Low back pain is the most common reason given by patients who visit a physical therapist or chiropractor, and it is the second most common reason for which patients seek a consultation with a primary care physician.
Up to 85 percent of people will experience an episode of low back pain in their lives.
The good news is that even though it may be worrisome and uncomfortable, low back pain is rarely serious.
Although people commonly describe their pain as their back “going out” or their SI joint “going out,” these are not accurate terms for what is causing their low back pain. The spine is actually very stable, and bones and discs don’t just slip out of place, or "go out."
The lumbar spine consists of five vertebrae, which are larger than the vertebrae in the cervical (neck) and thoracic (mid back) regions, due to their function of carrying more of the body’s weight. The vertebrae are separated by intervertebral discs, which provide shock absorption for the spine. The spinal cord runs from the head down to the low back through the space in the middle of each stacked vertebrae.
Nerve roots exit the spinal cord at each level through spaces in the bones, and carry messages from the brain to the muscles. The spinal cord ends at about the level of the first and second lumbar vertebrae and continues as a bundle of nerve roots called the cauda equina. Some of these nerve roots form the sciatic nerve, which continues down the leg. The entire spine is supported by strong muscles and ligaments.
The low back gains stability from the deep central stability system of the diaphragm, pelvic floor, deep abdominal muscles (transversus abdominus) and the spinal stabilizing muscles (the multifidus). In a properly functioning system, the ribs are aligned over the pelvis to take advantage of the piston-like relationship between the diaphragm and the pelvic floor. When we coordinate our breathing with our deep central stability system, our spine has additional protection when we lift heavy objects (whether it's a loaded barbell at the gym, or a bag of mulch at the nursery). I wrote much more about this system here.
When we experience some sort of trauma to the muscles and nerves around the low back, it sets off a cascade of events. This cascade of events is part of the “pain cycle.” For example, when we lift the heavy object, our tissues send a message to the brain through the spinal cord that something is going on. If the brain perceives that there is damage or the threat of damage to the body, pain occurs. Think about what happens when you hold your hand too close to a flame. The brain wants the hand to pull back. In fact, pulling your hand away from the flame is practically an involuntary reaction!
Pain is meant to motivate action as a way to protect the body.
With trauma, pain tells us that there is a problem, but pain is not good at telling us what the problem is, where it is, or how severe it is. In acute injuries, pain is important in that it allows for protection of the area (we stop lifting the heavy object) and healing of the area (we get in a comfortable position and let the injured tissues heal).
Sometimes pain persists, even after tissues are healed, and sometimes the protective mechanisms persist as well (we stay rigid to protect our low back and we are afraid to move it). Your brain is constantly evaluating the severity of the threat in order to allow you to function. The brain considers the input from your body, your beliefs, your context, your emotions, and your pain history.
In effect, our brain and nervous system “remember” pain, and our system can become more sensitive to pain, even long after tissue damage has healed.
Initially it might make sense to rest, use heat or ice to your back, and try to make yourself comfortable. But very shortly after an acute injury, treatment should be aimed at learning how to move your body in pain-free ways again. This helps to decrease the protective response (spasm and tightness in muscles) and encourages natural movement again.
Treatment of low back pain (and any other type of chronic pain) is largely about convincing your brain that you are strong and you no longer need protection.
Research shows that early access to physical therapy improves outcomes and saves money downstream. When you consult with your physical therapist early in the treatment process, we provide a thorough evaluation which assists in the diagnosis of the issue. Then we work with you to develop a treatment plan to get you moving again. We can help you examine the triggers for your pain, and develop a graded movement program to help you move without fear of pain.
Early consultation with a physical therapist may help you avoid unnecessary medications and diagnostic tests such as x-rays and MRI, which we know from research are often poorly correlated with pain (many people with no pain have MRI’s which show herniated discs and other issues). Your physical therapist will treat you, and not your MRI.
Complete treatment of low back pain involves partnering with your therapist to develop a specific exercise plan to allow you to move without pain, manual therapy to promote joint movement and desensitize your nervous system, education about your individual pain triggers, and lifestyle recommendations to improve your supportive environment for healing.
Most of all, we will help your brain begin to trust that you are strong and capable, and can move well without pain. If you are experiencing acute or chronic low back pain, you can find a physical therapist near you via the American Physical Therapy Association's website.
If you'd like to learn more about chronic back pain, managing back pain, and how to adjust your training around back pain, check out How To Deal With Back Pain, a free video I filmed with Dr. Cassandra Forsythe.
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