Clin J Pain. 2014 (Nov); 30 (11): 995–1005 ~ FULL TEXT
Susan C. Slade, PhD, PT, Shilpa Patel, PhD, C. Psychol, Martin Underwood, MD, FRCGP, and Jennifer L. Keating, PhD, PT
Faculty of Medicine,
Nursing and Health Sciences,
OBJECTIVES: The global burden of low back pain is the highest ranked condition contributing to years of living with disability. Exercise is moderately effective, and adherence to exercise may improve if participants are engaged. Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions. The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain.
METHODS: Two independent reviewers conducted a structured review and metasynthesis informed by Cochrane and Campbell Collaboration guidelines and the PRISMA statement. Fifteen papers were included for data extraction, method quality assessment, and thematic analysis.
RESULTS: Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue.
DISCUSSION: People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.
Key Words: exercise prescription, chronic low back pain, patient beliefs, qualitative research, review
From the FULL TEXT Article:
The global burden of low back pain (LBP) is now the
highest ranked condition contributing to years of living
with disability.  It is an important source of long-term
disability and absence from work and causes substantial
economic and societal burden. Nonspecific chronic LBP
(NSCLBP) is not a diagnosis but rather a description of
back pain for which a cause cannot be definitively identified
or a precise pathoanatomic diagnosis cannot be given. 
Nearly all people with chronic LBP are diagnosed with
NSCLBP; this does presume that specific pathologies have
been ruled out after a clinical assessment that includes
appropriate tests and imaging. [3–5] The condition manifests
as a continuation of an initial episode or periodic recurrences
and remissions. [6–11]
In addition to its specific effect on LBP, exercise is recommended
for the prevention of many other diseases and for its
general health benefits
World Health Organization and government recommendations focus on regular amounts of
exercise to improve health, and more recent recommendations
are for 1 hour of activity daily and moderately strenuous
exercise for 30 minutes 6 d/wk
Unless contraindicated, people with back pain should be
advised to exercise because of benefits to their general health.
Despite being recommended as the treatment of choice,
exercise is at best only modestly effective for NSCLBP. In
randomized controlled trials the effects of different types of
exercise appear comparable. [12–30] Clinical practice guidelines
for the management of NSCLBP recommend that patient
preferences should be considered and that exercises should be
individualized.  It is likely that adherence, as measured by
attendance or engagement with exercise, and the extent to
which a person’s behavior corresponds with agreed recommendations
from a health care provider, will improve if programs
align with participant preferences and beliefs.
Kolt et al  reported that participant adherence to
low back rehabilitation increased with supplementary printed
material, supervision, motivation strategies, clinic attendance,
positive reenforcement, goal setting, and therapist/participant
contracts. Supervised and individualized exercise with health
professional input and self-management techniques including
home audio and video-tapes have been demonstrated to have
a positive effect on exercise adherence in chronic
musculoskeletal conditions. [32–36] Self-efficacy, depression,
pain catastrophizing, and levels of physical activity and
ability have been demonstrated to have an impact on outcome
in self-management programs for chronic pain. 
et al  recommended that health providers who prescribe
exercise also consider program organization and leadership
skills, participant exercise history and level of ability, and
education requirements that could dictate the format of
explicit verbal instruction and written information. Identification
of program design features that enhance engagement
would enable clinicians to prescribe appropriate exercise and
activity interventions for the NSCLBP care-seeking population.  By examining and analyzing the gap between what
is offered and what participants expect, experience, and prefer,
the exercise program content may be more attractive.
Participant reports are central to the evaluation of health
care in terms of both outcomes and experience of the quality of
care and can be used to identify areas that require action to
improve the process and outcomes.  Varying approaches have
been developed to elicit participants’ experiences of discrete
aspects of health care and include interviews, focus groups,
and surveys or questionnaires.  People with chronic disease
and conditions, such as those with LBP, are often dependent
on regular care and can often have well-defined knowledge of
their own physical condition and ability. Consequently, many
people may have specific expectations of the purpose and goals
of management and may be able to provide insights into how
and why they engage and participate. 
We conducted a systematic review of qualitative studies
that have explored the perceptions and beliefs of people with
NSCLBP with regard to exercise therapy, physical activity, or
training for the management of their condition. Specifically,
we sought to identify and synthesize qualitative empirical
studies that explored what people with NSCLBP believe or
perceive about exercise therapy, physical activity, or training
for the management of their condition. We hoped that review
outcomes might enable us to make recommendations for
clinical practice and further research.
