I polled my readers several weeks ago asking them what they thought the tissue source was in low back pain?  Thanks to everyone who responded and provided feedback!  Results are:

tissue source in low back pain
tissue source in low back pain

An overwhelming winner at 41% “none: pain does not equal tissue damage”

So my next thought is: with this rationale, how would you treat an individual coming into your office?  I know this is a loaded question which varies from patient to patient, but everyone has their “go-to” treatment.  What is your typical “talk” that leads to an active recovery?




  1. Per the clinical practice guidelines for low back pain, if someone comes in with non-specific low back pain I try to reaffirm the benefits of active rehabilitation and reiterate the structural prowess of the spine to help debunk the “I have a sore back and should do anything to cause more pain/more tissue damage” myth. Also, taking a pain science perspective, spending the first session just speaking to them about 1) what pain is, but more importantly 2) what pain isn’t can help to deal with fear avoidance beliefs and thought viruses that perpetuate their unwillingness to engage in activity. Along the lines of activity, I discuss graded exposure and pacing so they aren’t overdoing it and have a boom bust cycle to activity induced pain. I also discuss he benefits of manual therapy but rather than using pathoanatomical language like I pnce did (I’m going to gap this joint to help improve the slide/glide of the joint”) I rather discuss how manual therapy helps augment the active rehabilitation by reducing the threat causing the pain experience and helping them to move better

    1. Great points Steve! Thanks for the feedback. I really like the “boom to bust” metaphor…as patients can overdo ADLs and have a spillover effect.

      We both agree that a combination of non threatening movements, patient education, and manual therapy to calm down the system work well together.

  2. An active approach to recovery is valid regardless of the exact source of chronic “non-specific” low back pain. Patient education, graded exposure, motor control training, exercise and manual therapy are my go-tos.

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