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Back pain is an enigma. The treatments are endless: massage, physiotherapy, even surgery.

But is the back pain really happening due to damage in the back? Are the symptoms a part of the bigger picture? Are invasive methods really necessary and will massage help the underlying issue or just band-aid the solution? Why, with all of the treatments out there, do you still have back pain?

This article will guide you through the best available evidence to help your client kill their back pain and get back to training.

There's Always an Assumed Cause

If you ask your client why they think their back hurts, they'll probably answer with something like:

  • "I blew a disc in college."
  • "I strained a ligament deadlifting."
  • "I slouch at my desk."

Logic seems to infer that if there's pain, the cause needs to be directly related. But a direct cause and effect is rarely the case.

Most of the time, their backs aren't damaged.

Back pain is rarely caused by tissue damage or some kind of biomechanical problem.(1)

Unfortunately, most people still think it is, including medical professionals.(1,2) That's why many of your clients have probably been told they shouldn't squat, they need to get surgery, or that they need to go through elaborate strengthening and corrective exercises to fix their back pain.

How many people have you seen that have uttered the phrase, "I've tried everything?"

Most treatments are based on the idea that your client's back is "out" or damaged in some way, and are designed to "correct" or heal their backs.(1) Despite this idea being so common, it's still unproven and probably false.(1,3)

Is Damage Synonymous With Pain?

If back pain were caused by damage, you'd expect people with the most damaged backs to be in the most pain. That's not the case.

Depending on the data you look at, around 22-40% of healthy, pain-free people will have herniated disks. The same studies show that around 21-93% of people have bulging disks, and 56% can have tears in the connective tissue around their spine.(4-8)

One study found that "... even spinal canal stenosis (narrowing) is routinely painless."(9)

Remember, these people have absolutely no pain, despite obvious damage. Pain is often in the brain.

Other studies have also found that people with minor and severe spinal deformities often have no back pain.(10-14)

It's still possible that some of your clients with back pain do have tissue damage, but that's not the norm. We'll come back to them in a second.

First, let's talk about some of the most common, and unproven ways people often try to heal back pain.

Are Corrective Exercises, Core Strengthening, and Stretching Overrated?

It's tempting to recommend special exercises to correct your client's posture, balance their muscles, and make them more flexible. Extolling the "benefits" of these are also a trap that many overzealous trainers fall into as they try to get a client to purchase training sessions.

These methods are cheap, easy, and safe. In fact, physical therapists recommend core strengthening and corrective exercises more than anything else when they have a patient with back pain.(15)

Unfortunately, these activities are also probably a waste of your client's time.

Core strengthening and "motor control exercises" will sometimes make people feel slightly better, but the benefits are very small and not reliable. Most studies have shown that these activities are no better than manual therapy or other kinds of exercise.(16-21)

Even when people feel better after doing corrective exercises, their backs don't function any differently. The benefits were probably due to feeling more confident, and a placebo effect, than from any physical change.(22)

The same thing is generally true with drugs.

Drugs Aren't Very Effective for Treating Back Pain

Medication can offer a band-aid solution, but it doesn't solve the issue. Do you really want your clients to be medicated for the rest of their lives?(23)

There's still very little research on the best drugs, drug combinations, dosing amounts, or dosing schedules for back pain.

Non-steroidal anti-inflammatories (NSAIDs) like Ibuprofen, and acetaminophen (e.g. Tylenol) seem to work well for acute back pain, but don't help much with chronic back pain. Even then, the results from most studies are mixed, and we're still not sure how effective these drugs are for any kind of back pain.(23-25)

Surprisingly, muscle relaxants are almost completely ineffective for treating back pain. They're generally no more effective than placebos or other cheap drugs like NSAIDs and acetaminophen.(26,27) In fact, people will actually tense their muscles if they're told a muscle relaxant is a stimulant. (28)

What About Surgery?

Doctors are often quick to tell people with back pain they need surgery. When you have a client who's tried everything else, you've probably been tempted to tell them the same thing.

Unfortunately, surgery is remarkably ineffective.(8,29-32)

Most surgeons still view back pain as a structural problem that needs to be fixed, and are often more likely to recommend surgery before exploring other options. As we saw above, a large percentage of people will present with an abnormality in their spine if scanned. It doesn't mean that there's an issue.

As a result, "Rarely are diagnoses scientifically valid, nor is the effectiveness of surgery proven by acceptable clinical trials."(29)

If your client has had surgery, it's likely they can exercise like a normal person. People who get spinal fusion, where a surgeon connects several vertebrae, are often able to function as if their back was completely normal.(33)

Considering the cost, risk, and time it takes, surgery might be one of the worst choices for treating back pain.

Now let's look at the best possible explanation for what causes back pain, so you can help you clients feel better.