A structured review process was adapted from the
Cochrane Collaboration, Cochrane Back Review Group,
PRISMA Statement, and Cochrane guidelines. [43–46] We used a
comprehensive set of search strategies recommended for
identifying qualitative reports. [47–52] The a priori inclusion and
exclusion criteria were established before conducting searches
of the electronic database and were applied to the final search
yield. Two reviewers (S.P. and S.C.S.) used the criteria to
screen titles and abstract. They independently extracted data,
appraised method quality, conducted thematic analysis, and
synthesized data in a narrative format. Two other independent
researchers acted as arbiters throughout the process, gave
expert opinion and assisted with consensus regarding methods,
forms, and tables (J.L.K. and M.U.).
Inclusion and Exclusion Criteria
Papers were included if: they were published in peerreviewed
journals; included >80% of participants over 18
years; participants consulted a practitioner who prescribed
exercise; >80% of participants had back pain of >6 weeks
duration; and papers reported data that enabled evaluation
of what patients believe, prefer, or have experienced regarding
exercise as a treatment for NSCLBP. Papers were
excluded if they were not published in English or were editorials,
expert opinion, letters, or commentary and when
participants had NSCLBP with specific underlying spinal
pathology. These criteria were applied to the search yield
using a standardized form (online Appendix 1, Supplemental
Digital Content 1, http://links.lww.com/CJP/A73) that was
initially tested on 3 papers by 3 researchers (J.L.K., M.U.,
and S.C.S.) for consistency and agreement was unanimous.
Literature Search: Identification and Selection of Included Papers
Eight electronic databases were searched without date
limits up until July 2012, using explosions and combinations
of key search terms for qualitative research, exercise, physical
fitness, physical training, conditioning, activity, LBP,
patient experience, patient preference, attitudes, perceptions,
expectations. Databases searched were AMED,
Campbell Collaboration, CINAHL, Embase, Medline,
PsychInfo, Sportdiscus, and ISI Web of Science. In addition,
we did forward and backward citation tracking of
included papers and selected review articles. Search language
was adapted to individual database formats. Search
strategies are available in online Appendix 2 (Supplemental
Digital Content 2, http://links.lww.com/CJP/A74). All of
the searches were downloaded to bibliographic management
software for deletion of duplicates and initial screening of
titles by the primary author who deleted those that were
clearly irrelevant. Two independent researchers (S.C.S. and
S.P.) screened the remaining abstracts and read papers in
full before making final inclusion/exclusion decisions. Disagreements
were resolved through discussion and a third
reviewer was approached if consensus was not reached or
when there was a conflict related to reviewer independence.
Data extraction guidelines and a data extraction form
(online Appendix 3, Supplemental Digital Content 3, http://links.lww.com/CJP/A75) were developed by consensus
(S.C.S., S.P., J.L.K., and M.U.) so that the same information
was extracted from each included paper. The following
data were systematically extracted under the following
headings: methods, population, data collection, data
synthesis, results, themes, discussion, conclusions, and
recommendations. The completed data extraction forms
were examined for consistency and merged for the data
synthesis phase. Themes and subthemes were extracted
from each included paper, independently confirmed by the
2 researchers, and transferred to a spreadsheet. The items
were assembled into common groups, and duplicates were
deleted to remove ambiguity. Reviewers did not extract
data from studies for which they were coauthors.
Method Quality Assessment
Two reviewers independently appraised included studies
using the Critical Appraisal Skills Programme checklist for
qualitative studies because it provided decision rules and
detailed instructions on how to interpret criteria.  Reviewers
were not involved in quality appraisal for studies on which
they were coauthors. This checklist consists of a series of
questions that helps the reviewer to assess the rigor, credibility,
and relevance of the study. Rigor refers to whether the
approach to the study is thorough and appropriate; credibility
refers to whether the findings are well presented and meaningful;
relevance refers to the usefulness of the study’s findings. [54–59] Disagreements were resolved by consensus and by a
third researcher if necessary. Papers were not excluded on the
basis of method quality but partitioned into high and low
scores for outcome comparison in the discussion.
The primary studies were combined, compared, and
contrasted to generate meaning that extended beyond any
individual study using interpretive synthesis, which is a
combination of metaethnography and grounded theory.
During data extraction, the themes and subthemes from each
paper were extracted, and a thematic framework was developed
for the entire data set. This involved reading all of the
included papers in-depth, noting the major themes reported
in all of the papers, and then developing a thematic framework
that encompassed all identified themes. In this way the
concepts from individual studies were “translated” into one
another to become overarching themes. This framework was
then applied to the extracted data and used to develop analytical
charts to manage the data.  The data synthesis built
interpretation from the original studies by firstly identifying
interpretations offered by the original researchers (secondorder
constructs) and, secondly, enabling the development of
new interpretations (third-order constructs) that go beyond
those offered in individual primary studies and offer a reinterpretation
based on primary research.
