049 - Changing the Game: Behavior Checklists for Chronic Low Back Pain in the Military
When it comes to chronic non-specific low back pain (CNSLBP), the root cause isn’t just tissue, it’s behavior. Military personnel with long-standing back pain often deal with more than biomechanics: fear-avoidance, low confidence in movement, poor pain coping strategies, and lack of continuity across providers.
This Canadian Armed Forces study took a critical step forward: developing and testing a Behavior Change Technique (BCT) Checklist to track and evaluate how providers embed behavior modification into CNSLBP rehabilitation.
WHAT THEY FOUND:
Checklist Development:
The researchers adapted the established BCT Taxonomy to create a 35-item checklist tailored for spinal rehab in a military context.
Practical Testing:
The tool was tested across 20 rehab sessions involving 6 CAF members and 4 providers. Sessions were video recorded, and independent coders assessed which BCTs were applied.
Top Behavior Strategies Used:
Instructions on how to perform the behavior
Demonstration of behavior
Feedback on behavior
Goal setting (behavioral)
Graded tasks
Underutilized But Important:
Social comparison
Self-monitoring
Habit formation
Action planning
The study highlighted variability across providers and the need for more consistency and transparency in how behavior change is delivered during pain rehab.
WHAT THIS MEANS:
If you're not tracking behavior, you're missing half the intervention.
Rehab isn’t just reps and sets, it’s belief systems, behavior loops, and neural rewiring. Especially in CNSLBP, providers must be trained not just to prescribe movements, but to coach behavior change.
The checklist isn’t about bureaucracy. It’s a mirror. It shows whether the provider is actually addressing the psychosocial and behavioral roots of chronic pain, or just winging it.
TACTICAL IMPLICATIONS:
Use Behavior Change Tools in Chronic Pain Management: Implement checklists or frameworks to track which techniques are being used—and which are missing.
Standardize Coaching Across Providers: Variability kills consistency. Train all team members in the top BCTs that reinforce movement, confidence, and self-efficacy.
Don’t Just Prescribe, Persuade: Use feedback, modeling, and graded exposure to shift beliefs and build trust in movement.
Target the Underused: Behavior strategies like self-monitoring, action planning, and habit formation are underutilized in rehab—and yet powerful.
Evaluate More Than Pain: Track behavior progress just as closely as strength, range of motion, or pain levels. Function follows belief.
QUESTIONS TO CONSIDER:
Are you assessing how you deliver behavior change, or just assuming it’s happening during rehab?
Which BCTs are your team actually using in chronic pain cases?
Could a checklist or standardized protocol help improve outcomes in patients stuck in a pain loop?
Are you coaching the mind as intentionally as you coach the movement?
What metrics are you using to know if behavior is truly changing in your patients?
Harman K, MacRae M, Vallis M. The Development and Testing of a Checklist to Study Behaviour Change Techniques used in a Treatment Programme for Canadian Armed Forces Members with Chronic Non-specific Low Back Pain. Physiother Can. 2014;66(3):313-321. doi:10.3138/ptc.2013-55BC