Gender Indifference in Low Back Pain Care: What We're Missing in Assessment and Management
Low back pain (LBP) is one of the most common presentations in exercise physiology. Most clinicians now apply a biopsychosocial approach, yet still find themselves asking: why isn't my patient improving?
Clinical reasoning usually covers loading tolerance, pain beliefs, fear-avoidance, graded exposure, and pain education. What's often forgotten is sex-specific biological, reproductive, and psychosocial factors. For some presentations, that exclusion is what influences treatment outcomes.
Hormones, the menstrual cycle, and pain
Oestrogen's relationship with pain is complex and tissue-dependent, it can be pro or anti-nociceptive depending on whether levels are stable or fluctuating, while testosterone is more consistently associated with higher pain thresholds [2, 3]. This fluctuation, rather than oestrogen level alone, influences pain sensitivity, symptom variability, rehabilitation tolerance and progression across the menstrual cycle, postpartum period, and perimenopausal transition [2, 3]. Without asking about hormonal and reproductive history, we risk missing information that's important to recovery.
Postpartum: delivery mode changes the clinical picture
Persistent pain at one year is reported by 22% of women following caesarean section, compared with 8% after vaginal delivery [5]. A common assumption is that this disparity in persistent pain is driven by a “weak core,” the reality is more complex.
Women who deliver by caesarean commonly show reduced transversus abdominis (TrA) activation compared with those who delivered vaginally [6]. Yet research has found no significant association between TrA strength and pain intensity in either group [6]. The muscle may be weaker, but it isn't necessarily what's causing the pain.
Management directed at core strength and stability doesn't outperform general exercise for LBP [10]. Exercise reasoned within a multidimensional approach accounting for delivery mode, sleep, physical conditioning, hormonal status, mental health, and pelvic floor history, better supports postpartum recovery alongside interdisciplinary care with a Women's Health or Pelvic Health Physiotherapist (where thorough pelvic assessment falls outside our scope).
Endometriosis: a clinical presentation we often miss
Endometriosis affects approximately 1 in 9 females of reproductive age [7], with an average diagnostic delay in Australia of eight years [8]. Recognising and acknowledging symptoms and their impact on quality of life is within our scope. This can present as persistent pelvic or back pain which is associated with cyclical symptom behaviour, dysmenorrhoea, dyspareunia, or bowel and bladder symptoms.
Central sensitisation is significantly elevated in women with endometriosis [9]; this should be considered when assessing and reasoning exercise management and education. Exercise should be tailored to specific movement triggers, with consideration of an overactive or underactive pelvic floor, and interdisciplinary care with a Women's Health Physiotherapist and Gynaecologist is often essential.
Within that framework, exercise physiology has a clear therapeutic role:
low-impact aerobic exercise (walking, cycling, swimming) eases pain via descending pain modulation and anti-inflammatory mechanisms while supporting hormonal regulation, pelvic circulation, and sleep
strength training builds functional capacity, with load adapted during flares;
and gentle mobility for hip, lumbar, and pelvic tension, alongside diaphragmatic breathing, helps manage pain symptoms during flares.
Critically, symptom variability is what makes exercise prescription in this population a balancing act; the goal is to provide education around how to adjust movement, not stop, when symptoms fluctuate.
Exercise selection: the problem with defaulting to core
Beyond how we conduct our initial interview, the exercises we choose carry implicit messages about what we, as clinicians, believe is "wrong" and needs "fixing".
LBP management typically centres on core and abdominal strengthening, yet core stabilisation exercises are no more effective than general exercise for chronic LBP [10]. Additionally, telling someone their pain stems from a weak core reinforces the idea their spine is vulnerable, requires protection, and that movement without bracing carries risk, further reinforcing guarding and protective behaviours commonly observed in chronic LBP.
For women, the missing piece is often not an imaging finding or a specific incident, it is a combination of factors:
movement beliefs
fear of pain aggravation
exercise mismanagement
underlying or undiagnosed comorbidities
an overactive pelvic floor
deconditioning, often due to tie constraints with juggling family and work life
hormonal changes across various life stages
Through a Cognitive Functional Therapy (CFT) approach, trained clinicians conduct in-depth interviews and assessment to understand the individuals LBP presentation. This informs exercise (exposure with control, for example reducing unhelpful bracing during bending), lifestyle interventions and sense-making [14]. Reduced superficial extensor muscle activity representing observed relaxed movement behaviours associated with increased trunk movement and velocity, improved pain self-efficacy, fear, catastrophisation and cognitive beliefs is observed in those who recover from LBP [12, 15, 16, 17, 19].
What this means in practice
The practical implication is not that female patients require a separate pathway, it’s that standard assessment should be truly biopsychosocial, accounting for biology (sex-specific considerations) and the influence of this upon the psychosocial state of the female. Of importance, the complex role of a female within society and throughout life-stages should be acknowledged and addressed (for example, how breastfeeding impacts sleep and time management).
Develop the knowledge and confidence to:
have in-depth conversations around hormonal and reproductive history
recognise signs and symptoms of pelvic health conditions that may warrant gynaecological or Women's Health Physiotherapy referral
understand how these factors may be influencing LBP and how to manage them concurrently alongside their lifestyle
With knowledge, appropriate assessment and reasoning you’ll start choosing exercises that address the drivers of pain and disability, not just the structures adjacent to the pain.
