Low back pain (LBP) is one of the most common conditions treated by health care professionals in the United States. Up to 70% of people will develop LBP in their lifetime and 5-10% of these cases will develop into chronic low back pain (more than a 3-month duration). Knowing this is a concern for millions of people, how do we stop it?
First, low back pain isn’t something to ‘stop.’ Pain is a part of our lives, a beneficial part in the right cases. Pain teaches us when to slow down or check for an injury. Acute pain – meaning pain within a few days or weeks of an injury – acts as an alarm system for the body. Chronic pain – pain lasting beyond the normal healing time – is the problem.
Here’s the interesting thing about LBP. Over 90% of cases will recover without any treatment within a couple of weeks. In most cases, the best medicine is to resume your life.
Did you tweak your back while gardening or rearranging the garage? No problem. Keep moving and your back will improve over a few days. Don’t try to set a new personal record in deadlifting or take up trampoline basketball for the first time, but don’t sit on the couch or pop Aleve like mints either.
The first objection I commonly hear to the “keep moving” recommendation is the fear of making things worse. This is understandable. It only takes a couple of clicks on the internet to find horrifying stories about low back pain leading to paralysis or being a precursor to cancer.
These are the exceptions, not the rule. A good healthcare provider will screen for red flags and find you the appropriate care.
What is the appropriate care? That’s what I am going to cover in the rest of this article.
I’m going to address Do’s and Don’ts for low back pain treatment according to current research and debunk a few myths. My goal is to provide you with the resources necessary to control your health. There is much misinformation on the internet about pain and treating it. You don’t need massage guns, adjustments, or injections to treat your pain. In most cases, you can manage the pain on your own. Sometimes, you just need a little guidance. That’s where we can help.
Let’s start with the most common myth regarding low back pain: a disc slipped.
While the MRI is a phenomenal invention and can provide life-saving information, it can also cause unnecessary harm and waste billions of healthcare dollars. “Poor” MRI findings cause people to seek unnecessary surgery, take unnecessary medications, and avoid activities they love. Paradoxically, it is the activities they are told not to do (e.g. run, hike, lift weights, play sports) that will reduce pain, improve strength and body resilience, and oftentimes reverse the concerning findings on an MRI.
Chief among these findings is the slipped disc, officially known as a herniation.
If you receive an MRI on your low back tomorrow, there is a decent chance it will show some combination of disc bulges (aforementioned herniation), arthritis, decreased space (stenosis), and bone spurs (osteophytes). These “abnormal” findings on an MRI are quite normal, especially as we age. Our bodies degenerate over time; it is a part of life. Most people with back pain have normal MRI reports while a significant portion of people without pain (asymptomatic) have “abnormal reports.”
Receiving an MRI is oftentimes more harmful than beneficial. Receiving an MRI as a first-line assessment can lead to poorer outcomes for patients with low back pain. The MRI causes fear-avoidance behaviors as patients become scared to move, fearing movement will cause further “damage”. In reality, lack of movement often intensifies symptoms and delays recovery.
Our bodies are remarkably resilient and robust. I am not saying stenosis or severe herniations are never a problem, but in most cases, a healthy lifestyle will resolve the pain and help you move the way you want to. Did you know herniations heal on their own?
The worst thing we can do for low back pain is to stop moving. This brings me to the second myth.
“Don’t round your back”, “Lift with your knees, not your back”, and “keep you back straight” are among the most commonly used phrases for “injury prevention.” When looking at the research, these phrases fail to hold water.
Lifting with a rounded low back (known as lumbar flexion) is not asking for a back injury. A recent study reviewed over 4,500 articles to determine what the current body of research has to say about lifting with a rounded low back. Here is what they concluded:
“There was no prospective association between lumbar spine flexion when lifting and the development of significantly disabling low back pain. There was no difference in peak lumbar flexion during lifting between people with and without LBP. Current advice to avoid lumbar flexion during lifting to reduce low back pain risk is not evidence based.”
Translation: lifting with a rounded low back does not cause or maintain low back pain.
Workplace ergonomics training focused on reducing lumbar flexion does not work. It is not worth the time or effort to teach people to keep their backs straight. Pain and injuries are multi-factorial and focusing on a single cause is rarely the answer.
Looking at work-related pain specifically, low job satisfaction, poor exercise tolerance, inactivity, and health issues are greater concerns than lifting technique. When looking at injuries in general, overload and poor recovery are the primary culprits.
This does not mean repeatedly maxing out deadlifts with a round back won’t lead to an injury, but the injury is more likely the result of excessive demand placed on the entire body, not just the spine (deadlifts are very demanding). Instead of focusing on lifting techniques, focus on overall health and exercise. Research shows exercise is one of the most effective treatments for back pain at work (you will start to notice a theme).
Current research does not support posture as a driver of pain. Simply sitting up straight will not eliminate or prevent pain.
Our bodies are very resilient, and they can hold up to sitting in a slouched position for some time. But what about all the “texting neck” imaging scaring people about the excess forces you are placing on your spine? Nope. Your spine and muscles are laughing saying “Is that all you’ve got?”
