Introduction
Low back pain is ubiquitous throughout the human population, odds are if you are above the age of 20, your back has been uncomfortable at least at some point in your life. Low back pain is among the most common causes people go to the doctors office in the United States, and the world point prevalence is ~7.4%. What this means is that nearly 540 million people at any given time will be experiencing low back pain. Low back pain is also as the LEADING cause of disability throughout the world, and its effect is spreading throughout low and middle income countries. Not only does low back pain cause problems on the individual suffering from it, but it also poses a public health threat, especially when considering how the incidence throughout the world is rising, and, despite drastic increases in medical investigative technology, we haven't gotten much better at treating low back pain. Observe the current opioid epidemic going on throughout the United States. Pain medication has historically been a common treatment for LBP, which really are only effective at blunting the pain but doing nothing to modify the conditions that led to the pain experience. Something has to change.
This article aims at giving some further understanding to what low back pain is, why it occurs, what are some useful tools to use to treat it, and what can we do to decrease its chances of coming back. Hopefully, we can also make some headway on dispelling common myths about low back pain, which, by the end of the article you will hopefully understand how false beliefs and misunderstandings about LBP are contributing factors.
What is Low Back Pain?
As stated earlier, LBP is incredibly common, so common that odds are many of you reading this has at one point in your life experienced it, but what IS LBP? Getting a baseline definition is a good place to start:
"pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain"
-European Guidelines for the Prevention of Low Back Pain
In laymen terms, this means it hurts somewhere between the bottom of the ribs and the bottom of the buttocks. The pain can be described as sharp, dull, achy, throbbing, warm, cold, tingly, or a whole host of other adjectives. These complaints can be helpful to clinicians to figure out what are some main contributing factors to their patients LBP, but not an end all be all.
To further expand on the definition we can look at the temporal aspect of LBP in regards to how long its lasted, breaking it down between acute, sub-acute and chronic LBP:
Acute: Pain that has lasted <6 weeks
Sub-acute: Pain that has lasted between 6-12 weeks
Chronic: Pain that has lasted >12 weeks.
An average bout of low back pain has a favorable outcome and typically regresses within 6-8 weeks. Once that time span starts expanding to and past 6 weeks we venture into the sub-acute territory, and beyond 12 weeks we can define a patients LBP as chronic. These are important distinctions, because the longer the LBP experience, the longer maladaptive behaviors have to settle in, making it harder to combat sub-acute and chronic LBP. So a key feature of treating LBP is addressing it in its early stages with useful techniques to avoid chronicity.
What causes Low Back Pain?
Historically, the causes of LBP were generally attributed to some physical damage done to the spine or areas of the low back. Clinicians would blame compressed nerves, pulled muscles, sprained ligaments, etc. as the source of a patients LBP. Chiropractors would blame subluxations (slight misalignments of vertebrae) as the source of all evil (eye-roll emoji). All these diagnoses stem from whats called the biomedical view of healthcare, which, despite it helping produce great advances in the 20th century, pigeonholes the cause of pain, which is incredibly dynamic, into a small, reductionist place and ignores many other factors that contribute to the pain experience other than tissue damage. Blaming a patients pain experience on one single cause is a harmful, reductionist narrative that needs to be stamped out if we want to make headway on treating patients.
Diagnoses for the cause of low back pain has also evolved with imaging technology. When doctors started to x-ray spines they started seeing changes in the joint structure and started blaming that on the cause of LBP. When MRI technology came about and we were able to view the soft tissues and discs between the vertebrae, we started blaming those structures as the source of low back pain. When we became able to view brain activity on fMRI we recognized the central role the brain plays in the genesis of pain and the "pain is all in your brain" movement started. Once we started using these technologies to image healthy subjects with no complaints, researchers started to notice that these changes are incredibly common, even in asymptomatic individuals, and become more common as we age.
This table does a fantastic job at breaking down the false narrative that spinal changes are the source of pain in LBP. Spinal changes shown on imaging are likely just age related changes, akin to graying of hair or wrinkling of skin and has no real predictive power when considering pain. The thought process that structural changes aren't the sole cause of pain is slowly making its way into the minds of healthcare professionals, but the public needs to be informed that the changes shown on their x-rays or MRIs are more than likely normal age-related changes and are not the sole reason they are in pain. Even with the increases in medical technology, which undoubtedly has helped advance healthcare in many ways, we haven't gotten better at identifying the cause of LBP and we certainly haven't gotten better at treating it, largely due to the healthcare field being stuck in a biomedical view of the pain experience.
