Treating Lower Back Pain
Lower Back Pain Treatment at ProTouch Physical Therapy
LOWER BACK PAIN
If you have lower back pain, you are not alone. About 80 percent of adults experience low back pain at some
point in their lifetimes. It is the most common cause of job-related disability and a leading contributor to missed
work days. In a large survey, more than a quarter of adults reported experiencing low back pain during the past
Men and women are equally affected by low back pain, which can range in intensity from a dull, constant ache
to a sudden, sharp sensation that leaves the person incapacitated. Pain can begin abruptly as a result of an
accident or by lifting something heavy, or it can develop over time due to age-related changes of the spine.
Sedentary lifestyles also can set the stage for low back pain, especially when a weekday routine of getting too
little exercise is punctuated by strenuous weekend workout.
Most low back pain is acute, or short term, and lasts a few days to a few weeks. It tends to resolve on its own
with self-care and there is no residual loss of function. The majority of acute low back pain is mechanical in
nature, meaning that there is a disruption in the way the components of the back (the spine, muscle,
intervertebral discs, and nerves) fit together and move.
Subacute low back pain is defined as pain that lasts between 4 and 12 weeks.
Chronic back pain is defined as pain that persists for 12 weeks or longer, even after an initial injury or
underlying cause of acute low back pain has been treated. About 20 percent of people affected by acute low
back pain develop chronic low back pain with persistent symptoms at one year. In some cases, treatment
successfully relieves chronic low back pain, but in other cases pain persists despite medical and surgical
The magnitude of the burden from low back pain has grown worse in recent years. In 1990, a study ranking the
most burdensome conditions in the U.S. in terms of mortality or poor health as a result of disease put low back
pain in sixth place; in 2010, low back pain jumped to third place, with only ischemic heart disease and chronic
obstructive pulmonary disease ranking higher.
“For over 13 years, I dealt with shoulder pain in both shoulders, which commonly lead to back pain in my upper back and neck due to overcompensation. For approximately 5 years, I was in and out of big name physical therapists and orthopedists who provided standard therapy to treat my shoulder injuries, but nothing really worked. It wasn’t until I started receiving therapy from Scott Gander that the daily chronic shoulder pain and back pain I was experiencing finally dissipated. Scott’s therapy stood out above the rest because he looked for the root causes of the problem. For me, it was a combination of issues with posture and a couple of vertebrae frequently out of place that lead to the overuse of my shoulders, ultimately leading to my shoulder pain and back pain. During the past two years, I have periodically received therapy on my shoulders from Scott. I no longer have daily shoulder pain, and can exercise and lift weights at a level I had not been able to for several years. Scott has helped me look beyond the obvious to resolve my aches and pains. Scott recently even helped me identify a concussion! Thank you Scott for your professionalism, amazing work, and top notch care.”
What causes lower back pain?
The vast majority of low back pain is mechanical in nature. In many cases, low back pain is associated with
spondylosis, a term that refers to the general degeneration of the spine associated with normal wear and tear
that occurs in the joints, discs, and bones of the spine as people get older. Some examples of mechanical
Sprains and strains account for most acute back pain. Sprains are caused by overstretching or
tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting
something improperly, lifting something too heavy, or overstretching. Such movements may also
trigger spasms in back muscles, which can also be painful.
Intervertebral disc degeneration is one of the most common mechanical causes of low back pain,
and it occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy
back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As
the discs deteriorate, they lose their cushioning ability.
Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge
outward or rupture(herniation), causing low back pain. Herniated discs are most common in the
neck(cervical spine), and the lower back(lumbar spine).
Spondylolysis (spon-dee-low-lye-sis) is a stress fracture of a section of the lumbar spine;
most frequently the fifth vertebrae. The injury can occur on the left, the right, or both sides of
the vertebrae. Spondylolysis occurs in up to 11.5% of the general population in the United
States, and is most frequently seen in young males. Spondylolysis is a common cause of low
back pain experienced in late childhood and adolescence. Highly active teens, both boys and
girls who engage in activities that require lifting heavy loads, repeated backward bending of
the back, or twisting of the trunk, are most at risk for spondylolysis, including athletes
participating in activities like football, hockey, gymnastics, or dance. Only a small percentage
of cases of spondylolysis require surgery, and 85% to 90% of young patients recover in 3 to
6 months with proper treatment.
