Lower back pain… It’s an emotional rollercoaster. For some of us, it is a constant battle to encourage ourselves that our lower back pain will get better and facing the harsh reality of the actual pain. This is a common issue, and research indicates that up to 4 in 5 people will experience lower back pain during their lifetime (Rubin, 2007). That statistic is staggering, and highlights the need for good information regarding lower back pain.
Lower back pain can occur from sport, lifting something too heavy or even during random occurrences that happen bending over to do something trivial. What does happen following the onset of lower back pain can be a flood of emotion, anxiety, worry and anger. Then, the sudden flurry of how did I do this, what should I do, how can I prevent lower back pain from happening to me, why me…?
The Golden Rule
Our number one rule for dealing with any back pain is:
Do Not Worry.
Lower back pain happens, and is a natural occurring part of life. Do not get hyper focused on the cause and the pathology of your lower back pain. Even experienced health practitioners are unable to diagnose you and deduce the exact anatomical reasons for your lower back pain. Investigations may be warranted in SOME situations, but are rarely necessary. What we want to make sure is we:
Take a deep breath
Calmly analyse the situations and rule out red flags
Plan and formulate a structured program for long-term pain management and prevention
Keep calm and keep moving!
Often following onset of lower back pain, our muscles will seize up. We will stress and worry about whether the next move we make will hurt our back. Good thing is, any movement you do is unlikely to cause any harm to your lower back (provided you don’t have any red flags). Instead, all kinds of movement is much more beneficial and can have fantastic effects on your pain and functional movement.
The One Big Myth
However, there is one myth in particular that can be damaging to your recovery and refuses to die. That is:
You must keep your back straight when you lift.
But in today’s world of modern science and medicine, is this actually relevant? Will you break your back if you lift from the ground with a bent back?
First things first… Slipped discs and broken backs are terms of the old. There’s now more than enough evidence to suggest that even with a “broken back” you could also have very little pain or issues. Even the MRI results that you receive is usually insignificant in establishing the link to your lower back pain. Instead, we should be focusing on aspects of your life including your physical activity levels, psychological barriers or even variables such as home or work stress.
What does the research say?
There is a large plethora of research to support the notion that lower back pain is not increased when bending your lower back while lifting (Nolan et al., 2018; Saraceni et al., 2020; Swain et al., 2020) . With no consistency of evidence that support the belief that lifting with a straight back is safer, why is it recommended?
In fact, the implementation of lifting advice in health care HAS NOT resulted in reduced lower back pain in occupational environments.
Well it seems that for many health professionals, previous experience and negative beliefs of lower back pains drives these recommendations (Nolan et al., 2018). Fortunately, with the advent of new research healthcare practitioners are steadily becoming informed. So why is this important?
Negative Beliefs and Lower Back Pain
Well, your lower back pain can improve by reducing the amount of factors that we need to worry about. Particularly, when considering the link between the severity of lower back pain AND negative beliefs (Urquhart et al., 2008). In a study of 506 participants, it was found that negative beliefs were associated with high pain intensity of those with lower back pain (Urquhart et al., 2008).
Through the use of a negative beliefs questionnaire, they were able to establish which individuals had poor perceptions of their lower back pain. An example of a negative beliefs questionnaire is the Fear Avoidance Belief Questionnaire (FABQ). Which includes questions such as:
I should not do physical activities which (might) make my pain worse
My work makes or would make my pain worse
I do no think that I will be back to my normal work within 3 months
What should we be worrying about?
There is emerging evidence that loading of the lumbar spine may be a risk factor for the risk and persistence of lower back pain (Saraceni et al., 2020). Essentially what this means is:
Heavier objects to lift = more stress on lower back
The natural response for most people would be to avoid lifting heavy objects. However, what do you do when lifting heavy objects is your job? In these situations, avoiding lifting is impossible and another solution is required. A simple principle can be applied when identifying these issues, and is one primarily built on the principle of “load tolerance.”
Take these two case studies for example:
Case Study 1
John initially came in complaining of lower back pain during a lifting task of his workplace equipment ~20kg. John started off lifting the bar (20kg) for the deadlift exercise in the gym. Initially he is hesitant, and lifting the 20kg bar was heavy and difficult to complete.
Over the next few weeks, John improves his strength and is able to lift progressively more and more weight. 12 weeks later, John is able to lift 60kg for the deadlift exercise in the gym. Now when John warms up for his session, the 20kg bar is now warmup weight and he does not need to be mentally focused or ready to complete this exercise.
