ArticlePhysical therapy2026
Psychological mediators in chronic spinal pain after fully remote digital rehabilitation: a real-world, large-sample study.
Article in Physical therapy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
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Who cites it
1 citing paper in PubMed.
- Exploring the Impact of Behavioral Engagement Indicators on Pain Outcomes in AI-Enabled Musculoskeletal Rehabilitation: A Real-World Investigation.Journal of pain research · 2026Article
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5 authors.
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Abstract
importancePsychological factors are associated with chronic spinal pain, yet their mediating role in postrehabilitation recovery remains poorly understood, particularly in fully remote digital care. Most research has focused on baseline predictors, with few studies evaluating psychological mediators and moderators.
objectiveThe objective of this study was to investigate whether changes in fear avoidance beliefs, depression, and anxiety mediate pain outcome following a digital care program (DCP) for chronic spinal conditions and whether these effects vary by Body Mass Index (BMI), self-reported gender, and socioeconomic status.
designThis was an ad hoc analysis of a real-world registry of patients undergoing a DCP.
settingThe setting was a fully remote DCP delivered across the United States.
participantsThe participants were adults who had chronic spinal musculoskeletal pain (N = 14,818) and who accessed the DCP via employer-sponsored health plans.
interventionThe DCP consisted of exercise, education, and behavior change, managed asynchronously by physical therapists. MAIN OUTCOMES AND MEASURES: The final pain score (11-point numeric pain rating scale) was the primary outcome. Candidate mediators were changes in fear avoidance beliefs, depression, and anxiety. Confounding was mitigated through demographic and clinical covariates. Moderation was tested for BMI, self-reported gender, and socioeconomic deprivation. Structural equation modeling was used.
resultsImprovements in fear avoidance beliefs (β = -0.10, SE = 0.00), depression (β = -0.05, SE = 0.01), and anxiety (β = -0.04, SE = 0.01) significantly mediated lower final pain scores after adjustment for confounding. The mediating effect of fear avoidance was especially pronounced among patients with severe obesity. Self-reported gender and socioeconomic status did not show moderating effects. The model's explained variance was 30%. CONCLUSIONS AND RELEVANCE: Changes in fear avoidance beliefs, depression, and anxiety play a central role in pain recovery following digital rehabilitation. Fear avoidance mediation was particularly strong in individuals with severe obesity, highlighting the need for targeted psychological support in this subgroup. The findings emphasize the pertinence of systematically screening, monitoring, and addressing psychological factors in remote care, contributing to understanding how digital rehabilitation promotes recovery.
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