The Gut–Brain–Back Connection: Why Low Back Pain Isn't Always Just a Spine Problem

Oct 30

8 min read

What an iceberg, your digestive system, and emerging research can teach us about persistent back pain.

“There! Right there! That's the spot!”

I hear some version of this regularly when I'm working with clients experiencing back pain.

Sometimes I wonder whether they're making sure I've found the exact place that hurts or hoping I'll stay there until the discomfort goes away.

Either way, they're giving me valuable information.

But here's the interesting part: identifying where someone feels pain and understanding everything contributing to that pain aren't necessarily the same thing.

Sometimes the painful area needs direct treatment. Sometimes we need to explore what's happening elsewhere. And often, it's a combination.

The iceberg: Looking beneath the surface

At Pelvicon 2026, pelvic health physiotherapist Michelle Lyons presented “Re-thinking Women's Back Pain: Why Pelvic Health Matters.”

She explored the importance of systems thinking—understanding how different parts of the body and different aspects of our lives influence one another.

One concept that particularly resonated with me was the iceberg model.

Imagine an iceberg floating in the ocean. The portion visible above the water is only a small part of the whole structure.

Pain can be similar.

The discomfort in your lower back is what you notice. It's what brings you into the treatment room. But beneath the surface, there may be contributing factors and relationships that aren't immediately obvious.

That doesn't mean every symptom has a mysterious hidden cause. It means we shouldn't assume the most obvious explanation is necessarily the complete explanation.

And sometimes, asking a few additional questions leads us somewhere unexpected.

What does your digestive system have to do with your back?

Possibly more than you might think.

Research has identified associations between gastrointestinal symptoms and low back pain, particularly in women.

Constipation, for example, can involve repeated straining, increased abdominal pressure, and difficulty coordinating the abdominal and pelvic floor muscles.

These processes may influence how the abdomen, pelvis, and lower back function together.

There are also connections between the nerves that process sensations from our internal organs and those involved in musculoskeletal pain. This can sometimes make it difficult to distinguish exactly where discomfort originates.

None of this means constipation automatically causes back pain or that resolving digestive symptoms will eliminate it.

But it does mean bowel habits may be relevant when we're trying to understand persistent back discomfort.

I see this clinically.

Some clients arrive wanting hands-on treatment focused exclusively on the area that hurts. And I understand that. When you're uncomfortable, you want relief.

But when they're open to exploring bowel habits, straining, pelvic floor coordination, and other possible contributors, I sometimes see improvements in their back symptoms that weren't happening when we focused only on the painful area.

It's a reminder that the questions we ask can be just as important as the techniques we use.

An emerging concept: The gut–brain–disc axis

Michelle introduced another concept I hadn't encountered before: the gut–brain–disc axis.

You may already have heard of the gut–brain axis, which describes the complex communication between our digestive system and nervous system.

Researchers are now exploring whether the gut microbiome—the community of microorganisms living in our digestive tract—may also influence processes associated with spinal disc health and chronic low back pain.

Intervertebral discs are the structures between the bones of the spine that help distribute loads and allow movement.

The proposed gut–brain–disc axis considers how interactions among gut microorganisms, the immune system, inflammation, and the nervous system might influence disc health and pain.

A 2026 pilot study by Sima and colleagues compared the gut microbiomes of 28 people with chronic low back pain and 28 matched participants without chronic low back pain.

The researchers found differences in microbial diversity and composition between the groups.

That's interesting, but it doesn't establish that changes in gut bacteria caused the participants' back pain.

And it certainly doesn't mean we can treat chronic back pain simply by changing someone's diet, taking probiotics, or trying to alter their microbiome.

The gut–brain–disc axis remains an emerging area of research. We don't yet have enough evidence to use it as an established explanation or treatment guide for an individual person's back pain.

So why bring it up?

Because it offers another example of how much we're still learning about relationships between body systems that have traditionally been studied separately.

And it reminds us to stay curious without jumping to conclusions.

Back pain, bladder symptoms, and the pelvic floor

The digestive system isn't the only connection worth considering.

Research has also identified relationships between low back pain and pelvic floor dysfunction, including urinary symptoms.

In a 2018 study by Dufour and colleagues, researchers assessed 85 women with lumbopelvic pain and found that many also had pelvic floor muscle tenderness, weakness, or other signs of dysfunction.

This was a specific group of women seeking orthopedic care, so the findings shouldn't be generalized to everyone with back pain. But the study reinforces why pelvic floor symptoms deserve attention during an assessment.

The pelvic floor muscles work alongside the diaphragm, abdominal wall, hips, and other trunk muscles to help manage movement, pressure, and everyday activities.

