Chronic low back is complex. It is associated with a variety of Behavioral Factors, Motor Changes, Sensorimotor Changes, Altered Body Image, Brain Changes; Neurocognitive Deficits, Co-morbidities, and NICE (Neuro-immune, Cardiometabilic, Endocrine) changes.
The central nervous system must simultaneously regulate spinal control, continence and respiratory function. There are also complex interactions with educational level, socioeconomic status, ACE (Adverse Childhood Experiences- without specific behavioral manifestations), atypical birth histories and early life development.
There are also huge variability in motor skill learning ability, neural efficiency, brain competition, and probably a lesser extent, exercise induced analgesia,
Add this to the influences of previous injuries (asymptomatic), and neurodevelopmental disorders (e.g. ADHD, DCD).
Plus the unknown influences of cross modal plasticity, synesthesia, atypical handedness and bifocals/trifocals.
Then we have the individuality of beliefs, readiness to change, lifestyle factors, therapeutic relationship and loading factors.
Lets not forget the non-modifiable factors (e.g. age, gender, ethnicity, genetics, anthropometrics).
The only way to address chronic low back pain is through individualized approaches. A multi-dimensional sub-classification model can guide this.
There are many of the above combinations of presentations that simply do not respond to isolated strengthening, get worse with isolated strengthening or have minimal improvement. There is likely a subgroup that does respond to isolated strengthening, but there are no strong predictor variables.
So simply "getting strong" is wrong (sometimes, or has minimal benefit). Certainly it should not be a focus of rehab. Sure, it can come later if required.
Undergraduate degree; Physiotherapy degree; maybe a post graduate degree; countless hours of continuing education. Physiotherapists aren't personal trainers.
We have so much more to offer and can do better than just strengthening.