Spondylolisthesis (spon-dee-low-lis-thee-sis) describes the forward slippage of a vertebrae
over the vertebrae beneath it. Because the mechanism of injury, age of the patient,
symptoms, and treatment are similar for both conditions, spondylolysis and
spondylolesthesis are often described together.
Radiculopathy is a condition caused by compression, inflammation and/or injury to a spinal nerve
root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or
radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when
spinal stenosis or a herniated or ruptured disc compresses the nerve root.
Sciatica is a form of radiculopathy caused by compression of the sciatic nerve, the large nerve that
travels through the buttocks and extends down the back of the leg. This compression causes shock-
like or burning low back pain combined with pain through the buttocks and down one leg, occasionally
reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and the
adjacent bone, the symptoms may involve not only pain, but numbness and muscle weakness in the
leg because of interrupted nerve signaling. The condition may also be caused by a tumor or cyst that
presses on the sciatic nerve or its roots.
Spondylolisthesis is a condition in which a vertebra of the lower spine slips out of place, pinching the
nerves exiting the spinal column.
A traumatic injury, such as from playing sports, car accidents, or a fall can injure tendons, ligaments
or muscle resulting in low back pain. Traumatic injury may also cause the spine to become overly
compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on
any of the nerves rooted to the spinal cord. When spinal nerves become compressed and irritated,
back pain and sciatica may result.
Spinal stenosis is a narrowing of the spinal column that puts pressure on the spinal cord and nerves
that can cause pain or numbness with walking and over time leads to leg weakness and sensory loss.
Skeletal irregularities include scoliosis, a curvature of the spine that does not usually cause pain until
middle age; lordosis, an abnormally accentuated arch in the lower back; and other congenital
Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they
require immediate medical attention. Serious underlying conditions include:
Infections are not a common cause of back pain. However, infections can cause pain when they
involve the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the
sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis.
Tumors are a relatively rare cause of back pain. Occasionally, tumors begin in the back, but more
often they appear in the back as a result of cancer that has spread from elsewhere in the body.
Cauda equina syndrome is a serious but rare complication of a ruptured disc. It occurs when disc
material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots,
causing loss of bladder and bowel control. Permanent neurological damage may result if this
Abdominal aortic aneurysms occur when the large blood vessel that supplies blood to the abdomen,
pelvis, and legs becomes abnormally enlarged. Back pain can be a sign that the aneurysm is
becoming larger and that the risk of rupture should be assessed.
Kidney stones can cause sharp pain in the lower back, usually on one side.
Other underlying conditions that predispose people to low back pain include:
Inflammatory diseases of the joints such as arthritis, including osteoarthritis and rheumatoid arthritis
as well as spondylitis, an inflammation of the vertebrae, can also cause low back pain. Spondylitis is
also called spondyloarthritis or spondyloarthropathy.
Osteoporosis is a metabolic bone disease marked by a progressive decrease in bone density and
strength, which can lead to painful fractures of the vertebrae.
Endometriosis is the buildup of uterine tissue in places outside the uterus.
Fibromyalgia, a chronic pain syndrome involving widespread muscle pain and fatigue.
What are the risk factors for developing low back pain?
Beyond underlying diseases, certain other risk factors may elevate one’s risk for low back pain, including:
Age: The first attack of low back pain typically occurs between the ages of 30 and 50, and back pain becomes
more common with advancing age. As people grow older, loss of bone strength from osteoporosis can lead to
fractures, and at the same time, muscle elasticity and tone decrease. The intervertebral discs begin to lose fluid
and flexibility with age, which decreases their ability to cushion the vertebrae. The risk of spinal stenosis also
Growing Young Athletes: in competitive sports or activities such as gymnastics, cheer leading, soccer,
football, baseball, wrestling, swimming, lacrosse, and volleyball.
Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal
muscles may not properly support the spine. “Weekend warriors”—people who go out and exercise a lot after
being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical
activity a daily habit. Studies show that low-impact aerobic exercise is beneficial for the maintaining the integrity
Pregnancy is commonly accompanied by low back pain, which results from pelvic changes and alterations in
weight loading. Back symptoms almost always resolve postpartum.
Weight gain: Being overweight, obese, or quickly gaining significant amounts of weight can put stress on the
Genetics: Some causes of back pain, such as ankylosing spondylitis, a form of arthritis that involves fusion of
the spinal joints leading to some immobility of the spine, have a genetic component.
