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Thinking Outside of the Box to Address Low Back Pain
By: Carli Grosso, Year 2 MscPT Student at U of T


If you’re reading this blog and you’re a healthcare provider, the chances are very good that you’ve seen patients with low back pain (LBP).

Low back pain - The most common musculoskeletal problem globally

You may have landed on this blog because you’re looking to better understand the various reasons for low back pain or factors that can affect outcomes, or perhaps you’re looking to broaden your clinical skillset.

You’re in the right spot.
Understanding the various components of your patient’s low back pain experience is important in allowing your patients to continue to engage in activities that bring value and purpose into their lives. 

This may involve exploring areas that are not usually considered in physiotherapy. 

For example, bladder health, endometriosis, and other visceral pain conditions. We need to understand these conditions and the role they play in low back pain to effectively treat our patients while using a biopsychosocial approach. 
The information in this blog post comes directly from the course series Weird and Wonderful Strategies that EVERY Physio Should Know to Effectively Treat LBP which is hosted by Reframe Rehab in collaboration with Embodia. 

Each course in the series focuses on a different topic, specifically how bladder health, endometriosis, inflammation, and cognitive discrimination play a role in low back pain. These courses are taught by Carolyn Vandyken with special guests Jilly Bond, Jill Mueller, Sinéad Dufour, and Ibbie Afolabi. 
Continue reading if you want to broaden your knowledge in the assessment and treatment of LBP! 

Here is what you can expect to learn more about in this blog:

  • Bladder Health in Low Back Pain
  • Endometriosis in Low Back Pain
  • Systemic Inflammation and Low Back Pain
  • Cognitive Sensory Discrimination in Low Back Pain
  • Low Back Pain in Labour and Delivery

Bladder Health in Low Back Pain (LBP) with Jilly Bond

Bladder health and LBP are highly co-morbid. 

Some considerations when screening your patients with low back pain for bladder health issues include a thorough examination of pelvic organ function during the subjective interview. The subjective interview should be trauma-informed and include a narrative assessment where you ask open-ended questions and let your patient tell their story. 

Using validated outcome measures such as the Australian Pelvic Floor Questionnaire and the Pelvic Psychological Screening Questionnaire as well as having your patient keep a bladder diary are critical components in screening your patients for bladder health issues. These outcome measures and the digital bladder diary are available as part of Embodia’s Tier 2 and 3 memberships

What’s Normal Bladder Function?

Normal bladder function includes:

  • Voiding for around 6-8 seconds,
  • Moderate volumes,
  • 1300ml urine output/day,
  • No pain, leakage, or urgency, and
  • The ability to hold for over 15 minutes. 

In a study of 588 females with chronic non-specific low back pain by Stockil et al., 2018, 11.8% had difficulty emptying, 22.9% had urogenital pain, and 41.5% with urinary frequency. This study demonstrates that your patients with low back pain may have some pelvic floor dysfunction and pain. 

Learning to screen for bladder health issues in your patients with LBP will broaden your perspective and allow you to address the whole person in a person-centered approach.

To learn more about this topic, please refer to the full online course by Jilly Bond ‘Bladder Health Matters in Low Back Pain.’ 

Endometriosis and Low Back Pain (LBP) with Jill Mueller

Endometriosis is a systemic, inflammatory disease where endometrium-like tissue is found outside the uterus with no known cause. It is one of the most widespread gynecological disorders as 10% of all fertile women have this condition. 

Common symptoms of endometriosis include: 

  • Painful periods,
  • Pain with intercourse,
  • Low back pain that worsens during menses. 

Other symptoms can include digestive issues, pelvic pain, and fertility challenges to name a few. 

The time between the onset of symptoms and diagnosis of endometriosis is typically a number of years. The delay in diagnosis can be reduced. Women who present with symptoms of endometriosis and LBP can be better treated when there is greater awareness by the healthcare community of the symptomatology of endometriosis.
Our job as clinicians is to take a thorough history and objective examination to determine a differential diagnosis. Once you have ruled out any red flags, determine if your patient’s symptoms are peripherally driven from the ovaries, uterosacral ligament, sciatic nerve, or pelvic floor muscles. Or, if the symptoms are centrally driven from the brain and the spinal cord. 

We also need to consider central sensitization, which is like an amplifier in a guitar - even with the same input your output is AMPLIFIED. 

Endo Together: Sensitive Nervous System Anology

Source: Endo Together

Central sensitization could be a reason why your patients experience pain even after medical intervention and traditional physical therapy. 

How to Screen for Central Sensitization

It is important to learn to screen for central pain mechanisms by using validated questionnaires in the endo population such as the Central Sensitization Inventory (CSI), Pain Catastrophizing Scale (PCS) or the Depression, Anxiety, Stress Scale (DASS). 

(All of the above questionnaires are available to share with your patients via Embodia). 

Once you have determined that your patient is experiencing central sensitization, considering strategies to desensitize the nervous system such as Qi Gong, meditation, yoga, mindfulness, and cognitive therapy are important.
Overall, the delay in diagnosis of endometriosis can be reduced and LBP can be better treated by being aware of the symptomatology of endometriosis and taking a detailed history. 


