Understanding Low Back Pain
Throughout this article, we’re going to provide specific insights and real-world examples that will help you to understand the true physiology behind pain.
Evidence shows that through a proper understanding of pain, we can significantly improve someones overall experience of pain, arguably having the greatest impact. This fantastic video below helps to articulate what is the summary of the most recent available evidence on pain in real-life patients. This resource is incredibly powerful and often goes against what many people have been lead to believe about their bodies.
We feel that through exploring the issue of back pain, we can learn through specific example, how our body creates & responds to pain, along with how we can best deal with this to ensure our optimal health & wellbeing.
Explain Pain: It’s in my head?
Pain is a long-studied and misunderstood concept. Recent insights have led to greater understanding of what pain is and how it comes about. The first thing we need to realise is that pain is an output of the brain, not an input from the tissues of the body. What the tissues do is send a danger signal to the brain which it then decides what to do with. This is a difficult concept for some people to comprehend so it is best explained through the use of a few examples.
A: The No Brainer
Person A is perfectly healthy with no existing issues or injuries. They inadvertently put their hand on a hot saucepan. The cells in the hand send a danger signal to the brain which then assesses the situation. The brain gets information from the eyes, seeing a saucepan over a flame, thinks back to the recent memory of you turning on the stove and thinks further back to previous experiences. It knows that fire is hot, heat can damage the skin and cause injury so it sends out a pain signal they move their hand away from the saucepan. In this scenario, pain has served its purpose as a protective mechanism.
B: It’s alright coach, I can’t feel a thing
The brain does not always follow this process. For example, Person B is an elite athlete playing in an important game. They suffer a traumatic injury, one that would normally leave them lying on the ground in agony. Despite this, they shake it off and continue playing, and it’s not until after the game that it begins to hurt and they realise they’ve injured themselves. What’s happened here is that in the state of excitement about the game the brain has received the danger signal but processed everything else that is going on and decided that the injury is not a priority (and the same is true of soldiers in battle, or other people in life-threatening circumstances). The priority is to finish the game (or get out of the battle) and once that is done, then the brain will send out pain signals for Person B to deal with the injury.
C: Lingering on
Our final example is the other of the spectrum. Person C has a bad back. They injured it 15 years ago and have had intermittent flare ups ever since. Every time it does flare up, they are in pain for a while, sometimes missing out on work and are unable to play their favourite sports. Due to this constant reinforcement, anytime a danger signal comes from their lower back, their brain is so wound up about the prospect of another flare up that it sends excessive amounts of pain out to stop them moving their back. However, this becomes counter-productive because not moving their back means it gets tight and weak and when they do need to use it they are at increased risk of re-injury. Further the brain’s pain signals are not helping so the brain increases its output of pain, to the point where any signal from the back is interpreted as dangerous and elicits a pain response. This wind-up in the pain process is known as chronic pain and can be extremely debilitating.
“Pain is a complex issue that requires a deeper inquiry than just the site itself”
What can we do about it [Stay strong & persevere; Don’t stop moving]?
What is required is actually the opposite of what the brain wants. Person C needs to move their back, get it stronger and retrain the brain that any movement of the back does not equal danger. However, we do need to be aware of the pain process and more importantly realise what is appropriate and inappropriate pain. This is explained in the graph below. The vertical axis represents pain, whilst the horizontal axis represents time as we exercise. The green line represents appropriate or good pain. As we start exercise the pain will increase. This is normal even for someone who is uninjured. However, the pain should plateau at a manageable level and once we finish exercising the pain should decrease. Maybe not to baseline but it should go down. The red line is inappropriate or bad pain. This is where the pain continues to worsen and becomes unmanageable. If this is the case then we need to stop what we’re doing and either take a break or change exercise. Recognising the difference between appropriate and inappropriate pain is crucial to retraining the pain pathway and recovering from chronic pain issues.
To go beyond what we’ve just spoken about, we want to share one of the best available resources on understanding pain. Professor Moseley has cut his teeth in creating useful stories & powerful narratives to help people properly conceptualise pain & reap the benefits because of it.
The crux of his message is that pain is something we should not fear. It’s a signal from our body to tell us there might be danger. In most chronic cases of pain, this mechanism has become overstimulated. It’s up to us to now teach our brain to downregulate this response by bringing in healthy lifestyle habits & changing the way we think about pain.
The Spine: Your best friend (Or worst enemy…) 33 little joints
The spine is known as the vertebral column because it consists of 33 separate bones known as vertebrae stacked on top of each other. In between each vertebrae is a cushion known as an intervertebral disc. It absorbs stress and allows the vertebrae to move around without grinding against each other. Meaning the spine is a series of joints designed to bend, twist and generally be very mobile. It consists of 5 sections:
- Cervical (neck): 7 small, but very mobile vertebrae.