Instead of shelling out money for copper-infused braces and fancy chairs, self-prescribe a frequent dose of movement and breaks from sitting.
“There is little evidence for the specific efficacy beyond sham for invasive procedures in chronic pain.”
This quote comes from a 2019 research study that pooled the results of 25 research trials. Surgery for low back pain was included in those trials.
Research suggests psychosocial health plays a large role in determining the success of post-operative care.
Patients with high levels of kinesiophobia (fear of movement) and pain catastrophizing (constant focus on pain and feeling of helplessness) are less active. Surgery does not cut away our fears, anxiety, and self-doubt. Personalized treatment centered around movement is needed for that.
Moving over to medication, the issues remain the same. Medicine does not address the root cause of chronic pain and brings side effects to the table. Medication has its place in pain management, but outside of surgical or traumatic experiences, it should not be the first line of defense, especially if it is prescribed as the only line of defense.
This is one of the primary reasons for the current opioid problem in the U.S. Not only do pain medications, such as opioids, fail to address the root cause of pain, but they also bring unwanted side effects into the equation. The Centers for Disease Control (CDC) has attempted to reverse the current trend in opioid reliance and stated in its Guideline for Prescribing Opioids for Chronic Pain that the number of side effects, paired with the addictive nature of the drugs, make them inappropriate as a first-choice treatment.
Research simply does not support the idea that our bodies fall out of alignment. Furthermore, we do not need to be balanced. Our bodies are resilient and adaptive (have I said that yet?).
Our bodies change relative to the demands we put on them. It is perfectly normal and healthy to be “unbalanced” and have more strength or more mobility on one side compared to the other, especially if you played (or currently play) any sports growing up. The alignment of our body does not matter; fitness, metabolic (nutrition), and mental health are what matters.
The common analogy floating around healthcare that our bodies are like cars and need regular maintenance is simply not true.
A key difference between a body and a car is the ability to adapt. Cars only break down. If you take a car on a road trip, you do not build its endurance. You cannot increase a car’s horsepower but taking it on hills or drag racing. Conversely, weightlifting and sprint training will build up a body. (source) Meditation and high-quality sleep can sharpen our minds. (source) High-quality gas will allow a car to run optimally, but high-quality nutrition can also enhance the human body beyond its current capacity.
Also, cars need someone else to do the maintenance for them. You are in control of your body. A physical therapist is a partner that can guide you, but you are ultimately the one in control.
Studies are clear that exercise and activity are the best medicine for bones, joints, and cartilage health.
But what kind of exercise?
Regardless of your age, moderate and high-intensity exercise are both appropriate and recommended. But you do not have to pump iron to be healthy.
According to recent research, walking is just as effective as other forms of exercise for treating low back pain. Walking can also help with endurance, bone health, depression, and anxiety.
Do exercise and activities you enjoy. If you enjoy it, you are more likely to stick with it. If you work with a physical therapist or personal trainer, make sure they are working towards your goals and incorporating the activities you enjoy. That doesn’t mean you won’t have to work hard to build muscle and strength – walking can’t do much there – but you can personalize your routine.
A quick disclaimer, stretching won’t solve LBP. Inflexibility is not a cause of LBP either. Contrary to popular opinion, stretching and mobility exercises in isolation do not reduce the risk of injury. Studies that do show a potential injury protective effect of multi-modal approaches, meaning when stretching is combined with an active warmup and other exercise interventions it may be beneficial. Stretching is not bad – if you enjoy it, do it – but it is never needed or an effective treatment.
At the end of the day, pain looks different for everyone and its effect on someone’s daily life is individual as well. The good news is there are a plethora of conservative treatment approaches without the side effects of medications and surgery. By focusing on exercise, nutrition, sleep, and emotional health (stress, happiness, purpose, etc.), you will build your body’s resilience to withstand future challenges.
If you are seeking a quick “fix” to low back pain, you may find yourself running into the same issues repeatedly. Instead, know that the next time you feel pain in your back, if you keep moving it will likely resolve in a few hours or days. If you feel an injury occurred, the progress isn’t to your liking, or you are concerned about future risks, reach out to us.
The goal of physical therapy is not to “fix” you, but rather, to help you gain the resources and confidence to live the life you want. Our physical therapists can teach you about pain, help you build strength, and navigate the minefield of health misinformation.
Zach has numerous research publications in peer-reviewed rehabilitation and medical journals. He has developed and taught weekend continuing education courses in the areas of plan of care development, exercise prescription, pain science, and nutrition. He has presented full education sessions at APTA NEXT conference and ACRM, PTAG, and FOTO annual conferences multiple platforms sessions and posters at CSM.
Zach is an active member of the Orthopedic and Research sections of the American Physical Therapy Association and the Physical Therapy Association of Georgia. He currently served on the APTA Science and Practice Affairs Committee and the PTAG Barney Poole Leadership Academy.