This is where a new model comes into play, the biopsychosocial (BPS) model. In 1977 physician George Engels wrote a paper criticizing the biomedical model and its inability to quantify the experience of patients suffering from disease. His paper gave diabetes and schizophrenia as examples, but since then the medical and research community has slowly expanded on his model to encompass the pain experience. The BPS model, in short, takes into account the dynamic experience of the human being; their thoughts, experiences, social status, culture, and yes, even tissue changes. The BPS model recognizes that ALL of these things contribute to the pain experience. Humans are humans, not Toyotas, they aren't machines that need to be twisted back into place in order to be fixed. If it were that easy we wouldn't see the poor treatment outcomes for LBP we do today.
Instead, we are now understanding that pain is an emergent experience that comes from a collection of factors including but not limited to:
Biological factors such as tissue damage, trauma, physiology, inflammation, disease, genetics, sleep
Psychological factors such as belief, expectations, self control, self-efficacy, depression/anxiety, anger, catastrophic thinking, hyper-vigilance
Social factors such as support systems, cultural norms, socioeconomic status, conditioned behavior, social learning, skepticism
All of these factors and more play a role in the pain experience, and to hyperfocus on one aspect ignores the rest. Think how effective treatment would be if we focused solely on a normal variant found on an x-ray but we completely ignored the amount of sleep an athlete was getting? Conversely, if an athlete presented to an office with a fractured femur and all we focused on was the amount of sleep they were getting? Or if a patient had a mistaken belief that x, y, or z condition was terminal and their clinician never corrected their belief? All of these factors play a large role in the genesis of pain and they should all be addressed when appropriate.
All of this isn't to say we need to ignore tissue changes entirely, that would be throwing the baby out with the bathwater. But recognizing tissue changes are merely a contributing factor to the pain experience, like flour for a pie recipe, and to ignore other aspects of the human condition would be akin to not using sugar, milk, baking powder, or fillings for a pie. The final product would be woefully incomplete and the results would be less than ideal. Now imagine paying a pastry chef to teach you how to make a pie and them telling you all you need is flour. This is what healthcare professionals do when they blame a pinched nerve, tight muscles, subluxations (again, eye roll emoji), or any other change shown on imaging as the cause of pain and ignore the rest of the ingredients.
The take home message from this section is sure, biology matters...to an extent, but often no more or less than factors like sleep quality, stress levels, belief and expectations, learned behaviors, self control, etc. An astute clinician will recognize these factors in the patient in front of them and address them when needed.
Why do athletes get low back pain?
This brings us to why some athletes get low back pain and some don't. Hopefully the reader has gathered that the answer is a complex, dynamic process that involves multiple factors, but what are some of the low hangings fruits.
Stress, The General Adaptation Syndrome, and poor recovery
In order to understand how fatigue plays a role in the genesis of pain its helpful to take a look at the General Adaptation Syndrome. Coined by Canadian Physician, Hans Seeyle, the GAS explains the way the body responds to stress. In short, when a stressor is applied to an organism it goes through 3 phases: Alarm, resistance, and finally exhaustion.
The alarm phase is the bodies immediate response to stress. In regards to the GAS, this is typically seen as a sympathetic response, more commonly understood as a fight or flight response. The fight or flight response is the bodies reaction to a perceived threat that involves a release of a hormonal cascade to help address the stressor. This includes an increase in heart rate and blood pressure, a release of adrenaline, the stress hormone cortisol, hormones that cause he release of energy sources to be readily available for use, and those that blunt the storage of energy for later use. It wouldn't be beneficial for the body to be focusing on digestion when running from a predator, right? This helpful in the short term, as it helps the organism address the problem in front of it, such as a gazelle running from a lion or recognizing your house is on fire, sending you into action. It's essentially a response that helps short term survival. However, a prolonged exposure to these hormones can be a bad thing, producing maladaptive changes that can lead to things such as suppressed immunity, disease, and eventually death.
The resistance stage involves adaptations that are beneficial to resist the stressor when subsequently exposed. When properly dosed stress can be a good thing, termed eustress. When the body is able to recover from eustress, its capabilities are increased and it can now better handle future stressors and increase chances of survival. To continue with the example of a gazelle being chased by a lion, the gazelle may be able to run a bit faster and be a little more aware of where the lions like to hang out, avoiding that area in the future. The adaptations to stress can be physical and psychological. But this is all dependent on the stressor being removed and the body being able to recover from being thrown off balance.
