Joanne Marley and Daniel Kerr
Regular physical activity and/or exercise therapy are widely endorsed in clinical guidelines for the management of low back pain. These approaches have been shown to reduce pain and disability associated with low back pain and are often considered key components of an effective self-management strategy.
Although the terms physical activity and exercise are often used interchangeably, it has been recommended that the terms should not be confused. Physical activity can be defined as “any bodily movement produced by skeletal muscles that results in energy expenditure;” it occurs across several domains, including occupational and domestic activities, active commuting and sport, and leisure time activities. Exercise on the other hand is a subcategory of physical activity; it tends to be planned, structured and repetitive with a specific focus on improving or maintaining one or more components of physical fitness – such as muscle strength, power, flexibility, endurance or cardiovascular fitness.
Both exercise and physical activity play an important role in spinal health. Targeted exercises are often prescribed to address features that are believed to be contributing to an individual’s low back pain experience. Such interventions tend to focus on improving or restoring strength and flexibility and reducing pain and disability—dependent on the theoretical approach to the condition (e.g., core stability, McKenzie exercises). Physical activity is promoted on the basis that prolonged periods of inactivity during a bout of acute low back pain negatively affects prognosis. Physical activity advice largely encourages individuals to return to their normal daily activities as soon as possible. However, there is increasing recognition that broader health benefits need to be attained in this population: several studies have suggested that chronic low back pain (greater than 3 months) is associated with an increased risk of developing a range of comorbidities, including cardiovascular disease, a leading cause of global mortality. Improving physical activity levels is well recognized as an effective way of reducing the risk of mortality and morbidity.1 As previously outlined, the terms physical activity and exercise are often used interchangeably. Whilst both have a role in managing low back pain, it is important to distinguish between the two: a prescribed programme of exercise is arguably quite different from an intervention designed to change habitual activity behaviors.
Although significant health resources are utilized in managing low back pain and research in this area has been increasingly rigorous, there is little evidence that this has translated to improved clinical outcomes. Despite both physical activity and exercise being consistently endorsed in clinical guidelines, clinicians face many challenges when developing and implementing these recommendations into practice. This is attributable, at least in part, to a lack of clarity regarding the effective components or characteristics of an intervention. For example, a number of systematic reviews of physical activity and exercise have been unable to conclude with any degree of certainty if one particular form or intensity of exercise is superior to another.2,3 These results are reflected in the current recommendations made by the National Institute for Health and Care Excellence (NICE) which suggest that exercise regardless of its form should be encouraged in individuals with low back pain. Developing a better understanding of the effective components of interventions is likely to improve implementation and clinical outcomes.
This chapter explores common approaches used within exercise and physical activity interventions; it primarily focuses on idiopathic chronic low back pain (CLBP). Recent systematic reviews and clinical guidelines have been used to summarize the evidence and where possible to compare intervention characteristics and their influence on efficacy. Although explored as individual treatments, physical activity and exercise interventions may deliver the best patient outcomes when delivered within a biopsychosocial model of care. The following intervention characteristics will be discussed in this chapter in relation to their purported effectiveness.
Type of physical activity or exercise
- Stabilization, strengthening and flexibility
- Cardiovascular exercise
- Yoga and Tai Chi
- Physical activity interventions (walking programs, behavior change interventions)
- Modes of delivery
- Intervention content (techniques)
- Duration, intensity and frequency
- Intervention provider
TYPE OF PHYSICAL ACTIVITY OR EXERCISE
Numerous types of physical activity and exercise are used in the management of CLBP. The following section is not an exhaustive summary, but does explore some of the common types of physical activity and exercise that are advocated in the management of CLBP.
