You wake up one morning and feel a little bit off. You shrug it off and go about your normal routine, including your scheduled workout. As you are moving the bench out of the way, you notice a little tweak in your low back. “No big deal,” you think to yourself. “It will work itself out.”
You finish your workout and head home. During the drive, you notice things are stiffening up a little bit. By the time you arrive home, you struggle to get out of the car. “Holy crap,” you think to yourself. “This back pain thing is no joke.”
Fast forward four weeks. Things periodically seem to feel a bit better, so you return to your normal activities, only to have things get worse again. You are frustrated, irritable, and ready to have your life back.
Fast forward another eight weeks. Things are still only minimally better. Occasionally, you will have moments where you forget about the pain, only to have it return. You continue to work out, because that is the only thing that preserves your sanity. Sometimes, training makes your back feel better; other times, worse. You are edgy, tired of the discomfort. You have tried massage, acupuncture, chiropractic care, cryotherapy, and steam rooms. Everything makes your back feel better temporarily, only to have the pain return. You even went to a back doctor, who took imaging of your back. “Other than a minor disc bulge at L1-L2,” he said, “you are perfectly healthy.” He says the pain isn’t coming from the disc bulge, but what if he’s wrong? What if you have a bad back? Maybe life as you knew it is over.
Everybody’s Back Is Bad
Eighty percent of adults in the US will experience low back pain at some point in their lives.1 Most clears up after twelve weeks, regardless of what type of intervention is pursued. However, in a small percentage of cases, it will linger, like a smell that won’t go away, no matter how many scented candles you light. For these individuals, pain becomes part of them. There are times when it’s turned up, shouting its presence, and times when it’s softer, barely more than a faint buzz. But it’s always there.
After striking out at the doctor’s office, these individuals often take to Google, looking for the magic answer, the thing that will get rid of this pain for good. And Google, like all good charlatans, will provide promises to “heal your back with these 5 yoga poses,” or “5 simple moves to eliminate pain,” or “4 Exercises to End Low Back Pain.” For the active individual, this information is frustrating, confusing, and often times fraught with contradictory advice. What is the athletic person to do?
Chronic low back pain is not just the result of injured tissue; when pain lingers, it’s a little more complicated than that. One of the current theories around low back pain is that there are biological factors, psychological factors, and sociological factors contributing to the presence of pain.2
“But wait!” you’re thinking, “I don’t have any psychological issues. I’m not crazy. And the internet says yoga, Pilates, McKenzie press-ups, breathing, meditation, deadlifts, and planks will all help my back. Shouldn’t I try all of those things at the same time and see which one works?” (I have tried this. It’s not terribly scientific, and when I finally felt better, I was left wondering which one actually helped). None of this is to suggest you are mentally ill, and there is research that shows all of the above are likely to help with low back pain, though which one is most effective is largely up for debate.3,4,5,6,7,8,9 But even if you aren’t crazy, life has a way of affecting you in a way that impacts your health.
Maybe there’s a systematic way to decrease your pain.
The Backdrop of Back Pain
Gregory Lehman, a leading pain educator and physiotherapist, has a very simple way of looking at chronic pain. “Calm shit down. Build shit up.” Before we dive into how to do this, it is helpful to make a list (pen and paper, on your phone, or in your head) of the following information:
- What daily stress do I regularly have in my life? This includes workouts, because yes, they are a positive stressor.
- What stress do I have that I cannot change?
- Do I get good quality sleep regularly?
- When do I notice my back the most? Is it positional (sitting, standing, lying down)? After an argument with my spouse? After I walk down an incline?
- When do I notice my back the least? After a massage, after a workout, while I am engaged with friends and family? When I’m writing, or working on a project?
Categorize Your Stress
Stress is not inherently bad. It makes us stronger, both physically and mentally, if we understand our relationship to it. However, if stress is left to its own devices, it can wreak havoc on our systems. The goal is not to eliminate stress. Rather, the goal is to understand our default response to stress and question, “does this serve me?”