The third stage is the exhaustion phase, where the organism has been exposed to the stressor for a prolonged time and isn't given the opportunity to recover. As stated earlier, this can lead to maladaptations and a downward spiral of more stress, exhaustion, disease, and even death. Anyone who has taken college exams understands this process, as the combined lack of sleep and high stress levels of studying all day lead to feeling whiped out. After understanding this process it should come as no surprise that colds generally spike during these periods on college campus'. The exhaustion phase is when the body is exposed to the sympathetic cascade for too long, causing a bunch of negative physiologic effects. These include, but are not limited to, suppressed immunity, excessive fatigue, altered blood sugar metabolism, and a decreased ability to recover from injury.
The GAS has been used by sports scientists to further understand the bodies response to a physical type of stress, exercise. In the next section we will go over the Stress-Recovery-Adaptation cycle and its relationship with how we adapt to exercise and how it plays a role in why we have pain.
Stress Recovery Adaptation Cycle
In regards to exercise, the Stress-Recovery-Adaptation (SRA) cycle is an extension of Seeyle's work. It explains the bodys response to physical activity.
Exercise can be looked at as a stressor to the body, and in many ways the hormonal cascade mirrors that of the GAS. Adrenaline is released, energy is mobilized for use, insulin release is blunted in order to allow for more energy to be available for use. Cortisol levels even spike during an exercise bout. This isn't to be looked at as a negative, as exercise should be seen as a eustress, something that is good for the body. But like anything, too much of a good thing can be a bad thing.
The alarm stage after an exposure to exercise causes fatigue and we see this in real time during and after an exercise bout. If you complete a heavy set of 5 on the squat, you won't be able to immediately perform the next set unless you have an adequate rest. In the same way you likely won't be able to repeat the same session the following day as there has not been enough time to dissipate the accumulated fatigue and recover from the previous exercise bout. After an exposure to physical activity your capability will have decreased in the short term and you will have to wait in order to be able to complete another effective session. The alarm stage plays a normal and necessary part in the process of adaptation.
The recovery (resistance) stage is just as important as the stress stage, as we need to be able to recover from the initial stressor in order to see the adaptations we want to manifest. The recovery stage involves repairing damaged tissue that occurs during an exercise bout, replenishing energy sources, returning heart rate and blood pressure back to resting levels, and clearing out all the stress hormones released during the stress phase. This stage is a key point to emphasize because if it doesn't happen it can trend us towards the exhaustion phase and send us down towards a path of pain and injury. Many coaches and clinicians will talk about recovery techniques and tools to use in aiding recovery, some of them are more useful than others, but none are more useful than time and sleep. Sleep is the ultimate recovery tool and if it is not adequate, all the foam rolling, massage guns, adjustments, or dry needling won't matter. In the same respect, adequate time until the next exposure is paramount. We need to give ample time to recover before we challenge the same muscle tissue again if we are going to get the most out of our performance. This is why coaches rarely program training the same muscle groups on back to back days.
Finally, the adaptation phase is what we are seeking when training. We train to realize the health and fitness benefits exercise bequeaths us. In the case of resistance training this involves increases in strength and power output, increases in skeletal muscle mass, decreases in fat mass, improved cardiometabolic health, improved tendon strength and resiliency, greater bone density, and improved nerve firing for better coordination of movement. These adaptations occur at different rates, but everyone who has undergone a resistance training program has noticed these changes at some point or another. The changes aren't just physical, but they are psychological, too. Like playing an instrument routinely our familiarity with the activity increases and our knowledge improves on how to perform it.
All of these adaptations allow us to be better able to handle the stress when subsequently exposed. But, like we observed in the GAS, if we aren't able to recover from said stress, we trend towards exhaustion, which in the case of physical activity, manifests as overtraining, pain and injury.
Pain, injury, and fatigue
This whole article has been leading up to this section to figure out why athletes get low back pain. By now you should realize its complicated. This last section can help shine some light on why LBP pops up sometimes and why it doesn't. Hopefully you recognize it likely isn't one causative factor (subluxations, muscle imbalances, arthritis, disc bulges, etc), but a collection of factors, and managing fatigue is a major low hanging fruit that you can modify with programming.
