Low back pain is one of the most common complaints in the U.S. and in the world today. Low back pain is the second leading reason for doctors’ visits and it costs at least $50 billion each year in health care costs and time lost from work. As many as 80% of Americans are estimated to suffer with issues with their backs at some time in their lives, the majority of which are rooted in mechanical issues rather than in conditions such as arthritis, cancer, or fractures.

It seems a lot of the people I see with low back pain and chronic low back pathologies usually show up once they’re stumped, having already tried a lot of other things. I typically work alongside colleagues and other providers on these cases and I’m proud to say we have a system where we can get many of these chronic cases better, even after many other attempts have failed. Today I’d like to share my general philosophy in regards to this major issue.

As with any injury, we providers must make sure we are moving beyond just treating the symptoms to addressing all underlying issues that could be causing the pain. If anyone reading this struggles with low back pain, you need to think through what your current provider is doing, and you also need to make sure you’re doing everything that you can do at home/in your gym. The standard treatments for low back pain include traction tables, chiropractic manipulation, inversion tables, massage, heat, ice, and stim, and ultrasound. I would say that these things are actually the least valuable that you could be doing as they are symptom-focused. I really think to break through with back pain we need to focus much more on strength, mechanics, posture, and environmental habits, and also on doing the targeted, specific manual therapy inputs and physical therapy.

For advanced or complex cases of low back pain, you have to look far beyond what’s happening just in the lumbar spine for possible root causes. A few of the biggest concerns are:

• Range of Motion of the Hip--This is very, very important. Someone who doesn’t have the right range of motion in the hip will certainly not get better function or symptoms in their back.

• Thoracic Spine--We need to consider the position of the thoracic spine through the day as well as how much motion, especially rotational movement and extension, you have in the thoracic spine.

• Lumbosacral Relationships--The relationship of the sacroiliac (SI) joints and the sacrum to the lumbar. If there’s dysfunction in any one of these four areas, we end up compensating and altering the mechanics of the lumbar spine, and due to gravity and activity, the lumbar spine tends to be an area where problems start or can first be felt.

You’ll know your provider is doing a good job if they’re treating your hip flexors, the psoas and the iliacus muscles, the erector spinae, and in fact, continuing that treatment of the erector spinae up the whole spine through the thoracic to the cervical, or at least appreciating where there may be altered mechanics or altered function along that chain. We also need to look at treating the multifidus muscle, which is deep to the erector spinae and is one of the most important muscles for a) low back health, b) optimizing movement in the spine, and c) absorbing impacts. As disc injury/disc compression occurs, typically the multifidus is one of the first things to become weak, dysfunctional and oftentimes very hypertonic (tight). We also need to treat the adductors, especially the adductor magnus, and the hamstring and quadricep.

If your provider is treating all of those structures/regions and you’re still not getting a result then that really does indicate a complex injury, but we need to also consider strengthening work. For strengthening I’m really big on five key things.

1. Pelvic position--We need to do exercises with the pelvis in the right position and learn how to hold that.

2. Abdominal tension--We have to keep tension in our core and brace tight when we go through different movements in the day. If you can’t do this, and many people can’t, that’s when you are asking for trouble. This is the story of that one moment when you simply bend over to pick up your child or anything else and then injure your back (even a pencil, no joke!, this has happened).

3. Gait-- We always have to work on gait. Basically this is learning how to preserve energy in the spine and to let the spine move naturally as we walk, and learning how to use the hip and foot on the ground. Doing functional strengthening that supports this is a must.

4. Rotational work--This is really important especially in the thoracic spine which is where a lot of the rotational movement should happen. This allows our shoulder girdle to be free, it allows us to use our core, and particularly to generate force from our core. If you don’t have that rotational aspect in your thoracic spine then you will likely end up stressing your lumbar area more. Additionally, rotation happens partly with the use of the oblique and spiraling musculature, having strength here provides key support for the spine.

5. Mobility for the hip (actually the whole area we spoke about earlier)--We must improve hip extension and rotation (similar to the thoracic area), lumbosacral relationships, and must get the SI joint to move optimally (it doesn’t move as much as other joints but it needs to move a few degrees with every step).

If you have an advanced low back injury, healing it fully will take a lot of work. It will take a lot of treatment, it will take a lot of work at home, and it can be a frustrating process. Most people don’t appreciate how much strengthening they may need to do and how many environmental changes they may need to make. Certainly getting away from being at a desk for long hours, or using a stand-up desk is one way to help this, if possible, and we also need to focus on learning and doing some of these rehab exercises to get the targets that were just outlined above.

Truthfully, as a provider, low back pain can actually be a very fun problem to help people with. I love to help people with this issue because since it’s so debilitating when it occurs, it’s correspondingly so rewarding to see it recede and people get well. If you start to think about the strategies above and consider your approach, contrasting and comparing with what you’re currently doing, I think you’ll see that there’s definitely room for hope that it can get better.

Sourcing for statistics in the first paragraph here.