{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T23:15:35Z","timestamp":1764890135656,"version":"3.46.0"},"reference-count":38,"publisher":"BMJ","issue":"10","license":[{"start":{"date-parts":[[2025,10,20]],"date-time":"2025-10-20T00:00:00Z","timestamp":1760918400000},"content-version":"unspecified","delay-in-days":19,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"NIHR","doi-asserted-by":"crossref","award":["16\/111\/78"],"award-info":[{"award-number":["16\/111\/78"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,9,25]]},"published-print":{"date-parts":[[2025,10]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>The SupportBack 2 randomised controlled trial (RCT) compared the clinical and cost-effectiveness of an internet intervention supporting self-management versus usual primary care in reducing low back pain (LBP)-related disability. In this study, we aimed to identify and understand key processes and potential mechanisms underlying the impact of the intervention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>This was a nested qualitative process evaluation of the SupportBack 2 RCT (ISRCTN: 14736486 pre-results).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Primary care in the UK (England).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>46 trial participants experiencing LBP without indicators of serious spinal pathologies (eg, fractures, infection) took part in telephone interviews at either 3 (n=15), 6 (n=14) or 12 months (n=17) post randomisation. Five physiotherapists who provided telephone support for the internet intervention also took part in telephone interviews.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Intervention<\/jats:title>\n                    <jats:p>An internet intervention \u2018SupportBack\u2019 supporting self-management of LBP primarily through physical activity and exercise delivered in addition to usual care, with and without physiotherapist telephone support.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Analysis<\/jats:title>\n                    <jats:p>Data were analysed thematically, applying a realist logic to develop context-mechanism-outcome configurations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Four explanatory themes were developed, with five context-mechanism-outcome configurations. Where benefit was reported, SupportBack appeared to work by facilitating a central associative process where participants linked increases in physical activity or exercise with improvements in LBP, then continued to use physical activity or exercise as key regulatory strategies. Participants who reported little or no benefit from the intervention appeared to experience several barriers to this associative process, including negative expectations, prohibitive beliefs about the cause of LBP or functional limitations preventing engagement. Physiotherapists appeared to provide accountability and validation for some; however, the remote telephone support that lacked physical assessment was viewed as limiting its potential value.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Digital interventions targeting physical activity and exercise to support LBP self-management may rely on mechanisms that are easily inhibited in complex, heterogeneous populations. Future research should focus on identifying and removing barriers that may limit the effectiveness of digital self-management support for LBP.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-103428","type":"journal-article","created":{"date-parts":[[2025,10,21]],"date-time":"2025-10-21T08:00:55Z","timestamp":1761033655000},"page":"e103428","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Understanding internet-supported self-management for low back pain in primary care: a qualitative process evaluation of the SupportBack 2 randomised controlled trial"],"prefix":"10.1136","volume":"15","clinical-trial-number":[{"clinical-trial-number":"isrctn14736486","registry":"10.18810\/isrctn"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7984-8351","authenticated-orcid":false,"given":"Adam W A","family":"Geraghty","sequence":"first","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephanie","family":"Hughes","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2662-6696","authenticated-orcid":false,"given":"Lisa","family":"Roberts","sequence":"additional","affiliation":[{"name":"School of Health Sciences, University of Southampton, Southampton, England, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6246-1409","authenticated-orcid":false,"given":"Jonathan C","family":"Hill","sequence":"additional","affiliation":[{"name":"Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, England, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nadine E","family":"Foster","sequence":"additional","affiliation":[{"name":"Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, England, UK"},{"name":"STARS Education and Research Alliance, The University of Queensland and Metro North Health, Brisbane, Queensland, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elaine","family":"Hay","sequence":"additional","affiliation":[{"name":"Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, England, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5479-2678","authenticated-orcid":false,"given":"Gemma","family":"Mansell","sequence":"additional","affiliation":[{"name":"School of Health & Life Sciences, Aston University, Birmingham, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Malcolm","family":"White","sequence":"additional","affiliation":[{"name":"PPI, University of Southampton, Southampton, England, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Firoza","family":"Davies","sequence":"additional","affiliation":[{"name":"PPI, University of Southampton, Southampton, England, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mary","family":"Steele","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3664-1873","authenticated-orcid":false,"given":"Paul","family":"Little","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lucy","family":"Yardley","sequence":"additional","affiliation":[{"name":"School of Psychology, University of Southampton, Southampton, England, UK"},{"name":"School of Psychological Science, University of Bristol, Bristol, England, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,10,20]]},"reference":[{"key":"2025120415073038000_15.10.e103428.1","doi-asserted-by":"crossref","DOI":"10.21037\/atm.2020.02.175","article-title":"Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017","volume":"8","author":"Wu","year":"2020","journal-title":"Ann Transl Med"},{"key":"2025120415073038000_15.10.e103428.2","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(18)30489-6"},{"key":"2025120415073038000_15.10.e103428.3","unstructured":"National Institute for Health and Care Excellence (NICE) . 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