Are you experiencing new, persistent, or recurring lower back pain that’s stopping you from doing the things you enjoy or just keeping you from feeling like yourself?
In this blog, I teach you all about low back pain rehab!
You Are More Than A Diagnosis
Have you heard any of the following statements?
- “If you have a disc herniation, you should avoid bending forward or movements that involve flexion of the low back.”
- “If you have spinal stenosis, you should avoid bending backward or movements that involve extension of the low back.”
- “If you have scoliosis, you should avoid lifting weights.”
While these statements are usually well-intentioned, they oversimplify low back pain and do not take into account that it is always an individualized experience.
- What if the person diagnosed with a disc herniation actually has an improvement in symptoms with bending forward?
- What if the individual with spinal stenosis is currently asymptomatic?
- For people with scoliosis, all forms of physical activity are recommended, and there’s no research to suggest that resistance training increases the degree of scoliosis or any associated symptoms.
The common belief is that a diagnosis completely dictates the rehabilitation process. In reality, a diagnosis can guide rehabilitation, but the history and presentation of the person are often more important. Two people can technically have the same diagnosis, but they might have vastly different symptoms, aggravating factors, alleviating factors, functional capabilities, goals, lifestyles, etc.
This is important to know because sometimes a diagnosis can cause people to become fearful of certain movements, exercises, or activities. However, the goal of rehab is to improve your overall function, confidence, and tolerance regardless of the specific diagnosis.
Does that mean that the diagnosis never matters? No. There are certain cases, such as when a fracture, inflammatory condition, or infection is present, when specific medical management is required. If you have any concerns, be sure to communicate them with your medical doctor.
You Are More Than An X-Ray or MRI
It’s also commonly believed that x-rays and MRIs can determine the exact cause of low back pain and how to fix it, but imaging does not change management or improve outcomes in the majority of cases. For that reason, and this might be very surprising, x-rays and MRIs are not recommended for most instances of low back pain.
Here are 3 things to consider:
- Degeneration, disc bulges, and other similar findings are common in asymptomatic individuals and should be considered a normal part of aging like wrinkling of your skin or graying of your hair. For example, despite having no symptoms, 37% of 20-year-olds demonstrate disc degeneration, while 96% of 80-year-olds show the same. This holds true for many cases of spinal stenosis, spondylolisthesis, and disc herniations. This is why a person’s history and presentation are so important.
- The degree of change on imaging doesn’t always correlate with a person’s symptoms or function. For instance, a larger disc herniation or more compression of a nerve doesn’t necessarily mean worse symptoms or outcomes. In fact, it’s possible to have compression of a nerve with no symptoms at all. Rehab doesn’t usually have to focus on the image because the image doesn’t have to change, and often doesn’t change, for symptoms and function to improve.
- Imaging costs more money, can create unnecessary worry, and may actually lead to worse outcomes if it results in further medical tests and treatments that are unwarranted (Webster et al 2013, Webster et al 2014, Shraim et al 2021).
Does that mean imaging is never required? Once again, the answer is no. Imaging may be necessary if a fracture, infection, inflammatory disease, or cancer is suspected, or if you’re considering surgery at the recommendation of your doctor. Similar to the previous section, this is a discussion to be had with your medical doctor.
Don’t get me wrong, diagnoses and imaging findings are helpful in the right context, but sometimes labels can negatively influence expectations and create self-limiting beliefs. I just want you to know that you’re more than a diagnosis or imaging finding. You’re not defined by a label.
After hearing all of this information, you might be wondering, “Well, what causes low back pain?”
Let’s start with posture.
Low Back Pain Is Not Caused By Poor Posture
While it’s easy to blame low back pain on posture, you can have “poor” posture with no back pain. You can also have “good” posture with significant back pain. Research doesn’t support the idea that any one posture or position is safer or riskier than another.
That doesn’t mean that posture never matters. If a certain posture or position is currently problematic, it makes sense to temporarily modify it. My concern, however, is that some individuals try to permanently avoid these positions or obsess over their posture because they’ve been told that it’s the primary reason for their pain.