Data management began with familiarization with the
data and the noting of recurrent themes, constructing an index,
and labeling the data with the index. The data were then sorted
by theme and summarized in a series of matrix-based charts,
retaining the context and language of the respondents.
Descriptive analysis involved identifying dimensions within the
data, categorizing these dimensions, and finally grouping sets
of categories together as classes. Explanatory analysis involved
identifying links between sections of and subgroups within the
data to try to explore why such associations and subgroups
existed. The reviewers independently developed overarching
models that linked together the translations and authors’
interpretations. These models were then discussed, merged, and
used to generate hypotheses to produce a “line-of-argument.”
Charting the data enabled us to compare how the same
theme was explained and interpreted within different studies
and whether there were recurring themes. Two independent
researchers (S.C.S. and S.P.) conducted thematic analysis,
consulted at stages during the process using the constant
comparison method, and identified major overarching or
higher-order themes. An approach was taken that primarily
applied thematic analysis, which was considered within a
grounded theory framework. We summarized the themes and
subthemes from each paper and collapsed them into the
overarching themes and summarized how the authors of each
paper explained and interpreted common understandings. The
richness of the data and thoroughness of explanatory analysis
was deemed more important than the frequency of reported
themes. It became apparent that the included studies shared a
number of major themes; we were able to assess the frequency
of these themes in comparison with the entire data set. [61-63]
Review Identification and Selection
The total search yield of 3,431 was sorted by title, and
3,311 clearly unsuitable titles were excluded. The remaining
121 titles were examined by title and abstract. Two independent
reviewers (S.C.S. and S.P.) excluded 75 papers after
applying the inclusion and exclusion criteria to the information
contained in the abstract. Of the remaining 48 papers, 33
were excluded after reading in detail and applying the
inclusion and exclusion criteria. The 2 authors (S.P. and
S.C.S.) were able to reach a consensus without an independent
arbiter. Figure 1 shows a flowchart of progress into
the review with a total of 15 included papers (12 studies). [64–78]
The method quality was assessed, using the Critical
Appraisal Skills Programme tool, by 2 independent
researchers, and consensus was reached regarding a rating
of low, medium, and high for each included paper (Table 1,
Supplemental Digital Content 4, http://links.lww.com/CJP/
A79, Table 2, Supplemental Digital Content 5, http://links.
Three studies (4 papers) were of high quality, [71, 73–76]
8 were of medium quality, [65–67, 69, 70, 72, 77, 78]
and 1 was of low quality. 
Interobserver agreement of
quality assessment was determined by calculating percentage
agreement and a k-coefficient. There were a total of 120
items (10 items for each of the 12 papers), and the reviewers
agreed on 103 items (85%) and disagreed on 17 items
(15%). The overall interobserver agreement of the individual
items (k=0.077) represents substantial agreement
between the reviewers. For the initial total method quality
score the 2 reviewers agreed on 8/12 scores. Following a
consensus and discussion round agreement was reached on
12/12 scores without the need for an independent arbiter.
Pilot data extraction for 2 papers conducted by S.C.S.
and S.P. in November 2012 indicated there was consistency
and unanimous agreement. [68, 78] Extracted data were merged
and synthesized from individual documents into a summary
table (Table 3, Supplemental Digital Content 6, http://links.
lww.com/CJP/A81). The included studies provide data
from studies conducted mostly in the United Kingdom and
1 each from Australia and New Zealand; there were no data
published for other cultural contexts.
After reading all the papers in-depth and noting the
major themes, it was agreed that the thematic framework
should be participant beliefs about exercise and activity for
Four key themes emerged:
(1) perceptions and classification of exercise;
(2) role and impact of the health professional;
(3) exercise and activity enablers/facilitators;
(4) exercise and activity barriers.
A table of all supporting
extracted quotes is available from the first author on request.
Theme 1: Perceptions and Classification of Exercise
Perceived Difference Between Medically and Nonmedically Prescribed Exercise:
Most participants acknowledged
the importance of being active but made a distinction
between general activity, real/fitness exercise, and medical
exercise. Many participants were not challenged by traditional
back exercise programs and perceived these as
unlikely to be helpful. Those who had extensive exercise
experience appeared less fearful, and more confident, about
exercise effects and various exercise environments. Some
people had pursued their own exercise programs or developed
relationships with trainers, often by “trial and error,” because they felt that physiotherapy and rehabilitation
classes did not push them hard enough.
