Implementation of a Best Practice Primary Health Care Model for Low Back Pain in Sweden (BetterBack): A Cluster Randomised Trial
Phase: NA
Conditions: Low Back Pain
Sponsor: Linkoeping University

 
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The effectiveness of implementing a best practice primary health care model for 
low back pain (BetterBack) compared to current routine care in the Swedish 
context: An internal pilot study informed protocol for an effectiveness-
implementation hybrid type 2 trial 
Allan Abbott1,2*, Karin Schröder1, Paul Enthoven1, Per Nilsen3, Birgitta Öberg1  
1Department of Medical and Health Sciences, Division of Physiotherapy, Faculty of Health 
Sciences, Linköping University, SE-58183 Linköping, Sweden. 
2 Faculty of Health Science and Medicine, Bond University, Gold Coast, Queensland, 4229, 
Australia.  
3 Department of Medical and Health Sciences, Division of Community Medicine, Faculty of Health 
Sciences, Linköping University, SE-58183 Linköping, Sweden. 
Allan Abbott* - allan.abbott@liu.se (TEL: 0046 13 282495); Karin Schröder - 
karin.schroder@liu.se; Paul Enthoven - paul.enthoven@liu.se; Per Nilsen - per.nilsen@liu.se; 
Birgitta Öberg - birgitta.öberg@liu.se;  
*Corresponding author 
ABSTRACT 
Introduction: Low back pain (LBP) is a major health problem commonly requiring health care. In 
Sweden, there is a user pull for the development, implementation and evaluation of a best practice 
primary health care model for low back pain best practice model of primary care for LBP.  
Aim: The overall aim is to investigate if and how the BetterBack model of care for LBP 
implemented with a multi-facetted strategy is potentially more effective than current routine care in 
the Swedish primary health care context. The specific trial objectives are to: (A) To improve and 
understand the mechanisms underlying changes in Health Care Practitioner (HCP) confidence, 
attitudes and beliefs for providing primary health care for patients with LBP (B) Improve and 
understand the mechanisms underlying illness beliefs, self-care enablement, pain, disability and 
quality of life in patients with LBP; (C) Evaluate the implementation process and cost-effectiveness 
of the BetterBack model of care for LBP in the Swedish primary health care context. 
Methods: This study is an effectiveness-implementation hybrid type 2 trial. This involves a 
prospective cohort study investigating implementation on the HCP level and a patient blinded, 
pragmatic cluster randomized controlled trial with longitudinal follow up at 3, 6 and 12 months post 
baseline for effectiveness on the patient level. A superiority trial design framework will be used. A 
parallel process and economic analysis will also be performed. Patients will be allocated to routine 
care (control group) or the BetterBack model of care (intervention group) according to the 
schedule of a dog leg design with 2 assessments in routine care. Short and long term HCP and 
patient level quantitative effectiveness outcomes will be compared between experimental conditions 
will be conducted as well as causal mediation analysis. Qualitative HCP and patient level 
experiences of the BetterBack model of care will also be investigated. 
Dissemination: The findings will be published in peer-reviewed journals and presented at national 
and international conferences. Further national dissemination and implementation in Sweden and 
associated national quality register data collection are potential future developments of the project. 
Trial registration: ClinicalTrials.gov: NCT03147300 
Date and version identifier: 30 Sept 2017, protocol version 2. 
Key words: Low back pain, model of care, effectiveness, implementation. 
Word count: 7421 words 

 
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Strengths and limitations of this study 
 This is the first study of effectiveness and implementation of a best practice model 
of care in LBP primary care in Sweden. 
 An international consensus framework has been used for the development, 
implementation and evaluation of the models of care. 
 The main trial’s a priori methodology has been informed and refined by an initial 
internal pilot phase. 
BACKGROUND 
Low back pain (LBP) is one of the most prevalent and burdensome problems for individuals and 
society in Sweden and worldwide [1,2]. LBP is often defined in terms of its localization, duration, 
severity, frequency, and interference on activities of daily living [3]. Most new episodes of LBP are 
self-limiting with only approximately 20% having persistent symptoms but a large majority 
experience pain recurrence [1]. The aetiology of LBP is often classified as specific or non-specific, 
based upon if a pathoanatomical cause can be identified through objective diagnostic assessment 
and confirmed by medical imaging [4]. The prevalence of LBP caused by specific pathology of 
serious nature such as malignancy, spinal fracture, infection, or cauda equine syndrome requiring 
secondary or tertiary health care has been reported to range between < 1%-4% in the primary health 
care setting [5,6]. Furthermore, nerve root problems associated with radiculopathy or spinal stenosis 
are thought to explain approximately 5%-15% of cases [7,8]. Medical imaging studies have 
highlighted that approximately 50% of younger adults and 90% of older adults have degenerative 
findings and large variations in lumbar spine morphology [9]. This is however evident in both 
symptomatic and asymptomatic individuals suggesting that low back pain is more typically a result 
of benign dysfunctional biological and psychological functions as well as social contextual factors 
influencing the pain experience. 
 
In Sweden, the health care process for patients with LBP tends to be fragmented with many health 
care practitioners (HCP) giving conflicting information and providing interventions of varying 
effectiveness [10,11]. Our studies have shown that only a third of patients on sick leave for 
musculoskeletal disorders receive evidence-based rehabilitation interventions in primary care 
[10,11]. Furthermore our research has also demonstrated that there are still interventions that 
physiotherapists in primary care consider to be relevant in clinical practice despite the absence of 
evidence or consensus about the effects [12]. Our preliminary data suggests that when patients with 
LBP are referred to a specialist clinics, up to 48% have not received adequate evidence-based 
rehabilitation in primary care. The development of clinical practice guidelines aims to provide HCP 
with recommendations based on strength of available evidence as well as professional consensus for 
the intervention’s risk and benefits for the patients. Such guidelines are lacking in Sweden but have 
recently been developed by the Danish Health and Medicines Authority and the English National 
Institute for Health and Care Excellence [13-15]. These national guidelines provide a thorough 
assessment of current evidence and can be used in Sweden to form the basis for locally adapted 
recommendations that are feasible to integrate in local health care setting.  
 
Common to LBP, central recommendations from evidence based clinical guidelines for arthritis are 
also education and exercise therapy aimed at improving patient self-care. These principles have 
been packaged in well-known models of care describing how complex patient interventions can be 
delivered by clinicians. These model of care include “Better Management of Patients with 
Osteoarthritis (BOA)” in Sweden [16] and “Good Life with Osteoarthritis” in Denmark (GLA:D) 
[17]. Annual reports from BOA and GLA:D indicate an HCP acceptance through a broad national 
use of the models of care [18,19]. Furthermore, improvements in patient reported pain, physical 
function and decreased use of pain medication after receiving these models of care have been 
reported [18,19]. There is currently a paucity of evidence to determine if and how a similar best 
practice model of care for LBP could improve therapist and patient rated outcomes in the primary 

 
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treatment and secondary prevention of LBP.  
 
Recently an international consensus has been reached proposing a framework for the development, 
implementation and evaluation of musculoskeletal models of care [20]. The theoretical 
underpinning is important in developing a model of care aimed at behavioural change to understand 
and explain the mechanisms of change [20]. Social-cognitve theories are widely used to predict and 
explain behaviour change. For example, the Theory of Planned Behaviour (TPB) [21] can be 
utilised to explain how intentions and volition of behaviour such as HCP use of a model of care can 
potentially be influenced by an intervention aiming to strengthen associations with attitudes, social 
norms and perceived behavioural control concerning the model. Furthermore, the Common Sense 
Model of self-regulation (CSM) [22] can been utilised to explain how behavioural change such as 
improved patient reported pain, physical function, self-care enablement and quality of life can 
potentially be influenced by an intervention aiming to strengthen associations with improved patient 
cognitive and emotional illness representations and comprehensibility through coping procedures 
[22].  
 
It is important to apply knowledge from implementation science to achieve effective 
implementation of a best practice model of care in primary health care [23-26]. Implementation 
science is the scientific study of uptake of research findings and evidence-based practices into 
routine practice to improve the quality and effectiveness of health care and services [27]. 
Implemetation strategies focus on determinants minimising barriers and maximising enablers that 
impact on the implementation and use of evidence-based practices. Recent implementation science 
studies investigating the uptake of national clinical guidelines for LBP in Denmark and the 
Netherlands have found multifaceted strategies to facilitate HCP behaviour change to be more cost-
effective than single-faceted strategies [28,29].  
 
There is therefore a clear rationale for evaluating the extent to which and how a best practice 
primary health care model for low back pain (BetterBack) implemented with a multi-facetted 
strategy is potentially effective in the Swedish context. This article describes the BetterBack trial 
internal pilot and protocol for the main trial. The protocol conforms to the SPIRIT guidelines [30]. 
 
AIMS 
The overall aim is to investigate the effectiveness of the BetterBack model of care for LBP 
implemented with a multi-facetted strategy in a Swedish primary health care context. The specific 
trial objectives are to: (A) To improve and understand the mechanisms underlying changes in HCP 
confidence, attitudes and beliefs for providing primary health care for patients with LBP (B) 
Improve and understand the mechanisms underlying illness beliefs, self-care enablement, pain, 
disability and quality of life in patients with LBP; (C) Evaluate the implementation process and 
cost-effectiveness of the BetterBack model of care for LBP in the Swedish primary health care 
context. 
 
HYPOTHESIS 
1. HCP reported confidence, attitudes and beliefs for providing primary health care for LBP 
will show statistically significant improvement after a multifaceted implementation of the 
BetterBack model of care compared to baseline before implementation. Intentional and 
volitional HCP rated determinants of implementation behaviour regarding the BetterBack 
model of care will mediate improved confidence, attitudes and beliefs in a causal effects 
model.   
2. The multifaceted implementation of the BetterBack model of care will result in more 
statistically significant and greater clinically important improvement compared to current 
routine care for LBP regarding patient-reported measures for illness beliefs, self-care 
enablement, pain, disability and quality of life. Improvements in illness beliefs will mediate 

 
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the effect on these outcomes. 
3. A multifaceted implementation of the BetterBack model of care compared to current 
routine care will result in fewer patients with persisting LBP, fewer requiring specialist care 
and more statistically significant incremental cost-effectiveness ratio (ICER) based on cost 
per EuroQoL-5 Dimension Questionnaire (EQ-5D) quality-adjusted life years (QALY) 
gained. 
 
METHODS 
Study design 
World Health Organization Trial Registration Data Set is presented in table 1. This study is an 
effectiveness-implementation hybrid type 2 trial [31]. This involves a prospective cohort study 
design investigating implementation on the HCP level and a patient blinded, pragmatic cluster 
randomized controlled trial with longitudinal follow up at 3, 6 and 12 months post baseline for 
effectiveness on the patient level. A superiority trial design framework will be used. A parallel 
process and economic analysis will also be performed. This design was chosen because the 
multifaceted implementation of the BetterBack model of care will be first targeted at changing 
HCP level behaviour who will then in turn implement behavioral change strategies on a patient 
level. Randomisation at the patient level is not possible due to potential carry-over effects of the 
HCP transitioning back and forth between providing routine care or the BetterBack model of care 
for different patients. Instead, patients will be allocated to routine care (control group) or the 
BetterBack model of care (intervention group) depending upon the clinics allocation. Patients will 
remain in their allocated group throughout the study. 
 
The main study design is a dog leg with 2 assessments in routine care [32,33]. This involves the 
first cluster being assessed after the implementation of the BetterBack model of care. The second 
cluster is assessed after a period of current routine care (control), and assessed again after the 
implementation of the BetterBack model of care. The third cluster will receive current routine 
care (control) throughout the trial. The initial implementation of the BetterBack model of care in 
cluster 1 allows for an internal pilot to determine the HCP acceptability of the intervention and trial 
within the first cluster [34,35]. A progression criteria for continuing to the main trial requires that 
HCP who have completed the BetterBack education workshop rate on average a maximum of 2.5 
out of 5 on the following determinant of implementation behaviour question: I expect that the 
application of BetterBack model of care will be useful (1 = agree completely - 5 = do not agree at 
all). 
 
The internal pilot also monitors patient recruitment during the first 2 months to provide a check 
point to optimize the main study design while data generated will still contribute to the final 
analyses to maintain trial efficiency [34,35]. Clusters are expected to recruit and gather data for at 
least 20 LBP patients per month in the internal pilot. In the dogleg design it is possible to vary the 
time point of cluster 2 to cross forward from the control to intervention condition if the patient 
recruitment process in either cluster 1 or 3 is more or less than expected in the internal pilot. In the 
event that cluster 1 recruit less than expected and clusters 2 or 3 recruit more than expected, then 
cluster 2 will cross forward to the intervention condition immediately after the internal pilot. If 
cluster 1 recruit more than expected and cluster 2 or 3 recruit less than expected during the internal 
pilot phase, then cluster 2 will cross forward to the intervention condition later in the main trial to 
allow adequate current routine care data collection. Implementation of the BetterBack model of 
care in cluster 3 will occur directly after the end of patient recruitment in cluster 3. The study design 
is outlined in table 2.  
 
Study setting  
The Östergötland public health care region has a total population of 453 596 inhabitants with 
approximately 5000 patients per year accessing primary care physiotherapy due to LBP. In the 

 
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public health care region of Östergötland, a large majority of consultations for LBP are via direct 
access to the 15 primary care physiotherapy rehabilitation clinics. A smaller percentage of 
consultations are via referral to these rehabilitation clinics from the 36 primary health care general 
practices in the region. Therefore the focus of this study is on the physiotherapeutic rehabilitation 
process for LBP in primary care. The rehabilitation clinics form three clusters in Östergötland 
health care region. These clusters are based on municipal geographical area and organisational 
structure of the rehabilitation clinics which helps to minimize contamination between separate 
clusters of clinics (Figure 1). Cluster west is comprised of 5 clinics with 27 physiotherapists, cluster 
central is comprised of 6 clinics with 44 physiotherapists and cluster east is comprised of 6 clinics 
with 41 physiotherapists. 
 
Eligibility criteria 
Registered physiotherapists practicing in the allocated clinics and regularly working with patients 
with LBP will be included in the study. These physiotherapists will assess the eligibility of 
consecutive patients before and after the implementation of the BetterBack model of care based 
on the following criteria: 
 
Inclusion criteria: Males and females 18-65 years; Fluent in Swedish; Accessing public primary 
care due to a current episode of a first-time or recurrent debut of benign low back pain with or 
without radiculopathy. 
 
Exclusion criteria: Current diagnosis of malignancy, spinal fracture, infection, cauda equine 
syndrome, ankylosing spondylitis or systemic rheumatic disease, previous malignancy during the 
past 5 years; Spinal surgery during the last 2 years; Current pregnancy or previous pregnancy up to 
3 months before consideration of inclusion; Patients that fulfil criteria for multimodal/multi-
professional rehabilitation for complex longstanding pain; Severe psychiatric diagnosis. 
 
A signed patient consent form will be collected by the physiotherapist before baseline measures are 
collected and intervention is commenced according to the study protocol. The therapist’s 
intervention will not be effected by the patient’s decision to participate or not participate in the 
study, only data collected will not be performed for those not participating. 
 
Interventions  
Control condition – current routine physiotherapeutic care for LBP in primary health care 
Patients attending rehabilitation clinic clusters that have not have not yet completed the 
implementation of the BetterBack model of care will receive treatment as usual according to 
current routine care clinical pathways (Figure 2). A clinical pathway specified in Östergötland 
public health care region requires that for patients accessing primary care due to LBP, a triage is to 
be performed by licensed HCPs (Physiotherapists, Nurses or General Practitioners (GP)), to triage 
for specific pathology of serious nature. These approximately 1-4% of patients with suspected 
specific pathology of serious nature are then to be examined by GPs and referred for specific 
intervention in secondary or tertiary health care. The majority of patients with LBP who on initial 
triage are assessed as having benign first-time or recurrent debut of LBP are then scheduled for 
physiotherapy consultation and implementation of a LBP management plan. If the patient has 
persistent functional impairment and activity limitation despite 2-3 months of primary care 
intervention, the clinical pathway specifies inclusion criteria for specialist care referral pathways 
(Figure 2). 
 
Intervention condition – The BetterBack model of care for LBP 
Development and design of the BetterBack model of care for LBP 
A framework for the development of musculoskeletal models of care [20] was used to guide 

 
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development of the BetterBack model of care for LBP. The high prevalence and burden of LBP 
[1,2], discordance in evidence based rehabilitation processes [10-12], a lack of physiotherapeutic 
clinical practice guidelines and a user-pull for a best practice model of care requested by 
physiotherapy clinic managers in the Östergötland health care region have been identified in the 
primary care of LBP. Therefore, a case for change has been justified to improve current 
physiotherapeutic health service delivery for the primary care of LBP. The structure and 
components of BetterBack where developed by engaging a work group of physiotherapy 
clinicians (clinical champions) from each primary care cluster in the Östergötland public health care 
region and physiotherapy academics at Linköping University. To identify which key areas of 
contemporary care were of relevance for BetterBack, the following tasks were performed by the 
work group:  
 
1) Discussion and outline of the current routine care clinical pathway for LBP and areas needing 
improvement: The work group concluded that a best practice model of care needed to focus on the 
primary care physiotherapy process outlined by the red square in figure 2. 
 
