5 Principles of Low Back Pain Rehabilitation

Welcome back to Squat University! We are currently on a series discussing the common squat injury of low back pain. Treating low back pain is no easy task. This is because there are so many different factors that can contribute to the development of pain in this area of the body. There are some treatments that may decrease pain in one person while the same movement may further the injury in another. For this reason, discussing specific treatment options for this injury can be very complex.

While the key to successful treatment of low back pain requires a proper diagnosis (the topic of last weeks lecture blog), there are several principles that should be considered when designing any program for someone with this injury. Today I want to share with you 5 key principles to treating low back pain.

  1. Reduce Pain
  2. Enhance Stability
  3. Restore Hip Mobility
  4. Normalize Movement Patterns
  5. Gradually Progress Back to Activates

Reduce Pain

When we are in pain, certain muscles in our body subconsciously shut down. The more pain we are in, the more our body unconsciously protects itself by limiting muscle activity (1). This means your athletic performance is automatically influenced and hindered if you have low back pain.

Medical professionals routinely use medication, electrical stimulation and ice (cryotherapy) to quickly reduce pain. In recent years there has been a backlash against the use of cryotherapy. Some of the criticism is well deserved. This is because many athletes today inappropriately use ice as a Band-Aid for sore muscles and achy joints. However, this type of treatment should only be reserved for treating injuries.

Ice on Knee.jpg

When we sustain an injury to our low back, specialized nerve endings called nociceptors are activated. These nerves transmit signals to the brain, which then recognizes the sensation as pain. When we apply ice to the injured area (either with a cold pack or ice massage), another set of nerve endings called thermoreceptors are activated. These nerves block the pain signaling process from the nociceptors (2). Cryotherapy also reduces muscle spasm and tissue metabolism (2). Theoretically, applying ice after an injury will limit further damage.

If you sustained a recent low back injury, don’t be afraid to apply ice to this area for 15-20 minutes. While this will not completely fix the issue, it can be a crucial part of a comprehensive treatment plan.

Enhance Stability

Dr. Stuart McGill, renowned expert in spine biomechanics, has a great analogy for explaining how each muscle of the core contributes to creating efficient stability. Suppose you take a fishing rod and stand it vertical with the handle on the ground. If you place a small load on the top of the rod, it will easily bend and buckle. The same goes for our spine. Without any help from the surrounding muscles and other soft tissues, the lumbar spine will buckle under 20lbs of compressive load (3).

However, take the same fishing rod and now attach guy wires at different levels in a circular pattern. Right away stability of the fishing rod is enhanced. The muscles of our body act just like the guy wires to prevent buckling of our spine. If one muscle (or guy wire from the fishing rod analogy) is not working correctly, stiffness of the entire spine is lost and injury can eventually occur.

core stability .png

Spine stability comes from the muscles and their ability to stiffen under load. Retraining the body to create this stability in a synchronous action is therefore a crucial step to the rehabilitation process. To find some of our favorite core stability exercises, check out the article “The Squat Fix: Core Stability.

Restore Hip Mobility

The “Joint-by-Joint” concept coined by Gray Cook and Mike Boyle is a simple and straight-forward way to understand the human body. Simply put, each joint complex of our body has a specific job to do in order for efficient movement to take place.

Joint By Joint

The hips are an area of the body that shows a tendency to benefit from increased mobility due to its inclination to become immobile and stiff. As we get older, our hips tend to stiffen due to lack of use and oftentimes from a sedentary lifestyle. If you don’t use the mobility, you lose it. If the hip loses its mobility it will affect the role of the joint complex directly above (the low back) and below (the knee).

In fact, research has shown that low back pain can be attributed to a lack of hip mobility (4). For this reason, it wouldn’t matter how much strength and stability work you perform on the core. If hip mobility is never addressed, no significant long-term improvements will be found. To check out our few of our favorite ways to improve hip mobility, check out the article “The Squat Fix: Hip Mobility Pt. 3.”

Normalize Movement Patterns

People dealing with low back pain often move differently as a protective mechanism to limit the onset of additional pain. In doing so, certain muscles other than the muscles of the back itself will be affected (1).

