Back Pain is something that will affect over 80 percent of the population (1-2). I would argue that number is higher. Back pain is also the leading cause of disability in the world (3). Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social experiences, accompanying actual or threat of tissue damage (4). I have had my own experience of suffering from low-back pain, and in helping in the treatment of low-back pain. There are many different phases of low-back pain (5). There is acute; this is when an insult to the tissue occurs, resulting in active tissue damage. Subacute is the timeframe of initial tissue damage, or three days following the initial tissue damage. Maturation is three weeks to three months. Finally, there is chronic, if pain persists longer than three months.
To understand how to manage low back pain, we must also understand what the underlying causes of low back pain are and can be. For years, it has been argued that if you had pain, there was a pain generator. You had a physical abnormality that was causing the pain, and you need to fix that. We still see that in treatment methodologies and prognosis of back pain. We would call that the pathoanatomical model of pain (6). As research and medicine has evolved, we have learned that this is not the only underlying cause of pain. Pain can be more complex than that, and you could have an abnormality that is asymptomatic, and it will cause no issues in your life. The ranges of pain can be caused by pathoanatomical causes, life stressors, depression, anxiety, social teaching, and learning about pain. Ninety percent of low back pain is nonspecific, meaning that there isn't a direct cause of the low-back pain. So, with all of that being said, what are the courses of action we can take in treating low-back pain (7)?
Low-back pain is very real. Dealing with low-back pain myself, I can testify to the crippling effects it can have on an individual. I went from being an active individual who lifted regularly, played sports and enjoyed recreational activity, to struggling to put my pants on and even walk the shortest of distances. It also put me into a precarious position as a strength coach.I initially went to a sports medicine orthopedic doctor. I was dealing with what I initially thought was a hip injury. He determined it was a disc herniation L5-S1. We didn’t do imagining because I was not presenting any red flag symptoms. A month went by and I had for lack of a better term a flare up. I began having issues using the bathroom and was in some of the worst pain I have had to deal with in my life. I ended up in the emergency room due to the fact I did begin to present troublesome symptoms. I received an MRI and spent almost 24 hours in the hospital. It was discovered I did have disc herniations L4-L5 and L5-S1 that were pressing on my sciatic nerve. I was also having issues with my pudendal nerve. I was scheduled to see a Spine Specialist. The doctor I saw was incredible. He took his time to understand the things that were important to me. He listened and was up on current research. We talked about lifting weights and we decided it was best to not go the route of surgery. Because the symptoms had lasted over 9 months he did want me to see a pain doctor. I scheduled an appointment. Two days before my appointment I woke up and was unable to move. The pain had gotten so bad I laid in bed wondering what the cuss happened to me. When I would stand for brief moments I looked like the boogeyman from the powerpuff girls. When I visited the pain specialist I didn’t feel heard. She suggested gabapentin and that was all. We didn’t discuss treatment options or a plan to get better. She also suggested physical therapy because my “core” might be weak…If you can plank for 2 minutes straight with 90 lbs on your back, farmer carry double your body weight, or lift the totals I was lifting I don’t think that is the issue...I saw her one more time a month later and had little progress outside the fact I stopped taking my medications because I didn’t like the way they made me feel. I felt hopeless at times and wondered what were options I could pursue to get better. I’d like to talk about methods people use and I was presented with for treatment/rehab, and what treatments are the gold standard.
Myofascial Massage and Releases:
This is a form of rehab I hear frequently talked about. It does offer some minor acute aid, but does not create any physiological change in fascia, and does not treat the issue at hand (8).
Manipulation/Chiropractic:
Much like massage therapy and fascial release, this can help with minor acute relief, but causes no physiological changes. Nobody can produce enough force safely and accurately enough to place a vertebrate back into place (9).
Corticosteroid injection:
Corticosteroids are low-risk, but have inconclusive to low rewards. Not everyone responds to this intervention in the same way. Some individuals swear by them, while others notice little to no difference. They are short-term, with the strongest effects lasting one week and tapering off over the course of three months. They do have negative effects if used frequently over time, increasing the risk of bone fractures and causing osteological weakness.(10)
Surgery:
High risk and expensive, surgery does not guarantee the desired outcome. There are several surgeries; some more invasive than others. Surgery can be a great option for some qualifying individuals but not for everyone.
Medications:
Medications are not always an appropriate treatment and some have a high risk of addiction.
Exercise with education:
This is what the research and I would consider to be the gold standard. There are several different forms of exercise interventions, from walk therapy, yoga, Pilates, and strength training. I do carry my biases, and believe strongly in strength training as the most efficient mode of therapy (11).