And these muscles need more than strength alone.

They also need to coordinate, respond appropriately to different demands, and relax when necessary.

Someone can have muscles that are tight or overactive and still experience weakness, poor coordination, or reduced endurance.

Pelvic floor dysfunction doesn't always announce itself as pelvic pain, either.

Sometimes the clues include urinary leakage, urgency, constipation, difficulty emptying, pelvic pressure, or discomfort involving the hips, abdomen, or lower back.

That doesn't mean the pelvic floor is responsible for every episode of back pain. It means these symptoms are worth asking about rather than assuming they're unrelated.

Thinking locally, regionally, and globally

Michelle encouraged clinicians to consider symptoms at several levels, which reflects how I approach assessment and treatment.

Locally, we look at the painful area itself. What's happening with movement, muscle activity, tissue sensitivity, and the physical demands placed on that region?

Regionally, we consider nearby structures and how they interact. The hips, pelvis, abdomen, and pelvic floor may all influence lower back function.

Globally, we consider the broader circumstances influencing someone's symptoms, recovery, and ability to participate in daily life.

That may include:

Hormonal changes and life stage, including pregnancy, postpartum recovery, and menopause
Sleep quality, stress, and fatigue
Previous injuries, surgeries, and other health conditions
Physical activity, work demands, and caregiving responsibilities
The nervous system's response to ongoing pain
Personal experiences, environment, and available support

Two people can experience similar back symptoms while having very different contributing factors and very different needs.

This doesn't mean pain is imaginary or simply caused by stress.

It means pain is a complex experience influenced by biological, psychological, and social factors. Thoughtful care takes those influences seriously without losing sight of the person's physical symptoms.

From reducing pain to building capacity

Understanding contributing factors is only part of the work.

The next question is: What can we actually do with that information?

Michelle emphasized building capacity, reducing unnecessary loads, and providing support while that capacity develops.

I love this perspective because it shifts the focus away from everything a person supposedly shouldn't do and toward what they can gradually become more capable of doing.

Sometimes we need to temporarily modify an activity or reduce a particular demand.

Sometimes we need to improve strength, endurance, coordination, or mobility.

Sometimes we need to address bowel habits, explore different movement strategies, or identify ways to improve sleep and recovery.

And sometimes hands-on treatment provides meaningful relief that makes it easier to move, exercise, or participate in everyday activities.

The goal isn't necessarily to eliminate every physical demand or avoid every movement that has been uncomfortable.

It's to help the body become better equipped to manage the demands that matter.

That process looks different for everyone.

Filling your self-care toolbox

One of the most important parts of my work is helping clients understand why we're doing what we're doing.

I don't want someone to leave with a list of exercises or instructions they feel obligated to follow without understanding their purpose.

I want them to recognize patterns in their symptoms, understand their options, and feel capable of making informed decisions about their own care.

That might mean learning how to modify an activity on a difficult day, recognizing when movement helps, understanding how bowel habits influence symptoms, or knowing when additional support might be useful.

We work together to identify strategies that are realistic, meaningful, and relevant to their lives.

And as their capacity changes, those strategies can change, too.

The goal is to build a self-care toolbox—not dependence on a single treatment, technique, or practitioner.

Better questions can lead to better care

The next time your back hurts, remember that the painful spot is important information, but it may not tell the whole story.

Sometimes the right approach is straightforward. Other times, persistent symptoms deserve a broader conversation.

What else is happening in your body? What patterns have you noticed? What activities are difficult? What helps? What makes things worse? And what would you like to be able to do more comfortably?

Those questions can help us move beyond simply chasing pain toward understanding what may be contributing to it—and what we can do about it.

Because meaningful care isn't just about helping you feel better during a session.

It's about helping you understand your body, build confidence, and have more choices in how you live and move.

Looking for a more comprehensive approach?

At Empowered Foundations, I combine pelvic health occupational therapy, hands-on bodywork, movement, and individualized education to help clients better understand and manage their symptoms.

If you're experiencing persistent back, hip, abdominal, or pelvic discomfort—particularly alongside bowel or bladder symptoms—we can explore whether a pelvic health evaluation or integrated treatment session might be appropriate.

Explore Services & Schedule an Appointment

Empowered Foundations Pelvic Floor Therapy & Bodywork

Thunderbolt, Georgia

Call or text: 912-372-8052

Educational note: This article is intended for general education and is not a substitute for individualized medical evaluation. Back pain has many possible causes, and new, severe, or concerning symptoms warrant appropriate medical assessment.

Serving Savannah, GA and the Surrounding Low Country Area