Research has shown the activity of our glutes to be commonly reduced in those with chronic low back pain (5). Emphasizing the activity of the glutes during functional movement is therefore a key part of the rehabilitation process. This starts by learning how to properly hip hinge during the squat.

Correct Squat %22Hips First%22

By pushing the hips back at the start of the squat, you effectively engage the glute muscles. A hip hinge is useful not only with barbell training but with functional movements of daily life such as sitting down in a chair or bending over to pick up a heavy box from the ground.

I find that some of my older patients say that they don’t need to learn how to squat. My simple answer to that is “how do you get up and down from a toilet???” Maintaining glute strength is crucial for the health of our low back. On top of the hips stiffening as we get older, our glute muscles tend to atrophy as well. We have to do our best to maintain both hip mobility and glute strength as we age.

Gradually Progress Back to Activities

As progression is made in all other aspects of the rehabilitation process for low back pain, there should be an eventual return to activities that resemble the demands of daily life and athletic training. The exercises used should provide enough stress to the body to adapt to the higher demands of barbell training but not so much as to hinder the healing process. For this reason, returning to heavy barbell training too soon can overstress healing structures/tissues and delay the rehabilitation process.

As barbell squatting is re-initiated the volume and intensity of training should be slowly progressed in a step-by-step manner. Each person will return to his or her previous level of strength and performance at a different rate

Final Thoughts

Treating low back injuries is never easy. However, I hope these principles can be helpful in establishing a treatment plan regardless of diagnosis. I highly recommend seeking out a health care professional (such as a physical therapist) when your low back pain is not getting better with these tools.

Until next time,

Dr. Aaron Horschig PT, DPT, CSCS, USAW


Kevin Photo

Dr. Kevin Sonthana PT, DPT, CSCS



  1. Verbunt JA, Seelen HA, Vlaeyen JW, et al. Pain-related factors contributing to muscle inhibition in patients with chronic low back pain. An experimental investivgation based on superimposed electrical stimulation. Clin J Pain. May/June 2005; 21(3): 232-240
  2. Nadler SF, Weingand K, & Kruse RJ. The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. A narrative review. Pain Physician. 2004;7:395-399
  3. Lucas D, Bresler B. Stability of the ligamentous spine. Tech report no 40. Biomechanics Laboratory. University of California, San Francisco. 1961
  4. Roach SM, San Juan JG, Suprak DN, et al. Passive hip range of motion is reduced in active subjects with chronic low back pain compared to controls. Int J Sports Phys Ther. 2015 Feb; 10(1):13-20
  5. Leinonen V, Kankaanpaa M, Airaksinen O, et al. Back and hip extensor activates during trunk flexion/extension: effects of low back pain and rehabilitation. Arch Phys Med Rehabil. Jan 2000. Vol 81: 32-37

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9 thoughts on “5 Principles of Low Back Pain Rehabilitation

  1. Saw your youtube video, figured I’d drop a comment in regards to back pain and addressing the potential build of adhesion that may be causing that pain. Love to get some dialogue going to get our wheels spinning.

  2. I am grateful to be learning about what to do to ease back pain. I did not realize that there were steps to rid this pain including enhancing stability and restoring hip mobility. I have heard that doing at home exercises everyday as well as seeking help from an orthopedist can offer remarkable results.

  3. Hi Dr Arron – MRI scan showed big disc bulge L4L5 left sided protrusion no nerve root compression – had 3/4 months off trap bar deads but slowly went back but LBP been persistent 12 sessions physio not much improvement – never stopped training but made adaptations – am 47 year old female best lift 120kgs 4 weeks ago 1 rep – finally took 2 weeks off (just) and back seems better – have sedentary job but do 2 hiits a week 2 vinyasa flow yoga n 2 strength plus 10,000 steps most days – want to get back to big lifts any advice? Not been given prognosis had symptoms 11 months declined steroid injections or surgery in favour conservative treatment any advice very welcome many thanks in advance Ginnene Cornwall

  4. Back pain is very dangerous. Students should be careful when playing sports and generally concentrate more on the educational process. I can advise you of a great website that will solve all your problems with laboratory report, I think this will help you to save your time and spend it with benefit.

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