41 Back Pain

Back Pain

Back pain affects roughly 568 million people worldwide and symptoms may vary from a dull ache to a sudden sharp shooting pain (Cieza et al., 2020). After a detailed history and clinical examination back pain is often classified three into broad categories:

  • Specific spinal pathology (< 1% of cases)
    • Vertebral fracture
    • Malignancy
    • Spinal infection
    • Axial Spondyloarthritis
    • Cauda equina syndrome
  • Radicular syndrome (∼ 5-10% of cases)
    • Radicular pain
    • Radiculopathy
    • Spinal stenosis
  • Non-specific LBP (90-95% of cases)
    • Presumed lumbar musculoskeletal low back pain. Difficult to reliably specify pathoanatomical source of low back pain

DocMikeEvans: Low Back Pain


Increasingly, research shows that attributing the experience of back pain solely to poor posture, minor leg length discrepancies, vertebral misalignment and other structural abnormalities is an oversimplification of a complex process (Green et al., 2018; Swain et al., 2020). So-called abnormalities are often normal variations or adaptations, in some cases they may even be advantageous. Even in the case of degenerative changes in the spine, landmark studies have shown that tissue tears revealed on imaging are a part of normal aging (Brinjikji et al., 2015). What’s more is that in the case of herniated discs 60-80% have been shown to spontaneously resorb (Zhong et al., 2017). This disconnect between tissue damage seen on imaging and clinical presentation often creates confusion for both patients and clinicians.


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Red Flags for Serious Spinal Pathology

Red flags are signs and symptoms that raise suspicion of serious underlying pathology, for patients with low back pain there are a number of serious spinal pathologies to be aware of, these are cauda equina syndrome (0.08% of low back pain patients presenting to primary care), spinal fracture, malignancy, and spinal infection (Finucane et al., 2020; Hoeritzauer et al., 2020).

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient-specific Functional Scale
  • Oswestry Disability Index
  • Roland-Morris Disability Questionnaire
  • STarT Back Screening Tool (SBST)

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Craig’s Test
  • Gaenslen’s Test
  • Gillet’s Test
  • Kemp’s Test (Lower Quadrant Test)
  • Kernig/Brudzinski Test
  • Rebound Tenderness (McBurney’s Point)
  • Piriformis Test (FAIR Test)
  • Cluster of Laslett (Sacroiliac Joint Pain Provocation)
  • Sacroiliac Compression Test (Squish Test)
  • Sacroiliac Distraction Test (Gap Test)
  • Slump Test
  • Valsalva Maneuver
  • Well Leg Raise
  • Straight Leg Raise (Lasègue’s sign) or Braggard’s Test
  • Bowstring Maneuver
  • Prone Gap Test (Hibb’s Test)
  • Prone Knee Bend Test/Femoral Nerve Stretch Test (Reversed Lasègue)
Once red flags and serious pathology are excluded low back pain guidelines recommend self-management, physical and psychological therapies and place less emphasis on pharmacological and surgical treatments; routine use of imaging and investigations is not recommended.


Most clinical practice guidelines for low back pain are moving towards an interdisciplinary approach with an emphasis on self-management, physical and psychological therapies and less emphasis on pharmacological and surgical treatments (Foster et al., 2018). Pharmacological treatments options such as opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) have small effects on low back pain (Chou et al., 2020; Kamper et al., 2020; Tucker et al., 2020; van der Gaag et al., 2020). Embracing an interprofessional strategy for pain management can include the use of education, exercise, acupuncture, massage therapy and spinal manipulation as part of a multi-dimensional approach for the management of back pain.


