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How to Train Clients With Low Back Pain

Low back pain is the leading cause of pain and disability worldwide. Globally, the prevalence of low back pain has increased 54 percent between 1990 and 2015 [1]. In light of this, it is naive to believe we are doing a better job at managing low back pain through protective messaging and training.

To me, this means that we need to change own beliefs about the spine and low back, so that we can properly coach, educate and empower our clients — low back pain or not.

Global burden of low back pain in disability adjusted life-years by age group [1]

Get Rid of Old Beliefs

In fitness, the first step is a basic conceptual change about biomechanics: understanding that, for most people, they are less important than we once thought [2,3]. We need to stop promoting the belief that people will break when they’re put under load in a way that doesn’t look good.

This fear and pathologization of movement is making a big problem worse, and perpetuating myths about our bodies through something called the nocebo effect (more on that later).

We can train ourselves to do almost anything — ask any dancer! — under any movement pattern and any load. The risk of injury is dependent on far more than just how we move.

Most people get injured doing things they’re not properly prepared for, versus doing things that don’tlook quite right.

In the world of physical therapy and fitness, where the longstanding tendency has been to optimize movement and performance through “safe” biomechanics, this tends to make people uncomfortable.

Don’t get me wrong here: optimizing performance is something we can still foster, but never at the cost of pathologizing movement.

Several studies have shown that spinal flexion cannot be avoided, even when working to keep the spine in a “neutral” position with activities like the deadlift, the squat, good mornings and kettlebell swings [4-7]. If such movement cannot be avoided, no matter the loads or conditions, why do we pathologize it and teach people this will systematically result in low back pain?

If a deadlift is pain free, seek to make progress in performance, instead of assuming injury. I am lifting 125 pounds in each example completely free of pain and injury. Since this is the case, knowing my goals with this lift is more valuable than setting the expectation that this will hurt me.

Change Your Language

Fear and limiting beliefs about the fragility of the spine are hurting our clients, plain and simple. With that in mind, the next step in training clients with low back pain, would be to be mindful of our use of language.

People with low back pain need to hear reassuring, positive and empowering language, even in coaching cues. That means using language that does not scare or cause judgment but rather uses the power of suggestion for good.

Time and time again, I find myself working with women who are fearful of returning to the gym. Why? Because every time they went, they were told they were doing something “wrong.” This fear-mongering gym culture and the language that surrounds it are hurting women everywhere and contribute to our sense of fragility.

If this something we can control and work to improve, don’t you think women of the world would benefit?

This brings me back to something I mentioned earlier called the nocebo effect. The nocebo effect is when the power of suggestion causes harm. This happens through setting negative expectations of injury using threatening language or suggestive communication [8-11].

The nocebo effect is very real and very harmful, in particular for women who have been shown to respond more strongly to nocebos compared to their male counterparts [12].

Avoiding flexion is difficult even when attempting not to flex the lumbar spine [4]. While this is still widely debated in the literature, the impact of certainty in lifting mechanics serves as nocebo for many people and leads to hyper-vigilance and overprotective behavior that hinders performance.

As coaches, trainers and physios, we have an incredible opportunity to keep people from becoming unnecessarily medicalized, and to empower them to stay active and strong in ways they enjoy.

This means forgoing scary or potentially threatening language in our conversations with our clients and in our coaching cues, and choosing to communicate in ways that build a person’s positive beliefs about themselves and enhances their resiliency in the process.

One of the best things you can do for your clients is shift to positive, affirmative, reassuring language, and find ways to reminds them that they are strong, that their spines are robust, that they will recover, and that you are in their corner to help them reach their goals.

Some Examples

Instead of discouraging your client (“That looked terrible. You have the weakest core I’ve ever seen”), use empowering language instead:

“You’re so strong. Your spine is a stable, robust structure.”

Replace negative statements (“That looked terrible. Stop right now or you’ll get hurt.”) by positive ones:

“That looked awesome. Good job. I’m so proud of you.”

Rather than zooming in on faults (“Your feet are flat and that’s why you have back pain.”), find ways to compliment your client.

