So you have back pain. It’s a tale as old as time – half of our country is estimated to have experienced low back pain in the last year [1]. Perhaps you blame it on that time when you “threw it out” playing basketball, slept on a couch one too many nights, or because you work a desk job that keeps you slouched over a computer. No matter the suspected cause of your pain, the healthcare industry used to treat us all the same. They put us in braces and told us not to move in case we damage our back. They ran us through costly imaging machines and prescribed us pills that created an opioid epidemic. Yet up to 50% of all people who experience low back pain will battle it again before a year is out [1].
Why can’t we treat low back pain effectively? When you do a quick google search, you’ll find hundreds of gimmicks, gotchas, and rubs all promising to cure your back pain once and for all. Surely the answer is out there somewhere? We buy belts, creams, massagers, and supplements until we’re blue in the face but still sore in the back. If there was one simple cure for back pain, none of us would experience it ever again.
But advances in neuroscience are helping us manage low back pain like never before. The old medical approach of imaging, prescription pills, and bed rest is falling out of favor as science continues to unearth new revelations about the complex nature of pain. Injuries can cause pain, but pain itself does not necessarily signify injury. We no longer treat the painful spine as damaged, because we know that for the majority of our cases, the back has not been significantly injured. In fact, we now blame the brain for many cases of low back pain.

Treating the Minority

For a very small amount of people, back pain is actually coming from damage to the spine or surrounding tissues. Immediately following an acute injury, like a fender bender, for example, it’s normal to be sore. A month later, those achy tissues should be healed and any pain that continues to persist is no longer due to physical damage. Medical conditions can cause tissue damage and low back pain in rare cases. Organs like the kidneys, stomach, gallbladder, and appendix can refer pain to the low back when they are sick. Cancers and infections can originate in or spread to the spine. Fractures in the bones of the spine can occur after a traumatic accident. Scary stuff, huh? Fortunately, only about 5% of low back pain cases end up being attributable to these “red flag” conditions [1]. Your healthcare professional will be able to screen you for these conditions. Now you’re probably wondering, how do we diagnose the other 95%?

Why you might not need a “diagnosis”

In 95% of cases, there is no one specific cause for back pain because there is no damaged tissue we can blame (1). Low back pain originates from a complex interaction of physical, mental, and social factors. The reasons that you have back pain are as unique as you. Although we often have different causes for our pain, many people with persistent back pain are going through the same process- central sensitization.
The reasons that you have back pain are as unique as you! Click To Tweet

The power of the brain

Central sensitization is a neurological and physiological process that is changing the way we approach low back pain. Central sensitization occurs when our brain becomes hyper-aware of the signals sent by the movement receptors in our body. The brain begins to associate activity that is normally pain-free with sensations of pain. Let’s look at a case example to see how this can occur:
Clare is an active 44-year-old woman. She goes on daily walks with her husband and participates in a Zumba class at the local YMCA. One night, she is rear-ended at a stop light while driving home from the grocery store. She wakes up the next morning with achy pain across her back that shoots up whenever she moves. Her physician prescribes muscle relaxers and suggests that she “ take it easy”. Clare goes back to work at an insurance company a couple days later but finds that she is unable to sit for long periods of time without pain. She takes a week off from work and spends most of her time in bed because her back feels better when she lies down. Clare goes back to work part-time, but is unable to clean the house, cook large meals, or walk around the grocery store without pain. She is afraid to go back to Zumba class because she thinks she might cause even more damage to her back. Two months after the accident, Clare is beginning to feel like a burden on her family. She wants to return to full-time work but she is barely able to tolerate a part-time schedule. She wonders if she should get surgery, but is concerned about the cost.
Clare’s story is a common one. If we feel pain when we move, we become afraid to move. Because Clare stopped all of her daily activities, her nervous system became hyper-sensitive to movement. Normal chores, like bringing in the groceries, became intolerable. Central sensitization can be prevented (and cured) with one thing- exercise!

What’s the best exercise for back pain?

Just like there is more than one cause for low back pain, there is more than one cure! Practically any exercise is beneficial when you have back pain. Movement helps desensitize your over-active nervous system and tells your brain that everything is okay. Movement is also crucial for the health of our back by lubricating the joints with the nutrients they need. The key to exercising with back pain, especially if you have been afraid to move, is gradual exposure. Beginning with a cardio kickboxing class after months or years of inactivity probably won’t feel too good.
Try one (or more) of the following low impact activities for 10 minutes to ease back into exercise:

• Walking
• Swimming
• Biking
• Yoga

You may be sorer after your first few attempts at exercising, but that is a healthy response. Remember that there is rarely an actual injury to the back when there is back pain. Your muscles simply aren’t used to that level of activity. Over time, you’ll experience less discomfort after exercising. Habitual exercise actually leads to higher levels of energy, better sleep, and a more positive mood [2, 3].

