Scientific stats show that 85% of low back pain is of unknown etiology. Have you ever hear the diagnosis "Idiopathic Low Back Pain?" It means low back pain of an unknown origin. In other words - it's really a way to weasel out of saying what the cause is. According to world renowned low back expert Stewart McGill, that simply means that most back problems are not adequately identified and are thus misdiagnosed!
Diagnosis often depends on the profession of the treating therapist or physician, each seeing the problem through the lens of their respective training. There’s that old aphorism of the many blind men identifying an elephant according to the respective part that they are each touching. Also, there's that old saying that if the tool you have is a hammer, everything looks like a nail!
The source of back pain can’t always be identified. Much research has gone into this question. Often, pain is the result of a microtrauma of the facets or the disc, small aberrant motions causing micro-tears or avulsions which in turn cause other structures to react. Disc endplate fractures from mechanical over-loading is common, and that damage causes pain. Such damage can occur from repeated low force trauma such as lifting boxes wrong at work, or from a one-time accident, such as landing hard on a jet-ski or snowmobile. Such endplate fractures can lead to the disc material draining into the vertebra over time, causing a decrease in its ability to cushion between the vertebra.
Another scenario might be a young gymnast doing excessive back bends for years developing a shear injury which leads to a facet fracture in the low back. This type of injury may only become an issue as an adult decades later, perhaps following a whiplash auto injury.
According to McGill, the best first step of any clinician, trainer or therapist is to find the movements which cause pain and train the patient to avoid them, and then find safe and pain free ways to move.
One of the safest exercises in an acute state is Cat-Camel, with the patient kneeling on all fours and gently flexing-extending their spine. This is safe because minimal load is placed on the disc due to the horizontal position of the spine.
Another surprising way of reducing some low back pain is to walk faster, swinging the arms with purpose. I like to refer to this as the angry parent walking towards a teen who's in trouble! This seems to engage muscles which otherwise aren’t adequately utilized due to the fear of reinjury and pain avoidance!
The spine is a rigid yet flexible structure which on its own cannot withstand much force (up to 90N). But the ligaments and spinal muscles surrounding the spine allow for significant tethering, much like a tent pole with ropes, to allow significantly more force. That said, most people can withstand sufficient forces in their backs in basic movements such as walking with no problem.
Muscles of the limbs are meant for movement, whereas muscles of the spine are meant more often for stabilization. One muscle which seems to do both is the Lats, where the upper part moves the arms and the lower part is a dense fascial low back stabilizer. The Abdominals form a network of muscles creating a hoop around the entire abdomen.
The deepest spinal muscles act as position sensors rather than movers. If muscles act like rubber bands, then ligaments act like duct tape to stabilize the bones of the skeleton, holding them together and resisting torque or shear movements. When a ligament is damaged, joint laxity occurs which can lead to arthritic changes.
That’s enough anatomy for now! I’ll close this segment with some common misperceptions of ways to avoid back pain:
Drawing the navel toward the spine does not protect the spine. In fact, it reduces stability! Increasing the distance between the abdominal wall and the spine enhances stability. Think of bracing your stomach to take a punch.
Stabilization exercises for the spine should be performed with correct motion patterns and low load (for the injured spine). As McGill says, practice does not make perfect, it makes permanent. Repeating an exercise often grooves motor patterns, ensuring stability.
Back Mechanic, by Sterward McGill: This is a terrific book which I highly recommend you get, read and follow. It is a great guide to understanding low back anatomy, discovering your particular movement patterns, learning how to avoid what causes pain and replace with proper movement mechanics (bending, squatting, etc), and good exercises to strengthen.
And the best chair is one you get out of often! Take frequent breaks throughout the day. I’ve seen great posture in poor chairs and horrible posture in expensive ones. We will go over ergonomics in a later blog. Since discs hydrate overnight, the spine is actually taller when you first get up. And it’s also less stable, so walk/move for at least 30 minutes before doing any exercise.
My next blog will introduce specific exercises to begin your journey out of back pain.
