Making Sense of the Management for Lower Back Pain: Insights for Athletes and Active Individuals

Lower back pain remains one of the most common health conditions in our society and it occurs in all demographics and populations. Decades of research has revealed that lower back pain is extremely complex, multifactorial and contextual. We know that various non-communicable diseases such as diabetes, obesity and cardiovascular disease as well as certain lifestyle behaviours such as smoking and inactivity are predictors of who may suffer from low back pain and for how long. However, it’s in populations like yourself – highly active and motivated people or athletes – who also seem to suffer from low back pain regularly. Management of back pain for this population is again, highly contextual.

For those of you who intentionally lead healthy and active lives, or even for those of you who may be professional or competitive athletes, physical activity and sport may be your identity. Therefore, when you suffer an injury – be it back pain or other – you may feel like we’ve been stripped of your identity. Does this ring a bell? I know it does for me personally. The anxiety and uncertainty surrounding any pain or injury can actually amplify pain, lead to fear of activity, and even depression if we truly feel like our identity or livelihood is threatened.

Therefore, whether you’re a professional athlete, eager to get back on the bike or in the gym, or just don’t want to miss another little league practice with your son or daughter, it’s essential that we understand: 1) what back pain is and isn’t and 2) how we can set ourselves up for success if we happen to suffer from low back pain.

The statistics don’t lie. More than 80% of the world’s population will suffer from low back pain in their lifetime, and nearly all of those who experience it once, will experience it again. Low back pain is also prevalent in sport, affecting 18-65% of individuals depending on the sport.

So, let’s not be scared, but rather prepared. You’re already likely doing all the good things that are known to keep you healthy and prevent musculoskeletal pain, but accidents and injuries can happen. That’s life. So, let’s dive in.

Setting the Tone

Despite recent research, technological advances, and increasing access to healthcare, the global burden of low back pain continues to rise and it continues to be the number one cause of disability, globally. A landmark 3-part series on low back pain in the Lancet called this issue a “public health crisis” — not because back pain itself is inherently dangerous, but because the way it is managed too often fuels chronicity, disability, and unnecessary over-medicalization.

For clinicians, coaches, and active individuals, this call to action is both timely and urgent particularly because back pain is common in those taking part in sport, exercise and living active lifestyles. Speaking from experience, I’ve dealt with recurrent low back pain since I was 16 years old. This was originally something I was confused about, but now with my academic and clinical training, I’ve been able to identify why and when periods of low back pain may occur. I’m fortunate to have this training so that I can try to look at these episodes objectively. Obviously, this isn’t the case for everyone.

The Ubiquity of Back Pain and Its Mismanagement

As I mentioned above, roughly 80% of people will experience low back pain at some point in their lives, making it the leading cause of years lived with disability worldwide. While only a small fraction of cases are due to serious pathology such as a spinal fracture, infection, or malignancy, most episodes are classified as nonspecific or mechanical, meaning the exact tissue responsible for the pain is not identifiable and the pain is resulting from something movement related. In a nutshell, this can be joints, ligaments, tendons, muscles and sometimes nerves and discs.

What we know about biological tissue such as bone, ligament, tendon and muscle, is that they become deconditioned and their physiology changes when they aren’t used and moved. Blood flow and oxygenation decrease, tissues stiffen and become more acidic, and healing stagnates. This is why movement-based approaches are at the forefront of evidence-based management of mechanical back pain. This includes foundational movements such as walking, stretching, mobility, yoga, tai chi, resistance training or others, but is typically catered based on the individuals’ interests and needs.

Want to get back on the bike? It may look a little different, but we’ll probably try to mimic cycling in some capacity. Back to running? We may start with immediate walking and progress to an alternating walk-jog. Adapting on the fly and using a bit of finesse with the dose of activity is how we should approach this at first.

What you can take to the bank is that those who are willing to continue engaging in activity in some capacity are actually more likely to recover compared to those who become avoidant or fearful of activity all together. The nuance here is that activity will be need to be scaled back, and then progressed appropriately. It’s not all or none. Exercise is not dichotomous. And don’t be scared of seeking some guidance from a professional of how and where to start.

The Lower Back Pain Management Crisis

Unfortunately, when we seek care in our healthcare system we don’t often receive immediate advice to remain active and education about the nature of back pain. Not only in Canada, but globally, the response to low back pain remains dominated by low value care including over-imaging, excessive medication prescription and surgical interventions, all of which are discouraged as first line management for nonspecific mechanical low back pain. Lack of training, clinical knowledge and expertise, low confidence, and outdated understanding of musculoskeletal management remains pervasive amongst healthcare providers, which continues to contribute to overspending, overwhelmed systems, and evidence-discordant care.

In the Lancet series mentioned above, the authors described this pattern as a “medical tragedy of over-treatment and under-education.” Too many patients are told their pain reflects structural failure —  “disc degeneration,” “arthritis,” “slipped discs” — when, in truth, imaging findings correlate poorly with symptoms in most cases. This structural narrative fosters fear, activity avoidance, and catastrophizing, all of which perpetuate pain and disability.

