If you suffer from chronic back pain, read on...
There’s little doubt that today the Western World is in the midst of a back pain epidemic. The numbers are staggering: there’s an 80% chance that at some point in your life you’ll suffer from severe back pain, and treating back pain costs about $26 billion annually in the US alone.(1)
You’ve probably heard the same story a number of times from friends, relatives or colleagues, they just bent over to pick something up, they weren’t even straining, but something ‘just went’. About 90% of those injuries will clear up in a relatively short period of time, causing some discomfort but no lasting pain.
It’s the 10% of back pain that doesn’t go away, turning into a chronic, debilitating, and often life ruining condition, which poses a major problem for human beings today. It’s also a fact that the medical establishment has largely failed to develop any significant understanding or treatment of the condition to date and in this vacuum it has largely resorted to possibly unnecessary pharmaceutical and surgical intervention.
So what’s going wrong with our backs? Is it all down to poor lifting technique and posture?
Poor lifting technique certainly plays its part, along with poorly maintained core musculature, bad posture and limited flexibility. A body showing signs of muscular and postural imbalance is primed for back pain even when moved properly.
So what can we do?
“A strong back knows no pain” is a phrase used by Kieser Training, a large multinational gym company. Kieser promote the use of machines that isolate and strengthen individual muscles, thus ‘protecting’ the joints and spine. We think they’re dead wrong, and here’s why:
This type of 1 dimensional machine training does exactly what it says on the tin, isolating and working each muscle individually. This makes your core musculature (which stabilises you when moving and lifting) almost completely redundant, and further reduces your flexibility. It creates a series of muscle imbalances – a leading cause of back pain.
A balanced body knows no pain
The key to avoiding and relieving back pain is a balanced body, achieved through functional training, strong core musculature and regular mobility and flexibility work (also known as pre-hab). This is the difference between working out 3 dimensionally: pushing, pulling, lunging, twisting using your whole body, and working out 1 dimensionally, isolating everything. Working out 3 dimensionally develops a balanced body which provides a solid base for your spine and promotes flexibility.
Allowing one muscle to become too short and tight or too long and loose directly affects the other muscles around it, creating an imbalance in your body. Many leading physical therapists have reported significant success in relieving back pain by working on muscles that are not located in the back.
According to leading physical therapist and soft tissue release innovator Stuart Taws, 90% of all chronic lower back pain is directly or indirectly caused by muscular imbalances in the muscles below:
1. Quadratus Lumborum (QL)
3. Gluteus maximus,
4. Glueus medius and minimus
5. Psoas (Hip Flexor)
In his experience the spinal erectors and abdominals are least involved in causing back pain.(2)
At Optimised we also see (along with the muscles mentioned above) a strong correlation between lower back pain and tight plantar fascia (muscles at the bottom of the foot), calves and hamstrings. These muscles are connected and referred to by Thomas Myers, a leading manual therapist, as the Superficial Back line.(3)
Simply chasing the effects of pain such as tight back muscles and pinched nerves does not bring long term relief. We need to look beyond the effects and locate the root cause of back pain, which is probably not in your back. Today we tend to spend all our time attempting to ‘fix’ the effects of the problem rather than the problem itself. When we fix the cause, the rest follows.
Physical solutions for back pain
A sedentary lifestyle, hunched over a computer or the latest games console, never mind many an inert hour sat ogling the television is definitely going to contribute to the muscle imbalances described above. You need to move your body.
Bad posture is also a factor in back pain, so make an effort to sit properly too.
If you suffer from back pain, try to find a personal trainer who specialises in functional and corrective exercise and stretching (like we do with our Optimised Perform personal training). A postural and movement assessment should be an essential part of your first session, and without one (and an appropriately designed program based on it) exercise might do more harm than good.
Sports therapy, soft tissue therapy, myo-fascial release and physiotherapy and can also help - these are all services we find of use at our Manchester city centre clinic, personal training gym, and yoga / movement studio.
For strengthening of the core musculature, Pilates can also be very beneficial, but be sure your instructor is aware of any existing conditions.
Nutritional stress and your back
What you eat can also contribute to back pain. Food intolerances, for instance to gluten and dairy, can compromise the integrity of the core muscles which provide stability for your spine. Because intolerances cause irritation and inflammation in the intestines, your brain ‘switches off’ certain nerve impulses emanating from your spine which usually keep your core muscles engaged and provide essential lower back stability.
