-page":"193","DOI":"10.1016\/j.berh.2010.01.002","volume":"24","author":"M van Middelkoop","year":"2010","unstructured":"van Middelkoop, M. et al. Exercise therapy for chronic nonspecific low-back pain. Best. Pract. Res. Clin. Rheumatol. 24, 193\u2013204 (2010).","journal-title":"Best. Pract. Res. Clin. Rheumatol."},{"key":"76_CR25","first-page":"CD000963","volume":"16","author":"SJ Kamper","year":"2014","unstructured":"Kamper, S. J. et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 16, CD000963 (2014).","journal-title":"Cochrane Database Syst Rev"},{"key":"76_CR26","doi-asserted-by":"publisher","first-page":"329","DOI":"10.1001\/jamainternmed.2015.8033","volume":"176","author":"NE Morone","year":"2016","unstructured":"Morone, N. E. et al. A mind-body program for older adults with chronic low back pain: a randomized clinical trial. JAMA Intern Med 176, 329\u2013337 (2016).","journal-title":"JAMA Intern Med"},{"key":"76_CR27","doi-asserted-by":"publisher","first-page":"1094","DOI":"10.1097\/BRS.0b013e3181a105fc","volume":"34","author":"R Chou","year":"2009","unstructured":"Chou, R. et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine 34, 1094\u20131109 (2009).","journal-title":"Spine"},{"key":"76_CR28","doi-asserted-by":"publisher","first-page":"1106","DOI":"10.1007\/s11999-011-2141-2","volume":"470","author":"SS Indrakanti","year":"2011","unstructured":"Indrakanti, S. S. et al. Value-based care in the management of spinal disorders: a systematic review of cost-utility analysis. Clin. Orthop. Relat. Res. 470, 1106\u20131123 (2011).","journal-title":"Clin. Orthop. Relat. Res."},{"key":"76_CR29","doi-asserted-by":"publisher","DOI":"10.2196\/rehab.9032","volume":"4","author":"S Huber","year":"2017","unstructured":"Huber, S. et al. Treatment of low back pain with a digital multidisciplinary pain treatment app: short-term results. JMIR Rehabil. Assist. Technol. 4, e11 (2017).","journal-title":"JMIR Rehabil. Assist. Technol."},{"key":"76_CR30","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1016\/j.msksp.2018.04.008","volume":"36","author":"AK Wahl","year":"2018","unstructured":"Wahl, A. K. et al. Is regular use of physiotherapy treatment associated with health locus of control and self-management competency? A study of patients with musculoskeletal disorders undergoing physiotherapy in primary health care. Musculoskelet. Sci. Pract. 36, 43\u201347 (2018).","journal-title":"Musculoskelet. Sci. Pract."},{"key":"76_CR31","doi-asserted-by":"publisher","first-page":"153","DOI":"10.2340\/16501977-1241","volume":"46","author":"BJ Wright","year":"2014","unstructured":"Wright, B. J., Galtieri, N. J. & Fell, M. Non-adherence to prescribed home rehabilitation exercises for musculoskeletal injuries: the role of the patient\u2013practitioner relationship. J. Rehabil. Med. 46, 153\u2013158 (2014).","journal-title":"J. Rehabil. Med."},{"key":"76_CR32","doi-asserted-by":"publisher","first-page":"1104","DOI":"10.1097\/00007632-199906010-00010","volume":"24","author":"MR Underwood","year":"1999","unstructured":"Underwood, M. R., Barnett, A. G. & Vickers, M. R. Evaluation of two time-specific back pain outcome measures. Spine 24, 1104 (1999).","journal-title":"Spine"},{"key":"76_CR33","doi-asserted-by":"publisher","first-page":"2940","DOI":"10.1097\/00007632-200011150-00017","volume":"25","author":"J Fairbank","year":"2000","unstructured":"Fairbank, J. & Pynsent, P. B. The Oswestry Disability Index. Spine 25, 2940\u20132952 (2000).","journal-title":"Spine"},{"key":"76_CR34","first-page":"1","volume":"67","author":"D Bates","year":"2014","unstructured":"Bates, D., M\u00e4chler, M., Bolker, B. & Walker, S. Fitting linear mixed-effects models using lme4. J. Stat. Softw. 67, 1\u201348 (2014).","journal-title":"J. Stat. Softw."},{"key":"76_CR35","first-page":"S36","volume":"26","author":"G Godin","year":"1997","unstructured":"Godin, G. & Shepard, R. J. Godin Leisure-time Exercise Questionnaire. Med. Sci. Sports Exerc. 26, S36\u2013S38 (1997).","journal-title":"Med. Sci. Sports Exerc."},{"key":"76_CR36","doi-asserted-by":"publisher","first-page":"487","DOI":"10.1037\/0278-6133.19.5.487","volume":"19","author":"R Schwarzer","year":"2000","unstructured":"Schwarzer, R. & psychology, B. R. H. Social-cognitive predictors of health behavior: action self-efficacy and coping self-efficacy. Health Psychol. 19, 487\u2013495 (2000).","journal-title":"Health Psychol."},{"key":"76_CR37","doi-asserted-by":"publisher","first-page":"632","DOI":"10.1002\/art.23563","volume":"59","author":"JC Hill","year":"2008","unstructured":"Hill, J. C. et al. A primary care back pain screening tool: Identifying patient subgroups for initial treatment. Arthritis Rheum. 59, 632\u2013641 (2008).","journal-title":"Arthritis Rheum."}],"container-title":["npj Digital Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41746-018-0076-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41746-018-0076-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41746-018-0076-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,17]],"date-time":"2022-12-17T18:29:14Z","timestamp":1671301754000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41746-018-0076-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,1,7]]},"references-count":37,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2019,12]]}},"alternative-id":["76"],"URL":"https:\/\/doi.org\/10.1038\/s41746-018-0076-7","relation":{},"ISSN":["2398-6352"],"issn-type":[{"value":"2398-6352","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,1,7]]},"assertion":[{"value":"11 June 2018","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"21 November 2018","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"7 January 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"All authors except J.F.B. are employed and\/or hold equity at Hinge Health, Inc. J.F.B. is a paid domain expert consultant with no other competing interests. The remaining authors declare no competing interests.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"1"}}