Question 1

Which conditions can I treat with this plan?

Accepted Answer

This plan has been designed to help people recover from mild to moderate lower back sprains or strains, mechanical back pain, and non-specific back pain.

This plan is not for people with osteoporosis, an acute disc injury, pain that refers to your legs, changes to sensation or muscle strength, a severe spinal injury, inflammatory arthritis, e.g., spondyloarthritis, scoliosis, or other illnesses.

If you have any of these conditions, please consult your doctor.

Question 2

Symptoms of lower back pain

Accepted Answer

Typical symptoms associated with non-specific or mechanical back pain and mild sprains and strains:

Pain in your lower back - across your whole lower back or more to one side, but it may also refer to your buttocks
A constant dull ache, crampy, burning sensation, or even sharp or stabbing pain when you move into certain positions
The intensity of the discomfort usually changes depending on your position and the activity you're doing; sometimes you may be aware of it most of the day
Running may worsen your symptoms at times but improve your symptoms at other times
Stressful or upsetting situations at work or in your social life can affect your symptom intensity

Question 3

When to see a doctor

Accepted Answer

You should consult your doctor or physical therapist before using the app to ensure you have the correct diagnosis and are ready to start rehab exercises.

If you have any concerns about your injury after you've started your rehab, schedule a review with your doctor, particularly if:

You have pain at night that keeps you awake or interrupts your sleep
You’re losing weight for no apparent reason or without trying
You feel pain, pins and needles, tingling, or numbness in one of your legs - this can indicate an injured nerve, and our rehab plan may not suit you
Your symptoms are getting worse
Your injury is not recovering as expected (see expected recovery times below)

Symptoms that require immediate attention

Speak to your doctor immediately or visit the emergency department of the hospital if you notice any of the following:

You suddenly develop severe pain
Difficulty urinating even though your bladder feels full
Loss of bladder or bowel control - you struggle to get to the toilet in time
Numbness or tingling in your genitals or buttocks area
Impaired sexual function, such as loss of sensation during intercourse or erectile dysfunction
Loss of power in your legs
If you are experiencing pain that runs down both legs
If you experience changes in sensation (like tingling, pins and needles, numbness) in both legs
Feeling unwell with back pain, such as a fever or significant sweating that wakes you from sleep

Question 4

Causes of back pain

Accepted Answer

Back pain can be persistent and intense, so we often assume that a severe injury must be the cause. However, researchers have found that most back pain cases fall into the non-specific category. That means a back scan will likely show no severe structural damage or cause of your pain.

A diagnosis like this can be frustrating because the pain is real. So it's natural to feel that someone has missed something. Scans can help pick up serious injuries, inflammation, and infections, but they don't show the more subtle causes of pain. For example, mild sprains and strains or painful and sensitive muscles and joints caused by doing too little or too much activity.

Although we don’t consider these causes serious, they can result in a lot of pain.

Our brains can also amplify pain and make it feel worse than it should. We discuss how this happens and what you can do about it in our article "Persistent pain - why it happens, and how to find relief from it".

Non-specific or mechanical back pain can have several causes, but some of the most common include:

Not moving enough during the day - this can cause your muscles, joints, and ligaments to become irritated and painful, especially if you spend long hours sitting or driving
Ramping up your activity too quickly when your body doesn't have the strength and endurance for the task - like suddenly doing a lot of gardening or increasing your running volume or intensity too fast
Doing repetitive daily tasks that can tire you out and predispose you to back strain - like repetitive bending, twisting, or lifting
Sudden or unexpected movements
Sometimes a lack of trunk and pelvis muscle strength may be to blame - particularly if you've not exercised for several months or recently given birth
Mental and physical fatigue from work stress, poor sleep, or not enough recovery time - these can predispose you to all kinds of injuries, including back pain

Question 5

Treatment, recovery times & prevention

Accepted Answer

Treatment

Research suggests that a well-rounded rehab plan for back pain should include:

Relative rest: Staying active and moving while cutting out or adapting the most aggravating activities, allowing your pain to settle
Changing habits: Adjusting habits that may be contributing to your back pain, e.g., how long you sit in a day
Learning about your pain: Getting to know and understand what influences your pain, what levels of pain are safe to train through, and how to adapt your activities accordingly
A slow, progressive exercise plan: Improving your core and general body strength and control
Mobility and range of movement exercises: Gaining and maintaining good mobility in your back and legs
Tailored aerobic exercises: Helping to reduce pain and improve function with the right choice of activity at the right intensity, e.g., swimming, deep water running, cycling, walking, and running
Stress and anxiety management: If you've noticed that your mindset, emotions, or mental health sometimes amplify or trigger your pain, some techniques can help you address them, e.g., making work or lifestyle changes, meditation, cognitive behavioral therapy, or consulting a sports psychologist

The rehab plan in the app includes all of these components. It starts with low-load exercises that help settle your pain, then slowly increases the exercise intensity as you grow stronger. We've also included advice to help you understand your pain and identify and change habits that may be contributing to your pain.