Taking on adequate amounts of water is important too: 75 percent of the weight of your upper body is supported by the water volume stored in the disc core of your vertebrae. Sufficient water can help to ease back pain.(4)
In terms of supplements, the respected doctor, nutritionist and health writer Dr John Briffa suggests 1500 – 2000mg of vitamin C helps in collagen formation – an essential component of the intervertebral discs in your spine. Dr Briffa also recommends 500mg of glucosamine sulphate 3 times daily, as this building block can help stimulate healing and repair in damaged discs.(5)
So why is back pain still such a big problem?
What we’ve discussed so far are techniques to prevent and eliminate the pain signal being generated at the site of physical stress or injury. Traditionally this is how we see pain – we have an injury that triggers a pain response and we experience pain.
Therefore to deal with the pain we must investigate the physical stimulus behind it and fix the injury, often meaning a range of scans, appointments with consultants, epidurals and painkillers with accompanying side effects, and when all else fails, surgery. But is it all necessary?
“After undergoing a full range of diagnostic tests, 85 percent of patients suffering from lower-back pain still don’t receive a precise diagnosis. Instead, their pain is parceled into a vague category, such as lumber strain or spinal instability. A 1994 study published in the New England Journal of Medicine imaged the spinal regions of 98 people with no back pain or back-related problems. The pictures were then sent to doctors who didn’t know that the patients were not in pain. The end result was disturbing: Eighty percent of the pain-free patients exhibited “serious problems” such as bulging, protruding, or herniated discs. In 38 percent of patients, the MRI’s revealed multiple damaged discs. These structural spinal abnormalities are often used to justify expensive treatments like surgery, and yet nobody would advocate surgery for people without pain.”(1)
The problem is that although techniques such as manual therapy outlined above do achieve considerable success both in preventing and relieving chronic pain signals, it’s not enough to treat only the physical aspects of pain. Treating the problem 3 dimensionally means looking at the whole human response, and at what happens in your mind and central nervous system when pain signals are received there.
The psychological paradigm – is back pain a disease of the nervous system?
New research into chronic back pain suggests that it’s our emotional, negative perception of pain that determines the level of discomfort we feel. Chronic pain is sensed predominantly by our mind, not at the location of the pain.
The pain signal is just an electrical impulse which is delivered to your brain. It’s your brain that decides how to understand it and what actions to take.
It works like this: our peripheral nervous system tells us we are experiencing pain by sending electrical messages to the central nervous system (brain), saying ‘hey, we have something wrong here!’. The part of your brain dealing with pain messages decides what level of priority to give it by passing the message on to the area that creates emotions. Your brain needs to do this because at the same time it’s also receiving millions of competing messages from your mouth, nose, eyes and of course the rest of the nervous system, plus other parts of your brain.
For instance, if you have chronic back pain and you see a bus heading straight for you at considerable speed, your brain will prioritise the visual and nervous signals telling it that you’re about to be flattened, above the nervous system telling it that you’ve got back pain, and if only for a few seconds, you don’t have back pain anymore, simply because your brain chose not to feel it. The pain signal didn’t go away. Your mind just chose not to do anything with it.
The pain signal itself doesn’t hurt that much. Our minds are acting to amplify the pain signal because of the importance our emotions and psychology place on it.
Sean Mackey, MD, PhD, an associate professor at Stanford University and director of the pain management division says “We’re now beginning to recognize that you can’t talk about chronic pain without talking about its psychological aspects. It’s a condition in which signals from the body are literally distorted by the brain.”(1)
A number of scientists and psychologists have developed therapies to train the mind not to assign negative emotions to chronic pain, such as cognitive behavioral therapy and self-regulatory therapies, which appear to be successful.
Of course, none of this means you’re crazy, deranged, or about to start howling at the moon. It just means that instead of only fishing around in your back for problems, we also need to re-train your central nervous system to help you out too.
Retrain your brain…
If you’ve got back pain, you probably don’t think pain is your friend, but actually it’s probably the best friend you’ve ever had. It’s just there to tell you that there’s a problem – the affected muscle is asking for help in the form of protection in the same way that if you touch a hot kettle your brain protects your hand by moving it away.
When we get an injury to one of our muscles, that muscle (peripheral nervous system) sends a message (pain impulse) to our brain (central nervous system) asking it for help.
Our central nervous system interprets the signal by telling the muscle to shorten at the site of injury and initiate other precautionary procedures. That keeps the injured muscle short, and in 90% of back pain it relaxes once the injury has healed itself and the peripheral nervous system stops sending the pain impulse to our brain.
