Contents

1 NON-SPECIFIC BACK PAIN

NON-SPECIFIC BACK PAIN

Non-specific low back pain (NSLBP) is deﬁned as low back pain not attributable to a recognisable, known specific pathology. Almost everybody will experience low back pain at some point, as it has become common in everyday life, like getting tired, feeling sad, or getting a cold.

While some episodes of low back pain can be severe and frightening, most people recover from the episode reasonably quickly (within six to eight weeks) and often without the need to see a health professional for treatment.

To know more about NSLBP, we need to know about pain and the importance of triage in low back pain.

Pain

Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Pain Is More Than Just Physical

You might be wondering why I chose to define pain before starting the introduction. Or maybe you’re asking yourself, how can pain be an emotional experience?

Here’s a simple example: Imagine you’re standing in a crowded bus and someone accidentally steps on your foot. Because you expect bumps and pushes in that situation, you’d probably just brush it off and not think much of it.

Now picture the same thing happening while you’re casually strolling through a mall. Here, it feels unexpected and out of place, so you might become annoyed, react more strongly, or feel the pain more intensely. Why? Because pain isn’t just about what happens to the body. The way we interpret it: our emotions, thoughts, and surroundings all shape how we feel and react.

Back pain works in the same way. It’s not just about muscles, bones, or nerves; it’s also about how stress, fear, and environment influence the experience. That’s why it’s crucial not to make patients fearful, as the fear lowers confidence and often leads to more disability than the pain itself.

Sorting Back Pain: Why Triage Matters

When it comes to low back pain, the first question isn’t ‘how do we treat it?’ but rather ‘what kind of back pain is it?’ Most cases turn out to be non-specific, but before we give it that label, we have to rule out the uncommon yet serious causes.

Triage is the process that helps us do exactly that—it sorts patients into categories based on warning signs, making sure we don’t miss conditions. Once those red flags are excluded, we can confidently label it as non-specific low back pain.

Triaging in LBP

The goal of the diagnostic triage for LBP is to exclude non-spinal causes of LBP and to allocate patients to one of three categories that subsequently direct management. ( Bardin, Lynn D et al.)

SERIOUS PATHOLOGY(Pangarkar, Sanjog S et al., Bardin, Lynn D et al.)

Possible serious conditions	Red flags (signs, symptoms, and history)
Cauda equina syndrome or conus medullaris syndrome	Urinary retention Urinary or faecal incontinence Saddle anesthesia Changes in rectal tone Severe/progressive lower extremity neurologic deficits
Infection	Fever Immunosuppression IV drug use Recent infection, indwelling catheters (e.g., central line, Foley)
Fracture	History of osteoporosis Chronic use of corticosteroids Older age (≥75 years old) Recent trauma Younger patients at risk for stress fractures (e.g., overuse)
Cancer	History of cancer with new onset of LBP Unexplained weight loss Failure of LBP to improve after 1 month Age >50 years Multiple risk factors present
Axial spondyloarthritis	Morning stiffness that improves with exercise Alternating buttock pain Younger age (20–40 years) Positive family history of spondyloarthritis Extra-articular manifestation

SPECIFIC PATHOLOGY (Pangarkar, Sanjog S et al.)( Bardin, Lynn D et al.)

Possible Other Conditions	Red flags (signs, symptoms, and history)
Herniated disc	Radicular back pain (e.g., sciatica) Lower extremity dysesthesia and/or paresthesia Severe/progressive lower extremity neurologic deficits Symptoms present >1 month
Spinal stenosis	Radicular back pain (e.g., sciatica) Lower extremity dysesthesia and/or paresthesia, Neurogenic claudication Older age Bilateral leg pain exacerbated by extended posture Severe/progressive lower extremity neurologic deficits. Symptoms present for >1 month
Inflammatory LBP	Morning stiffness Improvement with exercise Alternating buttock pain Awakening due to LBP during the second part of the night (early morning awakening) Younger age
Radicular pain / radiculopathy	Leg pain is typically worse than back pain. Leg pain quality — sharp, lancinating, or deep ache increasing with cough, sneeze, or strain Leg pain location — unilateral, dermatomal concentration (below the knee for L4, L5, S1) Numbness or paraesthesia (typically in the distal dermatome) Weakness or loss of function (e.g., foot drop)

NON-SPECIFIC BACK PAIN

Do we need imaging for back pain?

For patients with acute low back pain, without focal neurologic deficits or other red flags (e.g., signs, symptoms, history), we recommend against routinely obtaining imaging studies or performing invasive diagnostic tests. [Pangarkar, Sanjog S et al.]. Because structural damage can be present in asymptomatic individuals.

Pain ≠ Damage. Age-specific prevalence estimates of degenerative spine imaging findings in asymptomatic patients. [Brinjikji, W et al.]