Stabilization, Strengthening and Flexibility
Stabilization exercises involve training and encouraging individuals to engage specific muscles and muscle groups such as the transversus abdominus, the lumbar multifidus and the pelvic floor. These muscles have been reported as having an important role in stabilizing the spine. Individuals receiving this form of therapy are instructed by health or fitness professionals to “engage” their stabilizing or core muscles prior to movement. Activation of this musculature is then progressively integrated into a series of more challenging or functional movements (e.g., loading the spine). These techniques were integrated into the management of low back pain based on the view that impaired motor control systems (delayed or decreased activation) can lead to decreased spinal support and increased stress and load on joints and ligaments. This interpretation has, however, been questioned and is considered unhelpful by many. Prescribing exercises to correct patho-anatomical problems can perpetuate unhelpful beliefs that CLBP is simply the result of a structural or biomechanical problem.
Stabilization, strengthening and flexibility exercises may encompass a number of approaches such as stabilization or core stability programs, motor control exercises, Pilates or more global strengthening and flexibility programs. These forms of exercise therapy are popular choices in clinical practice. A number of reviews have been conducted to examine the efficacy of stabilization exercises in the management of low back pain: the majority focus on chronic or recurrent non-specific low back pain.2,4,5 Consistent evidence was found across these reviews to support the use of stabilization exercises in comparison to controls in the management of low back pain. However, when comparisons were made with other forms of exercise, the reviews largely concluded that stabilization exercises appear no more effective, particularly in the long-term for reducing pain and disability. A Cochrane review that focused specifically on Pilates interventions concluded that although there is some evidence that Pilates is effective for low back pain (any duration), there is no conclusive evidence that it is superior to other forms of exercises.6 The National Institute for Health and Care Excellence (NICE) guidance for the management of low back pain and sciatica suggest that biomechanical exercises (including but not limited to Pilates, motor control exercises and core stability programs) show some benefits compared to controls in reducing back or leg pain and disability.
Aerobic exercise is usually performed in a continuous manner in order to increase the rate of breathing and to increase the heart rate. Aerobic exercise is often used to improve cardiovascular fitness, it can however also have a positive impact on mood and wellbeing and its broader health benefits are widely recognized.1 Given the high prevalence of conditions such as depression, obesity and cardiovascular disease in CLBP populations, there is an intuitive argument that aerobic exercise should be considered as a treatment option for primary and secondary benefit. There is some evidence that aerobic exercise can reduce pain and disability in individuals with CLBP.7
To explore the effectiveness of aerobic exercises in the management of CLBP, Meng and Yue7 conducted a meta-analysis of cohort studies. The authors reported positive effects on measures of both pain and disability following aerobic exercise. In contrast, a review and meta-analysis of randomized controlled trials conducted by Searle and colleagues8 reported that a subgroup analysis of cardiovascular exercise showed no demonstrable effects on CLBP. The authors conducted subgroup analyses of three other forms of exercise; coordination and stabilization, strength and resistance, or combined exercises, all of which demonstrated positive effects on reducing pain. This lack of agreement in research findings is reflected in the studies used to support the recommendations for aerobic exercise in CLBP in the NICE guidelines. In terms of pain, aerobic exercise was reported as more effective than controls only when it was individually delivered. Similarly, for disability, aerobic exercise was only more effective than controls in individual interventions and only in the short-term. In comparison to biomechanical exercise, aerobic exercise was either slightly less effective or generally equally effective in improving measures of pain and disability regardless of whether it was delivered in a group or on an individual basis.
Tai Chi and Yoga
Tai Chi and yoga interventions involve a series of postures or movements that are conducted in a controlled manner. Tai Chi was developed from martial arts and the movements conducted are designed to improve physical and mental wellbeing. Similarly, yoga is practiced for physical and mental well-being; however, it incorporates stretching, flexibility and strengthening achieved by holding postures. Breathing and meditation exercises are integral disciplines in the practice of yoga.