What Causes Back Pain?

The most recent and comprehensive studies indicate that back pain is largely caused by a hyperexcited nervous system.(8,34,45)

When the nervous system becomes sensitive it will either:

a) overreact to small stressors that shouldn't be very painful, or

b) create the sensation of pain even if your body isn't damaged.

It's possible that this will happen after a real injury. Say your client really does hurt their back in the gym. Their injury heals in a few weeks, but the pain remains or gets worse.

Your client's emotional and mental state will also affect how much pain they experience. Stress, whether it's caused by feeling overwhelmed, lonely, tired, or scared, will make their back pain worse.(35)

A number of studies have shown that simply educating your clients about what really causes pain, can make them feel much better.(36-41) Even when people don't exercise, they still feel better after learning about how pain isn't necessarily caused by structural problems, but by their nervous system.(42)

At this point "... there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance."(36)

Cognitive functional therapy, which "targets the beliefs, fears and associated behaviours" with back pain, is thought to be more effective than manual therapy and exercise.(43)

Basically, this approach focuses on educating people about the real causes of low-back pain to ease their stress and fear around their condition. (Admittedly an over-simplification but adequate for this discussion.)

Studies have also shown that people who "catastrophize" their pain tend to have a slower recovery.(44,45) These are the clients who assume they're never going to get better, will never be able to squat again, and generally assume the worst. It's more important than ever that you help educate these people and calmly walk them through what really causes pain.

In short, telling clients what's really going on inside their body is one of the best ways to help them recover from their back pain.

Your Quick Start Guide to Helping Your Clients Overcome Back Pain

1. Ask your client about their history.

When your client says they have back pain, ask them the following questions and let them talk through the answers. Be careful not to interrupt them; nod your head and take notes as they speak:

  1. Where does it hurt?
  2. How long have you been in pain?
  3. When did it start?
  4. Have you been to see a doctor? If so, what did they say?
  5. Have you had any recent accidents that might have injured your back?
  6. Is the pain constant, or does it wax and wane?
  7. Are there any activities that you know make your pain worse?

Your goal at this point is to get a clear view of their condition, and help them stay as active as possible without causing them pain.

Phrasing is important. Don't ask a bunch of leading questions that reinforce the idea that their back is damaged.

For instance, if you ask "Have you had any scans of your low back?," "does your back ever make a 'popping noise,'" they're more likely to assume they're suffering because of some structural problem.

Resist the urge to immediately tell them to do a bunch of stretching and strengthening exercises. While it might make them feel a little better in the short-term, it still implies their back is damaged, misaligned, tight, or weak, which is probably not the case.

2. Educate them about the real causes of pain.

This is probably the most important thing you can do to help your clients feel better.

Read this article or print it out, and break the information down into simple chunks. Spread out the lesson over a few different personal training sessions.

In the first session, you might explain how pain is controlled in the brain, and that your tissues just send information about whether or not the brain should start making your body hurt.

The next session, you could talk about how stress and other issues affect their pain tolerance.

If you feel like they're not "getting it," then repeat yourself and use multiple examples. It's crucial they understand this information, as it's probably the best way for them to recover.

3. Encourage them to keep moving, even if they have low-back pain.

Most studies indicate that your clients will recover faster if they stay active, rather than resting.(49,50)

It doesn't matter what kind of exercise they do, as long as they're moving. Help them find activities that don't cause pain, but still give them a workout. It might be as simple as taking a walk every morning.

If they have pain all day, still urge them to workout a little. Complete rest tends to make back pain worse.(50)

4. Help them identify and cope with stress.

If you aren't asking your clients about their home life, start. Here are a few questions that will help you find what's stressing them out:

  • "How much sleep have you been getting recently?"
  • "How's work?"
  • "Are you and still dating?"
  • "How was moving into your new apartment?"
  • "When was the last time you took a day off?"

People often feel better just talking about what's bothering them, even if you don't offer a solution. (Or in other words, "it's not about the nail.)"

If your client is a type-a personality who rarely takes breaks, it's possible they need to add some more play to their life.

5. Suggest they get a massage.

There's a little evidence that massage might help people with back pain.(51)

Most people find massages relaxing, and if it can fit their budget, it's worth trying. If nothing else, it acts as a relief of the stress that could be leading to some of the symptoms.

6. Ask them to be patient, and reassure them they will get better.

Most cases of back pain, even "chronic" ones, go away with time.(52)

Even if they have a herniated disk, those usually correct themselves, too.(53)

As cheesy as it sounds, there's strong evidence that if your client believes they can get better, they will.(54-56)

Remind them of that fact.

