The Modern Approach to Back Pain

Lower back pain (LBP) is one of the most common causes of pain worldwide. It is one of the top reasons for visits to the GP and is responsible for vast numbers of sick-days. The way LBP is regarded in the medical profession, and in wider society, has historically been one of catastrophisation, over-protection, and over-prescription of complex and potentially harmful treatments. This standard way of thinking tends to assume that LBP means you have damaged your spine (or have other “misalignments” or “imbalances”), that you need a scan to find out what is wrong, that you should rest and protect your back at all costs, and that you need intense medical intervention.

Fortunately research is emerging that counters the standard ways of thinking. The Lancet recently published three papers which call for the removal of harmful and ineffective practices and warn about over-reliance on scans, surgeries and opioid prescriptions,  recommending instead treatment through self-management and less invasive physical and psychological therapies

Some of the things we are starting to understand through recent research:

  • Pain does not necessarily signify physical damage.
  • Rest and protection of the back may actually be counter-productive, with the advice now being more likely to recommend staying active.
  • Scans are being seen as less and less useful as pain-free patients are just as likely to have “defects” in the spine as those presenting with pain.
  • In many cases the more serious interventions such as drugs, injections and surgery are starting to emerge in the evidence as having little to no benefit in the majority of cases.

Around 85-90% of LBP cases are referred to as non-specific lower back pain. This means there is no serious physical damage, and the cause of the pain is likely to be a combination of issues. The modern way of looking at this is the biopsychosocial model.

  • Biological – Muscle strains, muscular tension, muscular weakness, lack of co-ordination may be physical causes of the pain.
  • Psychological – Belief in damage and fear of movement and loading the back may elicit a nocebo effect and make pain worse. This is the opposite of the more well known placebo effect. Negative beliefs about your pain can actually increase your sensitivity to the pain and feed a vicious circle.
  • Social – Lifestyle factors can be major contributors to pain. Lack of sleep, work/life stress, depression, anxiety and other aspects of mental health can increase our sensitivity to pain.


Only around 10-15% of LBP cases have a specific, identifiable cause – such as a herniated disc, or vertebral fracture. These cases may represent the more complex injuries, but aside from the most serious cases, treatment is often recommended to be similar to that of non-specific LBP – again working on the biopsychosocial model.

So what should you do if you are suffering with back pain? While it is important to remember that the majority of cases are not serious, it is still worth getting checked out by a sports therapist or physiotherapist. They will be able to rule out any more serious or complex issues, and advise you on the best way to speed your recovery.

A good therapist will carry out a full physical assessment to highlight any areas that need work such as muscular weakness or lack of co-ordination. They will also get to know their client to find out how psychological or social factors may be contributing to the issue. They will then take the time to reassure and educate you on the best approach to dealing with your pain, and a rehab plan will be recommended taking all the various factors into account.

As the evidence continues to emerge and as mainstream media features it more often, hopefully these low-risk, high-value interventions such as basic education and reassurance, simple exercise routines and encouragement to stay active will become the front line of treatment for back pain. The more high-risk, low-value interventions such as drugs, surgery and scans will be reserved for those individuals that actually need them.

In summary, lower back pain is rarely as serious as people think it is. Staying active, loading, moving well and often are all great for keeping your back strong and healthy, whereas bed-rest and time off work can be counter-productive. Psychological and social factors can be just as important as physical factors so don’t forget to take these into account. For the most part treatment should be based around education, reassurance and activity, not drugs, scans and surgery.

If your back pain is bothering you, contact me to book your appointment. I can work with you to rule out any more complex or serious issues, decipher the causes of your back pain and get you on the road to a full recovery.

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