In a systematic review exploring the effectiveness of Tai Chi in the management of chronic musculoskeletal conditions,9 two studies on non-specific low back pain were analyzed as a subgroup. The results showed that for measures of short-term pain there was no significant difference between Tai Chi and no treatment. Tai Chi appeared to be more effective than no-treatment in measures of medium-term pain and medium-term disability (results from single studies only). The quality of the evidence underpinning these analyses was rated as very low, to low, and as noted by the authors, it is therefore difficult to draw any firm conclusions regarding the effectiveness of Tai Chi in managing CLBP. A further review exploring the effects of Tai Chi in chronic pain conditions conducted a subgroup analysis of three studies in low back pain populations.10 In contrast to the results of the previous review,9 Kong and colleagues 10 found that the aggregated results indicated Tai Chi significantly improved pain immediately post treatment. It is of note that despite both reviews conducting subgroup analyses of the effects of Tai Chi on low back pain, the studies used in each review were different. Only one study was included in both reviews. It is possible that different search strategies and languages will account for these differences. To date, it appears that relatively few studies have been reported on the effects of Tai Chi versus other forms of activity in the management of CLBP.
In Cochrane review of yoga treatment for CLBP,11 the authors found that in comparison to non-exercise-based controls, yoga interventions had a greater impact on pain and disability for short, medium and long-term outcomes. However, the changes in pain were not deemed clinically significant. The review authors were unable to conclude whether there is any difference between yoga and other exercise for back-related function or pain or whether yoga added to specific exercise programs is more effective than exercise alone. The findings from this review appear broadly comparable to those of similar systematic reviews of yoga in the management of CLBP.12,13 These results suggest that yoga appears to be effective in reducing pain and disability associated with CLBP; however, in comparison to other forms of exercise, there is no clearly superior treatment.
Physical Activity Behavior Change Interventions
As described previously, the terms exercise and physical activity should not be confused: exercise is considered a sub-category of physical activity. In contrast to “exercise” interventions, physical activity interventions may incorporate activities such as walking, gardening or domestic and work-related activities; they may or may not include an “exercise” component. Physical activity occurs across several domains; all contributing to the accumulative amount of activity accrued each day. Research has shown that even small improvements to overall levels of physical activity can lead to significant health benefits.1 Enabling individuals with CLBP to make and sustain changes to habitual physical activity behaviors could have an important impact on health and also in maintaining benefits achieved in clinical interventions. Physical activity interventions are often less focused on correcting or improving aspects of the musculoskeletal system and are more focused on changing patterns of behavior. It has been recommended that appropriate theory should be incorporated into the design and development of interventions aimed at changing health behaviors. Although both physical activity and exercise are endorsed in the management of back pain, most evidence is from exercise interventions. Physical activity has largely been promoted as it is known that prolonged inactivity is likely to adversely affect recovery. Whether physical activity interventions can produce effects similar to or better than exercise on CLBP and disability is uncertain; however, some evidence suggests that physical activity interventions, such as walking programs, may be promising.
A systematic review of randomized controlled trials14 found low quality evidence that walking improves disability in adults with CLBP. However, in comparison to other forms of exercise the authors found no evidence to suggest walking was more effective. Similarly, a review that included non-randomized studies found some evidence to support walking as an effective intervention strategy for low back pain (of any duration).15 However, it is noteworthy that the effects from individual trials included in this review varied considerably. A further review explored the effects of walking compared to non-exercise controls in the management of chronic musculoskeletal pain.16 Of the 26 studies included in the review, five were in CLBP populations. A meta-analysis of the 26 studies showed improvements in both disability and pain for short and medium term outcomes and disability in the long-term.
Of course, walking programs may not always focus on changing behavior; interventions may be lab-based treadmill walking programs or the intervention could be delivered as a cardiovascular exercise regime. These factors should be considered when reviewing and considering these forms of intervention. Although there appears to be little evidence to suggest walking as a superior form of intervention for CLBP, a higher level of adherence and lower direct health care costs in comparison to other exercise therapies have been reported.17 Suggesting there is a place for it in the management of this condition.
The quality of the description of interventions in publications is acknowledged as being poor. Whilst efforts are in place to improve the quality of reporting (TIDieR checklist/CERT), clinicians are still faced with the challenge of developing treatment programs and implementing recommendations into practice. As poor maintenance of physical activity or poor adherence to prescribed programs of exercise will compromise the effectiveness of these interventions, it is of critical importance that a better understanding of the influence of intervention characteristics is developed.
