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Low Back Pain 101


Did you know that low back pain (LBP) is the 3rd highest reason for individual visits to doctors

on an annual basis? The number of visits to the ER, primary care physicians, or orthopedists

are so high it is actually considered an epidemic." Systematic reviews have estimated that the

annual incidence of LBP in Americans is as high as 33%.

Yet, we, the healthcare system, do not historically do a great job of helping individuals

manage or overcome their symptoms. In fact, LBP is the leading cause of activity limitation

and work absence throughout much of the world and is associated with an enormous

economic burden. The total cost of LBP in the United States exceeds over $100 billion per


Back pain is quite literally robbing you, your family, and your friends.


If you are like most Americans you may have been told that your symptoms are due to

spine degeneration, disc herniation, or arthritis. You may have received a radiograph (x-ray),

magnetic resonance imaging (MRI), or a computer-assisted tomography (Cat) scan to help

confirm this. But the truth about these expensive imaging techniques is that their findings are

not strong predictors of symptoms. In fact, research shows that upwards of 75% of individuals

with disc herniation confirmed through imaging experience no sciatic symptoms. Other

studies have found that 1/3rd of individuals with abnormal lumbar spines, as shown via

imaging, actually had no back pain symptoms at all.

Instead, other variables that require no fancy imaging studies have been shown to be more

accurate in predicting the need for low back pain related medical intervention. These

variables include: physical activity, sedentary lifestyle, physical job characteristics, age, sex,

and psychological aspects of work.

In spite of this, individuals often tell us that they believe their symptoms are correlated to core

muscle weakness, poor lumbar spine flexibility, genetics, or family history when in fact there

is no conclusive evidence to support these ideas either.

Again, if you are like most Americans when you hear statistics like this you probably think:

"then what is causing my symptoms?" The answer? It's complicated. When we consider our

anatomical make-up and understand that our bodies are complex systems we can begin to

wrap our heads around the idea that our symptoms are complex and multivariate. Generally

speaking, most low back pain symptoms are a combination of many factors, including:

biomechanics, instability, coordination, joint mobility, nutrition, sleep, or stress.


Now this is not to say that we do not and should not consider all anatomical sources as

potential causes or correlatives to your symptoms. We certainly consider muscles, ligaments,

nerve roots, joints, discs, fascia, and vertebrae to be potential drivers behind symptoms. But

also that sometimes tissue pathology and pain responses are not actually strongly correlated.

Which is to say the amount of tissue damage is not proportional to the amount of pain you

might experience.

Here's an analogy: I want you to imagine that you are walking through the woods when

suddenly you spot a bear! Your flight or fight response kicks in and you run. While you are

running you stub your big toe. What do you do?

A) stop and tend to your bleeding toe

B) forget the toe, there is more immediate danger at hand?

The answer is likely B and it is also likely that you do not even notice pain from the stubbed

toe. Why? Because the stubbed toe was not important enough to notice. Pain and pathology

are not correlated

Which is exactly why many individuals who have a surgery but continue to have the

same pain post surgically say that their surgery "failed. The surgery did not fail. It fixed

the pathology, but did not address the pain. Have you ever winced or grimaced in the

anticipation of a pain event only to find out the event was not painful at all? This happens

because the brain is phenomenal at protecting you against perceived threats. Pain is

processed in the brain. Not in peripheral tissues.

A classic example of this is found in the story of a builder who was under pressure to finish

a job. In rushing to finish, he jumped down from a ladder only to land on a large nail that

went through his steel toe boot and impaled his foot. He was in agonizing pain and had to

be sedated at the hospital. The doctors did an x-ray that clearly showed the nail penetrated

through one side of his foot and out the other. When they went to perform surgery they

removed the man's boot to find out the nail never penetrated his foot. It went right between

his toes. He had zero tissue damage, yet his pain response was astronomically high because

of the perceived threat. This is because the visual perception of the nail going through his

boot made him think he had sustained severe tissue damage: and, at the time of the accident

the pain experience was very real to him.

Contrary to this, is the story of a different builder who accidentally shot himself in the

head with a nail gun and did not even know it! He went to the dentist 6 years later for a

toothache and when the dentist did his x-rays he found a nail in the man's head. Again,

demonstrating that the extent of physical insult to tissues is not directly proportional to

our pain response.

"So you are telling me my pain is all in my head?"