Imaging Finding	20 yr	30 yr	40 yr	50 yr	60 yr	70 yr	80 yr
Disk degeneration	37%	52%	68%	80%	88%	93%	96%
Disk signal loss	17%	33%	54%	73%	86%	94%	97%
Disk height loss	24%	34%	45%	56%	67%	76%	84%
Disk bulge	30%	40%	50%	60%	69%	77%	84%
Disk protrusion	29%	31%	33%	36%	38%	40%	43%
Annular fissure	19%	20%	22%	23%	25%	27%	29%
Facet degeneration	4%	9%	18%	32%	50%	69%	83%
Spondylolisthesis	3%	5%	8%	14%	23%	35%	50%

Don’t rush for treatment!

Similarly, the medicines we call “painkillers” are not very effective at treating low back pain and often come with significant side effects.

They do not speed up your recovery and have greater potential for harm. For patients with chronic low back pain, we suggest against opioids.[ Pangarkar, Sanjog S et al. ]

Core stability: A myth?

There are a lot of things that can impact and influence someone’s LBP, including but definitely not limited to core weakness. When relevant, we should address deficits in not just the strength of the glutes and core, but mobility and stability of surrounding structures that may be impacting the load demand at the low back.

It may sound simple, but education and encouraging movement are one of the best, most researched methods of improving persistent pain. LBP is no different.

Build strength (not just in the core). [Reyes-Ferrada, Waleska et al]

Mind Your Back: Mind Your Language!

“Sit Up Straight.” In the absence of any good evidence that one posture exists to prevent pain, asking patients to work hard to achieve correct posture may set them up for a sense of failure and create more anxiety when their pain persists.

There is no single “correct” posture. Despite common posture beliefs, there is no strong evidence that one optimal posture exists or that avoiding the so-called “incorrect” postures will prevent back pain.[ Chun, Se-Woong et al.] [Laird, Robert A et al.]

Don’t be fooled by quick fixes!

1) Healing through needles

Acupuncture may not be a miracle cure, but it’s definitely an experience worth trying—especially if you’re into holistic healing, gentle approaches, or just want an excuse to lie down for 30 minutes without your phone.

For patients with chronic low back pain, we suggest against acupuncture. Acupuncture appears to have a small benefit for the reduction of pain for those with chronic LBP in the intermediate-term (3 – 12 months). [Pangarkar, Sanjog S et al.]

2) Traction “Because Clearly, Gravity Just Needed Some Extra Help”

Thirty minutes later, I was “reset,” “aligned,” and stood up. But my back still hurts, and now it hurts with intention.

Based on the available evidence, there is moderate evidence showing no statistically significant differences in short- or long-term outcomes between traction as a single treatment and a placebo, sham, or no treatment. [Delitto, Anthony et al]

3) How to “Realign” Your Spine With Cracks

Step 1: Believe in the Myth.

Forget muscles, discs, nerves, biomechanics, and neuroscience. The only thing standing between you and a pain-free back is a good crunch sound effect.

Step 2: Chase the Pop.

Remember: relief isn’t measured in actual stability, mobility, or healing… It’s measured in decibels. Louder = healthier. POP = PROGRESS. Ignore biology.

So after all the hype about “targeting the exact misaligned vertebra”, high-quality evidence says: “Yeah… just pick a spot and crack it, you’ll get the same result.”

Precision? Not so much. The spine doesn’t seem to care which bone you pretend to realign. [Nim, Casper et al.]

Which suggests the effect isn’t from “rearranging the spine” — it’s likely non-specific factors (placebo, patient expectations, therapist interaction, natural recovery).

“Back Pain and Rest: Helpful or Harmful?”

Instead of prolonged rest, current guidelines encourage staying active with tailored movement strategies that support recovery. Graded activity focuses on gradually increasing physical function based on what the person can tolerate, helping reduce fear of movement and improve long-term outcomes. [Maher, Christopher G et al.]

So what works for low-back pain?

In a world full of medical jargon and worst-case scenarios seen on the internet, simple, compassionate reassurance with movement is often the most powerful medicine.

So, how to reassure [Pincus et al, 2013]?

Reassurance can be cognitive and affective.

What are the questions your patient might ask about?

Prognosis[ Young, Anika et al. 2025 ]

Most people experience a rapid reduction in pain and resolution of symptoms in 6 to 8 weeks; it may even reduce within the first week or even exceed more than 8weeks, depending on the individual. Based on my assessment, you should recover from this episode within that timeframe.’

Fluctuating/episodic LBP

‘As you have seen from your previous experiences, your pain tends to come and go. Even though you’re uncomfortable now, I expect this episode to recover quickly, similar to your previous episodes.’

Persistent LBP or high-risk of poor outcome

‘We have identified some factor, such as [whatever the factors are,] that are contributing to your pain, and I am confident that if we can address those factors together, then I am confident you will start to improve.’

Movement is medicine

Exercise is very good for low back pain, and the best is the one that the person will do and stick with over time. Unfortunately, many people are given frightening information about certain exercises.

But one of the finest treatments for “low back” pain is to keep moving and start doing exercises. [Maher, Christopher G et al.]

Even improving the level of physical activity has been shown to reduce the risk of low-back pain. [Yakdan, Salim et al.]

