Aim: The aim of this project is to identify chronic low back pain patients´ beliefs about the origin and meaning of pain for developing a biopsychosocial web-based educational intervention. The other aim of this project is to assess the effectiveness of this web-based educational intervention for chronic low back pain patients on pain cognitions, pain intensity, and disability.

Methods: Mixed methods design, combining both qualitative and quantitative methodologies. For the qualitative part of this study, the investigators will use qualitative in-depth semi-structured interviews. For the quantitative phase we will use an experimental study design.

Subjects: Chronic low back pain patients between 18-65 years old, attending a primary care setting in the city of Lleida.

Expected outcomes: The investigators expect to change and modify chronic low back pain patients´ cognition by using our web-site educational intervention, with the further outcome of reducing pain and disability.

Hypothesis and outcomes

Hypothesis:

1. Persistent chronic low back pain and its consequences are maintained by the lack of understanding about the origin and meaning of pain.
2. Pain neurophysiology as an educational internet- based intervention for chronic low back pain will change cognition about the origin and meaning of pain, with the outcome of pain reduction, disability reduction, and better quality of life compared to normal care.

Outcomes:

There are specific objectives for each phase of the study.

Phase 1 (QUAL):

To identify chronic low back pain patients' beliefs concerning the origin and meaning of pain.

Phase 2 (Connecting procedure):

To construct and develop a biopsychosocial web- based educational intervention using the QUAL results.

Phase 2 (QUAN):

Primary outcome. To evaluate the effect of a biopsychosocial web-based educational intervention for chronic low back pain based on pain intensity compared to normal care.

Secondary outcomes. To assess the effect of a biopsychosocial web-based educational intervention for chronic low back pain compared to normal care on:

• Fear avoidance beliefs.
• Kinesiophobia.
• Disability.

Methodology Study design

To answer the research question, the authors will use a mixed-method sequential exploratory design. The pur- pose of mixed methodology is not to replace qualitative or quantitative methodologies, but to use the strengths of both while reducing their weaknesses. Specific- ally, the sequential exploratory design includes an initial qualitative phase followed by a quantitative phase, with the aim of developing an educational tool. In this project, we propose that both phases (qualitative and quantitative) must have the same relevance (QUAL- QUAN) for the development of the educational tool and that the development of the study must be conducted in three stages:

1. Qualitative data collection through semi-structured personal interviews followed by thematic analysis.
2. Construction of the educational tool with the results obtained in the previous step (topics or emerging categories).
3. Analysis of the effectiveness of the educational tool using a randomized controlled trial.

Scope: Primary care

SUBJECTS:

The recruitment process will be performed independently in each phase of the study, although in both phases this recruitment process will take place in the same pri- mary care centers in the city of Lleida through family physicians. The inclusion and exclusion criteria are also common to both phases. Prior to the beginning of the first phase, the first author of this study will perform a presentation of the project to the medical and nursing staff in each of the primary care centers involved in the study to ask for their cooperation.

QUAL: In this phase, patients will be recruited by their respective family physicians. Once the physician makes the diagnosis of CLBP and ensures that the individual meets the inclusion and exclusion criteria, the physician informs the patient about the existence of this project and invites him to contact the first author by telephone. If the person agrees to participate in the study, the inter- view will be scheduled to take place in the Faculty of Nursing and Physiotherapy of the University of Lleida.

QUAN: The recruitment process will start after the end of QUAL and the development of the educational tool. This phase will consist of an educational interven- tion using a randomized controlled trial design. The re- cruitment process will be the same as in QUAL. Prior to the beginning of the intervention, the first author will meet the study subjects individually to inform them of the study conditions and provide them with the informed consent form.

Inclusion Criteria:

1. History of CLBP longer than 6 months.
2. Patients between 20-65 years old.
3. To be able to read, speak and understand Spanish, Catalan, or English.
4. With access to the Internet, a computer or laptop and e-mail address.
5. To accept and sign the informed consent.

Exclusion Criteria:

• 1. Any red flag condition:

  • Onset age < 20 or > 55 years
  • Non-mechanical pain (unrelated to time or activity)
  • Thoracic pain
  • Previous history of carcinoma, steroids, HIV
  • Feeling unwell
  • Weight loss
  • Widespread neurological symptoms
  • Structural spinal deformity