2) Analysis and discussion of existing international evidence based guidelines: The following 
thorough and up-to-date systematic critical literature reviews and international clinical guidelines 
[13-15, 36] were analysed and discussed by the work group. 
 
 
3) Adaptation of evidence based recommendations to the Swedish context: The development of 
evidence based recommendations was based the Swedish National Board of Health and Welfare 
methods for guideline construction [37]. The overall grade of evidence together with a consensus 
position based on professional experience and patient net benefit versus harms and costs are the key 
aspects on which the work group has formulated local recommendations to reflect their strength 
[38]. The recommendations have been externally reviewed by local spinal physicians and 
international experts from the University of Southern Denmark. A summary of the Östergötland 
health care region physiotherapeutic clinical practice guideline recommendations for primary care 
management of LBP with or without radiculopathy as well as the implementation tools used in the  
BetterBack model of care is provided in the supplementary material to this protocol article. 
 
4) Considering potential barriers to the uptake of evidence based recommendations by health care 
professionals [39] and patient adherence to LBP management interventions [40], the work group 
identified and discussed targeted physiotherapist and patient behaviour change priorities of 
relevance for BetterBack. The Behaviour Change Wheel [41] (figure 3) was used to describe how 
the BetterBack model of care at the guideline policy level applies theory-informed HCP and 
patient focused intervention functions with specific behavioural change techniques [42]. To help 
understand the mechanism of action of behavioural change interventions, the Theoretical Domains 
Framework (TDF) [43] has been integrated into the Behavioural Change Wheel [41]. The TDF is 
comprised of 14 theoretical domains/determinants of behavioural change which can be matched 
with behavioural change techniques to understand their effect on the central source of behaviour 
[44]. The central source of behaviour in the behavioural change wheel is described by the COM-B 
model. In the COM-B model, a person’s capability (physical and psychological), opportunity (social 
and physical) can influence on motivation (automatic and reflective) enacting behaviours that can 
then alter capability, motivation and opportunity [41]. The COM-B provides a broad model of 
behaviour where our causal assumptions of the BetterBack model of care which are adapted from 
the TPB on a HCP level [21] and also adapted from the CSM on a patient level [22] can be applied 
in the Behavioural Change Wheel [41].  
 
The first step in the BetterBack model of care is to target HCP behaviour for the adoption of the 
BetterBack model of care. Impeding barrier behaviours requiring change include low awareness 
of the model, beliefs of negative consequences, a biomedical treatment orientation rather than a 

 
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biopsychosocial orientation and primarily low beliefs about skills/capabilities for improving self-
care patient management. Once HCP behaviour change has occurred, this can influence behaviour 
change on a patient level targeting patient understanding of the mechanisms and natural course of 
benign LBP and patient enablement of self-care. Impeding barrier behaviours requiring change 
include maladaptive beliefs on the cause and persistent course of LBP (low outcome expectation, 
anxiety, catastrophizing, fear-avoidance, and negative illness beliefs), contextual factors, low self-
care enablement and low baseline physical activity. The potential outcomes of behavioural change 
could be improved illness beliefs, self-care enablement, pain, function, quality of life and health 
care utilization. The specific BetterBack intervention content and mechanism of action for HCP 
behavioural change is outlined in table 3. A flow-diagram describing the BetterBack model of 
care patient intervention process is displayed in figure 4.  
 
Multifaceted implementation strategy for the BetterBack model of care 
The multifaceted implementation strategy is composed of the following 3 main facets: 
1) Forming an implementation forum including head of departments/managers of the 
rehabilitation units and the clinical researchers.  
 The implementation forum will collaborate on deciding overarching goals, timeline and 
logistics facilitating the implementation of the BetterBack model of care in primary care 
rehabilitation clinic clusters in the Östergötland public health care region. 
2) Forming a support team comprised of experience clinicians as local supervisors and faculty 
researchers as knowledge facilitators.  
 The support team is composed by trusted clinicians with special skills in LBP treatment 
from each participating unit and have had involvement in the work group for local 
adaptation of the BetterBack model of care in their health care region. 
3) Forming a package of education and training that the support team can utilize to assist the use 
of the BetterBack model of care by HCP.  
 Physiotherapists in the 3 geographical clusters of public primary care rehabilitation clinics in 
Östergötland will be offered to participate in a 13.5 hours (2 days), continued medical 
education (CME) workshop. The workshop is designed by the support team with at least 2 
clinical researcher and 1 experienced clinician (clinical champion) from the rehabilitation 
unit cluster present in the support team’s delivery of the workshop for each cluster. The HCP 
education provided in the workshop format is described in supplementary file 2. 
 Key components of the educational program are: 
 Education about evidence based recommendations for LBP care and the 
BetterBack model of care through an experiential learning process applying 
problem based case studies and clinical reasoning tools. 
 Practical use of the standardized BetterBack education and exercise programs 
aiming at self-care as well as function and activity restoration. 
 Access to a website describing the BetterBack model of care. A chat forum will 
give an opportunity for clinicians to ask questions and share different 
experiences of the new strategy managed by the support team. Researchers will 
respond to questions from the participating clinicians. 
 To consolidate education at the local clinics, the local support team member (clinical 
champion) will provide continued maintenance of education according to the BetterBack 
model. 
 
Outcomes 
HCP outcomes: 
1. Primary outcome measure 

 
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 Practitioner Confidence Scale (PCS) [45] mean change from baseline to 3 months post 
baseline. Practitioner reported confidence is the primary HCP behavioural change goal for 
the HCP education and training workshop in the multifaceted implementation of the 
BetterBack model of care. The 3 month time frame allows for the development and 
consolidation of HCP behavioural change after application in repeated patient cases. 
2. Secondary outcome measures 
 PCS [45] mean immediate change from baseline to directly after the HCP education and 
training workshop as well as mean long term change from baseline to 12 months post 
baseline. This secondary outcome is important for the understanding of longitudinal HCP 
behavioural change. 
 Pain Attitudes and Beliefs Scale for physical therapists (PABS-PT) [46] mean change from 
baseline, to directly after the HCP education and training workshop as well as at 3 and 12 
months post baseline.  
Patient outcomes: 
1. Primary outcome measure 
 Numeric rating scale for lower back related pain intensity during the latest week (NRS-LBP) 
[47]. The mean difference between control and intervention groups in change between 
baseline and 3 months post baseline will be analysed. Pain intensity is the primary 
functional impairment that patients with LBP contact primary health care for and has been 
recommended by international consensus to be included as a core outcome domain for 
clinical trials in non-specific low back pain [48]. International consensus even recommends 
patient reported NRS change over 6 months as a core metric for pain management 
interventions [49]. 
 Oswestry disability index version 2.1(ODI) [50]. The mean difference between control and 
intervention groups in change between baseline and 6 months post baseline will be analysed. 
Disability, analogues to decreased physical functioning and activity limitation has been 
recommended by international consensus to be included as a core outcome domain for 
clinical trials in non-specific low back pain [48]. International consensus even recommends 
patient reported ODI change over 6 months as a core metric for functional restoration [49]. 
2. Secondary outcome measures 
 NRS-LBP [47] and ODI [50] mean difference between control and intervention groups in 
short-term change from baseline to 3 months post baseline and mean long-term change from 
baseline to 12 months post baseline. These secondary outcomes are important for the 
understanding of longitudinal patient-rated changes in pain intensity and disability after 
primary care intervention. 
 The European Quality of Life Questionnaire (EQ-5D) [51]. The mean difference between 
control and intervention groups in change between baseline and 3, 6 and 12 months post 
baseline will be analysed. Health related quality of life has been recommended by 
international consensus to be included as a core outcome domain for clinical trials in non-
specific low back pain [48]. International consensus even recommends patient reported EQ-
5D change over 6 months as a core metric for pain management interventions [49]. 
 The Brief Illness Perception Questionnaire (BIPQ) [52]. The mean difference between 
control and intervention groups in change between baseline and 3, 6 and 12 months post 
baseline will be analysed. Illness perception has been shown to predict longitudinal pain and 
disability outcomes in several LBP studies [53-57]. 
 Patient Enablement Index (PEI) [58], Patient Global Rating of Change (PGIC) [59] and 
Patient Satisfaction (PS) [60] mean difference between control and intervention groups at 3, 
6 and 12 months post baseline will be analysed.   
Health care process outcomes: 
1. Primary outcome measure 
 Proportional difference between control and intervention groups for incidence of 

 
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participating patients receiving specialist care for LBP between baseline and 12 months after 
baseline. Incidence proportion, analogous to cumulative incidence or risk is calculated by 
taking the number of patients receiving specialist care of LBP and dividing it by the total 
number of patients recruited to the study. The main goal of both the control and 
interventions conditions in primary care for benign first-time or recurrent debut of LBP is to 
improve patient reported outcomes without the need of secondary or tertiary health care 
processes. 
2) Secondary outcomes measures 
 Mean difference between control and intervention groups for change between baseline and 
final clinical visit regarding grade of patient functional impairment and activity limitation 
according to the ICF brief core set for LBP [61].  
 The proportion of patients who receive the BetterBack model of care. 
 
Participant timeline 
The trial timeline is shown in table 2. The intervention schedule started with the development of 
evidence based recommendations and the BetterBack model of care which occurred during June 
2016 - February 2017. The enrolment schedule started with cluster enrolment and randomisation in 
March 2017. This resulted in the first allocated cluster 1 (west) entering internal pilot of 
implementing the BetterBack model of care HCP education and training workshop which 
occurred in March 2017. This was followed up with a 2 month internal pilot of patient enrolment 
schedule occurring in all 3 clusters during April-May 2017. In order to finalise a sample size 
calculation for the main trial, baseline data collected during the internal pilot is compared to follow-
up data 3 months after baseline for the primary outcome measure questionnaires to analyse initial 
HCP and patient effects of the implementation of BetterBack model of care in cluster 1 compared 
to the control conditions in clusters 2 & 3. In the transition to the main trial, patient enrolment and 
baseline assessments will then continue to occur until January 2018. The eventual time of crossing 
forward of cluster 2 into the implementation of the BetterBack model of care is determined by the 
internal pilot trial results. Participants in the trial will be follow-up longitudinally at 3, 6 and 12 
months after baseline measures. The schedule for assessments is also outlined in table 2. 
 
Sample size 
An initial sample size estimation in the planning stage of the study assumed at least a small Cohens 
d effect size (d=0.35) for the HCP behavioural change primary and secondary outcomes. This is 
based on previous literature showing small-moderate HCP behavioural change effects sizes using 
similar interventions to increase the uptake of evidence-based management of LBP in primary care 
[62-63]. Considering also a 1-tailed p = 0.05 for the benefit of the multifaceted implementation of 
BetterBack, 80% statistical power and a 20% loss to follow-up, a sample size of n = 63 HCP is 
needed for a matched pairs t-test statistics comparing baseline and follow-up means. We assume a 
possible carry-over of a similar effect size (d=0.35) on patient behavioural change primary and 
secondary outcomes. Considering also a 1-tailed p = 0.05 for the benefit of the multifaceted 
implementation of BetterBack compared to usual care and a 80% statistical power, the number of 
patients required for an individually randomized simple parallel group design would be n = 204. 
Adjusting for the design effect due to clustering randomizing, an intracluster correlation of 0.01 and 
a cluster autocorrelation of 0.80, a dog leg design with 2 assessments in routine care and 100 
patients in each cluster section would require at least n = 402 patients over 2.41 clusters according 
to algorithms described by Hooper & Bourke [32]. In a balanced recruitment schedule, this equates 
to 14 patient per months per cluster for a total of 3 clusters. Allowing for potential unbalanced 
recruitment flow and a potential drop-out in the longitudinal outcomes at 3, 6 and 12 months post 
baseline, each cluster will aim for up to 20 patients per month equating to a potential total study n = 
600.  
 
Recruitment 

 
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In an effort to curb recruitment difficulties, strategies to promote adequate enrolment of participants  
into the study will be used. We anticipate less problems with recruitment into the prospective cohort 
study design investigating the multifaceted implementation of the BetterBack model of care on 
the HCP level. This is due to the study having a user-pull endorsed by clinical department managers 
calling all HCP working with patients with LBP at their clinics to participate. However, recruitment 
of patients into the cluster randomized controlled trial is dependent upon the feasibility of 
recruitment processes adapted to the context of each individual clinic and the compliance of HCP to 
administer recruitment of consecutive patients. A strategy to optimise the administration of patient 
recruitment will involve the author KS regularly visiting participating clinics to inform HCP of the 
study protocol and help streamline practical administration of the protocol in the context of the 
individual clinics. KS will also monitor weekly recruitment rates from the clinics and provide 
motivational feedback on recruitment flow to clinical department managers and designated clinical 
champions who will provide additional motivational feedback to HCP.  In accordance with a 
Consolidated Standards of Reporting Trials, a flow diagram displaying participant enrolment, 
allocation, follow-up and analysis will be constructed [64]. Reasons for exclusion, declined 
participation, protocol violations and loss to follow-up will be monitored by KS.  
 
Allocation and blinding 
Random concealed allocation of clusters was performed by a blinded researcher randomly selecting 
from 3 sequentially numbered, opaque, sealed envelopes. The method resulted in the following 
order: 1=cluster west, 2=cluster central and 3=cluster east. The author KS informed the clinics in 
the different clusters of their allocation to the control or intervention study condition. Due to the 
nature of the study and intervention, HCP conducting patient measurements and treatment cannot be 
blinded to group allocation. Risk of bias is minimal as the primary and secondary outcomes are 
patient self-reported questionnaires. Patients will be blinded to group allocation. The researcher 
responsible for statistical analysis will not be blinded to group allocation. 
 
Data collection 
HCP reported professional behaviour questionnaires: 
 The PCS contains 4 items reported on 5-point Likert scales where a total score of 4 
represents greatest self-confidence and 20 represents lowest self-confidence for managing 
patients with LBP. The structural validity in terms of internal consistency of the items have 
been shown to be good with a Cronbach α coefficient = 0.73 in a single factor model for 
self-confidence [45]. The questionnaire has been forward translated by our research group 
from English to Swedish.  
 The PABS-PT consists of two factors where higher scores represent more treatment 
orientation regarding that factor. One factor with 10 items measures the biomedical 
treatment orientation (Score 0-60) and one with 9 items measures the biopsychosocial 
treatment orientation (Score 0-54) [45]. Each item is rated on a 6-point Likert scale ranging 
from 1=‘totally disagree’ to 6=‘totally agree’. The internal consistency of the biomedical 
factor has been shown to be good with a range between Cronbach α=0.77-0.84. Futhermore, 
the biopsychosocial factor has been shown to be adequate with a range between Cronbach 
α=0.62-0.68 [65]. Construct validity and responsiveness to educational interventions has 
been shown to be positive along with the test-retest reliability with reported intra-class 
correlation coefficient (ICC) on the biomedical factor=0.81 and on the biopsychosocial 
factor=0.65 [65]. The questionnaire has been forward translated from English to Swedish in 
a previously published study [66]. 
 The Determinants of Implementation Behaviour Questionnaire (DIBQ) was originally 
constructed based on the domains of the TDF [43, 67]. Confirmatory factor analysis resulted 
in a modified 93 item questionnaire assessing 18 domains with sufficient discriminant 
validity. Internal consistency of the items for the 18 domains was good, ranging from 0.68-
0.93 for the Cronbach α coefficient [68]. The questionnaire has been forward translated by 

 
 11 
 
 
our research group from English to Swedish. After face validity consensus in our research 
group regarding relevant domains for the implementation of BetterBack model of care, the 
questionnaire was shortened to the following domains: Knowledge, Skills, Beliefs about 
capabilities, Beliefs about consequences, Intentions, Innovation, Organisation, Patient, 
Social influence, Behavioural regulation totalling to 57 items. Questions were adapted to the 
context of HCP reported determinants of an “expected” implementation of BetterBack 
model of care for measurement directly after the HCP education and training workshop. 
HCP reported determinants retained orginal wording for the questionnaires at 3 and 12 
months after the implementation of BetterBack model of care. The response scale used for 
each DIBQ question in our study is a 5-point Liket scale ranging from 1= `totally agree´ to 
5=`totally disagree´. 
Patient reported outcome measures: 
 NRS-LBP intensity during the latest week is an 11-point scale consisting of integers from 0 
through 10; 0 representing ‘‘No pain’’ and 10 representing ‘‘Worst imaginable pain’’. 
Previous research in a LBP cohort has shown a test-retest reliability ICC = 0.61, a common 
standard deviation=1.64 points, the standard error of measure = 1.02 and minimal clinically 
important difference (MCID) in LBP after treatment=2 [69,70].  
 ODI version 2.1 assesses patient’s current LBP related limitation in performing activities 
such as personal care, lifting, walking, sitting, standing, sleeping, sex life, social life and 
travelling. The ODI consists of 10 items with response scales from 0 to 5, where higher 
values represent greater disability. The ODI is analysed as a 0 to100 percentage variable 
where lower scores represent lower levels of low back pain disability. A reduction of 10 
points is considered the MCID in LBP after treatment [50,70]. In Scandinavian conditions, 
the coefficient of variation, ICC and internal consistency of the ODI is 12%, 0.88-0.91 and 
0.94 respectively [71-73]. Good concurrent validity has also been shown [72]. 
 The EQ-5D measures generic health-related quality of life and is computed into a 0 to 1.00 
scale from worst to best possible health state by using the Swedish value sets [74]. A 
reduction of 0.08 points is considered the MCID in LBP after treatment [75]. Mean change 
after treatment for LBP has been reported to be 0.12 (SD±0.30) [76]. 
 The BIPQ analyses cognitive illness representations (consequences, outcome expectancy, 
personal control, treatment control, and knowledge), emotional representations (concern and 
emotions) as well as illness comprehensibility. An overall score 0-80 represents the degree 
to which the LBP is perceived as threatening or benign where a higher score reflects a more 
threatening view of the illness [52]. The BIPQ has been shown to be valid and reliable in a 
Scandinavian sample of patients with subacute and chronic LBP. The BIPQ has a 
Cronbach’s alpha =0.72 and a test-retest ICC = 0.86, an ICC range for individual items from 
0.64 to 0.88, a standard error of measurement (SEM) = 0.63 and minimal detectable change 
(MDC) = 1.75[77]. 
 The PEI has a score range between 0 and 12 with a higher score intended to reflect higher 
patient self-care enablement [58]. 
 PGIC asks the patient to rate the degree of change in LBP related problems from the 
beginning of treatment to the present. This is measured with a balanced 11 point numerical 
scale. A reduction of 2 points is considered the MCID in LBP after treatment [59]. 
 PS is measured with a single item patient reported question. The question asks “Over the 
course of treatment for this episode of low back pain or leg pain, how satisfied were you 
with the care provided by your health-care provider?” Were you very satisfied (1), 
somewhat satisfied (2), neither satisfied nor dissatisfied (3), somewhat dissatisfied (4), or 
very dissatisfied (5)?’’ [60]. 
 
