A new systematic review has landed in the low back pain world and it shines a light on something many trainers have noticed for years. People with chronic low back pain don’t recover simply because a programme gets heavier. Pain doesn’t fade because a barbell goes up by 10kg. Progress often comes from something far less visible and far more human, and that’s the way movement feels, the way it is framed and the meaning attached to it during coaching.
The study compared loaded resistance training with unloaded exercise for people with chronic non-specific low back pain. Both approaches reduced pain and disability. Yet the actual amount of weight on the bar didn’t make much difference to symptoms. This raises an interesting possibility for trainers, especially those who have completed or are studying low back pain management course, or who work closely with long-term pain clients. If load itself doesn’t create an advantage, something else must be doing the heavy lifting in a session. That “something” sits squarely in the coach–client interaction.
It’s Not the Load, It’s the Meaning
When they train, clients can become stronger over time and their tissues adapt nicely to repeated loading. The study confirmed this. Loaded training improved strength and endurance. Yet fear, catastrophising, avoidance behaviours and broader pain beliefs didn’t budge because of increased load. Heavier weights didn’t create psychological change.
This makes sense in practice. A client can deadlift 40kg with perfect form yet still panic when they need to tie their shoes. Another client can complete a loaded squat but freeze when asked to lift a box from the floor. Fear does not respond to weight selection. Fear responds to meaning. If a client sees a movement as threatening, that threat colours the entire experience no matter what sits on the bar.
Research over the past decade have reinforced this idea. Pain-related fear predicts disability more strongly than physical capacity (Jadhakhan et al., 2023). Catastrophising can amplify pain signals and reduce tolerance for movement (Marshall et al., 2017). Load doesn’t resolve these beliefs. Narrative does.
The Power of Language, Reassurance and Context
Every coaching session becomes a small psychological intervention. What you say shapes how a client interprets the sensations they feel during exercise. A calm tone, a confident explanation and a message of safety all work together to reduce perceived threat.
Simple phrases like “your back is adaptable” or “this movement is safe to explore” can change the emotional climate of a session. Clients often carry years of unhelpful messaging, warnings, restrictions and/or frightening language. A few reassuring sentences create a clearer path for progress.
The study emphasised this point. While load did not shift psychological variables, the authors highlighted the role of context and communication. When trainers normalise temporary discomfort, highlight successes and present movement as a chance to rebuild confidence, clients change the way they relate to their bodies. Back pain often softens when fear softens.
Exposure Strategies That Change Beliefs
Movement exposure works beautifully when used intentionally. Clients start with a movement that feels safe, even if it looks simple. Over time, the movement becomes slightly deeper, slightly faster or slightly more challenging. The exposure becomes a steady conversation between client and body. Each repetition reminds them that the feared action doesn’t have to be dangerous.
This isn’t the same as loading progression. A client might move through a pain-free range today and a slightly bigger one next week. They might lift an empty dowel before they touch a barbell. They might work on slow controlled bends before picking up anything off the ground. These experiences build trust and soften protective responses.
Exposure strategies have strong research support. Early work on graded exposure by Vlaeyen and colleagues (2001) showed that behavioural exposure to feared movements helped reduce pain-related fear. More recent papers reinforce this finding by demonstrating that behavioural change predicts symptom change more strongly than biomechanical measures.
Behavioural Dose vs Mechanical Dose
A lot of trainers focus automatically on mechanical dose, as in sets, reps, tempo, intensity, progression. Those variables matter for strength development and tissue adaptation. They don’t fully explain improvements in chronic pain.
Alongside mechanical dose sits behavioural dose. Behavioural dose reflects the amount of confidence gained, the number of success experiences accumulated, the removal of fear from movements and the meaningful steps taken towards self-efficacy. Clients who build these behaviours often report reduced pain and greater freedom of movement.
Imagine two sessions with the same exercises and rep ranges. One client receives reassurance, calm explanations and positive reinforcement. Another receives cues focused on protection, bracing or threat. The mechanical dose is the same, but the behavioural dose is completely different. Research shows that outcomes will follow the behavioural pathway.
Real Coaching Scripts That Shift Emotional Meaning
Shifts in meaning often come from simple sentences delivered at the right time. Here are a few that work well in practice:
- “That sensation is your body getting used to the movement again.” This frames discomfort as adaptation rather than damage.
- “You handled that really well. Your back coped with the load.” This reinforces the body’s resilience.
- “We’ll explore this movement gradually and keep it safe.” This reduces anxiety and anchors the experience in progression.
- “Your back isn’t fragile. It adapts like any other tissue.” This helps challenge long-held beliefs.
Scripts like these guide clients through uncertainty and remind them that movement is safe. Over time, the emotional meaning of movement changes. When meaning changes, pain often changes alongside it.
Why Personal Trainers Are Therapeutic Agents
Many trainers underestimate the therapeutic role they play. Clients share fears, frustrations, doubts and stories of past setbacks. They look for reassurance and guidance. They come to sessions carrying beliefs about pain that can either support or hinder recovery.
The study’s authors highlight the importance of communication, context and client interpretation. It reminds trainers that their influence stretches far beyond programme design. A trainer becomes a therapeutic agent through tone, presence, consistency and empathetic coaching. A trainer provides structure and safety, not just exercises. This holistic influence is mirrored in the evolution of many strength & conditioning coach courses, which now include psychologically informed approaches as standard content.
