Disability is an important outcome from a clinical and public health perspective. However, it is unclear how disability develops in people with low back pain or neck pain. More specifically, the mechanisms by which pain leads to disability are not well understood. Mediation analysis is a way of investigating these mechanisms by examining the extent to which an intermediate variable explains the effect of an exposure on an outcome. This systematic review and meta-analysis was aimed to identify and examine the extent to which putative mediators explain the effect of pain on disability in people with low back pain or neck pain. Five electronic databases were searched. We found 12 studies (N=2,961) that examined how pain leads to disability with mediation analysis. Standardized regression coefficients (â) of the indirect and total paths were pooled. We found evidence to show that self-efficacy (â = 0.23, 95% CI = 0.10-0.34), psychological distress (â = 0.10, 95% CI = 0.01-0.18), and fear (â = 0.08, 95% CI = 0.01-0.14) mediated the relationship between pain and disability, but catastrophizing did not (â = 0.07, 95% CI = -0.06-0.19). The methodological quality of these studies was low and we highlight potential areas for development. Nonetheless, the results suggest that there are significant mediating effects of self-efficacy, psychological distress, and fear, which underpins the direct targeting of these constructs in treatment.

Guidelines for low back pain (LBP) often recommend the use of self-management such as unsupervised exercise, booklets, and online education. Another potentially useful way for patients to self-manage LBP is by using smartphone applications (apps). However, to date, there has been no rigorous evaluation of LBP apps and no guidance for consumers on how to select high-quality, evidence-based apps. This chapter reviews smartphone apps for the self-management of LBP and evaluates their content quality and whether they recommend evidence-based interventions. This chapter shows that generally app developers are selecting interventions that are endorsed by guidelines, although their quality is low. There are many apps available for the self-management of LBP, but their effectiveness in improving patient outcomes has not been rigorously assessed. App developers need to work closely with healthcare professionals, researchers, and patients to ensure app content is accurate, evidence based, and engaging.