From protection to non‐protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain

Abstract

Background Movement and posture are commonly believed to relate to low back pain (LBP). Yet, we know little about how people make sense of the relationship between their LBP, movement and posture, particularly after recovery. We aimed to qualitatively explore this understanding, how it changes and how it relates to quantitative changes. Methods A mixed method study in the context of an existing single‐case design involving 12 people with disabling non‐specific LBP. Interviews were conducted before and after a 12‐week physiotherapy‐led Cognitive Functional Therapy intervention, and qualitative findings from these were integrated with individualized, quantitative measures of movement, posture, psychological factors, pain and activity limitation. Results Strong beliefs about movement and posture were identified during the baseline interviews. Lived experiences of tension and stiffness characterized the embodiment of ‘nonconscious protection’, while healthcare and societal messages prompted pain‐related fear and ‘conscious protection’. Through varied journeys, most participants reported improvements over time with less protective movement and postural strategies. For some, being less protective required focused attention (‘conscious non‐protection’), but most returned to automatic, normal and fearless patterns (‘nonconscious non‐protection’), forgetting about their LBP. One participant reported no meaningful shift, remaining protective. Greater spinal range, faster movement, more relaxed postures and less back muscle EMG accompanied positive changes in self‐report factors. Conclusion The findings offer a framework for understanding how people make sense of movement and posture during the process of recovery from persistent, disabling non‐specific LBP. This involved a re‐conceptualisation of movement and posture, from threatening, to therapeutic. Significance Findings from qualitative interviews before and after a Cognitive Functional Therapy intervention in 12 people with disabling low back pain highlighted an individualized recovery journey from conscious and nonconscious protection to conscious non‐protection for some, and nonconscious non‐protection for many. Pre and post‐quantitative measures of movement, posture, psychological factors, pain and activity limitation integrated well with the qualitative findings. The findings suggest movement and posture may form part of a multidimensional pain schema.

The relationships between spinal amplitude of movement, pain and disability in low back pain: A systematic review and meta‐analysis

“…As spinal amplitude is associated with psychological factors (Christe, Crombez, et al, 2021), interventions could notably improve spinal movement through reductions of unhelpful beliefs and pain‐related fear, which could at the same time decrease pain intensity (Christe et al, 2022). Similarly, reducing protective behaviours could reduce unhelpful beliefs and pain‐related fear (Caneiro et al, 2022; Wernli et al, 2022). Altogether, these findings support a biopsychosocial management of LBP, combining exercises and psychological interventions (Ho et al, 2022).…”

Distinction of non-specific low back pain patients with proprioceptive disorders from healthy individuals by linear discriminant analysis

“…The study suggested further investigation of “specific and personalized assessment of psychological variables, pain severity, and spinal motor behavior” ( Christe et al, 2021b ). Another study Wernli K et al (2022) demonstrated that each participant had an individual recovery journey from conscious and non-conscious protection to conscious and non-conscious non-protection. Prior to and following cognitive functional therapy intervention for 12 patients with disabling LBP, pre- and post-quantitative measures of movement, posture, psychological factors, pain, and activity limitation integrated well with the findings from qualitative interviews.…”

Understanding Discrepancies in a Person's Fear of Movement and Avoidance Behavior: A Guide for Musculoskeletal Rehabilitation Clinicians Who Support People With Chronic Musculoskeletal Pain

“…Although causal inference cannot be made, this is indirectly supported by clinical evidence showing that decreased safety behaviour during activities (e.g. greater spinal range of motion, faster movement, more relaxed postures and less back muscle activity) is associated with less pain and experienced disability during those particular activities [70][71][72] .…”