With respect to the SRA, the risk of pain and injury increases when we either the stress we are exposed to in the form of exercise exceeds our capacity to handle that stress, in essence making a distress from a eustress, or we aren't adquately recovering from the previous bout of exercise. This can happen in the short term, where the activity we are trying to accomplish outstretches our bodies capability to handle the stress. Or this can also happen over the long term, where over the course of a training program we don't have adequate recovery and let the adaptations we desire to set in. This leads to too much cumulative fatigue that is hard to overcome, leading to an increase risk of overtraining, pain, and injury.
Signs that your fatigue accumulation is too high comes in the form of stagnation, poor sleep quality, increased amount of colds, excessive fatigue (we all know what that feels like), and the normal bumps and bruises associated with training hang around longer than usual. These are all signs that your body could use some extra recovery or that your programming is in need of some modifications. Luckily, this doesn't mean to cease training altogether; but something needs to be modified. This can come in the form of decreasing the intensity or volume for a few days, adding in an extra rest day, figuring out how to improve sleep quality and quantity, or doing a de-load. I like programming in scheduled deload weeks and rest days to lower the risk. Managing fatigue can go a long way in reducing the risk of pain and injury popping up.
What does this look like in regards to low back pain? Some of the common training variables associated with LBP are deadlifts and squats. Your programming can be modified where you spread out the heavy days of both exercises, say do heavy squats on Monday and wait until Friday to perform heavy deadlifts. Or you can decrease the amount of backoff sets performed in order to decrease total volume. You could also add in variation for these lifts, such as substituting a hex bar or sumo deadlift for conventional, or trying out the safety squat bar instead of low bar squat. These changes can be just what you need in order to allow the body to recover from exercise bouts and avoiding excessive fatigue
thereby decreasing the risk of pain and injury.
Managing Fatigue
One metric I like to track fatigue is the Acute to Chronic Fatigue Ratio. This is a formula that tracks current fitness potential weighed against the adaptations made over the recent past. Generally, looking at the exercises you are doing the current week compared to the previous 4 weeks helps gauge what you are prepared for in regards to exercise. If you have been hitting it hard in the gym or on the track for the past 4 weeks, there is a good chance you have accumulated lots of fatigue over that period which may indicate a deload. Conversely, if you just came off an easier week, giving your body time to recover and realize the fitness adaptations made over the past couple weeks, you may be able to handle a bit of a higher load or greater intensity. Once understood, the A/C Ratio is a useful metric to take into account when considering your exercise program.
Other factors to address would be managing outside stressors. I will go deeper into this in another post, but recognize that stress doesn't just come in the physical form. It comes in the form of bills, family, work, politics, or any other part of life that isn't easy. To use a cup as an analogy, your body can only handle so much stress, be it physical or psychological/emotional, much like a cup can only handle so much water. The more stressors we put on our life the higher likelihood we'll eventually spill over, often in the form of pain or injury. Stress is a part of the human condition and the sooner we recognize it all contributes to our total stress load the sooner we can start figuring out ways to manage it.
Conclusion
Pain in general is an incredibly complex phenomenon and is represented in the experience of low back pain. Remember it is rarely one factor that leads to the genesis of pain. It can't simply be narrowed down to your postural imbalances, muscle imbalances, changes we see on imaging, "subluxations", etc. This reductionist view of pain does a better job of contributing to the pain experience rather than fixing the problem. These MAY just be one of the ingredients that contribute to the final product, (except subluxations), and they don't matter any more than outside factors such as belief, prior history, social factors, outside stressors, and workload. Recognize they all contribute to the pain experience.
If you are someone experiencing low back pain, remember you are not alone, as this problem effects millions of people around the world at any given point. Also remember that most cases of low back pain have a very favorable outcome and resolve in 6-8 weeks. If you are someone who is experiencing low back pain and searching for care, seek out clinicians who respect you as a human, not as a Toyota that needs to be wrenched back into place. These type of clinical interactions tend to increase reliance on the clinician, decrease self efficacy and ignore the fact that the human body is a robust and adaptable organism that responds to stress. Look at the amount of work you are doing in the gym and the stresses you are experiencing outside the gym to better be able to navigate the pain experience. You'll be surprised at how effective these small steps can be in combating the pain experience.
Thank you for reading this long winded explanation of low back pain. There was a lot to go through and I hope you gained some knowledge from it. As always, you can reach me on Instagram at aboyce_dc. I'm happy to help in whatever way I can. You can also subscribe to my website for future posts and to find out how to work with me.