Obviously, if anyone in your family is struggling with a chronic illness, or you are transitioning a family member to long term care, these are stresses that can’t be changed. It is important to recognize that type of stress, and if it’s impacting you negatively, it’s worthwhile to talk to a professional.
Stress isn’t bad in and of itself, unless you let it take control of you. [Photo credit: Craig Sunter | CC BY-ND 2.0]
The Nervous System and Sleep
There are two branches to your central nervous system (CNS): your parasympathetic nervous system and your sympathetic nervous system. Your sympathetic nervous system (SNS) is your “awake and engaged” nervous system. It is frequently thought of as your “fight or flight” system, but in reality, there are many hormonal responses associated with this system that lead to different levels of arousal. The parasympathetic nervous system (PNS) is commonly thought of as the “rest and digest” nervous system.
The SNS and the PNS work together to provide appropriate responses to stimulation throughout the day. You will have less SNS response, for instance, when you are watching a documentary on the cellular response to metabolism than you will during a job interview. Likewise, you will have less SNS activity during a leisurely walk than you will during wind sprints. Different activities induce different amounts of stimulation.
When you sleep, particularly when you are in the dream stage of sleep, your SNS gets the opportunity to relax. The prefrontal cortex, the area of your brain which assesses stress, goes quiet, allowing a deeper sense of restoration.10 This is also when your brain figures out what to do with information from the day, and when learning is believed to take place. Most people need 3-4 sleep cycles per night to get the full benefits of restoration; if you get less than that or you aren’t ever moving into the deeper stages of sleep, your nervous system activity will be thrown off. This leads to more stress on the system.
Movement Patterns Can Reinforce Pain
We all have specific ways we move. When we have pain, we tend to move differently in an effort to minimize or guard the injured area. Sometimes, the muscle guarding, like the injury, becomes chronic.
If you notice you feel your back when you stand for long periods, see what happens when you alter your standing position. You can try placing the weight more in the center of your feet instead of your heels, place one foot forward and one back, take a long exhale and feel your ribs come down… Did any of these things make your back feel better? And how is it different than your normal standing posture? You have the power to change your movement habits. This feels like effort at first, but eventually the awareness this creates will seep into other areas of your life, and might even make your workouts a little more efficient.
Breathing and Stress
All of us understand breathing is important. As one client said to me recently when I asked if she was breathing, “I hope so. It’s better than the alternative.” Breathing is an autonomic response that we have the ability to control consciously, unlike heart rate or digestion. One of the interesting things about breathing is its ability to alter our nervous system. Inhaling speeds up our heart rate slightly, while exhaling slows it down. When our exhale is longer than our inhale, we are slowing everything down. This can be a powerful calming tool.
It is not uncommon during stressful situations (physical or otherwise) for people to hold their breath. If you notice you hold your breath when you are lifting a box or driving in traffic, take a moment to focus on inhaling through your nose for a count of four and exhaling out your mouth for a count of four. This will alter how you are holding yourself and begin “calming shit down.”
Beat Your Back Pain, Part 1: Calm the CNS Down
Once you understand when your back feels better, see if you can build those activities into your day. We don’t always have time for a 60-minute daily massage, but we can probably carve out 5-10 minutes to do gentle self-massage techniques. Conversely, if you notice your low back always hurts when you sit for long periods of time, set a timer for every 30 minutes; when the timer goes off, shift your position, stand up, reach your arms overhead, do some seated cat/cows… Adding brief moments of extra movement, even if it’s as simple as shifting from one sitting bone to the other, gives our body a chance to experience a position in a different way. As we will discuss in a moment, adding variability to our regular movement patterns can be a great way to improve our relationship with painful movement.
Move Smarter, Hurt Less
Exercise is wonderful for low back pain. In fact, for most people, a general exercise routine provides a little bit of protection against the development of low back pain. However, (and it seems like there are always exceptions, doesn’t it?), sometimes, the exercise is part of the problem. Let’s look at this a little more closely.
