Low back pain

If you’re reading this, there is a good chance you have experienced low back pain (LBP) at some point in your life.  It is the number one musculoskeletal complaint globally and affects all age groups, from children to the elderly.    


Up to 80% of the population will at some point experience LBP, and of those who do, 70% - 80% will have at least one recurrence. Most episodes of LBP improve substantially within 6-8 weeks (sometimes within days), and often do not require any specific interventions to do so.  Sometimes however, the pain continues beyond 3 months, this is known as chronic, or persistent back pain.  

Importantly, less than 1% of LBP is caused by a serious underlying condition (e.g. fracture).  Your medical and/or healthcare professional will screen for, and remain vigilant for signs and symptoms suggesting a serious cause to your back pain.      


The remaining +99% of LBP is not a serious medical condition or pathology.  Within this +99%, 5-10% of LBP involves a nerve root (a nerve as it exits the spine - commonly known as sciatica).  The remaining 90-95% is known as non-specific LBP.  It is labelled non-specific because the precise source of the pain cannot be accurately identified (there are lots of different tissues in the back, we can’t identify exactly which one is causing the pain, but it doesn’t change how we go about treating it).

The Biopsychosocial Model

Although LBP very rarely has a serious cause, it can still have a serious impact on your life.  As the research into pain science and LBP develops, we are learning more about the complexity of pain and the variable contributing factors to LBP.  When addressing and treating LBP, evidence points to adopting a ‘biopsychosocial’ approach.  This recognises the contribution to LBP of biophysical, psychological, social, and genetic factors. It is recommended that LBP care and treatment  move away from a purely biomedical approach (over medicalisation of musculoskeletal pain can be problematic and clinical guidelines advise against unnecessary specialist referral and scans).

BPS model.png

Risk factors for an episode of LBP include:

  • Low levels of physical activity and poor general health (including smoking and obesity)

  • Previous episodes of LBP

  • Heavy manual tasks and high volume of bending and lifting

  • Being tired or being distracted during a lifting activity 

  • The presence of other chronic conditions including asthma, headache, and diabetes

  • Poor mental health (including psychological distress and depression)

  • Genetic influences

Risk factors for transitioning from

acute to chronic back pain include:

  • Initial severe pain intensity 

  • LBP with leg pain and/or accompanying pain at multiple body sites

  • Lifestyle factors that relate to poorer general health such as low levels of physical activity, smoking, and obesity

  • Genetic influences - this appears to be higher for more chronic and disabling low back pain than for acute LBP

  • Psychological distress, depression and anxiety 

  • Passive coping behaviours - a reliance on other people to ‘fix’ you 

  • Catastrophising - a belief that something is far worse than it really is

  • Low self-efficacy - belief in your ability to influence events affecting your life

  • Fear-avoidance - fear of pain can lead to the avoidance of certain activities and thus to changed behaviour, leading to reduced movement and worse outcomes in the longer term

  • Sleep quality

  • Low expectations of getting better - our beliefs can affect our experience of pain 

  • Lower health literacy - your ability to obtain, process, and understand basic health information 

  • Cognitive reasoning of pain - an understanding of what might be causing your pain and arguably, more importantly, what isn’t causing it.              

  • Increased exposure to low value, non-guideline recommended care increases the risk of developing chronic LBP (examples include unnecessary imaging, unnecessary use of medication, unnecessary referral to a specialist, reliance on passive therapies such as massage).


There is a lot of information floating around regarding LBP.  Unfortunately, not all of it is helpful or based on current evidence. Below are some evidence-based facts addressing a few of these misconceptions:
  • Persistent LBP is rarely dangerous or associated with serious tissue damage

We have already touched on this. 


  • Scans rarely show the cause of back pain

Scans are only helpful for a limited number of people and in fact current clinical guidelines recommend against imaging for most individuals.  Changes seen on scans are poorly correlated to pain, and changes on scans are very common in people without pain. For example, even by the age of 30, approximately 50% of individuals WITHOUT pain show disc degeneration on MRI, and 70% of 60 year olds WITHOUT pain have disc bulges. There is only a weak relationship between changes seen on scans and the presence/absence of low back pain.  A better way to label these changes is ‘normal age related change’.  Importantly, this doesn’t mean scan results are irrelevant, just that on their own, scan results usually can’t explain LBP, and form one piece of a bigger picture.   


