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What Triggers an LBP Flare? A Content Analysis of Individuals’
Perspectives
Nathalia Costa,* Paul W. Hodges, PhD,* Manuela L. Ferreira, PhD,
†
Joanna Makovey, PhD,
†
and
Jenny Setchell, PhD*
*School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia;
†
Institute of Bone and Joint Research/The Kolling
Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
Correspondence to: Jenny Setchell, PhD, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland,
4072, Australia. Tel: þ61733654506; Fax: þ617334687889; E-mail: j.setchell@uq.edu.au.
Funding sources: This study was supported by a Program grant (APP1091302), Centre of Research Excellence grant (APP1079078), and Fellowship
(PH – APP1102905) from the National Health and Medical Research Council (NHMRC) of Australia. MLF holds a National Medical and Health Research
Council of Australia Fellowship, is a Sydney Medical Foundation Fellow and Sydney University SOAR Fellow.
Conflicts of interest: The authors have no conflicts of interest to declare.
Abstract
Objective. For many, low back pain (LBP) is a lifelong condition with symptoms varying over time. Previous studies have
investigated long-term risk factors and triggers for onset of LBP. No study has examined causes for less distinct fluctua-
tions of symptoms, such as “flares,” which individuals with LBP identify as a significant and worrisome part of LBP. As
little is known about what triggers this type of fluctuation, we aimed to investigate individuals’ perspectives on LBP flare
triggers. Methods. We conducted an online survey of 130 people with LBP, asking what they think triggers their flares.
Data were qualitatively examined using content analysis. Results. Most participants identified biomedical (84.8%)
triggers, endorsing physical/biological factors to explain the flare occurrence. Themes included active movements
(35% of participants), static postures (28.1%), overdoing a task (5.3%), biomechanical dysfunction (4.4%), comorbid-
ities (4%), lack of exercise (3.3%), work (1.8%), and medications (1.5%). Nonbiomedical triggers were reported by
15.2% and included psychosocial and contextual factors, including psychological state (6%), weather (5%), sleep
(2%), diet (1.2%), and fatigue (1%). These results indicate that individuals consider biomedical factors to be the main
triggers of LBP flares, but some acknowledge nonbiomedical triggers. Conclusions. Study findings contrast with cur-
rent pain theories, which suggest that there is a need for a reduced emphasis on biomedical causes of LBP pain, es-
pecially when persistent. Recognition of patients’ views on causes of LBP flares is crucial to better guide clinical
practice and inform further research. The validity of triggers identified by LBP patients requires further investigation.
Key Words: Low Back Pain; Flare; Triggers; Content Analysis
Introduction
Low back pain (LBP) is the most common and burden-
some musculoskeletal condition globally in terms of
years lived with disability [1]. Along with individual and
social impact of activity limitation, the economic impact
of this condition is considerable, including high costs as-
sociated with health care and work productivity losses
[2,3]. LBP has been described by patients as characterized
by fluctuations in intensity [4]. Although not all fluctua-
tions are bothersome, flares are a fluctuation with a ma-
jor impact on LBP outcome. For example, greater
disability and work absenteeism are associated with the
occurrence of LBP flares in individuals with persistent
symptoms [5], and after an acute episode, higher flare
frequency is associated with worse disability outcomes
[6]. Qualitative studies have also revealed that the occur-
rence of flares disrupts work ability [4,7–9].
LBP flares are considered different than LBP episodes
[5,6,9,10]. Flares generally represent an increase in symp-
toms/bothersomeness, not necessarily preceded by at
least a month without symptoms, a requirement used to
define a new LBP episode [11,12]. People who experience
V
C2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 1
Pain Medicine, 0(0), 2019, 1–8
doi: 10.1093/pm/pnz021
Original Research Article
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LBP consider a flare of their condition to be an increase
in pain and/or other symptoms associated with impaired
function and emotional and cognitive changes [13].
Although some work has been conducted to better under-
stand factors that increase risk of a new LBP episode, lit-
tle attention has been directed to understanding what
causes LBP to fluctuate and trigger a flare.
