What makes low back pain such a hot topic? Why is it happening? And what can we do about it?
The stats about low back pain (LBP) are pretty astounding. Astounding in the “Holy moly that’s a lot” kind of way. Globally the lifetime prevalence is around 40%, meaning about 40% of the people in the world will experience LBP in their lifetime (Hoy et al., 2012). In the U.S., specifically, LBP is the second-highest source of disability and has an estimated lifetime prevalence of 80% (Fredburger et al., 2009). Holy moly, right?
There are many theories regarding why LBP occurs, but the most accepted reason is our relatively recent change to a sedentary, predominantly seated lifestyle. However, there are so many theories out there that nothing is for certain.
Researchers argue endlessly about what kind of treatment is the best, but for far too long, all back pain was treated the same. Nowadays, treatment is specific to the subclassification of LBP. Regardless of the type of pain someone experiences, the most important part is to be educated on pain and anatomy. If you already experience back pain, this article will give you the information you need to understand your pain. If you don’t experience LBP, remember that the best form of treatment is prevention; this too will be addressed.
What does the research say?
First and foremost, when discussing research, it is absolutely essential to understand the system within which research functions. Research is a hierarchical system. Similar to a monarchy of power, we have ourselves a pyramid structure.
Instead of giving you a whole lecture (which could actually be a whole course) on what each of these sections means, I will cut straight to what is relevant to us.
Opinions, reports, and observations are necessary in life and in research. However, they are inherently subjective as they come from data based upon an individual’s perspective. Researchers like experiments; they give quantifiable answers. But not all experiments are performed well. It is common to read a report and find heaps of flaws in their rigor, which unfortunately reduces its applicability.
Imagine if you discover a cobbler skipped on a few seams on your shoe. Would you believe that shoe is of high quality? If you liked how it looked, you might give it a try. Would you recommend your friend to wear that cobbler’s shoe? Maybe so. How about recommending your friend to wear that cobbler’s shoe if their wellbeing depended upon it? Probably not. Being the good friend that you are, I imagine you would suggest a cobbler that paid attention to the details and created a high-quality shoe that would provide the specific type of support your friend requires.
The same thing goes for research. Why would we base our wellbeing off something that has pieces missing? That’s where reviews come in, which serve an equivalent purpose to the friend’s cobbler recommendation. Reviews, or more precisely, systematic reviews and meta-analyses, take the highest quality experiments relating to a specific question and reanalyze the data. The new data presented is a consolidated version of many similar experiments. The outcomes of a review give us a specific answer to a question from all the relevant experiments out there. Systematic reviews are few and far between relative to the number of experiments out there, but when you find a review that answers the question on your mind, it’s as good as gold!
The only things that top a review are clinical guidelines. If reviews are gold, these are the diamonds. The most knowledgeable in the field produce these, and they take all the reviews and experiments out there to create recommendations for how all clinicians should approach treatment. If a practitioner decides not to follow these recommendations, it can be called malpractice.
How do we classify Low Back Pain?
Why did I run through all of this? Well, for me to break down low back pain (LBP), we must be on the same page so I can reference research with you completely understanding why it is important. Now that I’ve gone through the role of research let’s look at classifications of LBP. Then we can jump into different approaches to management.
Researchers do many different things to classify LBP. Technically there isn’t a universal rule to classifying. Basically, what I’m presenting to you is a consolidated form of all the knowledge I’ve acquired about LBP in a simple and accessible way.
Different ways to classify low back pain:
1) LBP by duration…
Acute = less than 1 month
Subacute = 1-3 months
Chronic = more than 3 months
Acute pain management is all about local structures and reducing inflammation. Once pain moves into the chronic stage, we begin to see neurological adaptations. This means that treatment expands beyond the local structures. It turns more into a focus on the neuromuscular aspects of movement.
2) LBP by source…
Joint pain feels quite achy and often stiff while nerve pain feels sharp, hot, or burning. Muscle pain tends to feel sore and cramp-like. Ligaments and tendons tend to feel less; except for during movement when pain becomes precise and intense.
