The physiotherapy site

Home > Low Back Pain

Low Back Pain

Low back pain is a common and disabling condition which most adults experience at some point in their life. Typically the experience is annoying and painful but the person gets over the episode and recovers to a level where they feel themselves to be normal again.

In some cases there are a number of back pain episodes over a number of years and in a smaller group the pain does not fully resolve after one of these, leaving a degree of chronic back pain to be managed. In still fewer cases the chronic back pain becomes worse and develops into a severe and disabling condition which compromises the independence of an individual.

Lower back pain is a significant cause of disability, expense and work loss in western countries, being the second most common reason for being unable to attend work. Other spinal pains such as middle back pain, upper back pain and neck pain can be important but are much less common than low back pain which is pain from below the lowest rib to the top of the legs.

Physiotherapy is a common management approach for people with back pain and the combination of explanation, advice, exercises, fitness and specific techniques such as mobilisation and manipulation can help greatly with back pain relief.

Further information is available at Patient UK and NHS Choices.


Back Pain Causes

The causes of back pain are often not clear but are often presumed to be due to a sprain or strain of the spinal structures which are pain sensitive, including the nerves, muscles, ligaments, facet joints and the intervertebral discs. Even with examination and investigations the exact back pain causes may not be discoverable.

Upper back pain causes and middle back pain causes are less difficult to work out as disc problems are much less common in the thoracic region and joint problems much more common.

Lower right back pain causes may be very similar to lower left back pain causes and relate to changes which have occurred to the anatomical structures on one side, radiating pain to the one side. Right side back pain causes could include the hip joint, the sacroiliac joint and the spinal structures of that side.

Back pain diagnosis is most often performed by spinal surgeons who broadly divide back pain into three major categories:

  • Serious medical conditions which underlie the back pain such as infection, inflammatory disease, fractures and cancer.

  • One of the group of specific back syndromes which can be recognised from the history and examinations such as sciatica (nerve root compression) and spinal stenosis.

  • Non-specific low back pain, which can be very severe but for which a clear cause cannot be identified. This is by far the biggest group of back pain sufferers.

Back Pain Causes – Serious Medical Conditions

A serious underlying cause for back pain is uncommon but examiners need to review the “red flags”, signs of a medical problem, with each patient to exclude conditions such as cancer, inflammatory disease, fractures, cauda equina syndrome and infections.

A careful taking of a history and then a thorough examination will indicate whether there are any worrying factors and if so the patient should be referred immediately for medical review.

Specific Back Pain Conditions

Once the examiner is happy with the patient's medical condition they will try and fit the patient's symptoms with one of the known back pain syndromes so as to move forward to a clear route of treatment. Nerve root compression (sciatica in the leg) and spinal stenosis in elderly patients are two clearly recognised syndromes. Degenerative disc disease and facet joint arthritis are typical diagnoses but are not so clearly defined or agreed upon.


Non-Specific Low Back Pain

Most people with back pain fit into this category as it is either inappropriate or impossible to pin down the precise cause of their pain.


Non-specific Lower Back Pain Symptoms

Acute back pain (recent or less than six weeks in duration) can be of sudden onset as you turn suddenly, lift something heavy or pull something hard although it can come on without any clear cause. Insidious (slow and sneaky) onset may come on from time to time and gradually increase in severity and constancy until it is a problem.

Non-specific back pain symptoms, also called simple back pain symptoms, can vary greatly from very severe and disabling pain to mild intermittent symptoms which cause no particular difficulty. Back pain must be present along with optional pains in the buttocks, side of hips and down the legs as far as the knee. Pain further down below the knee raises the possibility of nerve root compression (sciatica).

This kind of pain is referred to as mechanical back pain as it is due to the physical stresses on the back's anatomical structures such as the discs, joints, ligaments and muscles. Typical aggravating factors for this kind of pain will be sneezing, laughing, coughing, holding postures, sitting and leaning forward. This pain is better taking the stress off by lying down.

During the first few days of an acute back pain episode the pain will be sharp on movement, subsiding to a strong ache on resting and reducing in severity after several days although it may take weeks for the pain to settle completely. Repeated episodes of back pain are common in the first year after the initial episode and if pain remains for over six weeks then it is termed chronic back pain. However, troublesome chronic back pain is longer term than this and may remain for the foreseeable future.

