Acute low back pain (less than 6 weeks) usually resolves on its own, with or without treatment.

Chronic low back pain - defined as pain lasting more than 12 weeks - is a different problem.

By this point, the initial mechanical insult has usually healed.

What remains is a mix of central sensitisation, deconditioning, movement avoidance, and often a fair amount of fear about what the pain "means."

This is the protocol we use in the Johor network for chronic cases.

The three categories of chronic LBP

Mechanical / movement-driven. Pain that modifies clearly with specific movements - better or worse with flexion or extension, better with walking, worse with sitting. This group does well with a directional-preference based loading protocol.

Central sensitisation dominant. Pain that's diffuse, poorly localised, doesn't modify much with specific movements, often with disturbed sleep and widespread tenderness. This group needs a graded-exposure and pain-education approach rather than local mechanical treatment.

Structural with nerve involvement. Chronic disc-related radiculopathy, spinal stenosis in older patients. This group often needs a combination of physio, imaging-guided injection, and in some cases surgical consultation.

The first job of any good chronic LBP assessment is figuring out which category you're in.

Treating category 2 like category 1 produces months of frustrated patients and no progress.

What the evidence actually supports

For chronic LBP, the strongest evidence is for:

Structured exercise (any format - pilates, yoga, gym-based, walking programmes).

Adherence matters more than the specific type.

Graded exposure - progressively doing the things you've been avoiding.
Education - understanding that hurt does not equal harm in chronic pain.
Manual therapy as an adjunct for short-term symptom relief, not a stand-alone solution.

What the evidence does NOT support as first-line for chronic LBP:

Passive modalities (ultrasound, electrotherapy) alone without exercise.
Spinal manipulation as monotherapy (fine as an adjunct).
Long-term reliance on rest or bracing.

Our 12-week protocol in Johor

Weeks 1–3: Thorough assessment to determine category. Education session (what the pain means, what it doesn't mean).

Identify directional preference if mechanical.

Weeks 4–8: Progressive loading aligned with category - McKenzie-style for directional preference, graded-exposure hierarchy for central sensitisation. Two sessions a week early, dropping to once weekly.

Weeks 9–12: Return to meaningful activity and work. Introduce loaded strength work.

Build self-management capacity so you don't need ongoing physio indefinitely.

When physio alone hasn't worked

If 12 weeks of proper conservative care haven't moved the needle, consider:

Imaging-guided injection - helpful for a defined pain generator (facet, nerve root, SI joint) when a specialist radiologist at KPJ, Gleneagles, Regency or HSA can target it.
Pain clinic referral - for complex chronic pain with significant psychosocial contribution.
Surgical consult - only with clear imaging-correlating symptoms and structural cause.

Typical Johor RM costs

Chronic LBP rehab: 12–24 sessions at RM120-250.

Imaging-guided injections RM 1,000–3,000 per procedure at private hospitals.

How PhysioJohor matches chronic LBP patients

WhatsApp us with: duration of pain, what makes it better or worse, prior treatments tried, and daily-activity impact.

We match you to a physio who actually runs evidence-based chronic LBP protocols - not just a weekly heat-and-massage session that keeps you coming back without getting better.

Related guide: Physiotherapy in Johor - complete guide