Chronic lower back pain (CLBP) is the chronic experience of low back pain (LBP), which may be defined as “pain and discomfort below the costal margin and above the inferior gluteal folds, with or without referred leg pain” [1]. While LBP may be acute, CLBP is diagnosed as lasting seven to 12 weeks, or long-term intermittent recurrence [1]. CLBP can result from intervertebral disc degeneration, internal disc rupture, disc displacement, and a variety of other conditions [2]. These conditions can be caused by individual genetics and physiology, posture, heavy physical work or activities such as weightlifting, and lifestyle and psychological factors [1].

LBP is one of the most frequently reported musculoskeletal problems on the global scale. Hoy, et al.’s [3]systematic review of global studies (1980-2009) estimated that 23.2% of adults experienced LBP on a monthly basis, with the highest occurrence being for women and people aged 40 to 80 years. Although LBP may be relatively easily managed, CLBP can be much more difficult to manage, and as a result is a leading cause of disability in many countries [2]. Furthermore, the prevalence of LBP is expected to increase as the global population ages [3]. Thus, both LBP and CLBP need to be considered as serious public health concerns, even though they are frequently dismissed as minor health issues.

As in other countries, LBP and CLBP is a significant public health problem. One cohort study, which included 42,785 participants (2009 and 2013 waves) determined that 30% of the cohort reported CLBP [4]. This compares to 36.8% who reported no back pain, 21.7% who reported reverting back pain, and 15.3% who reported a single incident. CLBP sufferers were more likely to report limitations on everyday activities like climbing stairs (22.1%), walking 100 meters (26.8%), bending or stooping (62%) and dressing oneself (24.2%). Another study investigated causes of CLBP among Thai patients, finding that incorrect lifting and heavy lifting, along with incorrect posture and positioning, were among the most frequent causes of LBP [5].

Charoenchai, et al. [5] showed that income was a relevant predictor of CLBP, other studies have shown that LBP incidents and CLBP are common across different sectors of Thai society. In a study of migrant fruit farm workers, CLBP was one of the most frequently reported musculoskeletal disorders, reported by 41.3% of workers (including 38.9% of men and 44.7% of women] [6]. A survey of rice farmers found that lifetime prevalence of LBP was 77%, with one-year prevalence of 56% and point prevalence of 49% [7]. Prevalence was found to be similar across the adult lifespan, although women (61%) were at somewhat more risk than men (51%) for the one-year prevalence [7]. White-collar workers are also at risk. For example, one study of university workers showed that 83% of participants reported LBP over the course of a year (8). A second study, which examined dental health workers, found that point prevalence of LBP was 31.5%, with men (50%) being somewhat more likely to report this symptom than women (25.5%) [9]. Thus, even though CLBP may be more common among blue-collar and agricultural workers in Thailand, it can be considered to be a society-wide health problem.

There are a wide range of potential treatments available for CLBP, although the effectiveness of these treatments varies. Among the best-supported of these treatments are pharmacological treatments including nonsteroidal anti-inflammatory drugs (NSAIDs) [10,11] opioid analgesics [12] and muscle relaxants [13]. However, some pharmacological treatments are frequently used but may not be effective, like anti-depressants (14) or may have short-term effects only, like steroidal injections [15]. Non-pharmacological treatments including mild to moderate exercise, including physiotherapy and strengthening exercises [16,17], cognitive behavioral therapy (CBT) [18], and many other non-invasive treatments. In addition to these non-invasive treatments, there are surgical treatments such as lumbar fusion and decompression, which may be used in severe cases of CLBP [19]. However, comparison of surgical treatments against pharmacological, behavioral and other treatments has shown that it does not result in a statistically significant reduction in pain [20,21]. Furthermore, post-surgical rehabilitation can be difficult for patients, who may not experience improvements and whose pain levels and functional capabilities may decrease following surgery [19]. Therefore, surgical interventions should be considered as a last resort, rather than a first line of CLBP treatment and/or management.