Let’s pretend whenever you do loaded back squats, you notice your back pain increases a little bit for the next 24 hours; after the 24 hours, it returns to your new normal, a low-grade ache. Is the back squat part of the problem? Maybe in the short term. Your internal feedback loop, which determines whether or not there is the potential for injury to occur, has decided back squatting is a threat to the health of your back, so the pain volume is turned up whenever you perform that activity. What can you do?
This may seem like a no brainer, but if it hurts, don’t do that thing for a little while. I work with a lot of clients who initially present with pain of some sort. They love to show me positions which provoke pain, upon which I always reply, “so don’t do that.” In the case of the back squat, ask yourself if the pain is worse (or better) with other forms of squatting. Can you do a bodyweight squat without pain? What about a goblet squat? Eliminate the painful stimulus for a bit in an effort to mute the pain volume.
If back squats are what hurts you, you’ll need to stop doing them for a while.
We can apply the same logic to any form of exercise. It hurts when you run 12 miles, so run 3 instead. Or run uphill or on a trail. Change the exercise a little bit, either by volume, intensity, or the way in which it’s performed to change the feedback loop.
Research shows several different types of exercise interventions are effective for individuals with low back pain, including all of things I mentioned earlier, as well as motor control and stability exercises.11,12 Why could that be? Because whenever you learn a new discipline, you have to slow down and pay attention to what you are doing. This is because the input you are receiving about how to do that thing is novel. From a movement perspective, this is great because it changes your focus and forces you to move in ways that are unfamiliar. This can be really positive. If the discipline you are exploring has a breathing component, you get the additional benefit of thinking about breathing as you move, a potential win/win when a person is struggling with low back pain.
None of these modalities are slam dunks, however. The research on all of these modalities show while they are likely to help low back pain, not every intervention works for every body. If you are considering learning a new movement modality, be open-minded and accept the fact you might have to try a few different types until you find the one you find both enjoyable and effective.
Address Your Stress
As I mentioned earlier, stress happens. It is not bad, and should not be considered an enemy. If we catastrophize all of life’s small stressors and throughout the day you find yourself thinking, “this is going to suck,” we are doing ourselves a disservice. Instead, viewing stressful situations as challenges to be met can alter our physiological response to the stressful stimulus.
Ways to do this (other than a positive pep talk), include things like listening to a song that brings you joy, focusing on your breath, scanning your body and observing where you feel tension, or performing a quick set of squats/burpees/sun salutations/lunges. I used to get nervous before speaking engagements, and found that a little bit of total body movement calmed me down better than anything else. Meet challenges as challenges and save the stress response for the big stuff.
No, seriously, It’s good for your health. And there is actually science to support this.
Being outside in a natural environment causes a release of the hormone associated with the sense of awe. This has a natural calming effect, and can have a profound impact on those of us that are a touch high strung. Researchers find even looking at natural images can induce a decrease in SNS activity. Embrace the idea of natural settings as screen savers or plants inside your office. Better yet, go for a walk in a park at lunch, not for fitness, but for your mental well-being.
Beat Your Back Pain, Part 2: Build the Body Up
Alright, now that you have tools to calm your nervous system down, how do you become strong again in a pain-free way? By working thoughtfully and using the building phase as a way to master the regressions. We can start by following some basic guidelines for getting back to a regular exercise routine.
One thing that is clear with individuals struggling with chronic pain is they have trouble identifying the injured part of the body. In research on body image, subjects with chronic low back pain had difficulty ascertaining the outline of their trunk compared to a pain-free control group.13 Other studies show a disconnect between how much the individual with low back pain thinks their back is moving, and how much it is actually moving.1 This idea is the reason the very first guideline is learn how to isolate movement.
Learn Joint Isolation
Do you understand how to isolate movement at specific joints? Can you move different parts of your back? Can you move at your hip joint without moving your back? Can you lift your arms without flaring your ribs?
If you struggle with chronic low back pain, there is a pretty good chance you have a difficult time isolating movement at your pelvis, low back, or hip area.14 There is also a pretty good chance you move with a higher degree of stiffness than someone that doesn’t have low back pain.15 It can be surprising for people to learn that how they think they are moving and how they are actually moving are remarkably different.