Health care process measures: 

 
 12 
 
 
 At 12 months after baseline, data will also be extracted from the public health care regional 
registry for the total number of patient visits for LBP, the number patients needing primary 
care multimodal pain team treatment, the number referred to specialist pain clinic, 
orthopedic or neurosurgical care and the number receiving surgery.  
 Clinical reasoning and process evaluation tool (CRPE-tool): Grade of patient functional 
impairment and activity limitation according to the ICF brief core set for LBP is assesses by 
the physiotherapist at baseline and final clinical contact where light, moderate, severe and 
very severe impairment/limitation is coded 0-4 respectively. A total score for baseline and 
follow-up measures is calculated from the sum of the functional impairment divided by the 
number of functional impairments and a similar total score is calculated for activity 
limitations [61]. ICD-10 diagnosis codes and KVÅ codes for treatment interventions will 
also be recorded.  
 The Keele STarT Back Screening Tool is reported by patients at baseline providing a 
stratification of prognostic risk of persistent pain. The overall score ranging from 0-9 is used 
to separate the low risk patients from the medium-risk subgroups where patients who 
achieve a score of 0-3 are classified into the low-risk subgroup and those with scores of 4-9 
into the medium-risk subgroup. To identify the high-risk subgroup, the last 5 items must 
scoring 4 or 5. The CRPE-tool data will be analysed in terms of StarTback tool subgroups. 
 Qualitative SWOT analyses will be performed by HCP between 3-6 months after 
implementation.  
 Semi-structured interviews investigating the patient experience of recieving care for LBP 
will be performed on 10 patients. These patients will have received care after 
implementation of the BetterBack model of care. 
 
Data management 
All paper based questionnaire data will remain confidential and will be kept in a lockable filing 
cabinet in the research group office. A password-protected coded database only accessible to the 
research team will be kept on a data storage drive in the research department. The research team 
will regularly monitor the integrity of trial data. Trial conduct will be audited on a weekly basis by 
the research team. 
 
Statistical analysis 
Statistical significance will be assessed with an alpha level of 0.05. All results will be reported as 
estimates of mean ± standard deviation and also effect size (e.g. mean difference) with 95% 
confidence intervals (95% CI). An intention-to-treat (ITT) principle applying multiple imputation 
will be applied. A sensitivity analysis will compare per protocol and ITT databases. A sensitivity 
analysis will also be used to assess the significance of a washout period by comparing the complete 
database against the same database without data collected during the 2 weeks in conjunction with 
the Betterback implementation in each cluster  Matched pairs t-test statistics comparing baseline 
and follow-up means will be used for the HCP reported primary and secondary outcomes. Causal 
mediation analysis will be used to analyse indirect mediational effects of multiple putative 
determinants of implementation behaviour measured with the DIBQ directly after the HCP 
education and training workshop (intention stage) or at 3 or 12 months (volition stages) on the 
effect of baseline PCS or PABS-PT on 3 or 12 months follow-up measurement of PCS or PABS-
PT. If the HCP education and training workshop does not have a casual effect on improved 
prospective outcomes we will analyse where the causal pathway breaks down. Causal mediation 
analysis will be performed using the program PROCESS [81] within IBM SPSS (figure 5). 
 
Patient reported outcome measures for the control and intervention groups will be compared using 
multilevel analyses of repeated measurements and experiment condition as fixed effects and 
participants and clusters as random effects with IBM SPSS. Fixed effect interactions between 
experimental condition and The Keele STarT Back Screening Tool will also be assessed. Patient 

 
 13 
 
 
population specific minimal clinically important difference will be assessed för primary and 
secondary outcomes based on an anchor method where PGIC serves as an anchor. 
 
Applying a 1-1-1 multilevel mediation procedure with all effects random in MPLUS, the products 
of (1) the independent variable (Experimental condition: control or intervention) to the mediator 
(change in BIPQ), and (2) the mediator to the dependent variable (change in NRS, ODI or 
secondary outcome scores pre- to posttreatment) when the independent variable is taken into 
account, will be tested for mediation (figure 6).  
 
The EQ5D will be used to calculate the ratio of costs to quality adjusted life years (QALY) saved 
for patients. Incremental cost-effectiveness and cost-utility ratios for the multifaceted 
implementation strategy and the usual care condition will be calculated. This is based on the 
Swedish guideline priced direct costs of health service utilisation, costs of medications and overall 
intervention clinical outcome effectiveness and social security system utilisation (sickness benefits) 
as well as indirect productivity costs due to absenteeism and return to work. 
 
Data monitoring 
All outcome questionnaires are formatted for use of scan processing software for automated data 
entry into the Statistical Package for the Social Sciences package. The author KS who is not blinded 
to treatment allocation will perform regular data checks during data entry and provide feedback 
when necessary to HPC regarding data omissions. JS will also double check data entry to detect and 
correct input errors, and range checks will be undertaken prior to data analysis.  
 
Ethics and dissemination 
Ethical clearance for the study (Dnr:2017-35/31) has been attained through the Regional Ethics 
Committee in Linköping.  
 
Internal pilot trial results 
The initial implementation of the BetterBack model of care in cluster 1 allowed for an internal 
pilot to determine the HCP acceptability of the intervention and trial within the first cluster [34,35]. 
A progression criteria for continuing to the main trial required that HCP who have completed the 
BetterBack education workshop rate on average a maximum of 2.5 out of 5 on the following 
determinant of implementation behaviour question: The 27 HCP participating in the internal pilot in 
cluster 1 responded to the question I expect that the application of BetterBack model of care will 
be useful (1 = agree completely - 5 = do not agree at all). A mean value of 1.7 (SD 0.8) was 
recorded which subsequently fulfilled the HCP progression criteria. 
 
The resulting internal pilot patient flow for april and may were n=28, n=28 for cluster 1 west, n=5, 
n=12 for cluster 2 central as well as n=14, n=22 for cluster 3 east consecutively. This informed the 
decision to move cluster 2 central transition from control to intervention condition to occur later in 
the schedule, planned for september 2017. The flow of patient recruitment and the process of 3 
month follow-up in the internal pilot was used to inform the optimal time point of patient reported 
primary outcome for the main trial. Our initial planning was to measure patient reported primary 
outcome at 6 months post baseline based on the definition of persistence/chronicity of symptoms 
being often defined in the literature to be of 3 and up to 6 months duration [82]. However our intern 
pilot study with a 3 month follow rate of 80% after up to 3 reminders sent to patients informed of a 
likely risk of non-response at later follow-up time points as patients. Feedback from participating 
HCP even reported a larger clinical interest in 3 month patient follow-up data. Therefore the internal 
pilot informed the choice to revise our patient reported primary outcomes to 3 month post-baseline 
with subsequent amendments of the trial registration on ClinicalTrials.gov: NCT03147300.    
 
Our internal pilot study was also used to assess baseline variation and change over 3 months in HCP 

 
 14 
 
 
evaluation and patient reported primary outcome measures in the control and intervention arms to 
aid calibration of the sample size calculation. A multilevel analyses of repeated measurements and 
experiment condition as fixed effects and participants and clusters as random effects revealed a 
intracluster correlation of <0.01 for the all primary outcomes measures. Small effect sizes in favour 
of the intervention condition was shown for PCS (d=0.33) and NRS (d=0.28) primary outcome 
measures. Therefore, the internal pilot data supported our a priori sample size calculation for the 
main trial regarding PCS and NRS. However no effect size difference were observed between 
experimental conditions for ODI. It is possible that when statistical power improves within the main 
trail, potential differences in ODI may be detectable between experimental conditions.  
 
References 
1. Hoy D, Bain C, Williams G, et al. Systematic review of the global prevalence of low back pain. 
Arthritis Rheum 2012;64:2028-37.  
2. Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global 
Burden of Disease 2010 study. Ann Rheum Dis 2014;73:968-74.  
3. Dionne CE, Dunn KM, Croft PR, et al. A consensus approach toward the standardization of 
back pain definitions for use in prevalence studies. Spine 2008;33:95-103.  
4. Smart KM, O’Connell NE, Doody C. Towards a mechanisms based classification of pain in 
musculoskeletal physiotherapy? Phys Ther Rev 2008;13:1-10.  
5. Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in 
patients presenting with low-back pain. Cochrane Database Syst Rev 2013;1:CD008643.  
6. Henschke N, Maher CG, Ostelo RW, et al. Red flags to screen for malignancy in patients with 
low back pain. Cochrane Database Syst Rev 2013;2:CD008686. 
7. Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence 
estimates. Spine 2008;33:2464-72.  
8. Yabuki S, Fukumori N, Takegami M, et al. Prevalence of lumbar spinal stenosis, using the 
diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci 
2013;18:893-900. 
9. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of 
spinal degeneration in asymptomatic populations. Am J Neuroradiol 2015;36:811-16. 
10. Wahlin C, Ekberg K, Persson J, et al. Association between clinical and work-related 
interventions and return-to-work for patients with musculoskeletal or mental disorders. J 
Rehabil Med 2012;44:355-62. 
11. Nilsing E, Soderberg E, Öberg B. Sickness certificates in Sweden: did the new guidelines 
improve their quality? BMC Public Health 2012;12:907. 
12. Bernhardsson S, Öberg B, Johansson K, et al. Clinical practice in line with evidence? A survey 
among primary care physiotherapists in western Sweden. J Eval Clin Pract. 2015;21:1169-77. 
13. National clinical guidelines for non-surgical treatment of newly occurring lumbar nerve root 
affliction (lumbar radiculopathy), Danish Health Authority; 2016 (In Danish). 
https://sundhedsstyrelsen.dk/da/udgivelser/2016/lumbal-nerverodspaavirkning-ikke-kirurgisk-
behandling. Accessed 03-05-2016. 
14. National clinical guidelines for non-surgical treatment of newly occurring lower back pain. 
Danish Health Authority; 2016 (In Danish). 
https://sundhedsstyrelsen.dk/da/udgivelser/2016/nkr-laenderygsmerter. Accessed 03-05-2016. 
15. National Clinical Guideline Centre (NICE) Low back pain and sciatica: management of non-
specific low back pain and sciatica. Assessment and non-invasive treatments, England; 2016. 
https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0681/documents. Accessed 03-05-
2016.  
16. Thorstensson C, Garellick G, Rystedt H, et al. Better Management of Patients with 
Osteoarthritis: Development and Nationwide Implementation of an Evidence-Based Supported 
Osteoarthritis Self-Management Programme. Musculoskeletal Care. 2015;13:67-75. 

 
 15 
 
 
17. Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA:DTM): evidence-based 
education and supervised neuromuscular exercise delivered by certified physiotherapists 
nationwide. BMC Musculoskelet Disord. 2017:18:72.  
18. Thorstensson C, Dahlberg L, Garellick G. The BOA-register annual report 2014. 
https://boa.registercentrum.se. Accessed 03-05-2016.  
19. Skou ST, Roos EM. GLA:D annual report 2015. www.glaid.dk. Accessed 03-05-2016. 
20. Briggs AM, Jordan JE, Jennings M, et al. A framework to evaluate musculoskeletal models of 
care. Cornwall: Global Alliance for Musculoskeletal Health of the Bone and Joint Decade; 2016. 
21. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211. 
22. Leventhal H, Phillips LA, Burns E. The Common-Sense Model of Self-Regulation (CSM): a 
dynamic framework for understanding illness self-management. J Behav Med. 2016;39:935-46. 
23. Fixsen DL, Naoom SF, Blase KA, et al. Implementation Research: A Synthesis of the Literature. 
Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute. 2005. 
24. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci 
2015;10:53. 
25. Nilsen P. (red) Implementering av evidensbaserad praktik. Malmö: Gleerups, 2014. 
26. Nutley SM, Walter I, Davies HTO. Using Evidence. How Research Can Inform Public Services. 
Bristol: Policy Press. 2007. 
27. Eccles MP, Mittman BS. Welcome to Implementation Science. Implement Sci. 2006;1:1. 
28. Riis A, Elgaard Jensen C, Bro F, et al. A multifaceted implementation strategy versus passive 
implementation of low back pain guidelines in general practice: a cluster randomised controlled 
trial. Implement Sci 2016;11:143. 
29. Engers AJ, Wensing M, van Tulder MW, et al. Implementation of the Dutch low back pain 
guideline for general practitioners: a cluster randomized controlled trial. Spine 2005;30:559–
600.  
30. Chan A-W, Tetzlaff JM, Gøtzsche PC, et al. SPIRIT 2013 Explanation and Elaboration: 
Guidance for protocols of clinical trials. BMJ 2013;346:e7586. 
31. Curran GM, Bauer M, Mittman B, et al. Effectiveness-implementation hybrid designs: 
combining elements of clinical effectiveness and implementation research to enhance public 
health impact. Med Care. 2012;50:217–26. 
32. Hooper R, Bourke L. Cluster randomised trials with repeated cross sections: alternatives to 
parallel group designs. BMJ 2015;350:h2925. 
33. Girling AJ, Hemming K. Statistical efficiency and optimal design for stepped cluster studies 
under linear mixed effects models. Statist Med 2016, 35:2149–66. 
34. Eldridge S, Kerry S. A practical guide to cluster randomised trials in health service research. 
Wiley & Sons, 2nd ed, 2012. 
35. Avery KNL, Williamson PR, Gamble C, et al. Informing efficient randomised controlled trials: 
exploration of challenges in developing progression criteria for internal pilot studies. BMJ Open 
2017:7:e013537. 
36. SBU. Acute neck and back pain: preventive interventions – Effects of physical training, manual 
treatment and cognitive behavioral interventions. Stockholm: Swedish Agency for Health 
Technology Assessment and Assessment of Social Services (SBU); 2016. SBU report no 245 (in 
Swedish). http://www.sbu.se/en/publications/sbu-assesses/acute-neck-and-back-pain-preventive-
interventions--effects-of-physical-training-manual-treatment-and-cognitive-behavioral-
interventions/  
37. The Swedish National Board of Health and Welfare. National guidelines – Methods description. 
https://www.socialstyrelsen.se/SiteCollectionDocuments/metodbeskrivning-nationella-
riktlinjer.pdf . Accessed 03-05-2016. 
38. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 
2004;328:1490.  