Take-home message

We now know that low back pain can be triggered or increased by non-physical factors, which are also common in our lives. These triggers can be

Psychological (thinking you will not get better, depression, stress, fear of movement),
Health-related (being tired and run down, low energy),
Lifestyle-related (sleep problems, low levels of physical activity, being overweight, smoking) or
Social (money problems, poor relationships or support at work or home..

The goal isn’t to avoid pain entirely, but to build resilience and confidence through consistent, progressive activity guided by evidence-based practice.

Reference:

1) Pangarkar, Sanjog S et al. “VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain.” Journal of general internal medicine vol. 34,11 (2019): 2620-2629. doi:10.1007/s11606-019-05086-4

2) Maher, Christopher G et al. “Introducing Australia’s clinical care standard for low back pain: A new clinical care standard provides evidence-based guidance to help clinicians deliver best care for people with low back pain.” Chiropractic & manual therapies vol. 31,1 17. 15 Jun. 2023, doi:10.1186/s12998-023-00485-1

3) Bardin, Lynn D et al. “Diagnostic triage for low back pain: a practical approach for primary care.” The Medical Journal of Australia vol. 206,6 (2017): 268-273. doi:10.5694/mja16.00828

4) Brinjikji, W et al. “Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.” AJNR. American journal of neuroradiology vol. 36,4 (2015): 811-6. doi:10.3174/ajnr.A4173

5) Delitto, Anthony et al. “Low back pain.” The Journal of Orthopaedic and Sports Physical Therapy, vol. 42,4 (2012): A1-57. doi:10.2519/jospt.2012.42.4.A1

6) Reyes-Ferrada, Waleska et al. “Isokinetic Trunk Strength in Acute Low Back Pain Patients Compared to Healthy Subjects: A Systematic Review.” International Journal of Environmental Research and Public Health vol. 18,5 2576. 4 Mar. 2021,

7) Chun, Se-Woong et al. “The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis.” The spine journal: official journal of the North American Spine Society vol. 17,8 (2017): 1180-1191. doi:10.1016/j.spinee.2017.04.034

8) Laird, Robert A et al. “Modifying patterns of movement in people with low back pain -does it help? A systematic review.” BMC Musculoskeletal Disorders vol. 13 169. 7 Sep. 2012, doi:10.1186/1471-2474-13-169

9) Pincus, Tamar et al. “Cognitive and affective reassurance and patient outcomes in primary care: a systematic review.” Pain vol. 154,11 (2013): 2407-2416. doi:10.1016/j.pain.2013.07.019

10)Young, Anika et al. “Clinician experiences in providing reassurance for patients with low back pain in primary care: a qualitative study.” Journal of physiotherapy vol. 71,1 (2025): 48-56. doi:10.1016/j.jphys.2024.11.003

11) Yakdan, Salim et al. “Association of activity with the risk of developing musculoskeletal pain in the All of Us research program.” The Journal of Pain, vol. 35, 105516. 6 Aug. 2025, doi:10.1016/j.jpain.2025.105516

12) Nim, Casper et al. “The Effectiveness of Spinal Manipulative Therapy in Treating Spinal Pain Does Not Depend on the Application Procedures: A Systematic Review and Network Meta-analysis.” The Journal of Orthopaedic and Sports Physical Therapy vol. 55,2 (2025): 109-122.

Azarudheen

Azarudheen is a passionate physiotherapist and exercise prescriptor with a deeply rooted belief in the transformative power of movement and education. His journey began in 2013 as a first-year physiotherapy student, balancing academics with part-time work to support his ambitions. Early in his career, he sought practical experience and began working at a fitness center, eventually transitioning into roles that expanded his knowledge and skill set in both clinical practice and teaching.

Driven by a relentless curiosity and desire for growth, Azarudheen took on an anatomy tutor position, believing in the value of continuous learning. A pivotal turning point came with his experience in cardiopulmonary rehabilitation at PSG Hospitals, where he worked closely with lung transplant patients. This experience emphasized the life-changing impact of functional movement and patient education, inspiring him to dive deeper into respiratory and cardiovascular physiology.

With strong support and belief in his vision, Azarudheen pursued a Master’s in Exercise and Sports Science at Manipal University—choosing it over conventional MPT programs to focus more on biomechanics, exercise physiology, strength and conditioning, and lifestyle health. His dedication was evident as he spent late nights at the library, worked part-time in gyms and cricket academies, and honed his craft through practical application.

In 2022, despite initial doubts, he opened his first clinic in his hometown—an act of courage and self-belief supported by his family and mentors. Built from the ground up, this clinic marked the start of a new era. Today, Azarudheen leads a growing team of 21 physiotherapists across two thriving clinics in Chennai and Coimbatore. His philosophy centers on patient education, movement optimization, and professional growth, and he continues to evolve both as a clinician and a leader.

Azarudheen’s journey reflects the power of perseverance, vision, and lifelong learning. He is not only a practitioner but also a mentor and advocate for a more thoughtful, movement-centered approach to healthcare.