If you are active and want to return to a high level of activity, improving your perception of how you move is an important part of the process. If you aren’t sure whether this applies to you, you have two options: hire a coach that has a keen eye for movement differentiation, or film yourself at different angles and learn what isolated movement looks like. But do yourself a favor and adopt a mobility practice where you mindfully do joint isolation work in all three movement planes. It makes a great warm-up and can change both your relationship to movement and your internal perception of how you move.
Pick Your Movements
Now that the importance of mobility has been established, we can look at the appropriate exercises. Remember, we established earlier the basic guideline of “if it hurts, don’t do it.” But this doesn’t mean don’t do it ever. It’s not unusual for a movement to be painful the first time you try it, yet when you try it a week later, it’s no longer painful. Or it might not be painful if you slow it down, do it with load (or without), do it with a slightly different stance, or speed it up. You have control over how you move. Let pain be your guide, but don’t be afraid to play with variables to find a way that works.
Isometric exercises can be a great way to train positions and begin building strength in a controlled manner. Things like different kinds of planks, wall sits, and dead bug variations with a hold are examples of spine-focused isometrics. Isometrics also appear to cause an analgesic response, a little bit like a natural Advil.16 The plank lives on.
Whatever exercise you decide to go with, make sure you start with the idea, “less is more.” You used to be able to do a plank for 60 seconds, great! Start with 30 seconds. You were performing 6 sets of push-ups? Excellent, start with 2 and gradually work your way back up. Each workout is an opportunity to get stronger; it’s also a way to gently test your boundaries. If you do too much, too soon, the results will be disheartening.
What about the back squat mentioned earlier? When can you get back to that? First, I highly recommend hiring a coach or taking video to check your form. See what your normal habit is for back squatting and find out if there is a way to make it more efficient. When you do add it back into your routine, maybe perform one set with light weight. See how that feels the next day. If things feel pretty good, the next time you back squat, maybe add another set. Once you are comfortably performing three sets with light weight, beginning adding load. Your back pain did not become chronic overnight; it takes a little while to return to previous levels of pain free fitness.
Break the Cycle of Pain
The thing that is clear regarding chronic low back pain is there is really no one-size-fits-all exercise approach. It is easy to become bogged down in the information online and feel disheartened when the one method or approach that “works for thousands of people” isn’t working for you. Striking a balance between calming things down and building them back up is a powerful way to begin breaking the cycle of pain. Become unapologetically strong by returning to the basics, spending time with regressions, and moving in a variety of ways.
If this is a topic you would like to learn more about, I strongly recommend the book, “A Guide to Better Movement: The Science and Practice of Moving with More Skill and Less Pain,” by Todd Hargrove.
Disclaimer: This information should not be used in place of medical advice. If you have low back pain, see your doctor and get a prescription for physical therapy.
If you don’t understand the cause, your solution won’t work:
Why Your Approach to Fixing Your Low Back Is Making It Worse
1. Vrana, Andrea, Sabina Hotz-Boendermaker, Philipp Stämpfli, Jürgen Hänggi, Erich Seifritz, B. Kim Humphreys, and Michael L. Meier. “Differential Neural Processing during Motor Imagery of Daily Activities in Chronic Low Back Pain Patients.” PLoS One 10, no. 11 (2015): e0142391.
2. O’Keeffe, Mary, Helen Purtill, Norelee Kennedy, Peter O’Sullivan, Wim Dankaerts, Aidan Tighe, Lars Allworthy, Louise Dolan, Norma Bargary, and Kieran O’Sullivan. “Individualised cognitive functional therapy compared with a combined exercise and pain education class for patients with non-specific chronic low back pain: study protocol for a multicentre randomised controlled trial.” BMJ Open 5, no. 6 (2015): e007156.
3. Chang, Douglas G., Jacquelyn A. Holt, Marisa Sklar, and Erik J. Groessl. “Yoga as a treatment for chronic low back pain: A systematic review of the literature.” Journal of Orthopedics & Rheumatology 3, no. 1 (2016): 1.