 
 16 
 
 
39. Slade SC, Kent P, Patel S, et al. Barriers to Primary Care Clinician Adherence to Clinical 
Guidelines for the Management of Low Back Pain: A Systematic Review and Metasynthesis of 
Qualitative Studies. BMC Med Res Methodol 2017;17:38. 
40. Jack K, McLean SM, Klaber Moffett J, et al. Barriers to treatment adherence in physiotherapy 
outpatient clinics: A systematic review. Man Ther. 2010;15:220–228.  
41. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for 
characterizing and designing behaviour change interventions. Implement Sci 2011;6:42. 
42. Michie S, Wood CE, Johnston M, et al. Behaviour change techniques: the development and 
evaluation of a taxonomic method for reporting and describing behaviour change interventions 
(a suite of five studies involving consensus methods, randomised controlled trials and analysis 
of qualitative data). Health Technol Assess 2015;19:99. 
43. Cane JE, O'Connor D, Michie S. Validation of the theoretical domains framework for use in 
behaviour change and implementation research. Implement Sci 2012;7:37. 
44. Michie S, Johnston M, Francis J, et al. From theory to intervention: mapping theoretically 
derived behavioural determinants to behaviour change techniques. Appl Psychol 2008;57:660–
680. 
45. Smucker DR, Konrad TR, Curtis P, et al. Practitioner self-confidence and patient outcomes in 
acute low back pain. Arch Fam Med 1998;7:223–8. 
46. Ostelo RW, Stomp-van den Berg SG, Vlaeyen JW, et al. Health care provider’s attitudes and 
beliefs towards chronic low back pain: the development of a questionnaire. Man Ther. 2003, 
8:214–22. 
47. Jensen MP, Turner JA, Romano JM, et al. Comparative reliability and validity of chronic pain 
intensity measures. Pain 1999,83:157-62. 
48. Chiarotto A, Deyo RA, Terwee CB, et al. Core outcome domains for clinical trials in non-
specific low back pain. Eur Spine J 201;24:1127–42. 
49. Clement RC, Welander A, Stowell C, et al. A proposed set of metrics for standardized outcome 
reporting in the management of low back pain. Acta Orthop 2015;86:523–33. 
50. Fairbank JC, Pynsent PB. The Oswestry disability index. Spine. 2000;25:2940–53. 
51. EuroQol Group. EuroQol—a new facility for the measurement of health related quality of life. 
Health Policy 1990;16:199–208. 
52. Broadbent E, Petrie KJ, Main J, et al. The Brief Illness Perception Questionnaire. J Psychosom 
Res 2006, 60:631– 37. 
53. Foster NE, Bishop A, Thomas E, et al. Illness perceptions of low back pain patients in primary 
care: what are they, do they change and are they associated with outcome? Pain. 2008,60:177–
87.  
54. Foster NE, Thomas E, Bishop A, et al. Distinctiveness of psychological obstacles to recovery in 
low back pain patients in primary care. Pain. 2010;148:398–406. 
55. Glattacker M, Heyduck K, Meffert C. Illness beliefs and treatment beliefs as predictors of short-
term and medium-term outcome in chronic back pain. J Rehabil Med. 2013;45:268–276. 
56. Campbell P, Foster NE, Thomas E, et al. Prognostic indicators of low back pain in primary care: 
five-year prospective study. J Pain. 2013;14:873–83.  
57. Løchting I, Garratt AM, Storheim K, et al. The impact of psychological factors on condition-
specific, generic and individualized patient reported outcomes in low back pain. Health Qual 
Life Outcomes. 2017,15:40. 
58. Rööst M, Zielinski A, Petersson C, et al. Reliability and applicability of the Patient Enablement 
Instrument (PEI) in a Swedish general practice setting. BMC Family Practice 2015;16:31. 
59. Kamper SJ, PT, Maher CG, Mackay G. Global Rating of Change Scales: A Review of Strengths 
and Weaknesses and Considerations for Design. J Man Manip Ther 2009;17:163–70. 
60. Butler RJ, Johnson WG. Satisfaction with low back pain care. Spine J 2008;8:510–21. 
61. Cieza A, Stucki G, Weigl M, et al. ICF core sets for low back pain. J Rehabil Med 2004;44:69–
74. 

 
 17 
 
 
62. Slater H, Davies SJ, Parsons R, et al. A Policy-into-Practice Intervention to Increase the Uptake 
of Evidence-Based Management of Low Back Pain in Primary Care: A Prospective Cohort 
Study. PLoS One. 2012;7:e38037. 
63. Tzortziou Brown V, Underwood M, Mohamed N, et al. Professional interventions for general 
practitioners on the management of musculoskeletal conditions. Cochrane Database Syst Rev 
2016;6:CD007495. 
64. Campbell MK, Piaggio G, Elbourne DR, et al. Consort 2010 statement: extension to cluster 
randomised trials. BMJ 2012;345:e5661. 
65. Mutsaers JHAM, Peters R, Pool-Goudzwaard AL, et al. Psychometric properties of the Pain 
Attitudes and Beliefs Scale for Physiotherapists: A systematic review. Man Ther 2012;17:213-
18. 
66. Overmeer T, Boersma K, Main CJ, et al. Do physical therapists change their beliefs, attitudes, 
knowledge, skills and behaviour after a biopsychosocially orientated university course? J Eval 
Clin Pract 2009;15:724-732. 
67. Huijg JM, Gebhardt WA, Crone MR, et al. Discriminant content validity of a Theoretical 
Domains Framework questionnaire for use in implementation research. Implement Sci 
2014;9:11. 
68. Huijg JM, Gebhardt WA, Dusseldorp E, et al. Measuring determinants of implementation 
behavior: psychometric properties of a questionnaire based on the theoretical domains 
framework. Implement Sci 2014;9:33. 
69. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in patients with 
low back pain. Spine 2005;30:1331–4. 
70. Ostelo RW, Deyo RA, Stratford P, et al. Interpreting change scores for pain and functional status 
in low back pain: towards international consensus regarding minimal important change. Spine 
2008;33:90-4. 
71. Grotle M, Brox JI, Vøllestad NK. Cross-cultural adaptation of the Norwegian versions of the 
Roland-Morris Disability Questionnaire and the Oswestry Disability Index. J Rehabil Med 
2003;35:241-7. 
72. Lauridsen HH, Hartvigsen J, Manniche C, et al. Danish version of the Oswestry Disability Index 
for patients with low back pain. Part 1: Cross-cultural adaptation, reliability and validity in two 
different populations. Eur Spine J 2006;15:1705-16. 
73. Lauridsen HH, Hartvigsen J, Manniche C, et al. Danish version of the Oswestry disability index 
for patients with low back pain. Part 2: Sensitivity, specificity and clinically significant 
improvement in two low back pain populations. Eur Spine J 2006;15:1717-28.  
74. Burström K, Sun S, Gerdtham UG, et al. Swedish experience-based value sets for EQ-5D health 
states. Qual Life Res 2014;23:431-42.  
75. Walters SJ, Brazier JE. Comparison of the minimally important difference for two health state 
utility measures: EQ-5D and SF-6D. Qual Life Res 2005;14:1523–32. 
76. Soer R, Reneman MF, Speijer BL, et al. Clinimetric properties of the EuroQol-5D in patients 
with chronic low back pain. Spine J 2012;12:1035-39. 
77. Loechting I, Garratt AM, Storheim K, et al. Evaluation of the brief illness perception 
questionnaire in sub-acute and chronic low back pain patients: data quality, reliability and 
validity. J Pain Relief 2013;2:122. 
78. Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient 
subgroups for initial treatment. Arthritis Rheum 2008;59: 632–41. 
79. Hill JC, Vohora K, Dunn KM, et al. Comparing the STarT Back Screening Tool’s subgroup 
allocation of individual patients with that of independent clinical experts. Clin J Pain 2010;26: 
783–87. 
80. Hill JC, Dunn KM, Main CJ, et al. Subgrouping low back pain: a comparison of the STarT Back 
Tool with the Orebro Musculoskeletal Pain Screening Questionnaire. Eur J Pain 2010;14:83–9.  

 
 18 
 
 
81. Hayes AF. PROCESS: A versatile computational tool for observed variable mediation, 
moderation, and conditional process modeling [White paper]. 2012. Retrieved from 
http://www.afhayes.com/public/process2012.pdf 
82. Merskey H, Bogduk N. Classification of chronic pain. 2nd ed. Seattle: IASP Press, 1994. p. 1. 
 
Authors’ contributions: AA & BÖ formulated the trials orginal aims and hypothesis. AA, KS, BÖ 
developed interventions material. AA, KS, PE, PN, ÖB designed the study methodology. AA, KS, 
PE, PN, ÖB have reviewed and finalised the protocol 
Funding statement: This work was supported by the Research Council in Southeast Sweden, grant 
number [FORSS-660371] 
Competing interests statement: None 
 
 
 
 
 

 
 19 
 
 
Table 1. World health organisation trial registration data set. 
Data category 
Information 
Primary registry and trial identifying 
number 
ClinicalTrials.gov 
NCT03147300 
Date of registration in primary registry 
03 May, 2017 
Prospective Registration: 
Yes 
Secondary identifying numbers 
N/A 
Source(s) of monetary or material support 
Linköping University 
Primary sponsor 
Linköping University 
Secondary sponsor(s) 
N/A 
Contact for public queries 
Allan Abbott, MPhysio, PhD [+46 (0)13 282495] [allan.abbott@liu.se] 
Contact for scientific queries 
Allan Abbott, MPhysio, PhD 
Linköping University, Linköping, Sweden 
Public title 
Implementation of a Best Practice Primary Health Care Model for Low Back Pain BetterBack 
Scientific title 
Implementation of a Best Practice Primary Health Care Model for Low Back Pain in Sweden (BetterBack): A Cluster Randomised Trial 
Countries of recruitment 
Sweden 
Health condition(s) or problem(s) studied 
Low back pain 
Intervention(s) 
Behavioral: Current routine practice  
Behavioral: Multifaceted implementation of the BetterBack 
Key inclusion and exclusion criteria 
Health care practitioner sample  
Inclusion Criteria:  
- Registered physiotherapists practicing in the allocated clinics and regularly working with patients with LBP  
Patient sample  
Inclusion Criteria:  
- Males and females 18-65 years; Fluent in Swedish; Accessing public primary care due to a current episode of a first-time or recurrent debut of benign low back pain with or 
without radiculopathy  
Exclusion Criteria:  
- Current diagnosis of malignancy, spinal fracture, infection, cauda equine syndrome, ankylosing spondylitis or systemic rheumatic disease, previous malignancy during the past 5 
years; Current pregnancy or previous pregnancy up to 3 months before consideration of inclusion; Patients that fulfill criteria for multimodal/multi-professional rehabilitation for 
complex longstanding pain; Severe psychiatric diagnosis 
Study type 
Interventional 
Date of first enrolment 
April 1, 2017 
Target sample size 
600 
Recruitment status 
Recruiting 
Primary outcome(s) 
- Incidence of participating patients receiving specialist care [Time Frame: 12 months after baseline]  
- Numeric rating scale (NRS) for lower back related pain intensity during the latest week [Time Frame: Change between baseline and 3 months post baseline]  
- Oswestry disability index (ODI) version 2.1 [Time Frame: Change between baseline and 3 months post baseline]  
- Practitioner Confidence Scale (PCS) [Time Frame: Change between baseline and 3 months post baseline] 
Key secondary outcomes 
- Clinician rated health care process measures [Time Frame: Baseline and final clinical contact (Up to 3 months where the time point is variable depending upon the amount of 
clinical contact required for each patient)]  
- Numeric rating scale (NRS) for lower back related pain intensity during the latest week [Time Frame: Baseline, 3, 6 and 12 months]  
- Oswestry disability index (ODI) version 2.1 [Time Frame: Baseline, 3, 6 and 12 months]  
- Pain Attitudes and Beliefs Scale for physical therapists (PABS-PT) [Time Frame: Baseline, directly after education and at 3 and 12 months afterwards]  
- Patient Enablement Index (PEI) [Time Frame: 3, 6 and 12 months]  
- Patient global rating of change (PGIC) [Time Frame: 3, 6 and 12 months]  
- Patient satisfaction [Time Frame: 3, 6 and 12 months]  
- Practitioner Confidence Scale (PCS) [Time Frame: Baseline, directly after commencement of implementation strategy and at 3 and 12 months afterwards]  
- The Brief Illness Perception Questionnaire (BIPQ) [Time Frame: Baseline, 3, 6 and 12 months]  
- The European Quality of Life Questionnaire (EQ-5D) [Time Frame: Baseline, 3, 6 and 12 months] 

 
 20 
 
 
Table 2. Study design and schedule of enrolment, interventions and assessments 
Timeline 
June 2016  
- Feb 2017 
Mar 2017 
Apr 2017 May 2017 Jun 2017 Jul 2017 
Aug 2017 
Sep 2017 Oct 2017 Nov 2017 Dec 2017 
Jan 2018 
Final clinic 
visit 
Follow-up 
3 months 
after  
baseline 
Follow-up 
6 months 
after 
baseline 
Follow-up 
12 months 
after 
baseline 
Enrolment schedule 
 
HCP Cluster 
random 
allocation 
Patient recruitment 
during internal pilot 
phase  
Patient recruitment during main trial phase  
 
 
 
 
Intervention schedule 
MOC and 
protocol 
development 
Cluster 1 
West 
 
 
1 
 
 
 
 
1 
1 
1 
1 
1 
1 
1 
1 
1 
 
 
 
 
Cluster 2 
 Central 
0 
0 
0 
0 
0  
1 
1 
1 
1 
1 
 
 
 
 
Cluster 3 
East 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
 
 
 
 
Assessment schedule 
 
 
Baseline data  
 Internal pilot (T=0) 
Baseline data 
Main trial (T=0) 
Longitudinal repeated measures in cohorts 
(T=1)         ( T=2)          ( T=3)          (T=4) 
HCP implementation 
PCS 
 
 
Cluster 1 
before and after 
MOC 
implementation 
 
 
 
 
Cluster 2  
before and after 
MOC 
implementation 
 
 
 
 
Cluster 3  
before and after 
MOC 
implementation 
 
x 
 
x 
PABS-PT 
 
Cluster 1  
before MOC 
implementation 
 
 
 
 
Cluster 2  
before MOC 
implementation 
 
 
 
 
Cluster 3  
before MOC 
implementation 
 
x 
 
x 
DIBQ 
 
Cluster 1  
after MOC 
implementation 
 
 
 
 
Cluster 2  
after MOC 
implementation 
 
 
 
 
Cluster 3  
after MOC 
implementation 
 
x 
 
x 
PROMS 
NRS back pain and 
leg pain 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
x 
x 
ODI 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
x 
x 
EQ5D 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
x 
x 
BIPQ 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
x 
x 
PEI 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
Patient satisfaction 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
PGIC 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
Process 
HCP assessment, 
diagnosis and 
treatment of 
patients 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
 
Referrals to 
specialist care 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
MOC=model of care, 0=Control condition, 1=Intervention condition, PROMS=Patient reported outcome measures, grey shaded cells=internal pilot, T= assessment time.            Period where 2 week cross-over from control to 
intervention can occur dependent upon patient recruitment rates identified in the internal pilot study.
MOC 
implementation 
internal pilot 
MOC 
implementation 
MOC 
implementation 

 
 21 
 
 
Table 3. Characterizing the BetterBack model of care intervention content and mechanisms of action using the behaviour change wheel [41], 
Behavioural change technique (BCT) taxonomy (v1) [42], and the TDF [43]. 
Target 
behavior 
Rationale based on 
barriers to be addressed 
BetterBack Intervention content to overcome the modifiable barriers 
Mechanism of action 
Mode 
Content 
BCT[42] 
Functions 
COM-B 
TDF 
Improved HCP 
confidence and 
biopsychosocial 
orientation in 
treating LBP 
through 
adoption of 
BetterBack 
model of care 
 
1) Low beliefs about 
skills/capabilities for 
improving self-care patient 
management 
2) Use of a biomedical 
treatment orientation rather 
than a biopychosocial 
orientation 
3) Low awareness of the 
model 
4) Beliefs of negative 
consequences of the model 
1) Workshop 
 
Evidence based model of care and 
clinical implementation tools (See 
supplementary files 1 & 2) 
 
1.2 Problem-solving 
Enablement 
Psychological capability Behavioral regulation 
1.4 Action planning 
Enablement 
Psychological capability Goals 
2.2 Feedback on behaviour 
Training 
Reflective motivation 
Behavioral regulation 
3.1 Social support 
Enablement 
Social opportunity 
Social Influences 
4.1 Instruction on how to perform 
behaviour 
Education 
Psychological capability Knowledge  
 
5.3 Information about social and 
environmental consequences 
Persuasion  
Social opportunity 
Physical opportunity 
Social Influences Environmental 
context and resources 
6.1 Demonstration of behaviour 
Modelling 
Psychological capability Social Influences 
6.2 Social comparison 
Persuasion 
Social opportunity 
Social Influences 
6.3 Information about other’s 
approval 
Persuasion 
Social opportunity 
Social Influences 
8.1 Behavioural practice/rehearsal  Training 
Physical capability 
Physical skills 
8.7 Graded task  
Training 
Physical capability 
Physical skills 
9.1 Credible source 
Persuasion 
Reflective motivation 
Reinforcement 
9.2 Pros and cons 
Persuasion 
Reflective motivation 
Beliefs about Consequences 
9.3 Comparative imagining of 
future outcomes 
Enablement 
Reflective motivation 
Beliefs about Consequences 
13.2 Framing/reframing 
Enablement 
Psychological capability Cognitive and interpersonal skills 
15.1 Verbal persuasion about 
capability 
Enablement 
Psychological capability 
Physical capability 
Beliefs about capabilities 
2) Report and 
website 
dissemination 
Evidence based model of care and 
clinical implementation tools (See 
supplementary file 2) 
4.1 Instruction on how to perform 
behaviour 
Education 
Psychological capability Knowledge  
 
6.3 Information about other’s 
approval 
Persuasion 
Social opportunity 
Social Influences 
Decreased 
patient LBP and 
disability as 
well as 
improved 
patient 
enablement of 
self-care 
1) Maladaptive beliefs on 
the cause and course of LBP 
(Illness perception) = low 
outcome expectation, 
anxiety, catastrophizing, 
fear-avoidance, illness 
beliefs.  
 
