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A Pain in the Back

Around four out of five people have lower back pain at some point in their lives. It's one of the most common reasons people visit healthcare providers. As a Physical Therapist, I have treated hundreds of patients suffering from low back pain with a fairly high success rate. I follow a mix of evidence based treatment and years of clinical experience to determine the best approach for treating each patients individualized back pain.

So what are some conditions that may cause low back pain (LBP)? There are many different factors affecting LBP. Typically to best understand LBP, we need to be able to classify the different types. There is mechanical, non-mechanical and referred LBP. It can also be a symptom of an underlying condition such as cancer. It can be acute onset or chronic in nature, it may also persist a long time after injury has resolved.

  • Osteoarthritis is typically referred to as degeneration in the spine. This can occur with the disc (DDD-degenerative disc disease) or the joint (DJD-degenerative joint disease) and causes a narrowing of the disc or joint due to time/wear and tear. Problems arise with bone on bone and a lack of shock absorbers.

  • Disc issues can include a degenerative disc, bulging disc, herniated disc and thinning disc. This may put pressure on the spinal nerves (radiculopathy).

  • Spondylolisthesis refers to the slippage of a vertebral body forward in relation to the vertebral body below it.

  • Stenosis refers to the narrowing of the spinal canal

  • Muscular spasm is most commonly due to an event, activity or overuse. Pain from an eccentric use causes microtrauma which stimulates nocioceptors which trigger the sensation of pain.

  • Referred pain can arise from visceral organs (kidneys, bladder, pancreas, liver) or from the hip and sacroiliac joint.

  • Pregnancy elicits a change in spinal position, and hormones effect the laxity of ligaments in the spine.

Oof. Obviously that's a lot to take in

Another thing to consider is that by 30 years old, almost HALF of us will have disc degeneration, disc bulge and disc height loss. By the time we are 50-60 years old, more than four out of five of us will have disc degeneration and more than two thirds will have disc height loss and disc bulge.

So why don't we all look like this??

What this data suggests is that just because we see it on an MRI, this does not mean that the condition is the pain generator. Underlying pathology and clinical symptoms are two different things. This is why PTs can still work on you without imaging reports. We are trained in a systematic approach to diagnosis and treatment that will guide our treatment plan.

Classifications for treating low back pain

As I mentioned above, I follow a mix of evidence based treatment and years of clinical experience to determine the best approach for treating each patients individualized back pain. When I first evaluate my patients, I use a classification system to figure out what techniques will work the best for their specific presentation:

Extension Based

  • Commonly associated with radicular symptoms.

  • Feels better with walking or back bending.

  • Worse with forward bending, lifting or sneezing.

  • Treat with specific exercise

Flexion Based

  • Commonly associated with low back arthritis

  • Feels better when sitting down and bending froward.

  • Worse with walking and standing.

  • Treat with specific exercise


  • When there is pain with movement and often an observable demonstration of poor core control doing their sport or activity

  • Common in younger patients

  • Post-pregnancy


  • Common with acute injury

  • Recent onset of symptoms is less than 16 days

  • There are no symptoms distal (past) the knees

So wait...all patients just easily fall into one of these four groups??

As with most PTs I know, the best part of our profession is figuring out the puzzle! I can't even count how many times I've put patients in the wrong category. That's where clinical experience and expertise comes in. A skilled clinician will work with their patients to figure out exactly what the true PAIN GENERATOR is and focus treatment on that as opposed to the symptoms of the pain.

If you have low back pain and have not yet utilized a physical therapist, I encourage you to do so. PTs are skilled clinicians that can help to identify the cause of your pain and act to remedy it and get you back doing what you want to do!

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