[65–68, 71, 72, 75–77]
David (FG3): “the best thing that I can do is just
walk, even if it’s sore, I still think I’m better to keep
walking.”  (p1906)
“I’ve been doing the Pilates and the walking has vastly
improved my condition. I’m cycling 10–15 minutes and
then I swim for half an hour, but I try to do that 5 days
a week.”  (p1481)
Participant 21, 39–year-old woman: “I think you
should be made to do more. It wasn’t working me hard
enough. I think you need much more as you go
on.”  (p24)
A26-13-2038: “I am already a physically active person
and the study did not take this into account.”  (p754)
Carolyn: “when you’re working with a physiotherapist
you feel like you’re in a clinical situation. With a
personal trainer you feel like you’re in a motivational
situation, it’s more encouraging.”  (p117)
Participant 1, 39–year-old man: “I think physiotherapists
give you a type of exercise, which is very specific to
the back problem. These are the types of exercises that
you would do on your living room floor; people haven’t
got the motivation to do this on a daily basisy”  (p247)
“To me at a sports centre you’re exerting
yourself.”  (p66)
Individual Preferences for Types and Formats of Exercise:
There are individual preferences such as consideration
of experience, abilities, adequate physical challenge, exercise
mastery, individualization, and supervision and a belief
that spinal stabilization is beneficial. Matching people with
similar fitness, strength, and technical expertise was thought
important for enhancing group dynamics. Individual performance
could be enhanced when exercises were aligned with
fitness levels and previously acquired skills. [64–67, 70–72, 75, 77, 78]
Participation and engagement were facilitated by
familiarity with the exercise environment, culture and
training process, and knowledge acquired from previous
exercise programs. Individuals were more likely to engage
within programs that were fun and had variety than ones
that were boring, unchallenging, or onerous because they
disrupted daily activities.
G2:F40: “If you stabilise the muscles around your spine
then the spine will get more chance of staying
healthy.  (p182)
Michael: “Going to the gym is about physically going to
a safe place. I can do exercises there if I go to the gym. I
can use the equipment. I’m here; I’ll do those
things.”  (p117)
Participant 21, 39–year-old woman: “It wasn’t working
me hard enough. I think it could have been more. It
does work, but I think you need much more as you go
on. Like each time you should get more and
more.”  (p247)
Jean: “I’m not a gym person. If you’re taking people
who have never done exercise into an environment that
is so powerful, you’re intimidating them from the word
go.”  (p117)
A55-18-2004: “I am surprised that no one has asked
what forms of exercise I take, particularly as most of the
exercises I do at the class, I have already been doing
myself.”  (p754)
130-13-2001: “I find back pain improves with regular
exercise at local gym. If attending three times a week,
back pain eases.”  (p754)
Deborah: “I loathe exercise. I don’t like structured
exercise”. Surely there must be a fun way of doing it.
I was offered three free dancing lessonsyanother
creative way of getting exercise. It’s exercise without
exercising.”  (p118)
693-17-2000: “I feel that the exercise class is geared to
people who do no exercise. As I exercise every day I find
it a waste of time getting to and from the class.”  (p754)
“You can go at your own pace, and your own
capabilities. Nobody made you feel embarrassed or
anything.”  (p65)
Importance of Individualized Exercise:
Participants liked or wanted exercises, and the delivery of exercise
programs, to be individualized. Participants who felt that
their exercises made sense to them and were well explained
also felt that their individual needs were addressed, in
contrast to those who felt that their exercises did not make
sense or did not push them hard enough. Compliance was
difficult when they lacked confidence in correct exercise
performance and there was consensus that a sense of mastery
is essential for correct exercise technique and confidence
building. People wanted exercise instructors to
demonstrate exercises, observe exercise practice, give feedback,
and make subsequent corrections in technique. This
concurs with the NICE clinical practice guidelines that
exercise for NSCLBP should be individualized or tailored
to the person and supervised. [64–67, 70–72, 75, 77, 78]
Irene (FG2): “I went to a back classyphysio, and there
was about eight or nine people in the class, but it didn’t
work because what suited one person didn’t suit
another.”  (p1903)
Rita: “If they demonstrate it on your body you tend to
remember. It does help your image in your mind later
on.”  (p118)
Jean: “The important thing about being monitored is
they are giving you feedback. So, one-to-one is ideal,
one-to-four is reasonable as long as the person is
there.”  (p118)
Participant 9, 62–year-old woman: “I think I would have
liked maybe a little more time doing exercises with them.