My core is “weak”- does that matter?

That’s probably true for many of us, our sedentary culture promotes an underused core. However, plenty of people with strong cores have back pain and plenty of weak cores are pain-free. This underscores the often overlooked contribution of the nervous system to cases of persistent pain. You may be able to hold a plank for hours, but if your nerves are incorrectly sensing pain and your brain is screaming, “Danger!”, you’ll likely have back pain. Core exercises are still an excellent part of a comprehensive exercise program. Who doesn’t want a six pack anyways?
Habitual exercise actually leads to higher levels of energy, better sleep, and a more positive mood Click To Tweet

Why surgery is silly for the 95%

You’ve probably wondered about whether you need back surgery.  It’s a fairly common, and expensive, procedure. We spend over $1.5 billion on spinal surgeries every year [4]. Let’s think critically about the indications for surgery. In the most basic terms, we receive surgery to fix something in the body that is broken. Exercise isn’t going to fix a broken femur, blood clot, or cancerous organ. Sometimes we need to repair or remove the parts of our body that no longer work the way they should. In chronic low back pain, the body part we need to blame is the brain, not the discs, bones, and ligaments of the spine.
In fact, surgery often introduces damage to spinal tissues that were never causing problems in the first place. Even “minimally invasive” procedures set off inflammatory pathways in the body which can make it even more sensitive to pain. Low back pain is like having an overactive check engine light. You can pay a mechanic to replace the belt, change the oil, and tinker with the engine, but all you’re going to have at the end is a big bill and a check engine light that will be back on next week.

I know…an expensive x-ray or MRI will tell me the problem!

Just like surgery, you don’t always get what you pay for. Run anyone over the age of 40 through an MRI and you’ll likely see many degenerative changes in the spine. Imaging reports are full of scary terms like ‘bulging discs’, ‘degenerative joint disease’, ‘osteoarthritis’, and ‘narrowing joint spaces’. But many of these changes are normal aspects of aging. You wouldn’t want your doctor to refer to your wrinkles as  ‘degenerative face disease’, would you? Many people who have structural changes to their spine don’t have low back pain. Likewise, there are people with low back pain who don’t have structural changes. Pain is influenced by other often overlooked factors, like health care beliefs, social support, daily stressors, and emotional states.

Someone can just push it back in place!

Perhaps you have a friend or family member that has gotten an “adjustment done” on their back. Every few weeks they swing by a chiropractor and they leave feeling pain-free. But that’s the catch- they always have to schedule another appointment. Adjustments, manipulation, manual therapy, etc are all great short-term pain relievers. The small movements they create in the joint help desensitize the painful nerves, but only temporarily. They also promote the incorrect notion that your back is painful because it’s “out of alignment”. The spine is not a Jenga tower that can be rearranged or toppled at the slightest touch. Powerful ligaments and sheets of fascia support the bones of the spines which are also anchored by thousands and thousands of muscle fibers. Studies have shown that the bones of the spine can tolerate over 1,500 pounds of force, while the ligaments can withstand over 2,000 pounds per square inch [5,6]. Your chiropractor isn’t rearranging anything unless he or she wants to make use of a jackhammer.

It must be my chair, right?

How long you sit matters just as much, if not more, as to how or where you sit. Our bodies were not meant to be kept in prolonged positions, no matter what sort of chair you use. Research that examined the effect of chair type on low back pain has not reached significant conclusions [7,8]. While buying a stability ball chair sure looks cool and can give your core a “workout,” it’s not a sure fix for everyone [8]. Find a chair that’s comfortable for you, but make an effort to take standing breaks every 30 minutes. Prolonged sitting prevents the movement your back and body need to stay healthy. Studies have consistently shown that sedentary behavior increases the risk of diabetes, cardiac disease, and other life-threatening health conditions [9].

Oh, then it must be that old mattress…

Nope, just like the chair, there is no conclusive evidence for the best type of mattress to sleep on in order to reduce and prevent low back pain [10]. Sleep is still very important when it comes to managing chronic pain. Consistently getting a good night’s rest is linked to better health outcomes overall. Before you blame your mattress, consider whether aspects of your waking life may be contributing to a poor night of sleep. Are you stressed about work responsibilities? Do financial uncertainties keep you awake? Are you anxious about ever living a pain-free life again? These powerfully negative emotions can wreak havoc on our sleep, even if we aren’t consciously aware of our worries.

