<b>Strategic Management of Lower Back Pain with Application of Different Dynamics</b>

Background: Low back pain (LBP) is the foremost contributor to years lived with disability worldwide, and its prevalence continues to rise, placing substantial demands on healthcare systems. Contemporary guidelines advocate a shift toward individualized, non-pharmacological, and biopsychosocially informed management; however, real-world translation of these recommendations remains inconsistent, especially in low- and middle-income countries where private physiotherapy clinics are often the primary point of musculoskeletal care. Objective: This study aimed to characterize the real-world application of diverse non-pharmacological treatment modalities and technology-enabled strategies for LBP by licensed physiotherapists in Pakistan and to evaluate the extent to which these practices align with current evidence-based guidelines. Methods: A cross-sectional survey was administered to 200 licensed physiotherapists with more than six months of private clinical practice. A validated, structured online questionnaire captured demographic data, clinical characteristics, and frequency of modality use. Data were analyzed descriptively and inferentially (p<0.05) to identify utilization trends and associations with clinician variables. Results: Of the respondents, 61.0% were female and 39.0% male. Passive thermotherapies were the most frequently employed interventions, with heating pads used by 50.0% of clinicians and cold packs by 42.5%. Stretching exercises were reported by 46.5%, followed by transcutaneous electrical nerve stimulation (37.5%), manipulation (37.0%), weight management interventions (36.0%), and yoga (34.5%). More advanced or specialist approaches were less commonly applied, including neurodynamic techniques (32.0%), dry needling (22.0%), and weight-bearing functional exercises (17.0%). Across all categories, only thermotherapy exceeded the 50% usage threshold, and active guideline-recommended strategies remained underutilized. Conclusion: Physiotherapy practice for LBP in Pakistan remains disproportionately oriented toward passive modalities, underscoring the need for targeted implementation strategies, clinical decision frameworks, and education initiatives to support a transition toward active, personalized, and evidence-informed rehabilitation models