Because it is very rushed in there it’s a very busy unit,
and maybe a little more time, maybe 10 minutes,
15 minutes of actually doing the exercises with
them.”  (p249)
Female patient, age 46, nurse: “I think the exercises are
fine and when I asked how to do them they were further
explained to me. And it seems the exercises make you
clear how to do things automatically, as you would do
things in daily life.”  (p70)
R14 (female, age 52): “It was great to be supervised. I
was worried about doing the wrong thing, so to be told
why you’re doing thisyyou had confidence that it was
okayythe fact that someone was watching gave you
confidence.”  (p43)
Theme 2: Role and Impact of the Health Professional
People perceive that the health professional has a
definite role and preferred characteristics that include good
communication and being an effective educator. [64, 66, 72–76, 78]
Effective and Good Health Care Provider Communication
Skills Are Important:
Good communication was related
to participants feeling involved in the process. Participants
who were not able to discuss their needs or who received
poor explanations did not feel involved. According to
participants, good health professional communication
involved taking time over explanations; using appropriate
language and terminology; listening, understanding, and
getting to know the patient; and encouraging the patient’s
participation in the communication process. They particularly
valued behaviors such as listening and responding to
their questions, consulting with them about the effectiveness
of the therapy and relating the intervention to their
individual self-help needs. The key issue here is that the
process was seen as consultative, rather than prescriptive
and that the individual’s values, preferences, and life circumstances
Participant 4, 52–year-old woman: “Got boredythey
didn’t ask me what I thought I wanted, they just did
what they assumed was physiotherapy.”66(p248)
G2:M46: “He has got very much the right attitude. He is
encouraging you, explaining it to you clearly and
encouraging you to go through with it.” G2:F40: “In
addition to the video, his explanation of the rationale
behind it must have some benefits and it clearly
did.”  (p182)
Lynne, aged 47 years, who had a 10–year history of
NSCLBP: “the people who were running the program
would get angry with me (when I couldn’t do the
exercise correctly) and so it didn’t actually help (I felt
guilty for a long time).”  (p147)
Participant 0206, ATX24, EP: “You have to make
the appointment to go and see the GP for him to do the
prescription exercise. I thought he would go through
the do’s and don’ts. What to start off with, what to work
up to, how often, blah, blah, that sort of thingyI was in
there and out within 3 minutes, he just sat and read the
sheet of paper and that was it. He sent me away to work
it out for myself.  (p202)
Participant 5, 48–year-old woman: “I know somebody
else who went to a back class, and I don’t think they got
quite so much in-depth explanation about it, and they
just thought this exercises oh God, why do I have to do
them? But when you got it really explained to you, and
what the benefits, and to keep doing this.”  (p246)
Lynne: “With the personal trainer I learnt what I had to
do in a non-hazardous, for me, way. It basically turned
my life around. I don’t think I ever really knew what it
was I had to do. He was an educator.”  (p276)
Provision of Education and Information Are Important:
Participants liked or wanted treatments and diagnoses that were
well explained, and participants who received poor explanations
did not feel involved. There was a strong emphasis on wanting
an understanding and explanation of their situation, to be given
education material and resources, and accurate, understandable
explanations that are free from jargon.
Female patient, age 56, doctor’s receptionist: “They
explained everything carefully and assured me I
wouldn’t break anything.”  (p68)
Michael (FG1): “I think it’s (advice) crucialythe only
thing I would say is that the advice is often given at a time
when the patient is in pain and is least likely toyreflect on
it maturely. So I think it could be helpful to be given both
the advice when you are in pain and also the advice at a
period afterwards, when you are probably better.”  (p1903)
Participant 2: “It also gave you a greater understanding
of the actual physiology of the spine and how you can
damage it so easily but how strong it is in another sense
if you move properly and if your posture is right. I think
that was very helpful.”  (p170)
Carolyn: “Heaps of explaining, telling you why you’re
doing this particular exercise. I think just having things
explained to you is very important. Tell me why, tell me
why. Explain it to me.”  (p275)
G1:M56: “Mainly that (video) shows we should sort of
know a little bit more about how the body works, so that
we can be responsible to ourselves to a degree so that we
do the right things like bending/not bending.”  (p182)
Theme 3: Exercise and Activity Enablers/Facilitators
Across the included studies participants identified
additional enablers to exercise participation and engagement
that included self-efficacy and self-confidence, perceived
benefit, or good outcome, effective for pain reduction,
motivators, and incentives. Confidence was gained by
successful performance through supervision, pain control,
knowledge acquisition through the provision of information,
goal sharing, and follow-up contact.