4. Lin, Hui-Ting, Wei-Ching Hung, Jia-Ling Hung, Pei-Shan Wu, Li-Jin Liaw, and Jia-Hao Chang. “Effects of pilates on patients with chronic non-specific low back pain: a systematic review.” Journal of Physical Therapy Science 28, no. 10 (2016): 2961-2969.
5. Shah, Shlesha G., and Vijay Kage. “Effect of Seven Sessions of Posterior-to-Anterior Spinal Mobilisation versus Prone Press-ups in Non-Specific Low Back Pain–Randomized Clinical Trial.” Journal of Clinical and Diagnostic Research: JCDR 10, no. 3 (2016): YC10.
6. Anderson, B. E., and Bliven KC Huxel. “The Use of Breathing Exercises in the Treatment of Chronic, Non-Specific Low Back Pain.” Journal of Sport Rehabilitation (2016).
7. Michalsen, Andreas, Natalie Kunz, Michael Jeitler, Stefan Brunnhuber, Larissa Meier, Rainer Lüdtke, Arndt Büssing, and Christian Kessler. “Effectiveness of focused meditation for patients with chronic low back pain—A randomized controlled clinical trial.” Complementary Therapies in Medicine 26 (2016): 79-84.
8. Michaelson, Peter, David Holmberg, Björn Aasa, and Ulrika Aasa. “High Load Lifting Exercise and Low Load Motor Control Exercises As Interventions for Patients with Mechanical Low Back Pain: A Randomized Controlled Trial with 24-month Follow-up.” Journal of Rehabilitation Medicine 48, no. 5 (2016): 456-463.
9. Kong, Yong-Soo, Gwon-Uk Jang, and Seol Park. “The effects of prone bridge exercise on the Oswestry disability index and proprioception of patients with chronic low back pain.” Journal of physical therapy science 27, no. 9 (2015): 2749.
10. Bonvanie, Irma J., Albertine J. Oldehinkel, Judith GM Rosmalen, and Karin AM Janssens. “Sleep problems and pain: a longitudinal cohort study in emerging adults.” Pain 157, no. 4 (2016): 957-963.
11. Saragiotto, Bruno T., Christopher G. Maher, Tiê P. Yamato, Leonardo OP Costa, Luciola C. Menezes Costa, Raymond WJG Ostelo, and Luciana G. Macedo. “Motor control exercise for chronic non?specific low?back pain.” The Cochrane Library (2016).
12. Gomes-Neto, Mansueto, Jordana Moura Lopes, Cristiano Sena Conceição, Anderson Araujo, Alécio Brasileiro, Camila Sousa, Vitor Oliveira Carvalho, and Fabio Luciano Arcanjo. “Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis.” Physical Therapy in Sport (2016).
13. Moseley, G. Lorimer. “I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain.” Pain 140, no. 1 (2008): 239-243.
14. Roosink, Meyke, Bradford J. McFadyen, Luc J. Hébert, Philip L. Jackson, Laurent J. Bouyer, and Catherine Mercier. “Assessing the perception of trunk movements in military personnel with chronic non-specific low back pain using a virtual mirror.” PloS one 10, no. 3 (2015): e0120251.
15. Mokhtarinia, Hamid Reza, Mohammad Ali Sanjari, Mahshid Chehrehrazi, Sedigheh Kahrizi, and Mohamad Parnianpour. “Trunk coordination in healthy and chronic nonspecific low back pain subjects during repetitive flexion–extension tasks: Effects of movement asymmetry, velocity and load.” Human Movement Science 45 (2016): 182-192.
16. Rio, Ebonie, Mathijs van Ark, Sean Docking, G. Lorimer Moseley, Dawson Kidgell, Jamie E. Gaida, Inge van den Akker-Scheek, Johannes Zwerver, and Jill Cook. “Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial.” Clinical Journal of Sport Medicine (Canada) (2016).