foundational guide on back pain
Many people experience back pain in some shape or form, ranging from mild, annoying impingements to severe, disabling conditions. This common problem is approached very differently by the individuals experiencing it, as well as by the professionals treating it. The aim of this article is to provide a broad comprehensive guide for dealing with back pain from lowest to highest intensity as well as explaining all known (potential) causes. Take this as a sort of manual for all of you out there who are dealing with this or are close with someone who is dealing with this.
The cause is irrelevant
When we are experiencing any sort of pain, we are instinctively looking for a cause. This is reasonable only if two criteria are met: 1) We have the materials and methods to determine with 100% certainty what causes us pain, and 2) We have a predetermined treatment method that works only for that specific cause, reversing or destroying it. The example of this would be sore throat due to bacterial infection. We use tests to identify the cause and we take antibiotics to destroy that cause. For most instances of back pain, this is not the case, because we simply can't meet the aforementioned criteria; 1) We can’t pinpoint a single direct cause of pain 2) Even if we could identify the cause with very high certainty, the method for treating almost all different causes of back pain is universal and it is adjusted based on the severity of pain rather than the cause. For example, a person with back pain who has no structural abnormalities, a person with spondylolysis, a person with osteoarthritis, a person with a disc herniation, and a person with scoliosis will all benefit from strengthening the back musculature, and the individual approach will be adjusted based on the degree of functionality as well as the severity of the pain.
The anatomy illusion (structural abnormalities ≠ pain)
One meta-analysis looked at the relationship between structural abnormalities in the spine and back pain. They found that among 3,110 subjects who had no back pain, approximately 45% of them had some structural abnormalities in the spine (disc degeneration, protrusion bulging, spondylolisthesis, etc.). Additionally, one study followed 30 individuals with spondylolysis (a fracture of a facet spinal joint) for 45 years and found no association between this condition and back pain. This means that structural abnormalities do not guarantee pain, nor does having pain mean you have any structural abnormality. However, doing an MRI or CT and getting a diagnosis can create a “nocebo effect” – situation in which complicated diagnoses like “C7-S1 disc has protruded and is narrowing the foramen area” cause worsening of the symptoms. Since I know you are now wondering what causes back pain if not something fractured or impinged, I will propose the best answer I can based on the evidence. But again, the cause is irrelevant and treatment is planned based on symptoms.
Pain as message from an overprotective parent.
Our nervous system is like an anxious parent that screens and receives all kinds of signals coming from within our body and the outside world. If it interprets these signals as even slightly threatening, it triggers pain to influence our behavior. To explain it through an example, imagine that after a period of not training, you do a heavy deadlift workout. Your muscles and connective tissues are under strain, which creates mechanical stress in the form of deformation, metabolic stress in a form of accumulation of many different chemicals and structural stress in a form of microdamage. Inflammation is occurring and the surrounding nerves pick up on this and notify the CNS (aka. the brain and spinal cord). The CNS interprets this information together with all the other information it is constantly receiving. Have you noticed the pain being worse if you hadn't slept well, or are under work, family, or financial stress? It may also get worse when your mind goes to places of all the possible injuries you might have, then you get an MRI, and it shows some structural abnormality, and BOOM! You're so deep in the realm of pain, and it just keeps getting worse. Pain is a message, an alarm from your CNS, which integrates all internal and external information from your life into a unique experience of pain. This is exactly what biopsychosocial model of pain states, and it is the widely accepted explanation of the causes of pain.
How to treat back pain
Keeping everything we said in mind, let's jump to the most important part of this article– How the rehab for the vast majority of people with back pain should look like (whether they have structural deformations or not)?
ASSESSEMENT
Step one: rating the severity of pain
Is the pain constantly present, or does it only occur during certain movements? On a scale from 1-10 how severe the pain is, and can a person perform basic movements; can they walk? Sit straight? Bend forward? Lean backward? Rotate? Twist? Lean side to side? There are formal tests for this, but chances are that a person knows very well what their limits are. Does the pain worsen during one or more of aforementioned movements, or after prolonged sitting, standing, or walking? Is it worse at certain parts of the day (usually the morning)?