Pain self-management (PSM) refers to the active participation of persistent pain sufferers in the management of their pain response [22]. The antecedents identified in the definition introduced by Stewart, et al. [22] include self-awareness of the need to participate, willingness and capability, and support from others. The process of PSM includes personal development (learning the skills and knowledge required to manage pain), response to symptoms and control of symptoms. Potential outcomes include physical and psychological health improvements, improved social function and quality of life, and full engagement with the pain management process [22]. A meta-analysis of patient outcomes showed that PSM programs moderately reduced pain intensity for participants [23]. This study also demonstrated that PSM may somewhat reduce disability rates, although this effect is smaller than the effect on pain intensity [23]. Several other systematic reviews have shown that PSM activities can improve outcomes for CLBP sufferers. One of these reviews examined studies on self-management of back pain reported up to 2011 [24]. Authors identified 2,325 different papers, which hinged on a total of 13 different trials. Their quantitative meta-analysis showed that there was a moderate improvement of pain and disability associated with the use of self-management practices. In the short-term, an average reduction of 3.2 points in pain (on a scale of 0 to 100), along with 2.3 points reduction in disability, was observed. In the long term, a reduction of 4.8 points in pain and 2.1 points in disability was also observed [24]. Another study included CLBP as one of the conditions in their review of studies on chronic disease self-management (along with many other diseases such as arthritis and others] [25]. Although taken together the findings showed that the effect of self-management on the disease itself was relatively small, the authors did show that effects of PSM on CLBP were moderate and significant according to several studies [25]. Taken together, these studies show that PSM can assist CLBP patients in reducing pain and improving quality of life by lessening chances of disability. Furthermore, Nolte and Osborne [25] also showed that self-management was associated with better knowledge about the patients’ condition. Thus, PSM can be a key tool to address some of the negative outcomes of CLBP, including pain and disability.

There are a variety of tools and modalities available for self-management of CLBP. Among the most basic PSM strategies, which may be implemented even by patients with little knowledge of their CLBP condition, include medication (including over-the-counter and prescription medication) and application of heat to the affected area [26]. Regular physical activity, ranging from everyday activity such as walking and functional training to activities like tai chi and yoga to strength training, has also been identified as a PSM strategy [26, 27], although only progressive strength training has sufficient evidence for its effectiveness [27]. Thai patients may have some PSM strategies that may not be widely available to CLBP sufferers in other regions. One of these strategies is Thai massage, which is an active massage modality [28] Thai massage has been estimated to be as effective as Swedish massage in relieving LBP. Technology-assisted psychological interventions, which use mobile phone apps or similar devices to teach techniques like self-assessment, cognitive behavioural therapy (CBT) and similar strategies, are also increasingly popular and have been shown to be effective [29]. However, these authors did caution that it is as yet too early to determine whether these technology-assisted tools are as effective as in-person psychological interventions.

Self-management interventions (SMIs), or individual or group educational sessions about the treatment of chronic pain, are an essential part of PSM, as it provides the information patients need to understand, self-assess and take steps to treat their pain [30]. These interventions are customized to the specific problems and capabilities of the patients involved, and thus are intended to help patients address their specific sources of pain. However, it is important to note that not all patients will be willing or able to undertake an SMI, and they may not finish the program. One study of a PSM educational program for chronic pain sufferers in the United Kingdom, for example, reported a 71% uptake of the program to those whom it was offered to [31]. Of those, 82% completed the program, leading to a total completion rate of 58.3%. Thus, PSM strategies may not be fully implemented over time.

The evidence on PSM suggests that it is one of the most commonly used, and potentially the most effective, strategies for CLBP pain management. Furthermore, the modalities of PSM may be different for Thai CLBP sufferers compared to the Western populations typically investigated. There has not been any substantive research into PSM strategies that Thai patients use for back pain. As a result, there is limited evidence on the PSM strategies of Thai CLBP sufferers, the source of these strategies, and how effective they are at controlling pain. Considering the breadth of causes and the frequency of experience of CLBP in Thailand, this constitutes a significant research gap. Thus, this exploratory research study was conducted to fill this research gap. This study aimed to investigate how people with chronic lower back pain (CLBP) in Thailand manage their pain and the effectiveness of these management strategies.