People with LBP believe their symptoms persist and
recur mainly due to anatomical/biomechanical causes
[14]. Patients and physiotherapists agree that lifting,
bending, and prolonged sitting are the most important
triggers for LBP episodes [15]. Health care clinicians in
general consider triggers for new LBP episodes to be
mainly biomechanical and rarely endorse individual and
psychological/psychosocial factors [16]. A recent study
confirmed that patients can reliably identify a number
of biomechanical factors as triggers for their LBP epi-
sode (e.g., tasks involving heavy loads and vigorous
physical activity), but they underestimate the risk asso-
ciated with behavioral and psychological triggers [17],
even though the latter play an important role in devel-
opment of a new LBP episode [18]. It is unknown
whether people with LBP similarly emphasize biome-
chanical factors as triggers for their LBP flares. As an
LBP flare is different than a new episode, it may have
different triggers. For instance, weather parameters
have been shown to not increase the risk of developing
an LBP episode, yet patients commonly argue that cer-
tain weather conditions influence their symptom sever-
ity [19]. Although individuals’ perspectives on what
constitutes a flare [13] and their views on why symp-
toms persist/recur have been previously investigated
[14], what people think triggers their symptoms to flare
remains undetermined. We argue that views of people
with LBP on potential triggers for flares may provide
insights into triggers not discussed in the literature re-
garding triggers for episodes.
This study aimed to investigate individuals’ views
on triggers for LBP flare, as distinct from causes of an
episode. Addressing this gap in the literature is impor-
tant as the identification of potential flare triggers can
help manage this bothersome aspect of the LBP
experience.
Methods
Study Design
A mixed-methods online survey examined individuals’
experiences and understanding of LBP flare. Details of
this online survey are reported elsewhere [13]. To specifi-
cally investigate patients’ views on triggers for LBP flare,
we asked the following question: “What do you think
causes your low back pain to flare up? For example,
things that you do, things that happen to you, or things
that change in your environment.” Eight text boxes with-
out word limits were provided for answers. Data were
analyzed using content analysis to identify themes of trig-
gers highlighted by participants.
Participant Selection
Participants were recruited through advertisements
placed on social media, local community and health cen-
ters, promotion through pain-related consumer organ-
izations, and by contacting participants from previous
studies. Participants were considered eligible when the
following criteria were met: 1) age of 18 years and above,
2) ability to communicate in English, and 3) self-
identification as having experienced LBP. There was no
exclusion for LBP duration, other coexisting pain, or
comorbidities. If participants chose to answer the ques-
tionnaire and complete the study after reading the study
information page, consent was implied. A total of 622
participants enrolled to participate in the study. Four
hundred ninety-two incomplete questionnaires were re-
ceived and excluded from analysis. The remaining 130
complete questionnaires were included. Sample size was
determined by response rate. Saturation was achieved
with data from 130 questionnaires; that is, there was suf-
ficient depth and repetition of identified themes for flare
triggers, and no new themes were emerging from prelimi-
nary content analysis [20].
Theoretical Underpinnings
Our study is underpinned by relativist assumptions, that
is, reality is understandable through an individual’s
knowledge and interpretation [21]. We sought to better
understand triggers for LBP flares based on individuals’
views. In this context, we used content analysis to sys-
tematically analyze the data and code the occurrence of
triggers for LBP flares. In content analysis, a code is most
often a summative, salient, and essence-capturing word/
phrase symbolically assigned to a portion of language-
based data [22]. Themes are groupings of codes into
broader summative categories. These analytical group-
ings of concepts in the data enabled us to report individu-
als’ views of what triggers LBP flare. We used an
inductive approach to analysis, which means we did not
predetermine codes but created them from our reading of
the data. Therefore, we minimized interpretation and
drew meaning from participants’ responses.
Data Analysis
Demographic and clinical data were summarized using
descriptive statistics. Data for content analysis were
obtained from the words and short sentences used by
individuals to answer our survey questions. Content anal-
ysis was conducted independently by two investigators
(NC and JS). First, NC and JS independently read the en-
tire data set and made notes on the main concepts, scope,
and breadth of the data in relation to the research ques-
tions. Second, researchers reread the entire data set, man-
ually coding data extracts into data management
2Costa et al.
