When you come to a physiotherapist for back pain treatment, you expect relief and healing. However, it’s not uncommon to feel worse before you start feeling better.
This paradox can be confusing. But, understanding the healing process can help clarify things.
Physiotherapy starts a series of biological responses in your body which we’ll discuss below. Although they are aimed at recovery, they can sometimes cause temporary discomfort.
Keep reading to understand the science behind why sometimes your back hurts after physiotherapy.
Can Physiotherapy Make Back Pain Worse?
Yes, Initially, it might seem that a physiotherapy session increases your already terrible back pain.
As a physiotherapist with over a decade of experience, I’ve had my fair share of patients ask me different versions of this question.
My answer usually begins by emphasising that feeling worse after a physiotherapy session does not necessarily mean your condition is deteriorating; instead, it’s often a sign that your body is adjusting and healing.
This answer is usually not enough.
Because when you’re in pain, you want as many details as possible to find the will to endure the pain.
This blog has all the scientific reasons I tell my patients when they tell me their back pain got worse after their physiotherapy session.
I hope that learning about these gives you the reassurance you need to focus on your rehab and show up for your next back pain physio session.
Common Reasons for Increased Pain After Physio
Here are some reasons why your body responds to back pain treatment by increasing pain or discomfort:
1. Muscle Soreness and Microtrauma
Have you heard of Delayed Onset Muscle Soreness (DOMS)?
It’s the ache or discomfort you feel after spending the day at the trampoline park for your kids’ birthday or doing any activity that’s a bit more than usual. This phenomenon occurs when you stretch or strain your muscles beyond what they’re accustomed to, leading to microtrauma in the muscle fibres.
Engaging muscles that you don’t use often or don’t use as intensively can lead to DOMS. It’s a common after-effect of physical therapy if your session includes exercises that target inactive muscles.
This can be somewhat managed through a personalised and appropriately progressed physiotherapy program, but it’s hard to avoid altogether.
This discomfort after a physiotherapy session is part of the muscle remodelling process, which is necessary for recovery and strengthening. It usually peaks 24 to 72 hours after the exercise.
The good news is that you can decrease the pain intensity by stretching after the session and using a heating pad to relax the muscles.
2. Mobilisation of Joints
Physiotherapists often use joint mobilisation techniques to increase the range of motion in stiff joints in your back.
And no, it’s not the same as cracking your back and neck like you’ve seen on YouTube.
The process can irritate surrounding tissues, leading to temporary inflammation and discomfort. Your body’s natural response to this mobilisation can be to increase pain while the nervous system adapts to changes in joint mechanics.
We can minimise it by doing soft tissue massage on your muscles and relaxing them before passively mobilising the joints.
3. Activation of Dormant Muscles
Physiotherapy for back pain often involves increasing muscle control for stability and joint movements. This may require activating underused muscles through exercise, which can lead to temporary discomfort as they adjust to new demands.
I like to think of dormant back muscles as teenagers. They love to roll their eyes and protest when you ask them to take responsibility and pull their weight. But if you just stick with the program and manage the pain, you’ll be better off for it.
I want to point out here that theories about lactic acid buildup or metabolic waste buildup are common in the sports communities, but there’s a lack of recent good-quality studies backing these up.
In fact, lactic “acid” (I say “acid” in quotation marks because it’s not even acid, it’s broken down into lactate as soon as it enters the bloodstream), can be good because it’s a fuel source for long duration or hard exercise.
4. Neural Adaptation
After an injury or chronic pain, your nervous system can become over-sensitive to pain signals. That can make you more susceptible to feeling pain with less provocation.
Physiotherapy exercises often challenge this sensitization. Our goal is to desensitise your pain response over time. But initially, this can result in increased pain perception
5. Breaking Down Scar Tissue
When your body undergoes trauma, such as a cut or any form of injury that affects the skin or deeper tissues, the body repairs it by laying down a type of tissue known as scar tissue.
It’s made up of collagen, just like other tissues. But, instead of the orderly arrangement of normal tissue fibres, the collagen in scar tissue aligns more randomly and haphazardly. This can make them thicker, less flexible, and more pronounced than the surrounding tissue.
Scar tissue can affect normal function, leading to stiffness, reduced range of motion, and sometimes pain.
During physiotherapy for back pain, we use various techniques to break down this scar tissue to promote more organised healing and restore function.
Unfortunately, this can cause temporary pain.
6. Psychological Factors
Individual differences in pain perception can influence how one experiences discomfort post-therapy. Life stresses and worries can amplify your sensation of pain, affecting the physical healing process.
Most of my unconditioned patients become anxious at the thought of engaging in new or challenging exercises during physiotherapy. That can temporarily heighten pain perception and discomfort after physiotherapy.
Understanding the role of psychological factors in pain management can help in developing strategies to cope with this increased pain.
7. Correction of Postural Imbalances
Many back issues stem from or are worsened by poor posture.
Physiotherapy exercises that aim to correct these long-standing postural imbalances can initially cause discomfort as your body adapts to new, healthier postures
The adjustments can cause muscle fatigue and contribute to the feeling of increased pain.
I believe it’s important to mention here that there’s no perfect posture for standing or sitting or lying down or any activity. Our bodies are incredibly flexible and adaptable. However, there are some very wrong postures that stress the body unnecessarily and can lead to terrible back pain.
You may be interested in this blog: What Should You Not Do With Lower Back Pain?
8. Fluid Shifts and Swelling
Exercise and manual therapies can cause shifts in bodily fluids, leading to temporary increases in interstitial fluid in tissues. That can contribute to swelling and discomfort.
This fluid shift is part of the body’s natural response to healing. It helps to remove waste products from tissues, but it can initially increase the sensation of pain.
Final Thoughts
Experiencing more back pain after physiotherapy can be disconcerting, but it’s often a vital part of the healing process.
Understanding these mechanisms can help you manage your recovery with more confidence and less anxiety. Remember, ongoing communication with your physiotherapist is crucial to tailor your treatment plan to your body’s responses. If pain continues or significantly interferes with your quality of life, it’s important to seek further evaluation and support from your healthcare provider.
Your journey to recovery is a collaborative process, and your proactive participation is key to its success.
It’s important to distinguish between normal soreness and signs that something else might be going on. If you’re unsure, book an appointment with our physiotherapy clinics in Southeast and Southwest London, particularly in Eltham, Battersea and Norbury.
