Understanding and Treating Lower Back Pain: The Role of Physiotherapists
Updated: 5 days ago
Low back pain is one of the most common health problems worldwide and a leading cause of time off work. The good news is that most episodes are not caused by serious damage, and most people improve significantly within weeks. Physiotherapists play a key role in assessing low back pain, ruling out serious causes and guiding an active recovery. This post explains the different types of low back pain, how physiotherapists assess it and what the evidence says about treatment.
Types of Low Back Pain
1. Acute and Persistent Low Back Pain
Acute low back pain lasts less than six weeks. It may start after lifting, bending or an awkward movement, or with no obvious cause. It can be very painful, but most people improve considerably within a few weeks.
Persistent (chronic) low back pain lasts longer than three months. It is influenced by many factors, including physical activity, sleep, stress, mood, work and beliefs about pain, and pain levels often fluctuate.
2. Non-Specific Low Back Pain
Around 90% of low back pain is described as "non-specific", meaning no single structure can be identified as the cause. This isn't a sign that something is being missed: it reflects the fact that scans often show changes, such as disc bulges or "wear and tear", in many people with no pain at all, so these findings rarely explain symptoms.
3. Radicular Pain (Sciatica)
Radicular pain travels from the back down the leg, usually below the knee, because a nerve root is irritated, most often by a disc bulge or narrowing around the nerve (spinal stenosis). It may come with pins and needles, numbness or weakness. Most cases improve over weeks to a few months.
4. Serious (Specific) Causes
A small number of cases, around 1%, are caused by a serious condition such as a fracture, infection, cancer, inflammatory disease or cauda equina syndrome. A careful assessment helps identify these.
How Physiotherapists Assess Low Back Pain
1. Comprehensive Assessment
History: how the pain started, how it behaves, your general health, work, activity and any previous episodes.
Physical examination: movement, strength, function and, where relevant, neurological tests of sensation, reflexes and muscle power.
Your concerns and goals: what worries you and what you want to get back to.
2. Screening for Serious Causes
Physiotherapists check for warning signs such as:
Unexplained weight loss or feeling generally unwell
A history of cancer
Significant trauma, or a minor fall in someone with osteoporosis
Fever, or a recent infection
Constant pain that doesn't change with position, or severe pain at night
Numbness or weakness in the legs that is getting worse
Seek emergency care (Emergency Department) straight away if you have numbness around your genitals, buttocks or back passage, new difficulty passing or controlling urine, loss of bowel control, or sexual dysfunction. These can be signs of cauda equina syndrome.
3. Imaging
Scans such as X-rays and MRI are not needed for most people with low back pain. They are recommended only when a serious cause is suspected or when the results would change treatment, for example before considering surgery. Routine scanning can lead to worry about findings that are common in people without pain.
4. Assessing Function and Risk
Physiotherapists often use questionnaires such as the Oswestry Disability Index to measure how pain affects daily life, and tools such as the STarT Back tool to identify people who may need more support. This helps match the level of care to each person's needs.
Treatment for Low Back Pain
International guidelines, including those from NICE, recommend a stepped, active approach.
1. Reassurance and Education
Understanding that your back is strong, that pain doesn't usually mean damage and that most episodes improve is an important first step. Staying as active as possible and continuing or returning to work, with adjustments if needed, helps recovery.
2. Exercise
Exercise is the main treatment for persistent low back pain. No single type of exercise has been shown to be clearly better than others, so the best programme is one you enjoy and will stick with. Options include:
Strength training: for the trunk, hips and legs
Pilates or yoga
Aerobic activity: walking, swimming or cycling
Graded activity: gradually building up the activities you've been avoiding
3. Hands-On Treatment
Spinal mobilisation, manipulation and soft-tissue techniques can provide short-term relief for some people. Guidelines recommend these only as part of a package that includes exercise, not on their own.
4. Psychological Approaches
For persistent pain, combining exercise with psychological approaches such as cognitive behavioural therapy (CBT) can be helpful, especially when fear, worry or low mood are affecting recovery. Physiotherapists increasingly use these principles, for example in graded exposure to feared movements.
5. Self-Management
Pacing: spreading activities through the day and building up gradually
Heat: can help ease pain in the short term
Managing flare-ups: having a plan for flare-ups, which are common and usually settle
6. Lifestyle
Staying active: regular physical activity reduces the risk of future episodes
Weight management, sleep and stress: all influence back pain
Smoking: stopping smoking supports overall health and recovery
7. Medication
Your GP or pharmacist can advise on pain relief. Medication can help you stay active in the short term but is not a long-term solution on its own.
8. Working With Other Professionals
For complex or persistent cases, physiotherapists work alongside GPs, pain specialists, psychologists and surgeons to provide coordinated care.
Disc-Related Pain and Muscle-Related Pain
It's common to hear back pain described as a "disc" or "muscle" problem. In practice, the exact source of non-specific low back pain usually can't be identified reliably, and the treatment approach is similar: reassurance, staying active and progressive exercise.
When pain travels down the leg (sciatica)
Explanation and reassurance about the usually good outlook
Staying active and finding comfortable positions
Graded exercise, sometimes including movements that ease leg symptoms
Referral for further assessment if there is significant or worsening weakness, or if symptoms aren't improving after several weeks
Manual therapy doesn't "put discs back" or realign the spine. Where it helps, it does so by easing pain and stiffness in the short term.
Conclusion
Low back pain is very common and usually not serious. Physiotherapists can assess your pain, check for rare serious causes and help you build an active, milestone-based plan to recover and stay well. The most effective approach combines understanding your pain, staying active, exercise you enjoy and, where needed, short-term hands-on treatment and support from other professionals.
If you're struggling with low back pain, a physiotherapist can help you understand it and get back to the things you enjoy.
References
Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. The Lancet. 2021;398(10294):78–92.
National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management (NG59). 2016, updated 2020.
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