Effectiveness of App-Delivered, Tailored Self-management Support for Adults With Lower Back Pain-Related Disability: A selfBACK Randomized Clinical Trial

Louise Fleng Sandal, Kerstin Bach, Cecilie K Øverås, Malene Jagd Svendsen, Tina Dalager, Jesper Stejnicher Drongstrup Jensen, Atle Kongsvold, Anne Lovise Nordstoga, Ellen Marie Bardal, Ilya Ashikhmin, Karen Wood, Charlotte Diana Nørregaard Rasmussen, Mette Jensen Stochkendahl, Barbara I Nicholl, Nirmalie Wiratunga, Kay Cooper, Jan Hartvigsen, Per Kjær, Gisela Sjøgaard, Tom I L NilsenFrances S Mair, Karen Søgaard, Paul Jarle Mork

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaperJournal articleResearchpeer-review


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.

Original languageEnglish
JournalJAMA Internal Medicine
Pages (from-to)1288-1296
Number of pages9
Publication statusPublished - 1 Oct 2021


  • Adaptation, Psychological
  • Disability Evaluation
  • Exercise
  • Female
  • Humans
  • Low Back Pain/diagnosis
  • Male
  • Middle Aged
  • Mobile Applications
  • Outcome Assessment, Health Care
  • Pain Management/methods
  • Pain Measurement/methods
  • Primary Health Care/methods
  • Quality of Life
  • Self-Management/methods
  • Surveys and Questionnaires


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