Supervision of exercise programs was considered
important to provide individual correction:
expressed the need for follow-up support and reassurance
from the practitioner that they were carrying out instructions
correctly, and assistance with appropriate treatment
progression in line with their stage of recovery. It was
generally expressed that exercise instructors should demonstrate
exercises, observe exercise practice, give feedback,
and make subsequent corrections in technique rather than
hand out a sheet or list of exercises. [64–67, 70, 71, 73–75, 77, 78]
Michael (FG1): “In my own case I think it (exercise) is
very important. I would now exercise every day at least
by walkingyI would also swim and occasionally I
would do the exercises if I feel that my back’s beginning
to tighten again, so I think it’s crucial.”  (p1903)
Participant 0401, ATX6 and EP: “I don’t think it will
cure the pain but I think it will, hopefully, help to ease
it. That’s what I’m hoping for. And at least make me,
I’m hoping that, you know, if I’m doing things wrong it
will correct it.”  (p200)
R16; female, age 52: “When I first started doing the
exercises, I wasn’t confident enough to do it, because I
was frightened that I was going to harm my back. After
a while I got the confidence to know that I could do it
and it wasn’t harming my back.”  (p43)
G1:M56: “I did find the exercise made it more
comfortable and made me more flexible”; G2:F53: “I
still get pain, but it is not tending to be of the same
severity as it was before.”  (p182)
233-11-2019: “The exercise classes have got me in a very
much improved mental state.”  (p754)
A71-18-2020: “I have found this (exercise routine) to be
very beneficial, both physically and mentally.”  (p754)
Participant 14, 41–year-old man: “It would be helpful if
there was somebody you could phone and say well, you
know my background, this is how I’m feeling, is there
some exercises I should be starting again, or is there
something else I could try.”  (p45)
Theme 4: Exercise and Activity Barriers
Across the included studies participants identified
barriers to exercise participation and engagement. These
included lack of time, diagnostic uncertainty, fear of pain,
and lack of fit into daily life.
Difficulties with exercise adherence and not
seeing benefits of exercise were frequently attributed to lack
of time and fit into daily life. Participants believed that
being disciplined to prioritize exercise within routine daily
life and family commitment was important for their ongoing
participation. [67–69, 71, 72, 75, 76, 78]
Participant 0206: “Fit into your daily life? A nightmare!
There is a cre`che at the gym but that is £3.75 an hour
andyby the time my husband gets home in the evening;
there isn’t any time to get to the gym.”  (p202)
Participant 12, 64–year-old man: “I only do them
(exercises) one lot in the morning. Certainly they were
saying three times a day, which I think is probably not
easy for everybody to doyI used to find difficulties with
doing them at work.”  (p45)
Alan, a patient: “Doing your exercises twice a day or
whatever. Finding the time in the morning and find the
time in the evening. That’s something I’m not yet
managing to do regularly enough I think to really make
the difference.” Harry, a patient: “There’re always a
thousand things that need to be done and somehow
doing exercisesytends to fall further and further down
the list.”  (p629)
Participant 5: “If you keep the exercises up, which I
don’t all the time because I haven’t got the time but I do
when I can.”  (p170)
G2:F53: “To do them all (stabilisation exercises) you
need to set the alarm and get up early in the morning,
I mean it is something once you get into a habit of
doing.”  (p183)
G2:F40: “And I try sort of bring into like my everyday
life rather than do the whole exercises two or three times
Steven aged 60, with a 42–year history of NSCLBP:
“They structured what they wanted me to do around my
work and life.”  (p274)
Peter aged 43, with a 1–year history of NSCLBP:
“Understanding you and your lifestyle, ask you questions
about your life, what you do.”  (p274)
Alan: “Eventually I’ll get my act together and absorb it
into my lifestyle but it’s not something I can do
overnight.”  (p629)
The need for an accurate
diagnosis was typically considered to be an acceptable means
of “validating” the individual’s distress, and contributing to
improved treatment outcomes and a means of reducing the
risk of doing the wrong exercises. Verbeek et al42 reported
that patients expect an accurate diagnosis, so that they can
prove to themselves and others that their pain is real. Patients
are often dissatisfied either about not receiving a diagnosis,
inadequate diagnoses, or different diagnoses over time. The
inability of practitioners and exercise programs to relieve
pain, for many people, was a source of much frustration and
disappointment and could invoke perceptions of not being
believed. The explanations patients had already been given
for their LBP may have affected their beliefs regarding the
level of exercise and activity they could manage. These
experiences were felt to contribute to nonadherence to medical
regimens and unsuccessful rehabilitation. The lack of a
precise diagnosis is typically associated with poor recovery.
Clinicians may need to reflect on the way they handle
uncertainty of this nature and how this diagnostic uncertainty
may influence treatment decisions and communication with
care seekers. [65, 66, 71, 72, 75, 77]
Participant 22, 33–year-old woman: “I think by the
middle or the end of my treatment I would have
expected to know what was going on, what was wrong
with my back. I think, if it’s curable or if it’s not. If it’s
just going to be a long-term thing, I would like to have
found out.”  (p248)
Jean: “I found out since that it’s not been diagnosed
correctly. They’ve been giving me the wrong exercises
for somebody with what I’ve got now. For 10 years I’ve
been doing exercises according to this type of pain,
when it’s been aggravating the other thing that was
never diagnosed, it was always there but they never
looked at it.”  (p150)
David (FG3): “There was a real element of the doctor,
you know, stabbing at different treatments, you know?
