Back pain is common, very common.
In fact, it is responsible for thousands of lost work days each year and, more alarmingly than that, you are more likely to die from issues related to lower back pain than you are Malaria (1).
That, of course, is a relative risk and the chances of you dying from Malaria are far higher if you live in an actual jungle, rather than an urban one.
But, like so many other health conditions in the developed world, it’s not so much the condition itself that’s the problem but the lifestyle that leads to it and your reaction to the condition.
This is where doctors come in!
First, let me just say, I am not one of those fitness lunatics who thinks modern medicine is the devil and that scientists are paid by “Big Pharma” to lie to you.
Rather, the point I am making here is that your GP is a jack of all trades and most likely not a back-pain specialist.
Without trying to trivialise the work that General Practitioners do, they are trained to identify symptoms and then treat the symptoms, mostly (but not always) with drugs.
What a GP can’t do is diagnose, with any level of clinical certainty, the cause of your pain.
So, if you have back pain, visit a doctor and come away with no clear diagnosis of the condition, the cause of that condition or a practical strategy for reducing the pain (and managing the cause) you haven’t seen a back-pain specialist!
In a perfect world your GP would confirm that you have pain of an undetermined cause and then refer you to the relevant department for further clinical investigation.
That should then lead to physiotherapy and a prescription of corrective exercise BEFORE anyone mentions surgery.
But, as amazing as surgeons are at what they do, if all you have is a hammer everything looks like a nail!
Let me explain in a little more detail…
What is chronic pain?
According to the NHS, chronic pain is pain that has lasted for at least 12 weeks (2).
Anything less than that is what’s known as acute (or short-term) pain and is associated with injuries.
After 12 weeks most injuries, if treated correctly, should heal and the pain be greatly reduced.
But what causes chronic pain?
Many things! The most common causes are falls and accidents – like falling off your bike or doing kettlebell swings with poor form; along with injuries such as prolapsed discs or infections (2).
In a moment, I’ll explore that in more depth, but for now, let’s just say that tissue damage isn’t necessarily a cause of pain.
What else do the NHS say about chronic back pain?
Let’s take a look:
Most back pain is what’s known as “non-specific” (there’s no obvious cause) or “mechanical” (the pain originates from the joints, bones or soft tissues in and around the spine).
This type of back pain:
- Tends to get better or worse depending on your position – for example, it may feel better when sitting or lying down.
- Typically feels worse when moving – but it’s not a good idea to avoid moving your back completely, as this can make things worse.
- Can develop suddenly or gradually.
- Might sometimes be the result of poor posture or lifting something awkwardly, but often occurs for no apparent reason.
- May be due to a minor injury such as sprain (pulled ligament) or strain (pulled muscle).
- Can be associated with feeling stressed or run down.
- Will usually start to get better within a few weeks.
This is where I start to take issue. There is no such thing as “non-specific pain” there is ALWAYS a cause!
In his book Back Mechanic, Dr Stu McGill says this about degenerative disc disease:
You don’t have a disease in your back, what you have is an ageing spine. You wouldn’t tell your mother in law she has degenerative face disease because she has a few wrinkles.
Who is Stu McGill?
He’s only the world’s leading expert on spine biomechanics, someone who has published over 200 clinical research studies on the subject. He’s not some celebrity quack like Dr Oz or Mercola, he’s the real deal.
What does imaging tell you?
What if you did get referred on and you got a scan, what does that scan tell you?
It is a snap shot of what your spine looks like right now. When your doctor explains to you what she’s seeing, she’ll point out the dark areas; “this is where the degeneration is,” she’ll say. Or, she might tell you it’s arthritis – “well, you’re not getting any younger” – arthritis really should require a blood test to be diagnosed. But I digress.
According to Stu McGill, those dark areas are dehydration.
The spongy gelatinous discs in your spine are drying out due to ongoing compressive loads. This may be exacerbated by carrying heavy loads, but no number of back squats are going to even touch the sides compared with the compressive load placed on your body by gravity, so don’t worry too much about that.
The imaging gives us interesting feedback, but the real question is this; what did your spine look like before you started to experience pain?
You probably hadn’t had a scan done prior, so how do you know anything has changed?
Let’s look at the evidence.
In 2015 a review of a longitudinal study by Suri et al which examined 123 people over a 3-year period to explore the validity and predictive nature of MRI findings (3).
They found that only two pathologies were potentially indicative of pain experience.
However, in their conclusion they even questioned this:
Although incident annular fissures, disc extrusions, and nerve root impingement were associated with incident symptom outcomes, the 3-year incidence of these MRI findings was extremely low and did not explain the vast majority of incident symptom cases.
This was further brought into question in a 2015 study by Nakashima et al, which looked at 1,211 healthy subjects aged 20-70 (4).
They received a cervical MRI (the cervical region of the spine is what you know as the neck).
It was found that 87.6% of subjects had varying forms of disc bulges which actually increased in both severity and frequency with age.
Most subjects aged 20-50 displayed asymptomatic (no pain) disc bulges; however, subjects aged 50-70 had more severe levels of both disc bulge and spinal cord compression (SCC) which was associated with higher levels of pain.