Occupational risk factors: Having a job that requires heavy lifting, pushing, or pulling, particularly when it
involves twisting or vibrating the spine, can lead to injury and back pain. An inactive job or a desk job may also
lead to or contribute to pain, especially if you have poor posture or sit all day in a chair with inadequate back
Mental health factors: Pre-existing mental health issues such as anxiety and depression can influence how
closely one focuses on their pain as well as their perception of its severity. Pain that becomes chronic also can
contribute to the development of such psychological factors. Stress can affect the body in numerous ways,
Backpack overload in children: Low back pain unrelated to injury or other known cause is unusual in pre-
teen children. However, a backpack overloaded with schoolbooks and supplies can strain the back and cause
muscle fatigue. The American Academy of Orthopaedic Surgeons recommends that a child’s backpack should
weigh no more than 15 to 20 percent of the child’s body weight.
How is low back pain diagnosed?
A complete medical history and physical exam can usually identify any serious conditions that may be causing
the pain. During the exam, a health care provider will ask about the onset, site, and severity of the pain;
duration of symptoms and any limitations in movement; and history of previous episodes or any health
conditions that might be related to the pain. Along with a thorough back examination, neurologic tests are
conducted to determine the cause of pain and appropriate treatment. The cause of chronic lower back pain is
often difficult to determine even after a thorough examination.
Imaging tests are not warranted in most cases. Under certain circumstances, however, imaging may be
ordered to rule out specific causes of pain, including tumors and spinal stenosis. Imaging and other types of
X-ray is often the first imaging technique used to look for broken bones or an injured vertebra. X-rays show the
bony structures and any vertebral misalignment or fractures. Soft tissues such as muscles, ligaments, or
bulging discs are not visible on conventional x-rays.
Computerized tomography (CT) is used to see spinal structures that cannot be seen on conventional x-rays,
such as disc rupture, spinal stenosis, or tumors. Using a computer, the CT scan creates a three-dimensional
image from a series of two dimensional pictures.
Myelograms enhance the diagnostic imaging of x-rays and CT scans. In this procedure, a contrast dye is
injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or
fractures to be seen on an x-ray or CT scans.
Discography may be used when other diagnostic procedures fail to identify the cause of pain. This procedure
involves the injection of a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s
pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the
damaged areas on CT scans taken following the injection. Discography may provide useful information in
cases where people are considering lumbar surgery or when their pain has not responded to conventional
Magnetic resonance imaging (MRI) uses a magnetic force instead of radiation to create a computer-
generated image. Unlike x-ray, which shows only bony structures, MRI scans also produce images of soft
tissues such as muscles, ligaments, tendons, and blood vessels. An MRI may be ordered if a problem such as
infection, tumor, inflammation, disc herniation or rupture, or pressure on a nerve is suspected. MRI is a
noninvasive way to identify a condition requiring prompt surgical treatment. However, in most instances, unless
there are “red flags” in the history or physical exam, an MRI scan is not necessary during the early phases of
Electrodiagnostics are procedures that, in the setting of low back pain, are primarily used to confirm whether
a person has lumbar radiculopathy. The procedures include electromyography (EMG), nerve conduction
studies (NCS), and evoked potential (EP) studies. EMG assesses the electrical activity in a muscle and can
detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles
are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular
area of the body. NCSs are often performed along with EMG to exclude conditions that can mimic
radiculopathy. In NCSs, two sets of electrodes are placed on the skin over the muscles. The first set provides a
mild shock to stimulate the nerve that runs to a particular muscle. The second set records the nerve’s electrical
signals, and from this information nerve damage that slows conduction of the nerve signal can be detected. EP
tests also involve two sets of electrodes—one set to stimulate a sensory nerve, and the other placed on the
scalp to record the speed of nerve signal transmissions to the brain.
Bone scans are used to detect and monitor infection, fracture, or disorders in the bone. A small amount of
radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some
abnormality. Scanner-generated images can be used to identify specific areas of irregular bone metabolism or
abnormal blood flow, as well as to measure levels of joint disease.
Ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to
obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual
image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the
Blood tests are not routinely used to diagnose the cause of back pain; however in some cases they may be
ordered to look for indications of inflammation, infection, and/or the presence of arthritis. Potential tests include
complete blood count, erythrocyte sedimentation rate, and C-reactive protein. Blood tests may also detect HLA-
B27, a genetic marker in the blood that is more common in people with ankylosing spondylitis or reactive
arthritis (a form of arthritis that occurs following infection in another part of the body, usually the genitourinary
In the beginning, when you are in pain and having difficulty performing your normal daily routine,
Show you how to rest the injured vertebrae, use lumbar bracing, modify your activities, and
avoid painful movements
Help you reduce and manage your pain symptoms
Help you maintain fitness while healing, through pain-free cross-training, such as aquatic
Initiate symptom-free hamstring stretching and activation of your core muscles, either in or
When you are pain free, and the healing of your injured structures has begun, your physical therapist
Improve the flexibility of your hip and leg muscles
Improve your core and leg strength
Improve your spine flexibility
Prepare for a return to sport or work activities by improving your overall fitness levels
Begin a gradual progression of higher-risk movements, such as back extension and trunk
rotation to reduce the chance of reinjury
Conventionally used treatments and their level of supportive evidence include:
Hot or cold packs have never been proven to quickly resolve low back injury; however, they may help ease
pain and reduce inflammation for people with acute, subacute, or chronic pain, allowing for greater mobility
Activity: Bed rest should be limited. Individuals should begin stretching exercises and resume normal daily
activities as soon as possible, while avoiding movements that aggravate pain. Strong evidence shows that
persons who continue their activities without bed rest following onset of low back pain appeared to have better
back flexibility than those who rested in bed for a week. Other studies suggest that bed rest alone may make
back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and
Strengthening exercises, beyond general daily activities, are not advised for acute low back pain, but may be
an effective way to speed recovery from chronic or subacute low back pain. Maintaining and building muscle
strength is particularly important for persons with skeletal irregularities. Health care providers can provide a list
of beneficial exercises that will help improve coordination and develop proper posture and muscle balance.
Evidence supports short- and long-term benefits of yoga to ease chronic low back pain.
Medications: A wide range of medications are used to treat acute and chronic low back pain. Some are
available over the counter (OTC); others require a physician’s prescription. Certain drugs, even those available
OTC, may be unsafe during pregnancy, may interact with other medications, cause side effects, or lead to
serious adverse effects such as liver damage or gastrointestinal ulcers and bleeding. Consultation with a health
Spinal manipulation and spinal mobilization are approaches in which professionally licensed specialists in
Physical Therapy such as the professionals at ProTouch Physical Therapy use their hands to mobilize, adjust,
massage, or stimulate the spine and the surrounding tissues. Manipulation involves a rapid movement over
which the individual has no control; mobilization involves slower adjustment movements. The techniques have
been shown to provide small to moderate short-term benefits in people with chronic low back pain.
Traction or spinal decompression involves the use of mechanical force to apply constant or intermittent force to
gradually “pull” the skeletal structure into better alignment. Some people experience pain relief while in traction
due to the gentle separation and decompression(taking pressure off) of the pinched nerve or nerves.
Acupuncture is moderately effective for chronic low back pain. It involves the insertion of thin needles into
precise points throughout the body. Some practitioners believe this process helps clear away blockages in the
body’s life force known as Qi (pronounced chee). Others who may not believe in the concept of Qi theorize that
when the needles are inserted and then stimulated (by twisting or passing a low-voltage electrical current
through them) naturally occurring painkilling chemicals such as endorphins, serotonin, and acetylcholine are
released. Evidence of acupuncture’s benefit for acute low back pain is conflicting and clinical studies continue
Biofeedback is used to treat many acute pain problems, most notably back pain and headache. The therapy
involves the attachment of electrodes to the skin and the use of an electromyography machine that allows
people to become aware of and self regulate their breathing, muscle tension, heart rate, and skin temperature.
People regulate their response to pain by using relaxation techniques. Biofeedback is often used in
combination with other treatment methods, generally without side effects. Evidence is lacking that biofeedback
provides a clear benefit for low back pain.
Nerve block therapies aim to relieve chronic pain by blocking nerve conduction from specific areas of the body.
Nerve block approaches range from injections of local anesthetics, botulinum toxin, or steroids into affected soft
tissues or joints to more complex nerve root blocks and spinal cord stimulation. When extreme pain is involved,
low doses of drugs may be administered by catheter directly into the spinal cord. The success of a nerve block
approach depends on the ability of a practitioner to locate and inject precisely the correct nerve. Chronic use of
steroid injections may lead to increased functional impairment.