Let’s begin with the gold standard and with a little pain education what beliefs we need to know about ourselves. We are not broken; pain is temporary, and we will overcome it. Pain is part of the human experience, and it shouldn’t prevent you from living your life. Pain does not always equal tissue damage (4). We should begin regular daily activity as soon as we can. Bed rest does not improve symptoms of low-back pain (12). It is safe to walk, run, jump, sit, sleep how you feel comfortable; bend over, twist (and shout). The body is incredible and resilient. It is not a machine, and is ever-adapting and changing to the demands we place upon it. My biases lay within resistance training. There is research that shows that this is one of the best forms of exercise for low-back pain (11). There are several other forms of exercise that work as well; Pilates, yoga, and walking, to name a few. There are benefits of both physiological and psychological that occur. Eliminating the idea that we aren’t capable of certain movements or fear they will make it worse, goes a long way. Taking our body through ranges of motion, we are capable of eliminating fear of movement and reintroducing the movement patterns we have been incapable of getting into. Exercise improves strength. (Getting stronger will not guarantee that we will become pain-free, but it does mitigate the risk of flare ups in the future (11). It improves confidence in one's self. It becomes empowering to be able to move again.
That all being said, with resistance training, we can't just jump in and expect to return to our previous performances. We must learn to manage our expectations of where we are at, and the timeline it will take us to get to feeling healthy. With managing expectations, I'm a believer in setting goals. I believe our goals should be process-oriented. We should not set number goals, because our progress will not be linear, and we need to avoid discouragement and falling off of our routine that has been working.
With my own rehab, this has been a process that has proven to be successful. I have had to learn that I will not jump back into the gym and start deadlifting 435 pounds, or squatting. Those numbers are abstract, and for right now, do not matter. My progress and goals are, “Did I go to the gym today?” “Did I squat or deadlift?” “How did it feel?” “Did I get up and do a physical activity I enjoy?” When I change my focus away from number goals and to process-oriented thinking, I find myself getting less discouraged and ready to tackle my rehab. I have created a plan with our great coach Mike Stroud. Currently I am making progress. It’s not always as fast as I would like, it’s not always as clean as I would like. When I get discouraged I take a step back and look how far I have come. I vent to Mike and he listens and talks about the route I can take to return to the activities that matter to me.
Low-back pain is something that a majority of people in this world are going to experience in life. It can affect the world's greatest athletes to sedentary individuals. (Those who reach activity guidelines and are healthy weight have lower risks.) Our management and expectations of low-back pain have massive effects on how we overcome it. We must remember to stay active, and that the pain is not going to last forever (12). As soon as we can return to activity, we should.
There are several options we can use to treat low-back pain, but exercise and education appear to produce the best results. Without the presence of red flag symptoms, imaging is not necessary.(13) When seeking out help for low-back pain, we should strive for gold standard treatment plans. Searching out a qualified physical therapist and/or strength coach is a good place to start. You are not inherently broken, and are capable of overcoming this pain. Our goal shouldn’t be to eliminate pain altogether, because that is not possible. The goal should be to learn how to manage the pain, decrease the time we have it, and the frequencies in which it occurs.
Freburger J.K., Homes G.M., Agans R.P., Jackman A.M., Darter J.D., Wallace A.S., Castel L.D., Kalsbeek W.D., Carey T.S. (2009). The Rising Prevalence of Chronic Low Back Pain. Archives of Internal Medicine, 169 (3), 251-258.
National Institute of Health. (2009, Aug 13) Low Back Pain Fact Sheet. Retrieved from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet
Centers for Disease Control and Prevention. (2019, Sep 9). Disability and Health Related Conditions. Retrieved from: https://www.cdc.gov/ncbddd/disabilityandhealth/relatedconditions.html
International Association of the Study of Pain (IASP). (2017, Dec 14). IASP Terminology. Retrieved from: https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Pain
Nijs J., Meeus M., Cagnie B., Roussel N.A., Dolphens M., Oosterwijck J.V., Danneels L. (2014). A Modern Neuroscience Approach to Chronic Spinal Pain: Combining Pain Neuroscience Education With Cognition-Targeted Motor Control Training. Physical Therapy, 94 (5), 730-738.
Ludewig P.M., Kamonseki D.H., Staker J.L., Lawrence R.L., Camargo P.R., Braman J.P. (2017). Changing Our Diagnostic Paradigm: Movement System Diagnostic Classification. International Journal of Sports Physical Therapy, 12 (6), 884-893. DOI: 10.16603/ijspt20170884
Koes B.W., Van Tulder M.W., Thomas S. (2017). Diagnosis and Treatment of Low Back Pain. British Medical Journal, 332 (1), 1430-1434.
Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T. (2008). Three-dimensional mathematical model for deformation of human fasciae in manual therapy. Journal of American Osteopathic Association, 108(8):379- 390.
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Imamura M., Imarura S.T., Targino R.A., Quezada L.M., Tomikawa L. C. O., Tomikawa L.G.O., Alfieri F.M., Filippo T.R., da Rocha I.D., Neto R.B., Fregni F., Bttistella L.R. (2016). Paraspinous Lidocaine Injection for Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial. Journal of Pain, 17(5), 569-576. DOI: 10.1016/j.jpain.2016.01.469.
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