UNDERSTANDING AND EVALUATING THE ROLE OF GRADED ACTIVITY IN THE MANAGEMENT OF CHRONIC NON-SPECIFIC LOW BACK PAIN

Abstract

Chronic non-specific low back pain (LBP) is a major global cause of disability. While exercise is a recommended treatment, the relative effectiveness of different approaches and the influence of psychosocial factors remain unclear. This thesis aimed to evaluate the effectiveness and clinical equivalence of graded activity compared to other exercise interventions, and to explore how psychosocial factors contribute to recovery. Three studies were conducted. A Cochrane systematic review found very low certainty evidence from three trials (401 participants) that graded activity may not provide meaningful improvements in pain, disability, or psychosocial outcomes when compared to no trial treatment. Given that the evidence is very uncertain, future studies may lead to different conclusions. A large equivalence randomized controlled trial (425 participants) showed that graded activity and motor control exercises were equally effective in reducing physical disability, pain intensity, and physical function, with no significant differences in adverse events. Further, a longitudinal mixed- methods study followed 10 participants who received graded activity and identified five distinct recovery trajectories. Participants with higher optimism, self-efficacy, and lower fear of movement reported better outcomes and sustained engagement. In contrast, those with psychological distress, unhelpful beliefs, or contextual barriers experienced limited benefit. These findings suggest that graded activity may be a valid treatment option for chronic LBP, with similar effectiveness to motor control exercises. However, psychosocial factors may influence individual trajectories of LBP recovery. Although graded activity incorporates personalized functional goals, individuals facing significant psychological or contextual challenges may require additional support to substantially benefit from exercise-based interventions.