Let’s say you have low back pain with prolonged periods of sitting. Could your symptoms be associated with the position of your spine? Sure. But your symptoms could also be related to a lack of movement and inactivity, the stress of what you’re working on, and a variety of other factors. Reasonable options include changing your sitting position, standing up for a bit, or going for a walk, without ever having to worry about the position of your spine.
It’s just as possible for someone to experience pain with prolonged periods of standing. Sometimes people actually feel worse trying to stand up straight or sit up tall all the time because they’re trying to avoid slouching based on the belief that it’s harmful.
Being sensitive to certain postures, positions, or movements doesn’t mean they’re inherently bad or the sole cause of pain.
What about core strength?
Low Back Pain Is Not Caused By A Weak Core
Similar to posture, there’s no research to support the idea that low back pain is caused by a weak core.
This is important to know because the belief that low back pain is caused by a weak core can lead to unhelpful behaviors, such as feeling the need to constantly brace your trunk muscles in order to “protect” your back. While bracing may be helpful while lifting heavy objects, such as deadlifting in the gym, it’s unnecessary to consciously contract your muscles while sitting, walking, or doing most day-to-day tasks.
Try clenching your fists for 60 seconds. Now imagine doing that all day long. You’d probably want to relax your hands and muscles to relieve tension, right?
Well, the same is true for the muscles of the trunk. It’s okay to let them relax. In most cases, you don’t even need to think about bracing your core before performing a task.
Have you ever carried all of your heavy grocery bags into your home in one trip? If you have, then you know your body was smart enough to do what it needed so you could focus on closing the car door and navigating the pathway to your kitchen.
Now, there are times when someone experiencing acute low back pain discovers that bracing the trunk musculature is helpful for reducing their symptoms during day-to-day tasks. However, this should be thought of as a temporary modification, not a long-term requirement.
What about specific muscles?
There Is Not A Muscle To Blame For Low Back Pain
Depending on the day, you might read or hear that low back pain is caused by a ____ (tight/weak/short/long/underactive/overactive) ____ (hip flexor, quadratus lumborum, multifidus, transverse abdominis, gluteus maximus, etc). These are just a few of the many examples.
Exercise can be helpful for low back pain, which is why I’ll discuss examples later in this blog. Unfortunately, though, if low back pain was as simple as stretching tight muscles and strengthening weak muscles, it wouldn’t be the leading cause of disability worldwide and continuing to increase.
I understand that this information may contradict other information you have heard or read. I’m not trying to be controversial and I’m okay with you disagreeing with aspects of what I’m saying. The main point I’m trying to get across is that low back pain is complex and multifactorial, which means that it cannot be boiled down to a singular cause and a simple solution.
What Can You Do For Low Back Pain?
This doesn’t mean that nothing can be done for low back pain. In fact, I think it allows for more possibilities and opportunities.
As a physical therapist, it’s not uncommon for me to see someone who’s had back pain for years and they feel lost, desperate, frustrated, and maybe even depressed because they haven’t found THE answer. This person might have gone down the rabbit hole of posture, then core stability, then muscle imbalances, then breathing mechanics, and a variety of other ideas and approaches, all while becoming more hopeless because they haven’t made the expected progress toward their goals.
Everyone promises a quick fix, but a quick fix rarely exists.
Also, rehab shouldn’t make you feel bad about yourself. You can improve aspects of your body and life without the guilt and shame that come with many treatment philosophies. Instead, rehab should empower you with the knowledge and tools to feel more confident, capable, and resilient.
So rather than searching for the perfect solution to back pain, what I think is more realistic is trying to identify any possible contributing factors and addressing those factors to the best of your ability.
Modifying Aggravating Activities
The first thing to start with is modifying aggravating activities.
As I mentioned earlier, if you have low back pain with prolonged periods of sitting, you could consider modifying your sitting position, changing your desk set-up, standing up for a bit, going for a walk, or integrating short bouts of exercise into your daily routine.
Although this sounds simple in theory, it can be difficult to implement. For example, if you get lost in your work because you’re passionate about what you do, you might need to set a timer on your computer or use sticky notes as reminders.