2) Low belief in ability to 
control pain. Low belief in 
ability to perform activities, 
low baseline physical 
activity. 
1) BetterBack 
Part 1. 
Individualised 
information at 
initial and 
follow-up visits. 
Lay language pedagogical 
explanation of function 
impairment and activity limitation 
related assessement findings and 
matched goal directed treatment 
designed for these.  
5.1 Information about health 
consequences  
Education 
Psychological capability Knowledge  
 
9.1 Credible source 
Persuasion 
Reflective motivation 
Reinforcement 
2) BetterBack 
Part 1. Patient 
education 
brochure  
Lay language education on the 
spine’s structure and function, 
natural course of benign LBP and 
advice on self-care 
4.1 Instruction on how to perform 
behaviour 
Education 
Psychological capability Knowledge  
 
5.1 Information about health 
consequences  
Education 
Psychological capability Knowledge  
 
3) BetterBack 
Part 2. Group 
education 
Pain physiology, biomechanics, 
psychological coping strategies 
and behavioural regulation 
1.2 Problem-solving 
Enablement 
Psychological capability Behavioral regulation 
3.1 Social support 
Enablement 
Social opportunity 
Social Influences 
4.1 Instruction on how to perform Education 
Psychological capability Knowledge  

 
 22 
 
 
behaviour 
 
4.3 Re-attribution 
Education 
Psychological capability Knowledge  
5.1 Information about health 
consequences  
Education 
Psychological capability Knowledge  
 
6.1 Demonstration of behaviour 
Modelling 
Psychological capability Social Influences 
6.2 Social comparison 
Persuasion 
Social opportunity 
Social Influences 
8.1 Behavioural practice/rehearsal  Training 
Physical capability 
Physical skills 
8.2 Behaviour substitution 
Enablement 
Psychological capability Behavioral regulation 
9.1 Credible source 
Persuasion 
Reflective motivation 
Reinforcement 
9.3 Comparative imagining of 
future outcomes 
Enablement 
Reflective motivation 
Beliefs about Consequences 
10.8 Incentive (CME diploma) 
Enablement 
 
Reinforcement 
11.2 Reduce negative emotions 
Enablement 
Reflective motivation 
Emotion 
12.4 Distraction 
Enablement 
 
Memory, attention and decision 
processes 
12.6 Body changes 
Training 
 
Physical skills 
13.2 Framing/reframing 
Enablement 
Psychological capability Cognitive and interpersonal skills 
4) BetterBack 
Part 1. 
Individualised 
physiotherapy 
Physiotherapist mediated pain 
modulation strategies and 
functional restoration strategies. 
Treatment matched to patient 
specific functional impairment 
and activity limitations. 
Individualised dosing.  
 
1.1 Goal-setting 
Enablement 
 
Goals 
1.5 Review behaviour goal(s) 
Enablement 
 
Goals 
2.2 Feedback on behaviour 
Training 
Reflective motivation 
Behavioral regulation 
6.1 Demonstration of behaviour 
Modelling 
Psychological capability Social Influences 
7.1 Prompts/cues 
Environmental 
restructuring 
 
Environmental Context and 
Resources 
8.1 Behavioural practice/rehearsal  Training 
Physical capability 
Physical skills 
8.7 Graded task  
Training 
Physical capability 
Physical skills 
9.1 Credible source 
Persuasion 
Reflective motivation 
Reinforcement 
12.6 Body changes 
Training 
 
Physical skills 
15.1 Verbal persuasion about 
capability 
Enablement 
Psychological capability 
Physical capability 
Beliefs about capabilities 
5) BetterBack 
Part 2. Group or 
home based 
physiotherapy 
 
Patient mediated self-care pain 
modulation strategies, functional 
restoration strategies and general 
exercise. Treatment matched to 
patient specific functional 
impairment and activity 
limitations. Individualised dosing. 
 
1.1 Goal-setting 
Enablement 
 
Goals 
1.5 Review behaviour goal(s) 
Enablement 
 
Goals 
1.8 Behavioural contract 
Incentivisation  
Intentions 
2.3 Self-monitoring of 
Behaviour (Training diary) 
Training 
 
Behavioral regulation 
2.2 Feedback on behaviour 
Training 
Reflective motivation 
Behavioral regulation 
3.1 Social support 
Enablement 
Social opportunity 
Social Influences 
6.1 Demonstration of behaviour 
Modelling 
Psychological capability Social Influences 
6.2 Social comparison 
Persuasion 
Social opportunity 
Social Influences 
8.1 Behavioural practice/rehearsal  Training 
Physical capability 
Physical skills 
8.7 Graded task  
Training 
Physical capability 
Physical skills 
9.1 Credible source 
Persuasion 
Reflective motivation 
Reinforcement 
12.6 Body changes 
Training 
 
Physical skills 
15.1 Verbal persuasion about 
capability 
Enablement 
Psychological capability 
Physical capability 
Beliefs about capabilities 

 
 23 
 
 
Figure 1. Municipal resident population and number of physiotherapy rehabilitation clinics and therapists in the west, central and east organisational 
clusters in Östergötland health care region 
 

 
 24 
 
 
Figure 2. Current routine care clinical pathway for LBP in Östergötland health care region. The primary care physiotherapy process outlined by the red 
square is the focus area for the implementation of the BetterBack model of care for LBP 
 
 

 
 25 
 
 
 
 
Figure 3. The Behavioral Change Wheel 

 
 26 
 
 
Figure 4. BetterBack model of care for LBP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Individual based 
treatment conducted by 
therapist 
 
 
 
 
 
 
 
 
 
 
 
 
Group based care 
 
 
 
 
 
 
Follow-up with first contact therapist for assessment of treatment outcomes 
Biomechanics
Behaviour
Psychology: 
emotion and 
throughts
Neuro
physiology
Group education 
on back pain
1. Subjective and objective assessment + STarTBack Tool 
2. Assessment findings  
 
Functional impairments, activity limitations. 
 
Yellow flags and risk of continuing pain based on STarT Back Tool 
 
ICD-10 diagnosis  
4. BetterBack part 2 
 
Graded training of posture and motor 
control in combination with 
functional movement including 
spinal movement 
 
Range of movement exercises if 
indicated 
 
Option of group training (6w 2/w) 
during 12w intervention 
 
Group training supervised by 
another therapist
3. Treatment matched to functional impairments, activity limitations 
BetterBack part 1 
 
 
Individualised information 
 
Neuromusculoskeletal mobilisation 
techniques if indicated 
 
Individualised training to improve functional 
impairments and activity limitations 
 
Patient education (brochure) 

 
 27 
 
 
Figure 5. Causal mediation model to analyse indirect mediational effects (akbk) of multiple 
putative determinants of implementation behaviour measured with the DIBQ directly after the 
HCP education/training workshop (intention stage) or at 3 or 12 months (volition stages) for 
the effect of baseline PCS or PABS-PT on 3 or 12 months follow-up measurement of PCS or 
PABS-PT (c´). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
b1 
Independent 
variable: 
Baseline PCS or 
PABS-PT 
Mediator: DIBQ knowledge 
domain direct after, 3 months 
after or 12 months after 
implementation 
Dependent 
variable: PCS or 
PABS-PT at 3 or 
12 month 
follow-up 
Mediator: DIBQ skills domain 
direct after, 3 months after or 12 
months after implementation 
 
Mediator: DIBQ beliefs about 
capabilites domain direct after, 3 
months after or 12 months after 
implementation 
Mediator: DIBQ beliefs about 
consequences domain direct 
after, 3 months after or 12 
months after implementation 
Mediator: DIBQ intentions 
domain direct after, 3 months 
after or 12 months after 
implementation 
Mediator: DIBQ innovation 
domain direct after, 3 months 
after or 12 months after 
implementation 
Mediator: DIBQ organisation 
domain direct after, 3 months 
after or 12 months after 
implementation 
Mediator: DIBQ patient domain 
direct after, 3 months after or 12 
months after implementation 
 
Mediator: DIBQ social influence 
domain direct after, 3 months 
after or 12 months after 
implementation 
Mediator: DIBQ behavioural 
regulation domain direct after, 3 
months after or 12 months after 
implementation 
a1 
a2 
a3 
a4 
a5 
a6 
a7 
a8 
a9 
a10 
b10 
b9 
b8 
b7 
b6 
c´ 
b5 
b4 
b3 
b2 

 
 28 
 
 
 
 
 
Figure 6. 1-1-1 multilevel mediation model with all variables measured at level-1 but all 
causal paths (direct=cj´, indirect=ajbj, and total effects= cj´+ ajbj) are allowed to vary between 
level-2 clusters.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Independent 
variable: 
Control or 
intervention 
Mediator:  
Change in BIPQ from baseline to 
3, 6 or 12 month 
 
Dependent 
variable: 
Change in NRS, 
ODI or 
secondary 
outcomes 
aj 
bj 
cj´ 
Level 1: Patients 
Level 2: Clusters 

 
 29 
 
 
Supplementary file 1 
Östergötland health care region physiotherapeutic clinical practice guideline 
recommendations for primary care management of benign LBP with or without 
radiculopathy 
Each evidence based guideline recommendation is supported by a clinical priority ranking. 
This is based on an overall assessment of the severity of the condition, reported effect of the 
intervention, strength of evidence assessment (GRADE), cost-effectiveness and the benefit of 
the intervention based on professional experience and patient benefit. A scale from 1 to 10 is 
used where the number 1 indicates recommended practices with the highest priority while the 
number 9 indicates recommended practices of low priority. The number 10 indicates 
recommendations that provide very little or no benefit or utility and are therefore not 
recommended.  
 
 
Recommendation 1 
PRIORITY RANKING = ❶
❿ 
Routine care should consist of standardised processes for subjective and objective 
assessment and diagnostics. A thorough screening of red flags is essential to rule out 
serious pathology. Treatment should be individualised for each patient. Basic treatment 
principles should be based on reassurance of a good prognosis, maintenance of 
appropriate physical activity and self-care enablement.  
Justification: The work group’s reasoning is based on clinical experience of the importance 
of careful screening to rule out serious pathology. Furthermore, standardised assessment 
and diagnostics provide quality assurance but treatment needs to be individualised for 
each patient case. The work group also reasoned based on clinical experience that 
appropriate physical activity is likely to contribute to maintaining the patient's functional 
level, psychosocial and general health as well as have positive effects on self-care 
enablement. In some cases, may physical activity temporarily aggravate pain and 
symptoms, but there are no known persisting side effects. The work groups reasoning is 
also based on evidence showing a statistically significant advantage for maintaining 
appropriate physical activity compared to bed rest for improving pain and function. 
Despite this, evidence that proves the benefit of appropriate physical activity is so great to 
be clinically relevant is missing. In addition, the best available evidence has however a 
currently limited scientific basis (○○). The working group proposes the following 
resources in the BetterBack model of care to support the implementation of 
Recommendation 1 (See sections 7.1-7.5) 
Recommendation 2 
PRIORITY RANKING = ❶❷
 
Do not perform routine medical imaging investigations (eg X-ray, CT, MRI) 

 
 30 
 
 
Justification: The work group´s reasoning is based on evidence that shows no differences 
in outcomes of pain, function and quality of life between patients who received or did not 
receive routine medical imaging investigations in the primary care context. The best 
available evidence has however a currently inadequate scientific basis (○○○). It was also 
discussed that imaging cannot confirm or reject a preliminary diagnosis as the relationship 
between patient symptoms and degenerative imaging finding is usually weak. Moreover, 
degenerative secondary findings are common in asymptomatic individuals. The work group 
however suggests that early use of medical imaging is motivated in the presence of 
symptoms or signs suggesting possible serious underlying pathology (red flags). Medical 
imaging may also be relevant when pain persists despite primary care treatment. 
Recommendation 3 
PRIORITY RANKING = ❶❷
❿ 
Consider using a patient-reported tool (eg STarT Back risk assessment tool) as usual care 
during the early-stages of patient management to screen the risk of continued LBP 
Justification: The work group’s reasoning is based on studies showing that STarT Back Tool 
is the only valid tool to investigate the risk of continued back pain in the primary care 
context. It shows the highest accuracy for detecting patients with low risk profile (total 
score ≤3) and medium-high risk profile (total score ≥4) for continued back pain. Studies 
also show that STarT Back Tool has the best ability to predict functional and pain-related 
outcomes. The best available evidence has however a currently inadequate scientific basis 
(○○○). No economical evaluations were identified but the working group discussed the 
importance of a simple and fast tool. STarT Back Tool can be filled in and analyzed in a few 
minutes to advantage over other tools that can be an administrative burden for patients 
and healthcare professionals. The working group argues that the predictive value of the 
tool should support, but not replace, regular examination procedures and clinical decision 
making. See section 7.3 for STarT Back Tool. 
Recommendation 4 
PRIORITY RANKING = ❶❷
❿ 
Consider using a patient-reported tool (such as the STarT Back risk assessment tool) and 
classification of examination findings during the early-stages of patient management to 
aid the stratification of care to prevent continued LBP 
Justification: The work group reasoned that for the choice and scope of targeted treatment 
measures, consideration should be given to the assessment of risk profile for long-term 
LBP and classification of examination findings. This has been shown to have a better effect 
on pain, function and quality of life, as well as less economic costs compared to no 
treatment stratification. The best available evidence has however a currently inadequate 
scientific basis (○○○). For a patient with low risk profile (total score ≤3 on STarT Back 
Tool) usual care is relevant and requires only few visits, but the working group 
recommends that adequate treatment measures directed at examination findings is of the 
highest importance. For patients with medium-high risk profile (total score ≥ 4 on STarT 
Back Tool), usual care will require additional visits. Information provided in questions 5-9 
on STarT Back Tool that investigate anxiety with psychological risk factors can guide the 
need, focus and extent of behavioral medicine measures. The working group argues that 
stratified care classified after assessing a risk profile for long-term back pain should 

 
 31 
 
 
support but not replace conventional examination procedures and clinical decision-making 
for treatment measures. The working group proposes the following resources to support 
the implementation of targeted treatments based on stratification (See sections 7.1-7.5). 
Recommendation 5 
PRIORITY RANKING = ❶❷
❿ 
Consider giving individualised patient education as a part of usual care (e.g. an 
explanatory model based on pain neuroscience and psychological mechanisms) 
Justification: Based on the best available evidence, the work group reasoned that 
individualised patient education as part of usual care can result in reduced work sickness 
absenteeism. The priority of the recommendation has been strengthened by consensus 
within the work group based on proven experience that individual adapted patient 
education is an important part of patient-centered care. The best available evidence has 
however a currently inadequate scientific basis (○○○). The intervention requires that 
the patient is receptive for education. The extent of patient education can depend upon 
whether the patient has a distorted image of the underlying mechanism of LBP and a high 
degree of negative outcome expectations, anxiety, and fear-avoidance or if they are 
inactive or passive in managing the LBP. Patient education should include a reassuring 
dialogue and other cognitive and behavioural therapeutic techniques of relevance to 
support change in the individual's maladaptive thoughts, feelings and behaviors. 
Pedagogical explanation models should be used to provide the patient with knowledge 
about symptoms and disorders, as well as to strengthen and support self-care ability to 
master everyday activities. The work group proposes the following resources to support of 
the implementation of patient education (See sections 7.6-7.7) 
Recommendation 6 
PRIORITY RANKING = ❶❷
❿ 
Consider a supervised exercise program as part of usual care 
Justification: Supervised training is defined as general or back-specific exercises or physical 
activities conducted under the guidance of a healthcare professionals. The work group’s 
reasoning is based on scientific evidence and proven experience that supervised training 
as part of usual care can result in clinically relevant improvement in pain, function, quality 
of life and produces lower health care costs compared with no supervised training. There 
is however no evidence that a specific type of exercise would be superior to another. The 
best available evidence has however a currently limited scientific basis (○○). 
The work group proposes the following resources to support the implementation of a 
supervised training program (see section 7.8). 
Recommendation 7 
PRIORITY RANKING = ❶❷
❿ 
Consider mobilisation techniques for neuromusculoskeletal structures as part of usual 
care (including active or passive motion in an angular and / or translational plane) 
Justification: The working group reasoning is based on evidence that for patients with 
segmental movement impairments, mobilization techniques can provide a statistically 
significant reduction in short-term pain. It is however uncertain whether the effect is 
sufficiently large so that patients experience a clear improvement overtime. At group level, 
there is no evidence that a particular technique is be superior to another. It cannot be 

 
 32 
 
 
ruled out that for subgroups of LBP patients, more positive effects on pain and function 
may be produced by specific mobilisation techniques. It is expected that these subgroups 
can be identified by careful diagnostics and short trial treatments. Mobilizing techniques 
as part of multimodal treatment provide better results. Serious side effects are rare. 
However, the best available evidence is based on a currently limited scientific basis 
(○○). 
Recommendation 8 
PRIORITY RANKING = ❶❷
❿ 
Consider acupuncture treatment in addition to usual care 
Justification: The working group reasoned based on evidence that cannot exclude 
acupuncture has a short-term pain relief effect in addition to a placebo effect. 
Acupuncture has however no effect on function. Side effects in the form of brief superficial 
bleeding or inflammation may occur. Pneumothorax and systemic infections are not 
common, but the prevalence is unknown. The best available evidence has however a 
currently inadequate scientific basis (○○○). 
Recommendation 9 
PRIORITY RANKING = ❶❷
 
Do not offer corset, shoes, traction, ultrasound or electrotherapy 
Justification: The work group’s reasoning is based on evidence that passive treatments 
such as corset, shoots / soles, traction, ultrasound or electrotherapy do not reduce pain or 
improve function and quality of life in patients more than no treatment or when offered as 
part of multimodal treatment. However, the best available evidence is based on a currently 
limited scientific basis (○○). It cannot be ruled out that subgroups of patients may 
experience positive effects of these interventions when a hypothesised effect mechanism 
is aimed at specific functional impairment or activity limitation. 
Recommendation 10 
PRIORITY RANKING = ❶❷
❿ 
Consider prescription-free NSAID medication if necessary in addition to usual treatment 
(lowest dose and shortest possible treatment time). 
NSAIDs: There is evidence of the effect of NSAID in patients with long-term LBP but the 
effect has not been highlighted on short-term pain or functional outcomes. There are no 
adverse reactions reported in systematic review studies on LBP, but potential transient side 
effects of NSAIDs such as reduced blood clotting, reduced stomach mucous function and 
reduced kidney function are known from studies on other conditions. The work group 
reasoned that lowest dose and shortest possible treatment time decreases the risk of side-
effects. The work group anticipates that there are differences in patient preferences 
regarding NSAIDs, where some patients will agree to NSAID treatment, while others will 
decline. The best available evidence for NSAID effects on LBP outcomes is based on an 
inadequate scientific evidence (○○○). The work group reasoned based on clinical 
experience that it cannot be excluded that the NSAID may have a pain relief effect in the 
short term. 
Recommendation 11 
PRIORITY RANKING = ❶❷
 

 
 33 
 
 
Do not offer paracetamol or opioids 
Paracetomol: Has no effect on the degree of LBP and functional ability. There are no 
reported adverse reactions in studies, but side effects of paracetamol in the form of 
hepatic effects are known from studies on other conditions. The best available evidence is 
based on a moderately strong scientific basis (○). 
 