- Thoracic (chest): 12 larger vertebrae with ribs attached.
- Lumbar (lower Back): 5 large and less mobile vertebrae.
- Sacrum (between the hips): 5 vertebrae that are fused together and wedged between the hips.
- Coccyx (tailbone): Usually 4 but can be 3-5 small fused vertebrae at the bottom of the column.
Why does it even exist?
The spine has three main functions:
- Protect the spinal cord: Nearly all nerves in your body travel from the brain down through the spine along the spinal cord before branching out into the body. The spine provides a tough exterior cover to protect these nerves.
- Provide structural support and balance to maintain upright posture: There’s a reason backbone is a term used to describe the foundation of things. Your spine is the foundation for the majority of muscles and other bones to ‘anchor off’ providing support and stability and allowing you to remain upright.
- Enable flexible motion: Just as the spine is the basis for stability, it also provides the basis for most movements. Whether you’re moving your legs, arms or whole body, the movement is almost always initiated at the spine. If the spine is stiff and immobile other areas have to compensate leading to poor movement patterns and in some cases injury.
That’s all well and good, but my back still hurts [the ultimate warning sign]!
Pain in the back is common but doesn’t necessarily mean there is a serious injury. Often back pain is a warning sign that things aren’t moving well and you are putting your back or other areas at risk of injury. This may be due to strenuous exercise with poor movement patterns, sitting for long periods or imbalances caused by everyday activities. The good news is that clearing up these issues, be it mobility or strength, will often cause the pain to decrease or even disappear. The key is to focus on function rather than pain.
The Core: More than you might think. You mean six-pack abs right?
The ‘core’ has been a buzzword in fitness and rehab circles for quite a while but its exact definition can be ambiguous. When we talk about the core we are really talking neck to knees, that is your trunk/spine and its immediate attachment to the peripheries (hips, shoulders and neck).
The core is usually divided into the deep and global core. The deep core consists of muscles that attach directly to multiple spinal sections and create stability. These muscles include the transverse abdominous, multifidus and diaphragm muscles.
The global muscles cover the prime movers. These range from the prime movers of the spine such as rectus abdominous, erector spinae and the external obliques to muscles of the hips and shoulders. These muscles are considered prime movers – their function is to create movement at the joints they cross, however, they also help create stability.
Dynamic stabilisers: a matter of movements
As mentioned, the main function of the core is to stabilise the spine and transfer force between limbs. In doing so, it allows us to move freely, lift and carry loads, all whilst protecting the spine and joints. The problem with core exercises and low back rehab is that practitioners have a tendency to focus on one part of the core. For example, there is research that transverse abdominus activation is delayed in people with low back pain, so that for a while everyone with low back pain was given transverse abdominus exercises. However the core, like everything else in the body needs to be viewed as a system in its entirety.
This is why, when assessing the core, the best approach is assess an individual’s movement patterns. Can they perform basic movements such as a squat, step, push up or lift an object from the floor whilst maintaining stability of their trunk and symmetrical movement?
Over the course of this class we will be practising a number of exercises designed to strengthen the musculature of the hips, shoulders and back and encourage better movement. These exercises will get progressively harder over the term, so in the beginning some may feel a bit easy. If on the other hand some exercises are quite difficult this may be a sign that these muscles are weak and you should practice this exercise at home.
Neutral Spine: even distribution
What is neutral spine?
A neutral spine refers to the shape of a healthy spine with three ‘natural’ curves. When viewed from behind the spine should be straight but when viewed from the side the cervical (neck) region curves inwards, the thoracic (chest) curves outward and the lumbar (lower back) curves inwards. It is the position where our back is at it’s most neutral load sharing capacity & helps to minimise the amount of pressure on any one particular part of the spine.
Why is a neutral spine important?
This is a topic of hot debate! When the back is in a neutral position, the muscles are in an optimal position to take the load, protecting the joints of the spine and preventing sudden injury. Therefore, as a general rule of thumb, it is important to aim for a neutral spine when lifting heavy things or if you are in a static position for a long period of time (eg, sitting at work). However, we must remember that our spine is designed to move!
The spine is a series of joints that are designed to bend, twist and move. Just like any structure in our body, it has the capacity to adapt, become stronger & tolerate more force. This means that if we happen to go out of neutral spine (this exercise is all about getting out of neutral spine) in our training or regular activity, then this will be absolutely fine, provided we don’t overdo things & find the level that doesn’t push our spine too far (as we would do with any form of training). The video below helps to articulate how our body adapts to & what is likely to cause injury. So, in summary, while it is important to be aware of your spinal position in general & aim for neutral spine when lifting very heavy things it should not be to the extent of becoming afraid of movement or avoiding movements that you want to do. The person who does the thing they wish to do regularly is the person who is adapted enough to avoid being injured from it [See our Load management concept for more on this].