Epidural steroid injections are a commonly used short-term option for treating low back pain and sciatica
associated with inflammation. Pain relief associated with the injections, however, tends to be temporary and the
injections are not advised for long-term use. An NIH-funded randomized controlled trial assessing the benefit of
epidural steroid injections for the treatment of chronic low back pain associated with spinal stenosis showed
that long-term outcomes were worse among those people who received the injections compared with those
Transcutaneous electrical nerve stimulation (TENS) involves wearing a battery-powered device consisting of
electrodes placed on the skin over the painful area that generate electrical impulses designed to block
incoming pain signals from the peripheral nerves. The theory is that stimulating the nervous system can modify
the perception of pain. Early studies of TENS suggested that it elevated levels of endorphins, the body’s natural
pain-numbing chemicals. More recent studies, however, have produced mixed results on its effectiveness for
When other therapies fail, surgery may be considered an option to relieve pain caused by serious
musculoskeletal injuries or nerve compression. It may be months following surgery before the patient is fully
healed, and he or she may suffer permanent loss of flexibility.
Surgical procedures are not always successful, and there is little evidence to show which procedures work best
for their particular indications. Patients considering surgical approaches should be fully informed of all related
Vertebroplasty and kyphoplasty are minimally invasive treatments to repair compression fractures of
the vertebrae caused by osteoporosis. Vertebroplasty uses three-dimensional imaging to assist in
guiding a fine needle through the skin into the vertebral body, the largest part of the vertebrae. A glue-
like bone cement is then injected into the vertebral body space, which quickly hardens to stabilize and
strengthen the bone and provide pain relief. In kyphoplasty, prior to injecting the bone cement, a
special balloon is inserted and gently inflated to restore height to the vertebral structure and reduce
Spinal laminectomy (also known as spinal decompression) is performed when spinal stenosis causes
a narrowing of the spinal canal that causes pain, numbness, or weakness. During the procedure, the
lamina or bony walls of the vertebrae, along with any bone spurs, are removed. The aim of the
procedure is to open up the spinal column to remove pressure on the nerves.
Discectomy or microdiscectomy may be recommended to remove a disc, in cases where it has
herniated and presses on a nerve root or the spinal cord, which may cause intense and enduring pain.
Microdiscectomy is similar to a conventional discectomy; however, this procedure involves removing
the herniated disc through a much smaller incision in the back and a more rapid recovery.
Laminectomy and discectomy are frequently performed together and the combination is one of the
more common ways to remove pressure on a nerve root from a herniated disc or bone spur.
Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve
root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space
through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and
weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit,
allowing the surgeon to cut away the blockage and relieve pressure on the nerve.
Intradiscal electrothermal therapy (IDET) is a treatment for discs that are cracked or bulging as a
result of degenerative disc disease. The procedure involves inserting a catheter through a small
incision at the site of the disc in the back. A special wire is passed through the catheter and an
electrical current is applied to heat the disc, which helps strengthen the collagen fibers of the disc wall,
reducing the bulging and the related irritation of the spinal nerve. IDET is of questionable benefit.
Nucleoplasty, also called plasma disc decompression (PDD), is a type of laser surgery that uses
radiofrequency energy to treat people with low back pain associated with mildly herniated discs. Under
x-ray guidance, a needle is inserted into the disc. A plasma laser device is then inserted into the
needle and the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the tissue in the
disc, reducing its size and relieving pressure on the nerves. Several channels may be made depending
on how tissue needs to be removed to decompress the disc and nerve root.
Radiofrequency denervation is a procedure using electrical impulses to interrupt nerve conduction
(including the conduction of pain signals). Using x-ray guidance, a needle is inserted into a target area
of nerves and a local anesthetic is introduced as a way of confirming the involvement of the nerves in
the person’s back pain. Next, the region is heated, resulting in localized destruction of the target
nerves. Pain relief associated with the technique is temporary and the evidence supporting this
Spinal fusion is used to strengthen the spine and prevent painful movements in people with
degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two
or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal
devices secured by screws. The fusion can be performed through the abdomen, a procedure known as
an anterior lumbar interbody fusion, or through the back, called posterior fusion. Spinal fusion may
result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts
to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of
disc degeneration at adjacent levels of the spine.
