Back Pain: A Complete Guide

Lower back pain is common throughout life.¹ It can be worrisome and limit your activities. In a small number of cases, a serious condition is the cause. Your symptoms, when they began, and the physical exam can help identify signs that require medical attention.² Pain and functional ability often improve over time, especially early in a new episode.³ This guide explains possible causes, what imaging results mean, and ways to resume your activities.⁴ Physical therapy can help you choose exercises and progress at a pace that suits your needs. Our comprehensive guide to physical therapy outlines this process.

What is low back pain and how is it classified?

Low back pain is pain located between the lower ribs and the buttocks; it is classified based on its cause and duration. A specific cause may be identified, or the pain may be classified as nonspecific following evaluation. The categories “acute,” “subacute,” and “chronic” describe its duration, as detailed below. Its intensity ranges from mild discomfort to severe pain. Back pain is a common reason for seeking medical care.¹

The lumbar region consists of five vertebrae, the bones of the spine. The discs between these bones distribute the load and allow for movement. Muscles move and support the back; ligaments connect the bones. Nerves transmit commands to the muscles and carry sensory information, among other things. This guide focuses on the lower back. Our guide on thoracic pain focuses on the upper back, where physical therapy for thoracic back pain adapts techniques to the mobility of the ribs.

Low back pain affects people in many countries and walks of life.⁵ In a 2000 review, between 11% and 84% of adults surveyed reported having experienced it at some point, depending on the studies and their methods.⁶ This variation explains why a single percentage cannot describe all populations. Back pain can limit family and professional life in a wide variety of contexts.⁵

The intensity of pain cannot be determined simply by the appearance of the back. In a study of 3,369 people, the changes observed on imaging generally showed only a weak association with pain experienced or measured six years later. Nearly all discrepancies were less than one point on a scale of ten.⁷ This does not mean that imaging is useless: its results must be compared with symptoms and a physical examination.

The following categories will help you understand what your healthcare professional is looking for during the evaluation.

What is the difference between specific and nonspecific pain?

Nonspecific low back pain means that, following evaluation, no specific disease or injury can explain the symptoms.² The healthcare professional first looks for signs of a fracture, infection, cancer, or nerve damage that would require a different course of treatment. The term “nonspecific” does not mean that the pain is imaginary. It does not preclude the need for further evaluation if the symptoms change.

Specific pain can result from a fracture, an infection, or a tumor, among other causes. A herniated disc—when part of a disc protrudes beyond its normal boundaries—can irritate a nerve. Spinal stenosis is a narrowing of the space through which the nerves pass. Both of these conditions can also occur without pain; the examination determines whether they are consistent with your symptoms.

How does your pain behave?

Pain may increase or decrease depending on your movements and positions. Your physical therapist observes these reactions along with your other symptoms, your abilities, and your goals. The examples in the table are not rules that apply to everyone.

Responding to movement can help you choose a starting point, and then the plan adjusts as things progress. Our guide on lumbar directional preference explains how to identify the direction that brings you relief.

What is the difference between acute and chronic pain?

Acute pain lasts less than six weeks; chronic pain persists for more than twelve weeks. Pain that falls between these two categories is referred to as subacute. These time frames do not measure the intensity of the pain.⁸

In some people, central sensitization contributes to pain: the brain and spinal cord—the nerve cord within the spine—react more strongly to the signals they receive.¹⁰ This mechanism cannot be inferred from duration alone and does not, by itself, indicate the condition of the tissues. Chronic pain can nevertheless improve, even several months after it begins.¹¹

What actually causes back pain?

Back pain can be influenced by the condition of the tissues, activities, nerve sensitivity, sleep, and stress.⁵ A specific cause cannot always be identified. Genetics and the environment also contribute to changes in the intervertebral discs. In twin studies, physical labor was found to account for these changes to a lesser extent than previously thought.¹² These findings regarding the discs do not mean that genes determine your pain.

What is the biopsychosocial model?

The biopsychosocial model considers the body, emotions, and life context as a whole. For example, disrupted sleep, anxiety about movement, and challenging work tasks can all influence how back pain is experienced. This approach acknowledges that pain is real, without reducing it to a single image or a single factor.⁴

Why do imaging studies show changes in people who aren't experiencing pain?

Magnetic resonance imaging (MRI) produces detailed images using a magnetic field. It also reveals changes that do not cause pain. Disc degeneration is characterized, in particular, by a loss of water content or a reduction in disc height. A bulge protrudes beyond the disc’s outline over a large area. A protrusion is a type of herniation: a localized portion protrudes, but its base remains wider than the protruding part. The table presents age-specific estimates for people with no history of back pain. Our article on the usefulness of medical imaging explains how to interpret these results.

In another study of 98 adults without pain, 27% had a protrusion and 1% had an extrusion—a herniation in which the protruding portion is wider than its base in at least one image plane. These results apply to all the adults studied and are not estimates specific to 40-year-olds.¹⁶

Some changes become more common with age and are painless.¹⁵ An imaging study must therefore be interpreted in conjunction with symptoms and a physical examination. In a trial involving 283 people with a lumbar herniated disc and sciatica—pain radiating down the leg—84% reported a complete or nearly complete resolution of their symptoms after one year. These participants were followed as part of a trial comparing surgery with prolonged conservative management—that is, treatment without initial surgery. The MRI performed at one year was unable to clearly distinguish between those who had recovered and those who had not.¹⁷ This figure does not predict recovery from leg pain based on the initial MRI.

Imaging reports can also vary. A 63-year-old woman underwent ten lumbar MRIs at ten different centers over the course of three weeks. The reports contained 49 distinct findings, 16 of which appeared in a single report; none of the findings appeared in all ten reports.¹⁸ This case illustrates potential variability, though it does not reflect the frequency of such variability across all patients. Your healthcare provider can help you understand which results are consistent with your symptoms.

How do stress and sleep affect pain?

Stress can affect attention, sleep, and how symptoms are experienced.¹⁰ A study of people with persistent pain in multiple areas of the body found lower cortisol levels at certain times of the day. Cortisol is a hormone—a chemical messenger in the body—that plays a role in the stress response. Depression and anxiety altered this association. The study does not prove that this hormonal change causes back pain.¹⁹

Sleep and pain can influence each other in both directions.²⁰ If you live with chronic pain, keeping track of your sleep and symptoms can help you identify issues to discuss with your healthcare provider. A review notes that sleep problems may precede an increase in pain, but the relationship varies among individuals and across studies.²⁰

When should I seek urgent care?

Back pain accompanied by new urinary problems, numbness around the genitals, or symptoms in both legs requires immediate evaluation in the emergency department. Other signs require a same-day or prompt evaluation, as specified in the table. Do not wait six weeks if a concerning sign appears.^{21, 22}

What specific conditions can cause lower back pain?

A herniated disc that irritates a nerve, a fracture, an infection, or a tumor can cause lower back pain. Narrowing around the nerves or certain joints can also contribute to the symptoms. Your medical history and a physical exam help rule out these possibilities; imaging alone is not enough.⁵ The table lists common diagnoses and symptoms, along with their limitations.

What other conditions can affect the lower back?

Spondylolisthesis: a vertebra slips forward relative to the one below it. Mild degenerative forms are often asymptomatic.²⁶ Another review found no clear link between pain and isthmic spondylolisthesis—which is caused by a defect in a small bony portion of the vertebra—in the general adult population.²⁷ These results do not rule out the possibility that a slippage may contribute to a given individual’s symptoms.²⁸

Degenerative disc disease: changes in a disc, such as a loss of water content and height. These changes become more common with age and may remain painless. One review estimates that 68% of people with no history of back pain have disc degeneration by age 40.¹⁵

Sacroiliac pain: pain that may originate in the joint connecting the sacrum—the bone at the base of the spine—to the pelvis.²⁹ Several tests that replicate the typical pain can increase the likelihood that this joint is the cause. No single test is sufficient on its own.³⁰ Its range of motion is usually limited.³¹ These tests do not prove that the pelvis is misaligned.

Two other possible diagnoses are: lumbar facet syndrome, pain attributed to the small joints at the back of the vertebrae; and lumbar radiculopathy, a condition affecting the portion of a nerve that exits the spine. This condition can alter strength, sensation, or reflexes in the leg.

What myths should I stop believing?

The myths about a fragile back, perfect posture, core muscles being the inevitable culprits, and prolonged rest paint a misleading picture of back pain. Pain does not automatically mean that the back is damaged. An evaluation helps determine the necessary precautions and, later, when to resume activities.³²

Is there an ideal posture for preventing pain?

No single posture is universally good or bad. Studies on posture and back pain yield mixed results: some find a link, while others do not. A link does not prove that a posture causes the pain.³³ Studies on spinal curvatures do not establish a consistent link to pain.³⁴

Your back can handle a wide variety of positions. No single posture is inherently bad; however, varying your positions and moving within your comfort level may be more comfortable.

Do you need to strengthen your core muscles to feel better?

Core strengthening can be part of treatment, but it is not necessary to follow just one type of program. Muscle strength and control alone do not fully explain all pain.³⁸ Exercises should be chosen based on your abilities, your goals, and how your body responds.

For chronic nonspecific low back pain, exercises that improve core muscle control are likely to reduce pain more than minimal intervention. A review of 32 trials compared these exercises to other exercises and manual therapy for both recent and chronic pain. The differences observed were not large enough to be clinically significant for patients. Manual therapy uses the hands to move a joint or work on the muscles.³⁹ The stabilizing muscles, which help maintain core stability during your movements, are assessed based on the tasks that cause you difficulty. Our movement rehabilitation program can help improve control and coordination, for example, when standing up from a chair or moving a load.

How does back pain change over time?

Recent lower back pain often improves significantly during the first few weeks, after which the rate of improvement slows. Pain that is already persistent tends to improve more slowly on average.^{40, 8} Feeling better does not always mean that all symptoms have disappeared. Episodes may also recur after an improvement.⁴¹

In a review of acute low back pain, pain and functional limitations decreased by an average of 58% during the first month, with further improvements continuing through three months.⁴⁰ A more recent review found an average decrease in acute pain from 56 to 26 out of 100 six weeks after study enrollment. For pain that had been present for three to twelve months at baseline, the average decrease was from 56 to 48, with very uncertain evidence.⁸ These averages describe groups receiving various types of care; they do not determine your timeline for recovery.

Pain that lasts longer than three months isn't necessarily permanent.⁴² The term “chronic” describes its duration, without predicting its future.⁸ In a follow-up study of 406 people whose pain had just reached the three-month mark—and who had no nerve root-related pain—41% had fully recovered one year after entering the chronic phase.¹¹ This result does not automatically apply to pain that has been present for several years.

Factors associated with a less favorable recovery:

• Avoiding activities out of fear of injury may be associated with a slower return to work, especially during the subacute phase. This link to recovery is less clear for very recent or chronic pain⁴³.
  
• Distress and negative expectations may be associated with a slower recovery following a recent episode⁴⁴
  
• Talking about the fear of returning to work helps identify tasks that are being avoided and adjustments to consider⁴³
  
• In a follow-up study, seeking compensation and depression were associated with a slower recovery. This association does not prove that seeking compensation causes persistent pain⁴⁵
  
• Work-related difficulties, such as dissatisfaction or a dispute, should be discussed in order to arrange for support and a return to work

What role does physiotherapy play?

Physical therapy helps reduce pain and restore your ability to perform daily activities through guidance, exercises, and a tailored progression plan. Manual therapy may be used to complement this treatment as needed.^{46, 47, 48} The treatment plan takes into account the activities you want to resume, such as walking, sitting, or lifting your child.

Physical therapy is one of the recommended options for several types of low back pain, depending on the clinical situation. The guidelines recommend appropriate nonsurgical management, which may include physical therapy.^{46, 49}

Our physical therapists tailor exercise programs to your abilities and the activities you want to resume.

The McKenzie Method, among other things, assesses whether certain movements reduce symptoms or cause them to travel from the leg back toward the back. This response, when present, can guide the initial selection of exercises.

Consult our Physiotherapy for Low Back Pain guide for detailed strategies.

Does physical therapy really work for back pain?

Physical therapy can reduce pain and improve functional ability, particularly through exercise in cases of nonspecific chronic low back pain. The average benefits remain modest and vary depending on the treatment and the comparison group.

A 2021 Cochrane review, which synthesizes the results of comparative trials, found that exercise reduces pain by about 15 points out of 100 more than no treatment, usual care, or sham treatment. The difference in disability scores is about 7 points out of 100, which is below the threshold the authors had set as clinically significant. These results apply to adults with nonspecific pain lasting more than twelve weeks at the first follow-up measurement.⁵² The plan can combine therapeutic exercises, manual therapy, and educational guidance based on your needs.

A 2025 review limited to comparisons with a placebo—a sham treatment—also found a small benefit of exercise for chronic pain. For pain lasting less than twelve weeks, it found no clear benefit of exercise programs for pain compared with a placebo.⁵³ This limitation does not mean you should stay in bed or that all physical therapy is useless. Assessment, counseling, and the gradual resumption of activities address other needs. Exercise may cause muscle soreness; its intensity is adjusted based on your response.

What types of medical care are covered after an accident?

Quebec’s public health programs may cover physical therapy following a work-related or traffic accident, provided certain conditions are met.

If your pain is the result of a workplace accident, request an evaluation. Our CNESST program supports your return to work. The CNESST, Quebec’s workers’ compensation agency, covers the medical care you’re entitled to when it’s prescribed and related to a recognized work-related injury. Check your eligibility with the clinic and the CNESST; you cannot be charged for these covered services.⁵⁴

If your pain is the result of a traffic accident, the SAAQ, Quebec’s public auto insurance agency, may reimburse you for physical therapy. The treatments must be necessary, related to the accident, and prescribed by a doctor or a specialized nurse practitioner. Reimbursement is subject to approval and the established limits.⁵⁵ Our SAAQ program can help you. For an evaluation, see our services for back pain.

How to tell if your treatment is working and what to remember?

Treatment is effective when your daily activities become easier, your pain decreases, or you’re better able to manage your symptoms. Follow-up care compares these changes to the goals you set at the beginning. Pain, sleep, medication, and confidence may change at different rates.⁵⁶

Pain and your ability to perform daily activities are measured separately. A questionnaire can track, for example, walking or household tasks that are becoming easier.^{57, 58} You should also work with your healthcare provider to choose specific benchmarks, such as the duration of a walk.

The plan aims to gradually increase independence: knowing which movements to try, how to adapt an activity, and when to ask for help. A lack of progress calls for a discussion and, at times, a new evaluation. Any changes to your medications should be discussed with the prescribing healthcare professional or your pharmacist.

Key points to remember:

A single image is not enough to explain the pain. The course of recovery varies, and the plan can support a gradual return to activities based on the individual’s abilities and goals.⁵⁹

1. Back pain doesn't automatically mean your back is weak. Movement can help you regain your strength. However, a specific injury may require precautions.⁴

2. An image doesn't tell the whole story. Changes in the disc can occur without causing pain. Your healthcare provider will determine whether the image is consistent with your symptoms and exam findings.⁷

3. Recent lower back pain often improves during the first few weeks. Persistent pain may also subside, although recovery is generally slower.³

4. Activity is gradually resuming. It is generally recommended to stay active rather than stay in bed.³⁶

5. Appropriate explanations can help. Education can help some people better understand their symptoms and resume their activities with less apprehension.⁶⁰

6. Your pain is still real even when stress affects it. Sleep, emotions, and activities can be discussed along with other factors.¹⁰

7. Clear and appropriate explanations can reassure some people with acute or subacute low back pain. They can also slightly reduce the number of back-related medical visits⁶¹.

8. Recovery takes time. A temporary worsening of symptoms does not necessarily mean the treatment has failed. However, the warning signs described above do require a reevaluation.

9. Your pain is real. The absence of structural findings does not make your suffering any less real.

10. Some factors can be modified. The plan can address activities, sleep, worries, and coping strategies that seem relevant.

Our physical therapists combine all of these approaches into a personalized program. Learn more about our services for muscle tightness, stiffness, and loss of mobility.

References

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1. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363-70. (Back to sections: 1, 2)
2. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-747. (Back to sections: 1, 2)
3. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ. 1994;308(6928):577-80. (Back to sections: 1, 2)
4. O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, et al. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther. 2018;98(5):408-423. (Back to sections: 1, 2, 3)
5. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367. (Back to sections: 1, 2, 3, 4)
6. Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000;13(3):205-17. (Back to section: 1)
7. Kasch R, Truthmann J, Hancock MJ, Maher CG, Otto M, Nell C, et al. Association of Lumbar MRI Findings with Current and Future Back Pain in a Population-Based Cohort Study. Spine (Phila Pa 1976). 2022;47(3):201-211. (Back to sections: 1, 2)
8. Wallwork SB, Braithwaite FA, O'Keeffe M, Travers MJ, Summers SJ, Lange B, et al. The clinical course of acute, subacute, and persistent low back pain: a systematic review and meta-analysis. CMAJ. 2024;196(2):E29-E46. (Back to sections: 1, 2, 3, 4)
9. Schuttert I, Timmerman H, Petersen KK, McPhee ME, Arendt-Nielsen L, Reneman MF, et al. The Definition, Assessment, and Prevalence of (Human-Assumed) Central Sensitization in Patients with Chronic Low Back Pain: A Systematic Review. J Clin Med. 2021;10(24). (Back to section: 1)
10. Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. J Pain. 2015;16(9):807-13. (Back to sections: 1, 2, 3)
11. Costa Lda C, Maher CG, McAuley JH, Hancock MJ, Herbert RD, Refshauge KM, et al. Prognosis for patients with chronic low back pain: an inception cohort study. BMJ. 2009;339:b3829. (Back to sections: 1, 2)
12. Battié MC, Videman T, Kaprio J, Gibbons LE, Gill K, Manninen H, et al. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J. 2009;9(1):47-59. (Back to section: 1)
13. Mansell G, Corp N, Wynne-Jones G, Hill J, Stynes S, van der Windt D. Self-reported prognostic factors in adults with neck or low back pain: An umbrella review. Eur J Pain. 2021;25(8):1627-1643. (Back to section: 1)
14. Cedraschi C, Nordin M, Haldeman S, Randhawa K, Kopansky-Giles D, Johnson CD, et al. The Global Spine Care Initiative: A Narrative Review of Psychological and Social Issues Related to Back Pain in Low- and Middle-Income Communities. Eur Spine J. 2018;27(Suppl 6):828-837. (Back to sections: 1, 2)
15. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6. (Back to sections: 1, 2, 3)
16. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69-73. (Back to section: 1)
17. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ, Van der Kallen BF, van den Hout WB, Jacobs WC, et al. Magnetic resonance imaging in the follow-up assessment of sciatica. N Engl J Med. 2013;368(11):999-1007. (Back to section: 1)
18. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates at 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017;17(4):554-561. (Back to section: 1)
19. Generaal E, Vogelzangs N, Macfarlane GJ, Geenen R, Smit JH, Penninx BW, et al. Reduced hypothalamic-pituitary-adrenal axis activity in chronic multi-site musculoskeletal pain: partly masked by depressive and anxiety disorders. BMC Musculoskeletal Disorders. 2014;15:227. (Back to section: 1)
20. Finan PH, Goodin BR, Smith MT. The association between sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-52. (Back to sections: 1, 2)
21. nhs.uk. Back pain. 2017. (Back to section: 1)
22. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-9. (Back to section: 1)
23. Beall DP, Kim KD, Macadaeg K, Donboli K, Chauhan K, Sowlay M, et al. Treatment Gaps and Emerging Therapies in Lumbar Disc Herniation. Pain Physician. 2024;27(7):401-413. (Back to section: 1)
24. Zhong M, Liu JT, Jiang H, Mo W, Yu PF, Li XC, et al. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45-E52. (Back to section: 1)
25. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic resonance imaging of the lumbar spine in asymptomatic subjects. A prospective study. J Bone Joint Surg Am. 1990;72(3):403-8. (Back to section: 1)
26. Evans N, McCarthy M. Management of symptomatic low-grade degenerative lumbar spondylolisthesis. EFORT Open Rev. 2018;3(12):620-631. (Back to section: 1)
27. Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V. A systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. Eur Spine J. 2015;24(6):1289-95. (Back to section: 1)
28. Kalichman L, Hunter DJ. Diagnosis and Conservative Management of Degenerative Lumbar Spondylolisthesis. Eur Spine J. 2008;17(3):327-335. (Back to section: 1)
29. Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg. 2005;101(5):1440-1453. (Back to section: 1)
30. Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RS. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain. 2009;10(4):354-68. (Back to section 1)
31. Cho HJ, Kwak DS. Movement of the sacroiliac joint: Anatomy, systematic review, and biomechanical considerations. Proc Inst Mech Eng H. 2021;235(3):357-364. (Back to section: 1)
32. O'Sullivan P, Caneiro JP, O'Keeffe M, O'Sullivan K. Unraveling the Complexity of Low Back Pain. J Orthop Sports Phys Ther. 2016;46(11):932-937. (Back to section: 1)
33. Swain CTV, Pan F, Owen PJ, Schmidt H, Belavy DL. No consensus on the causality between spinal postures or physical exposure and low back pain: A systematic review of systematic reviews. J Biomech. 2020;102:109312. (Back to sections: 1, 2)
34. Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature addressing associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008;31(9):690-714. (Back to sections: 1, 2)
35. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low back pain and sciatica. Cochrane Database Syst Rev. 2010;2010(6):CD007612. (Back to section: 1)
36. Malmivaara A, Häkkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, et al. The treatment of acute low back pain—bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332(6):351-5. (Back to sections: 1, 2)
37. Martimo KP, Verbeek J, Karppinen J, Furlan AD, Takala EP, Kuijer PP, et al. Effect of training and lifting equipment on the prevention of back pain during lifting and handling: a systematic review. BMJ. 2008;336(7641):429-31. (Back to section: 1)
38. Lederman, E. “The Myth of Core Stability.” J Bodyw Mov Ther. 2010;14(1):84-98. (Back to section: 1)
39. Saragiotto BT, Maher CG, Yamato TP, Costa LOP, Costa LCM, Ostelo RWJG, et al. Motor Control Exercise for Nonspecific Low Back Pain: A Cochrane Review. Spine (Phila Pa 1976). 2016;41(16):1284-1295. (Back to section: 1)
40. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: a systematic review of its prognosis. BMJ. 2003;327(7410):323. (Back to sections: 1, 2)
41. da Silva T, Mills K, Brown BT, Pocovi N, de Campos T, Maher C, et al. Recurrence of low back pain is common: a prospective inception cohort study. J Physiother. 2019;65(3):159-165. (Back to section: 1)
42. Itz CJ, Geurts JW, van Kleef M, Nelemans P. Clinical course of nonspecific low back pain: a systematic review of prospective cohort studies conducted in primary care. Eur J Pain. 2013;17(1):5-15. (Back to section: 1)
43. Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear-avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014;14(5):816-36.e4. (Back to sections: 1, 2)
44. Otero-Ketterer E, Peñacoba-Puente C, Ferreira Pinheiro-Araujo C, Valera-Calero JA, Ortega-Santiago R. Biopsychosocial Factors for Chronicity in Individuals with Nonspecific Low Back Pain: An Umbrella Review. Int J Environ Res Public Health. 2022;19(16). (Back to section: 1)
45. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prognosis in patients with recent-onset low back pain in Australian primary care: an inception cohort study. BMJ. 2008;337(7662):a171. (Back to section: 1)
46. Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. National Clinical Guidelines for the non-surgical treatment of patients with recent-onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60-75. (Back to sections: 1, 2)
47. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. (Back to section: 1)
48. Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42(4):A1-57. (Back to section: 1)
49. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: a systematic review. Br J Sports Med. 2020;54(2):79-86. (Back to section: 1)
50. Hidalgo B, Detrembleur C, Hall T, Mahaudens P, Nielens H. The efficacy of manual therapy and exercise for different stages of nonspecific low back pain: an update of systematic reviews. J Man Manip Ther. 2014;22(2):59-74. (Back to section: 1)
51. Dos Santos ECS, Dos Santos AT, da Silva NA, Carneiro SR, Rampazo ÉP, Magalhães MO. Effectiveness of adding manual therapy to exercise for pain and disability in chronic nonspecific low back pain: A systematic review and meta-analysis. Musculoskelet Sci Pract. 2026;82:103508. (Back to section: 1)
52. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. (Back to section: 1)
53. Cashin AG, Furlong BM, Kamper SJ, De Carvalho D, Machado LA, Davidson SR, et al. Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomized trials. BMJ Evid Based Med. 2025. (Back to section: 1)
54. Pricing and Billing for Physical Therapy and Occupational Therapy. (Back to section: 1)
55. SAAQ. Reimbursement for physical therapy. (Back to section 1)
