Rest works. That’s the problem.
When your back flares, rest helps. The pain drops, the guarding settles, and within a week or two you feel more or less normal. So rest gets the credit, and the whole thing looks solved.
It isn’t. Rest works by reducing what you ask of your back, not by increasing what your back can give. When you go back to your normal week, the same demand meets the same capacity it overwhelmed last time. Sometimes that takes a month. Sometimes six. But the arithmetic hasn’t changed, so the outcome doesn’t either.
This is the single most common pattern I see. Not people who’ve done nothing, but people who’ve done a lot of the wrong thing, repeatedly, for years.
What “under-built” actually means
Your back is a load-bearing structure. Discs, joints, muscles, connective tissue, and a nervous system deciding how much protection the whole arrangement needs.
Every structure has a ceiling. Sitting for nine hours, then lifting a toddler, then deadlifting on Thursday, all draw on the same account. When demand consistently exceeds capacity, the tissue complains and your nervous system turns up the sensitivity to make sure you notice.
That’s not damage. That’s a system telling you the load is beyond what it’s currently built for.
Two things follow. First, the fix has to raise the ceiling, which only happens through progressive loading. Second, the fix takes time, because tissue adapts on a biological schedule rather than a convenient one.
What your scan does and doesn’t tell you
If you’ve had an MRI and it found a disc bulge, degeneration, or “wear and tear”, that finding is far less alarming than it sounds. In people with no back pain at all, roughly half have disc bulges on imaging. By 50, most people show degenerative change. These findings are common in people who feel completely fine.
The size of a bulge doesn’t predict how much it hurts, and the grade of degeneration doesn’t predict how you’ll do.
There are situations where imaging genuinely matters, and I screen for them: progressive weakness, changes in bowel or bladder function, saddle numbness, significant trauma, or a pattern that suggests something other than a mechanical problem. Those are specific and identifiable. Absent them, a scan usually adds fear rather than information.
I’ve written more on this in what a disc bulge actually means, and on why sciatica keeps returning when it’s treated as a symptom rather than a capacity problem.
What the first appointment actually involves
Most of it is working out where your back is losing the argument, which means understanding what your week actually asks of it, not just where it hurts.
I’ll take a proper history first, because the pattern over months usually tells me more than the pain does today. What I assess from there depends on you - what you do for work and training, what’s provoking it, how long it’s been going on, what you’re trying to get back to. I don’t run the same checklist on everyone, because the answer isn’t in the same place for everyone. I’ll also screen for the findings that would change the plan or need a referral on.
You’ll leave understanding what’s driving it and what the plan is. That second part matters more than people expect, because not knowing is itself part of what keeps a nervous system protective.
What a course of care looks like
I’ll be straight about this, because most clinics aren’t.
For something that’s been recurring a while, the typical shape is around 8 to 12 sessions over 3 to 4 months. That’s a rough guide, not a programme - some people need less, some need considerably longer, and it depends on how long you’ve had it and what you’re rebuilding towards. What I can tell you is that it isn’t three visits, and it isn’t indefinite maintenance either.
Broadly it moves through three phases:
- Settle it down, typically the first few weeks. Calm the pain and restore confident movement. Pain usually drops here, and this is exactly where most people stop.
- Rebuild, through the middle stretch and usually the longest phase. Progressive loading through the patterns your life actually demands, getting heavier over time. This is the part that changes the outcome.
- Integrate, towards the end. The work stops being rehab and becomes how you train. Capacity ends up past where it was before it started hurting, which is the point.
How long each of those takes is the bit that varies. The order doesn’t.
Then you’re discharged. There’s a finish line, and getting you to it is the job. If you need me again in two years for something else, good, but I’m not interested in seeing you fortnightly forever to keep something at bay that could have been fixed.
That’s also why the timeline is what it is. A three-visit version would get your pain down and change nothing underneath it.
Who I work with
Most of the people I see with recurring back pain have had it for a while, have tried treatment that helped temporarily, and have quietly started shrinking their life around it. Lifting less. Choosing the chair. Skipping the game.
A lot of them are fathers in their thirties and forties trying to get back to training. The pattern is usually the same: they were active, life got busy, capacity fell away while expectations didn’t, and their back is the thing that gave first. The stop-start injury cycle is the version of this most people recognise.
Not all of them, though. Desk workers, tradespeople, people who’ve never trained and don’t want to. The principle doesn’t change with the job. The load and the plan do.
The exercises
Worth saying plainly: there’s no universal list. The right loading depends on where your capacity is actually failing, which is what the assessment is for.
That said, the principles hold, and I’ve set out the kind of work that builds capacity rather than just soothing symptoms if you want to understand the logic before you book.
If you’ve done physio before and it didn’t hold
That’s common, and it usually isn’t because you did it badly.
It’s because the course stopped when the pain did. Symptoms improve well before capacity does, so a plan that ends at week three ends before the part that would have made it stick. That gap is where “physio didn’t work for me” comes from.
If that’s your history, it’s worth a second opinion rather than another round of the same thing.