Article Text

Original research
Direct and mediated effects of treatment context on low back pain outcome: a prospective cohort study
  1. Felicity Bishop1,
  2. Miznah Al-Abbadey1,2,
  3. Lisa Roberts3,4,
  4. Hugh MacPherson5,
  5. Beth Stuart6,
  6. Dawn Carnes7,
  7. Carol Fawkes7,
  8. Lucy Yardley1,8,
  9. Katherine Bradbury1
  1. 1Department of Psychology, University of Southampton, Southampton, UK
  2. 2Department of Psychology, University of Portsmouth, Portsmouth, UK
  3. 3Health Sciences, University of Southampton, Southampton, UK
  4. 4Therapy Services, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  5. 5Health Sciences, University of York, York, UK
  6. 6Primary Care and Population Sciences, University of Southampton, Southampton, UK
  7. 7Institute of Population Health Sciences, Queen Mary University of London, London, UK
  8. 8School of Psychological Science, University of Bristol, Bristol, UK
  1. Correspondence to Dr Felicity Bishop; F.L.Bishop{at}


Objectives Contextual components of treatment previously associated with patient outcomes include the environment, therapeutic relationship and expectancies. Questions remain about which components are most important, how they influence outcomes and comparative effects across treatment approaches. We aimed to identify significant and strong contextual predictors of patient outcomes, test for psychological mediators and compare effects across three treatment approaches.

Design Prospective cohort study with patient-reported and practitioner-reported questionnaire data (online or paper) collected at first consultation, 2 weeks and 3 months.

Setting Physiotherapy, osteopathy and acupuncture clinics throughout the UK.

Participants 166 practitioners (65 physiotherapists, 46 osteopaths, 55 acupuncturists) were recruited via their professional organisations. Practitioners recruited 960 adult patients seeking treatment for low back pain (LBP).

Primary and secondary outcomes The primary outcome was back-related disability. Secondary outcomes were pain and well-being. Contextual components measured were: therapeutic alliance; patient satisfaction with appointment systems, access, facilities; patients’ treatment beliefs including outcome expectancies; practitioners’ attitudes to LBP and practitioners’ patient-specific outcome expectancies. The hypothesised mediators measured were: patient self-efficacy for pain management; patient perceptions of LBP and psychosocial distress.

Results After controlling for baseline and potential confounders, statistically significant predictors of reduced back-related disability were: all three dimensions of stronger therapeutic alliance (goal, task and bond); higher patient satisfaction with appointment systems; reduced patient-perceived treatment credibility and increased practitioner-rated outcome expectancies. Therapeutic alliance over task (ηp2=0.10, 95% CI 0.07 to 0.14) and practitioner-rated outcome expectancies (ηp2=0.08, 95% CI 0.05 to 0.11) demonstrated the largest effect sizes. Patients’ self-efficacy, LBP perceptions and psychosocial distress partially mediated these relationships. There were no interactions with treatment approach.

Conclusions Enhancing contextual components in musculoskeletal healthcare could improve patient outcomes. Interventions should focus on helping practitioners and patients forge effective therapeutic alliances with strong affective bonds and agreement on treatment goals and how to achieve them.

  • rehabilitation medicine
  • primary care
  • back pain
  • complementary medicine

Data availability statement

Deidentified participant data may be requested from the corresponding author, FB ( Access may only be permitted for the purposes of checking the reported analyses and an analysis plan must be submitted with any request for access to the data. Due to ethical considerations, reuse for any other purpose is not permitted.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Deidentified participant data may be requested from the corresponding author, FB ( Access may only be permitted for the purposes of checking the reported analyses and an analysis plan must be submitted with any request for access to the data. Due to ethical considerations, reuse for any other purpose is not permitted.

View Full Text

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Twitter @Flis_Bishop_PhD

  • Deceased Deceased

  • Contributors FB led the study conception and design and drafted the manuscript. FB, KB, HM, LY and LR conceptualised the study and drafted the protocol and the associated grant application. FB, KB, HM, LY, MA-A, DC, CF and LR drafted the manuscript. MA-A was the research fellow on the study, responsible for data collection under the supervision of FB and KB and in collaboration with all authors. BS undertook the statistical analysis. All authors revised the manuscript critically for important intellectual content and gave final approval of the version to be published.

  • Funding This work was supported by Arthritis Research UK Special Strategic Award grant number 20552.

  • Competing interests FB received an honorarium and travel expenses for presenting the preliminary results of this research at the Acupuncture Research Resource Centre research symposium and has also received speaker’s fees and travel expenses from the Acupuncture Association of Chartered Physiotherapists. The authors declare that they have no other competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.