Acute low back pain (less than six weeks duration)​

Chronic low back pain (more than 12 weeks duration​)

First line treatments​

Advice to stay active; patient education​

Advice to stay active; patient education; exercise therapy; cognitive behavioral therapy​

Second line treatments​

Spinal manipulation; massage; acupuncture​

Spinal manipulation; massage; acupuncture; yoga; mindfulness-based stress reduction; interdisciplinary rehabilitation​

If the above treatments fail​

Non-steroidal anti-inflammatory drugs​

Non-steroidal anti-inflammatory drugs; selective norepinephrine reuptake inhibitors; surgery​

*Reference – Foster et al., (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet.


When consulting with someone living with low back pain provide reassurance and educational resources on condition and management options and encourage the use of active approaches (e.g., lifestyle, physical activity) to help manage symptoms. As an example of an educational resource a recent review published in the British Journal of Sports Medicine provided a list of ten sensible evidence-based recommendations for the management of low back pain (O’Sullivan et al., 2020).

Back to basics: 10 facts every person should know about back pain

Once red flags and serious pathology are excluded, evidence supports that:

  1. Low back pain (LBP) is not a serious life-threatening medical condition.
  2. Most episodes of low back pain improve and LBP does not get worse as we age.
  3. A negative mindset, fear-avoidance behavior, negative recovery expectations, and poor pain coping behaviors are more strongly associated with persistent pain than is tissue damage.
  4. Scans do not determine prognosis of the current episode of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes.
  5. Graduated exercise and movement in all directions is safe and healthy for the spine.
  6. Spine posture during sitting, standing and lifting does not predict LBP or its persistence.
  7. A weak core does not cause LBP, and some people with LBP tend to tense their ‘core’ muscles. While it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren’t needed.
  8. Spine movement and loading is safe and builds structural resilience when it is graded.
  9. Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.
  10. Effective care for LBP is relatively cheap and safe. This includes education that is patient-centered and fosters a positive mindset, and coaching people to optimize their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment).

Manual Therapy

There have been several studies looking at the use of massage therapy for patients with low back. One study published in the Annals of Internal Medicine randomized 401 people with nonspecific chronic low back pain. The control group in the study received usual care and the other two groups received two different types of massage, what this study found was that massage therapy was beneficial for this patient population and there did not appear to be a meaningful difference between the two types of massage that patients received (Cherkin et al., 2011).

Two additional randomized controlled trials demonstrated that a treatment approach focused on the compression at myofascial trigger points (MTrPs) significantly improved subjective pain scores compared with compression at non-MTrPs for patients suffering for back pain (Takamoto et al., 2015Kodama et al., 2019).

Structures to be Aware of When Treating Back Pain

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance, back pain may be caused by disc herniation, spondylolisthesis or soft tissue irritation. Structures to keep in mind while assessing and treating patients suffering from sciatica may include neurovascular structures and investing fascia of:

  • Erector Spinae (iliocostalis, longissimus, spinalis)
  • Quadratus Lumborum
  • Multifidus
  • Thoracolumbar Fascia and Latissimus Dorsi
  • External Obliques, Internal Obliques, and Transverse Abdominis
  • Iliopsoas (iliacus and psoas major)
  • External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior, and quadratus femoris)
  • Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)
  • Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)
  • Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
Someone receiving massage therapy
A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance.

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as routine healthy sleeping habits, Pilates, resistance training and aerobic exercise may be useful for people with back pain (Hutting et al., 2019Owen et al., 2020).


International clinical practice guidelines for low back pain contain consistent recommendations including the need for a multi-modal therapeutic approach, advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids (Kamper et al., 2020). A multi-modal approach can involve a number of management strategies that include but is not limited to education, reassurance, analgesic medicines and non-pharmacological therapies (Chou et al., 2018).

Recommendations from The American College of Physicians and The Canadian Medical Association represent a monumental shift in pain management. Physicians now more than ever are recommending conservative treatment options including massage, spinal manipulation, acupuncture and exercise as part of a multi-modal approach for patients suffering from low back pain (Chou et al., 2017; Qaseem et al., 2017; Traeger et al., 2017)

Massage Sloth: Massage Tutorial – Full Back Massage Routine

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for back pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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