Other treatments you may encounter:

Complete rest: It may calm your pain initially, but resting for prolonged periods is not advised as it can make you lose strength and increase your pain over time
Massage: Can help reduce pain in the short term
Heat packs: Can help reduce pain
Medication: Not necessary in most cases, but may be helpful for some - if so, it should be prescribed by a doctor
Electrotherapy (like ultrasound): Not recommended by current research

Recovery times

Mild back pain episodes usually recover within 2 to 12 weeks. Moderate to severe flare-ups may take longer than 3 months to settle down fully.

Recovery is never linear; it is normal to experience days when your pain is more pronounced. As you recover, you can expect your back pain to become more intermittent (you feel it less frequently), harder to provoke, and less severe when it is present.

It is also normal to experience a recurrence of pain if you fall back into bad habits or find yourself in a stressful situation.

Prevention

You may reduce your risk of developing back pain by:

Avoiding long periods of inactivity during the day
Doing strength training and mobility exercises
Doing regular aerobic exercise
Not ramping up your training volume or intensity too quickly
Reducing physical fatigue by allowing enough recovery time
Taking steps to reduce mental fatigue, stress, and anxiety

Once you've completed your rehab, switch to the injury prevention plan in the app - it’s designed with all these elements in mind.

Question 6

Research References

Accepted Answer

Anheyer, Dennis, et al. "Yoga for treating low back pain: a systematic review and meta-analysis." Pain 163.4 (2022): e504-e517.
Fernández-Rodríguez, Rubén, et al. "Best exercise options for reducing pain and disability in adults with chronic low back pain: pilates, strength, core-based, and mind-body. A network meta-analysis." Journal of Orthopaedic & Sports Physical Therapy 52.8 (2022): 505-521.
Niederer, Daniel, Matthias Weippert, and Martin Behrens. "What modifies the effect of an exercise treatment for chronic low back pain? A meta-epidemiologic regression analysis of risk of bias and comparative effectiveness." Journal of Orthopaedic & Sports Physical Therapy 52.12 (2022): 792-802.
Larivière, Christian, et al. "Derivation of clinical prediction rules for identifying patients with non-acute low back pain who respond best to a lumbar stabilization exercise program at post-treatment and six-month follow-up." Plos one 17.4 (2022): e0265970.
Siddall, Benjamin, et al. "Short-term impact of combining pain neuroscience education with exercise for chronic musculoskeletal pain: a systematic review and meta-analysis." Pain 163.1 (2022): e20-e30.
Gianola, Silvia, et al. "Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis." British journal of sports medicine 56.1 (2022): 41-50.
Sutanto, Dhananjaya, et al. "Effects of Different Trunk Training Methods for Chronic Low Back Pain: A Meta-Analysis." International journal of environmental research and public health 19.5 (2022): 2863.
Disantis, Ashley E., and RobRoy L. Martin. "Classification Based Treatment of Greater Trochanteric Pain Syndrome (GTPS) with Integration of the Movement System." International Journal of Sports Physical Therapy 17.3 (2022): 508.
Fleckenstein, J., Flössel, P., Engel, T., Krempel, L., Stoll, J., Behrens, M., & Niederer, D. (2022). Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability. The Journal of Pain.
Grooten, W.J.A., Boström, C., Dedering, Å. et al. Summarizing the effects of different exercise types in chronic low back pain – a systematic review of systematic reviews. BMC Musculoskelet Disord 23, 801 (2022).
Ho, Emma Kwan-Yee, et al. "Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis." bmj 376 (2022).
Nice guidelines: Back pain - low (without radiculopathy)
Pourahmadi M, Delavari S, Hayden JA, et al Does motor control training improve pain and function in adults with symptomatic lumbar disc herniation? A systematic review and meta-analysis of 861 subjects in 16 trialsBritish Journal of Sports Medicine 2022;56:1230-1240.
Shahidi, B., Padwal, J., Lee, E., Xu, R., Northway, S., Taitano, L., ... & Raiszadeh, K. (2022). Factors impacting adherence to an exercise-based physical therapy program for individuals with low back pain. PloS one, 17 (10), e0276326.
Shanbehzadeh, S., ShahAli, S., Hides, J., Ebrahimi-Takamjani, I., & Rasouli, O. (2022). Effect of Motor Control Training on Trunk Muscle Morphometry, Pain, and Disability in People With Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Journal of Manipulative and Physiological Therapeutics.
Clijsen, Ron, et al. "Local heat applications as a treatment of physical and functional parameters in acute and chronic musculoskeletal disorders or pain." Archives of Physical Medicine and Rehabilitation 103.3 (2022): 505-522.