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software (Microsoft Excel) and developing provisional
overarching themes, themes, and codes. Third, coding
was refined after discrepancies were discussed to agree
with each other and subsequently with PH. During this
process, we developed a set of coding rules to guide data
analysis: 1) when participants’ answers related to two or
more codes, investigators decided which code was pre-
dominant, and thus each trigger was coded only once; 2)
answers with unclear meaning were excluded from cod-
ing analysis (e.g., “everything,” “bad choices”); 3) all
codes were included in the results, regardless of the fre-
quency of which codes were mentioned.
Trustworthiness and Rigor
NC and JS coded the entire data set independently, and
discrepancies were discussed to agreement with PH pro-
viding an additional perspective. All other authors
reviewed data set and agreed upon results and analysis. A
researcher external to the project (TH) confirmed the
trustworthiness of the coding. TH is an occupational
therapist with both clinical and qualitative research expe-
rience. Qualitative rigor was secured through STROBE
[23]. All relevant categories of the checklist were satisfied
in research design and reporting.
Results
The characteristics of the participants are described in
Tables 1 and 2. Almost all participants lived in Australia,
they varied considerably in age (mean [range] ¼43 [22–
72] years), and over half were female (74.6%). Eighty-
two percent of the sample experienced LBP daily, and for
over a half of participants symptoms varied daily
(55.4%).
One hundred twenty-eight of 130 participants
(98.4%) listed at least one factor they thought triggered
their LBP flares. Most people provided short answers, us-
ing one or two words to describe triggers. Only a few
people answered in a phrase, making some additional
clarifying comments to their answers. Of the 676 trig-
gers, 23 (3.4%) were excluded from coding for lack of
precision (e.g., “bad choices,” “pressure,” “too little”).
The remaining 653 triggers were clustered for existence
and frequency into several themes and codes (Table 3),
and then these were further categorized into two over-
arching themes, biomedical triggers (N ¼554, 84.8%)
and nonbiomedical triggers (N ¼99, 15.2%). The over-
arching themes were intended to give a broad overview
of how the data fit into these categories, and it is ac-
knowledged that some themes and codes could cross over
into both overarching themes. More than half of partici-
pants provided four or more potential triggers for their
LBP flares (55%), and 24% used all text boxes, citing
eight or more flare triggers. Nearly half of participants
(N ¼59, 45.5%) discussed both biomedical and nonbio-
medical triggers. All percentages reported for
overarching themes, themes, and codes were calculated
as a proportion of the total number of responses.
Overarching themes, themes, and codes are discussed
below.
Overarching Theme 1: Biomedical Triggers
Overwhelmingly, people discussed biomedical factors as
triggers for their LBP flare. Fifty-three percent of partici-
pants mentioned only biomedical triggers. Within bio-
medical triggers (N ¼554, 84.8%), a multitude of
different factors were clustered into 11 themes (Table 3).
Active movement (N ¼228, 35%) and static postures
(N ¼183, 28.1%) were the most common themes.
Larger themes included several codes; all are described
below.
Active Movement
Active movement was the most common theme of bio-
medical trigger discussed by participants. Participants
discussed many types of active movement (Table 3).
These were grouped into four codes: moving in a particu-
lar way (N ¼77, 11.8%), physical activity (N ¼65,
10%), life’s daily tasks (N ¼49, 7.5%), and lifting
(N ¼37, 5.6%). Within the code moving in a particular
way, “bending” was the most common trigger, followed
by “twisting.” Some participants specifically addressed
the quality of movement (e.g., “sudden,” “wrongly,” and
“repetitive”), highlighting that their flare causes were not
simply movement but also how movement happens. The
Table 1. Demographic characteristics of study participants
Age, mean 6SD, y 43.2 612.05
Gender, %
Female 74.6
Male 25.4
Country, %
Australia 98.5
Other 1.5
State, %
Queensland 56.9
New South Wales 16.9
Victoria 15.4
Other 10.8
Table 2. Characterization of study participants’ low back pain
Duration of LBP, mean 6SD, y 13.09 610.33
LBP every day, %
Yes 82
No 18
Time frame of LBP variation, %
Daily 55.4
Weekly 23.1
Monthly 7.7
Other 13.8
Periods of no LBP, %
Yes 29.7
No 70.3
LBP ¼low back pain.