The Glutes: More than just a pretty face
The Strongest Muscle in the Body
The term ‘glutes’ refer to the three muscles of your bum; the gluteus maximus, gluteus medius and gluteus minimus. The glutes maximus is a large powerful muscle that extends/straightens the hips. However, in conjunction with the gluteus medius and minimus they all play an important role in stabilising the hips. The role that they play is to pull the thigh out and stop the knees rolling in when we squat and jump, etc.
A Strong Foundation
The simplest way to think of the glutes is to imagine your back as a tower with the glutes being the base. A strong base is needed to keep the tower upright and strong. If the base is weak and wobbly, it doesn’t matter how strong the rest of the tower is, it will always be wobbly. When we spend a lot of time sitting, our hip flexors (at the front of our hips) become tight and the glutes switch off. This means that when we go to do physical activity we can have trouble engaging our glutes and rely on other parts of our body for stability (such as hamstrings or hip flexors) which can then become tight and compound lower back pain.
The Scapula: A floating joint
Free as a bird
The Scapula is commonly known as the shoulder blade. The shoulder is a highly complex joint that is able to move through many different planes of motion. However this greater mobility comes at the cost of stability. Therefore unlike other joints, which have large, thick ligaments holding them in place, the shoulder joint has a group of muscles known as the rotator cuff. These muscles originate on the scapula, so the scapula can be thought of as the anchor for these stabilising muscles. If however, the ‘anchor’ of the scapula isn’t strong, then it will move under load meaning the stabilising power of the rotator cuff is lost.
Causing compensations: Chicken or the egg?
The scapula can directly affect back pain, the scapula and surrounding muscles also support the neck. Poor control here can lead to kyphosis or a ‘forward head’. This can cause neck and upper back pain. The scapula can also affect the back indirectly. If the shoulders are weak, unstable or even sore the body will compensate and try to work around the weakness. This will often involve moving the back in vulnerable positions, such as swaying far back to press over head, or snaking the spine during a push up. This repeated loading in a poor position can then leading to back pain over time.
The Most Important Thing to Know: Your Body Is Strong & Resilient!!
The most important message in all of this simple.
Our body is strong & resilient.
It thrives on movement & has the ability to constantly adapt to the demands we place upon it. Back pain is usually just a manifestation of a weakness of ‘de-adaptation’ somewhere in our body that is now causing our brain to perceive threat (which is compounded even more if we’re fearful of movement). As such everything, we do at MTP aims to educate you with the strength that your body is capable of. To see more in-depth about this process check out our article on our top program for building longevity.
Great! Thanks for all the Info, But What Can I Do Now?
If you’re experiencing a lot of pain, it is strongly recommended that you book in to see a physiotherapist to provide immediate relief & get you started on the right track. An initial consult with a Physiotherapist or Exercise Physiologist is always the point of entry we recommend for people coming to see us. If unsure who to see, see our guide through our Instagram Post below.
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With all of this said, this article helps to articulate the rough theory behind how MTP Health aims to address the issue of back pain, with specific examples to articulate precisely how the physiology of pain works. Now that you have all the theory, you can start making real inroads into your own experience of pain & finally free yourself from the shackles it is placing on your life.
For those who don’t know, MTP stands for Move > Train > Perform. In our experience progressing someone through these phases is the absolute best way to resolve someone’s issue for life, while empowering them to be genuinely healthier as a result of their treatment. The perform phase is absolutely critical in all of this, as it helps to make sure what has been learnt can be maintained so that your body will be strong & optimised for the rest of your life!
In terms of what you can do to start addressing your back pain. It’s best to determine exactly where you’re at. At MTP, our approach takes form into 3 distinct phases.
- Relief & Recovery. This stage is aimed at understanding your specific situation, identifying the factors that are causing your pain & providing you with immediate relief so you can go about living your life without being affected by the pain.
- Build [Restore & Momentum]. (Move & Train phase of Move > Train > Perform) This is where we address the fundamental root cause of your pain & work to allow your body to adapt through specialised exercise. This is where we can make the biggest change, in working to teach you new habits & build a stronger body. This phase will be guided by a practitioner the whole time
- Teach [Freedom]. (Perform phase of Move > Train > Perform) This final phase is where we start to move you into your own, goal-based activities & help you to build your overall body strength to empower you for a healthy & robust life. We work in all of the principles that have been taught in the first stages & continue you on towards steady progressing that keeps you moving forward. A big part of this phase is complimenting the activities you love, with the work we do in our clinic. It’s all about giving you the tools for a sustainable way to manage your body for life.
So there you have it, just about everything you will ever need to know about back pain & how you can resolve it. We hope you got a lot of value from what we had to say! If you have any questions, please don’t hesitate to reach out to us through one of our many channels!
In need of immediate relief? Check out this quick video for one of our favourite exercises