How to manage and prevent back pain?

Back pain is extremely common. In fact, about 75-84% of people worldwide will experience back pain at some point in their lives (Thiese et al. 2014). The good news is that the vast, vast majority of back pain cases are not indicative of something serious. In fact, most cases will alleviate within days to weeks (Hartvigsen et al. 2018). That said, we understand that back pain can be incredibly uncomfortable and frustrating.

So given the prevalence of back pain, we thought it would be good to talk about some of the common myths we hear and give some tips about managing and preventing back pain. 

 1. Lifting weights, especially with a bent back is bad.

Just like lifting weights makes muscles stronger, lifting weights makes the back stronger and more resilient. Of course, lifting something awkwardly or a load you are unaccustomed to can be a factor that contributes to pain, just like any other part of your body. However, we know that an appropriate resistance training program that starts with manageable loads and builds up slowly is safe and beneficial. Research has also not demonstrated an association between lifting with a bent back and pain (Saraceni et al. 2020). The human body is very adaptable and as long as you start low and go slow, it is very unlikely that you will injure yourself.

2. That’s fine, but I know I have a bad back. I have had an MRI that showed I had lots of things wrong with my back.

Scans are only useful in the very small minority of people where there is a suspected fracture, cancer or infection. Scans will almost always show scary sounding findings like disc bulges, stenosis and degeneration, and these findings become more and more prevalent with age (Brinjikji et al. 2015). Unfortunately, the report doesn’t tell you how common these findings are in people without pain and that they don’t predict how much pain you experience. The prevalence of these findings increases with age, so you can think of them more like wrinkles than injuries. Scans can also change over time – most disc prolapses shrink, and the worse the prolapse the more likely it is to do so (Macki 2014).

It’s also good to catch yourself when you adopt harmful beliefs about your back. When people get a lot of back pain, sometimes they can start believing their back is fragile, or ‘bad’. People who think like this, often feel the need to protect their back by avoiding movements like lifting and twisting. These people tend to have more back pain, and they often miss out on the benefits of resistance training because they are afraid of loading their back. The fact is that the spine is an incredibly strong and robust structure, so even though you might get pain, you should do your best to be confident that your back is a resilient structure.

3. Someone I know had back pain, they saw a surgeon and ended up needing an operation.

Surgery is rarely an appropriate option for back pain, since the vast majority of cases improve without the need for high risk, high cost, surgical management (Hartvigsen et al. 2018). The scientific community used to think that if we could operate and take out the structure causing pain, we could solve someone’s back symptoms. We now know that pain is the result of a multitude of factors such as health status, socioeconomic status, attitudes and beliefs about back pain (Moseley 2007). Often removing a structure has no effect on pain. Of course, in a very small minority of cases it can be useful, but we know the best way to improve back pain is keeping active and understanding that the pain is highly unlikely to be the result of something serious (O’Sullivan 2019).

4. I’m worried my back pain will get worse as I get older.

There is no evidence to suggest that getting older causes or worsens back pain (ibid). In fact, stopping or avoiding activities because of fear may leave you less prepared to handle those tasks – meaning you are more likely to experience pain when you have to perform such an activity. Pain fluctuates throughout the lifespan (Thielke et al. 2012), and back pain affects all age groups roughly evenly.

5. I have terrible posture – that’s why I get back pain.

There is no one CORRECT way to sit, stand or lift, even though sometimes these activities can be painful.  Rather than restricting yourself to sitting up perfectly straight, try relaxing and regularly changing your position. Being relaxed during everyday activities is far more important than being in any one position (O’Sullivan 2019). For more information on posture, check out our posture blog here.

6. The reason I have back pain is my weak ‘core’.

The word ‘core’ implies a particular set of muscles that are more important than others and it is often thrown around when people talk about back pain. In fact, we have a very hard time defining, let alone measuring how strong these muscles are. Having weak ‘core’ or trunk muscles does not cause back pain (O’Sullivan 2019).. People with back pain often tense their trunk muscles in a bid to keep their back straight and stiff whenever they bend over. This is unhelpful. We need to learn to trust our backs and move in a relaxed way. For more detailed information about the ‘core’ check out this blog.