Centrally or Peripherally driven back pain


To learn more about this topic, please refer to the full online course by Jill Mueller ‘The 10% Club: Endometriosis Matters in Low Back Pain.’ 

Systemic Inflammation and Low Back Pain (LBP) with Dr. Sinéad Dufour

Our understanding of the role of inflammation and pain has drastically changed over the past five years. 

Idiopathic LBP is one condition that is often connected to systemic inflammation. 

Pain, anxiety, depressed mood, and fatigue are all outputs of a system that is experiencing systemic inflammation. 

As a clinician, you should be thinking about what kind of stressor has come into the patients’ system and what the response is.

The response can either be adaptive, where your client copes well, which allows for the return to normal levels of epinephrine, norepinephrine, cortisol, and inflammation.

The response can also be maladaptive, such as catastrophizing or feeling helpless, which can lead to prolonged or excessive HPA axis activation. 

Proposed role of stress related HPA axis activation.

Source: Hannibal KA, Bishop MD. Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. Physical Therapy, Volume 94, Issue 12, 1 December 2014, Pages 1816–1825,

Prolonged cortisol secretion creates a fear-based memory of the stressful stimulus that is sensitized and readily reactivated by future stressors. Prolonged cortisol secreted ultimately leads to systemic inflammation and then a potential pain response.
We can apply this to physical therapy practice by addressing sensitivity and targeting systemic inflammation by addressing patients’ cognitions, diet, exercise, sleep, and stress levels.

Overall, inflammation is often a pathological process. Taking a broader approach to systemic inflammation is an important component of assessing and treating low back pain from a whole-person perspective.

To learn more about this topic, please refer to the full online course by Dr. Sinéad Dufour ‘A Modern-Day Approach to Inflammation and Low Back Pain.’

Cognitive Sensory Discrimination in Low Back Pain with Carolyn Vandyken

The RESOLVE trial (2022) has provided us with Level 1 evidence that addressing sensorimotor dysregulation in low back pain is an important aspect of addressing LBP within a biopsychosocial approach. This study was also published in JAMA because of its strong placebo intervention. 

Here’s a short video that discusses the components included in the RESOLVE intervention:

The above video shows the components included in the RESOLVE intervention. Specifically, as part of the neuroscience-informed pre-movement strategies, they used cognitive sensory discrimination. 

How to Use Cognitive Sensory Discrimination:

This was done by using chopsticks that had both a dull and a sharp end. The patient lay prone and their back was divided into 9 grid areas. The patient would then have to determine whether you touched them with the dull or sharp end of the chopstick and in which grid area on their back they were touched.

Cognitive sensory discrimination was practiced for 30 min per day before getting them moving. The main disadvantage of this strategy is that it requires an additional person and cannot be done with pelvic floor patients.

What Can We Take from the RESOLVE Study into Clinical Practice?

Ben Wand developed a brand-new questionnaire called the Fremantle questionnaire that measures sensorimotor dysregulation. Clinicians can use it to inform their clinical practice. 

Carolyn Vandyken discusses that in her clinical practice, she uses novel, global, sensorimotor-rich movements like Yoga and Qi Gong for patients who score lower than the median on the Fremantle and who have no mechanical presentation. 

Qi Gong is an excellent way of increasing descending inhibition while evoking a relaxation response to complete the stress response. 

Carolyn also uses novel, targeted sensorimotor-rich movements like the Feldenkrais exercises with patients who score higher than the median on the Fremantle and have no mechanical presentation. 

Overall, when addressing patients with low back pain, sensorimotor dysregulation is a critical biological construct to assess and address, and starting to use the Fremantle questionnaire in your clinical practice is a great start! 

To learn more about this topic, please refer to the full online course by Carolyn Vandyken ‘The RESOLVE Study: Cognitive Sensory Discrimination in Low Back Pain.’ The Fremantle questionnaire is available for download in the course!

Low Back Pain in Labour and Delivery with Ibukun Afolabi

Physiotherapists have an important role to play in helping women manage their pain during labor and delivery. And this is an emerging role!

Many pregnant women are worried about the pain that they may experience during labor and delivery. Some risk factors for LBP in the perinatal period include:

  • Pre-existing LBP particularly in menstruation
  • History of pelvic trauma
  • Previous pregnancy with LBP
  • Work dissatisfaction
  • Early onset of symptoms in pregnancy
  • Lack of physical activity

Clinicians may have biases and beliefs surrounding the meaning of labor pain, who experiences pain and why, the causes of pain in pregnancy, and the uniqueness of labor as a type of pain. 

Some common provider responses to low back pain in pregnancy could be “Of course, you have back pain…you’re pregnant!”

These unhelpful beliefs can contribute to patients developing a sense of powerlessness, increased anxiety and fear, decreased self-efficacy, central sensitization, and heightened fragility. 

As clinicians, we need to examine our foundations including our biases and beliefs that may influence the way we approach our clients’ pregnancy experiences. 