Maybe it’s in my head then?

In a way, yes… pain often comes from the brain. The process of central sensitization is fueled by emotions and beliefs found in the brain. Our brain is constantly rewiring and forming new connections. Over time, our brain can not only learn to associate normal movement with pain but also will link certain emotions and memories with the experience of pain. This creates a harmful cycle where pain can cause fear and fear can trigger more pain [11]. This is an unfortunate side effect of the amazing power of the brain. The good news is that we can also use this process of association to relieve pain. If we are able to change our beliefs and expectations about the way we experience pain, we can break the cycle. The key is beginning to associate movement with the absence of pain and replacing fearful thoughts with positivity.

Stress

We won’t be able to rid ourselves of these negative emotional thoughts unless we address the most common source- stress. Looming deadlines, health scares, backed-up traffic, negative relationships, and important meetings all raise the level of cortisol in our bloodstream. Cortisol is a stress hormone that is associated with negative health effects if it persists in the body for long periods of time. It also sensitizes our nerves to feel pain more easily [12]. Stressful events are expected in life. We can’t avoid stress completely, but we can affect how we react to it. Finding positive coping strategies to reduce stressful feelings quickly is an important step towards a life with less pain.

Easy to Harm, Hard to Heal

The back gets a bad rap. Research has consistently shown that people believe the back is easily injured and must be protected at all costs [13]. An injury to the back is seen as serious and not expected to heal well [13]. These incorrect assumptions are pervasive in our society and are affecting the outcomes of people with low back pain. The back is not “easy to harm”. Look at your fingers. Your finger bones are tiny and supported by hardly ligaments and muscles when compared to the bones of the spine. Yet you don’t walk around all day afraid to write, pet your dog, open a candy wrapper, or open a door. Your spine is strong. Limiting daily activities in an attempt to “protect” your back will only keep you away from things you love to do. Likewise, you would expect a scab on your knee to heal. The same process that heals a scab also heals the tissue in your back. Back pain often persists because we expect it to. What’s the point in hoping your back pain will go away if you don’t believe it will actually happen?

I must be getting old!

Age is a common blame for back pain. We assume that any pain we feel after the 4th decade is just another sign that we’re “over the hill” and on the decline. While it’s true that our bodies experience general wear and tear throughout life, persistent pain should not be expected as we age. Believing that pain is part of getting older just gives us an excuse not to do anything about the pain. The cells in our bodies are constantly replacing themselves throughout our life. The same cellular processes that gave us bigger biceps after pumping iron in our twenties are still functioning in our fifties, sixties, seventies, and beyond! You are always able to improve the health of your body, no matter your age.

I could just take some drugs, right?

Pain medications, especially prescription pain medications, serve an important purpose in the healthcare field. They can help us withstand procedures and injuries that would otherwise be excruciating. Good luck getting a tooth extracted without a lidocaine injection or recovering in the hospital from a broken femur without morphine. But pain medication doesn’t fix the source of our pain. That femur won’t heal without a cast, crutches, and a lot of rehabilitation. So why would pain medication help take away your low back pain?
The term “painkillers” leads us to believe that medication can destroy the pain once and for all. Unfortunately, pain medication can only really put our pain to sleep. Sooner or later the pain will wake up again. If we rely on medication to manage our pain, we will never truly escape the pain. Pain medication is also highly addictive [14]. Over the long term, drugs are both ineffective and dangerous for those with low back pain.

Can diet really help my back?

They say we are what we eat. For some people with low back pain, a good diet turns out to be a key for pain relief. We’ve all heard that a healthy diet consists of many various foods- leafy greens, whole grains, fibrous fruits, healthy fats, etc. But we often fail to account for the effects of inflammation in our diet. Certain foods will affect the levels of inflammation (and pain) in our body.
Basic nutritional science tells us there is a link between spinal degeneration, type 2 diabetes, and diets high in advanced glycation endproducts (AGEs). [15]
AGEs are proteins or lipids (fat-like substances) that have become coated in sugars. A diet high in heat-processed foods, including fried foods, plays a role in AGE formation. Over time the persistence of AGE’s cause tissues in the body to break down increases inflammation that could lead to disc degeneration and contributes other degenerative diseases, including diabetes, atherosclerosis, and Alzheimer’s disease.
An anti-inflammatory diet often benefits those with pain, inflammation and spinal degeneration. You begin with a whole foods or Mediterranean style diet but many need to figure out their own food intolerances to foods such as sugar, dairy, and gluten. Removing certain inflammatory foods can lead to further resolution of pain and joint stiffness.