Coaching Behaviours That Help Chronic Pain Clients
Supportive coaching behaviours create a learning environment that feels safe and predictable. Reassurance helps reduce worry around new movements. Normalisation helps clients interpret fluctuating symptoms as part of the process instead of failure. Graded exposure helps rebuild confidence step by step. Reframing can challenge beliefs that restrict activity.
A client who trusts their trainer often attempts movements they previously avoided and they also stay consistent. Consistency plays a huge role in back pain recovery. It builds momentum. It builds identity. It stabilises routine and expectation. These factors feed directly into the behavioural side of pain reduction.
Why the Therapeutic Relationship Shapes Outcomes
The relationship between trainer and client can support long-term recovery. A strong relationship creates trust through clarity, consistency and empathy. That relationship helps clients explore movements that once felt impossible. They begin to reinterpret pain sensations as manageable. They gather evidence that movement feels safe.
Pain is influenced by expectations and predictions. When the therapeutic relationship supports a shift in expectations, the system reacts differently. A supportive environment reduces perceived threat and helps the nervous system down-regulate protective responses.
Practical Techniques for Fearful or Frustrated Clients
Clients with chronic pain often feel stuck. Some become disengaged after repeated setbacks. Others become fearful when symptoms fluctuate. Trainers can help by creating a predictable structure with achievable wins. Starting with familiar tasks helps create early momentum. Visible progress markers, such as improved ease of movement or increased confidence, help sustain motivation.
Simple reflective questions also work well. Asking a client, “What movements feel safest today?” invites collaboration and reduces pressure. Validating their frustration without amplifying it helps maintain connection. These techniques support psychological engagement in the training process, which influences pain more reliably than changes in mechanical load.
Load as a Tool, Not a Treatment
Loaded exercise has value in low back pain rehab. It builds strength and capability. It helps clients feel athletic again. It offers structure and a sense of progression. Load simply doesn’t control symptoms on its own. The meaning attached to load and the way the movement experience is framed, often does the real work.
The study reinforces this idea by showing similar outcomes for unloaded and loaded groups. Those who complete a personal trainer course with a biopsychosocial lens tend to appreciate how much influence coaching has on recovery. The emotional environment of a session changes how a client interprets and responds to movement. Every rep becomes a chance to rebuild confidence.
Pain extends beyond tissue mechanics. It is shaped by belief systems, memories, emotions and context. Trainers stand in a unique position to influence these elements through skilled, thoughtful coaching. The most effective back pain programmes blend load with reassurance, exposure with autonomy and progression with emotional safety.
Reference
- Ranzani, M., Pozzi, A., Fornasari, D., Ristori, D., & Testa, M. (2025). Is resistance training with external loads superior to unloaded exercise in the management of chronic low back pain? A systematic review and meta-analysis. Archives of Physiotherapy, 15, 297-313. Click here to review the full research article.
- Jadhakhan, F., Sobeih, R., & Falla, D. (2023). Effects of exercise on fear of movement in people with spine-related pain: a systematic review. Frontiers in Psychology. Click here to review the full research article.
- Marshall, P. W. M., Schabrun, S., & Knox, M. F. (2017). The mediating effect of fear, depression, anxiety, and catastrophizing on pain-related disability in chronic low back pain. PLOS ONE. Click here to review the full research article.
- Vlaeyen, J. W. S., de Jong, J., Geilen, M., et al. (2001). Graded exposure in vivo in the treatment of pain-related fear. Behaviour Research and Therapy. Click here to review the full research article.
Gain The Skills That Truly Change Low Back Pain Outcomes
The recent systematic review on chronic low back pain makes something very clear: progress isn’t determined by how much weight a client lifts. In fact, across 13 randomised trials and 778 participants, loaded and unloaded exercise produced almost identical improvements in pain and disability. The only consistent advantage of load showed up in strength and endurance, not symptoms. This is a reminder that confidence, reassurance and skilful coaching often drive change more than kilos on a bar. That philosophy sits at the core of our Level 4 Certificate in Low Back Pain Management course, where you learn to work with clients through a biopsychosocial lens, build trust through communication and apply graded exposure strategies that genuinely shift fear and improve movement confidence. The study also highlighted that psychological variables didn’t change simply because load increased, which is exactly why this qualification teaches you how to support beliefs, behaviours and expectations which are the real levers behind long-term results. If you want to help clients move with more freedom and less fear, this course gives you the tools to do it properly.
Low Back Pain Management Course – Distance Study
Prepare for a Career in Strength & Conditioning with a Focus on Low Back Pain Management
The new systematic review on chronic low back pain highlights something every future strength and conditioning specialist should know. And that’s physical strength improves with load, but meaningful change comes from how clients experience movement. In the review, resistance training improved back muscle endurance by an average of 0.50 minutes in short programmes and 0.47 minutes in longer ones, showing clear performance gains even when pain outcomes didn’t differ much between loaded and unloaded exercise. Across the sample, 395 participants completed externally loaded programmes and the research showed that well-structured progression, thoughtful cueing and psychological safety played a major role in how confidently people moved. The Strength & Conditioning Exercise Master Diploma™ prepares you to coach with this level of insight, blending personal training foundations with advanced strength programming, biomechanics, behaviour change and dedicated low back pain management skills. You learn to drive physical adaptation while also shaping the beliefs and movement patterns that help clients feel capable, resilient and ready to train with purpose. For anyone who wants to specialise in S&C and support clients with complex movement needs, this Diploma is the pathway that brings the full picture together.
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