Individuals’ Perspectives on LBP Flare Triggers 3
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code physical activity included length, type, and intensity
of exercise, with most participants clearly defining their
own thresholds (e.g., “walking for longer than an hour,”
“long distance running,” “strenuous exercise”). Within
the code life’s daily tasks, a variety of tasks were men-
tioned, such as “gardening,” “vacuuming,” “carrying,”
and activities “where arms are above head.” In the code
lifting, the idea of the load was implicit in most responses
(e.g., “lifting heavy things,” “constant lifting”).
Static Postures
Static postures were the second most common response.
Among participants’ answers used to describe static pos-
tures, most could be coded as sitting (N ¼65, 10%).
Sitting was often mentioned as a trigger, with a qualify-
ing description of length of sitting (e.g., “for too long,”
“over thirty mins,” “all day,” “too much”). Similarly,
exposure to prolonged standing (N ¼35, 5.4%) was con-
sidered a potential trigger. The code posture (N ¼36,
5.5%) covered impressions of bad postural habits during
both waking and sleeping hours (e.g., “not sitting
straight while biking,” “sleeping in a bad position”), as
well as maintenance of a certain position for a long pe-
riod of time (e.g., “static posture”). The code travel/driv-
ing (N ¼24, 3.7%) incorporated both car and airplane
trips, overlapping with sitting but adding other
components to it, as there are possible effects of factors
such as changes in air pressure and whole-body vibra-
tion. Type of mattresses/seats (N ¼23, 3.5%) included
sitting or lying on unfamiliar surfaces (e.g., “different
bed for a few nights,” “sitting in other people’s houses as
with uncomfortable sofas”).
Overdoing a Task
The theme overdoing a task (N ¼35, 5.3%) clustered
answers provided by participants that referred to behav-
iors such as not pacing and/or overdoing a task or activ-
ity. This relationship is captured well by one
participant’s comment: “It’s a fine line between doing as
much as you can re: exercise, social, home and that a tiny
bit too much. Some days you can get away with doing
something and the next day it will stop you.” Answers
provided by patients alluding to overdoing a task at their
workplace were clustered exclusively within the theme
work (discussed below).
Biomechanical Dysfunction
The theme biomechanical dysfunction incorporated code
changes in motor control (N ¼15, 2.3%) and damage to
the spine (N ¼14, 2.1%). In the group of codes empha-
sizing changes in motor control (N ¼15, 2.3%), partici-
pants identified poor core strength and overuse of lower
back muscles as causes for their flares. An interesting
finding in this code was that some participants discussed
a lack of cognitive control over movements as a potential
trigger (e.g., “moving without thinking,” “not paying at-
tention to how I move”). The second code clustered trig-
gers that referred to structural spinal changes, often
portrayed as recurrent or irreversible (e.g., “recurring
bulging disk,” “I have lumbar osteoarthritis. It is
constant.”).
Other Biomedical Themes
There were eight smaller themes with no codes (Table 3).
In the theme comorbidities (N ¼26, 4%), a range of
other conditions such as knee pain, endometriosis, and
constipation were highlighted by participants as potential
triggers for their LBP flare. For example, one participant
highlighted “flare-ups in other places causing chain reac-
tion.” Lack of exercise (N ¼22, 3.3%) arose as a theme
in two different contexts: inactivity (e.g., “being too sed-
entary,” “reduced walking”) and lack of specific exer-
cises, highlighting the idea of exercise as medicine (e.g.,
“lack of correct exercise,” “not doing specific strengthen-
ing exercises”). The theme work (N ¼12, 2%) was also
identified from participants’ responses, indicating that
they believed their work triggered their flares. Some
responses overlapped with the theme overdoing a task,
described above (e.g., “work too hard at the office,”
“increased workload”). The theme medications (N ¼10,
2%) was mainly associated with medicine intake as part
of management of LBP, which participants discussed as a
Table 3. Summary of qualitative analysis findings
Overarching Themes,
Themes, and Codes
Frequency,
No.
