What causes lower back pain?

This episode is entitled ‘what causes lower back pain’. Now in this episode you will learn why the ‘misaligned vertebra’ or ‘bone out’ theory is wrong and how it’s holding you back, why diagnoses are often unhelpful and what is better. And finally, what the real causes of lower back pain are.

Bone out of line/ Misaligned vertebra

So firstly, what about ‘this bone out’ theory, having been a practitioner for 28 years, specializing in lower back pain and sciatica, I have lost count of the number of times people have referred to ‘their spine being out of line’ or ‘I think I slipped a bone out’. But this theory has generally has been perpetuated by other healthcare practitioners, especially those in the physical therapies.

So why is it wrong?

Well, it’s simply wrong because there is no evidence that having a bone out of line or indeed a group of bone’s out of line is related to symptoms. As an example, there’s lots of evidence that people are walking around with disc prolapses and degenerative changes in their spines without any pain at all. So if you can have a fully prolapsed disc without any pain, should it make any difference if one vertebra is marginally misaligned compared with its neighbours? No, it doesn’t.

Gavin’s anecdote

And there’s an example of this because I know we all like stories. Many years ago I was in a shopping mall waiting for someone. I had a bit of time to kill and I saw a (unnamed) physical therapist with a stand up. Offering free spinal checks. And I was intrigued as to what this other healthcare professional was doing. What their modus operandi was.

I went along and sat in a small, rapidly moving, queue to have my spine checked. Although I won’t go into the details of what that involved. It certainly didn’t involve x-rays. Just somebody running their hand down my back to feel my spine. I was told that I had a number of problems in my spine. All of them to do with bone’s being misaligned. But if I signed up today, I could get 10% off a course of 10 treatments, which would sort me out.

Now, not only was I not convinced I had any bones out. I certainly had no pain. At no point did the practitioner asked me if I had any pain. Even if I did have bones out, which I reckon I didn’t, they certainly weren’t correlated with pain. So ‘bone out’ theory discredited across all professions and any decent practitioner will not be talking to you about the bone being out of line.

In practice

Now hands up in embarrassment here. If a patient has come to me and said, “Oh, I’ve got this bone out in the middle of my back and I need it manipulated and I’ll feel much better, and that’s what’s happened in the past”. Over my years in practice, if it’s obvious they have a very strong belief about this, I will just let this discussion slide. After making a full assessment and I will determine whether manipulative techniques or other techniques are appropriate. The client and I will decide how to proceed. But if you’ve been to a practitioner and told them that you have a bone out, but they’ve continued to treat, the important thing is do you feel better afterwards? Perhaps as importantly, it’s really vital that the physical therapy professions do not perpetuate this myth of the ‘bone being out’.

Diagnoses are unhelpful

Moving along from the bone out theory, why are diagnoses often unhelpful? And what is better? Well, this is closely related to the bone out theory. As mentioned earlier, lots of people are walking around with imperfections. If we sent you for an MRI or an x-ray, we would see that things are not straight. That perhaps you have some degenerative changes in your lower back. You may even have the odd disc bulge or prolapsed disc, but you have no symptoms. Now, maybe not. You might not because you probably wouldn’t be reading this if you didn’t have symptoms. However, there are lots of people walking around with these imperfections and yet no symptoms.

Making what we would call a structural diagnosis is often unhelpful, particularly because it makes you very focused on something physically being wrong with your back. And the research shows that providing a structural diagnosis tends to lead to a longer term period of suffering. Now this is after all other variables have been taken into account. But basically what I’m saying is that after all other things have been considered, it’s important not to focus too much on structural deformities, misalignments and all these other possibilities in your back. This links back to episode 6 and the pain equation – particularly attention to body part (ATBP).

P = (N – MWP) + (NO – PO) + (ATBP) + (PVOP)

A better alternative- functional labels

What is much more helpful here is having what I describe as a functional label. So a functional label describes what is wrong with you. The duration and nature of symptoms, and the way your back is working. Therefore it’s empowering because it helps you to decide, and us as clinicians, what you should and should not be doing.

Here is an example of a functional label-

Acute, Recurrent, Flexion Intolerant Lumbago

This is probably one of the most commonly used in my practice because it’s generally the most commonly seen collection of symptoms and patterns. Let’s break that down.


