Using Behavioural Experiments in Persistent Low Back Pain

Pain education is commonly used in persistent low back pain. We might explain that pain does not necessarily mean tissue damage, that pain is influenced by multiple factors, and that the pain system can become sensitised. But, as many of us will have experienced first-hand, simply providing information on these concepts does not necessarily change how someone responds when faced with a painful or feared movement.

In his Case Study demonstrating telehealth management of persistent disabling low back pain, Dr Kevin Wernli shows how pain education may need to extend beyond providing information into more experiential learning. This blog outlines how he uses behavioural experiments.

If you want to see exactly how an expert manages disabling low back pain across seven telehealth appointments, watch Dr Kevin Wernli’s full Case Study here.

The case

Kevin’s patient was a 29-year-old office worker living in Switzerland. His low back pain began while deadlifting eight months earlier and had never completely resolved. He had seen multiple physiotherapists, experienced a dramatic flare following prescribed exercises, and received corticosteroid injections targeting the facet joint and disc without improvement. By the time he saw Kevin, his pain was limiting his usual activities and he was unable to sit comfortably.

Several features suggested that nociplastic mechanisms could be contributing to his presentation, including pain persisting beyond expected tissue-healing timeframes and latent or delayed pain responses. See Kevin explain these nociplastic pain indicators in this clip from his Case Study:

Kevin’s movement assessment also revealed some interesting patterns. The patient habitually braced his trunk and breathed shallowly. Left rotation was painful on the first repetition but comfortable on subsequent repetitions. He habitually loaded his left leg to protect the painful right side, but this appeared to increase tension on the right. Meanwhile, forward bending was almost pain-free.

Rather than simply identifying which movements provoked pain, these observations provided opportunities to explore how his behaviours might be influencing his symptoms.

Avoiding painsplaining

Using the Twin Peaks model, Kevin explained that pain does not necessarily equal damage and that pain is multifactorial. When the nervous system perceives more evidence of danger than safety, pain can be produced as a protective response. Importantly, this system is not fixed. Kevin explained that the same bioplasticity that can contribute to persistent pain means the system can also be retrained.

However, in the first session, Kevin tried to avoid ‘painsplaining’, instead focusing on opportunities for the patient to experience something different himself rather than hitting him with a bunch of information all at once.

Introducing experiential learning through behavioural experiments

A patient may understand that pain does not equal damage while continuing to brace, avoid movement or protect their back whenever they encounter a threatening activity. Behavioural experiments provide an opportunity to test these expectations. Sitting provided one of the first opportunities to do this. See Kevin explain how in this clip from his Case Study:

Rather than simply telling the patient that sitting was safe, Kevin explored how he approached it. He encouraged him to notice when he was bracing, relax and breathe. Even noticing the behaviour can be considered progress, so Kevin encouraged him to celebrate each time he caught himself bracing rather than viewing it as something he was doing ‘wrong’.

Movement provided further opportunities to experiment. Kevin explored sit-to-stand with more loading through the right leg, alongside relaxed rotations and forward bending.

These were not simply exercises prescribed to strengthen the back or correct movement. They allowed the patient to explore what happened when he changed the protective strategies he had developed around pain.

Kevin also used a ‘threat ladder’. Activities the patient found frightening or threatening were ranked, beginning with those that felt most manageable. He could then progressively work his way up the ladder, gaining experience with increasingly threatening movements and activities.

What happens when symptoms flare?

Progress was not straightforward. By the second session, the patient was sore after continuing core exercises prescribed by another physiotherapist.

Around session four, he developed new hypersensitivity through his upper back alongside very high levels of pain. He returned to his doctor and underwent another MRI, which showed no new findings.

These setbacks are important in persistent pain management. Pain education and behavioural experiments do not mean symptoms immediately disappear or that new symptoms should be ignored. Instead, this framework can help clinicians and patients make sense of symptoms while continuing to assess for new or concerning findings.

Wrapping up

Yes, explaining that pain does not necessarily mean damage, that pain is influenced by multiple factors and that the nervous system is adaptable can be useful. But Kevin’s case demonstrates how these ideas can be taken further.

Behavioural experiments allow patients to test what happens when they breathe rather than brace, load rather than protect, or gradually approach rather than avoid a feared activity. Instead of only being told that movement may be safe, they have an opportunity to experience it themselves, supported by a physio’s guidance.

If you want to see exactly how Dr Kevin Wernli clinically reasoned his way through this case, watch his full Case Study here.