Non-specific low back pain (NSLBP) causes more global disability than any other condition. NSLBP is a recurrent and chronic condition affecting individuals of all ages, costing billions of pounds in the United Kingdom (UK). Physical activity is recommended in National and International guidelines as a self-management strategy for patients with NSLBP. However, the effectiveness of using physical activity as a self-management strategy for patients with NSLBP is still debated in the literature. The use of behaviour change theories and behaviour change techniques (BCTs) in the development of physical activity interventions in NSLBP research has not been investigated.
This thesis had a distinct aim with five key objectives. The aim of this thesis was to explore “how” physical activity intervention should be designed, developed, and delivered to NSLBP patients. The first objective was to scope the literature of non-prescribed, unsupervised physical activity interventions for NSLBP patients. The second objective was to investigate the content of non-prescribed, unsupervised physical activity interventions for NSLBP patients, and to evaluate the use of behaviour change theories and BCTs in the interventions. The third objective was to test the validity of wearing an accelerometer around the waist, using a belt, to measure physical activity levels in humans. The fourth objective was to systematically design and develop four physical activity interventions using a relevant and valid behaviour change model and to select the BCTs to aid behaviour change, and increase the physical activity levels of a NSLBP population. Finally, the last objective was to perform a randomised mixed methods feasibility-pilot trial in a student-led osteopathy clinic, using the knowledge and resources gained from the previous objectives to deliver four non-prescribed physical activity interventions to NSLBP patients.
Methods: Objective 1 was met by conducting an initial scoping review to assess the breadth and depth of the literature of non-prescribed, unsupervised physical activity interventions for NSLBP patients. To meet objective 2, a systematic review was conducted to analyse the content of non-prescribed, unsupervised physical activity interventions used to increase physical activity levels in NSLBP patients. The results of this study informed the two proceeding accelerometer pilot trials and the randomised feasibility-pilot trial. The two pilot trials were performed to evaluate the validity of mounting an accelerometer around the waist on a belt, compared to the ‘gold standard’ of attaching the accelerometer directly to the skin. This trial aimed to validate the wearing method (belt method) and test the reliability of a set of instructions to be used by the participants in the feasibility-pilot trial (objective 3). Objective 4 was completed by using the Behaviour Change Wheel (BCW), incorporating the relevant BCTs to aid behaviour change and increase the physical activity levels of a NSLBP population, to design four physical activity interventions. A randomised, mixed-methods feasibility-pilot trial was performed to evaluate the acceptability, viability, and credibility of the trial protocol and the four interventions, designed using the BCW, for the NSLBP patients (objective 5). The acceptability, viability, and credibility of the trial protocol for the clinicians at the University College of Osteopathy (UCO) student-led clinic was also evaluated.
Results: The systematic review demonstrated that the use of non-prescribed, unsupervised interventions normally takes the form of “advice to be active”, as the minimal intervention in the control group. All the interventions in the included trials did not appear to be informed by behaviour change theories, used few BCTs and do not use an objective measure for physical activity. The two pilot trials showed no significant differences between the two mounting methods of the accelerometer and demonstrated that the instructions were reliable in guiding participants to wear the belt method in the correct place (spinal level L4-L5). The feasibility-pilot trial indicated that more in-depth planning of the trial is warranted if it is to be used in the UCO student-led clinic due to 1) poor patient participant recruitment, 2) the nature of the clinic and 3) the acceptability of the term “NSLBP” amongst the clinicians, whom all used variations in definitions for NSLBP. The use of the BCT “feedback on behaviour”, in two of the interventions, was identified as the most useful component for the NSLBP patients in encouraging them to increase their activity levels.
Conclusion: The work presented in this thesis has identified three novel and valuable findings which will advance NSLBP and physical activity research. This thesis identified 1) a method to comfortably wear an objective measure to monitor physical activity over several weeks, 2) has demonstrated that future NSLBP research should investigate the use of BCTs in interventions to increase physical activity, particularly the BCT “feedback on behaviour” and 3) the acceptability, confusion and different understandings of the term NSLBP between clinicians. The different understandings of this term hampered the recruitment of NSLBP patients in the feasibility-pilot trial. Qualitative research in this field is sparse but required. Future qualitative studies need to investigate the thoughts and perceptions of practitioners and clinicians about the term NSLBP to create standardised terminology which is acceptable to practitioners and clinicians, and which can be used in future trials.