Opioids: A weak analgesic effect of oxycodone in combination with paracetamol has been 
demonstrated in a study but the intervention has no effect on functional capacity for up to 
12 weeks. Other positive effects or adverse effects were not shown. A wide range of opioid 
side effects are known from other studies. Therefore, the working group reasoned that 
treatment results in more risks than benefits to the patient. The best available evidence is 
based on a currently limited scientific basis (○○). 
 
 
 
 

 
 34 
 
 
Implementation support tools 
1. Subjective assessment proformer for therapist use
LOW BACK SUBJECTIVE ASSESSMENT PROFORMER 
Name:………………………………………………………. Date of birth:………………………………………………..  
Date:………………………………………….. 
History of the present condition (debut, duration, 
activity limitation) 
 
 
 
 
 
 
 
 
 
 
 
 
Symptom localisation  
 
Symptom Description 
Localisation back 
Localisation  
right leg 
Localisation  
left leg 
Pain nature (Dull, stabbing, radiating etc) 
 
 
 
 
Pain frequency (Constant/ Intermittent) 
 
 
 
 
Pain Intensity (NRS 0-10) 
 
 
 
 
Daily variation (am/pm, night time pain/disturbed sleep) 
 
 
 
 
Irritability (non-irritable/highly irritable) 
 
 
 
 
Aggravating factors (loading etc) 
 
 
 
 
Easing faktors (rest etc) 
 
 
 
 
Course (Improving/same/worse) 
 
 
 
 
Other symptoms (Instability, weakness, paresthesia, 
stiffness) 
 
 
 
 
Past medical history  
Previous level of function/activity: 
 
 
Previous treatment: 
 
 
Red flags: (malignancy, unexplained weight loss, 
trauma, osteoporosis, infection, inflammatory 
disease, spinal cord compression symtoms, drug use) 
 
Other illnesses/ General health: 
 
Work, Social, Family history 
 
 
 
Patient förväntningar  
 
Medication 
 
 
Medical imaging/Laboratory tests 

 
 35 
 
 
2. Physical assessment proformer  
LOW BACK PHYSICAL ASSESSMENT PROFORMER 
1. INSPECTION – Postural screen 
Sitting: good/fair/poor      
                                       
Postural correction: Better/Worse/No effect 
Standing: good/fair/poor     
                                        
Postural correction: Better/Worse/No effect 
Lordosis: Hyper/hypo/normal       
                                 
Kyphosis: Hyper/hypo/normal                             Lateralt shift: Right/Left/none      
Spinal symmetry: 
 
Shoulder symmetry: 
Pelvic symmetry: 
Leg & fot symmetry: 
 
Muscular hypo/hypertrophy: 
Scars: 
2. SCREENING OF FUNCTIONAL MOVEMENT:  
Shoes on/off, sit-stand, 2 leg/ 1 leg squat, lunge right/left  
Gait:   Trendelenburg right/left 
            Limp right/left      
            Weight transfer right/left   
            Toe walking right/left  
            Heel walking right/left   
Work or sport specific:_______________________________ 
3. SCREENING TEST IN STANDING/SITTING  
 
Right 
Left 
Slump test + sensitisation  
head/foot  
 
 
Foramen compression/unloading 
 
 
 
Hip loading/unloading in standing 
 
 
 
4. TEST IN STANDING/SITTING  
LUMBAR ACTIVE ANGULAR MOVEMENT 
 
Range 
Quality 
Symptoms 
 
Large  Med Small High 
Low 
During 
range 
End 
range 
Rep 
Mov 
Flex 
 
 
 
 
 
 
 
 
 
Ext 
 
 
 
 
 
 
 
 
 
Lateral 
flex 
 R   L 
 R    L  R    L  R    L  R    L  R    L 
 R    L R    L 
Side 
Glide 
 R   L 
 R    L  R    L  R    L  R    L  R    L 
 R    L R    L 
Rot 
 
 R   L 
 R    L  R    L  R    L  R    L  R    L 
 R    L R    L 
Coupled  
flex 
 R   L 
 R    L  R    L  R    L  R    L  R    L 
 R    L R    L 
Coupled  
ext 
 R   L 
 R    L  R    L  R    L  R    L  R    L 
 R    L R    L 
5. TEST IN SIDE LYING  
LUMBAR PASSIVE ANGULAR MOVEMENT 
 
Range 
Symptoms 
 
Large 
Med 
Small 
During 
range 
End  
range 
Rep  
Mov 
Over  
press 
Flex 
 
 
 
 
 
 
 
 
Ext 
 
 
 
 
 
 
 
 
Lat  
flex 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
Rot 
 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
Coupled   
flex 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
Coupled  
ext 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 R    L 
 
6. PRONE  
ACCESSORY MOVEMENT/NERVE & MUSCLE FUNCTION 
Spinal extension in prone  
Better/Worse/No effect 
Segmental provocation 
 
- Central P/A,  Springing test 
- Unilateral P/A  
- Rotation provocation 
- Prone instability test 
       Movement 
Hyper   Hypo  Normal       
Pain 
 
 
 
 
Femoral nerve tension test 
 
 
Isometric/dynamic back muscle  
tests 
 
 
8. PALPATION 
7. SUPINE  
DIFFERENTIAL DIAGNOSTICS HIP/SI-JOINT/BACK 
Spinal flexion in supine 
Better/Worse/No effect 
Isometric/dynamic abdominal  
muscle tests 
 
 
      Right 
       Left 
Hip: Angular movement,  
Patricks test, quadrant 
 
 
SI-joint provocation test, ASLR 
 
 
 
Passive SLR + head/foot  
sensitisation, crossed SLR 
 
 
Myotomes- L1-2(I), L2-3(Q),  
L4-5(TA), L5(EH), L5-S1(P), S1(TS) 
 
 
Dermatomes 
 
 
 
Reflexs: Patella L3-4, Achilles S1 
 
 
 
Babinski, Klonus 
 
 
 
 
 
 
 

 
 36 
 
 
3. STarT Back Tool  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4. Clinical Reasoning and Process Evaluation tool (CRPE-tool) for therapists 

 
 37 
 
 
PATIENT NAME:_______________________ 
DATE OF BIRTH:_______________________ 
First assessment date:___/___/___ 
Final assessment date:___/___/___   
Totalt number of physiotherapy visits:_________ 
ASSESSMENT 
 First assessment - cross X relevant assessment findings 
 Final assessment - circle  relevant assessment findings 
 
1. Assess grade of FUNCTIONAL IMPAIRMENT  
 
None 
 
Lite 
 
Moderate 
 
Severe 
 
Complete 
KVÅ 
code 
Energy and drive (motivation) 
0 
1 
2 
3 
4 
PA006 
Sleep functions 
0 
1 
2 
3 
4 
PA007 
Emotional functions (anxiety, low mood) 
0 
1 
2 
3 
4 
PA011 
Thought functions (physical symptoms caused by 
cognitive/rational factors) 
0 
1 
2 
3 
4 
PA013 
Sensory function (sensitivity for pain ”sensitisation”) 
0 
1 
2 
3 
4 
PB008 
Pain (choose relevant category) 
 
 
 
 
 
 
          Back pain 
0 
1 
2 
3 
4 
PB009 
          Lower extremity pain 
0 
1 
2 
3 
4 
PB009 
          Pain in a dermatome 
0 
1 
2 
3 
4 
PB009 
          Pain in another body part (Buttock, hip, groin, thigh) 
0 
1 
2 
3 
4 
PB009 
          Generalised pain localisation (3 of 4 body quadrants) 
0 
1 
2 
3 
4 
PB009 
Exercise tolerance (endurance related activities) 
0 
1 
2 
3 
4 
PD009 
Joint mobility 
0 
1 
2 
3 
4 
PG001 
Joint stability 
0 
1 
2 
3 
4 
PG002 
Muscle power 
0 
1 
2 
3 
4 
PG003 
Muscle tone 
0 
1 
2 
3 
4 
PG003 
Muscle endurance 
0 
1 
2 
3 
4 
PG003 
Motor reflex functions (decreased or increased) 
0 
1 
2 
3 
4 
PG004 
Control of movement (Quality, coordination, balance) 
0 
1 
2 
3 
4 
PG006 
Gait pattern 
0 
1 
2 
3 
4 
PG007 
Sensation of muscle stiffness, tightness, spasm, contraction, 
heaviness 
0 
1 
2 
3 
4 
PG003 
Mobility of spinal meningies, periferal nerves and surrounding 
tissue 
0 
1 
2 
3 
4 
PG000 
 
2. Assess grade of ACTIVITY LIMITATION  
 
None 
 
Lite 
 
Moderate 
 
Severe 
 
Complete 
KVÅ 
code 
Perception of non-harmful sensory stimuli (kinesiophobia)  
0 
1 
2 
3 
4 
PJ001 
Carrying out daily routine (ADL) 
0 
1 
2 
3 
4 
PK003 
Handling stress and other psychological demands 
0 
1 
2 
3 
4 
PK004 
Changing and maintaining body position (shifting body weight 
away from the spine (increased lever arm) 
0 
1 
2 
3 
4 
PM001 
Changing and maintaining body position (bending) 
0 
1 
2 
3 
4 
PM001 
Maintaining a lying position  
0 
1 
2 
3 
4 
PM001 
Maintaining a sitting position 
0 
1 
2 
3 
4 
PM001 
Maintaining a standing position 
0 
1 
2 
3 
4 
PM001 
Maintaining an upright neutral posture 
0 
1 
2 
3 
4 
PM001 
Lyfting and carrying objects 
0 
1 
2 
3 
4 
PM004 
Walkning 
0 
1 
2 
3 
4 
PM007 
Moving around in different ways (crawling/climbing, 
running/joging, jumping) 
0 
1 
2 
3 
4 
PM008 
Household tasks 
0 
1 
2 
3 
4 
PP003 
Work ability and employment 
0 
1 
2 
3 
4 
PR002 
Recreation and leisure activities 
0 
1 
2 
3 
4 
PS002 
 
  
 
 

 
 38 
 
 
 
DIAGNOSTIC  SUBGROUPING AND ICD-10 CODING 
3. Matching assessment findings to diagnostic codes  
Choose a primary assessment finding category:  
 First assessment: Cross X one or more related ICD-10 diagnostic codes in the same row 
 Final assessment: Circle  a new diagnostic codes if relevant. 
Primary assessment category 
ICD-10 diagnos 
LBP with muscular functional impairment 
 M54.5 Lumbago 
LBP with segmental mobility impairment 
 M54.5 Lumbago 
 M99.0 Segmental dysfunction 
LBP with movement coordination impairment/ 
segmental instability  
 M54.5 Lumbago  
 M99.1K Segmental instability in the lumbar 
spine 
LBP with referred lower extremity pain (nociceptive 
pain proximal of the knee)  
 M54.5 Lumbago  
 M51.2 Other specificed dislocation of 
intervertebral disc 
 M47.9K Spondylosis in the lumbar spine 
LBP with radiating pain (neuropathic pain)  
 M54.5 Lumbago  
 M54.1 Radiculopathy (femoralis) 
 M54.4 Lumbago with ischias 
LBP with related cognitive or affective tendensies 
 M54.5 Lumbago  
 G96.8 Other specified disorders of the CNS 
(pain sensitivity) 
LBP with related generaliserad pain (pain in 3 of 4 
body quadrants) 
 M54.5 Lumbago  
 G96.8 Other specified disorders of the CNS 
(pain sensitivity)  
 F45.4 Chronic somatoform pain syndrome 
LBP with postural related symptoms  
 M54.5 Lumbago  
 M40.3 Flatback syndrome 
 M40.4 Hyperlodosis 
SI-joint symptoms or Coccygodynia 
 M53.3 Sacrococcygeal disorders 
LBP radiating pain + Medical imaging disc pathology 
and nerve compression finding 
 M51.1K Disc degeneration/disc herniation in 
the lumbar spine with radiculopathy  
LBP with radiating pain/neurogenic claudication + 
Medical imaging verifieried degeneration and nerve 
compression findings 
 M48.0K Central spinal stenos in the lumbar 
spine (bilateral symptoms) 
 M99.6 Stenosis of intervertebral foramin 
(unilateralt symptoms) 
Ländryggsbesvär med nedsatt rörelse kontroll i 
ryggen och/eller segmentell instabilitet + Medicinsk 
bild verifierad Spondylolys/Spondylolisthes 
 M43.0 Spondylolys 
 M43.1 Spondylolistes 
 

 
 39 
 
 
 
 
TREATMENT 
4. Record at final assessment:  
Has the BetterBack model of care Part 1 been applied? 
 Yes      No 
Has the BetterBack model of care Part 2 been applied? 
 Yes      No 
Cross X all modes och types of treatments used 
Physical exercise  
MODE 
KVÅ code 
 Non-supervised individual training 
 
 Supervised individual training 
QV011 
 Supervised group training  
QV012 
TYPE 
 
 Muscle strengthening training 
QG003 
 Range of movement training 
QG001 
 Muscle endurance training 
QG003 
 Cardiovascular training 
QD016 
 Balance training 
QB001 
 Postural control training 
QG004 
 Coordination training 
QG005 
 Pelvic floor training 
QF001 
 Postural training 
QM005 
 Relaxation training 
QG007 
 Physical activity prescription (FaR®) 
DV002 
 Other ………………………… 
 
Behavioural medicine interventions 
MODE 
 
 Individual based intervention 
QV011 
 Group based intervention 
QV012  
TYPE 
 
 Information / education on pain  
QV007  
 Cognitive-behavioural therapy  
DU011 
 Mindfulness 
DU032  
 Motivational interviewing 
DU118  
 Relapse prevention 
DU119 
 Supportive conversation 
DU007 
 Other ………………………… 
 
Manual therapy 
TYPE 
 
 Joint mobilisation 
DN006 
 Joint manipulation 
DN008 
 Massage 
QB007 
 Stretching 
DN009 
 Nerve mobiliseration 
QG001 
 Trigger point pressure 
DN007 
 Traction 
QG001 
 Other…………………………. 
 
Occupational medicine interventions 
TYPE 
 
 Workplace training 
DV084 
 Training of work ability 
QR003 
 Work and employment counciling 
QR002 
 Information /education on ergonomics 
QV010 
 Other ............................ 
 
Physical modalities 
TYPE 
 
 TENS 
DA021 
 Cryotherapy 
QB011 
 Heat 
QB011 
 Ultrasound 
QB011 
 Shockwave therapy 
QB011 
 Laser therapy 
QB011 
 Short wave diathermy 
DV042 
 Interferential therapy 
DA021 
 Orthosis 
DN003 
 Taping 
DN003 
 Bio-feedback 
DV010 
 Acupunkture 
DA001 
 Other…………………………. 
 