Sometimes it’s even more challenging. Perhaps you’re a truck driver who works 12-14 hour days, so you can’t just take standing breaks. You might have to find a cushion or back support that makes sitting more tolerable, or try to incorporate small bouts of exercise in the morning, during pit stops, or at night if you’re not doing so already.
This thought process applies to any activity, but keep in mind that many modifications are not meant to be permanent. For instance, if you’ve had to swap out walking for riding a stationary bike as a form of exercise because walking long distances is currently problematic, this might just be a temporary change until your symptoms and function gradually improve.
So, try to identify if certain positions, movements, and activities exacerbate your symptoms and then determine if there are ways that you can modify them. And if you can’t, don’t stress about it. There’s plenty more that you can do.
While it’s logical to address the biggest contributing factor, it might be more practical to reach for the lowest hanging fruit (whatever that may be).
Load Management
Load management, a concept frequently applied in sports, ties in with this concept.
Follow along for a moment. Let’s assume that your aggravating activity is barbell back squatting. Do you have to discontinue it completely? Maybe not. You might manipulate the frequency (how often you squat), intensity (how heavy you squat), and/or volume (the number of sets you perform per day or each week).
If that’s not enough, you may have to modify the exercise by changing the range of motion, tempo, type of squat, or, if all else fails, swapping it out entirely for a few months while symptoms calm down.
Now, this is a very specific example that might not apply to the majority of people reading this blog, but you could apply the same rationale to other activities. If you sit for 2 hours total during your commute to and from work, another 8-9 hours at work, and then come home to sit for another few hours in front of the TV at night, you would try to manage the duration of sitting you do each day (assuming it’s a possible contributing factor to your symptoms).
A lot of this has to do with reflection. You’re just trying to gain a better understanding of what’s currently tolerable for you and respecting whatever that limit may be.
Graded Loading, Graded Activity, & Graded Exposure
Over time, you can slowly build off this baseline and progressively work toward your meaningful activities, whether that’s barbell back squatting, watching a movie on the couch, reading in your favorite chair, walking more, or just playing with your kids.
Just know that setbacks happen. While it would be nice for rehab to always be a perfectly linear process, ups and downs are inevitable.
Earlier I stated that sometimes a diagnosis can cause people to become fearful of certain movements, exercises, or activities. Explanations about back pain can do the same. This is why I spent time talking about posture and core stability. Some individuals are led to believe that they have to always brace their core or maintain a neutral spine when performing day-to-day movements to avoid back pain and injuries. This is not possible, nor is it necessary.
If you’re currently sensitive to flexion of your lower back and feel better when trying to keep it rigid or flat while doing certain activities, that’s completely understandable. This is a type of temporary activity modification. However, this is not meant to be a lifelong change. Not only is the back designed to move, it’s healthy for it to do so.
Ultimately, you want to work toward thoughtless, fearless movement, and this may eventually involve exposing yourself to positions, movements, and activities that were previously uncomfortable or worrisome.
Low Back Exercises
This is one scenario in which exercise can be extremely beneficial.
For example, let’s say you temporarily minimized the amount of lumbar flexion you performed over the past 2 weeks because it was the position or movement that elicited the most symptoms. A simple way to reintroduce flexion of the back in a low threat manner would be an exercise like the cat-cow since it’s an unloaded movement that allows you to easily control the range of motion.
Another example would be a gymnast with a symptomatic spondylolisthesis. This individual would likely be advised to initially avoid backbending and other lumbar extension exercises that highly stress the region.
Eventually, the same cat-cow movement could be used as a starting point for reintroducing extension of the low back.
In either case, the person is gradually exposing themselves to positions, movements, and activities that were previously uncomfortable or worrisome in an effort to prevent lifelong restrictions or fears.
Exercise can also be used to break up prolonged periods of inactivity. For instance, if you work from home and spend 8 hours per day sitting at your computer, you could use the same cat-cow exercise every few hours to introduce some variability into your routine.
These exercise breaks are sometimes referred to as “movement snacks.” I keep referring to the cat-cow exercise for simplicity, but any movement or exercise can be used here, whether that’s bird-dogs, bridges, or dancing.
