What motivated you to look beyond the effectiveness of goal setting and pain science education and instead explore the mechanisms driving their impact? 

A 2019 trial by Gardner et al (bjsm.bmj.com/content/53/22/1424) demonstrated that patient-led goal setting combined with pain science education produced clinically meaningful and sustained benefits in pain and disability for people with chronic low back pain. 

Yet the mechanisms driving these benefits were unexplored. 

Growing recognition in the field highlights the importance of evaluating mechanisms within randomised trials, not only to establish whether an intervention works but to understand how and why it does or doesn’t work. 

This mediation analysis helped identify the processes underpinning change and informed the refinement of the CAPACITY intervention, which is now being tested to support implementation of patient-led goal setting and pain science education in practice. 

Your analysis found that pain self-efficacy explained most of the reduction in disability. Why is building self-efficacy so important in chronic low back pain care? 

Pain self-efficacy is consistently suggested as a contributing factor to long-term pain and disability in chronic low back pain. 

It refers to a person’s confidence in performing tasks and managing daily activities despite pain. 

It shapes how people respond to pain, including whether they are able to persist with activities, maintain work and continue with their social roles. 

Low self-efficacy often stems from beliefs about the incurability of the pain or fears of worsening symptoms through activity, leading to avoidance. 

Those with high self-efficacy can show greater effort, persistence and resilience. Self-efficacy and competence are closely linked. 

As patients build skills, overcome barriers and experience success, they develop the confidence to manage pain and re-engage with meaningful activities long-term. 

Fear of movement (kinesiophobia) also emerged as a key mediator. How can physiotherapists address unhelpful beliefs about activity and harm in everyday practice? 

Clinicians can help by encouraging gradual re-engagement in meaningful activities, providing reassurance that activities are safe and achievable and communicating about chronic low back pain in ways that both legitimise the person’s experience and reduce the perceived threat. 

Listening for statements like ‘If I bend, I’ll injure my back’ and addressing them with clear, relatable explanations can help reframe beliefs. 

Pairing education with movements that feel safe, graded exposure and reinforcing positive experiences provides powerful ‘mini-evidence’ that helps reframe threat. Over time, these strategies improve knowledge, build new skills and encourage the development of problem-solving abilities, which help patients tackle challenges in the long term. 

Health-related quality of life was another important pathway. What practical steps can clinicians take to ensure that treatment goals connect with patients’ broader life values and priorities? 

Eliciting meaningful goals requires understanding individuals’ experiences of pain beyond physical symptoms, including their beliefs, confidence, coping strategies, expectations, challenges, valued activities and context. 

Building trust and identifying the emotional significance of goals is critical. 

This involves listening carefully, validating experiences, acknowledging the patient’s story and being curious. 

It is also important to demonstrate empathy, explore possibilities for the person’s future and respect their unique circumstances. 

Quality of life extends beyond activity or symptom reduction. It also includes broader life values, ambitions, identity and relationships. 

Stress appeared to play a smaller role than the other mechanisms. How should we interpret this finding and does it mean stress is less relevant in back pain management? 

Our analysis suggests that stress played only a small role in explaining improvements but that doesn’t mean it is unimportant. 

Stress may still be a meaningful contributor to pain and disability but within the context of how the trial intervention was designed and provided, it was not the main driver of change. 

Mechanisms often overlap or inform each other; targeting one mechanism (such as self-efficacy) may indirectly reduce stress or fear. 

Stress may therefore be best addressed within broader strategies that build confidence, reframe threat and help people re-engage with valued activities. 

Looking ahead, how can understanding these mechanisms shape the next generation of physiotherapy interventions for chronic low back pain? 

Biopsychosocial interventions, though based on different theoretical models, may share common mechanisms of action. 

Identifying these mechanisms explains similarities across treatments and offers opportunities to refine both new and currently available interventions. 

Knowing which mechanisms matter most allows us to design targeted, scalable approaches in efficient and meaningful ways. 

If pain self-efficacy is central to chronic low back pain, physiotherapists should embed strategies that intentionally help patients build confidence in engaging with activities despite pain. 

We can learn a lot from our colleagues in psychology and the strategies they have been applying for decades. 

Targeting specific mechanisms doesn’t replace addressing other factors but it does help clarify the core ‘active ingredients’ that may underpin care. 

>>Emily Walker is a PhD candidate at the University of New South Wales and Neuroscience Research Australia, using process evaluation to understand patient-led goal setting and pain science education. She is an exercise physiologist and an associate lecturer at the University of New South Wales, teaching research methods and musculoskeletal health.

• References