Acute simply means less than six weeks. So you’ve had the symptom for less than six weeks. People often think acute refers to severity and you might use it for that means. But we as practitioners have a format. Subacute means between six and 12 weeks and chronic means more than 12 weeks. So acute, subacute and chronic refer to the duration that you’ve had the symptom.


Recurrent means you’ve had more than one episode of this pain in the last year in addition to the one you’re currently having. So more than one previous episode in the last 12 months. Non recurrent we tend not to use.

The way your back is working

Flexion intolerant means your back doesn’t like bending forward. Flexion means bending forward. Intolerant means it doesn’t like it, I. E. it produces more pain and this is very common in people who sit. When you sit your back tends to drop into relative flexion/ bends forward and either while you’re sitting or when you get up from the chair it will be more painful. That means your back is flexion intolerant.

Which part hurts

Lumbago is an old, old term that simply means pain in your lower back. This part of the label indicates where the pain is. Other labels we use include NNCS and NCS.

So there we have it. Acute, recurrent, flexion intolerant lumbago. You’ve had it for less than six weeks. You’ve had it before in the last 12 months. It’s worse for bending forward and it’s just a pain in your lower back. ‘Just’ meaning as opposed to anywhere else as well as your lower back. That is a functional label and it helps us as practitioners to know what techniques to use to help you to get better.

Most importantly this informs us as to what to advise in terms of what you should and should not be doing. For example, those who are flexion intolerant should avoid bending forward. This is the movement that causes the most pain and should be avoided- as discussed in episode 6. Movement without pain inhibits the pain pathway and perception of pain. Moving without pain will speed up the healing process.

What causes lower back pain?

To explain what causes lower back pain, lets refer you back to episode one. The first of those six pillar episodes. Where I introduced the cliff of pain theory. And if you haven’t started at number one in this podcast but you are a sufferer of lower back pain, I would really encourage you to go back and start at the beginning. So the cliff of pain, simply means you are travelling along fine, fine, fine, fine, fine in life and then all of a sudden you fall off that cliff. Now the thing that knocked you off the cliff is merely a trigger. It’s the last thing that happened. It generally isn’t really the cause of lower back pain because it’s something you’ve done many times before without back pain. The real causes are the things that have pushed you closer to the edge, those risk factors.

Risk factors

Having previous episodes

The first one is having had it before, which is why it’s so important that we note that this is recurrent. If you’ve had lower back pain before, you are at a much increased risk of having it again.

Lack of physical activity

Second biggest risk factor for lower back pain is a lack of physical activity. This is for various reasons, weight gain due to lack of activity being one.


And then we have loading. So in terms of loading, I don’t necessarily mean carrying extra weight, I just mean carrying any weight including your own body weight. So loading can be split down into heavy loading.

So what we call peak loading. Sustained. Staying in one position for a long period of time. Or you keep doing the same thing again and again. For 72% of our client base sitting is a big factor here and it may be for you too. Sitting is sustained. You do it for a long period and it’s repetitive. For many people they will do it five days a week and more seven days a week. So loading is a big issue.

Poor trunk muscle endurance

Poor trunk muscle endurance, whether you want to call that core stability or just that clunky term, poor trunk muscle endurance. This can also be a result of lack of physical activity.


Stress, especially work related stress as a risk factor for lower back pain. As well as low mood, anxiety and depression. This links back to the pain equation from episode six. Which explains how mood fits into the severity of pain that you experience (positive and negative outlook).

Other factors

Lack of sleep can be a risk factor. As mentioned above, being very overweight is a risk factor for lower back pain. And, unfortunately, being over 40 is also a risk factor.

In this episode ‘what causes lower back pain’ we have discussed how diagnoses and the age old ‘bone out’ theory can be unhelpful. As these make us believe something is wrong and we begin to ruminate on this idea. This added attention to the body part will increase pain. What is more helpful is giving the pain a functional label which will help practitioners tailor advice and treatment specifically to your symptoms. And, finally, the real cause of pain- the risk factors outlined above. These cause us to fall off the cliff into the sea of lower back pain.

If you haven’t listened to Episodes 1-6 – our pillar episodes – please go back and start at the beginning!  It will lay the foundation for you to make a long-term, sustainable recovery.

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