In some cases, exercise can be used to relieve symptoms in the moment. It’s often recommended to perform back extensions for disc herniations or flexion-based exercises for spinal stenosis.
My primary concern is that responses to these exercises are variable and it can be discouraging if a specific exercise doesn’t eliminate your symptoms as promised. There is not one best exercise for each designated category of low back pain, so it’s okay to figure out what works best for you through trial-and-error.
Perhaps one of the best applications of exercise is using it to restore your function and confidence over time. However, you don’t have to be married to one approach. You can do trunk strengthening exercises like planks and side planks, leg strengthening exercises like squats and bridges, and mobility-type exercises like cat-cows and side bends. It’s safe and healthy for the spine to be loaded and moved through different directions.
And there’s nothing that’s inherently off limits, whether that’s sit-ups, deadlifts, yoga, boxing, cycling, or pickleball. You just want to find the amount and type of exercise that fits your goals and preferences. Something is always better than nothing.
Lifestyle Factors
Aside from exercises that focus on the low back and surrounding areas, general physical activity is highly recommended. This could be 5 minute walks, 3 times per day; one 30 minute walk each day; recumbent cycling for 15 minutes, 3 times per week; or something else entirely. Once again, something is always better than nothing. Start at whatever your current baseline is and try to progress as tolerated.
Why?
Well, part of rehab is often about trying to improve your overall health. Sometimes this is just as important, if not more important, than some of the other things I’ve discussed.
How’s your sleep? How’s your stress? Are you interacting with loved ones and doing things you enjoy?
This can be challenging and it’s not always obvious.
If you hurt your low back performing a deadlift, you might look to errors in technique, programming, or something else directly related to the gym. But maybe you also have to consider that you’ve been in a calorie deficit as a means of losing weight, and you haven’t been sleeping much the past week because you’ve been stressed and staying up late studying for your college finals.
On the other hand, maybe your back pain started after trying to tie your shoes, which doesn’t make much sense. You weren’t lifting heavy or doing anything unusual or awkward.
Digging deeper into what’s going on in your life might be helpful. Perhaps you’re that truck driver who works 14 hour days and as a form of relaxation, you play a few hours of video games at night while eating relatively unhealthy foods. Maybe there are some small changes to consider here that could make a difference.
There are six points I want to mention:
- I’m not saying that these things are the cause of your pain or even contributing factors, but they might be worth considering, especially if you’ve been meaning to improve aspects of your overall health anyway.
- There doesn’t have to be guilt or shame attached to any habits or behaviors. You’re just trying to look at things with an objective lens to determine how you can assist with your own recovery.
- Modify the modifiable. For example, if you would benefit from improving your sleep quality or quantity, but have a newborn baby at home, don’t stress about it. Focus on what is truly in your control.
- Reach for the lowest hanging fruit. You don’t have to overhaul your entire life. What’s the easiest thing you can change that will make the biggest impact?
- Start small. Let’s say you identified that you would benefit from walking more, but you’re currently relatively inactive. Aim for something that you can confidently accomplish on a regular basis as opposed to setting an unrealistic goal that doesn’t get done.
- If you can, write down your goals, reflect on how you’re doing, and try to build momentum.
Preventing Low Back Pain
What about preventing low back pain?
Unfortunately, there is no surefire method or secret as low back pain recurrence is common.
It’s not a perfect analogy, but hopefully it’s one that makes sense – How can you guarantee that you never get sick?
You can’t, but washing your hands, sleeping well, exercising regularly, eating a balanced diet, and managing life stressors will help reduce your chances. There might be some inevitable exposures that increase your risk, too, such as having kids or traveling frequently for work.
It’s discouraging when you get a recurrence of low back pain, but don’t let it deter you completely. Focus on what’s in your control, whether that’s modifying aggravating activities, implementing lifestyle changes, or including exercises that are manageable for you.
You’re not broken and you’re not alone.
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before?
Check out our coaching and consultation services!
Want to learn more? Check out some of our other similar blogs:
Sciatica Advice, Disc Herniations, Anterior Pelvic Tilt, Core Stability
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