Frequency,
%
Biomedical triggers 554 84.8
Active movements 228 35
Moving in a particular way 77 11.8
Physical activity 65 10
Life’s daily tasks 49 7.5
Lifting 37 5.6
Static postures 183 28.1
Sitting 65 10
Posture 36 5.5
Standing 35 5.4
Travel/driving 24 3.7
Types of mattresses/seats 23 3.5
Overdoing a task 35 5.3
Biomechanical dysfunction 29 4.4
Changes in motor control 15 2.3
Damage to the spine 14 2.1
Comorbidities 26 4
Lack of exercise 22 3.3
Work 12 1.8
Medications 10 1.5
Sex 4 0.6
Type of shoes 3 0.4
Medical treatment 2 0.3
Nonbiomedical triggers 99 15.2
Psychological state 39 6
Weather 33 5
Quality of sleep 14 2
Diet 8 1.2
Fatigue 5 1
4Costa et al.
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trigger for flares when failed (e.g., “forget pain medi-
cation,” “cortisone injections wearing out”). The themes
sex (N ¼4, 0.6%), shoes (N ¼3, 0.4%), and medical
treatment (N ¼2, 0.3%) were cited only for a few
people.
Overarching Theme 2: Nonbiomedical Triggers
Participants identified considerably fewer nonbiomedical
(N ¼99, 15.2%) than biomedical triggers (N ¼554,
84.8%). Only two participants (one male and one fe-
male) reported only nonbiomedical triggers without any
concomitant biomedical parameters. Both participants
reported stress and weather as the only triggers of their
LBP flares. In the overarching theme nonbiomedical trig-
gers, among five identified themes (no codes as themes
were not large), the most frequently discussed were psy-
chological state (N ¼39, 6%) and weather (N ¼33, 5%).
Psychological State
Within this theme, participants most frequently reported
“stress” as a trigger for LBP flares. Some also discussed
other mood states such as “anxiety” and “emotional
lows.” Some answers were more specific and outlined
specific reasons for emotional and psychological reper-
cussions, for example: “life complications,” “money
problems,” “family issues,” and “attitude to pain.” A
few people associated occurrence of flares with the neces-
sity to be productive: “need to feed my creativity,” “need
to do anything constructive.”
Weather
Within the theme weather, participants mostly pointed to
cold weather and barometric pressure changes as poten-
tial triggers (e.g., “cold weather,” “being too cold espe-
cially in air conditioning,” and “barometric pressure
changes”). Temperature changes, rainy weather, and
warm weather were each mentioned by at least one
participant.
Other Nonbiomedical Themes
Quality of sleep (N ¼14, 2%) clustered responses refer-
ring to “lack of or restless sleep” and “poor sleep qual-
ity.” Only a few participants referred to triggers that
could be classified under the themes diet (N ¼8, 1.2%)
or fatigue (N ¼5, 1%). We classified fatigue separately
from psychological state as most responses were ambigu-
ous as to whether this referred to mental or physical ex-
haustion. One participant referred to both: “When I’m
mentally and physically exhausted, its [sic] the first thing
to flare up.”
Discussion
This study surveyed people who have experienced LBP to
determine what they believe to be triggers for their LBP
flares. Our primary finding is that participants
considered biomedical factors to be the main triggers of
their LBP flares, but some also cited nonbiomedical trig-
gers. The most frequently reported reasons for experienc-
ing this type of fluctuation of symptoms were active
movements and static postures. When considered to-
gether, these triggers represent over half of the total num-
ber of participant-identified causes for an LBP flare.
