Activity among people with chronic low back pain: How activity behaviours reflect beliefs

For Body Matters, the Massive Open Online Course (MOOC) 23,000+ participants, led by Professor Ian Shrier, hosted by McGill University, Canada.

By Kieran O’Sullivan (@kieranosull)

University of Limerick Kieran O'Sullivan.  .  Pic Sean Curtin Photo.Disability due to chronic low back pain (CLBP) has actually increased in recent decades, indicating a need for significant change in CLBP management1. Improved outcomes in other chronic health conditions (e.g. cardiovascular diseases, cancer), illustrate the requirement of changes in both (i) beliefs and (ii) behaviours. For example, for cigarette smoking rates to be reduced, both clinicians and the public had to (i) really believe smoking was a major concern and (ii) only then did smoking behaviours shift to reflect this evidence.

While we know that increasing activity levels among people with CLBP significantly reduces disability, people with CLBP often remain relatively inactive2. While this “behaviour”may be criticised, one may argue that this is a sensible strategy to adopt based on their existing (albeit inaccurate) beliefs. For example, let’s look at some common inaccurate beliefs held by people with CLBP:

  1. The idea that pain is always an accurate indicator of whether a body part is damaged is still widely held3, despite being completely out of touch with contemporary neuroscience4. For example, people with what appears to be significant tissue “damage” often report no pain, while others with seemingly “normal” scans can report terrible pain5.
  2. Many forms of activity, e.g. running6 and bending7, 8 which are not harmful to the body, are considered somewhat dangerous and a potential cause of “wear and tear”3.
  3. Finally, recuperation from CLBP is considered to be more related to the “magic” hands (or needle / scalpel / scan) of the clinician or health service rather than factors the person themselves can learn to control such as physical activity, stress management, sleep and thoughts9.

When we consider even just these three widely held beliefs, it seems clear why people with CLBP avoid activity, as it is often associated (at least initially) with some pain, which they deem to be an indication of further damage. Add in the fact that healthcare programmes often significantly understate the role of self-management strategies such as physical activity, and the observed low levels of activity are not at all surprising.

In summary, to increase activity levels among people with CLBP, we need to (i) shape their beliefs and better contextualise what is happening to their body (e.g. rarely is tissue damage the biggest concern); (ii) eliminate fears that everyday activities are dangerous even if they are difficult initially, and (iii) empower patients to regain control through active self-management strategies such as physical activity.

Finally, we could learn from other public health initiatives (e.g. non-smoking areas, taxation on cigarettes) and indeed other non-healthcare environments10, 11 on how we can help shape these behaviours to make it easier for people to make a better, more active lifestyle choice12 (e.g. why is the stairs usually harder to find than the elevator in a hotel; why are some cities more cyclist and pedestrian friendly).


  1. Deyo, R.A., S.K. Mirza, J.A. Turner, et al., Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 2009. 22(1): p. 62-68.
  2. Griffin, D.W., D. Harmon, and N. Kennedy, Do patients with chronic low back pain have an altered level and/or pattern of physical activity compared to healthy individuals? A systematic review of the literature. Physiotherapy, 2012. 98(1): p. 13-23.
  3. Goubert, L., G. Crombez, and I. De Bourdeaudhuij, Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain, 2004. 8(4): p. 385-394.
  4. Butler, D.S. and G.L. Moseley, Explain Pain:(Revised and Updated). 2013: Noigroup Publications.
  5. Brinjikji, W., P. Luetmer, B. Comstock, et al., Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 2015: In Press.
  6. Lane, N., J. Oehlert, D. Bloch, et al., The relationship of running to osteoarthritis of the knee and hip and bone mineral density of the lumbar spine: a 9 year longitudinal study. The Journal of Rheumatology, 1998. 25(2): p. 334-341.
  7. Wai, E., D. Roffey, P. Bishop, et al., Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J, 2010. 10(6): p. 554-566.
  8. Wai, E., D. Roffey, P. Bishop, et al., Causal assessment of occupational bending or twisting and low back pain: results of a systematic review. Spine J, 2010. 10(1): p. 76-88.
  9. Verbeek, J., M.-J. Sengers, L. Riemens, et al., Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine, 2004. 29(20): p. 2309-2318.
  10. Heath, C. and D. Heath, Switch: How to change when change is hard. 2010, New York: Broadway Books.
  11. Thaler, R.H. and C.R. Sunstein, Nudge. 2008: Yale University Press.
  12. Trost, S.G., S.N. Blair, and K.M. Khan, Physical inactivity remains the greatest public health problem of the 21st century: evidence, improved methods and solutions using the ‘7 investments that work’as a framework. Br J Sports Med, 2014. 48(3): p. 169-170.


Dr Kieran O’Sullivan is a lecturer at the Department of Clinical Therapies at the University of Limerick, Ireland. He has been awarded €1 million in funding and has over fifty peer-reviewed publications. He has been awarded ‘specialist’ status by the Irish Society of Chartered Physiotherapists. He has a particular interest in the management of chronic musculoskeletal conditions such as chronic low back pain.

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