Re-Thinking Low Back Pain
Re-Thinking Low Back Pain

Re-Thinking Low Back Pain

Low back pain (LBP) is estimated to affect 84% of adults in the US at some point in their lives, and is a leading cause of disability worldwide. LBP and neck pain together are the conditions associated with the highest medical costs in the US! (Casiano 2023) LBP can cause a lot of problems for both the person in pain and the people in their lives depending upon how much their pain affects their life. And, most of the time, LBP isn’t the result of a serious medical condition even if the pain is severe.  But, that fact doesn’t help much when you feel like your pain is controlling you instead of the other way around.

By Stephanie Dillon, PT, DPT, WCS

Why do so many people develop problems with their lower backs?

This is a great question without a specific answer! However, we do know what places people at greater risk of developing LBP. They include genetics, poor general health such as smoking, physical stress on the spine like repeated vibration, and psychological stress such as depression (Parreira 2018). Note that core strength (or lack thereof) doesn’t show up on that list!

The one thing we do know for certain is that LBP is highly unlikely to be due to something scary like cancer. The rate of ominous causes of LBP that present in primary care settings is less than 1% worldwide (Finucane 2020). 

My LBP is SO severe when it occurs, and keeps coming back. How do I know it’s not something scary?

This is a great time to talk about word choices. LBP is very frequently serious, as in it causes a lot of pain, disruption to daily life, and can be very costly between visits to the doctor and missed time from work. However, serious doesn’t equal dangerous. In most cases with LBP, pain is not an indicator of tissue damage.

And in fact, the severity of pain is typically not associated with the seriousness of the underlying cause! Think about a muscle cramp, or even a Charley horse in your leg. This can be SO painful and even completely rob you of your ability to walk for a short period of time, but is not serious. The same thing applies to the majority of people with severe LBP. And oddly-enough, many times very serious issues with the lower back often present with little to no pain at all. Instead, they present as symptoms such as severe weakness or numbness in the legs—more on this below. (Ingraham 2023) 

What are the signs I should watch out for that mean I need immediate medical attention?

Your pain may be an emergency if either of the following are true:

  • You have pain and weakness in both legs. This is especially true if you are having a hard time getting your pee out, or you lose control of your bowels or bladder (incontinence).

  • You had an accident with a force strong enough to potentially fracture your spine, such as a fall from a large height, or a car accident at high speed. In this case, you do need an X-ray immediately to rule out a broken segment of your spine.

If either of these things apply to you, please seek emergency medical care immediately. (Ingraham 2022)

You shouldn’t worry about your pain unless all three of the following things occur:

  • Your pain has been present for more than six weeks

  • It’s severe, not improving, or actively getting worse

  • There is at least one other “red flag” symptom, such as a personal history of cancer elsewhere in the body, unexplained weight loss, new onset of incontinence or inability to urinate, fecal incontinence, unexplained fever or chills, prolonged use of steroids, drug abuse, significant trauma, numbness or tingling in the groin area, numbness or tingling in both legs, loss of strength in one or both legs

If you meet these last three criteria, that doesn’t necessarily mean something is certainly wrong, it’s just an indication that more medical investigation is needed. (Ingraham 2022)

I feel like I should get an X-ray or MRI to figure out what is going on with my back, but my doctor won’t order one. What gives?

We have actually found over the years that less imaging is better, not more. The problem is that what may show up on an X-ray or MRI is not actually responsible for your pain. In fact, we will see pretty advanced spine changes on MRI in people that have no pain at all, and people that have very severe pain with a pretty perfect MRI. 80% of 50 year-olds have “disc degeneration,” and 60% of 50 year-olds have “disc bulging”, without any pain (Check out this graphic and this graphic for a great visual explanation of this issue!). These “degenerative” spine changes start to show up in your 20s. So unless you meet the three criteria above, an MRI will likely only send you on a wild goose chase, rather than provide helpful information about your spine.

And it turns out, how you feel about your pain may actually be more important than what you do to relieve it! Something called “fear avoidance” is a really important predictor of how long your back pain will be there. So if you believe your spine is fragile, your pain will never improve, or are so nervous that any new move you make will bring about the next bout of pain, this actually tricks your nervous system into producing MORE pain. Learning about how pain neuroscience works, and more importantly treating your nervous system instead of just focusing on the physical part of your pain, is really important. Check out this video for some great, basic information on Explaining Pain, or this website for more info on chronic pain specifically.

If I don’t meet any of those criteria, what can I do about my pain? It’s so frustrating!

As a proud owner of someone with herniated discs, degenerative disc disease, even weakness in my legs from pinched nerves in my back—I am with you. It is incredibly frustrating to continue to have pain flare-ups, or feel limited by your lower back, no matter what you do. So, here’s a list of evidence-based treatments to try!  

But, definitely know that most back pain is “self-limiting,” meaning, it will most likely get better on its own anyway with an appropriate balance of rest (not bedrest!) plus movement, and time. (George 2021, Qaseem 2017)

  • Exercise & movement. While generally a good idea for LBP, exercise seems to be more important in the management of chronic LBP (lasting greater than 3 months) vs. acute LBP. Studies show really great evidence for exercise in chronic pain, whereas for acute pain the evidence is either inconsistent or doesn’t show that exercise helps very much.

  • Physical therapy (PT). There is pretty decent evidence for PT for LBP, especially improving trunk muscle strength and endurance. Joint mobilization (the small movements a therapist makes when they push on the joints in your spine) does have really good outcomes for both acute and chronic LBP. And, completing movement retraining with most patients also seems to help!

  • Yoga. Yoga has fair-to-good evidence behind it, especially for those with chronic LBP.

  • Mindfulness-based stress reduction (MBSR). MBSR has been shown to improve both short-term and long-term pain in people with LBP, as well as better overall function.

  • Psychological therapies. Many different types of therapies including progressive relaxation and cognitive behavioral therapy have been shown to be very effective for reducing pain. Progressive relaxation is the only psychological therapy that has shown improvements in function as well (not sure what progressive relaxation is? Try this!). Plus, other than that one difference, it doesn’t matter what type of psychological therapy you choose for your pain—they all show benefits.

For a longer rundown of what helps and what doesn’t for LBP, click here.


Casiano VE, Sarwan G, Dydyk AM, et al. Back Pain. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: 

Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., Beneciuk, J. M., Leech, R. L., & Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy, 50(7), 350–372. 

George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., & Norman, K. S. (2021). Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. The Journal of orthopaedic and sports physical therapy, 51(11), CPG1–CPG60. 

Ingraham, P. (2023, October 5). The complete guide to low back pain. 

Ingraham, P. (2022, October 22). When to worry about low back pain.

Photo by Karolina Grabowska: