Lower Back Pain: When to Worry and When to Move

Lower back pain (LBP) is the leading cause of disability worldwide and a frequent reason for seeking physiotherapy care. Despite its prevalence, not all back pain is created equal - and knowing when to worry versus when to move is essential for effective recovery and peace of mind.

Lower Back Pain Epidemiology and Clinical Presentation

• Up to 80% of adults will experience LBP at some point in their lives (Rubin, 2007; Hartvigsen et al., 2018).

• Around 90-95% of cases are considered non-specific, meaning no definitive pathoanatomical cause can be identified (Maher et al., 2017).

• Most cases are self-limiting, but recurrence rates are high without proper management.

Red Flag Clusters: When to Be Concerned

Red flags are warning signs of serious spinal conditions. They should be considered in clusters, not as isolated symptoms. Here are the three most clinically important red flag conditions:

Condition	Key Red Flags	Clinical Notes
Spinal Fracture	- Significant trauma (especially in older adults) - Age >70 - Osteoporosis - Localised bony tenderness	A cluster of 3 or more greatly increases suspicion. Most useful in elderly patients with recent falls.
Spinal Malignancy	- History of cancer (especially breast, prostate, kidney) - Age >50 - Unexplained weight loss - Failure to improve with conservative care	A previous cancer diagnosis is the most predictive single red flag (LR+ 15.0). Symptoms are often constant and progressive.
Cauda Equina Syndrome	- Saddle anaesthesia - Urinary retention or incontinence - Bilateral leg weakness or numbness	This is a medical emergency. Immediate referral for MRI and surgical decompression is required.

⚠️ Red flags are rare, but missing them can have serious consequences. When in doubt, refer promptly for further investigation.

Understanding Non-Specific Lower Back Pain

Non-specific lower back pain (NSLBP) refers to pain in the lumbar region that cannot be traced to a specific structure such as a fracture, herniated disc, or serious systemic condition. It accounts for approximately 90-95% of all lower back pain cases seen in physiotherapy and primary care settings (Maher et al., 2017).

This doesn’t mean the pain isn’t real - rather, it reflects how complex back pain can be. NSLBP is often caused by a combination of factors, including:

• Muscle weakness or imbalance (e.g. poor trunk or hip control)

• Prolonged sitting or poor posture

• Deconditioning or lack of movement variety

• Stress, poor sleep, or fear of movement

Importantly, research shows that these cases often respond best to active rehabilitation, education, and reassurance, rather than passive treatments or unnecessary imaging (Hartvigsen et al., 2018; Brinjikji et al., 2015).

A key takeaway:

Pain does not always mean damage. 

Most cases of lower back pain are mechanical, manageable, and improve with the right approach.

When to Move: The Role of Active Recovery

Contrary to old-school thinking, extended rest does not promote healing. Research shows that exercise therapy improves outcomes, reduces pain and recurrence, and enhances functional capacity.

Exercise Benefits for Lower Back Pain

• Improves pain and disability

• Boosts confidence and reduces fear-avoidance

• Prevents future episodes

Effective Types of Exercise for Lower Back Pain

• Motor Control Training (MCT): Retrains deep core muscles - e.g. multifidus, transversus abdominis (Saragiotto et al., 2016)

• General Strength/Aerobic Exercise: As effective as MCT for many patients (Owen et al., 2020)

• Graded Exposure: Gradual return to feared or painful movements

“Exercise therapy, regardless of type, is more effective than passive modalities or advice alone.” 

- Cochrane Review, Hayden et al., 2021

Modern Physio Management:

What We Do at Endurance Health Lab

At our clinic, we take a personalised, evidence-based approach to managing lower back pain, aiming not just for short-term relief but long-term resilience and recurrence prevention.

Initial Clinical Assessment

• Comprehensive subjective history to identify red flags, aggravating factors, and psychosocial influences (e.g. stress, fear of movement, sleep quality).

• Functional movement screening:

  • Trunk flexion/extension, hip dissociation, single leg stance

  • Control during transitional tasks (e.g. sit-to-stand, hip hinge)

• Manual muscle testing and movement coordination, focusing on:

  • Lumbopelvic control

  • Gluteal strength

  • Abdominal bracing strategies

  • Hamstring and hip flexor flexibility

This clinical reasoning helps us identify dysfunctional patterns and tailor your plan beyond pain relief.

Treatment Strategy

• Manual therapy: Joint mobilisations, soft tissue release, and neurodynamic techniques for symptom modulation.

• Education and reassurance: Understanding pain mechanisms reduces fear, improves self-efficacy, and promotes recovery (Traeger et al., 2015).

• Progressive loading and motor control:

  
  

  • Stage 1: Local control (e.g. deep core activation, supine/quadruped work)

  • Stage 2: Functional loading (e.g. bridging, deadlift patterning, anti-rotation core drills)

  • Stage 3: Return-to-task (e.g. work lifts, sports movement, dynamic control)

We combine structured progressions with real-world relevance — whether your goal is to lift a barbell, sit pain-free at work, or get back on the field.

What About Imaging?

Routine imaging is not recommended for most LBP cases, especially in the first 6 weeks unless red flags are present.

• Degenerative findings like disc bulges, facet arthropathy, or annular tears are commonly seen in pain-free individuals (Brinjikji et al., 2015).

• Imaging can increase patient fear and lead to unnecessary interventions.

Guidelines: Avoid imaging unless red flag pathology is strongly suspected (NICE 2020).

Takeaway: Movement is Medicine

Pain is real — but so is recovery. In the absence of red flags, your best course of action is to stay active, stay informed, and stay supported by a skilled clinician.

Lower back pain doesn’t have to define your movement.

With the right plan, most people return to doing what they love — pain-free and stronger than before.

When Should You See a Physiotherapist?

While some back pain may resolve on its own, it’s best not to wait and hope — especially if the pain is impacting your work, training, or quality of life.

Seeing a physiotherapist early can help you get clarity, restore movement, and prevent recurrence.

You should book a physiotherapy consultation if:

• Your pain has lasted more than a few days without improvement

• It’s interfering with sleep, work, or exercise

• You’re feeling stiff, weak, or fearful of movement

• You’ve had multiple episodes of back pain before

• You want a clear plan for rehabilitation, strength, and long-term spinal health

At Endurance Health Lab, we assess, treat, and guide you through a structured recovery tailored to your goals — whether that’s lifting pain-free, getting back to sport, or simply walking and working without restriction.

📅 Book an assessment today or Email us to chat about your lower back pain.

Located in Chatswood, 2067

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📚 References

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR: American Journal of Neuroradiology, 36(4), 811–816.

Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., & Underwood, M. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367.

Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, 2021(9), CD009790.

Maher, C., Underwood, M., & Buchbinder, R. (2017). Non-specific low back pain. The Lancet, 389(10070), 736–747.

National Institute for Health and Care Excellence. (2020). Low back pain and sciatica in over 16s: Assessment and management (NICE Guideline NG59).

Owen, P. J., Miller, C. T., Mundell, N. L., Verswijveren, S. J. J. M., Tagliaferri, S. D., Brisby, H., Bowe, S. J., & Belavy, D. L. (2020). Which specific modes of exercise training are most effective for treating low back pain? A network meta-analysis. British Journal of Sports Medicine, 54(21), 1279–1287.

Saragiotto, B. T., Maher, C. G., Yamato, T. P., Costa, L. O., Menezes Costa, L. C., Ostelo, R. W., & Macedo, L. G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, 2016(1), CD012004.

Steffens, D., Maher, C. G., Pereira, L. S., Stevens, M. L., Oliveira, V. C., Chapple, M., Teixeira-Salmela, L. F., & Hancock, M. J. (2016). Prevention of low back pain: A systematic review and meta-analysis. JAMA Internal Medicine, 176(2), 199–208.

Traeger, A. C., Henschke, N., Hübscher, M., Williams, C. M., Kamper, S. J., Maher, C. G., Moseley, G. L., & McAuley, J. H. (2016). Estimating the risk of chronic pain: Development and validation of a prognostic model (PICKUP) for patients with acute low back pain. PLOS Medicine, 13(5), e1002019.