Low back pain is everywhere. It’s in the grocery line, in the leather office chair, in that wince made when getting out of their car. It’s that nagging soreness that steals sleep, makes stairs feel like a negotiation technique, and turns picking up objects from the floor into a well-choreographed dance. According to the American Family Physician summary of the VA/DoD guidelines, 84% of adults in the United States will experience low back pain at some point, and nearly 40% report an episode within a three?month window. Low back pain is the leading cause of disability worldwide, and it’s become a common, painful reality for far too many people.1
So… what are some principles
physical therapists may consider when evaluating low back pain? To me, it’s a
combination of science, coaching, and detective work. Physical therapists often
watch how the person sitting in front of them moves, how they hold themselves
when standing/sitting, how the rest of their body attempts to pitch in and
help. Physical therapy patients aren’t necessarily weekend warriors who blew
their back while deadlifting too much weight. Chronic low back pain can be
associated with factors such as long-time postural habits, workplace
ergonomics, or even just looking down at the phone for hours every day.
Here’s the part that may be
surprising: Eighty to ninety percent of low back pain is “nonspecific.” As the New
England Journal of Medicine explains, low back pain “probably develops from
the interaction of biologic, psychological, and social factors.”2 In
other words, it’s rarely just a disc, or a muscle, or a joint. It’s the whole
system — both physical body and mind — reacting and, in many cases,
overprotecting.
I’ve found low back treatment
usually isn’t just generalized stretching or strengthening—it’s about creating
patient-specific plans.* Physical therapists can use techniques such as motor?control
exercises to help improve coordination of the deep stabilizers and assist in
contributing to spinal support. We can incorporate functional movement
training, graded exposure, manual therapy when appropriate (though often a
patient-favorite), and patient education.
Taking the deep stabilization
example a step further, say after assessing a sample patient, the physical
therapist determines that they would benefit from core control training.
Sometimes clinicians observe movement patterns whereby a person may over-rely
on increased tension in their hips or shoulders to help create artificial
stability—rather than engaging their core. In this situation, think the phrase “firing
a cannon from a canoe;” while this patient might have felt protected in the
moment, generalized over-tensing may be associated with an increase in
tightness or discomfort for some individuals.
Many people picture the core as
that six?pack muscle. A mover. A flexor. A muscle that works in specific
directions (e.g., endless crunches). However, focusing on improving core
stability often means also learning how to target those deep core muscles to
create a 360° seatbelt—controlling and maintaining the position of the spine
and pelvis during movement. Many clinicians conceptualize core engagement as
anticipating movement and pre-emptively activating the appropriate abdominal
musculature—not remembering afterward after lifting too many groceries to save
a trip from the car.
As a nuance, core stabilization
doesn’t necessarily mean all-out core stiffening. In fact, too much core
bracing can sometimes limit mobility and increase fatigue. A common therapeutic
aim for many people is to create adaptable, task-specific control—stabilizing
without over-gripping. Personally, I like to think of it as a dimmer switch,
and not only as an either-or light switch.
Depending on the individual’s
presentation, helping stabilize the core is one approach physical therapists
may incorporate. Given that every patient is unique, working one-on-one with a
physical therapist can be a meaningful way to better understand various
pain-contributing factors. Living with constant low back pain isn’t always
inevitable; reach out to explore whether physical therapy may be appropriate
for your situation and/or to help you explore strategies that may support your
goals.
Rachel Fingerer PT, DPT holds a doctorate
in physical therapy and is certified by the American College of Sports Medicine
as a personal trainer. She can be reached at RE Physical Therapy and Wellness: 410-929-0760
or rephysicaltherapyandwellness@gmail.com) for more information or to schedule
a session.
References:
1. Buelt,
A., McCall, S., & Coster, J. (2023, April 15). Management of low
back Pain: Guidelines from the VA/DOD.
AAFP. https://www.aafp.org/pubs/afp/issues/2023/0400/practice-guidelines-low-back-pain.html
2.
Chiarotto, A., & Koes, B. W. (2022). Nonspecific Low Back Pain. New
England Journal of Medicine, 386(18), 1732-1740.
https://doi.org/10.1056/nejmcp2032396
* This article is for general
educational purposes only and should not be interpreted as a personalized
exercise prescription. It does not establish a physical therapist–patient
relationship. Always consult a qualified healthcare professional before beginning
any new exercise program, especially if you have pain, prior medical
conditions, or recent injuries.