Recommend they see a doctor... if they meet the following criteria:

  • They've had back pain for more than 6 weeks.
  • They've had an obvious accident that might have been traumatic enough to fracture their spine, like a car crash.
  • Their pain is extremely severe, and getting worse instead of better.
  • They have numbness around their butt or groin and trouble staying continent.

Otherwise, it's best to stick to the above methods first.

Chronic back pain is frustrating. It's poorly understand, often misdiagnosed, and over-prescribed. Help your client understand what's really going on. Alleviate their concerns, listen to them, and help them find ways to move that don't cause pain.



1. Zusman M. Belief reinforcement: one reason why costs for low back pain have not decreased. J Multidiscip Healthc. 2013;6:197-204.

2. Stockard AR, Allen TW. Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. J Am Osteopath Assoc. 2006;106(6):350-355.

3. Chou R, Loeser JD, Owens DK, et al. Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society. Spine. 2009;34(10).

4. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72(3):403-408.

5. Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology. 1998;209(3):661-666. doi:10.1148/radiology.209.3.9844656.

6. Stadnik TW, Lee RR, Coen HL, Neirynck EC, Buisseret TS, Osteaux MJ. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology. 1998;206(1):49-55. doi:10.1148/radiology.206.1.9423651.

7. Borenstein DG, O'Mara JWJ, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am. 2001;83-A(9):1306-1311.

8. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363-370. doi:10.1056/NEJM200102013440508.

9. Haig AJ, Tong HC, Yamakawa KS, et al. Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Arch Phys Med Rehabil. 2006;87(7):897-903. doi:10.1016/j.apmr.2006.03.016.

10. Maurer M, Soder RB, Baldisserotto M. Spine abnormalities depicted by magnetic resonance imaging in adolescent rowers. Am J Sports Med. 2011;39(2):392-397. doi:10.1177/0363546510381365.

11. Fox AJ, Lin JP, Pinto RS, Kricheff II. Myelographic cervical nerve root deformities. Radiology. 1975;116(02):355-361. doi:10.1148/116.2.355.

12. Magora A, Schwartz A. Relation between low back pain and X-ray changes. 4. Lysis and olisthesis. Scand J Rehabil Med. 1980;12(2):47-52.

13. Magora A, Schwartz A. Relation between the low back pain syndrome and x-ray findings. 2. Transitional vertebra (mainly sacralization). Scand J Rehabil Med. 1978;10(3):135-145.

14. Akhaddar A, Boucetta M. Dislocation of the Cervical Spine. N Engl J Med. 2010;362(20):1920-1920. doi:10.1056/NEJMicm0908013.

15. Liddle SD, David Baxter G, Gracey JH. Physiotherapists' use of advice and exercise for the management of chronic low back pain: a national survey. Man Ther. 2009;14(2):189-196. doi:10.1016/j.math.2008.01.012.

16. Unsgaard-Tondel M, Fladmark AM, Salvesen O, Vasseljen O. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Phys Ther. 2010;90(10):1426-1440. doi:10.2522/ptj.20090421.

17. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89(1):9-25. doi:10.2522/ptj.20080103.

18. O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa 1976). 1997;22(24):2959-2967.

19. Childs JD, Teyhen DS, Casey PR, et al. Effects of traditional sit-up training versus core stabilization exercises on short-term musculoskeletal injuries in US Army soldiers: a cluster randomized trial. Phys Ther. 2010;90(10):1404-1412. doi:10.2522/ptj.20090389.

20. Nadler SF, Malanga GA, Bartoli LA, Feinberg JH, Prybicien M, Deprince M. Hip muscle imbalance and low back pain in athletes: influence of core strengthening. Med Sci Sports Exerc. 2002;34(1):9-16.

21. George SZ, Childs JD, Teyhen DS, et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial. BMC Med. 2011;9:128. doi:10.1186/1741-7015-9-128.

22. Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J. 2012;21(4):575-598. doi:10.1007/s00586-011-2045-6.

23. Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):505-514.

24. Deyo RA. Drug therapy for back pain. Which drugs help which patients? Spine (Phila Pa 1976). 1996;21(24):2840-9- discussion 2849-50.

25. Roelofs PDDM, Deyo RA, Koes BW, Scholten RJPM, van Tulder MW. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine (Phila Pa 1976). 2008;33(16):1766-1774. doi:10.1097/BRS.0b013e31817e69d3.

26. Khwaja SM, Minnerop M, Singer AJ. Comparison of ibuprofen, cyclobenzaprine or both in patients with acute cervical strain: a randomized controlled trial. CJEM. 2010;12(1):39-44.

27. See S, Ginzburg R. Choosing a skeletal muscle relaxant. Am Fam Physician. 2008;78(3):365-370.

28. Flaten MA, Simonsen T, Olsen H. Drug-related information generates placebo and nocebo responses that modify the drug response. Psychosom Med. 1999;61(2):250-255.

