Low back pain flares: Reflections on how physical activity, sleep, and stress shape individual experiences

Low back pain often follows a fluctuating course, characterised by periods of worsening symptoms that are difficult to tolerate and impact daily function and emotional wellbeing. These transient periods are referred to as "flares". Although physical activity, psychological stress, and sleep are believed to influence low back pain, little is known about how individuals perceive their role in relation to their flare experiences. This study aimed to explore how individuals relate these factors to their flares. The design was descriptive and qualitative, using semi-structured individual face-to-face interviews of 29 adults with low back pain. Inductive reflexive thematic analysis was used to identify patterns of meaning. The perceived relationship between pain flares and physical activity, stress and sleep varied substantially amongst participants, from no perceived connection, to recognising complex interactions shaped by physical, emotional, and contextual factors. Three themes were identified: (1) Physical activity and flares: a two-sided and individualised relationship, with activity viewed as either protective or provocative depending on intensity, type, and personal context; (2) Stress and flares: an indirect link via disrupted routine, tension and awareness; and (3) Sleep and flares: uncertain links and clear disruptions, understood through sleep positioning, or via sleep's impact on mood and sensitivity to pain. Thoughts and beliefs regularly diverged from current evidence, highlighting a need for better patient education and accessible evidence-based resources. Findings support the need for a tailored approach to the management of low back pain flares, considering an individual's unique experience. PERSPECTIVE: People with low back pain describe flares as shaped by complex, indirect interactions between physical activity, stress and sleep. These perceptions often diverge from emerging evidence, highlighting opportunities for tailored education and self-management strategies that align patient beliefs with contemporary pain science.