George, Steven Z., et al. "Interventions for the management of acute and chronic low back pain: revision 2021: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American Physical Therapy Association." Journal of Orthopaedic & Sports Physical Therapy 51.11 (2021): CPG1-CPG60.
Fischer, S. C., Calley, D. Q., & Hollman, J. H. (2021). Effect of an exercise program that includes deadlifts on low back pain. Journal of Sport Rehabilitation, 30(4), 672-675.
Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021 Sep 28;9(9):CD009790.
Kanitz, A. C., Machado, B., Rodrigues, D., Zambelli, G., Ivaniski, A., Carvalho, N., ... & Martins, L. F. (2021). Deep-water running training at moderate intensity and high intensity improves pain, disability, and quality of life in patients with chronic low back pain: a randomized clinical trial. Arch. med. deporte, 38 (201), 28-35.
Maselli, F., Esculier, J. F., Storari, L., Mourad, F., Rossettini, G., Barbari, V., ... & Testa, M. (2021). Low back pain among Italian runners: A cross-sectional survey. Physical Therapy in Sport, 48, 136-145.
Nice guideline: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain
Wu, B., Chen, C. C., Wang, J., & Wang, X. Q. (2021). Incidence and risk factors of low back pain in marathon runners. Pain Research and Management , 2021.
Maselli, F., Storari, L., Barbari, V., Colombi, A., Turolla, A., Gianola, S., ... & Testa, M. (2020). Prevalence and incidence of low back pain among runners: a systematic review. BMC musculoskeletal disorders, 21(1), 1-25.
O'Sullivan PB, Caneiro J, O'Sullivan K, et al Back to basics: 10 facts every person should know about back pain British Journal of Sports Medicine 2020;54: 698-699.
Owen PJ, Miller CT, Mundell NL, et al. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British Journal of Sports Medicine 2020;54:1279-1287.
Hides, J. A., Murphy, M., Jang, E., Blackwell, L., Sexton, M., Sexton, C., & Mendis, M. D. (2019). Predicting a beneficial response to motor control training in patients with low back pain: a longitudinal cohort study. European Spine Journal, 28(11), 2462-2469.
O’Sullivan K, O’Sullivan PB, Gabbett TJ, et al. Advice to athletes with back pain—get active! Seriously? British Journal of Sports Medicine 2019;53:324-325.
Traeger AC, Buchbinder R, Harris IA, et al Avoid routinely prescribing medicines for non-specific low back pain. British Journal of Sports Medicine 2019;53:196-199.
Vanti, C., Andreatta, S., Borghi, S., Guccione, A. A., Pillastrini, P., & Bertozzi, L. (2019). The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials. Disability and rehabilitation, 41(6), 622-632.
Lee, S. P., Bailey, J. P., Smith, J. A., Barton, S., Brown, D., & Joyce, T. (2018). Adaptations of lumbar biomechanics after four weeks of running training with minimalist footwear and technique guidance: Implications for running-related lower back pain. Physical Therapy in Sport, 29, 101-107.
Rahman Shiri, David Coggon, Kobra Falah-Hassani, Exercise for the Prevention of Low Back Pain: Systematic Review and Meta-Analysis of Controlled Trials, American Journal of Epidemiology , Volume 187, Issue 5, May 2018, Pages 1093–1101.
Huber, S., et al. (2017). "Treatment of low back pain with a digital multidisciplinary pain treatment app: short-term results." JMIR rehabilitation and assistive technologies 4(2): e11.
Saragiotto BT, Latimer J Prevention of low back pain (PEDro synthesis)British Journal of Sports Medicine 2016;50:1345.
Boucher, JA., Preuss, R., Henry, S.M. et al. The effects of an 8-week stabilization exercise program on lumbar movement sense in patients with low back pain. BMC Musculoskeletal Disord 17, 23 (2016).
Welch, Neil, et al. "The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI-defined lumbar fat infiltration and functional cross-sectional area in those with chronic low back." BMJ open sport & exercise medicine 1.1 (2015): e000050.
Moseley, G. Lorimer, and David S. Butler. "Fifteen years of explaining pain: the past, present, and future." The Journal of Pain 16.9 (2015): 807-813.
Berglund, Lars1,2; Aasa, Björn2; Hellqvist, Jonas1; Michaelson, Peter3; Aasa, Ulrika1. Which Patients With Low Back Pain Benefit From Deadlift Training?. Journal of Strength and Conditioning Research 29(7):p 1803-1811, July 2015.
Gallagher, Laura, James McAuley, and G. Lorimer Moseley. "A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain." The Clinical journal of pain 29.1 (2013): 20-25.
Malliaropoulos N, Bikos G, Tsitas K, et al Low back pain in elite track and field athletes British Journal of Sports Medicine 2011;45:e1.
Manninen JS, Kallinen M Low back pain and other overuse injuries in a group of Japanese triathletes.British Journal of Sports Medicine 1996;30:134-139.

Lower back pain treatment plan