Making decisions about activity when your back hurts

Participating in physical activity is an important part of recovering from low back pain. The fear-avoidance model is often used to explain the way in which people who have pain approach activity. This model proposes that when someone experiences pain they may either avoid movement and activity due to fear of further pain or injury, or they confront their fears and engage in activity. Taking the first path (often termed Avoiders) is proposed to result in disuse, depression and disability, whereas taking second path (often termed Copers) results in recovery.

A number of studies have investigated views about activity amongst those with chronic back pain, but very few have explored the views of those experiencing acute back pain. The views of those with acute back pain are important to understand as habits and beliefs created during this period may influence the progression to, and maintenance of, persistent back pain.

In this study we explored views about activity amongst twelve people who had acute low back pain (less than six weeks of pain) and eleven people who had chronic low back pain (greater than six months of pain). We aimed to analyse barriers and facilitators to physical activity amongst people with acute back pain and consider whether these were similar or different to those with persistent back pain. We hoped that this might indicate if similar or different strategies were required to encourage activity participation in these two groups.

Our analysis of these interviews indicated that people with acute and chronic back pain made conscious decisions about participating in activity and rest, and that both groups used the same conceptual framework. This involved balancing the perceived risks against the perceived benefits within their current context. This process appeared to be more considered, complex and situation dependent than proposed by the fear-avoidance model. The perceived risks of activity identified were more pain, more injury, more impairment, or more suffering. These were similar to those found by a number of previous studies of participants with chronic back pain. Interestingly, the perceived benefits of activity were predominantly psychosocial rather than physical, such as elevated mood, an ability to shift focus away from the pain, being able to fulfil life roles, feeling less disabled and positive social interaction. Rest emerged as a behaviour in which participants consciously engaged following a similar evaluation of risks and benefits. Once again psychological risks (e.g. depressed mood, or focusing on pain) were discussed more commonly than physical risks (e.g stiffness or weakness). A number of participants reported avoiding rest because they were concerned about these risks.

We also found that decisions about activity were strongly influenced by the context in which these were made. Important factors included the nature and acuity of the pain (keeping in mind that even for those with chronic pain, their pain experience was punctuated by acute aggravations, periods of stability and even remission), the type of activity they were considering and its perceived importance, their past experience of back pain and the activity in question. As a result different decisions could be made about the same activity in different contexts. People who were classified as having high levels of fear avoidance (by the Tampa Scale of Kinesiophobia) reported engaging in activities they considered harmful when the benefits were sufficient in a given context. Similarly, people classified as having low levels of fear avoidance reported avoiding activities for which they considered the risks were too great. This indicates that there is not as clear a distinction between copers and avoiders as the fear avoidance model indicates.

We also found that, although they used a similar conceptual framework to make activity decisions, those with acute pain often had less experience which they could use to inform these judgements. Many people with chronic back pain seemed to have well developed cognitive rules which they used to guide decisions, whereas those with less experience were less certain. This indicates that acute back pain may be a time during which these rules are developed and when clinicians can positively influence someone’s views and behaviours related to activity.

We recommend that rather than labelling people as being fear avoidant, it may be more helpful to explore the factors being considered when someone is making decisions about activity and the effect of context on these judgements. This may enable to clinicians to provide an informed assessment of the risks being considered or highlight additional benefits beyond those already recognised by the person. It appears from this study that focusing on psychosocial benefits (or risks in the case of rest) may be particularly useful. Reframing activity discussions in this way may help to shift focus away from decreasing pain or avoiding adverse outcomes toward highly valued goals like feeling better or having more social interaction.

About Ben Darlow

Ben Darlow reducedBen spends his time interacting with patients as a Musculoskeletal Physiotherapy Specialist at Capital Sports Medicine, and conducting research and teaching medical students as a Senior Lecturer in the Department of Primary Health Care and General Practice at the University of Otago, Wellington. Ben’s main research interest is related to back pain, particularly understanding beliefs about backs and back pain amongst clinicians, people with back pain, and the general public, and how these all influence each other. He is also interested in strengthening health care teams and improving patient care through interprofessional education. More information about his research and publications can be found here.


Ben Darlow, Meredith Perry, Sarah Dean, Fiona Mathieson, G. David Baxter, Anthony Dowell (2016) Putting Physical Activity While Experiencing Low Back Pain in Context: Balancing the Risks and BenefitsArch Phys Med Rehab 97 (2), 245–251.e7

Commissioning Editors: Lorimer Moseley and Carolyn Berryman


  1. Good article ben…As a practising physical therapist at healthclues, Hyderabad I want to mention that…A lack of physical activity can be the worst activity of all. In fact, being sedentary can increase your lower back pain. One of the common misconceptions about managing pain is that you should cease all activity and focus on rest, which usually is not the case.

    but I found that, when patients go on bedrest for more than three days, their pain actually increases or remains constant. While rest is certainly an important component of the pain management process, you have to manage rest with movements to help decrease the pain you are experiencing in your lower back.