"I could 100% see myself getting hurt if I did it wrong": a qualitative exploration of exercise

Key points

1. 01'Core' or trunk-targeted exercises were ranked most beneficial and the bird dog was preferred over the deadlift and Jefferson curl by nearly all participants
2. 02Spinal flexion (bending) was widely perceived as harmful or risky technique, despite evidence that bending does not cause chronic low back pain
3. 03External load was feared by most participants because they believed it increased injury risk when technique was imperfect
4. 04Participants drew a sharp line between 'rehabilitation' exercises (for pain relief) and 'gym' exercises (for general health), which created barriers to returning to enjoyable activity
5. 05Distrust of healthcare practitioners arose when recommended exercises did not relieve pain, and trust was higher when the practitioner was seen as an exercise expert

How it was conducted

Design

Qualitative study using online semi-structured interviews and reflexive thematic analysis (critical realism and social constructivism lens)

Participants

16 adults with self-reported low back pain lasting more than 3 months (4 female, 12 male; mean age 39.6 +/- 13.8 years)

Setting

Online via Zoom; convenience sample recruited around UNSW Sydney and via social media, April to August 2023

Procedure

Participants discussed their pain history and exercise beliefs, then watched the interviewer perform a deadlift, Jefferson curl, and bird dog without naming the exercises, and rated each for benefit in chronic low back pain

Analysis

Six-stage reflexive thematic analysis using NVivo 12; theoretical saturation guided cessation of recruitment

Measures

Oswestry Disability Index, Fear Avoidance Beliefs Questionnaire (physical activity subsection), and Visual Analogue Scale for pain

What they found

• All 16 participants viewed all three exercises as beneficial for general health, but perceived benefit for pain relief varied markedly across exercises
• Of 15 participants who ranked exercises, the bird dog was ranked most beneficial for chronic low back pain and the Jefferson curl least beneficial
• Mean disability score (Oswestry Disability Index) was 15.88 +/- 10.41 and mean fear avoidance score (FABQpa) was 10.5 +/- 5.34
• Spinal flexion was perceived as harmful or poor technique by the majority of participants regardless of personal experience with bending exercises
• External load was perceived as increasing injury risk by most participants, with perceived capacity being the key moderator of that fear
• Participants who had received conflicting advice from multiple healthcare practitioners showed heightened distrust, particularly when recommended exercises worsened their pain

Limitations

• Small sample of 16 participants, all from one city in Australia, limits generalisability
• The lead interviewer (AN) was a novice qualitative researcher, and social desirability bias may have influenced participant responses
• Online format (Zoom) prevented participants from physically performing the exercises as originally planned, potentially limiting the depth of experiential data
• Member checking (returning transcripts to participants for validation) was not conducted due to time constraints, which may reduce analytical rigour

Why it matters

For patients

If you have chronic low back pain, it is worth knowing that the common belief that bending or lifting weights will damage your back is not well supported by evidence, and that all forms of exercise, not just 'core' work, can be part of safe and effective management.

For clinicians

The exercises you prescribe carry implicit messages; prescribing only core-specific exercises may unintentionally reinforce fear of movement and load in patients, so pairing exercise choice with explicit education about spinal bending and loading is important.

For readers

This study shows that patients' exercise beliefs are shaped as much by cultural assumptions and clinician behaviour as by their own experience, and that closing the gap between perceived and actual exercise risk should be a priority in chronic low back pain rehabilitation.