3) LBP by symptom…
Radiating pain vs Local pain
Flexion pain vs Extension pain
Expansion pain vs Compression pain
Radiating pain would be a sign of nerve involvement. Local pain would suggest joint, muscle, tendon, or ligament injury. Flexion pain would indicate disc involvement. Extension pain would allude to joint involvement. Expansion pain would make me think the pain is on the opposite side of where you rotate or bend; it makes me consider the structures being stretched. Meanwhile, compression pain would be on the same side you rotate or bend, so it takes my thoughts towards what’s being shortened.
PLEASE NOTE: These descriptions are basic guides and there are always exceptions!
How do we develop Low Back Pain?
All of these descriptors tell a story of what is actually happening to this specific back. Why is this important? Because the way to treat flexion pain is often opposite to how you’d treat extension pain. The tools you’d use to treat acute pain would be different than how you would treat chronic pain. The strategies to heal nerve pain are not the same as how you would heal a ligament injury.
The question I always ask myself when seeing a new person with LBP is, “why did this start?” Sometimes it can be quite simple, such as falling during a footy game. Sometimes it can seem to occur without reason. Most often, though, it makes sense.
Our lumbar spine (the low back region of our spine) gets heaps of movement relative to its upper (thoracic) and lower (sacral) connections. Because of this mobility, it often generates the most amount of use. If we have a healthy spine, then all the lumbar segments would share the load and movement would be evenly dispersed. If we have an abnormally restricted thoracic spine or hip/pelvic region, or a few segments of restriction in our lumbar spine, then our few mobile lumbar regions take on even more work.
Our joints, spinal segments included, are really only designed to last a certain timeframe doing the amount of activity that they have evolved to do. So if we use our body more than it was intended, then we get more wear and tear. Or if we hold our body in a posture that is not a natural loading position, then we get more wear and tear. Basically anytime we misuse a part of our body, we get more wear and tear, which means greater risk of injury.
Let’s think about this in practice. Say you’re an average person who sits regularly throughout the day (commuting, eating, working, relaxing, etc.). Most of us will sit with a flat or rounded lower back, or an over-exaggerated curve, aka not in our natural lumbar curve. Plus, our local and surrounding joints and muscles become stiff and shortened from maintaining this same position. This all creates more reliance on our lumbar spine for movement, which creates greater segmental loading, and more wear and tear. This causes muscular and neural adaptations that stray from our natural patterns. Over time, this leads to overuse and injury in our lower back, where we often feel our pain, while other regions are underutilized.
You can think of it like having a few doors entering into your house. All of them, but one, are a bit more difficult to use. Maybe one lock is fiddly. Maybe another door always slams. And maybe another usually gets stuck. So instead, you always use the same door. Eventually, that one door gets worn out, and things keep on breaking. So you to fix its hinges, or fix its knob. The other three doors get used less and less and become more and more problematic. Maybe rust starts to form. Or maybe it squeaks when opening. Or maybe it doesn’t open at all anymore. What do we do here? Do we keep fixing the same one door, or should we fix all the doors, so the problem doesn’t recur? Wouldn’t it have been best to just fix those little issues at first before it became one whole big problem? Technically there’s not much of a right or wrong answer, but an answer that promotes the process to figure out what is best for each person.
How do we prevent Low Back Pain?
Rewinding back to research, let’s go over a recent systematic review. Sadler et al. searched databases to find relevant trials that answered the question, “Which factors of our musculoskeletal system increase the risk of developing low back pain?”
Unfortunately for those of you that are pregnant, have had previous low back surgery, or have been diagnosed with cancer, these three qualities were excluded from this study. Therefore, the findings cannot be directly applied to you. However, that does not mean they cannot be of benefit; it just means that your circumstance has more components to it than being just plain ol’ LBP. So you can still give this information a try, but remember there are other pieces to your puzzle.
Now, let me break this research down. In 2017, Saddler et al. published their findings that looked at how different aspects of our body that could influence LBP. Or more precisely, which boney, muscular, or ligamentous structural changes could increase the risk of developing LBP. What did they find?
restricted side bending,
limited lumbar lordosis,
reduced hamstring length
increased your chances of having LBP
No other musculoskeletal source was found to have significant effects on increasing your risk of LBP. That means (1) low back flexion and extension range of motion, (2) quadriceps flexibility, (3) fingertip to floor distance, (4) back muscle strength and endurance, (5) cross-sectional area of spinal erector muscles and quadratus lumborum, and (6) abdominal strength do not predict the chances you will have low back pain. Only decreased side bending, lumbar lordosis, or hamstring length are indicators of an increased risk!
