{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T01:20:31Z","timestamp":1791854431265,"version":"4.3.4"},"reference-count":45,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,2]],"date-time":"2026-01-02T00:00:00Z","timestamp":1767312000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objective: The purpose of this study was to determine whether the effects of pain education combined with physiotherapy could be explained by changes in psychological well-being and self-efficacy in individuals with chronic low back pain (LBP). Methods: This study includes a secondary analysis (mediation analysis) of a randomized controlled trial (RCT) that compares the effect of physiotherapy and pain education with physiotherapy alone. The Roland-Morris Disability Questionnaire, assessed at six weeks, was used as a primary outcome in this study, with pain intensity as a secondary outcome. The World Health Organization Five Well-Being Index (WHO-5) and the General Self-Efficacy Scale were evaluated as potential mediators. Causal mediation analysis based on a counterfactual framework was employed to estimate both direct and indirect effects. Results: The analyses comprised 46 participants (mean age = 42.2 years; 54.3% female) who received pain education along with physiotherapy. In the mediation models, improvements in emotional well-being (assessed by WHO-5) explained approximately one quarter of the effect of the intervention on disability (average causal mediation effect = \u22121.66, 95% CI [\u22122.8, \u22120.72], p &lt; 0.001). By contrast, self-efficacy did not significantly mediate disability, and neither factor accounted for changes in pain intensity. Sensitivity analyses suggested that the indirect effect on psychological well-being was reasonably robust against potential unmeasured confounding factors. Conclusions: Enhancements in psychological well-being were associated with reductions in disability following pain education, whereas self-efficacy did not emerge as a significant mediator. These findings may support the value of incorporating mental well-being strategies within rehabilitation programs for chronic LBP.<\/jats:p>","DOI":"10.3390\/jcm15010348","type":"journal-article","created":{"date-parts":[[2026,1,2]],"date-time":"2026-01-02T11:11:46Z","timestamp":1767352306000},"page":"348","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Causal Mediation Analysis of the Effects of Pain Education on Disability and Pain Intensity in Individuals with Chronic Low Back Pain"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5667-8150","authenticated-orcid":false,"given":"Ahmed","family":"Alalawi","sequence":"first","affiliation":[{"name":"Department of Medical Rehabilitation Sciences, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah 24382, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e316","DOI":"10.1016\/S2665-9913(23)00098-X","article-title":"Global, regional, and national burden of low back pain, 1990\u20132020, its attributable risk factors, and projections to 2050: A systematic analysis of the Global Burden of Disease Study 2021","volume":"5","author":"Ferreira","year":"2023","journal-title":"Lancet Rheumatol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2356","DOI":"10.1016\/S0140-6736(18)30480-X","article-title":"What low back pain is and why we need to pay attention","volume":"391","author":"Hartvigsen","year":"2018","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"514","DOI":"10.7326\/M16-2367","article-title":"Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians","volume":"166","author":"Qaseem","year":"2017","journal-title":"Ann. 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