56. Chapman JR, Norvell DC, Hermsmeyer JT, Bransford RJ, DeVine J, McGirt MJ, et al. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976). 2011;36(21 Suppl):S54-68. (Back to section: 1)
57. Chiarotto A, Boers M, Deyo RA, Buchbinder R, Corbin TP, Costa LOP, et al. Core outcome measurement instruments for clinical trials in nonspecific low back pain. Pain. 2018;159(3):481-495. (Back to section: 1)
58. Maughan EF, Lewis JS. Outcome measures in chronic low back pain. Eur Spine J. 2010;19(9):1484-94. (Back to section: 1)
59. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, et al. Low back pain: a call for action. Lancet. 2018;391(10137):2384-2388. (Back to section: 1)
60. Moseley GL. Community-wide pain education for back pain. Why does primary care receive almost no attention, and what exactly are we waiting for? Br J Sports Med. 2019;53(10):588-589. (Back to section: 1)
61. Traeger AC, Hübscher M, Henschke N, Moseley GL, Lee H, McAuley JH. Effect of Primary Care-Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(5):733-43. (Back to section: 1)
62. Steele J, Bruce-Low S, Smith D. A Reappraisal of the Deconditioning Hypothesis in Low Back Pain: A Review of Evidence from Three Research Methods on Specific Lumbar Extensor Deconditioning. Curr Med Res Opin. 2014;30(5):865-911.
63. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-91.
64. Battié MC, Videman T, Levälahti E, Gill K, Kaprio J. Genetic and environmental effects on disc degeneration by phenotype and spinal level: a multivariate twin study. Spine (Phila Pa 1976). 2008;33(25):2801-8.
65. Beattie PF, Meyers SP. Magnetic resonance imaging in low back pain: general principles and clinical issues. Phys Ther. 1998;78(7):738-53.
66. Bogduk N. Clinical and Radiological Anatomy of the Lumbar Spine. 5th ed. Edinburgh: Churchill Livingstone; 2012.
67. Angus M, Curtis-Lopez CM, Carrasco R, Currie V, Siddique I, Horner DE. Identification of potential risk factors for cauda equina compression in emergency department patients presenting with non-traumatic back pain: a 4-year retrospective cohort analysis at a tertiary referral neuroscience center. Emerg Med J. 2021.
68. Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, et al. Systematic review of tests to identify the disc, SIJ, or facet joint as the source of low back pain. Eur Spine J. 2007;16(10):1539-50.
69. Kader D, Radha S, Smith F, Wardlaw D, Scott N, Rege A, et al. Evaluation of perifacet injections and paraspinal muscle rehabilitation in the treatment of low back pain. A randomized controlled trial. Ortop Traumatol Rehabil. 2012;14(3):251-9.
70. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of a lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184-95.
71. Konstantinou K, Dunn KM. Sciatica: a review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976). 2008;33(22):2464-72.
72. Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015;15(6):1461-77.
73. Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, et al. Prevalence of spinal stenosis and its association with symptoms: the Framingham Study. Spine J. 2009;9(7):545-50.
74. Haig AJ, Tomkins CC. Diagnosis and management of lumbar spinal stenosis. JAMA. 2010;303(1):71-2.
75. Haig AJ, Geisser ME, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, et al. Electromyography and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and the absence of back symptoms. J Bone Joint Surg Am. 2007;89(2):358-66.
76. Adams MA, Roughley PJ. What is intervertebral disc degeneration, and what causes it? Spine (Phila Pa 1976). 2006;31(18):2151-61.
77. Videman T, Battié MC, Ripatti S, Gill K, Manninen H, Kaprio J. Determinants of the progression of lumbar degeneration: a 5-year follow-up study of adult male monozygotic twins. Spine (Phila Pa 1976). 2006;31(6):671-8.
78. Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106(3):591-614.
79. Manchikanti L, Pampati V, Fellows B, Bakhit CE. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain. 2000;4(5):337-44.
80. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1. Upper Half of the Body. 2nd ed. Baltimore: Williams & Wilkins; 1999.
81. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015;54(3):392-9.
82. Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM R. 2015;7(7):746-761.
83. Gurney B. Leg length discrepancy. Gait & Posture. 2002;15(2):195-206.
84. Hides J, Fan T, Stanton W, Stanton P, McMahon K, Wilson S. Psoas and quadratus lumborum muscle asymmetry among elite Australian Football League players. Br J Sports Med. 2010;44(8):563-7.
85. Slater D, Korakakis V, O'Sullivan P, Nolan D, O'Sullivan K. "Sit Up Straight": Time to Re-evaluate. J Orthop Sports Phys Ther. 2019;49(8):562-564.
86. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56.