Exactly! But that does not make it any less real. Pain is a subjective experience and varies greatly from person to person. Pain is meant to protect us, it alerts us to danger, it makes us move differently, think differently

and behave differently. Understanding pain, being able to discern threatening from nonthreatening stimuli, and learning to manage our symptoms are the most important steps in improving pain symptoms.


When it comes to low back pain our attitudes and beliefs about our symptoms are

significantly tied to the amount of limitations we have in life. Perhaps the event that initially

triggered your symptoms was as traumatizing as falling down stairs, or perhaps it was as

trivial as bending down to pick something up, or better yet simply sneezing. These are all

real events that can cause low back pain. Therefore, when we encounter and event like

this that left us in pain for days, weeks, or even months we tend to avoid those types of

positions or movements in general, just as any intelligent organism would. This speaks to

our most primitive survival instinct: the fire burned me = I won't touch fire again. Bending

down threw my back out = I won't bend down.

The issue with this protective mechanism is that movement and exercise are hugely

important when it comes to improving low back-related pain. In fact, when it comes to

the majority of low back injuries, movement and exercise have demonstrated over and

over again to be the best treatment interventions; even better than surgery in many

cases. Why? Because your body heals through movement. Your joints get lubrication from

movement Blood flows more easily with movement. Muscles repair and remodel with

movement. Just as a car is meant to be driven, your body is meant to move. Just as a car

will rust when not driven, your body will stiffen up when sedentary.


Depending on the pain mechanism at hand-this is for your practitioner to help you figure

out-the beginning of your treatment will vary. However, no matter your signs or symptoms

we know that all individuals with LBP will benefit from neuromuscular re-education (NMR).

NMR is essentially learning how to move properly again by recruiting the proper muscles,

sustaining muscle contractions, utilizing the range of motion we have, and applying

biomechanical knowledge to move more efficiently.

"But how will I know that movement is not doing further damage?"

All the movements you do should exist in a relatively pain free range to begin with. I tell

people to find their pain within a movement and then to stay just shy of the range that will

elicit that pain. Kiss the pain and back off. The more you move, the more that pain barrier

reduced. Additionally, I inform people to use what we call the rule of 3. If pain exists on a

0-10 spectrum (0 being no pain at all and 10 being you are in excruciating pain and need an

ambulance) you should not deviate more than 3 points from your baseline.

Before you do your exercises take inventory of how you are feeling. If your pain is a 2/10 as

you move through that exercise your pain should not exceed a 5/10. Your pain is a 0/10?

Don't go higher than a 3/10. Make sense?


Which exercises should you do?

Below are exercises with descriptions of things that you can work on to improve your


CAT-COW - on all fours (hands and knees) round your back up like an angry cat rounding

your pelvis and tucking your chin, holding for a few seconds, then extend out the other

way, arching your back, extending your head, and sticking your buttocks out. Do that at a

slow pace 10-20 times.

PRONE PRESS - lie on your stomach and prop up on your elbows, trying to extend

through your low back. Hold this position for a few seconds, then lay back down on the

ground, moving between positions of propping on your elbows and laying flat. Do this 10-

20 times

LOWER TRUNK ROTATION - Lie on your back with your knees bent and your feet on the

floor, slowly and gently drop both your knees to the same side. Then rotate your knees to

the opposite side. Repeat this 10-20 times,

ASSISTED SQUATS - find a doorframe, counter top, or back of a sofa. Then hold on and

sit your bottom back is if you were going to sit in a chair, ensure that you are sticking

buttocks out and not allowing your pelvis to round out, your knees should be at a 90

degree angle, hold for a second and push back up, repeat that 10-20 times.


These exercises are not a one-time "fix' and will not work after you've done them for just

a few minutes. You must be vigilant and consistent with your exercises. Think of brushing

your teeth. You don't brush your teeth only when you have a cavity. You do it every day, for

life. View these exercises the same way. Do them always. Even when you feel good.


Dimsdale JE, Dantzer R. A Biological Substrate for Somatoform Disorders: Importance of Pathophysiology.

Psychosomatic medicine. 2007;69(9):850-854. doi:10.1097/PSY.Ob013e31815b00e7.

Delitto A. George SZ, Van Dillen L, et al. Low Back Pain: Clinical Practice Guidelines Linked to the

International Classification of Functioning, Disability, and Health from the Orthopaedic Section of

the American Physical Therapy Association. The Journal of Orthopaedic and sports physical therapy.

2012;42(4):21-57. doi:10.2519/jospt.2012.424.AL

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