What does that mean for us? Pretty simple; if you want to reduce your risk of developing LBP, focus on these three areas. How? Here’s some advice:
1) Practice your pelvis tilts!
Copy cat the video above. Start with placing on hand on top of your bladder and the other where your spine meets your pelvis. Play with these two points as leverage. As one hand folds inwards, the other lengthens towards the ground. Once you find this comfortable, feel free to reposition your hands to where you please (I like mine on my pelvis so I can feel for symmetry between right and left). Then start to add your whole body into this by weight shifting forward and back. Notice what parts of your body activate and what parts feel lengthened. Use this information to guide you in understanding how you typically hold your pelvic position. Ideally, when you come to rest in a neutral position, there is a slight lower back curve (slight anterior pelvic tilt), your pubic bone points to the ground just between your arches and your tailbone points to your heels. Yes, this does leave you with your body weight slightly more in the front half of your feet; particularly, the balls of your feet instead of your toes.
Why is this important? Our pelvic tilt directly impacts how our spinal curve rests. As we talked about before, we want to promote having a natural, neutral curve. That means if our pelvis is too posteriorly tilted (tailbone tucking underneath us), then our lumbar spine tends to rest in a flat or rounded position. If our pelvis is too anteriorly tilted (pubic bone reaching behind us), then we get an over-exaggerated lower back curve. These two extremes generate excessive loading through our lower back.
2) Work through those hammies of yours.
Since our hamstrings attach to our sit bones (aka our ischial tuberosities) at the base of our pelvis, our hamstrings have a direct relationship to our pelvic position. Most of us have a hard time differentiating between a pure hip flexion movement versus a posterior pelvic tilt and lumbar flexion movement to generate hamstring length. This video demonstrates how to enter into a forward fold with hip flexion as the primary driver.
Begin with finding your neutral (slight anterior tilting) pelvic position that we worked with in the last video. Then, gently bend your knees as you reach your sit bones directly behind you. Directly behind you is important, not above your pelvic height! Keep reaching behind you as your weight shifts to your heels, and you slowly straighten your knees. **The moment you start to feel your pelvic position begin to tuck under (pelvis starts to tilt to the ground), and your lower back slightly round, stop straightening your knees, round your whole spine, and roll up to standing.**
This is designed to help us learn what is hip vs. what is pelvis and low back. If we can find this more clearly then when we go to other activities, particularly sitting, we can find lengthening of our hamstrings to maintain a neutral pelvis. This will give us movements that will minimise lower back loading.
3) Do more side bending.
Ooh, my favourite! I am a total side bending fanatic. Something about it just feels so relieving after a day living our linear, frontal plane lives.
With side bending, the key is finding an even bend through all segments, instead of our far easier move to hinge at a couple of segments. So that is why this video is demonstrated with one hand reaching upwards while the other hand slides down. This keeps our spine lifting and lengthening, rather than folding. Say we have our left hand reaching up and our right hand sliding down, to deepen in this, shift your weight to the left and take your pelvis over to the left. Only let yourself go as far you will be able to come up from. When you come up, draw a half-circle with your right hand, which forces your obliques to switch on.
Two-thirds of this review’s outcomes made perfect sense, but this one third took me by surprise. Why is that? Well, it isn’t the typical pathway to treat lower back pain. After some thinking, it does make perfect sense from a preventative perspective. If we are trying to minimise overloading of our lumbar spine, and our mechanics are “normal patterns,” then it only makes sense to use our spine in multiple planes of movement as it is designed to do to challenge our loading patterns.
What do we do after some training?
Yes, training our body with specific exercises is essential to developing our movement patterns. But I would also like to point out that the MOST important part is finding ways to integrate the exercises into daily life. What’s better than not having to do an exercise because your daily life promotes feeling good? So here’s a tip list:
1. Find a time a day when you’re out and about or doing a typical daily task
2. Slow down that task and pick a part of your body to watch (AKA low back)
3. Then, see how you can alter your movement patterns while completing this task to benefit that region (This can be from the above videos!)
