Introduction

Low back pain remains undoubtedly one of the most disabling musculoskeletal conditions. Nearly everyone will experience low back pain now or later on in life. In some people, pain develops to be more chronic. Often, these people with chronic low back pain have negative pain cognitions, frequently caused by misinformation, contributing to their pain experience. Poor illness beliefs are among the negative contributing factors thought to influence low back pain and recovery. By studying how people feel before and after their recovery from persisting low back pain and how this integrates with quantitative data, this study wanted to answer how people make sense of the variables contributing to their low back pain recovery journey.

Methods

By using a mixed methods design this study combined qualitative and quantitative approaches within a single-case design framework. Participants were eligible to participate in this study when they had low back pain for more than 3 months which was disabling and nonspecific. Disabling low back pain was defined as having a score of at least 5 on the Roland Morris Disability Questionnaire (RMDQ).

All participants participated in a 12-week Cognitive Functional Therapy (CFT) intervention following a 5-week baseline period, during which measurements were collected and an interview was conducted. Following the 12-week CFT intervention, a 5-week follow-up period with another interview and quantitative data collection was held.

Cognitive Functional Therapy (CFT) is a tailored, physiotherapy-led strategy for treating chronic musculoskeletal pain, particularly low back pain. CFT combines cognitive and behavioral techniques with physical rehabilitation, addressing the psychological, social, and physical variables that contribute to a patient’s pain and handicap.

The main components of CFT are:

• Education: Patients are given information to assist them in comprehending the multifaceted nature of their pain, which includes confronting harmful ideas and worries about mobility and damage.
• Exposure Therapy: Patients are gradually exposed to fearful movements and activities in a controlled setting, which assists them in overcoming avoidance habits and regaining confidence in their physical abilities.
• Movement Retraining: CFT aims to repair dysfunctional movement patterns and promote relaxed, efficient, and pain-free movement.
• Psychological Support: CFT addresses psychological aspects like fear, anxiety, and catastrophizing by incorporating cognitive-behavioral techniques to reduce the emotional impact of pain.

The current study was not an effectiveness study. CFT has already earned his praises in earlier trials, like the study we reviewed a while ago.

Qualitative data were collected from semi-structured interviews in which participants’ beliefs, experiences, and emotional responses related to movement and posture in the context of their low back pain. The baseline interviews examined initial beliefs, and the follow-up interviews reflected on changes post-intervention.

Using questionnaires and wearable sensors, disability, self-efficacy, catastrophizing, and spine kinematics were collected respectively.

• Pain intensity, interference, and bothersomeness were all rated on a 0-10 numeric rating scale.
• Pain-related activity limitations were assessed using the Roland Morris Disability Questionnaire (RMDQ), and the Patient-Specific Functional Scale (PSFS)
• Pain-related cognitions were measured with the
  • Pain Self-Efficacy Questionnaire (PSEQ),
  • Pain Catastrophizing Scale (PCS),
  • Body perception-Fremantle Back Awareness Questionnaire (Fre-BAQ).
  • Pain Controllability-3 items questionnaire
  • Back pain beliefs-Back Pain Attitudes Questionnaire (Back-PAQ)
  • Answer to “I trust my back” on a 0 (= no trust) to 10 (= complete trust) scale
• Pain-related emotion was assessed via
  • Fear of movement – Tampa Scale of Kinesiophobia (TSK)
  • Short-Form Örebro Musculoskeletal Pain Screening Questionnaire
• Using wearable sensors postures and movements were analyzed weekly.
  • Lumbar muscle activity
  • Saggital plane kinematics

These data were collected and integrated into this mixed methods design. As part of the integration process, a collaborative display was made to show how shifts in movement patterns and attitudes relate to specific clinical outcomes.

Results

Twelve participants with persisting, disabling non-specific LBP were recruited and completed the study. They were on average 39 years and had low back pain for over a mean period of 4 years (range 11 months to 17 years). They had high levels of disability, measured through a score of 17.5 out of 23 on the RMDQ (range 12-22). They were at risk for work disability as objectified through the average score of 56.5/100 on the Short-Form Örebro Musculoskeletal Pain Screening Questionnaire (range 41-79).

Baseline

The qualitative interviews revealed that the overarching theme was low back protection. Some people protected their backs consciously.

Others had adopted a form of nonconscious lower back protection.

The people who adopted a strategy of conscious protection often followed some “rules” around moving and posture. Some had imposed their own rules, but these “rules” commonly originated from previous encounters with healthcare professionals and societal beliefs.

Those with conscious protection were protective in movement and postural patterns, but they also avoided several perceived threatening tasks.

Some participants indicated that these protective patterns were helpful and helped them control their pain. But further questioning revealed how the conscious protective behaviors contrasted with a lack of conscious protection or concern about their back before they had pain. Although this contrast emerged, this conscious protection was maintained despite some participants describing situations where more relaxation was less painful, or when muscle tension and following ‘postural rules’ exacerbated their suffering.

The assessment of the cognitions of these people at baseline revealed that many thought there was something structurally wrong with their spines (“damaged”, “broken”, or “injured”). Further, they thought that they had “bad” postures or they moved “wrong”. Together, they believed that they had a fragile back vulnerable to further damage or injury.

These beliefs originated from either strong aversive pain experiences or healthcare encounters and societal beliefs.