29. Nachemson AL. Newest knowledge of low back pain. A critical look. Clin Orthop Relat Res. 1992;(279):8-20.

30. Dyer VE. Nursing - a microscopic examination. Zambia Nurse J. 1976;8(1):4-6.

31. Jacobs WCH, Rubinstein SM, Willems PC, et al. The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Eur Spine J. 2013;22(9):1936-1949. doi:10.1007/s00586-013-2823-4.

32. Jacobs WCH, Rubinstein SM, Koes B, van Tulder MW, Peul WC. Evidence for surgery in degenerative lumbar spine disorders. Best Pract Res Clin Rheumatol. 2013;27(5):673-684. doi:10.1016/j.berh.2013.09.009.

33. Niemeyer T, Bovingloh AS, Halm H, Liljenqvist U. Results after anterior-posterior lumbar spinal fusion: 2-5 years follow-up. Int Orthop. 2004;28(5):298-302. doi:10.1007/s00264-004-0577-7.

34. Nijs J, Meeus M, Cagnie B, et al. A Modern Neuroscience Approach to Chronic Spinal Pain: Combining Pain Neuroscience Education With Cognition-Targeted Motor Control Training. Phys Ther. 2014. doi:10.2522/ptj.20130258.

35. Jones LE, O'Shaughnessy DFP. The Pain and Movement Reasoning Model: Introduction to a simple tool for integrated pain assessment. Man Ther VL - IS - SP - EP . 2014.

36. 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):2041-2056. doi:10.1016/j.apmr.2011.07.198.

37. Udermann BE, Spratt KF, Donelson RG, Mayer J, Graves JE, Tillotson J. Can a patient educational book change behavior and reduce pain in chronic low back pain patients? Spine J. 2004;4(4):425-435.

38. Gross AR, Aker PD, Goldsmith CH, Peloso P. Patient education for mechanical neck disorders. Cochrane Database Syst Rev. 2000;(2):CD000962. doi:10.1002/14651858.CD000962.

39. Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302.

40. Van Oosterwijck J, Nijs J, Meeus M, et al. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. J Rehabil Res Dev. 2011;48(1):43-58.

41. Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: systematic review and meta-analysis. Man Ther. 2011;16(6):544-549. doi:10.1016/j.math.2011.05.003.

42. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain. 2004;8(1):39-45. doi:10.1016/S1090-3801(03)00063-6.

43. Vibe Fersum K, O'Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. EJP. 17(6):916-928. doi:10.1002/j.1532-2149.2012.00252.x.

44. Smeets RJEM, Vlaeyen JWS, Kester ADM, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain. 2006;7(4):261-271. doi:10.1016/j.jpain.2005.10.011.

45. Sullivan MJL, Adams H, Rhodenizer T, Stanish WD. A psychosocial risk factor--targeted intervention for the prevention of chronic pain and disability following whiplash injury. Phys Ther. 2006;86(1):8-18.

46. Ferreira ML, Smeets RJEM, Kamper SJ, Ferreira PH, Machado LAC. Can we explain heterogeneity among randomized clinical trials of exercise for chronic back pain? A meta-regression analysis of randomized controlled trials. Phys Ther. 2010;90(10):1383-1403. doi:10.2522/ptj.20090332.

47. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142(9):776-785.

48. van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010;24(2):193-204. doi:10.1016/j.berh.2010.01.002.

49. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain--bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332(6):351-355. doi:10.1056/NEJM199502093320602.

50. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated cochrane review of bed rest for low back pain and sciatica. Spine (Phila Pa 1976). 2005;30(5):542-546.

51. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2008;(4):CD001929. doi:10.1002/14651858.CD001929.pub2.

52. Costa LDCM, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009;339:b3829.

53. Bozzao A, Gallucci M, Masciocchi C, Aprile I, Barile A, Passariello R. Lumbar disk herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology. 1992;185(1):135-141. doi:10.1148/radiology.185.1.1523297.

54. Gross DP, Battie MC. Work-related recovery expectations and the prognosis of chronic low back pain within a workers' compensation setting. J Occup Environ Med. 2005;47(4):428-433.

55. Kongsted A, Vach W, Axo M, Bech RN, Hestbaek L. Expectation of recovery from low back pain: a longitudinal cohort study investigating patient characteristics related to expectations and the association between expectations and 3-month outcome. Spine (Phila Pa 1976). 2014;39(1):81-90. doi:10.1097/BRS.0000000000000059.

56. Schultz IZ, Crook J, Meloche GR, et al. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain. 2004;107(1-2):77-85.

57. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769-781. doi:10.1016/j.berh.2010.10.002.