‘Cause I was never properly diagnosed, you know, you
try this, try exercises, physiotherapy, tablets, put you in
traction then for a while). It was just, I mean, nobody’s
ever, you know, if they can’t put their finger on what it
isythen they can’t treat it.”  (p1903)
Participant 6: “But all they tell me is it’s probably wear
and tear.”  (p169)
Participant 2: “I do suffer from a lot of what I’ve been
told is soft tissue pain, which is the damage caused to all
the tissues, I have got some spikes on the vertebrae on
the X-ray, it shows up, I don’t know what they call
them, but there is a problem there.”  (p169)
Participant 3, 50–year-old woman: “I think [I’d have
liked] some more insight into the back pain, and really
find out what’s going on, you know.”  (p248)
Roberta (FG2): “Yes it comes down to the point again, of
diagnosis and specialist advice and treatment.”  (p1904)
Fear of Movement and Pain Aggravation:
Fear of pain aggravation and the avoidance of
potentially painful activities were associated with decisions
to exercise and could lead to avoidance or loss of confidence
with exercise and activity. Fear of pain returning
could also be an incentive to continue exercise when this
strategy had been successful. Exercise confidence could be
enhanced by health care providers who demonstrated how
to do the exercises correctly and gave feedback on performance
and how to pace. As exercise is unlikely to produce an
immediate tangible benefit, such as pain relief, it is difficult
for many patients, for whom pain relief is their primary
concern, to recognize the value of exercise. [65, 68, 70, 72, 75–77]
R16 (female age 52): “When I first went, started doing
the exercises, I wasn’t confident enough to do it, because
I was frightened I was going to harm me back, and after
a while I’d got the confidence to know that I could do it
and I wasn’t harming me back.”  (p43)
“It was great because you felt you were being
supervised, I was worried about doing the wrong thing,
so to be told why you’re doing thisyyou had
confidence that it was okayythe fact that a physiotherapist
was actually there watching you, gave you
confidence.”  (p43)
Participant 4: “It aggravates you to the point sometimes
where you think, I’m not going to do that it really really
hurts, and I know you’ve got to get beyond that stage
but it’s easier to say thaty[than] actually do it.”  (p170)
G1:F29: “I wanted to play tennis and was afraid it was
going to really hurt me”; G1:F38: “When we played
tennis we felt we had a similar sort of fear avoidance
thing going on.”  (p182)
A04-10-2007: “The exercise classes were pointless; they
just caused me more pain and aggravated pelvic injury
from two years ago, causing a lot of pain which doctors
just don’t seem to want to know.”  (p754)
“I usually pace myself on what I do on a daily basis and
I know what I can and can’t do. If I carry on working all
the time, just continuously doing housework or bending
down, doing the dusting and things, it comes and it
won’t go. The back pain gets worse and worse until I
actually stop. Then I have a rest and then I just have to
leave it for next time.”  (p1482)
It is interesting that very few of the papers we located
actually reported on participant beliefs about exercise as a
treatment for NSCLBP and barriers and motivators to
adherence. Within the included studies there was inconsistency
in the provision of supporting quotes, and often the
emphasis was on experience of pain and health care provider
opinions rather than exercise beliefs or perceptions. In
the area of exercise and LBP research, there is a paucity of
qualitative data. This contrasts with 336 randomized controlled
trials of exercise as a treatment for chronic LBP that
are listed in the Cochrane Library.
Four of the studies we identified were secondary analyses
nested within randomized controlled trials. [64, 76–78] Two
papers reported a research question, [64, 75] and all papers
reported research aims or objectives. The method quality was
variable but the majority of studies (8/12) were in the fair/
medium range and had the following consistent deficits in
method quality: justified and explicit description of recruitment,
data collection, and analysis steps that would enable
replication, consideration of the researcher/participant relationships,
and researcher biases. Linking the discussion to the
research aims, examination of strengths and limitations, and
recommendations for research were variable. It would be
difficult to replicate many of the studies and build on existing
work, and consideration might now be given to mechanisms
for improved reporting of qualitative studies.
Key themes within the identified studies included perceived
effectiveness, exercise ability and preferences, clinician
communication skills, individualized care, supervision and
motivation, system inflexibility, fear of pain, and compatibility
with daily life. In all the included studies people classified
exercise into formal exercise, which was exercise that
they undertook with the purpose of being active, medical
exercise for specific rehabilitation, physical activity involved
in everyday life, and competitive sports. These clear distinctions
between different forms of exercise and physical
activity may provide a framework for shaping recommendations
to undertake more exercise or be more physically
active. This may take the form of raising awareness of incidental
exercise and the World Health Organization and
NHMRC recommendations for physical activity in daily
recommendations/). Those who are more confident or
physically advanced could be directed to more demanding
programs in a preferred environment or format.
