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

Review written by Dr Sarah Haag info

Key Points

  1. Helping people with low back pain move towards being less protective may be an effective way to address low back pain.
  2. Reconceptualizing movement and posture from threatening to therapeutic, may improve outcomes for people experiencing chronic low back pain.


Low back pain (LBP) is the most disabling health condition globally. Improved posture and proper body mechanics are often recommended to address LBP. However, the impact of LBP has not diminished with the application of “improved posture and body mechanics”.

This study aimed to understand how people with persistent, disabling LBP conceptualize relationships between movement, posture, psychological factors, and activity limitation and how this conceptualization changes following an individualized, multi-dimensional intervention.

Correcting posture and body mechanics has not resulted in a dramatic decrease in low back pain.
Introducing the concepts of conscious and nonconscious non-protection into common clinical practice may positively impact outcomes for people with low back pain.


  • A pre-post triangulation convergent mixed methods design was used to incorporate both qualitative and quantitative approaches in the context of an existing replicated single-case design study.

  • 12 participants with chronic LBP completed a five-week baseline phase, a 12-week Cognitive Functional Therapy (CFT) intervention, and a five-week follow-up phase.

  • Interviews were conducted with each participant, exploring how participants felt regarding certain movements and postures. The interviews were then analyzed via reflexive thematic analysis by the researchers.

  • All participants completed a Qualtrics survey collecting a Numeric Rating Scale (NRS) for pain, pain interference, and pain bothersomeness, as well as others not reported here.


  • All 12 participants completed the study. All participants reported significant interactions with the healthcare system and various healthcare providers.

  • 7 out of 12 participants reported comorbidities such as atherosclerosis, anxiety, depression, or migraines. An overarching theme of protection (conscious or non-conscious) was identified in all participants.

  • Following the 12-week intervention of CFT, most of the participants reported that they no longer believed their pain was due to damaged structures. There was also a shift in emotions from fear, worry, and frustration to happiness, hope, and confidence (see figure below).



  • The study design did not allow for any causal inferences about mechanisms or mediators of outcomes.

  • The participants in this study were limited to 12 people with BMIs less than 30, which may not allow the findings to be applied to all people presenting with LBP.


Despite extensive resources dedicated to treating LBP, disability levels continue to rise (2). Inaccurate beliefs about LBP, posture, and activity are present in society and are often reinforced by well-meaning healthcare practitioners. Posture assessment and recommendations to use “proper” posture to treat or prevent LBP have been used for years in and continue to be taught today. These beliefs continue to be held despite no causal relationship being found between posture and LBP (3). This is supported by a review of clinical practice guidelines where only 3 out of 15 guidelines reviewed mention posture assessment (4).

This study identified that there are levels of conscious and nonconscious protection that are present when people are experiencing more pain or disability. Advice from healthcare providers, such as “be careful” or messages that suggest damage or pathology, may contribute to increased conscious and nonconscious protection. One of the most telling quotes from the study was “doing everything the opposite to the way that you’re told to do it… feels better… way better”. Introducing the concepts of conscious and nonconscious non-protection into common clinical practice may positively impact outcomes for people with LBP.


Wernli K, Smith A, Coll F, Campbell A, Kent P, O’Sullivan P (2022) From protection to non‐protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain. European Journal of Pain, 26(10), 2097–2119.


  1. Wernli, K, O’Sullivan, P, Smith, A, Campbell, A & Kent, P 2020, ‘Movement, posture and low back pain. How do they relate? A replicated single‐case design in 12 people with persistent, disabling low back pain’, European Journal of Pain.
  2. Dieleman, JL, Cao, J, Chapin, A, Chen, C, Li, Z, Liu, A, Horst, C, Kaldjian, A, Matyasz, T, Scott, KW, Bui, AL, Campbell, M, Duber, HC, Dunn, AC, Flaxman, AD, Fitzmaurice, C, Naghavi, M, Sadat, N, Shieh, P & Squires, E 2020, ‘US Health Care Spending by Payer and Health Condition, 1996-2016’, JAMA, vol. 323, no. 9, p. 863.
  3. Swain, CTV, Pan, F, Owen, PJ, Schmidt, H & Belavy, DL 2019, ‘No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews’, Journal of Biomechanics, p. 109312.
  4. Oliveira, CB, Maher, CG, Pinto, RZ, Traeger, AC, Lin, C-WC, Chenot, J-F, van Tulder, M & Koes, BW 2018, ‘Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview’, European Spine Journal, vol. 27, no. 11, pp. 2791–2803.
From protection to non‐protection:… By Dr Sarah Haag