Artificial disc replacement is considered an alternative to spinal fusion for the treatment of people
with severely damaged discs. The procedure involves removal of the disc and its replacement by a
synthetic disc that helps restore height and movement between the vertebrae.
Can back pain be prevented?
Recurring back pain resulting from improper body mechanics is often preventable by avoiding movements that
jolt or strain the back, maintaining correct posture, and lifting objects properly. Many work-related injuries are
caused or aggravated by stressors such as heavy lifting, contact stress (repeated or constant contact between
soft body tissue and a hard or sharp object), vibration, repetitive motion, and awkward posture. Using
ergonomically designed furniture and equipment to protect the body from injury at home and in the workplace
The use of lumbar supports in the form of wide elastic bands that can be tightened to provide support to the
lower back and abdominal muscles to prevent low back pain remains controversial. Such supports are widely
used despite a lack of evidence showing that they actually prevent pain. Multiple studies have determined that
the use of lumbar supports provides no benefit in terms of the prevention and treatment of back pain. Although
there have been anecdotal case reports of injury reduction among workers using lumbar support belts, many
companies that have back belt programs also have training and ergonomic awareness programs. The reported
injury reduction may be related to a combination of these or other factors. Furthermore, some caution is
advised given that wearing supportive belts may actually lead to or aggravate back pain by causing back
muscles to weaken from lack of use.
Recommendations for keeping one’s back healthy
Following any period of prolonged inactivity, a regimen of low-impact exercises is advised. Speed walking,
swimming, or stationary bike riding 30 minutes daily can increase muscle strength and flexibility. Yoga also can
help stretch and strengthen muscles and improve posture. Consult your ProTouch Physical Therapist for a list
of low-impact, age-appropriate exercises that are specifically targeted to strengthening lower back and
Always stretch before exercise or other strenuous physical activity.
Don’t slouch when standing or sitting. The lower back can support a person’s weight most easily when
the curvature is reduced. When standing, keep your weight balanced on your feet.
At home or work, make sure work surfaces are at a comfortable height.
Sit in a chair with good lumbar support and proper position and height for the task. Keep shoulders
back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to
relieve tension. A pillow or rolled-up towel placed behind the small of the back can provide some
lumbar support. During prolonged periods of sitting, elevate feet on a low stool or a stack of books.
Wear comfortable, low-heeled shoes.
Sleeping on one’s side with the knees drawn up in a fetal position can help open up the joints in the
spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface.
Don’t try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep
the head down and in line with a straight back. When lifting, keep objects close to the body. Do not
Maintain proper nutrition and diet to reduce and prevent excessive weight gain, especially weight
around the waistline that taxes lower back muscles. A diet with sufficient daily intake of calcium,
phosphorus, and vitamin D helps to promote new bone growth.
Quit smoking. Smoking reduces blood flow to the lower spine, which can contribute to spinal disc
degeneration. Smoking also increases the risk of osteoporosis and impedes healing. Coughing due to
heavy smoking also may cause back pain.
What research is being done?
The National Institute of Neurological Disorders and Stroke (NINDS) is a component of the National Institutes
of Health (NIH) and is the leading federal funder of research on disorders of the brain and nervous system. As
a primary supporter of research on pain and pain mechanisms, NINDS is a member of the NIH Pain
Consortium, which was established to promote collaboration among the many NIH Institutes and Centers with
research programs and activities addressing pain. On an even broader scale, NIH participates in
the Interagency Pain Research Coordinating Committee, a federal advisory committee that coordinates
research across other U.S. Department of Health and Human Services agencies as well as the Departments of
NINDS-funded studies are contributing to a better understanding of why some people with acute low back pain
recover fully while others go on to develop chronic low back pain. Brain imaging studies suggest that people
with chronic low back pain have changes in brain structure and function. In one study, people with subacute
back pain were followed for one year. Researchers found that certain patterns of functional connectivity across
brain networks correlated with the likelihood of pain becoming chronic. The findings suggest that such patterns
may help predict who is most likely to transition from subacute to chronic back pain. Other research seeks to
determine the role of brain circuits important for emotional and motivational learning and memory in this
transition, in order to identify new preventive interventions.
Disc degeneration remains a key cause of chronic low back pain and the pain often persists despite surgery.