4. Play with that movement by finding more ways and times to integrate it into other activities
5. Even take it to the point of recognizing what that region of your body is doing when you are in a stressed time of a day
6. Finally, find a way to move that region out of the held pattern even while stressed
Why does this work? Well, it is all neuroscience and the cerebellum, which means building patterns and sequences. When we are in an environment or situation, we reproduce certain patterns. When we are in a tense situation, we tend to have different motor patterns than when we are in a relaxed environment. Most of our bodily pain comes on during the times of reduced awareness, when we are preoccupied with something else. Then, of course, when we are stressed, we are so beyond preoccupied, we hardly notice what our body is doing. This is the perfect time to break a motor pattern and rewire your brain to move in a beneficial way! All of this will help your body to find comfort and pleasure in movement, so your practice time doesn’t have to be dedicated to regaining balance but dedicated to growth and expansion.
In other words, find ways to move your pelvis, low back, and legs that differ from your usual patterns as you go about your day. Then, maybe, you will notice how your hamstrings activate if you side bend much, or when you change your low back curve. That way, you have less of a chance of going through the process of healing your LBP.
Prevention is the best medicine, right?
How do you treat your Low Back Pain?
It would be irresponsible for me to tell everybody with LBP to do the same thing. That is why there is only one rule of thumb that I follow and repeat regardless of the condition…
If it feels good,
If it doesn’t feel good,
don’t do it.
Pain is not a process to push. In opposition to the classic belief of “no pain, no gain,” when we are dealing with an injury, it is more like “pain means less gain.” This does not mean to be afraid of pain, but it means to be aware of your pain. Pain is a way our body communicates to our brain, telling it something is not going well. Pain causes changes to the muscles activated and can cause changes in our brain that alter motor patterns in the long-term. If we continue to move with pain, then our brain continues to recognise that there is a threat to the region. If there is an ongoing threat, then our stress response continues. If our stress response continues, then the healing response doesn’t occur to its fullest capacity.
The best way to manage pain is to recognise it and respect what it is telling you. Simply watch what causes your pain and what eases your pain. Find descriptive language to discuss the sensations you feel. Engage with learning how your system responds to having pain. Then, find a way to subtly move that creates a pleasurable, relieving sensation in your body; this is your body telling your brain that it is safe and that it is okay to ease protection. This is when healing occurs best! Our healing process isn’t very effective when we are stressed simply because our energy goes towards the defense force instead of the cleanup crew.
I would say 75% of the job any type of musculoskeletal therapist has is learning to interpret the story somebody is sharing about his or her pain. Then, that last 25% is all about applying the right research and knowledge to their treatment. If you can watch the story that unfolds when you are in pain, then you can provide your treating practitioner with the information they are seeking, and you can provide yourself with the opportunity to better self-manage. If you can recognize the signs of oncoming pain or the signs of easing pain, then you could learn what the source of your injury is and what helps your body to heal itself.
What is more liberating than
being to care for yourself?!
Use all the tools we have talked about, use all the knowledge you have learned through reading this and through your experience with injury, and trust yourself to find connections with areas of apprehension. Our body wants to heal, and our body knows how to heal. All we have to do is use our minds to help promote those healing patterns.
Please note all of the information provided is intended for personal education; this information is not intended for diagnosis and/or treatment. Seek a healthcare professional for your health concerns.
Cleveland Clinic. (2019). Musculoskeletal Pain | Cleveland Clinic. [online] Available at: https://my.clevelandclinic.org/health/diseases/14526-musculoskeletal-pain [Accessed 23 Jul. 2019].
Freburger, J. K., Holmes, G. M., Agans, R. P., Jackman, A. M., Darter, J. D., Wallace, A. S., … & Carey, T. S. (2009). The rising prevalence of chronic low back pain. Archives of internal medicine, 169(3), 251-258.
Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., … & Buchbinder, R. (2012). A systematic review of the global prevalence of low back pain. Arthritis & Rheumatism, 64(6), 2028-2037.
Low Back Pain Fact Sheet. (2019, May 14). Retrieved July 23, 2019, from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet
Illustration by Ksenia Sapunkova
Edited by Sarah Dittmore