This is because John has built up “load tolerance,” and now has 40kg off leeway from his heaviest attempts to complete his warm-up deadlifts. Now when John goes to work, lifting the 20kg equipment is significantly easier.
Have no fear, because… Unless you have clearly identified red flags that warrant immediate medical attention, your lower back pain will get better. While not having a straight back doesn’t have evidence to support its utility from any normal lifting motions, doing whatever feels comfortable for you and what will let you go through daily life is the most important.
However, we must learn to limit the amount of negative connotations and thoughts we have associated with lower back. As negative mental status can lead to detrimental outcomes in lower back pain.
Nolan, D., O’Sullivan, K., Stephenson, J., O’Sullivan, P., & Lucock, Mi. (2018). What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskeletal Science and Practice, 33, 35 – 40.
Rubin, D. (2007). Epidemiology and Risk Factors for Spine Pain. Neurol Clin, 25(2), 353 – 71
Saraceni, N., Kent, P., Ng, L., Campbell, A., Straker, L., & O’Sullivan, P. (2020). To Flex Or Not to Flex? Is There A Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 50(3), 121-130.
Swain, C., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312.
Urquhart, D. M., Bell, R, J., Cicuttini, F. M., Cui, J., Forbes, A., & Davis, S. R. (2008). Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women
Have you ever seen or heard of a family member who had an MRI of their lower back and were told:
“Your back is degenerative”
“You have a slipped or bulging disc”
“Your back is like an 80 year olds”
Back pain is prevalent, and is increasingly common in members of all ages. It isn’t uncommon to see a 20 year old student experiencing the same debilitating back pain of a person who is 50 years old. Regardless of age, common thoughts that many have following the acute onset of lower back pain is:
Is this permanent
Will this ever go away
Will I ever be the same
The Initial Fear of Lower Back Pain…
The first point of action for most individuals is to seek our professional healthcare advice, usually from a physiotherapist or a doctor. Unfortunately, there are still many healthcare professionals who will immediately send you off for a scan of your lower back. Then, tell you there’s“nothing that we can do about it“ until the scans come back.
This leads into a negative spiral as individuals can depend on the results of the MRI scan as a “life or death” diagnosis. Namely, the severity of their lower back pain and their outcome is dependent on the results seen on the scan.
However, as I have mentioned in my previous lower back pain post, pain is multifaceted and cannot be attributed to only one cause. As I will allude to in a second, there is no supporting evidence that directly links the results of the scan to lower back pain.
Compare the following statements:
Individuals who have severe anatomical or pathological change on their MRI can have minimal or no pain, but
Individuals that have minimal anatomical or pathological change on their MRI can have severe pain
So what’s the difference and why do some people get pain?
The Complexity of Pain…
Pain is complex… If you want to see scientific discourse on the ambiguity of pain, I would highly recommending reading this article by Treede (2018). Our understanding of pain is only continuously evolving and there are still many things that we need to learn in order to truly understand “pain.”
“… Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons.”
The interpretation of pain includes cognitive (i.e. our emotional association and relationship with the pain or threat) and social dimensions (i.e. our interaction or lack thereof with family, friends and peers)
When assessing pain, tissue pathology and actual injuries are not the only factors that we must consider. In modern healthcare, we commonly have a paradigm which we follow called: The Biopsychosocial Model of Health / Pain. Essentially, the interpretation of pain can be defined in three seperate factors / cateogories:
Biological factors (e.g. physical health, genetics, age etc.)
Social factors (e.g. relationships with family, friends or peers, work or stress issues)
As we know, emotional factors such as stress and anxiety can elevate and heighten our perception of pain. Similarly, if we were taught pain was a very bad sensation when we were young, then naturally we may develop a fearful response to it when it does happen. However, this is outside the realm of this blog post and will be explored further in the future!
So What About the MRI?
The interpretation of lower back MRI’s often give you insight into many pathological anatomical changes. The most common of which include:
Interestingly enough, lower back pain is not actually synonymous with disc pathology. One study from 1990 by Boden and colleagues researched MRI results on 67 volunteers who had no history or current symptoms of lower back pain. What they found was:
20% of people aged 20 – 59 had abnormal scans
57% of people aged >60 had abnormal scans
54% under 60, and 79% over 60 had bulging discs
Perhaps most extraordinary, 93% of people aged 60 and older had degenerated discs.
Let me just repeat that last one for you. 93% of people aged 60 and older had degenerated discs, but had no lower back pain. So you’re thinking, that’s insane. There’s no way that you can have degeneration and bulging discs without pain?