Reflective questioning
When you think about your female patients with chronic LBP who have not responded as expected, how much of your assessment addressed hormonal context, delivery history, or movement beliefs versus physical findings alone?
If your exercise prescription for LBP defaults to core stabilisation, what is the rationale? Is it targeting the driver of their presentation, or purely the diagnosis provided upon referral?
For women presenting with cyclical or pelvic pain alongside back pain, does your current assessment process prompt discussion or consideration of referral for gynaecological or women’s health physiotherapy assessment?
References
Chenot, J. F., et al. (2008). Sex differences in presentation, course, and management of low back pain in primary care. The Clinical Journal of Pain, 24(7), 578–585. https://doi.org/10.1097/AJP.0b013e31816ed948
Athnaiel, O., et al. (2023). The role of sex hormones in pain-related conditions. International Journal of Molecular Sciences, 24(3), Article 1866.
Gulati, M., et al. (2023). Sex hormones and musculoskeletal pain across the life course. The Lancet Rheumatology, 5(10), e582–e592.
Wijnhoven, H. A. H., et al. (2006). Hormonal and reproductive factors are associated with chronic low back pain and chronic upper extremity pain in women. Spine, 31(13), 1496–1502.
Kainu, J. P., et al. (2016). Persistent pain after caesarean section and vaginal birth: A cohort study. Anesthesia & Analgesia.
Ali, M. G., et al. (2025). Testing the association between low back pain intensity and core muscle strength in postpartum women with different delivery modes. Journal of Clinical Medicine. https://doi.org/10.3390/jcm14186505
Avery, J. C., et al. (2023). Non-invasive diagnostic imaging for endometriosis part 1: A systematic review of recent developments in ultrasound, combination imaging and artificial intelligence. Fertility and Sterility. https://doi.org/10.1016/j.fertnstert.2023.12.008
Armour, M., et al. (2020). Endometriosis and chronic pelvic pain have similar impact on women, but time to diagnosis is decreasing: An Australian survey. Scientific Reports. https://doi.org/10.1038/s41598-020-73389-2
Viscardi, M. F., et al. (2026). Central sensitisation in endometriosis: Comparison with other chronic pain conditions. Human Reproduction.
Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, 2021(9), Article CD009790. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009790.pub2/full?highlightAbstract=effectiveness%7Cexercise%7Cpain%7Cexercis%7Ceffect
Wernli, K., et al. (2022). From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain. European Journal of Pain. https://doi.org/10.1002/ejp.2022
Schütze, R., et al. (2025). Mechanisms of change in cognitive functional therapy: A longitudinal mediation analysis of the RESTORE clinical trial. Behaviour Research and Therapy. https://doi.org/10.1016/j.brat.2025.104853
Kent, P., et al. (2023). Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE). The Lancet. https://consensus.app/papers/details/9f92b144aa395f29aed968777777bc53/
O'Sullivan, P. B., et al. (2018). Cognitive functional therapy: An integrated behavioral approach for the targeted management of disabling low back pain. Physical Therapy, 98(5), 408–423. https://doi.org/10.1093/ptj/pzy022
Klem, N.-R., O’Sullivan, P., Smith, A., & Schütze, R. (2024). A prospective qualitative inquiry of patient experiences of cognitive functional therapy for chronic low back pain during the RESTORE trial. Qualitative Health Research. Advance online publication. https://doi.org/10.1177/10497323241268777
Chang, R., Campbell, A., Kent, P., O’Sullivan, P., Hancock, M., Hoffman, L., McGregor, A., Laird, R., & Smith, A. (2024). Improvements in forward bending are related to improvements in pain and disability during cognitive functional therapy for people with chronic low back pain. Journal of Orthopaedic & Sports Physical Therapy, 54(11), 721–731. https://doi.org/10.2519/jospt.2024.12727
Chang, R., Campbell, A., Kent, P., O’Sullivan, P., Hancock, M., Hoffman, L., & Smith, A. (2025). Relationships between changes in forward bending, pain catastrophizing, and pain self-efficacy during cognitive functional therapy for people with chronic low back pain. Journal of Orthopaedic & Sports Physical Therapy, 55(4), 284–294. https://doi.org/10.2519/jospt.2025.13114
Chang, R., Smith, A., Kent, P., O’Sullivan, P., Hancock, M., & Campbell, A. (2024). How movement is assessed matters: Changes in forward bending during cognitive functional therapy treatment for people with chronic low back pain. Journal of Orthopaedic & Sports Physical Therapy, 54(3), 209–221. https://doi.org/10.2519/jospt.2023.12023
Au, I. P. H., Smith, A., O’Sullivan, P., Ng, L., Saraceni, N., Hoffman, L., & Campbell, A. (2025). Increases in trunk velocity during lifting are associated with improvements in disability and self-efficacy in people with chronic low back pain during cognitive functional therapy: A longitudinal analysis of the RESTORE trial. Occupational and Environmental Medicine, 82(5), 245–252. https://doi.org/10.1136/oemed-2025-110200
