Low Back Pain & Training

So many of us have had this happen, that tweak or pinch that stops you in your tracks, the initial thoughts of why me and the next few days of walking around like something far too big just got put somewhere far too small. Lower back pain is very common, and, fortunately, we do have a good approach to dealing with it. So, why, you may ask, hasn’t your doctor already told you about it? Well, they probably have, they just didn’t have the time to explain it to you. Your doctor has about 15 minutes to put out as many fires as they can before they need to move on to the next person. When they told you to go home and carry on with life, it’s not because they don’t know what else to do or don’t care, but because that really is the best approach. They will probably also send you to see a physio. Most doctors are likely not familiar with prescribing exercise, so of course they would refer you for this. The Lancet 2018 series on lower back pain [1], and later the 2022 low back pain clinical care standard [2] both show the most effective approach for combating lower back pain is a mixture of both education and exercise. So, let’s take a quick look at both.

Education.

What kind of education? Information on imbalances? Or misalignments? No [3-6]. Instead, we would look to the biopsychosocial model of pain. This is made up of biology (physical inputs), psychology (what are our thoughts, feelings, and experiences with this) and socio-environmental factors (what are the thoughts, experiences, and narratives of those around us). Our past experiences, and those of people around us, feed our expectations of what is happening to us, and what we believe will happen to us. Most incidences of lower back pain are what is called non-specific. Now that does not mean it doesn’t matter, it means there are multiple inputs that go into this experience, and those inputs are helping to shape our outcome. The pain and discomfort associated with this can range from annoying to an experience that is quite debilitating. However, most non-specific lower back pain will feel better within a couple of weeks. Some can last up to 6-weeks with even fewer lasting up to 12-months. This 6-week to 12-month time span seems to be related to how it is handled initially. Did we wallow in sadness and lay in bed or on the couch, or did we tell ourselves a more positive story, get up, and start encouraging movement.

‘The experience of pain affects both body and mind, so treatments targeted at both factors can reduce pain and disability more than medical care alone. Back pain does not usually mean your back is badly damaged. It means it is sensitised. The brain acts as an amplifier: the more you worry and think about your pain, the worse it can get’. [2].

Less than 5% of incidences of lower back pain are from more serious causes [7] and it is recommended to see your doctor if you experience a lack of bowel or bladder control, or numbness in your legs, back or genitals. I would encourage you to talk to your doctor about any diagnosis, what that means, and importantly what it doesn’t mean. If we are familiar with what is most likely occurring and what we can say probably isn’t occurring, then we can better direct our resources towards interventions that will likely have a greater impact and get us back to normal activity sooner. Move early and move often, this is the recommendation. Now this should not translate into some rendition of ignoring all pain and tough your way through it, but hey, some discomfort isn’t the end of the world, it is expected, you’ll be okay. Fluctuations in the degree of pain and discomfort are a normal part of feeling better and this too will improve with time, though if pain continues to get worse then it’s time to see your doctor. Consider this, have you ever not moved a limb for a long time and then when you did it was stiff or even sore? Well, you can think about it like that, we know we need to move that limb to make it feel better, you wouldn’t just put it back where you found it. The goal here is to get back to normal movement as soon as possible, and the way to get back to normal movement is to attempt to move normally.

“Sure, that sounds great, but how do I move normally when I can’t even bend over to tie my shoes or stand up off the couch without doing the sideways plank roll thing?” Slowly, at first, is the answer. Stay calm, and take your time, you’re clearly not going anywhere in a hurry anyway. Be patient and just encourage yourself in the direction you want to head in, little by little you’ll get there. It doesn’t need to look perfect you just need to keep trying, keep showing yourself that you’re not broken and that you can do this. An equally important part of the process is to try to stay calm. We don’t want to build up an idea that we are broken and always will be. This is what’s referred to as catastrophising [8] and can lead to worse outcomes. You can think about this kind of like the force from Star Wars, are we going to let the dark side get us or are we going to Jedi this thing! Encouraging ourselves back into normal routines and ways of life is the way to go. With the right approach the feelings of helplessness will pass, your mood will improve, tissues heal, discs reabsorb [9], and if you have any concerns then talk to your doctor. So, stay calm, and try to focus on what you can do as opposed to what you currently can’t. The choices you make can create more positive outcomes for yourself and others.

