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Chronic Non-Specific Low Back Pain

Rehabilitation clinical resource for Clinical Exercise Physiologists (CEPs)

Clinical Profile

Low back pain persisting 3+ months with no clear pathological cause1 (age-related 'degeneration' is common in pain-free people).2 Often limits sitting, bending, lifting and ADLs, and can be maintained by protective bracing, reduced movement variability, and belief that pain equals damage.3

CEP role: Using Te Whare Tapa Whā framework4, co-develop a personalised, evidence-based exercise plan with the client and whānau (taha whānau) to support return to full function (taha tinana), address pain beliefs (taha hinengaro), and meet the client's goals (taha wairua).

Rehabilitation Phases

1Create safety
Reduce bracing through safe positions and breathing. Increase movement variability and confidence.
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2Graded exposure
As per phase 1 + graded exposure to threatening positions, reducing bracing and increasing tolerance.
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3Return to ADLs
Build on phase 2 to increase load, build tolerance and endurance for ADLs.

Exercise Selection

Exercise improves chronic LBP; differences between modalities are small, so adherence matters more.5 Choose an enjoyable and symptom-relieving exercise (e.g., walking)6 and encourage client to continue with it.

Phase and exercise progression occurs when the client can do exercises with minimal pain (0-3/10) that settles within 24 hours, and without bracing or compensation.1

Assessment

Functional assessments selected based on the client's ADLs and goals. Examples: sit-to-stand, hip-hinge lift, gait.

Patient-reported outcome measures:

  • ODI: tracks LBP impact on ADLs; use to identify functional limitations & track improvement.7
  • PCS: tracks pain catastrophising; higher scores predict worse outcomes. Address with pain neuroscience education, consider referral.8

Red Flags

Stop & refer
New or progressive neurological deficit; unremitting night pain; unexplained weight loss, fever or cancer history.
Emergency
Cauda equina symptoms: saddle anaesthesia, bladder/bowel incontinence, bilateral leg weakness or numbness.

Acronyms: ADLs Activities of Daily Living; LBP Low Back Pain; ODI Oswestry Disability Index; PCS Pain Catastrophising Scale.

References

  1. Tuninetti, A., Barbari, V., Storari, L., Bisconti, M., Piano, L., Dunning, J., Mourad, F., & Maselli, F. (2025). Therapeutic exercise progression in patients with nonspecific low back pain: A systematic review. Journal of Pain Research, 18, 6397–6407. https://doi.org/10.2147/JPR.S539160
  2. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173
  3. O'Sullivan, P. B., et al. (2018). Cognitive functional therapy: An integrated behavioral approach for the targeted management of disabling low back pain. Physical Therapy, 98, 408–423. https://doi.org/10.1093/ptj/pzy022
  4. Durie, M. (1994). Tirohanga Māori — Māori health perspectives. In Whaiora, Māori health development (pp. 67–81). Oxford University Press.
  5. Hayden, J. A., et al. (2021). Some types of exercise are more effective than others in people with chronic low back pain: A network meta-analysis. Journal of Physiotherapy, 67, 252–262. https://doi.org/10.1016/j.jphys.2021.09.004
  6. Vanti, C., Andreatta, S., Borghi, S., Guccione, A. A., Pillastrini, P., & Bertozzi, L. (2019). The effectiveness of walking versus exercise on pain and function in chronic low back pain: A systematic review and meta-analysis of randomized trials. Disability and Rehabilitation, 41(6), 622–632. https://doi.org/10.1080/09638288.2017.1410730
  7. Fairbank, J. C. T., & Pynsent, P. B. (2000). The Oswestry Disability Index. Spine, 25(22), 2940–2953. https://doi.org/10.1097/00007632-200011150-00017
  8. George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., & Norman, K. S. (2021). Interventions for the management of acute and chronic low back pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1–CPG60. https://doi.org/10.2519/jospt.2021.0304