Unfortunately, with our current medical technology, we are unable to directly propose that scan result = pain. The only way that we would be able to attribute or interpret your MRI results to lower back pain is:
If you took a scan directly prior to your injury that showed an absence of any pathological changes
If you took a scan directly after your injury that showed a pathological change at the area of your pain
The Slippery Disc
A common fear that many individuals have is “slipped discs.” Fortunately, there’s no scientific literature or reasoning to support discs “slipping.” There’s just too much structural and anatomical stability around the area to allow for a disc to slip. An excellent article written by Dr Jarod Hall titled “Discs don’t slip DAMMIT” outlines these specific concerns and the reasoning behind it.
So if you did have an MRI scan and have been diagnosed with a bulging disc, do not worry! The research shows that a disc can actually REABSORB and present you with a ‘normal’ MRI scan. Yet again another amazing article written by Dr Jarod Hall titled “What if I Told You That……Discs Heal!?!?” talks in detail about the spontaneous healing or “regression” of a bulging disc.
A Word of Caution
As I mentioned in my lower back pain blog post, you need to be aware of any red flags. This includes:
This could be indication that you need to have an emergency consultation with your doctor, or visit the emergency department of your local hospital. Similarly, a trip to your local healthcare professional should be considered if you have ongoing concerns regarding your lower back pain or your condition suddenly deteriorates.
Lower back pain is common amongst all ages, and is something that we need to consider as we grow older and change. The main takeaways from this article can be summarised as follows:
Pathological changes on your MRI results DOES NOT equal pain
MRI are usually only required to rule out serious, medical emergencies
93% of people aged 60 and older had degenerated discs, but had no lower back pain.
Discs cannot slip, but they can bulge. Fortunately, bulging discs are not always painful and can also heal by themselves!
Lower back pain is scary, but hopefully these blog posts will help with your knowledge and understanding of them!
How would you explain this to your friend or family or coworker that had lower back pain?
Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. The Journal of Bone and Joint Surgery. American Volume, 72(3), 403–408. https://doi.org/10.2106/00004623-199072030-00013
Ramanayake, R. P. J. C., & Basnayake, B. M. T. K. (2018). Evaluation of red flags minimizes missing serious diseases in primary care. J Family Med Prim Care, 7(2), 315 – 318.
Treede R. D. (2018). The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. Pain reports, 3(2), e643. https://doi.org/10.1097/PR9.0000000000000643
Usually, you’re not sure of what caused it, and it was only when you were getting ready to sleep that night that you thought “my back doesn’t feel quite right.” The next morning, you’ve woken up and your back feels terrible. You’re thinking:
“It hurts to roll out of bed”
“It hurts to bend over”
“It hurts to stand up straight”
“It hurts to sit down”
“It hurts if I move”
Part 1 – Back Pain Red Flags
First things first. Let’s clear some red flags. Red flags are signs and symptoms that, if present, need to be reviewed immediately and is a medical emergency. If you have any of the following signs and symptoms, it would be highly recommended that you go to the emergency room of your local hospital, or contact your local general practitioner.
Pain in your lower back that may travel down the back of the thigh, the calf and to your feet.
Frequent pins and needles, or numbness in both legs
Severe weakness in both legs
Faecal incontinence (i.e. sudden loss of the control of your poo)
Urinary retention (i.e. trouble urinating)
Gait / walking abnormalities
Numbness around the saddle region (i.e. the rectal and genital areas and the inner thighs)
These symptoms are synonymous with Cauda Equina Syndrome. If you already have a pre-existing history of these symptoms and have been cleared by a medical professional, then monitor for any changes to your normal signs and symptoms. Generally, if there are no red flags, then the individual is recommended to move as much as tolerated. It should be noted, that if pain does continue to worsen, or if the individual notices that their function is deteriorating quickly, then they should go to the emergency room to eliminate any sinister pathology.
Part 2 – What causes back pain?
My scan says I have a bulging disc and degeneration of my spine. My back is “out.”
Unfortunately, there is still a large disconnect between the current body of research and some health practitioners. As we now know, most investigation results from MRI, X-Ray or CT scan for your lower back doesn’t really tell you much. In fact, one study by Herzog et al. (2017) showed an individual who had 10 MRI’s within three weeks, and had results reported by 10 different radiologists! So what was the consensus? There was none. 49 different issues were reported, but 0 were reported in all 10 scans. Which shows that there is high variability in reported findings, even within the same patient.