Back pain treatment by a physiotherapist may be useful to give advice, suggest exercises and progression of activity back towards normal.

The Outlook for Low Back Pain

Acute back pain can be expected to settle quickly in most cases and most people will recover fully with few or no future problems. However a large minority of people take longer for their pain to subside and many may have some pain at one year from the onset. Once settled, people are at high risk of a pain recurrence within the next year.

Relapsing and remitting pain (getting better then getting worse again) can occur over a period of years, with the pain episodes becoming somewhat worse and the intervals between episodes becoming somewhat shorter. At some point after an episode the pain does not completely settle any more and the person is left with a level of constant pain. This is chronic back pain and can be steady with episodes of worse pain again.

This worse and better pattern can continue for some time and may become easier with time but can also become much worse, leading to severe and disabling chronic back pain.

It is often unrealistic to expect a back pain cure and if back pain does settle this may be due to the natural changes occurring in the spine and nervous system rather than a specific treatment. If pain disturbs the normal day to day function of a person then taking pain relief for back pain makes good sense to increase the ability to get things done.

Information-back pain gives a summary of the self management techniques for low back pain and a back pain blog can be useful to consult as it gives a first hand view of a real person's experiences of back pain and how it was treated and managed.

Chronic Back Pain

Chronic back pain be defined in various ways. The recent definition is that back pain is chronic if it has been present for more than six weeks and this is meant to address the need to change the management and treatment of back pain if the pain has not settled by six weeks. Chronic back pain which presents a problem is usually present for much longer and at a moderate or severe level of symptoms. Many people have chronic back pain at a low level with worsenings at times and manage their lives normally, coping with the interruptions.

Chronic back pain may be mild or very severe, may be steady and predictable or exhibit sudden worsenings with high levels of disability. The long term nature of chronic pain can cause a series of problems for a person such as inability to work, reduced income, psychological difficulties such as depression and negative effects on the family and social networks.

Chronic back pain treatment for an acute episode is similar to back pain treatment for acute back pain – stay calm, keep activity levels up as able, pace your activity carefully, take painkillers as medically allowed, steadily increase activity, get back to your job or normal activity asap and resume the exercises you normally do.

Chronic Back Pain Treatments

NICE, the National Institute for Clinical Excellence, has recommendations for managing back pain problems:

  • An exercise programme, structured in nature and for at least eight sessions over a period of 8-12 weeks, usually supervised by a professional such as a physiotherapist. These take place as group exercises with 6-8 people at the same time and patients are routinely encouraged to take up exercise between sessions and after the programme has ended. Physios include advice on pain management, muscle strength work, core stability, aerobic exercise and posture correction and maintenance.

  • Manual therapy from an osteopath, physiotherapist or chiropractor which typically may include specific back exercises, joint manipulation, joint mobilisations, massage and advice.

  • Acupuncture, while the evidence is not yet very strong for its effectiveness.

  • CBT or cognitive behavioural therapy, a psychological therapy which has proven useful for a wide range of conditions as well as pain management. This therapy challenges us to change the way we think about our situation which then can strongly affect how we feel and behave.

Pain clinic referral should be given early consideration in the back pain management process as pain management strategies and CBT may need to be applied early in some cases to prevent the patient sliding into chronic pain and disability. Delay is always damaging.

Back Pain Prevention

The best evidence indicates that back pain is best managed and prevented by sticking to an exercise programme and keeping fit. Most active pursuits fit into this category such as swimming, jogging, aerobic classes and gym workouts. Specific back exercises or core work is not well supported by present scientific evidence.

It may be sensible to avoid obviously difficult activities in awkward postures such as twisting round whilst carrying a weight and lifting objects from very low positions.


Clinical Knowledge Summary – Low back pain (without sciatica type symptoms)


Searcg, find, book

for fast appointments with
qualified local physiotherapists

Search for a local Physiotherapist

Tick a box below to focus
your local search results on:

Neuro Physiotherapy
Home Visits
Female Physiotherapists

More on Physiotherapy

Physiotherapy Blog

Physiotherapy Podcast

Physiotherapy Resources