Written by Dr. Amy Mackinnon, Chiropractor | Vital Performance Care | Calgary, AB
Low back pain is the leading cause of disability worldwide. At any given time, roughly one in four Canadians is dealing with it. Most episodes are short-lived, they resolve on their own or with minimal intervention within a few weeks. But for a significant portion of people, back pain becomes persistent, and the treatment pathway becomes expensive, frustrating, and often ineffective.
I see this in practice constantly. People who have had back pain for months or years, who have seen multiple providers, who have had imaging, who have been given advice that ranges from "just rest" to "you'll need surgery eventually," and who are no better, and sometimes considerably worse, than when they started.
A lot of what is still being communicated to people with low back pain does not reflect what the research actually shows. This post is an attempt to closesome of that gap.
Most Low Back Pain Has No Specific Structural Cause
This is perhaps the most important and most poorly communicated fact in low back pain management: approximately 85–90% of low back pain is classified as "non-specific," meaning no identifiable structural cause can be found, or the structural findings present do not adequately explain the pain.
This does not mean the pain is fabricated or exaggerated. It means the reductive model, find the damaged structure, fix the structure, eliminate the pain, does not apply to the majority of low back pain cases.
Yet the majority of people with low back pain are subjected to imaging that finds "abnormalities," told those abnormalities explain their pain, and treated as though fixing those findings will resolve the problem. The research says this approach is not working. The rates of low back pain and associated disability have not improved despite massive increases in imaging, injections, and spinal surgery over the past several decades.
What Imaging Can and Cannot Tell You
Imaging low back pain is appropriate in specific circumstances, when red flags are present, when there's suspicion of serious pathology, when neurological deficit needs to be characterized. For most people with low back pain, routine early imaging does not improve outcomes and often makes them worse.
The reason: imaging finds things. And most of what it finds is normal aging, disc desiccation, facet joint changes, disc bulges, mild foraminal narrowing, that is present in a large proportion of pain-free people. When those findings are presented as explanations for pain without context, they become nocebo inputs (as covered in a previous post) that increase fear, catastrophizing, and avoidance of movement.
One landmark systematic review found disc degeneration in 37% of asymptomatic 20-year-olds, rising to 96% by age 80. Disc bulges were present in 30% of pain-free 20-year-olds, rising to 84% by age 80. These are not diseases. They are age-related changes that coexist with perfectly normal, pain-free function in the vast majority of people who have them.
Telling someone with low back pain that their scan shows "significant degeneration" without explaining that their 55-year-old neighbour with no back pain has the same finding is not always helpful. It can be harmful.
What the Evidence Says Actually Works
The evidence base for low back pain has shifted substantially over the past two decades. The treatments that have the best evidence for reducing pain and improving function are not the ones that are most commonly recommended.
Staying active is consistently one of the most effective interventions for low back pain. Not bed rest. Not complete avoidance of activities that are uncomfortable. Active movement, walking, swimming, progressive loading, has better outcomes than rest at virtually every timepoint in the research.
Exercise and graded loading, progressive resistance training, core strengthening, and general aerobic exercise, produce meaningful reductions in pain and disability, particularly for persistent low back pain. The body adapts to load. A spine that is gradually, progressively exposed to increasing demand becomes more resilient, not more vulnerable.
Manual therapy, chiropractic manipulation, mobilization, soft tissue work, acpuncture and needling, has good evidence for short-term pain relief and improving function, particularly when combined with exercise and education. It is most effective as part of a broader approach rather than as a stand-alone treatment.
Pain neuroscience education, helping people understand what pain is, why it persists, and what they can do about it, consistently improves outcomes in persistent low back pain. Patients who understand pain move more, fear less, and recover more completely.
What does not have strong evidence for most people with non-specific low back pain: prolonged rest, opioid medication, passive treatment only (massage or manipulation without exercise), and early surgical intervention for non-specific presentations.
The Role of the Nervous System in Persistent Back Pain
For back pain that has persisted beyond the expected acute phase, beyond 3 months, the contribution of central sensitization and nervous system sensitization is significant and often underaddressed.
Persistent low back pain is not simply a structural problem that has failed to resolve. It is a pain system that has remained on alert, one where the inputs to pain have expanded beyond the original tissue signal and now include stress, sleep disruption, fear of movement, and the accumulated weight of months or years of a pain experience that hasn't been understood or properly addressed.
This is why purely structural treatments have a ceiling. Treating the disc, the facet joint, or the muscle in isolation without addressing the nervous system, the psychology of the pain experience, and the patient's activity patterns produces incomplete results. The spine is embedded in a nervous system, which is embedded in a human being with a life, and treating all of those dimensions is what effective low back pain management looks like.
Red Flags: When Low Back Pain Requires Urgent Assessment
The vast majority of low back pain does not require emergency evaluation. But there are presentations that do, and it's important to know them.
Seek urgent care if your back pain is accompanied by:
🚩 Loss of bladder or bowel control (potential cauda equina syndrome, this is a medical emergency)
🚩Progressive neurological weakness in the legs
🚩Numbness in the saddle area (inner thighs, perineum)
🚩Severe pain following significant trauma
🚩Back pain with unexplained weight loss, fever, or a history of cancer
🚩Pain that is constant, non-mechanical, and progressively worsening without any positional relief
These presentations require medical assessment before any other management. If you're uncertain, it is always appropriate to ask.
What Good Low Back Pain Care Looks Like
A first appointment for low back pain should involve a detailed history, a thorough physical examination, and an individualized explanation of findings, not an order for imaging, a generic exercise sheet, and a referral to rest at home.
At Vital, an assessment for low back pain involves understanding the clinical picture in full: where the pain is, how it behaves, what's happening in the nervous system, what hasn't worked before and why, and what a realistic, progressive plan toward improvement looks like. Sometimes that means chiropractic treatment. Often it means coordinated care, a combination of manual therapy, exercise progression, and education. Occasionally it means referral to rule out serious pathology or to access other services.
The goal is never to manage your back pain indefinitely. It's to give you enough understanding and capacity that you're managing it yourself, and doing it well.
Book a complimentary 15-min consult with Dr. Amy →
References
Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–2367.
Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816.
Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368–2383.
Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–S15.
Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16(9):807–813.
More About The Author
Amy MacKinnon, Co-Founder of Vital Performance Care
Dr. Amy MacKinnon is the co-owner of Vital Performance Care, Coven Health Collective, and Coalition Health Group. A former varsity soccer athlete turned chiropractor, she works with athletes and individuals across all levels, from grassroots to Olympic and professional sport.
Amy has served as Performance Director for multiple sport organizations and worked internationally with Bobsleigh Canada Skeleton, including at the 2018 PyeongChang Olympic Winter Games. Her work is grounded in community, connection, and bridging therapy and performance to help people move and live better.