# Perceptions and use of self-management support strategies to improve the management of spine pain patients in a French-Canadian chiropractic teaching program: a mixed method study

## TL;DR

This study explores how chiropractic students and supervisors in a French-Canadian program perceive and use self-management strategies for spine pain patients, identifying barriers and facilitators to implementation.

## Contribution

The study introduces a mixed-methods approach to assess patient activation and provider beliefs in a chiropractic context, highlighting theoretical barriers to self-management support.

## Key findings

- Most patients showed moderate-to-high activation in their care.
- Interns and clinicians had limited implementation of evidence-based practice and self-management support strategies.
- Key barriers included knowledge gaps, environmental context, and social influences.

## Abstract

Clinical guidelines for managing non-specific spine pain recommend providing patient education and self-management support strategies (SMSS) as first-line treatment. However, SMSS implementation in daily chiropractic care remains challenging. This study aimed to assess the level of patient activation in their care, explore chiropractic senior interns and clinician supervisors’ beliefs about evidence-based practice (EBP) and self-management support, and identify theoretical barriers and facilitators to implementing SMSS.

We used a three-phase mixed-methods convergent design. In phase 1, during the spring and summer of 2022, 250 consecutive adults with spine pain at the outpatient chiropractic clinic at the Université du Québec à Trois-Rivières, Quebec, Canada, were invited to complete the patients’ activation measure (PAM). In phase 2, all senior interns (n = 39) and clinician supervisors (n = 29) were invited to complete three self-administered online questionnaires: 1) EBP Beliefs and Implementation Scales, 2) Pain Attitudes and Beliefs Scale (PABS), and 3) the Practice Style questionnaire. In phase 3, patients, interns and clinicians having completed the questionnaires were convened to semi-structured individual interviews based on the Theoretical Domains Framework (TDF).

In phase 1, three quarters of patients (76.3%) reported a moderate-to-high level of activation. In phase 2, interns and clinician supervisors had similar EBP Beliefs mean scores (62.8% and 62.5%, respectively) and EBP Implementation scores (28.6% and 38.2%, respectively). For the PABS, no predominant biomedical or behavioural treatment orientations were observed among interns (mean (SD) = 34.8 (6.3) /60 vs 36.7 (3.5) /48) or clinicians (34.7 (9.1) /60 vs 34.6 (4.9) /48). Interns primarily had a pragmatic practice style, whereas clinicians were equally pragmatic and receptive. In phase 3, four key TDF domains emerged for patients (Social influences, Behavioural regulation, Emotions, and Goals); five for interns (Knowledge, Environmental Context and Resources, Skills, Memory, Attention and Decision Process, and Goals), and four for clinicians (Knowledge, Environmental Context and Resources, Social Influences and Beliefs on Consequences).

Although patients demonstrated moderate-to-high activation, EBP and SMSS implementation among interns and supervisor was limited. Treatment orientation, practice style, and contextual factors highlight the need for targeted educational and organizational strategies to bridge the knowledge-practice gap.

The online version contains supplementary material available at 10.1186/s12998-025-00611-1.