Modes of Delivery (Group, Individualized, Face-to-face or Remote)
Strategies to improve outcomes in exercise-based management of CLBP have suggested that individually tailored, supervised programs may be superior to generic or unsupervised exercise programs. It may be important to note that some studies, although not specific to CLBP populations, suggest that gender differences exist in relation to the types of and preferences regarding physical activity that males and females tend to engage in. These suggestions are in keeping with the current NICE guidance for the management of low back pain and sciatica. NICE suggest that clinicians should consider group based delivery of exercise programs within the National Health Service (NHS) and that peoples’ specific needs, preferences and capabilities should be taken into account when choosing the type of exercise. Although group-based interventions are frequently recommended, this likely reflects the cost-effectiveness as opposed to offering a clearly superior mode of delivery.
Interventions that are delivered remotely are becoming an increasingly common mode of delivery. These interventions also provide a potentially cost-effective method for delivering interventions, particularly in the long-term. Remotely delivered interventions include those delivered by telephone or written information. However, digital technology, such as internet or web-based interventions and apps, are increasingly used. The effectiveness of internet-based interventions has been demonstrated in a small number of exercise or physical activity interventions for CLBP low back pain.18,19 These interventions have shown positive but somewhat inconsistent effects on physical activity levels, pain, and disability. A review of web-based interventions in the general management of CLBP (not specific to exercise) found inconsistent and mixed results for measures of disability.20 In the general population a Cochrane review of remote and web-based interventions found consistent evidence supporting the effectiveness of these interventions in improving physical activity levels, but a further review21 could not establish whether face-to-face interventions or remote and web-based approaches were more effective at promoting physical activity.
Supervised, individually tailored group-based interventions appear to be practical and cost-efficient modes of delivery for exercise and physical activity interventions. The role and efficacy of remote and web-based interventions in reducing pain and disability or improving levels of physical activity in CLBP populations is, as yet, unclear. However, these interventions may offer some advantages over face-to-face interventions in terms of convenience of access and reduced costs.
Techniques to Improve Adherence and Changes in Physical Activity Behaviors
The techniques used within an intervention to encourage adherence can play an important role in effectiveness. It is, therefore, important to identify and foster techniques that are effective and to retire those that are not. Interventions that promote behavior change, such as exercise and physical activity, may be referred to as behavior change techniques. Behavior change techniques that are observable, replicable and irreducible have been described as the active components of an intervention.22 Taxonomies of behavior change techniques have strengthened the use of a standardized language to describe intervention content. It is hoped that this will lead to improved reporting and replication of intervention content.
Taxonomies have been used to describe intervention content in a number of physical activity behavior change interventions in both clinical and non-clinical populations. Across these interventions and consistent with NICE recommendations for individual level behavior change some consistent techniques appear to be associated with more effective interventions. These include self-monitoring behavior, providing feedback, goal setting and social support. These techniques are remarkably similar to behavioral techniques identified in a Cochrane review of adherence to exercise in the management of chronic musculoskeletal pain. The specific components associated with more effective interventions included providing positive reinforcement, using goal setting, providing feedback, self-monitoring (diary or logbook), using an exercise contract and using problem solving to overcome barriers to exercise. A review of techniques to improve adherence to therapeutic exercise in older adults with CLBP or arthritis found emerging evidence from individual high-quality trials that support the use of motivational strategies and behavioural graded exercise.23
This is an emerging area and further research is required to evaluate the efficacy of particular techniques in promoting exercise and physical activity specifically within CLBP populations; however, it would appear prudent for clinicians and researchers to consider incorporating techniques that are frequently associated with improved measures of adherence or successful behavior change.
