It has been acknowledged that just because a factor is prognostic (has been found to be related to outcome) does not mean it is necessarily causally related to outcome.

25, 26 These factors, known as treatment mediators, help explain how a treatment led to an effect on the outcome of interest 27 by looking at which factors change as a result of treatment, which are then related to a change in the outcome. To improve the effectiveness of future interventions, key factors explaining improved patient outcomes must be identified to guide interventions. 21, 22 However, it remains unclear how interventions addressing psychological factors improve patient outcomes, 23 with mixed results being found in primary care populations in particular. Guidelines on the management of LBP also recommend screening for and management of psychological factors. Psychological factors (eg, fear-avoidance behaviors and beliefs, 9– 17 catastrophizing thoughts, 9, 18 self-efficacy, 9, 19 and depression 9, 11, 14, 20) have been found to be strong predictors of LBP outcomes and evidence suggests that they are potentially important in influencing the effect of treatment. 5 Although the prognosis of patients with an acute episode of LBP is often good, 6, 7 prognosis varies substantially for individual patients 8 and persisting symptoms are reported by many patients up to a year after their initial consultation. 4 In the UK, musculoskeletal (MSK) conditions are predominantly managed in primary care, with back pain being the most common reason for patient health care visits.

2 In the UK, LBP has been found to affect between 49% and 80% of the population at some point in their lifetime, leading to high costs in terms of health care, workplace absence, 3 and impact on individual quality of life.

Worldwide, the prevalence of low back pain (LBP) has been estimated to be 9.4% (95% confidence interval, 9.0-9.8), 1 with lifetime prevalence estimates of between 51% and 84%.

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