NIH-funded basic science and preclinical studies are investigating molecular-level mechanisms that cause
discs in the spine to degenerate, as well as protective mechanisms involved in disc remodeling that may
diminish with advancing age. Such studies may help identify future therapeutic strategies to block degenerative
mechanisms or promote remodeling processes. NIH also is funding early research on stem cell approaches to
promote disc regeneration and rejuvenate cells of the nucleus pulposus, the jelly-like substance in the center of
intervertebral discs that loses water content as people age.
Other NIH-funded studies are investigating physical therapy and chiropractic approaches. For example,
researchers are studying whether therapy programs that emphasize certain types of exercises, such as core
stabilization exercises, provide benefit to people who experience recurrent low back pain.
The increasing use of spinal manipulation and mobilization, despite lacking evidence for more than small or
moderate benefit, has prompted NIH-funded researchers to study the mechanisms of these two techniques and
to conduct a randomized controlled trial to assess and compare their effectiveness for the treatment of chronic
Finally, NIH-funded researchers are studying various complementary and alternative therapies for low back
pain, including those aimed reducing stress and negative emotions believed to aggravate the experience of
pain. For example, virtual reality programs are being studied for their ability to help people cope with persistent
Where can I get more information?
For more information on neurological disorders or research programs funded by the National Institute of
Neurological Disorders and Stroke, contact the Institute’s Brain Resources and Information Network (BRAIN)
Information also is available from the following organizations:
American Chronic Pain Association
American Association of Neurological
Tel: 847-378-0500/888-566-AANS (2267)
National Institute of Arthritis and Musculoskeletal and Skin
Diseases Information Clearinghouse
1 AMS Circle
Bethesda, MD 20892-3675
Tel: 877-22-NIAMS (226-4267) 301-565-2966 (TTY)
American Academy of Orthopaedic Surgeons/ American
Association of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
American Academy of Neurological and Orthopaedic
10 Cascade Creek Lane
Las Vegas, NV 89113
American Academy of Physical Medicine
“Back PainFact Sheet”, NINDS, Publication date December 2014.
The American Physical Therapy Association (APTA) believes that consumers should have access to
information that could help them make health care decisions and also prepare them for their visit
The following articles provide some of the best scientific evidence related to physical therapy
treatment of degenerative disc disease, low back pain, spondylolysis, and spondylolisthesis. The
articles report recent research and give an overview of the standards of practice both in the United
States and internationally. The article titles are linked either to a PubMed* abstract of the article or to
free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Sundell CG, Jonsson H, Adin L, Larsen KH. Clinical examination, spondylolysis and adolescent
athletes. Int J Sports Med. 2013;34(3):263-267. Article Summary on PubMed.
A patient’s guide to Spondylolysis/Spondylolisthesis. University of Maryland Medical Center Spine
Center website. Published 2003. Updated June 20, 2013.
Lumbosacral spondylolysis treatment & management. Medscape Reference. Updated August 27,
Spondylolysis and Spondylolisthesis in the pediatric patient: an interview with surgeon Daniel W.
Green, MD. Hospital for Special Surgery website. Published February 4, 2009. Updated December
Kim HJ, Green DW. Spondylolysis in the adolescent athlete. Curr Opin Pediatr. 2011;23(1):68-
72. Article Summary on PubMed.
Syrmou E, Tsitsopoulos PP, Marinopoulos D, et al. Spondylolysis: a review and reappraisal.
Hippokratia. 2010;14(1):17-21. Free Article.
Kalichman L, Kim DH, Li L, et al. Spondylolysis and Spondylolisthesis: prevalence and association
with low back pain in the adult community-based population. Spine(Phila Pa 1976). 2009;34(2):199-
*PubMed is a free online resource developed by the National Center for Biotechnology Information
(NCBI). PubMed contains millions of citations to biomedical literature, including citations in the
National Library of Medicine’s MEDLINE database.
Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific
low back pain: a systematic review. Phys Ther. 2009;89:9–25. Free Article.
Beattie PF. Current understanding of lumbar intervertebral disc degeneration: a review with
emphasis upon etiology, pathophysiology, and lumbar magnetic resonance imaging
findings. J Orthop Sports Phys Ther. 2008;38:329–340. Article Summary on PubMed.
Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P. Clinical Guidelines: 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;147:478-491. Article Summary on
Roh JS, Teng AL, Yoo JU, Davis J, Furey C, Bohlman HH. Degenerative disorders of the lumbar
and cervical spine. Orthop Clin North Am.2005: 36:255-262. Article Summary on PubMed.