Intervention Duration, Intensity and Frequency
The influence of duration, intensity and frequency of an exercise or physical activity intervention may somewhat depend on the specific aims and outcomes to be achieved. For example, the importance of these features may vary somewhat depending on the purpose of the specific intervention, i.e., improving muscle strength or improving cardiovascular fitness or making changes to behavior. However, in reality the majority of interventions are likely to include some variation of all of these elements with an overarching aim of reducing the symptoms and impact of CLBP on daily life. As CLBP populations are a heterogeneous group, the duration, intensity and frequency of any intervention will largely depend on the individual presenting for treatment. This approach is in keeping with recommendations that exercise should be tailored to the capabilities and preferences of the individual, even when delivered in a group setting. Nonetheless, some systematic reviews have demonstrated that higher intensity interventions—in terms of the overall intervention contact time—have been associated with greater improvements in pain and disability in adults with CLBP.24,25 However, the evidence is conflicting. A recent randomized controlled trial of physical activity promotion in CLBP reported that a multicomponent intervention was no more effective than a low intensity intervention in promoting physical activity at six months follow-up.19 Reviews of primary care interventions have concluded that brief and very brief interventions (delivered across various populations) are effective in improving physical activity levels. The influence of the duration, intensity and frequency at which an intervention is delivered and the effect this has, if any, on clinical outcomes is unclear.
For individuals with CLBP, exercise and physical activity advice is often provided by physiotherapists; however, other professionals such as general practitioners, psychologists, occupational therapists, nursing staff and fitness professionals also advise and provide guidance on physical activity and exercise. Similar to the duration, frequency and intensity of interventions, the most appropriate intervention provider will depend somewhat on the presentation of the patient. For example, those with high levels of psychological distress and disability are likely to require more specialist support or even multidisciplinary input in order to achieve good outcomes.
To improve the outcomes of exercise and physical activity interventions for CLBP, intervention providers need to receive appropriate support and training to enable them to effectively deliver and implement these forms of interventions. NICE suggest that all health and social care professionals should receive training and updating in behavior change knowledge, skills and delivery techniques. However, many challenges to the implementation of clinical guideline recommendations into practice persist: a better understanding of these difficulties and strategies for improving implementation need to be developed.
Multiple studies have investigated implementation strategies to hasten and improve the implementation of clinical guideline recommendations. The majority of this research appears to suggest that the passive dissemination of educational information through for example, clinical guidelines alone, is of little value in changing professional practices. In line with this, a recent systematic review synthesized implementation strategies used to improve the management of low back pain.26 The results of the review suggested that although implementation interventions could improve professional practice to ensure it was more in line with clinical recommendations, there were no clearly superior strategies for achieving this (education, audit, feedback, etc.). The authors concluded that single one-off implementation strategies are largely unsuccessful in changing professional practice and that implementation interventions that were more frequent, regular and sustained demonstrated greater success in changing clinical practice.
Physical activity and exercise, regardless off the specific form, or intensity should be promoted to individuals suffering from CLBP. As there is no clearly superior approach, interventions should be tailored to suit the needs of the individual. Group based interventions and interventions delivered in part or entirely remotely may have some economic advantages.
It is evident that the effects of exercise and physical activity interventions are modest and generally difficult to sustain in the longer term. To improve the outcomes of physical activity and exercise interventions in the management of CLBP behavior change is required on the part of both the service-user and the health professional/service-provider. Continuing to promote physical activity or exercise based on biomedical models may hinder progress in this area. Prescribing exercises to “stabilize” the spine or “educating” patients on exercise approaches based on spinal pathology using visual aids (spinal models) may be inadvertently reinforcing fears about back pain and/or catastrophizing symptoms. These approaches might encourage individuals to adopt maladaptive behaviors such as bracing or guarding prior to movement and fear of bending their spine. In the longer term this could have a negative effect on both prognosis and disability. Inadequate physical activity and exercise interventions may lead to poor service-user engagement and lessen the potential impact of these forms of interventions. To improve the current status quo factors influencing the promotion of physical activity by health professionals and factors influencing engagement in physical activity for those with CLBP need to be better understood. The appropriate structures then need to be in place to support the development and delivery of these forms of interventions.
Single therapies generally fail to achieve large positive effects for patients with CLBP. Whilst exercise and physical activity should be promoted, this should be done within the context of the patient presentation and within a biopsychosocial model of care. It should be considered that psychological, social, cultural or economic factors may have a more adverse effect than pain on the uptake or adherence to physical activity and exercise advice. It may be these are the important features that need to be addressed.