TREATEMENT
Step two: adjusting the rehab approach
The rehab should always consist of two basic things: exercises adapted to the assessment we made in step one, and lifestyle changes. Rehab can also consist of certain manual methods to add neural and psychological benefits.
| Condition / Pain Type | Recommended Rehab Timeline |
|---|---|
| Mild to moderate pain constantly present not worsening with movements |
First 1-4 weeks: exercise all spine movements patterns (bending with straight spine, flexion, extension, rotation, side bending, isometric holds) with low load and in a slow controlled manner.
Next 2-5 weeks: gradually increase the load on the exercises and continue performing them in a slow and controlled manner.
Next 3-5 weeks: maintain the same load on the exercises but speed up the tempo. You can also add light fast movements, like jumps or drop variations.
Next 3-5 weeks: gradually increase the load on exercises maintaining the natural tempo.
|
| Severe pain constantly present not worsening with movements |
First 1-2 weeks: get some weight-free movements done; like walking, lunges, glute bridges, deadbugs, and if possible, machine lower and upper body training.
Next 2-4 weeks: start introducing all spine movement patterns into exercise routine without any external load.
Next 2-4 weeks: exercise all spine movements with low load in a slow controlled manner.
Next 2-5 weeks: gradually increase the load on the exercises and continue performing them in a slow and controlled manner.
Next 3-5 weeks: maintain the same load on the exercises but speed up the tempo. You can also add light fast movements, like jumps or drop variations.
Next 3-5 weeks: gradually increase the load on exercises maintaining the natural tempo.
|
| Mild to moderate pain occurring only with specific movements |
First 1-2 weeks: exercise all spine movement patterns in a slow controlled manner. Keep the load light on those movement patterns that cause you pain, while maintaining regular load (or reducing it slightly) on movement patterns that don’t cause you pain.
Next 2-5 weeks: gradually increase the load of all exercises and continue performing them in a slow controlled manner.
Next 3-5 weeks: maintain the same load on exercises but speed up the tempo. You can also add light fast movements, like jumps or drop variations.
Next 3-5 weeks: gradually increase the load on exercises maintaining the natural tempo.
|
| Severe pain occurring only with specific movements |
First 2-3 weeks: exercise all spine movement patterns in slow controlled manner, but those that cause you pain without any external load, and reduce the load significantly on those that don’t cause you pain.
Next 2-4 weeks: exercise all spine movement patterns with low load in a slow and controlled manner.
Next 2-5 weeks: gradually increase the load in all exercises and continue performing them in slow and controlled manner.
Next 3-5 weeks: maintain the same load on exercises but speed up the tempo. You can also add light fast movements like jumps or drop variations.
Next 3-5 weeks: gradually increase the load on exercises maintaining the natural tempo.
|
| Mild to moderate pain constantly present worsening with one or more movements |
First 1-4 weeks: exercise all spine movement patterns in slow controlled manner. Those movements that make the pain worse perform without external load and keep the load light on movements that don’t worsen the pain.
Following 2-4 weeks: start gradually adding load to movements that were worsening the pain, and increase the load slightly on movements that weren’t. Both should still be performed in a slow controlled manner.
Next 3-5 weeks: maintain the same load on exercises but speed up the tempo. You can also add light fast movements, like jumps or drop variations.
Next 3-5 weeks: gradually increase the load on exercises maintaining the natural tempo.
|
| Severe pain constantly present worsening with one or more movements |
First 1-2 weeks: get some weight-free movements done like walking, lunges, glute bridges, deadbugs, and if possible machine lower and upper body training.
Next 2-4 weeks: start introducing all spine movement patterns into exercise routine without any external load.
Next 2-4 weeks: start adding light load to those movement patters that aren’t (or weren’t) worsening the pain, while still performing the movements that are (or were) worsening the pain weight-free. Perform all exercises in a slow controlled manner.
Next 2-4 weeks: Gradually start adding weight to movements that were worsening the pain and maintain the same load (or increase it slightly) on movements that weren’t. Perform all movements in a slow controlled manner.
Next 3-5 weeks: maintain the same load but speed up the tempo. You can also add light fast movements, like jumps or drop variations.
Next 3-5 weeks: gradually increase the load on exercises maintaining the natural tempo.
|
A disclaimer for the end. While most back pain is non-specific, there are some rare specific cases when the cause of back pain does dictate the rehab and requires urgent medical attention. These cases include:
- Loss of bowel/bladder control, and saddle anesthesia
- Cancers/Malignancies
- Spinal Infectio ns
- Traumatic Fractures (car accidents, high falls)
- Neurodegenerative diseases