Some examples of outcome measures that look at provider biases and beliefs about (low back) pain include: Back Pain Attitudes Questionnaire, Fear Avoidance Beliefs Tool, and the Pain Truth Test.
In addition, using psycho-social inventories with your clients are great ways to identify the biopsychosocial contributors to low back pain during pregnancy and childbirth. For example, the CSI, DASS, and PCS. These outcome measures are available for clinicians to use with their patients on Embodia.

pain-modulating strategies you can use with your patients who suffering from low back pain

To learn more about this topic, please refer to the full online course by Ibukun Afolabi and Reframe Rehab ‘Addressing (Back) Pain in Labour and Delivery.

Wrapping It Up 

Incorporating the strategies suggested here will help develop your clinical reasoning skills and will hopefully change the way you assess and treat low back pain.

For more information in these specific areas take a look at the course series: Weird and Wonderful Strategies that EVERY Physio Should Know to Effectively Treat LBP.


Written: 04 Jan, 2023
Last update: 04 Jan, 2023

Jill Mueller
BKin, BHScPT (Pelvic Health)

Jill has been a physiotherapist for 20 years, focusing on pelvic health, orthopaedics, and visceral therapy. She has been assisting courses for the past 5 years and is ready to share her knowledge by teaching her own course on Endometriosis. She has a keen interest in using a patient-centered approach, integrating an evidence-based, biopsychosocial model into her practice.

Jill has explored using these approaches, having endometriosis herself, and is now able to manage symptoms and live a more productive life. She feels that physiotherapists can play a vital role in helping these clients regain a better quality of life, and hopes to show others how they can help their clients suffering with similar symptoms.

Jilly Bond
Physio Researcher Speaker Educator

Jilly Bond is a pelvic health physiotherapist based in Wales, UK, with a special interest in pelvic pain. She is a regular speaker at international conferences, runs professional development courses for physios in the UK and online, and her Youtube channel has free resources for patients and clinicians. Her research interests include understanding how graded motor imagery may help in the treatment of centralised mechanisms in visceral pain. If you’re interested in pelvic pain she’d love to hear from you.

To learn more about Jilly checkout her website:

Dr. Sinéad Dufour

Dr. Sinéad Dufour is an academic clinician who shares here time between clinical pursuits as the Director of Pelvic Health at the WOMB and academic pursuits in the Faculty of Health Science at McMaster University. She has been a practicing physiotherapists for 20 years. She completed her MScPT at McMaster University (2003), her PhD in Health and Rehabilitation Science at Western (2011), and returned to McMaster to complete a post-doctoral fellowship (2014). Her current research interests include: conservative approaches to optimize pelvic floor function, pregnancy-related pelvic-girdle pain, interprofessional collaborative practice models of service provision to enhance pelvic health and perinatal fitness for elite athletes.

Sinéad is an active member of several organizations charged with optimizing perinatal care and pelvic health and has led and contributed many national and international clinical practice guidelines to improve care provision. Sinéad also currently serves as a council member for the College of Physiotherapists of Ontario, Canada. Sinéad is a well-recognized speaker at conferences around the world and a sought out expert to consult with companies whose aim to improve perinatal care and pelvic health.

Relevant Links:

IG: @dr.sinead

Ibukun Afolabi
MScPT, BA(Hons.)Kin, PCES, CCE, CD

Ibukun is an Integrative Pelvic Health Physiotherapist whose passion lies at the intersection of women’s pelvic health and childbirth. She has been practicing as a registered physiotherapist since 2007 and the bulk of her career has been focused on serving pelvic and perinatal health population.

Ibukun is a certified childbirth educator, certified postpartum doula, and birth support physio/doula. She is an instructor with Doula Canada and Physio-Plus. Ibukun is a sought-after speaker and has offered training workshops for midwives, labour and delivery nurses, birthing families, and other health professionals. She is fascinated by the applications of pain neuroscience within the context of birth.

Reframe Rehab
Online Teaching Company

We are a passionate group of highly trained clinicians who champion virtual, live online education courses to develop a biopsychosocial framework for your clinical practice. Our mission is to break down the silos in clinical practice between musculoskeletal pain, pelvic pain, pain neuroscience education, and psychology by providing timely, cost-effective, live online learning opportunities from the world's leading clinical educators on these topics.

Interested in learning more about Reframe Rehab or taking a course with us? Check us out on Instagram @reframerehab or visit our website to view all our course offerings.

Carolyn Vandyken

Carolyn is the co-owner of Reframe Rehab, a teaching company engaged in breaking down the barriers internationally between pelvic health, orthopaedics and pain science. Carolyn has practiced in orthopaedics and pelvic health for the past 37 years. She is a McKenzie Credentialled physiotherapist (1999), certified in acupuncture (2002), and obtained a certificate in Cognitive Behavioural Therapy (CBT) in 2017.

Carolyn received the YWCA Women of Distinction award (2004) and the distinguished Education Award from the OPA (2015). Carolyn was recently awarded the Medal of Distinction from the Canadian Physiotherapy Association in 2021 for her work in pelvic health and pain science.

Carolyn has been heavily involved in post-graduate pelvic health education, research in lumbopelvic pain, speaking at numerous international conferences and writing books and chapters for the past twenty years in pelvic health, orthopaedics and pain science.

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