Although both exercise and physical activity interventions have a role to play in managing CLBP, at present, the evidence for exercise-based interventions is more abundant. However, physical activity interventions appear promising. Addressing habitual physical activity behaviors could influence the life course trajectory concerning not only CLBP related disability but also reduce the risk of developing comorbidities commonly seen in this population. It is possible that clinical outcomes will be improved if interventions are developed using appropriate theory and address the appropriate determinants of behavior.
PEARLS AND PITFALLS
- Clinicians should avoid making assumptions that a reduction in pain and disability will automatically lead to improved levels of physical activity. Habitual patterns of behavior, including patterns of physical activity, attribute to the development of most non-communicable diseases including chronic low back pain. Reductions in pain and disability alone are unlikely to change habitual patterns of behavior.
- Understanding the determinants of healthcare professional practice and service-user behaviors may improve the implementation of clinical guideline recommendations and the uptake and maintenance of physical activity and exercise advice.
- All activity appears to be helpful in managing chronic low back pain – as the type of activity does not appear to be overly important, helping individuals to re-engage with activities or hobbies that they enjoy are likely to be more achievable and sustainable
- Deficits in an individual’s Capability (physical and psychological), Opportunity (social and physical) or Motivation (automatic and reflective) to engage in desired behaviors should be considered and addressed.22
- Although there may be indications for specific targeted forms of exercise to address a particular pathological spinal problem these should not be confused with the majority of patients who have chronic non-specific low back pain
- Reducing pain is an important outcome in low back pain interventions, however, in the absence of a clearly efficacious treatment, broader outcomes such as sleep quality or mood should be routinely considered in practice and research
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- Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348.
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- NICE. Behaviour change: individual approaches. PH49. London: National Institute for Health and Care Excellence; 2014.
- NICE. Non-specific low back pain and sciatica: management. NG59. London: National Institute for Health and Care Excellence; 2016.
- Slade SC, Dionne CE, Underwood M, Buchbinder R. Consensus on Exercise Reporting Template (CERT): Explanation and Elaboration Statement. British Journal of Sports Medicine. 2016.
- WHO. Physical Activity Factsheet. 23 February 2018; http://www.who.int/mediacentre/factsheets/fs385/en/. Accessed June 5, 2018.
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- Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for chronic non-specific low-back pain. Cochrane Database Syst Rev. 2016(1):Cd012004.
- Chang DG, Holt JA, Sklar M, Groessl EJ. Yoga as a treatment for chronic low back pain: a systematic review of the literature. J Orthop Rheumatol. 2016;3(1):1-8.
- Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89(1):9-25.
- Wang XQ, Zheng JJ, Yu ZW, et al. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PloS one. 2012;7(12):e52082.
- Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for low back pain. The Cochrane Database of Systematic Reviews. 2015(7):Cd010265.
- Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phy Med Rehabil. 2015;94(5):358-365.
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- Wieland LS, Skoetz N, Pilkington K, Vempati R, D'Adamo CR, Berman BM. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;1:Cd010671.
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- Hendrick P, Te Wake AM, Tikkisetty AS, Wulff L, Yap C, Milosavljevic S. The effectiveness of walking as an intervention for low back pain: a systematic review. Eur Spine J. 2010;19(10):1613-1620.
- O'Connor SR, Tully MA, Ryan B, et al. Walking exercise for chronic musculoskeletal pain: systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(4):724-734.
- Hurley DA, Tully MA, Lonsdale C, et al. Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial (ISRCTN17592092). Pain. 2015;156(1):131-147.
- Krein SL, Kadri R, Hughes M, et al. Pedometer-based internet-mediated intervention for adults with chronic low back pain: randomized controlled trial. J Med Internet Res. 2013;15(8):e181.
- Schaller A, Dintsios C-M, Icks A, Reibling N, Froboese I. Promoting physical activity in low back pain patients: six months follow-up of a randomised controlled trial comparing a multicomponent intervention with a low intensity intervention. Clin Rehabil. 2016;30(9):865-877.
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- Michie S, Richardson M, Johnston M, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81-95.
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