When we experience something, our brain re-organises itself (which is known as neuroplasticity) in order to remember it, and to remember a response to that experience.
It’s like when you try a food and don’t like it. Your brain re-organises its connections to remember that food, what it looks like and that you should avoid it in future. I have a friend who we’ll call R (we’ll keep his name secret so we don’t embarrass him) who, at the age of 31, won’t go near a raw tomato (cooked are fine). When I ask him why, he says he doesn’t know, it’s just the way it’s been since he was a kid. He picks them out and puts them to one side.
Sometimes with chronic back pain it’s exactly the same. Your brain re-organises its connections in order to remember what to do – keep an injured muscle short and restrict movement, for instance.
Then, instead of those connections disappearing when the muscle and peripheral nervous system stops sending the pain impulse, our brain retains the connection, and keeps telling our peripheral nervous system to keep that muscle short – and might keep doing so for a long, long time.
Just in the same way that our friend R still doesn’t like raw tomatoes.
The trouble is that when you move short, tight muscles, they complain by sending more pain signals, the muscle spasms, and your brain initiates further muscle shortening in the connected muscles to restrict the movement that caused the tight muscle to stretch.
Then you’re into a vicious cycle of pain, because your peripheral nervous system has red alerts going off all over the place, and your brain is constantly remapping to take into account these new messages while reinforcing the existing connections.
Now the original site of injury – that piriformis muscle for instance - is just fine. Or at least it would be if your brain would stop telling your peripheral nervous system to keep it short (which amongst other things can clamp your sciatic nerve).
But because the neuroplastic connections in your brain didn’t let go when the muscle stopped sending a pain impulse, you can’t sit down or walk upright, never mind play sport, drive for long periods and so on.
When we release that muscle through this specialist form of manual therapy, your peripheral nervous system in the piriformis muscle is sending messages to your brain saying ‘hey I’m long and there’s no problem here’.
Your brain then takes the existing neuroplastic connections (including all the emotional connections) that have been causing you so much trouble and reorganizes them according to the new message it’s getting.
And you say goodbye to your chronic back pain.
In our practice it often takes just a few sessions, along with some specific self stretching at home, to get that muscle retraining your brain. Then you’re pain free.
Even one single session can be enough. And it’s long term too – your brain, once trained or retrained, is extremely powerful.
Chronic back pain and depression
If chronic back pain is a condition of the nervous system, does depression cause the pain signal to be amplified even further? A team from the Department of Psychiatry at Manchester University in England certainly thinks so:
“Considerable previous research has investigated the impact of depression on pain experience. Depression increases the risk of first onset pain and increases the risk of the development of chronic pain complaints over time. Among pain sufferers, depression is associated with greater pain intensity and unpleasantness, more bodily pain sites, and a higher degree of pain related disability. Overall, the weight of evidence seems to indicate that depressed subjects are more vulnerable to developing pain and, once pain has developed, have a broader spectrum of more negative experiences and outcomes… Chronic pain results in reorganization of pain pathways so that both central and peripheral nociceptive processing is enhanced. This process might be further enhanced by the presence of depressed mood.”(6)
Overall, there seems to be little doubt that although the pain message is real enough, it’s our minds that decide how we perceive and experience it, and that depression feeds and enhances our experience of chronic back pain.
Optimised back pain relief strategy
At Optimised we believe that treating chronic pain holistically means a greater chance of reducing and eradicating it. It seems clear that there are at least two known factors in our perceptions of chronic back pain; the nervous system creating and transmitting the pain impulse, and our minds reaction to it.
By engaging in proper manual therapy, corrective exercise and functional nutrition, we can treat the cause. And that means you can say goodbye to back pain.
To your lean, healthy, optimised future,
Matt & Dee
- British Sports Therapy, Soft Tissue Release Training Series, Stuart
- Anatomy Trains - Myofascial Meridians for Manual and Movement
Therapists, Thomas Myers, Churchill Livingstone, 2001
- "Your Body's Many Cries for Water - You Are Not Sick, You Are Thirsty!" by Dr Fereydoon "Batman" Batmanghelid, Tagman, 2006
- Dr John Briffa’s Natural Solutions to Common Ailments, Dr John Briffa, 2006
- Dickens, McGowan and Dale, Psychosomatic Medicine 65:369-375 (2003)