We don’t need to make people more fearful of doing the things they love, especially if activity is part of their identity. We need to explain the condition and facilitate environments where they feel safe getting back to the things they love, with guidance.

Movement as Medicine

Across plenty of randomized trials and systematic reviews, the consistent message is clear: exercise and activity are the most effective management strategy. This is why movement-based interventions, exercise and providing the advice to remain active are first-line management strategies in US, UK and Danish clinical practice guidelines. Essentially, getting out for a walk is going to do you better than strapping on the TENS unit for an hour.

Whats great is that physical activity also acts as a preventative measure for low back pain in the future. A large Norwegian cohort of over 11,000 adults demonstrated that individuals who walked at least 100 minutes per day had a 23% lower risk of developing chronic low back pain compared to those who walked less than 78 minutes daily.

It’s important to recognize, however, that those in sport, and those of us that are highly active may fall into a unique category. With more activity and more training exposures we may experience more fatigue, higher training volume and cumulative exposures to repetitive movements. With exposure to activity obviously comes some degree of risk of injury – as with anything. So, although physical activity in general is preventative, those of us who are highly physically active may also experience episodes of low back pain. This is just because we’re using our bodies. And honestly, in my opinion this is a “risk” (and I saw “risk” lightly), that we should be willing to take given the immense cardiovascular, muscle, bone, metabolic and mental health benefits we get from training.

So, keep on going. Exercise. Run. Cycle. Play with your kids. You’re doing yourself many favours. If you happen to have pain or injury, seek care. Get it looked at by someone you trust who is an expert in low back pain management. And in the meantime, keep moving within tolerance.

The Biopsychosocial Shift: Context Matters

I want to come back full circle to speak about anxieties and uncertainties that may arise with low back pain. These are so common, and it’s a frequent discussion I have with my patient’s and athletes every day.

Importantly, psychological distress — fear of movement, depression, stress, and low social support – is actually a strong predictor for developing chronic low back pain. But knowledge is power. I tell this to my patients. The earlier we can talk through pain and injury and re-contextualize the injury while coming up with an action plan, the earlier we can get ahead of the issue, and prevent anxiety and maladaptive modifications in behaviours. For you reading this, I hope this knowledge also serves as a cushion of information so you can self-identify if you’re suffering from the stressors of uncertainty. Maybe you have a child who is an athlete who wants to make it to the next level, who you can also share this information with. It may come to serve them.

For example, if you or a loved one is feeling stuck in a cycle or stuck in a flare-up, I want you to ask: what are your stress levels like? Is there outside pressure from coaching staff? Are you in the midst of contract negotiations? How’s your sleep? How's your diet? How’s home life? These all play an important role in recovery from any injury, although they may be seemingly unrelated.  

Rehabilitation: Individualization Over Algorithm

There is no single “best exercise” for back pain. Instead, what matters is consistency, relevance, patient preference and understanding the goals in mind.

Before one gets immediately into sport specific tasks, some may respond best to core stabilization or motor control exercises; others to general resistance training, yoga, or pilates. The important take home is that everything, from day 1 to day ‘x’, needs to be relevant for the patient, and they need to trust that the process will get them back to doing what they love.

If someone online is telling you about “the single best exercise for low back pain”, ignore them.

Do they know what your goals are? Do they know you have a competition coming up in 3 weeks? Do they know that you might be pregnant? Probably not. This emphasizes that everyone’s situation is different, and you must be met where you are by your healthcare professional.

When to Investigate and When to Reassure

High-value care depends on discernment. There is absolutely a time and place for medical investigation and advanced studies, but that time is less frequent than our system makes it seem. Imaging should be reserved for cases with red flags such as significant trauma, neurological deficits, or systemic illness or in cases that are unresponsive to evidence-based care. Again, context always matters.

For the vast majority, reassurance and education are more powerful than scans. When structural findings do appear, clinicians must interpret them within context: the spine is not fragile; it is adaptable.

A Call to Action for All of Us

The future of low back pain management lies not in new machines or miracle procedures, but in returning to fundamentals: movement, education, empowerment, and goal-oriented exercise prescription.

Whether you are a back pain sufferer or not, I hope that this week’s edition of my newsletter leaves you with a little bit more confidence as to the nature of most cases of back pain and the importance of trying to remain active. I must say, that this newsletter is absolutely not a replacement for seeking a thorough assessment from a healthcare provider who specializes in musculoskeletal health, if you are in fact suffering from pain.

Lastly, I want to put forth the thought that occasional back pain is not a failure, but a feedback mechanism and insight into where other areas of your life may need to change. Reflect on your sleep, your nutrition, your training schedule, your stress levels and your relationships and look at it as an opportunity to recalibrate load, recovery, and mindset.

Yours in good health,

Andrew

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