The decision whether or not to exercise was influenced
by beliefs about who should take responsibility for the
decision to exercise (the participant or the clinician), participant’s
feelings of self-efficacy to exercise, and the role of
fear of exercise or fear avoidance. Exercise is unlikely to
produce an immediate tangible benefit, such as substantial
pain relief, and may require sustained commitment. It may
therefore be difficult for many patients, for whom pain
relief is their primary concern, to recognize the value of
exercise. If pain relief is a factor that is known to feature
highly in treatment expectations, the use of treatment
programs that promote the improvement of functional
activities despite pain will consistently fall short of patient
expectations. The practitioner’s core listening and interpretation
skills may have as much of an influence on
treatment outcomes as the technical aspects of treatment.
Factors such as access to facilities and programs, time
constraints, work and/or family responsibilities, and environmental
structure may not be modifiable but exercises
can be designed to accommodate these variables by using,
for example, alternate forms of equipment, low-cost community
programs, work or home-based facilities, email and
telephone coaching, and periodic face-to-face follow-up.
The incorporation of exercise into daily activity and
exercising in a nonclinical environment is perceived as
helpful. Investing in routine exercise could help reinterpret
LBP as part of everyday life. If LBP is placed within a
nonmedical context and becomes part of everyday life then
addressing it with exercise might not be perceived as very
disruptive. Exercise becomes routine or habitual; it is no
longer a treatment belonging to the health care domain.
Clinical practice guidelines recommend individualized
exercise (tailored to the person) and consideration of
patient preferences for NSCLBP. Participants reported a
preference for supervised exercise over advice to exercise.
People feel encouraged to continue exercising when they
have regular contact with a health care professional and feel
understood. Countering fear-avoidance beliefs, building
confidence, and providing support were also important.
Individual exercise experience, ability, and preference may
influence interpretation of the message to stay active and
necessitate clarification by good health care provider communication
skills. Consideration may be given to the wellness
rather than the sickness model of normalizing or
demedicalizing the implementation of exercise programs
and framing them in the context of participant preferences.
Throughout the metastudy process, we remained aware
of 2 important limitations. First, the process decontextualizes
data, removing it from the context in which it was originally
presented or reported. Our access to this original context was
limited by the primary research report, which could omit
contextual factors. Second, a metasynthesis of this nature
does not analyze original data; the synthesis relies on the data
reported by the primary researchers. Two included studies (4
papers) were conducted and reported by review authors
(S.C.S., J.L.K. and M.U.). We have endeavored to reduce
bias by using a priori inclusion/exclusion criteria, assigning
data extraction and method quality assessments to those
review authors not involved in the studies, and ensuring a
range of supporting quotes from across the included studies.
The inclusion of only English language publications may be
considered a limitation; however, examination of the entire
search yield revealed that there were no non-English titles
from the searched databases.
Recommendations for Research
Research is recommended to test the effectiveness of
patient input into their exercise, activity, and rehabilitation
programs. Studies that do not involve an intervention but
explore patients’ beliefs specifically toward exercise or comparing
before and after exercise interventions are required to
replicate and build on the findings of this review and explore
additional cultural contexts. A decision-aid for exercise prescription
is currently not available. A questionnaire that
clinicians can use to determine participant exercise preferences
and inform their practice of exercise prescription has been
recommended by Slade et al.  This questionnaire requires
testing of the effects of participant-preferred exercise programs
on outcomes in NSCLBP in the clinical environment to
determine its utility as a method of systematic evaluation of
care-seeker needs and preferences related to exercise. 
Investigation of important and effective communication
skills to determine explicit forms of communication
that are helpful in conversations designed to encourage
healthy behaviors or attitudes and activity participation are
recommended. This may be done through identification of
communication skills essential to best practice, investigation
of methods to teach and assess these skills, and the
measurement and efficacy of behavior change and communication
training for health professionals.
Recommendations for Clinical Practice
Often assumptions are made that health care professionals
inherently understand patients’ beliefs. This may
lead to patients becoming stereotyped and generalizations
being made about their behavior. Effective communication
and listening skills enhance and facilitate the clinical
encounter. It is appropriate for practitioners to consider
factors that facilitate participant engagement and incorporate
these into exercise program design and to identify and
remove barriers to participation. This experiential knowledge
of people who have experience of back pain and beliefs
about exercise may be used to inform and engage potential
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