Exercise.

The idea is to get ourselves back to moving in ranges of motion that we currently perceive as threatening, giving us confidence and autonomy over our current situation. So, if a person has a history of simply continuing to go to work and has found that this has them back to normal in short order, then it likely will. If they think yoga is the answer, then they are far more likely to engage with the process of movement that yoga offers. If they believe that resistance training will be the thing that works, then there’s a very high chance that it will. The key is they have buy-in to an idea that will make them compliant with a process of movement, and it’s the movement that appears to be the active ingredient [10]. Providing that the chosen intervention isn’t further aggravating the current situation, then whatever movement patterns a person is most likely to repeat is the thing that will likely show the best outcomes.

So, whether it be resistance training or some other method of movement, what does this look like when we are actually doing it? Well, the default position is everything is fine until proven otherwise. What does that mean? Let’s use the squat as our example. Perhaps you get some discomfort while squatting, enough that it makes you not want to do it. Well, I assume you can still deadlift, bench press, overhead press, or any other movement just fine, until proven otherwise. What if these other movements do cause discomfort, what do we do then? As mentioned above, we want to encourage ourselves back to normal movement so we’re going to look for ways that we can alter what is currently unachievable to make it achievable. Look for the part of the movement that is making it too uncomfortable to do. If it’s a certain load, then drop the load to something tolerable. If load is controlled with some form of autoregulation, such as rate of perceived exertion (RPE), then you will likely notice this as you increase the weight, with the method allowing you to increase appropriate doses of stress as you feel more confident and capable to do so. If there is a particular range of motion that is currently out of reach, then cut out that part of the movement for now and slowly reintroduce it as you feel able to do so. What if we introduce variants, such as a very slow speed, pin squats, box squats, or change the bar position. What if there is no range to cut out or adjust? What if the whole thing is currently out of reach? Well then is there a different form of the movement that we can do? Can we do a leg press? A lunge? A step up? Leg extension? We would want to take advantage of whatever ranges of motion we currently have available to us. So, the recommendation is trying to do whatever movement you had planned. If something about that movement is currently out of reach then look for a variation, or something similar that you can do. Even if it’s only a partial range and regardless of how much the weight is reduced, if it’s all the way down to bodyweight then that’s fine, that’s where we begin. Keep regressing until you find something tolerable then work your way forward. Building autonomy through this process, showing ourselves that we are capable of managing situations like this, in and of itself also adds to a more positive outcome [11].

So, what is our takeaway here? After clearing up any concerns you have with your doctor, carry on with life. Try not to catastrophise, and keep encouraging movement as best you can, the odds are in your favour. And hey, if an incident like this leads you to resistance training, then you may just wind up stronger and more resilient than before it happened. If you would like to discuss this, or how you can learn to manage interruptions to the normal flow of training in general, then make a time to come in and chat, I’m happy to help.

1. Foster, N.E., et al., Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet, 2018. 391(10137): p. 2368-2383.

2. Care, A.C.o.S.a.Q.i.H., Low Back Pain Clinical Care Standard (2022). 2022.

3. Thomas, J.S., et al., Effect of Spinal Manipulative and Mobilization Therapies in Young Adults With Mild to Moderate Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Netw Open, 2020. 3(8): p. e2012589.

4. Senna, M.K. and S.A. Machaly, Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine (Phila Pa 1976), 2011. 36(18): p. 1427-37.

5. Salehi, A., et al., Chiropractic: Is it Efficient in Treatment of Diseases? Review of Systematic Reviews. Int J Community Based Nurs Midwifery, 2015. 3(4): p. 244-54.

6. Furlan, A.D., et al., A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med, 2012. 2012: p. 953139.

7. Care, A.C.o.S.a.Q.i.H., Low Back Pain Clinical Care Standard (2022) Initial clinical assessment. 2022. p. 13.

8. Baraki, A. Fear, Catastrophizing, and Training. 2018; Available from: https://www.barbellmedicine.com/blog/catastrophizing/.

9. Zhong, M., et al., Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician, 2017. 20(1): p. E45-e52.

10. Qaseem, A., et al., Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med, 2017. 166(7): p. 514-530.

11. Care, A.C.o.S.a.Q.i.H., Low Back Pain Clinical Care Standard (2002) Encourage self-management and physical activity. 2002. p. 31-34.