Predominance of Biomedical Triggers
Although our study is the first to seek patients’ perspec-
tives of what triggers flares of LBP, our finding of a prev-
alence of biomedical triggers is not surprising. Previous
literature indicates that people with LBP emphasize bio-
mechanical causes for their symptoms [7,24]. A cross-
sectional survey investigating triggers for new LBP epi-
sodes revealed that individuals hold biomedical/biome-
chanical beliefs about causes for a new LBP episode and
rarely endorse psychosocial aspects [15]. The most com-
mon types of triggers were also unsurprising (e.g., bend-
ing, twisting, and prolonged sitting) and largely coincide
with those of a new LBP episode [15]. However, our data
revealed a layer of complexity regarding the role of
movement in triggering LBP flares: Lack of exercise was
believed to be a trigger, indicating that some participants
might consider maintenance (rather than avoidance) of
physical activity to be an important factor to reduce LBP
flares. This perspective agrees with previous research,
which found that a lack of regular physical activity pre-
dicts future sick leave due back pain [25]. To our knowl-
edge, no other research has shown that people with LBP
recognize lack of exercise as a risk factor for their LBP
flares.
Our data also revealed that participants may not al-
ways be able or willing to avoid triggers or their conse-
quences. This is captured well by one participant’s
comment: “Some experiences are worth the pain you
know you will get later—it’s your choice.” Another par-
ticipant stated: “Making love with my partner will al-
ways make it worse the next day—something I prefer to
accept.” These responses highlight the need to recognize
the complex interaction between flares and patients’
quality of life as part of management strategies and indi-
cate that individuals may be able to exert control over
certain triggers better than others, which might play a
role in their coping strategies.
Potential Underestimation of Nonbiomedical
Triggers
Within the group of nonbiomedical triggers, the theme
psychological state revealed stress as a potential trigger.
This has been reported in the literature related to LBP
flares [5]. Other psychological factors such as anxiety,
changes in mood, and emotional lows were identified as
triggers in our content analysis. Those factors have been
discussed as long-term exposure risk factors for LBP.
There is evidence that distress, depressive mood, and
Individuals’ Perspectives on LBP Flare Triggers 5
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somatization are predictors of disability and chronicity
of LBP [26]. A bidirectional relationship has been sug-
gested between back pain and mental health, as back
pain symptoms are associated with increased odds of de-
pression, psychosis, anxiety, stress, and sleep disturban-
ces [27]. However, whether psychological factors have a
causal relationship to fluctuation of symptoms such as
flares remains unknown.
Few participants endorsed the theme sleep as a poten-
tial flare trigger. This contrasts with research that out-
lines a bidirectional relationship between sleep
disturbance/quality and LBP pain intensity [28]. A study
conducted with people with LBP showed that a night of
poor sleep quality, difficulty falling sleep, waking after
sleep onset, or low sleep efficiency is followed by a day
with higher pain intensity [28]. Weather was also identi-
fied as a potential trigger for LBP flare in our analysis.
Past research has demonstrated that changes in weather
parameters (i.e., temperature, humidity, pressure) are not
associated with risk of developing a new LBP episode af-
ter a period without pain [19]. Whether weather changes
can trigger a fluctuation of severity of ongoing pain is
unknown and cannot be excluded.
Fatigue was the least commonly reported nonbiomedi-
cal trigger for LBP flare. People who experience a new
episode of LBP rarely consider fatigue to be a trigger
[17]. However, it is likely that the risks associated with
this psychosocial trigger have been underestimated.
Previous research has shown that manual tasks involving
heavy loads and engaging in physical activity are more
likely to cause a new onset of back pain when fatigued
[18]. For other musculoskeletal conditions, fatigue has
been identified by patients as an important domain of
flare, in addition to being considered a potential trigger
for this experience [29–31]. Whether there is an associa-
tion between feeling fatigue and an increase in the likeli-
hood of experiencing LBP flares is undetermined, and
therefore further investigation is warranted.
Contextualizing Findings
This study adds to our previous investigation of individu-
als’ perspectives on what constitutes an LBP flare [13]
and their explanations for why symptoms persist and re-
cur [14]. It is important to understand not only what
flares are [13], but also why [14] and when they occur.
