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Low Back Pain: Passive Approaches Result in 280% Higher Recurrence

Across Australia, the cost of low back pain is on the rise, but outcomes are not improving.(1) Part of the problem may be lingering misconceptions of back pain

It was previously held that low back pain (LBP) resolves spontaneously, in a few weeks, in the majority of cases.(2-4) Looking at back pain this way often results in a passive, wait-and-see approach involving mild pain relievers and advice to stay active. The problem is that this passive approach results in a 280% higher recurrence rate. Most back pain cases that seem to have resolved on their own have, in fact, not resolved.

This was demonstrated in studies led by Julie Hides, PhD and published in the medical journal Spine.(5-6) They tracked patients who reported to the hospital emergency department with complaints of first-episode low back pain with a duration of less than three weeks. Patients were randomized into normal, passive care (advice and pain meds) or active physiotherapy. At 4-week follow-up, 100% of the physical therapy group had resolution of their pain, but 80% of the passive group saw spontaneous resolution. The difference came at one-year follow-up. Over the course of the year, 84% of the passive group had recurrence, while only 34% of the physiotherapy group had recurrence.

Interestingly, researchers used ultrasound to measure the multifidi. These are muscles on either side of the spine that provide 2/3 of spinal stability in the low back (L4 / L5) area. At the baseline, in every case, researchers found an atrophied, asymmetrical multifidus muscle on the same side of the back as the pain. At four and ten-week follow-ups, multifidus symmetry had been restored in the physiotherapy group. In the passively managed group, the atrophied multifidi remained roughly 15% smaller than their contralateral comparisons. This was true despite the fact that 80% of the passively managed group had returned to work after six weeks.

To really overcome non-specific low back pain, patients should pursue exercise therapy.   


  1. Australian Institute of Health and Welfare 2016. Impacts of chronic back problems. Bulletin 137. Cat. no. AUS 204. Canberra: AIHW.
  2. Dixon A. Problems of progress on back pain research. Rheumatol Rehabil 1973; 12: 165-75.
  3. Evans C, Gilbert J, Taylor D, Hildebrand A. A randomized controlled trial of flexion exercises, education and bed rest for patients with acute low back pain. Physiother Can 1987; 39: 96-101.
  4. Farrell J, Twomey L. Acute low back pain: Comparison of two conservative treatment approaches. Med J Aust 1982; 1: 160-4.
  5. Hides J, Gwendolen A, Richardson C. Long-term effects of specific stabilizing exercises for first episode low back pain. Spine. 2001; 26 (11): pp e243-248
  6. Hides J, Richardson C, Gwendolen J. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996; 21 (23): 2763-2769.

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