How do people with chronic low back pain perceive specific and general exercise? A mixed-methods study

Key points

1. 01Specific exercises (bird dog, motor control movements) were rated more beneficial than general exercises (squats, deadlifts) on a 6-point Likert scale, though the magnitude of difference was small.
2. 02Eight qualitative themes emerged: importance of the core, strengthening, load, technique (including spinal flexion subtheme), stability, achievability, all exercise has an effect, and beliefs from personal experience.
3. 03Spinal flexion in any exercise, whether specific (curl up) or general (Jefferson curl), was frequently perceived as bad technique and potentially harmful.
4. 04Participants attributed their beliefs primarily to interactions with healthcare practitioners such as physiotherapists, exercise physiologists, and chiropractors.
5. 05These perceptions contrast with evidence that general exercise is not inferior to specific exercise for chronic low back pain outcomes.

How it was conducted

Design

Mixed methods cross-sectional online survey (Qualtrics platform)

Participants

Adults aged 18-65 with low back pain for 3 months or longer; recruited via social media and noticeboard advertisements in the Sydney area, June to November 2022

Sample

135 began the survey; 117 met eligibility criteria and consented; 113 completed all survey questions; 94 provided qualitative data

Quantitative component

6-point Likert scale rating agreement with 'this exercise is beneficial for chronic low back pain' for 10 exercises (5 specific, 5 general) presented as still images in random order

Qualitative component

Three open-ended questions on perceived benefit of specific vs. general exercise and sources of views; analysed using six-stage reflexive thematic analysis with inductive coding (NVivo)

Primary outcome

Proportion of agreement ratings for specific vs. general exercises; thematic content of beliefs about exercise

What they found

• Specific exercises were perceived as more beneficial than general exercises on the Likert scale, though the magnitude of the difference was described as small.
• The bird dog was the most positively perceived specific exercise; the Zercher squat was the most positively perceived general exercise.
• The curl up was the most negatively perceived specific exercise; the Jefferson curl was the most negatively perceived general exercise.
• Except for the curl up, all specific exercises had a greater proportion of 'agree' and 'strongly agree' responses compared to any of the general exercises.
• Eight main themes and five subthemes were identified from the qualitative analysis; most themes contained conflicting views between participants.
• The theme 'load' carried a solely negative view towards general exercises; the theme 'strengthening' carried a solely positive view towards specific exercises.
• Most participants attributed their exercise beliefs to interactions with healthcare practitioners (physiotherapists, exercise physiologists, chiropractors, personal trainers, medical doctors).

Limitations

• Anonymous online survey design means responses may not reflect participants' true opinions, and social desirability bias cannot be excluded.
• Still images rather than video were used to represent exercises, which may have led to different perceptions than dynamic observation of movement.
• The majority of participants were physically active, which may not represent more sedentary people with chronic low back pain.
• Thematic analysis is inherently subjective; the study could not discriminate how beliefs were originally formed (direct clinician interaction vs. social or media influences).

Why it matters

For patients

If you have chronic low back pain, the exercises your clinician prescribes carry an implicit message about what they think is wrong with your back, even if nothing is said, so it is worth discussing the rationale openly.

For clinicians

Exercise prescription for chronic low back pain communicates meaning beyond the movement itself, and patients may disengage from general or loading exercises without targeted education to address fears around spinal flexion and load.

For readers

There is a clinically important gap between what patients believe about exercise for chronic low back pain and what the evidence supports, driven largely by biomedical narratives from healthcare practitioners.