The assessment of the emotions these people experienced showed that constantly protecting their spines led to higher pain vigilance and negative emotions such as frustration, fear, worry, and depression.

Follow-up 

The interviews taken after the 12-week CFT program revealed that most participants were no longer protective of their backs. They reported that not protecting themselves by learning how to relax and regain normal movement patterns during threatening situations helped them to reduce their pain. In turn, this influenced their beliefs about damage and worry positively.

Some had to focus on moving or putting themselves in “less-protective” or “non-protective” ways (conscious non-protection), while others progressed to automatic habitual and fearless movements and postures (nonconscious non-protection).

Those who switched to conscious non-protection after their low back pain recovery indicated that they learned to consciously use relaxing and breathing techniques when pain arose during movement/postures and they indicated that this reduced their pain. Although most people adopting the strategy of conscious non-protection felt that this was obvious, others had to be more attentive to imply those altered strategies.

People were often surprised to learn that this relaxation technique made their pain disappear. Changing one’s movement and posture to reduce pain was a significant learning experience, frequently surprising due to its simplicity and contrast with usual healthcare advice. These experiences challenged their earlier views about spinal injury, transforming previously painful movements into restorative opportunities. This approach was aided by new clinician communications that granted authorization to move rather than previous messages of ‘do not move’, ‘protect’, or ‘avoid’.

Another group of participants switched to nonconscious non-protection strategies. These participants progressed to habitual and instinctive movements and postures. The switch from conscious non-protection to nonconscious non-protection let those people regain automatic, fearless movements. Even, they no longer considered themselves to have a back problem. You could say that they had a successful low back pain recovery despite having a longstanding history of pain.

Following low back pain recovery, the cognitions of these people changed significantly. Most of the participants no longer believed that damaged structures were causing their pain. They had understood that their protective patterns (consciously or unconsciously like muscle tension) had been a dominant contributor to their pain.

These changes in cognitions were facilitated by experiential learning and personalized evidence-based education. Learning that less or no pain arose during perceived threatening tasks made participants think about their previous understandings of what was causing their pain. Experiencing that those “threatening” movements were safe helped them to understand that their bodies were not fragile or vulnerable.

Instead of uncertainty, participants said the evidence-based instruction that accompanied the experiential learning helped them make sense of their pain. Some participants also reported increasing their self-efficacy and being discharged from care.

Altogether, the reconceptualization of the links between their movements, postures, and the relationship with pain, led to a shift in emotions. Fear, worry, anxiety, frustration, and depression shifted to happiness, hope, confidence, and trust.

Ultimately, the goal of this study was to examine how qualitative data on pain, posture, and movement seen from the participants’ eyes integrated with quantitative data. The quantitative data on muscle tension and sagittal spine kinematics supported the qualitative findings. The objective biomechanical measures and self-report questionnaires frequently supported participants’ perceptions about their movement and postures.

Some participants had increased movement speed, but not their range of motion (P1), while for others, speed did not change, but range did (P5), and for some, both changed (P8).

Questions and thoughts

This population was largely affected by low back pain and had been suffering for many years. They had consulted multiple healthcare practitioners over the years and were frequently taking medication for their lower back pain. Many had reported taking significant time off work due to their lower back pain. As such, this study included a population of people who had been affected on various levels for many years.

Given that there was some variation in how participants conceptualized the relationship between their movement, posture, and low back pain during the follow-up interview (protection, conscious non-protection, or nonconscious non-protection), it was investigated whether participants who progressed to nonconscious non-protection (n = 7) improved more in activity limitation, movement, and psychological factors than those who remained consciously non-protective (n = 4). Graphs showed that those who proceeded to nonconscious non-protection experienced greater benefits than those who stayed consciously non-protective.

As healthcare professionals, I think we have to be aware of the way people understand our well-intentioned messages. Shifting the way we speak could have a large impact on how people conceptualize pain.

Talk nerdy to me

Almost all of the participants (11 out of 12) in the follow-up interviews after the 12-week CFT intervention discussed the significance of “less protective” techniques—which were often surprisingly effective—in lowering pain. Rather than worrying about, protecting, or avoiding movements and postures, participants felt they could reduce their pain by being ‘less protective’ during threatening activities such as bending, lifting, sitting, or standing. In this approach, non-protective movements and postures become helpful rather than harmful.

The picture just above sums up nicely. In most participants, a shift from protective behavior or symptoms to non-protection significantly reduced negative factors surrounding people’s pain. This shift was seen both in objective and subjective data.

For example:

Clinicians should take their clinical population’s profile into account while evaluating transferability, as the study only included 12 participants with BMIs under 30. The possibility of desirability bias should also be considered.

Take home messages

This study followed people with disabling chronic low back pain in their low back pain recovery journey. These participants were interviewed about their pain and how they related it to posture and movement. The qualitative data indicate a considerable shift in how individuals perceive the link between movement, posture, and low back pain. At first, the participants believed that uncomfortable movement and postures posed a threat and that they sought to protect their supposedly injured back. During the follow-up, the participants saw movement and posture (that was relaxed) as a therapeutic recovery technique, implying that it was safe to move.

Reference

Wernli K, Smith A, Coll F, Campbell A, Kent P, O’Sullivan P. From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain. Eur J Pain. 2022 Nov;26(10):2097-2119. doi: 10.1002/ejp.2022. Epub 2022 Sep 5. PMID: 35959703; PMCID: PMC9826080.