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Physiotherapy & Rehabilitation
Physiotherapy for Lower Back Pain
A surgeon's perspective on physiotherapy for low back pain — why it is the right first step for the great majority of people, and why surgery is the exception rather than the rule.
As a spinal surgeon, one of the most important things I tell people with low back pain is that most of them will not need me. The great majority of low back pain settles with time and active, non-operative care, and physiotherapy — delivered by expert physiotherapists, not by me — is the cornerstone of that care. I am not a physiotherapist, and the design of an individual programme is theirs. My role is to make the diagnosis, exclude the small number of serious causes, reassure, and point people towards the treatment that the evidence most strongly supports. This page explains that from a surgeon's point of view.
For information only — not medical advice. The content on this page is patient education to help you understand a condition or treatment. It is not a substitute for personalised assessment by a qualified clinician. Always consult your doctor or specialist about your own symptoms, diagnosis, and treatment decisions.
What lower back pain usually is
Most low back pain is what is called non-specific — meaning it comes from the ordinary structures of the back (muscles, joints, discs and ligaments) rather than from a serious or dangerous cause, and no single "damaged part" can or needs to be identified. This is reassuring, not dismissive: it means the pain, though real and often severe, is usually not a sign of harm and tends to improve. A small proportion of back pain does have a specific cause that needs investigation or treatment, and part of my job as a surgeon is to recognise those "red flag" situations. For everyone else, the message is that the back is robust and that staying active, guided by physiotherapy, is the way forward.
What physiotherapy involves
A physiotherapist assesses the individual and builds an active programme, usually centred on graded exercise to restore movement, strength and confidence, together with education about the condition and advice to stay active rather than rest. Manual therapy may be used as an adjunct. The emphasis throughout is on the person doing the work, supported and progressed by the therapist. This is not something I deliver — it is the physiotherapist's expertise — but it is what I most often recommend.
Why surgery is the exception
It is worth being direct about this, because people are sometimes surprised to hear a surgeon say it. For ordinary, non-specific low back pain, surgery is rarely the answer and is not what the evidence supports. Operations on the spine are aimed at specific problems — a trapped nerve, instability, deformity, or a structural cause that matches the symptoms — not at back pain in general. When I assess someone, I am looking for whether such a specific, surgically treatable problem exists. Usually it does not, and the honest and evidence-based recommendation is physiotherapy and time, not an operation.
What the evidence shows
The evidence for exercise-based physiotherapy in low back pain is among the strongest in the field. A large Cochrane review of exercise therapy for chronic low back pain found it reduces pain and improves function versus no treatment or usual care, and systematic reviews and meta-analyses agree. International guidelines — the American College of Physicians, and the Lancet Low Back Pain Series — recommend exercise and active care as first-line treatment, and advise against routine imaging, prolonged rest and reliance on medication. This consensus is precisely why I regard physiotherapy, not surgery, as the right starting point for the great majority.
What to expect
Improvement with physiotherapy is usually gradual and depends on engagement over weeks. A physiotherapist will set realistic goals and adjust the programme over time. If back pain does not settle, or if specific warning features develop, that is useful information — it prompts me to reassess and consider whether investigation or, in a minority, a surgical opinion is warranted.
Disclaimer. The information provided on this page is intended for educational purposes only and should not be considered personalised medical advice. Mr Madi is a spinal surgeon; physiotherapy is delivered by qualified physiotherapists. Every patient is different, and treatment options, expected recovery and outcomes depend upon an individual's diagnosis, symptoms, general health and personal circumstances. Decisions regarding treatment should always be made following consultation with your treating spinal surgeon, physiotherapist or healthcare professional.
Evidence & further reading
- —Hayden JA, et al. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev 2021. (PMID 34580864)
- —Qaseem A, et al. Noninvasive treatments for low back pain: ACP clinical practice guideline. Ann Intern Med 2017. (PMID 28192789)
- —Foster NE, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018. (PMID 29573872)
- —Searle A, et al. Exercise interventions for chronic low back pain: systematic review and meta-analysis. Clin Rehabil 2015. (PMID 25681408)
- —Hartvigsen J, et al. What low back pain is and why we need to pay attention. Lancet 2018. (PMID 29573870)
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Every patient is different. The information on this page is a starting point — Mr Madi will tailor any plan to your specific imaging, symptoms and goals.