One of the key issues for discussion here is that the participants were not offered a formal educational intervention for PSM. Instead, they sought out their own sources of information, which could be highly variable. This is a potentially critical problem for the ability of patients to use PSM because one of the requirements for PSM is not just the willingness to participate, but also access to resources for learning and personal development about the practice [22]. For patients with little knowledge about PSM, the modalities they choose may be limited to only the most basic pain relief strategies, like use of over-the-counter medication and application of heated compresses [26]. On the other hand, patients that have access to formal PSM interventions, which provide customised knowledge about modalities that could be effective, typically have higher levels of PSM implementation [30] [though not all participants may choose to be involved [31].] The implication of this is that in order to be fully effective at PSM, Thai CLBP patients should be offered the opportunity to participate in a PSM intervention that provides education and reliable information about strategies. It should be noted that providing patient information and education is one of the clinical best practices guidelines for non-surgical treatment of low back pain, and is considered essential for patient success [36]. Thus, this actually is a significant gap in the clinical practice, and is something that while it is not currently addressed in the clinical practice guidelines should be included. This has been addressed with the clinic site and is in the process of being remedied.

Another key finding was that PSM interventions may be particularly useful for older patients, who were particularly concerned about the potential safety of various treatments, especially those like herbal treatments that did not have a lot of information or exercise, which they feared could exacerbate their pain. This is one area where nursing practitioners could play a critical care role, since they could identify the specific circumstances and complex set of patient needs. The literature did not strongly support the importance of PSM for older patients, but there are some indications that it may be more appropriate for them. For example, studies on SMIs have shown that patients enrolled in these interventions, and who complete them, do tend to be older [30,31]. At the same time, it is possible that interventions like guided exercise therapy [16,17], CBT [18] and pharmacological treatments like NSAIDs, opioid analgesics, and muscle relaxants [10–13] could be used effectively for older patients as well. While most patients in this study were using at least some oral medication, re-assessment of oral medications could be investigated to determine if they can be improved. However, surgical interventions are not recommended, especially for older patients, due to their relatively poor effectiveness and long and difficult recovery [19–21]. Overall, these findings as well as previous studies call for a more comprehensive assessment of the needs of older adults with CLBP, including both treatments and as noted above, educational and informational support methods that will reach them most effectively.

Another key finding of this research is that Thai CLBP patients do have some different PSM modalities to Western patients. One of these modalities, Thai massage, has been discussed in the literature previously and been shown to be as effective as Swedish massage at pain reduction [28]. However, other PSM modalities, especially the use of Thai medicine and herbal treatments such as herbal compresses, do not have as much evidence for their effectiveness. In contrast, technology assisted psychology interventions were not used, even though they are increasingly popular [29]. This could be because either they were not introduced by medical professionals (the educational gap discussed above) or because the sample was relatively older and did not make use of such tools regularly. These differences are potentially crucial to the outcomes of treatments, but they may not be.

This research showed that in order to successfully implement PSM, Thai patients involved in the study needed a significant amount of knowledge about PSM strategies and the causes of pain. Once the patients had this information, they frequently tried multiple PSM modalities, among which the most common were: exercise of different types; modifying food consumption; increased sleeping or rest; herbal treatments; hot compression; cold compression; Thai massage; and acupressure. The patients also used meditation and making merit as spiritual and psychological coping tools. However, not all patients tried or were successful with the same strategies. Factors like pain severity and support systems influenced which of these processes could be successful, as did religious belief and social support. Thus, no one PSM process was suitable for all patients. Another problem that was encountered was that there was limited knowledge and information available to patients on PSM. For example, patients were sometimes offered written documentation, but were not always offered PSM intervention sessions or personalized training on the practice of PSM. This means that some patients faced significant barriers in using PSM to its full potential.

In conclusion, this research showed that Thai CLBP patients used a combination of PSM modalities that are familiar from the Western literature (such as exercise and compression) and those that are not typically found in Western literature (such as Thai massage, herbal treatments, acupressure and meditation). This difference in PSM strategies points to the psychological nature of PSM and its effectiveness, demonstrating that cultural and spiritual context as well as physical intervention is a potentially important part of PSM education and treatment.

This study was limited in that it was a qualitative and exploratory study. Thus, the findings from these patients cannot necessarily be generalised, since the experience of a limited number of patients from one clinic is not necessarily representative of the breadth of CLBP PSM in Thailand. However, the research could be used as the basis for further inquiry into this question, for example by conducting a survey or more extensive interview based research. This could provide more extensive information about how PSM may be characterised in Thai or other Asian contexts and what cultural differences may influence the choice of PSM strategies and their effectiveness. Since CLBP is a global problem, this should be an area of global inquiry.