5. Rate overall treatment effect             
 
  Much better  
  Quite much better 
  Unchanged  
  Quite much worse 
  Much worse 

 
 40 
 
 
 
 
 
5. Clinical reasoning and process pathway for therapists 
A thorough history and adequate physical examination are of great importance in order to target treatment 
interventions. In addition, it is very important to exclude the few red flag cases that require acute medical or 
specialist referral for the investigation and treatment of tumors, infections, inflammatory diseases, more 
severe back pathology and neurological conditions, as well as the strong influence of psychosocial factors 
which can also cause back pain. StarT Back Tool can be used to support decision making regarding the 
extent of health care needed and the need for psychosocial focus based on an assessment of risk factors for 
continued back pain. The physical assessment should include an analysis of functional movements, posture, 
active movements, passive movements, combined movements and / or static positions, joint accessory 
movement / provocation tests and neuromuscular function. This is to investigate how the symptoms are 
related to motion dysfunction. 
Based on assessment findings, relevant treatment measures with effect mechanisms directed at functional 
impairments and activity limitations should be tested. These may include range of movement exercises 
(active/passive or accessory joint mobilisation or neuromuscular structure mobilisation), motor control 
exercises, muscle stretching, balance exercises, coordination, muscle strength, muscle endurance, general 
physical fitness or cardiovascular exercise. For example: 
1. In the identification of movement directions and positions that reduce or centralize the patient's 
localised pain, distal pain or radiculopathy, these may be considered as a treatment techniques. This 
allows the patient to learn strategies to control pain and thus take better responsibility for his or her 
own situation. 
 
2. In the identification of movement restriction due to joint, muscle or nerve related impairment, 
mobilisation strategies for the relevant structure may be considered to reduce the movement 
restriction. 
 
3. In the identification of segmental instability or trunk motor control impairment in the, exercises with 
a focus on movement control can be tested aiming to improve muscle function, reduce pain and 
optimise loading of the trunk during full body movement. 
 
4. In the identification of a psychogenic causes of back pain, supervised exercise could be tested to 
minimize kinesiophobia. This can often be complemented with patient education that can help pain 
management and enable self-care. 
 
5. In the identification of a postural impairment, posture correction and ergonomic interventions can be 
tested. 
Dosage of treatment measures should be individualised and sufficient to achieve the desired effect. Initial 
targeted treatment should be through individual patient care. As a complement to the initial targeted 
treatments, the purpose of a general training and patient education is to restore or improve function and 
activity. The suitability of group-based patient care is assessed in consultation with the patient as general 
training and patient education is considered relevant to support the patient's self-care. 

 
 41 
 
 

 
 42 
 
 
6. BetterBack Model part 1 – Patient education brochure  
 

 
 43 
 
 
 
 
 

 
 44 
 
 
 
 

 
 45 
 
 
 
 

 
 46 
 
 
 
 

 
 47 
 
 
 
 

 
 48 
 
 
7. BetterBack Model part 2 – Group education seminar for patients 
 
 
 
 

 
 49 
 
 
 
 
 

 
 50 
 
 
 
 
 

 
 51 
 
 
 
 
 

 
 52 
 
 
 
 

 
 53 
 
 
 
 
 

 
 54 
 
 
8. BetterBack Model – Training program for patients 
Training program for patients receiving the BetterBack model of care for LBP 
Part 1: Posture, 
muscle control and 
coordination of basic 
body movements 
Goal: To ensure the patient has satisfactory posture and trunk muscle 
activation in static positions as well as in conjunction with basic body 
movement in the sitting, sitting and standing. 
Implementation*: Exercises and dosages are individually adjusted by 
the treating therapist. Exercises are performed as home programs and 
daily training is recommended for optimal results. 
 
The therapist assesses when basic competencies in program 1 are 
achieved before progressing to program 2. 
Training range of 
movement 
Goal: Restore normal 
mobility. 
Implementation: 
Individualise based on if the 
patient has movement 
restriction. 
 
Part 2: Graded 
training of muscle 
strength, coordination 
and endurance 
Goal: To ensure the patient has satisfactory ability to perform more 
challenging body movements with adequate strength, corrdination and 
endurance. 
Implementation*: Exercises and dosages are individually adjusted by 
the treating therapist. Exercises are performed twice a week for 12 
weeks with follow-up conducted by the treating therapist. During the 
first 6 weeks, patients are offered the opportunity to train in a group 
supervised by a physiotherapist. The patient will then receive support 
and feedback regarding the practice of exercises and help to upgrade 
exercises if necessary. Patient education on self-care and management 
of back pain is also performed in groups.  
*Prerequisite for upgrading the training program is that the patient can satisfactorily perform basic exercises for posture and trunk control in Part 1. Using Part 
2 as a basis, the physiotherapist selects and individualises relevant exercises and dosing based on the assessment findings. If support with the traning program 
is required (in addition to a self-mediated home based program), group traning supervised by another therapist can implemented. However, the follow-up of 
the patient is still the responsibility of the therapist who first assessed and initiated the patient’s treatment plan. The program is designed with graded levels 
where difficulty level is increased by successively progressing from stages A through to C. Patients are to perform the exercises as instructed. Training can 
initially produce some muscle soreness, but this is normal and decreases gradually. Contact your physiotherapist if you have questions or feel unsure.  

 
 55 
 
 
Part 1. Posture, muscle control and coordination of basic body movements 
1a. Basic trunk muscle activation and control in a lying position 
1b.  Basic trunk muscle activation and control in 
conjunction with body movement in a lying position  
Pelvic control exercise 
 
Lay on your back with your knees bent. Put your hands under your pelvis. Press your lower 
back down so it flattens down on the surface you are laying on. Feel how the pelvis tilts 
backwards and has rolled over your hands. Tip the pelvis forward and feel how the lower 
back rises again. Remove your hands and repeat the tipping forward and backward with less 
and less movement. Stop when you come to a normal neutral pelvic position. 
  
Activating your inner trunk muscles 
This exercise focuses on the activation of core muscles in your back, abdomen and pelvis. It is also 
known as ”core activation” 
 
Lay on your back with your knees bent and put your hands on your waist.  
 
 Breathe calmly in and out and make an ssss sound and feel your fingers 
how the inner muscles between your pelvis bones become activated. This 
muscle activation should be done slowly and with a minimal force where you 
feel that the lower part of the stomach is pulled inward-backward-upward.  
o 
Alternative instructions 
 
Draw the lower part of your stomach inwards from the waist of you pants 
 
Imagine that you activate your lower stomach muscles just like if you were 
tightening av belt around you waist 
 
Imagine that your holding on to go to the toalet 
 
Make sure that you dont: 
o 
Hold your breath, press your lower back down or bend your back forward 
 
In conjunction with leg movement 
Lay on your back with your knees bent.  Start with 
”core activation”  Move your knee on one side 
out towards the side with and back to the 
middle with slow controlled movement. Repeat 
alternately on each side. Maintain a stable positioning of 
your trunk and pelvis.   
Repetitions_______________ 
 
Perform the same exercise in side lying with movement 
of one leg. Perform even on the other side thereafter 
Repetitions_______________ 
 
In conjunction with arm movement 
 Start ”core activation”.  Bring your arms up över 
your head, together or alternately, with slow controlled 
movement.  Maintain a stable positioning of your trunk 
and pelvis.   
Repetitions________________ 
 
 
 

 
 
 

 
 56 
 
 
2a.  Basic trunk postural control in a sitting position 
 
With neutral posture, loading of the spine is 
optimally distributed. Feel how the physical loading 
on your back increases when you sit with hunched 
posture, and how it relieves when you hold a neutral 
posture. 
 
Training of posture in sitting position: 
 
Sit on a chair with your hands under your 
buttocks.  
 
 Rotate your pelvis forward over your 
hands. You should feel like you are arching 
your back more. Rock your pelvis backward 
so you return to a neutral back posture.  
Rotate your pelvis backwards so that you 
have a hunched posture. Continue to rotate 
your pelvis backards and forwards a few 
times 
 
 
Stop in a position where you feel you have a 
even weight distribution over your hands 
and neutral back posture.  
 
Your ears, shoulders and hips should create 
a straight line vertically.  
 
2b.  Basic trunk muscle activation in a sitting 
position 
 
Sit on a chair with good posture.  Train 
holding a ”core activation”.  
 
Repititions_______________ 
 
 
 
 
2c.  Basic trunk muscle activation and control in 
conjunction with body movement in a sitting position 
 
In conjunction with leg movement 
Sit on a chair or training ball.  Start with ”core 
activation”.  Lift up your knees alternately with slow 
controlled movement.  Maintain a stable positioning of 
your trunk and pelvis.   
Repetitions_______________ 
 
In conjunction with arm movement 
 Start ”core activation”.  Bring your arms up över 
your head, together or alternately, with slow controlled 
movement.  Maintain a stable positioning of your trunk 
and pelvis.   
Repetitions________________ 
 
 
 
 
 
 
 
 
 
 
 

 
 57 
 
 
3a. Basic trunk postural control in a standing 
position 
With neutral posture, loading of the spine is 
optimally distributed. Feel how the physical loading 
on your back increases when you sit with hunched 
posture, and how it relieves when you hold a neutral 
posture. 
 
Training of posture in sitting position: 
 
Stand with your feet hip width apart 
 
 Shift your weight forwards and 
backwards and find a neutral weight 
distribution over the soles of your feet. 
 
 Bend and straighten your knees a few 
times and find the position where your 
knees are slightly bent. 
 
 Tilt your pelvis forwards and backwards 
a few times and the position in the middle 
where you pelvis has a neutral position. 
 
 Move your head backwards with your 
chin in.  
 
 Bring your shoulders up and then relax 
your shoulders. 
 
Your ears, shoulders, hips, knees and feet 
should now be in a straight line.  
 
3b.  Basic trunk muscle activation in a 
standing position 
 
 
Stand with a neutral posture.  Train holding 
a ”core activation”. 
Antal_______________  
 
 
 
 
3c. Basic trunk muscle activation and control in 
conjunction with body movement in a standing 
position. 
 
In conjunction with weight transfering 
Stand with a neutral posture. Place you feet wide apart.  
 Start ”core activation”.  Transfer your weight from 
one leg to the other alternately.  Maintain a stable 
positioning of your trunk and pelvis. 
Repetitions_______________ 
 
 
In conjunction with arm movement 
Stand with a neutral posture. Start ”core 
activation”.  Bring your arms up över your head, 
together or alternately, with slow controlled movement.  
Maintain a stable positioning of your trunk and pelvis.   
Repetitions________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 58 
 
 
Part 2: Graded training of muscle strength, coordination and endurance 
Difficulty level A 
Difficulty level B 
Difficulty level C 
1A) Pelvis lifts in lying position 
Lay on your back with your knees bent and arms by 
your side.  
 Start with ”core activation”.  
 Lift up your pelvis from the floor. 
Repetitions_______________ 
 
 
Tip: Increase resistance by using theraband placed 
over you pelvis and hold the ends down with your 
hands.  
 
 
1B) Pelvis lifts + leg kicks in lying position  
Lay on your back with your knees bent and arms by 
your side.  
 Start with ”core activation”.  
 Lift up your pelvis from the floor. 
 Lift and extend one leg while maintaining a stable 
positioning of your trunk and pelvis. Lower your foot 
to the floor again and lower the pelvis. Repeat and 
change legs every time. 
Repetitions_______________ each side 
 
 
Tip: Increase resistance by using theraband placed 
over you pelvis and hold the ends down with your 
hands.  
 
 
 
 
 
1C) Single leg pelvis lift i lying position 
Lay on your back with your knees bent and arms 
by your side.  
 Start with ”core activation”.  
 Lift up your pelvis from the floor and at the 
same time lift and extend one leg. Lower your foot 
to the floor again and lower the pelvis. Repeat and 
change legs every time. 
Repetitions_______________ each side 
 
  
 
Tip: Increase resistance by using theraband placed 
over you pelvis and hold the ends down with your 
hands.  
 
 
 
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 59 
 
 
2A) Knee lifts in lying position 
Lay on your back with your knees bent and put your 
hands on your waist.  
 Start with ”core activation”.  
 Lift one fot slowly up by bending your hip while 
maintaining a stable positioning of your trunk and 
pelvis. Slowly bring your fot back to the floor.  
Repeat and change legs every time. 
 
Repetitions_______________ each side 
 
 
 
 
 
 
 
 
 
2B) Straight leg raises in lying position 
Lay on your back with your knees bent and put your 
hands on your waist.  
 Start with ”core activation”. 
 Extend and lift one leg while maintaining a stable 
positioning of your trunk and pelvis. Slowly bring 
your leg back to the floor. Repeat and change legs 
every time. 
 
Repetitions_______________ each side 
 
 
2C) Rotating sit-ups in lying position 
Lay on your back with your knees bent.   
 Start with ”core activation”. 
 Place your hands behind your head and bring 
your opposite knee and elbow together by 
bending you back forwards. Repeat alternately on 
each side. 
 
Repetitions_______________ each side 
 
 
 
 
 
 
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 60 
 
 
3A) Hip muscle training in lying position 
Lay on your back with your knees bent and arms by 
your side. Tie a theraband around your knees.  
 Start with ”core activation”. 
 Move your knees slowly away from each other 
and slowly back again while maintaining a stable 
positioning of your trunk and pelvis. 
 
Repetitions_______________ 
 
 
 
 
 
 
3B) Hip muscle training in side lying position 
Lay on your side with your knees bent. Tie a 
theraband around your knees.  
 Start with ”core activation”. 
 Move your top knee slowly away from the other 
and slowly back down again while maintaining a 
stable positioning of your trunk and pelvis.  
 
Repetitions_______________ each side 
 
 
 
 
 
3C) Hip muscle training in side lying position 
Lay on your side with your legs straignt. Tie a 
theraband around your ankles.  
 Start with ”core activation”. 
 Move your top leg slowly away from the other 
and slowly back down again while maintaining a 
stable positioning of your trunk and pelvis. 
 
Repetitions_______________ each side 
 
 
 
 
Alternative 
Stand on one leg in a crouched position. 
Straighten up and move your free leg diagonally 
backwards just like skating. Repeat alternately on 
each side. 
 
 
 
 
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 61 
 
 
4A) Side plank + arm movement 
Lay on your side with support of your lower arm and 
knee and lift up your pelvis.  
 Start with ”core activation”. 
 Maintain a stable positioning of your trunk and 
pelvis while bringing your free arm up over your 
head.  
 
The exercise can be done with the pelvis still (static) 
or by moving the pelvis up and down (dynamically). 
Perform also on the other side. 
 
Repetitions_______________ each side 
 
 
 
4B) Side plank + arm movement 
Lay on your side with support of your lower arm and 
feet and lift up your pelvis.  
 Start with ”core activation”. 
 Maintain a stable positioning of your trunk and 
pelvis while bringing your free arm up over your 
head.  
 
The exercise can be done with the pelvis still (static) 
or by moving the pelvis up and down (dynamically). 
Perform also on the other side. 
 
Repetitions_______________ each side 
 
  
4C) Side plank + arm movement 
Lay on your side with support of your lower arm 
and feet and lift up your pelvis.  
 Start with ”core activation”. 
 Maintain a stable positioning of your trunk and 
pelvis while bringing your free arm up and 
rotating your back.  
Repetitions_______________ each side 
 
 
 
Alternative: Stand beside a therband tied to a 
pole. Pull the theraband diagonally across your 
body and rotate your back. 
Repetitions_______________ each side 
 
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 62 
 
 
5A) Chair plank 
Stand on your knees and support your lower arms on 
a chair or pilates ball.  
 Start with ”core activation”. 
 Maintain a stable positioning of your trunk and 
pelvis while you lift your knees from the floor. Hold 
_______ seconds. Bring your knees back down to the 
floor.    
 
Repetitions_______________ 
 
 
 
 
 
 
 
 
 
 
 
 
5B) Floor plank 
Stand on your knees and support your lower arms on 
the floor.  
 Start with ”core activation”. 
 Maintain a stable positioning of your trunk and 
pelvis while you lift your knees from the floor. Hold 
_______ seconds. Bring your knees back down to the 
floor.    
 
Repetitions_______________ 
 
 
 
5C) The plank + leg lifts 
Stand on your knees and support your lower arms 
on the floor.  
 Start with ”core activation”. 
 Maintain a stable positioning of your trunk and 
pelvis while you lift your knees from the floor 
holding your legs straight. Lift one foot up from 
the floor and hold _______ seconds. Bring your 
foot back down to the floor.    
 
Repetitions_______________ each side 
 
 
 
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 63 
 
 
6A) 4-point kneeling superman exercise 
Position yourself on your hands and knees with your 
back straight.  
 Start with ”core activation”.  
 Maintain a stable positioning of your trunk and 
pelvis while you lift up and down one arm 
alternately. Try instead one leg alternately. When this 
is easily accomplished, combined these so that you 
lift an arm and opposite leg up and down 
simultaneously and alternate sides. 
Repetitions_______________ each side 
 
 
6B) 4-point kneeling theraband exercise 
Positition yourself on your hands and knees with 
your back straight. Tie a theraband around your fot 
and hold on to the other end with your hands. 
 Start with ”core activation”. 
 Lift up and straighten your leg. Hold 5 seconds 
and then bring your leg down again.   
 