There is a current life course conceptualization of LBP as
an underlying condition with histories of LBP across mul-
tiple life stages, in which the unpredictable fluctuation
course differs from the course marked by recurrent epi-
sodes [32]. It has been argued that there is a back pain
subtype (with flares) that is etiologically distinct from
LBP without flares [33]. Thus, triggers for LBP flares
might differ from risk factors for prevalence and recur-
rence of LBP. The bias toward biomedical triggers for
LBP in our findings contrasts with current evidence,
which argues that psychosocial factors such as negative
beliefs and pain catastrophizing are associated with per-
sistence of LBP [26,27,34]. In order to enhance education
and management of this condition, it is imperative to test
the validity of the triggers identified in our study. As this
study provides insights about what people believe trig-
gers their LBP, the results are likely to be a valuable
source of information for clinicians who work with indi-
viduals with LBP. These findings provide insights into
how clients conceptualize their condition, and also work
toward a better understanding of triggers for LBP flares.
Both elements are likely to help with clinical manage-
ment of LBP and its fluctuations.
Although this exploratory study provided insights into
individuals’ beliefs about what triggers their LBP flares, a
number of factors should be considered when interpret-
ing the findings. The study was conducted online in a sur-
vey format. Although this means that participants are
likely to have felt comfortable expressing their thoughts
anonymously, and that it therefore likely represents what
participants believe triggers their LBP flares, the method-
ology is not intended to determine causation (i.e., it does
not investigate whether a specific factor actually triggers
a flare). Further research designed to investigate causa-
tion could utilize the triggers reported in this study. We
also acknowledge that the phrasing of our question may
have led participants to provide certain answers. We ac-
knowledge that our use of the terms “biomedical” and
“nonbiomedical” are somewhat restrictive in their divi-
sion of the data discussed in our study; yet the dominance
of biomedical themes remained clear regardless of occa-
sional potential anomalies. There was a large difference
between the number of people who commenced the sur-
vey and those who completed it and were included in the
sample. We believe this was due to survey length (55
questions). Those completing the survey might have been
individuals with a greater personal interest in the topic;
this may be one reason why our sample had a high repre-
sentation of people with daily and severe symptoms.
There are also limitations to transferability of findings to
be considered when applying findings to different popu-
lations. For example, most of the participants live in
Australia. Thus, although there may be similarities, our
findings may not be entirely transferable to individuals
with LBP from other countries. Further, the sample was
mostly female, and participants frequently had severe
and persistent symptoms; thus perhaps not all people
who experience LBP would describe similar triggers.
Future studies could be designed to test possible differen-
ces between such subgroups. Data on education level and
socioeconomic status of participants were not collected.
Whether such parameters influence an individual’s con-
ceptualization of triggers for flare is unknown and could
be considered in future work. Finally, we did not provide
participants with a definition of flare, but rather relied
on participants’ interpretation of the term. This can be
considered both a strength and a limitation of our study.
By not constraining participants to a specific definition,
6Costa et al.
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we allowed them to highlight triggers that matched their
own unique experience of LBP flares. However, this also
means that we might have identified triggers for flare
that mean different things to different individuals. Recent
work has identified that individuals with LBP regard
flares of LBP as more than an increase in pain, including
other elements such as interference with function and
emotions [13]. This could be considered in future work.
Conclusions
Participants believed that the triggers for their LBP flares
are primarily biomedical. Nevertheless, some partici-
pants recognized the existence of nonbiomedical triggers.
As both clinical practice and research should be guided
by a person-centered perspective, the triggers identified
in this study should be investigated further. Future re-
search assessing symptoms over time would be valuable
to quantitatively identify the biomedical and nonbiomed-
ical triggers that increase the likelihood of experiencing
an LBP flare. The examination of LBP triggers helps de-
velop optimal prevention strategies in clinical practice
and better guides how to modify maladaptive illness per-
ceptions. Management of LBP flares may lead to an in-
crease in productivity and less time off at work, with the
potential to contribute to a decrease in the large LBP bur-
den on health care systems worldwide.
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