Ultimately, scans can help exclude serious medical emergencies, but does not isolate your source of pain, and doesn’t really change your treatment strategy. An MRI of your lower back may be able to tell you what changes have happened to your back, but may not necessarily mean that it is the source of your pain/
This is important, because lower back pain – or even any musculoskeletal pain – is multifaceted, and there are several other variables that can affect your ability to recover from injury / pain and your pain levels. This includes your general health, factors such as sleep and nutrition, as well as previous injuries and fitness level.
Perhaps understated, is your belief systems about your back pain and what back pain means to you. Unfortunately, it is not well addressed at times, and many patients and clients are always left thinking – My back will never be better and I have to be extremely careful about everything I do otherwise I’ll throw my back out and never be able to walk again. This couldn’t be further than the truth, and these negative thoughts and connotations are much more detrimental to your overall health and well being.
Timeline for Recovery Generally, the first 0 – 72 hours (3 days) will be the worst after the initial injury or flare-up. This is due to a normal acute inflammatory process that occurs with most injuries. Resolution of the majority of pain usually occurs in the first 4 – 6 weeks following injuries.
Following this time period, most individuals will be relatively pain-free. However, some will still have a lingering sensation, which they explain as “I can feel it’s there, but it doesn’t bother me.” Usually we can describe this sensation as the “last 5%”, and full recovery can sometimes still take weeks to months following injury and is dependent on a large plethora of other factors.
So in the meantime, what should you do?
Part 3 – General recommendations
With your newfound understanding of lower back pain, here are some quick tips to facilitate your recovery from any acute back pain, or flare-ups that you may experience.
Keep moving as much as possible. Motion is lotion.
Use pain relief strategies as needed. Whether that includes over the counter pain relief medication, heat packs or getting a massage.
Change your posture OFTEN.
Go for a walk.
Don’t worry!!! Your back will get better. Unfortunately, it does take time and a bit of effort, but eventually the pain will settle and your function will begin to return.
It really is that simple! Unfortunately, after experiencing your first bout of lower back pain, many individuals still look for that “magical cure” and “instant pain relief” strategies. Some individuals get suckered into paying for magical TENS (transcutaneous electrical nerve stimulation) and Ultrasound treatments (sounds extremely fancy, but really doesn’t have much scientific evidence to promote its use) or get round after round of massages, which provide fantastic short term relief, but very little for long-term changes.
With that being said, there are some certain movements and exercises that I do encourage doing as these can promote healthy movement through the spine and get you going just a little bit quicker!
Part 4 – 4 Simple Exercises to Relieve Your Back Pain
Here are four simple exercises, that may provide some pain relief and will encourage movement in the lower back. If these exercises are painful, then stop. Back pain is very individual to each person, so a blanket recommendation of exercises will not necessarily target YOUR back pain.
1. Knee rocks
Holding your knees, gently rock your knees backwards and forwards.
Continue this motion for 20 – 30 seconds while taking some deep breaths.
The same as knee rocks, but gentle rocking side to side.
2. Sitting side stretch
This stretches the quadratus lumborum (QL)
In a sitting position, reach one hand over your body.
When you feel the stretch in your side, take a deep breath through your chest.
You should feel your ribcage rise, and a large stretch through your side / back.
Take two to three deep breaths, then repeat on the other side.
3. McKenzie Extensions (Lumbar extension)
Lying on your stomach, prop yourself onto your forearms.
Slowly push your arms away. This should extend your lumbar spine.
Then, slowly lower yourself back into the starting position.
Repeat this motion 10 – 15 times or as needed.
STOP if it is painful. Do not push into the pain, instead stop just before the painful point.
4. Sitting Forward Stretch
Sitting in a chair, tuck your chin and bring your body down to the ground.
Slowly feeling each vertebrae move one at a time.
At the bottom position, take two to three deep breaths, and then slowly raise yourself back up.
STOP if it is painful. Do not push into the pain, instead stop just before the painful point.
Part 5 – Conclusion
Remember that your lower back pain will get better.
It does take some time and it becomes frustrating, as it really takes away your ability to do anything. However, you should keep moving as much as your pain allows you to, and don’t worry! If you’re worried about your lower back, or it hasn’t been getting better weeks after your initial injury, please contact a local health practitioner. Preferably a physiotherapist, as they can perform a detailed assessment and treatment plan that should be individualised to your case.
So what will a pain-free lower back let you do?
Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine, J, 17(4), 554 – 561.