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

Key points

1. 01At baseline all 12 participants showed conscious and nonconscious protective movement patterns driven by beliefs that their spine was damaged or fragile.
2. 02Common sources of harmful beliefs included advice from healthcare professionals, imaging results, and societal messages such as 'sit up straight' and 'lift with your knees'.
3. 03After the CFT intervention, 11 of 12 participants reported that deliberately relaxing and moving less protectively reduced their pain, which in turn challenged their damage beliefs.
4. 04Recovery followed a pathway from conscious non-protection (deliberate relaxed movement) to nonconscious non-protection (automatic, fearless movement) for 7 of 12 participants.
5. 05Participants who reached nonconscious non-protection showed significantly greater improvements in pain self-efficacy (p=0.042) and pain catastrophising (p=0.042) compared to those who remained consciously non-protective.

How it was conducted

Design

Pre-post triangulation convergent mixed methods study embedded within a replicated single-case design (n=12); qualitative interviews integrated with wearable-sensor kinematics, surface EMG, and self-report questionnaires

Participants

12 adults with persistent (>3 months), disabling (RMDQ >=5), non-specific LBP; median age 39 years (range 22-76); median LBP duration just over 4 years (11 months to 17 years); median RMDQ 17.5/23

Setting

Metropolitan Perth, Western Australia; two waves of six participants, January to December 2018

Intervention

12-week individualised Cognitive Functional Therapy (CFT) delivered by trained physiotherapists; up to 10 sessions; initial session 60 min, subsequent sessions 30-45 min

Qualitative component

Semi-structured in-depth interviews before and after the intervention; reflexive thematic analysis guided by the Common-Sense Model; codebook saturation reached after 7 participants

Quantitative component

Wearable inertial sensors and surface EMG measuring nominated painful movements weekly during 5-week baseline and 5-week follow-up; self-report outcomes including RMDQ, PSFS, TSK, PSEQ, PCS, FreBAQ, BackPAQ, pain NRS

What they found

• 11 of 12 participants reported moving less protectively at follow-up, with subjective descriptions shifting from 'stiff, seized up, rigid' to 'fluid, free, automatic'.
• 7 of 12 participants progressed to nonconscious non-protection (automatic, fearless movement) by follow-up; 4 of 12 remained in conscious non-protection; 1 of 12 showed no meaningful change.
• Nonconscious non-protection group showed greater improvement in pain self-efficacy (p=0.042) and pain catastrophising (p=0.042) compared to conscious non-protection group.
• Differences in fear of movement (TSK-change, p=0.109), back pain attitudes (BackPAQ-change, p=0.230), and bending speed (p=0.171) were not statistically significant between groups.
• RMDQ-change (p=0.618), FreBAQ-change (p=0.242), and bending ROM-change (p=0.609) did not differ between groups.
• Exemplar case P8 (nonconscious non-protection): pain intensity 5.8 to 0, RMDQ 18 to 0, TSK 37.5 to 18, PSEQ 37.5 to 60, PCS 15.5 to 0, bending ROM 74.8 to 94.6 degrees, bending speed 29.5 to 59.7 degrees per second, back muscle EMG 0.0002 to <0.00001.
• Exemplar case P5 (conscious non-protection): pain intensity 5.7 to 1.7, RMDQ 12 to 8, bending ROM 70.2 to 87 degrees.
• Exemplar case P1 (remained protective): pain bothersomeness 7.8 to 4.8, bending ROM 110 to 115 degrees, bending speed 30 to 51 degrees per second; no subjective sense of recovery.

Limitations

• Very small sample of 12 participants limits generalisability; design precludes causal inferences about mechanisms or mediators of outcome.
• Participants required BMI under 30 kg/m2 and were recruited in one Australian city, restricting transferability to other populations.
• No control group and no randomisation; treatment efficacy was not the study aim, so comparisons of CFT against other treatments cannot be drawn.
• Potential for desirability bias as participants knew the interviewer was affiliated with the research team and the CFT approach.

Why it matters

For patients

People with long-standing back pain who have been told to protect their spine may find that gradually learning to move more freely and with less tension is both safe and central to recovery.

For clinicians

CFT-style reconceptualisation of movement and posture from threatening to therapeutic appears important for recovery, and reaching nonconscious fearless movement is associated with greater psychological improvement than conscious effortful non-protection alone.

For readers

This study provides a qualitative framework and supporting biomechanical data showing that protective movement beliefs, often reinforced by healthcare advice, can be a key driver of persistent disability in LBP.