“You are so incredible!”

Instead of making your client believe they have no options (“There’s only one way to do this and you’re doing it wrong.”), work to offer choices:

“You can do this a number of different ways, I’ll let you choose.”

Eschew scare tactics (“My dad has had back pain for 20 years, you better get checked.”), and choose to reassure your client:

“It’s going to be OK. You will adapt and get better.”

Once you’ve obtained the trust of your client through reassuring and positive language, you’ll want to work to find ways to keep them enjoying the activities they want to do — even in pain — and this is best achieved through activity modification.

Go for Modification, Not Avoidance

Activity modification is valuable for many people who are struggling with low back pain, but never at the cost of complete avoidance.

We know that avoidance often leads to deconditioning, which can lead to more distress and ultimately becomes a ripe environment for ongoing and persisting pain.

As with any training task, repetitive conditioning, graded exposure and consistency are key when working with a person experiencing low back pain. That means helping people with low back pain grade their exposure to tasks that will foster resiliency.

Modifying activities is a great starting point for many people. Often, this means unloading the activity that is most bothersome and recommending they perform it more frequently at the lower loads — essentially exposing them to the task more regularly so that they become more tolerant and resilient to that task.

If removing some of the load is still not tolerated, finding a way that person can perform the same exercise in a different capacity is precisely where you’d want to take things. But again, always with the expectation that you’ll return to the bothersome task when they feel ready and when acute symptoms have largely resolved.

Deadlift modifications for people with low back pain

For example, with something like the deadlift, moving from conventional stance to sumo stance could be a relevant modification. The sumo stance brings a person lower to the ground and tends to be a less threatening movement for most folks dealing with low back pain.

We have the power and responsibility to use our knowledge for good when training clients with low back pain. Show clients where they are strong, where they excel and pay them compliments that foster their confidence.

Educate yourself about the robustness of the spine. Know that it is not a body part to be feared, but rather revered. It is a sturdy and stable part of our bodies.

People with low back pain need you.

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  2. Dreischarf M, Rohlmann A, Graichen F, Bergmann G, Schmidt H. In vivo loads on a vertebral body replacement during different lifting techniques. J Biomech. 2016;49: 890–895.
  3. van Dieën JH, Hoozemans MJM, Toussaint HM. Stoop or squat: a review of biomechanical studies on lifting technique. Clin Biomech . 1999;14: 685–696.
  4. Holder LJ, AUT University. Faculty of Health and Environmental Sciences. The Effect of Lumbar Posture and Pelvis Fixation on Back Extensor Torque and Paravertebral Muscle Activation: A Thesis Submitted to Auckland University of Technology in Partial Fulfilment of the Requirements for the Degree of Master of Health Science (MHSc), 2013.
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  6. Vigotsky AD, Harper EN, Ryan DR, Contreras B. Effects of load on good morning kinematics and EMG activity. PeerJ. 2015;3: e708.
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  9. Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open. 2013;3: e002654.
  10. Evers AWM, Colloca L, Blease C, Annoni M, Atlas LY, Benedetti F, et al. Implications of Placebo and Nocebo Effects for Clinical Practice: Expert Consensus. Psychother Psychosom. 2018;87: 204–210.
  11. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11: 527–534.

Vambheim S, Flaten MA. A systematic review of sex differences in the placebo and the nocebo effect. J Pain Res. 2017;10: 1831–1839.


About The Author: Dr. Ellie Somers

Dr. Ellie Somers is a physical therapist of 10 years, with a special focus on treating the female athlete. She has a background in sports performance and rehab, including extensive training and education in the science of pain. She started her practice, Sisu Sports Performance & PT, in Seattle, WA with the goal of empowering female clients to help them reach their unlocked potential. She hopes to keep women actively engaged in sport and activity for their lifetime. Dr. Somers has spoken at the Women in Physical Therapy Summit in New York City as well as at several continuing education courses and professional conferences. She is a lover of soccer, running, heavy things, craft beer, and the great PNW. You can follow Dr. Somers on Facebook, Instagram, and Twitter!