  • Backs do not wear out with everyday loading and bending, and pain with exercise does not mean you are doing harm.  

Our spines are made to move, and no particular movements are inherently bad for our backs.  Sometimes we can develop sensitivity to certain movements but this sensitivity does not mean we are causing damage. In these circumstances, it can be a good idea to temporarily limit movements that feel sensitive or painful until symptoms settle down.  Some pain or discomfort while exercising is perfectly acceptable, and it is a good idea to progress gradually.  Also, for everyday activities, bending and lifting with a rounded spine is no worse for us than ‘bending at the knees’ and keeping our spines straight.  This is a well researched subject.  


  • Back pain is not caused by ‘poor’ posture

There is no ideal or correct posture, posture is highly variable between individuals, and posture is poorly correlated to pain.  If you find you have pain in a particular position, it often has more to do with how long you spend in that position than the posture itself.  


  • Back pain is not caused by a weak core

Firstly, there isn’t a standardised assessment or reference data for identifying a ‘weak core’.  Secondly, this is not a risk factor for, or predictive of, low back pain.  Good clinical outcomes for LBP are not associated with improved abdominal muscle function. 


  •  Pain flare-ups do not mean you are damaging yourself   

Common triggers for flare-ups are things like unaccustomed activity, inactivity, poor sleep, stress, worries, and low mood.  Controlling these factors can help prevent exacerbations.  As mentioned previously, flare-ups most often have more to do with tissue sensitivity than tissue damage. 


  • Getting older is not, in itself, a cause of back pain

Research does not support the belief that getting older causes or worsens LBP and some data shows peak incidence to be in middle age, followed by a decline in LBP numbers with increasing age. No matter what your age, evidence based treatments can help.


  • Your hips and/or spine do not slip out of place or alignment

Our spines are robust structures made of, and surrounded by, bone, muscles, tendons, ligaments, and thick collagen.  They do not slip or move out of alignment in the absence of severe trauma (e.g. car accidents).  Considering it takes such huge forces to alter these structures, hands on therapies do not realign vertebrae or put joints back in place (manual therapy can offer temporary relief to symptoms, but it’s not through ‘realignment’).  


  • Injections, surgery, and strong drugs usually aren’t a cure

Research shows that these can help with symptoms but in the mid to long term, often do not have better outcomes than more conservative treatments such as exercise therapy.  Additionally, these interventions come with risks.  

Treatment and the Role of Exercise

Current clinical guidelines place exercise therapy and education as first-line treatment interventions.  There is no one best exercise or exercise program for LBP.  The type, frequency, and intensity of the prescribed exercises and physical activity will depend on your unique individual circumstances. This includes the severity, type, and duration of symptoms, provoking activities or movements, fear of movement, exercise tolerance, preferences, needs and goals.  Exercise therapy is aimed at improving function  and quality of life as well as aiming to improve pain symptoms.  A gradually progressed program is recommended.  Exercising into some pain is ok, however it might not be an appropriate starting point for everyone.  

Education is aimed at helping you understand your symptoms and what might be contributing to them. It can help address unhelpful beliefs and behaviours, and also assist with self management.  

Below are current clinical treatment guidelines for LBP (considered high value care)

Acute LBP (<6 weeks):

First-line treatment:

  • Remain active (non provoking activities) and avoid bed rest

  • Education 


Second-line / adjunct treatment 

  • Superficial heat

  • Passive therapies (massage / spinal manipulation / acupuncture) 

  • Non-steroidal anti-inflammatories (NSAIDs) if required 

Persistent LBP (>12 weeks)

First-line treatment:

  • Prescribed exercise therapy 

  • Education

  • Cognitive behavioural therapy


Second-line / adjunct treatment 

  • Passive therapies (massage / spinal manipulation / acupuncture)

  • Yoga

  • Mindfulness for stress reduction

  • Multidisciplinary treatment

  • NSAIDs

  • Some prescription medications

  • In limited cases, injections for those with severe or progressive radicular pain (sciatica)

  • Surgery - select procedures for limited number of select individuals

At Vitruvian Exercise Physiology, we aim to provide evidence based exercise prescription for conditions that have been proven in the research to benefit from this.  Hopefully the information above has helped you gain a better understanding of low back pain, its multifactorial nature, and the approaches taken to treat and manage it.