Finally, a 10-year longitudinal study released in 2017 looked at 91 subjects who were recruited in 2006, with 41 returning for follow up in 2016 (5).
Of those 41 examined in the follow up, almost all of them displayed increased disc degeneration (as you might expect). The group was split into those with lower back pain (LBP) and those without.
There were no statistically significant changes in spinal pathology (including disc bulges and spondylolisthesis) that were associated with increases in incidences of LBP.
The concluding findings were thus:
The progresses of these findings were also not associated with the LBP history. In addition, baseline MRI findings were not associated with LBP history during the 10 years; therefore, our data suggest that baseline MRI findings cannot predict future LBP.
Basically, there is a current weight of evidence which suggests that imaging is not an accurate diagnostic predictor of pain. Interesting, right?
So what causes the pain?
Pain catastrophising is conceptualised as a negative cognitive–affective response to anticipated or actual pain (6).
Basically, it’s how you think about pain, the expectation of pain and, in some cases a fear of movement based off a perceived prediction of potential pain outcome.
This is why the words your doctor uses are so important.
As soon as a trusted authority (your GP) tells you that you have a disease in your spine that is likely to change your whole dialogue surrounding your personal experiences with pain.
Like those people in the previously mentioned studies, some had pain and some didn’t, but ALL had various spinal pathologies, so is the pathology the cause of the pain or is it the expectation?
This neuro-emotional aspect is becoming more widely researched now.
One such area of psychological theory is the neuromatrix concept, where pain outcomes, expectations and experiences are determined by a number of external inputs (7).
Essentially, the theory goes like this; the things you think, feel and sense are thrown into a metaphorical vortex from which a number of end-point outputs emerge, all leading to behaviours or compensations which enhance your experience of pain.
According to painscience.com a section of chronic pain sufferers develop a perception of fragility, something they call “’fraidy-cat back.” These people think they are made of glass and believe that almost anything will hurt their back.
I can identify with that. When I first injured my neck, I thought my life was over. I’ll never play sport again, I’ll never reach the level of strength or fitness I had always wanted, I’ll be a cripple, etc.
These were the pessimistic stories I was telling myself. But when I asked my physio if I should play in a work football match, he said “why not?”
I was stunned, how could he be so dismissive about my condition? It’s almost as though it’s not that serious… Oh, wait…. NOT THAT SERIOUS!
I played the match, my neck was fine, I was catastrophising my injury!
The pain was still there and so were the referral sensations in my left arm but after this revelation it was never severe enough to stop me from doing anything.
I stopped catastrophising and suddenly, my pain was no longer my identity, it was just something that I had, not something that defined me.
Practical take homes
The first thing I would say to you if you are suffering with chronic pain is get a proper diagnosis, get a second and a third opinion if necessary.
If all you have is a disc bulge or some age-related degeneration that is no reason to stop leading an active life.
Identify movements and postures that trigger pain and do what you can to avoid those. Find a sleep position that enables better sleep quality and reduces pain outputs while asleep.
If necessary, take some time off exercise and allow the affected area to just relax and calm down, it may require some natural healing and that’s fine.
Then, the best thing to do is to strengthen your body! Even elderly populations with degenerative conditions were shown to experience improvements in pain symptoms when progressive resistance training was introduced (8).
I wouldn’t just jump straight in with 2x bodyweight deadlifts though, strength and exercise intensity are relative to each individual. Again, according to Stu McGill, promoting core stiffness is an important consideration for both reducing pain and preventing the onset of chronic pain (9).
Starting with a simple bodyweight core routine might be the best starting point for someone with a low level of conditioning, or a trained person coming back from acute injury.
Lastly, if you are prone to anxiety and pain catastrophising, I would advise you to create a mindfulness practice to try and change the dialogue from one of pessimistic expectation to one of acceptance and optimism.
You are NOT your pain!
- Institute for Health Metrics and Evaluation. The Global Burden of Disease: Generating Evidence, Guiding Policy. Seattle, WA: IHME, 2013.
- nhs.uk. (2019). Causes. [online] Available at: https://www.nhs.uk/conditions/back-pain/causes/ [Accessed 8 Mar. 2019].
- Suri, P., Boyko, E., Goldberg, J., Forsberg, C. and Jarvik, J. (2014). Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders, 15(1).
- Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T. and Kato, F. (2015). Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine, 40(6), pp.392-398.
- Tonosu J, Oka H, Higashikawa A, Okazaki H, Tanaka S, Matsudaira K. The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PLoS One. 2017;12(11):e0188057. Published 2017 Nov 15. doi:10.1371/journal.pone.0188057
- Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745-58.
- Leung L. Pain catastrophizing: an updated review. Indian J Psychol Med. 2012;34(3):204-17.
- Ishak NA, Zahari Z, Justine M. Effectiveness of Strengthening Exercises for the Elderly with Low Back Pain to Improve Symptoms and Functions: A Systematic Review. Scientifica (Cairo). 2016;2016:3230427.
- McGill, S. (2010). Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal, 32(3), pp.33-46.