A likely story
There's a strategy that works extremely well in health marketing: tell a simple, tidy, convincing story. You're out of alignment, your back's in a bad way. I'll sort you out. It's reassuring, it makes sense of everything, and it often comes at a steep price.
The trouble is, that story rarely reflects how the body actually works.
Working with complex systems like the body requires something less comfortable: the honesty to explain that there's no perfect architecture to restore, that the body adapts, and that the process is messier than we'd like to believe.
That's less reassuring than a story with a simple cause and a quick fix, but closer to the truth.
"I'm falling apart."
"I've been told my back is in terrible shape. I'm falling apart."
Maura was 65 when she first came to the clinic. Climbing stairs had become a monumental task. She gripped the handrail with both hands, stiff as a board, terrified of falling, as if there were a raging river beneath her rather than three ordinary steps. Yet it was obvious she still had good strength in her legs, trunk and arms. In fact, the handrail was lucky to be a sturdy one. Otherwise, I might have worried she would pull it straight out of the wall, the way she was clinging to it.
Pain had started a chain reaction: less movement, less confidence, more fear, and then even less movement. In time, climbing a few stairs became a major undertaking.
Pain does not always imply damage
Around 30-40% of people over the age of 30 have disc bulges without experiencing any symptoms.
By the age of 60, that figure rises to around 60-70%.1
A bit like grey hair: common, expected and often clinically irrelevant.
The problem is that when an MRI reveals something, there is a strong temptation to treat it as the explanation for everything. Often, it isn't.
Most disc bulges and herniations discovered incidentally cause no symptoms at all.
And many symptomatic disc herniations shrink or resolve on their own over time: according to the literature, around two thirds do so ².
Pain is therefore not a direct readout of the condition of our tissues.
Instead, it is the result of a complex system involving the nervous system, movement, stress, sleep, expectations and fear.
This is why someone can have an MRI that looks alarming and feel perfectly well, while another person may experience significant pain despite relatively unremarkable imaging findings.
Both situations are real and both make physiological sense.
The MRI is an extremely valuable tool, but it is most useful when it is used to confirm a well-founded clinical suspicion,not when it is used as a starting point. Used the other way around, it often identifies findings that have probably been there for years and may have nothing to do with the symptoms, creating unnecessary worry.
The nocebo effect, in other words the worsening of symptoms caused by frightening diagnostic explanations, is well documented and far from trivial. In some countries, it is not generally possible to arrange a private lumbar MRI without a medical referral, partly to reduce the risk of this process.
This is one reason why international guidelines discourage routine MRI scanning in cases of non specific low back pain. Not because MRI is useless, but because when used without a clear clinical indication it can sometimes do more harm than good.
1(Brinjikji et al., 2015)
²(Zhong et al., 2017)
Acute back pain: its bark is worse than its bite.
Acute low back pain typically comes on suddenly. It can be really rather horrible and may make everyday movements difficult. In most cases, however, it is not a sign of anything serious.
Around 90% of acute episodes of low back pain improve on their own within a few weeks, regardless of treatment.3 It is one of the most consistent findings in the scientific literature, and one of the least talked about.
This means that many people recover while they are doing something: physiotherapy, osteopathy, acupuncture, rest, or any number of other interventions, and naturally attribute their recovery to whatever they happened to be doing at the time. That is understandable. The problem arises when the practitioner knows this and chooses not to explain it, allowing the patient to become dependent on a solution that may never have been necessary in the first place.
A good clinician knows when the body needs time rather than treatment, and should be honest about that.
³ (NCBI, Low Back Pain guidelines)
"My back's all crooked."
Lucia, a 35-year-old office worker, arrived convinced she had a chronic structural problem. The practitioner she had been seeing had explained that her body kept shifting out of alignment. He would "straighten her out", only for her to become "crooked" again a few days later. An impeccable business model!
In the meantime, Lucia had stopped exercising, started avoiding certain movements, and built an identity around the idea that there was something wrong with her back.
The spine is a remarkably robust structure, designed to move, bear load and adapt. It does not typically become crooked through normal daily activities. Believing that your back is fragile, crooked or somehow damaged increases fear, reduces movement and, paradoxically, often increases pain.
This is not only a matter of psychology. It is mainly neurophysiology.
Why Pain Sometimes Travels Down the Leg
Nerves are the body's electrical cables. They carry signals over long distances, transmitting sensation and controlling movement.
When a nerve root is compressed by a disc herniation, a disc bulge or narrowing of the spinal canal, symptoms do not always stay at the site of the problem. Instead, they may follow the course of the nerve, travelling down the leg and sometimes as far as the foot. This is what we call sciatica.
But there is an important caveat. Buttock pain, tingling, or symptoms travelling down the thigh are not always caused by a disc pressing on a nerve root.
Muscles can also irritate nerves and produce very similar symptoms. Myofascial trigger points * are common both in people with localised low back pain and in those whose symptoms travel into the leg.They often coexist with nerve-related pain rather than replacing it.⁴
Whatever the cause, pain and other symptoms can appear far from the place where the problem actually originates.
*Trigger points are localised areas of increased muscle tension found, for example, in muscles such as the piriformis, gluteus maximus and quadratus lumborum.
4(Monclús-Díez et al., Biomedicines, 2025)
The Rest Trap
Roberto, 72, had settled into a familiar cycle: wait for the pain to arrive, rest, wait for it to settle, start moving again. Then the pain would return, and the cycle would begin all over again.
Complete rest seems like the logical thing to do when we are in pain. Yet we have known for decades that prolonged rest tends to slow recovery, increase stiffness and reduce confidence in movement. In most cases, gentle movement, walking and regularly changing position are far better strategies than staying still.
When to Seek Medical Advice Promptly
There are situations where further medical assessment is appropriate and should not be delayed.
Seek medical attention promptly if you develop:
- severe, persistent pain that does not change with position and becomes worse at night
- progressive weakness in one leg
- significant loss of sensation
- difficulty controlling your bladder or bowels
- unexplained fever or weight loss
- pain following a significant injury or trauma
- other severe or disabling symptoms
The good news is that most people with back pain experience none of these warning signs.
Common Symptoms That Are Often Not an Emergency
In the absence of the warning signs listed above, it is very common to experience:
- pain that changes with movement or position
- morning stiffness that improves once you start moving
- a sudden feeling that your back has "locked up"
- pain that becomes worse during periods of stress or fatigue
These symptoms can be worrying, but they are often manageable with the right approach.
The Role of Physiotherapy (and Manual Therapy)
Returning to Maura's story: we spent the first two sessions reducing her symptoms and helping her start moving again, using Manual therapy, which can be useful in the early stages to reduce pain and stiffness, but it is not the solution in itself.
From there on, the focus shifted to strength, balance, movement strategies, and confidence in movement.
After eight sessions, she was able to climb the stairs without holding on to the handrail.
I didn't "realign" or "reposition" anything. I didn't fix anything structural, partly because that is physically impossible. And if it were possible, it would probably require a surgeon rather than a physiotherapist.
What I did was help her understand what was happening, reduce some of the pain, and put movement back at the centre of the process.
That is what the job usually involves: not correcting a broken structure, but restoring confidence in a body that works far better than the patient has come to believe.
The goal is not to protect the back or put it back into place. The goal is to train it, challenge it, and help it become reliable again. renderla di nuovo affidabile.
Fortunately, I never saw Maura again.