Statistically, it’s likely that at some point in your life you will experience low back pain. Billions of dollars are spent each year treating back pain, and hundreds of thousands of careers are devoted to treating it. Cause and severity of back pain vary widely from a simple sprain or strain to catastrophic trauma or even cancer. Thankfully, the vast majority of causes and severity tend to be on the benign end of the spectrum and for the purposes of this article, it is this end of the spectrum we will refer to. Although not life threatening, a nagging sprain, strain, or herniated disc can have a significant negative impact on your activities of daily life and well-being. As such, there is certainly merit for figuring out why this pain happens and how to treat it.
But what is “treatment”? Is it applying a strategy to address the root cause, or is it simply alleviating the symptoms associated with the root cause? Treatment should consist of the former, but more often than not, it falls into the latter category. Consequently, this is why pain tends to be cyclic. It seems as though patients alternate sides of a threshold line where on one side they are in pain, but just below the line, they are not symptomatic and written off as healed. However, we can do better than just shuttling you from one side of the threshold to the other. It begins by understanding the difference between removing the symptoms of pain and addressing the root cause of pain.
Pain is a funny thing. Because it’s highly subjective, the exact same stimulus can be registered by the brain in a completely different fashion from one person to the next. A large portion of this inter-individual variability can be attributed to the degree of personal identification the individual assigns to the pain they are experiencing. In other words, for some individuals the pain they experience is as much a part of their identity as their face is. They strongly identify the pain as a part who they are. The longer pain lasts, the stronger the identity becomes. In the same way, another individual may interpret the pain they experience as a mere annoyance to which they assign very little identity to. This is confounding for clinicians because a 70-year-old farmer can walk into their office with a fractured hip but only complain of a minor limp whereas another patient will show up in a wheelchair with a stubbed toe and rate the pain as 12 out of 10. With this in mind, one of the first steps toward addressing the root cause of pain is for the clinician to explain this nature of pain to the patient. This has to be done carefully, though. There is a fine line between patient education and being dismissive of the pain the patient is experiencing. The pain of the person with the stubbed toe isn’t any less “real” than the person with a fractured bone. But revealing the strong psychological component of pain with a non-contemptuous approach can definitely help the patient manage the pain they are experiencing at the battleground where it is taking place: the brain.
Again, we’re talking about low back pain where the major orthopedic and pathophysiological red flags have been ruled out. As far as pain generators go, we are primarily left with soft tissue damage and/or inflammation that is exacerbated by a particular load, position, or movement. Here’s a good bit of news: if you simply did nothing but avoid movement that aggravates the damaged tissue or inflammation, it’s not unlikely the pain will resolve within 6 weeks. So in a sense, time itself is a “treatment”. Not surprisingly, this is the route that many people take. But we have to ask, are we addressing the root cause or are we just “treating” until the symptoms to go away? By now you might be wondering what the root cause is. Well here it is: these low back injures happen because movement occurs at the spine when it shouldn’t, especially while the spine is under a load or in a position that it isn’t conditioned to handle. The key word here is condition. This is why the same low back injury can occur in one person while they deadlift 500lbs as someone else who is getting off of a toilet. While under a load that borders the condition/robustness of the spine, it needs to be in a good position, which we call a neutral position, and it needs to maintain adequate rigidity, or resist losing its position. So if movement isn’t happening at the spine, where should it happen? At the hip socket, plain and simple. If movement is resisted at the spine, movement is shuttled to the hips. There may already be a road block here because if movement is shuttled away from the spine and toward a hip joint that lacks proper mobility, the movement can become very awkward, like trying to write with your non-dominant hand. Thankfully, hip mobility is readily improved and new movement patterns can be readily learned, if one is so inclined. To avoid oversimplification, it’s worth recognizing that the spine is indeed built to move. That’s why it is composed of intersegmental parts called vertebrae, as opposed to being composed of a singular rod, like the femur. What I’m saying is that appropriate movement of the vertebrae needs to be accompanied by adequate stability/rigidity when needed. The majority of your stability and rigidity comes from correct positioning of the spine and recruitment of its supporting musculature. Musculature that is very responsive to conditioning. Can you see where we’re going with this?
The key to back pain prevention lies in the beauty of your body’s ability to adapt to stress. This is conditioning. Just as your resting heart rate and blood pressure decreases in response to repeated bouts of endurance training, your spine can be conditioned to remain injury-free at heavier loads by improving your ability to maintain a particular spinal position through a particular movement pattern. There are many movement patterns that the human body is capable of and are extremely valuable to learn. Of these movements, it is argued (and argued successfully) that the deadlift movement pattern is a great place to start and even better to master. As the strength expert Chris Duffin says “You need to know how to handle and pick up loads off the floor. This is a human proposition that you MUST know how to do.” The deadlift movement pattern encompasses the principles of back pain prevention: maintaining optimal spinal position while going through a movement while imposing a load. In addition to improved positioning maintenance, your soft tissues become stronger, more resilient to stress, and your bones become denser and stronger in response to the imposed demands.
The deadlift also promises a large degree of load capacity which in turn promises a large potential for adaptation and conditioning. Click here for Load Capacity article. (Load Capacity article coming soon).
At the end of the day, be mindful of the difference between addressing back pain symptoms and the root causes of back pain. In a perfect world we would never need “treatment” because injury would be nipped in the bud via prevention. But that’s far from reality. In fact, I recently experienced my own stint of low back pain because I lost spinal positioning while going through a movement under a load that challenged the condition of my spine (and the load won). Through my rehabilitation I had to put more emphasis on my kinesthetic awareness and employ improved movement and stabilization strategies of which breathing and core bracing where the most important. The thing you have to remember with injury is that although it seems like they hit you out of nowhere, there’s always a series of events that lead up to the injury. We all have a tendency to dwell on the moment the injury became painful but the answer to resolving your injury is hidden in the events that led up to it. Injuries are incredibly frustrating because, on a fixed timeline, it seems as though you are losing progress in performance. However, the downtime is truly an opportunity to figure out why it happened and how to fix it. Unfortunately, it’s not uncommon for clinicians to write off the activity the patient was doing at the time as “not good for them.” But more times than not, it’s not the exercise that’s bad for you, it’s how you do it. With that in mind, utilize injury downtime as an opportunity to reevaluate your movement strategy and condition your weaknesses.
This is not an attack on treatment or implying that treatment isn’t necessary. The point is that your body doesn’t “lack” treatment. Your body isn’t deficient in Biofreeze, tape, an adjustment, manual therapy, ultrasound, or cupping. You may look to these modalities for symptom relief, but don’t look to them for addressing the root cause. Look to your chosen movement/positioning strategies and investigate how they might be improved.
-Dr. Karl Huebner, DC, CSCS