Repetitions_______________ each side 
 
 
 
 
 
 
 
6C) Superman exercise with theraband 
Position yourself on your hands and knees with 
your back straight. Tie a theraband around your 
fot and hold on to the other end with your 
opposite hand. 
 Start with ”core activation”, curl your back and 
bring your opposite knee and elbow together 
while holding the theraband. 
. Slowly straighten your back, arm and opposite 
leg to stretch out the theraband. Perform the 
movement with good control of motion. 
 
Repetitions_______________ each side 
  
 
Alternativ: Try performing the same exercise while 
standing on one leg. 
 
 
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 64 
 
 
7A) Push-ups against a wall  
 Start with ”core activation” 
 Perform push-ups against a wall while maintaining 
straight back posture. 
 
Repetitions_______________ 
 
7B) Push-ups against a table 
 Start with ”core activation” 
 Perform push-ups against a table while 
maintaining straight back posture. 
 
Repetitions_______________ 
 
 
7C) Push-ups on the floor 
 Start with ”core activation” 
 Perform push-ups while maintaining straight 
back posture. 
 
Repetitions_______________ 
 
 
 
 
Alternativ: Try performing the same exercise with 
your feet on a pilates ball. 
 
 
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 65 
 
 
8A) Standing arm lifts 
Hold on to the ends of a theraband and stand on the 
middle of theraband 
 Start with ”core activation”. 
 Maintain a straight back posture while you lift 
your arms up over your head against the resistance 
of a theraband. 
 
Repetitions_______________ 
 
 
8B) Standing rows 
Hold on to the ends of a theraband placed around a 
pole. 
 Start with ”core activation”. 
 Maintain a straight back posture while you 
perform arm rows alternately from side to side. 
 
Repetitions_______________ 
 
 
8C) Standing straight arm lifts 
Hold on to the ends of a theraband and stand on 
the middle of theraband. 
 Start with ”core activation”. 
 Maintain a straight back posture and straight 
arms while you lift your arms alternately against 
the resistance of a theraband. 
 
Repetitions_______________ each side 
 
 
 
Alternative:  Try performing straight arm ski rows. 
 
 
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 66 
 
 
9A) Squats 
Stand with your back against the wall or with a 
pilates ball between your back and the wall. Place 
your feet hip width apart.  
 Start with ”core activation”. 
 Maintain a straight back posture while you 
perform a squat up to about 90 degrees of knee and 
hip bending.  
 
Repetitions_______________ 
 
 
9B) Squats with your arms över your head 
Stand with your back against the wall or with a 
pilates ball between your back and the wall. Place 
your feet hip width apart and your hands över your 
head. 
 Start with ”core activation”. 
 Maintain a straight back posture while you 
perform a squat up to about 90 degrees of knee and 
hip bending.  
 
Repetitions_______________ 
 
 
 
9C) Standing high knee lifts 
Stand with your back against the wall, place your 
feet hip width apart and your arms on the wall. 
 Start with ”core activation”. 
 Maintain a straight back posture while you 
perform high knee lifts with alternating legs. 
 
Repetitions_______________ each side 
 
 
 
 
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 67 
 
 
10A) Tandem stance lunging weight tranfers 
Stand with one foot a step length in front of the 
other foot. 
 Start with ”core activation”. 
 Maintain a straight back posture while you 
perform weight transfer forwards and backwards 
from foot to foot. Try even with your other foot 
forward. 
 
Repetitions_______________ each side 
 
 
10B) Lunges 
Stand with your feet hip width apart and your arms 
up horizontal to your body.  
 Start with ”core activation”. 
 Maintain a straight back posture while you 
perform forward lunges by taking av step forward 
with your weight over that leg och then taking a step 
back again. Alternate which foot you step forward 
with.  
 
Repetitions_______________ each side 
 
 
 
10C) Lunges with simultaneous upper body 
movement 
Stand with your feet hip width apart and your 
arms up horizontal to your body.  
 Start with ”core activation”. 
 Maintain a straight back posture while you 
perform forward lunges by taking av step forward 
with your weight over that leg och then taking a 
step back again. Alternate which foot you step 
forward with. At the same time as you lung, try 
lifting upp your arms over your head or rotating 
your upper body from side to side when holding a 
stick. 
 
Repetitions_______________ each side 
 
 
 
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 68 
 
 
Training range of movement 
1A) Backward bending (elbow support)  
 
Lay on your stomarch and support yourself on your 
underarms/elbows. Bend your back backwards by 
pressing up from your underarms/elbows and return 
to the start position again. 
Repetitions_______________ 
 
1B) Backward bending (bent arms) 
 
Lay on your stomarch and support yourself with your 
hands. Bend your back backwards by pressing up 
from your hands but dont straighten your elbows 
and thereafter return to the start position again. 
Repetitions_______________ 
 
1C) Backward bending (straight arms) 
 
Lay on your stomarch and support yourself with 
your hands. Bend your back backwards by 
pressing up from your hands and straightening 
your elbows and thereafter return to the start 
position again. 
Repetitions_______________ 
 
2A) Foward bending while laying on your back 
Lay on your back and bring your knees up to your 
stomach, then return to the start position. 
 
Repetitions_______________ 
 
 
 
 
2B) Forward bending on hands and knees 
Position yourself on your hands and knees with your 
back straight. Bend your back forward pressing your 
lower back upwards while bending your hips and 
knees so that your knees are in contact with your 
chest. Return to the starting position. 
 
Repetitions_______________ 
 
 
 
2C) Forward bending in sitting or standing 
Stand/sit with your back straight. Starting bending 
forwards nd bringing your hands down towards 
the floor. Try to even bend your lower back. 
Return to your starting position. 
 
Repetitions_______________ 
 

 
 69 
 
 
3A) Back rotation (lower back) 
Lay on your back and bring your knees down towards 
the floor on onside and then over to the other side. 
 
Repetitions_______________ each side 
 
 
3B) Back rotation (lower back and thoracic) 
Lay on your back and bring your knees down towards 
the floor on one side while simultaneously reaching 
out with your opposite arm upwards and sidewards. 
Change sides by bringing your knees over to the 
other side and reach out with your opposite arm 
upwards and sidewards. 
 
Repetitions_______________ each side 
 
 
 
3C) Back roation (full range) 
Lay on your back and bring your left knee down 
towards the floor on your left side while 
simultaneously reaching out with your left arm 
upwards and sidewards. Change sides by bringing 
your knee over to the other side and reach out 
with your opposite arm upwards and sidewards. 
 
Repetitions_______________ each side 
 
Before and after exercise, stretching exercises help 
your muscles. Each stretch can be done several 
times, with <30 second holds. Here are suggestions 
for stretching.  
 
 
Stretching of your buttock muscles 
 
Stretching of your hip muscles 
 
Stretching of your thigh muscles 
 
Stretching of the back of your thighs 
 
 
Stetching of the inside of your thighs/groin 
 

 
 70 
 
 
General training - getting in shape 
Training form 
Regular physical exercise as a part of everyday life is important for maintaining good health and 
fitness. For this, we recommend following a training program prescribed by your physiotherapist. 
Your training can consist of, for example: walks, nordic walking, cycling, jogging, swimming, 
dancing, gym. Choose which training form is best for you. You can work out alone or with others in 
a group. The most important thing is that you feel that you take the time for physical activity in your 
everyday life. 
Training intensity 
Training intensity can be regulated through a so-called "pacing model". This means that you slowly 
and gradually increase your training intensity without overloading. You "pace" yourself in a 
controlled way to reach your goals. You can monitor your level of exertion by using a scale of 6-20 
where the scale is based on your approximate pulse when you multiply by 10. 
You should preferably training with a level of exertion between 
11 (fairly light) and 14 (somewhat hard). 
You should start exercising at about 20% less duration than you are capacble of. If you feel that the 
exercise feels very easy (at level 9 or below), you can increase your exercise duration slightly so 
that you feel at least a farily light exertion level (level 11). 
When you experience your exercise exertion is on average under a "somewhat hard" lavel (below 
14), you can increase your exercise by 20% after 2 weeks. If you are on level 15 or more, you can 
continue with the same training for an additional 2 weeks. 
When your training duration lasts 30 minutes, you can increase the load by increasing the intensity 
to 15/16 (Hard - you can not speak on at this intensity) in 10 minute intervals. Then you can 
increase the number of minutes on this intensity (15/16) every second week. 
If you have a bad day, you should work out half of what you planned. In this way you can increase 
your exercise gradually, without risking doing too much. 
 
 
 
Training Contract: 
I will perform  …………………………….. as my training form 
I will train 3 times/week 
I will begin with ………….. minutes 
I will increase my training intensity with 20 % every second week until 
reach my goal capacity. 
 
 

 
 71 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Training diary 
Name:  
 
 
Your physiotherapist will fill in which exercises you should train. You can cross off when you have 

 
 72 
 
 
performed the exercises. 
 
 
 
 
 
 
 
 
 
 
 
Week 
Day 
BetterBack 
Part 1 
BetterBack 
Part 2 
BetterBack 
Range of 
movement 
General training 
1 
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10 
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2 
3 
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 73 
 
 
Supplementary file 2 
Summary of the workshop to provide training in the use of the BetterBack model of care. 
Schedule Content 
 
Brief description  
Learning objectives  
BCTs used 
Day 1  
08:15-
08:30 
Presentation 
 
Welcome and introduction  
 
Day 1  
08:30-
08:50 
Questionnaire Participating 
physiotherapists 
record 
background 
information, 
PABQ, PCQ, 
DIBQ 
Participants receive 20 
minutes to complete the 
questionnaire 
To generate 
descriptions recorded 
by physiotherapists 
before and after 
BetterBack model of 
care 
 
Day 1  
08:50-
09:40 
Presentation 
LBP clinical 
guidelines 
Present evidence based 
guideline 
recommendations and the 
development process 
behind the 
recommendations 
To understand current 
evidence based 
recommendations for 
primary care of LBP 
and stakeholder 
involvement in their 
development 
- Instruction on 
how to 
perform the 
behavior 
- Credible source 
- Information 
about other’s 
approval 
Day 1  
09:40-
10:00 
Presentation  
 
 
Background to 
BetterBack 
model of care 
 
Outlines the goals for the 
day, defines and 
conceptualizes the 
BetterBack model of care 
and communicates need 
for the model of care 
To understand aims, 
objectives and 
learning outcomes for 
the practitioner 
education 
 
- Credible source 
- Social reward 
- Pros and cons 
- Comparative 
imagining of 
future outcomes 
Day 1  
10:00-
10:20 
Swedish fika 
Reflection 
Informal discussion about 
aims of the BetterBack 
model of care compared to 
current practice 
To evaluate the 
practical aims of the 
BetterBack model 
- Social support 
Day 1  
10:20-
11:40 
Demonstration Use of 
implementation 
tools 
Demonstration of how 
evidence based 
recommendations can be 
practically applied in the  
BetterBack model of care 
To understand how to 
practically use 
implementation tools 
to assist clinical 
reasoning for 
matching assessment 
findings with 
appropriate diagnosis 
and treatment 
- Instruction on 
how to 
perform the 
behaviour 
- Demonstration of 
behaviour 
- Problem-solving 
- Feedback on 
behaviour 
Day 1  
11:45-
12:00 
Reflection 
Use of 
implementation 
tools 
In pairs, participants 
discuss reflections upon 
how they can practically 
apply the implementation 
tools into their clinical 
practice 
To evaluate the 
practical use of the 
BetterBack model  
clinical reasoning tools 
- Behavioural 
practice/rehearsal 
- 
Framing/reframing 
Day 1  
12:00-
13:00 
Lunch break 
 
 
 
 
Day 1  
13:00-
14:30 
Task 
Use of 
implementation 
tools 
Participants are divided 
into 3 work groups who 
each transition between 
3x30min patient scenario 
workstations. Participants 
practice the application of 
the BetterBack model 
implementation tools using 
To develop practical 
skills in the use of the 
BetterBack model 
clinical reasoning tools 
- Behavioural 
practice/rehearsal 
- Feedback on 
behaviour 
- Social support  

 
 74 
 
 
therapist-patient role-play. 
Feedback is provided from 
the tutor and between 
peers 
Day 1  
14:30-
15:00 
Task 
Feedback on 
work with 
patient 
scenarios 
Each group discuss and give 
feedback on their work 
with the first patient 
scenario station (10min per 
group) 
To learn how peers 
used BetterBack 
model clinical 
reasoning tools 
- Graded task 
- Verbal 
persuasion about 
capability 
Day 1  
15:00-
15:20 
Swedish fika 
Reflection 
Informal discussion about 
the practical use of the 
BetterBack model of care 
compared to current 
practice 
To evaluate the 
practical use of the 
BetterBack model  
clinical reasoning tools 
- Social support 
Day 1  
15:20-
15:40 
Summary of 
the day 
Question and 
answer 
session and 
close 
Learning outcomes are 
summarised 
 
- Feedback on 
behaviour 
Day 2  
08:15-
08:30 
Discussion 
 
Reflections after the first 
day of the workshop 
 
 
Day 2  
08:30-
09:00 
Presentation 
 
Benefits of using the 
implementation tools for 
assessment, diagnosis and 
intervention  
To appreciate how to 
practically use 
implementation tools 
to assist clinical 
reasoning for aligning 
assessment, 
diagnostics and 
treatment 
- Instruction on 
how to 
perform the 
behaviour 
- Information 
about social and 
environmental 
Consequences 
- Credible source 
- Information 
about other’s 
approval 
Day 2  
09:00-
09:20 
Demonstration BetterBack 
model 
treatment tools 
Patient education 
(brochure) 
To understand how to 
use the 
implementation tools 
for LBP patient 
education 
- Instruction on 
how to 
perform the 
behaviour 
Day 2  
09:20-
10:00 
Demonstration BetterBack 
model 
treatment tools 
Group education 
To understand how to 
use the 
implementation tools 
for LBP patient 
education 
- Instruction on 
how to 
perform the 
behaviour 
 
Day 2  
10:00-
10:20 
Swedish fika 
Reflection 
Informal discussion about 
which patients group 
education is relevant 
To reflect on the 
practical use of the 
BetterBack model 
- Social support 
Day 2  
10:20-
11:00 
Demonstration BetterBack 
model 
treatment tools 
Exercise program 
To understand how to 
use the 
implementation tools 
for an exercise 
program for LBP 
- Instruction on 
how to 
perform the 
behaviour 
Day 2  
11:00-
12:00 
Task 
Use of 
implementation 
tools 
Participants are divided 
into 3 work groups who 
each transition between 
3x30min patient scenario 
workstations. Participants 
practice the application of 
the BetterBack model 
treatment tools using 
To develop practical 
skills in the use of the 
BetterBack model 
treatment tools 
- Behavioural 
practice/rehearsal 
- Feedback on 
behaviour 
- Social support  

 
 75 
 
 
 
 
 
therapist-patient role-play. 
Feedback is provided from 
the tutor and between 
peers 
Day 2  
12:00-
13:00 
Lunch break 
 
 
 
 
Day 2  
13:00-
13:30 
Task continued Use of 
implementation 
tools 
Participants are divided 
into 3 work groups who 
each transition between 
3x30min patient scenario 
workstations. Participants 
practice the application of 
the BetterBack model 
treatment tools using 
therapist-patient role-play. 
Feedback is provided from 
the tutor and between 
peers 
To develop practical 
skills in the use of the 
BetterBack model 
treatment tools 
- Behavioural 
practice/rehearsal 
- Feedback on 
behaviour 
- Social support  
Day 2  
13:30-
14:00 
Task 
Feedback on 
work with 
patient 
scenarios 
Each group discuss and give 
feedback on their work 
with the first patient 
scenario station (10min per 
group) 
To develop practical 
skills in the use of the 
BetterBack model 
treatment tools 
- Graded task 
- Verbal 
persuasion about 
capability 
Day 2  
14:00-
14:30 
Demonstration BetterBack 
model of care 
website 
Display of to navigate the 
BetterBack model of care 
website 
To understand how to 
use the  BetterBack 
model of care website 
- Instruction on 
how to 
perform the 
behaviour 
Day 2  
14:30-
15:00 
Task 
Potential future 
outcomes of  
the 
BetterBack 
model of care 
implementation 
Participants write on post-
it notes the most important 
future outcomes of the 
BetterBack model of care 
implementation based on: 
1. A professional 
perspective 
2. A patient perspective 
To appreciate the 
potential outcomes of 
the BetterBack 
model of care 
- Comparative 
imagining of 
future outcomes 
Day 2  
15:00-
15:30 
Presentation 
 
Clinical champion presents 
an administrative action 
plan (designed earlier in 
consensus with clinical 
colleagues) for the 
implementation of the 
BetterBack model of care 
at their clinic  
To reflect on the 
practical use of the 
BetterBack model of 
care website 
- Action planning 
Day 2  
15:30-
15:50 
Questionnaire Participating 
physiotherapists 
record 
background 
information, 
PABQ, PCQ, 
DIBQ 
Participants receive 20 
minutes to complete the 
questionnaire 
To generate 
descriptions recorded 
by physiotherapists 
before and after 
BetterBack model of 
care 
 
Day 2 
15:50-
16:00 
Diploma 
 
Participants completing the 
workshop receive a CME 
diploma 
 
- Incentive