7. I’ve been told I have sciatica, what can I do about that?

Sciatica refers to nerve pain related to the sciatic nerve, which is a nerve that travels down the backs of the legs. However, it’s impossible to put pain down to one structure, so this is not a diagnosis that we use. The same management principles apply, if you are experiencing symptoms in your legs. Maintain your exercise as much as you can manage. If needed, you can modify your resistance training:

1. Weight - the first thing is to reduce the weight to a load that you can tolerate.
2. Range of Motion - some of the movements may require you to reduce the distance you move your limbs through - for example, you may not be able to squat all the way down - so you should perform a shallower squat. Or you may not be able to perform a pick up from the floor, so you can lift the weight from a raised surface, like a stack of books.
3. Exercise selection - If the above has not allowed you to continue your resistance training, you can substitute in an alternative exercise. For example, if you can’t perform a squat, you could do a sit-to-stand instead.

8. What is the best treatment for back pain?

Whenever you have an episode of back pain, you may feel as though you should rest, especially during the first couple of days where you are particularly sensitive to movement and it seems like everything is painful. However, we know that bed rest can increase the likelihood that back pain persists, so here are some evidence-based tips for managing your back pain and reducing the risk of recurrence:

1. Keep Active! – Rest will nearly always make things feel better, but it’s important that you keep moving, even if it is a gentle walk. Over time it’s important to slowly reintroduce exercise and movement that you are used to and enjoy. Remember that pain with movement DOES NOT mean you are doing harm. Any form of exercise is beneficial. We recommend aiming to meet or exceed the national physical activity guidelines of 150 minutes of moderate or 75 minutes of aerobic exercise each week and 2+ resistance training sessions. Getting started with resistance training can be a little daunting if you haven’t done it before. You can get started with some free workouts when you sign up for a free account on our Be Mobile Exercise Platform. 
2. Educate yourself on Pain and understand that back pain is very rarely associated with serious damage. Tissue healing virtually always occurs within 3 months, so if pain persists past this time, it’s usually the result of other factors. This video by Pain Scientist Lorimer Moseley is a good place to start in understanding your pain more. 

When is back pain serious?

Although the majority of back pain is not serious in nature, it can sometimes be associated with a serious medical condition which may require further investigation or specific treatment. Studies have shown that these specific medical conditions account for less than 1% of all low back pain with fracture being the most common condition (Henschke et al., 2009). Other specific causes of back pain include infections, malignancy, inflammatory disorders or cauda-equina syndrome. 

The signs and symptoms of these specific medical conditions are known as ‘red flags’. Roughly 80% of low back pain cases will have at least one ‘red flag’ despite less than 1% having a serious disorder.

These ‘Red flags’ include - Back pain associated with or accompanied by:

• A recent surgery or illness
• Fever/chills or generally feeling unwell
• Recent unexplained weight loss
• A major trauma, such as a bad car accident, significant fall or sports injury
• A low trauma incident in the presence of osteoporosis.
• A history of cancer
• Severe unremitting night pain
• Severe or progressive sensory alteration or weakness (medical emergency, call 000)
• Bladder/bowel incontinence (medical emergency, call 000)
• Saddle anaesthesia (medical emergency, call 000)

Should you experience one or more of these red flags, it’s advisable to seek the opinion of a healthcare professional who will determine likelihood of a serious condition and the best course of action moving forwards.

Takeaway

We understand that back pain can be very frustrating and stop you from doing your daily tasks as well as the things you love. Try to remember though, that low back pain is a very common experience, and that it is very rarely a cause for concern. Most cases of low back pain get better within days to weeks and the best thing you can do is to keep moving. If you have any questions please reach out to us at [email protected].

References

Brinjikji, W., Luetmer, P., Comstock, B., Bresnahan, B., Chen, L., & Deyo, R. et al. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal Of Neuroradiology, 36(4), 811-816. doi: 10.3174/ajnr.a4173

Hartvigsen, J., Hancock, M., Kongsted, A., Louw, Q., Ferreira, M., & Genevay, S. et al. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356-2367. doi: 10.1016/s0140-6736(18)30480-x

Henschke, N., Maher, C. G., Refshauge, K. M., Herbert, R. D., Cumming, R. G., Bleasel, J., ... & McAuley, J. H. (2009). Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology, 60(10), 3072-3080.

Macki, M., Hernandez-Hermann, M., Bydon, M., Gokaslan, A., McGovern, K., & Bydon, A. (2014). Spontaneous regression of sequestrated lumbar disc herniations: Literature review. Clinical Neurology And Neurosurgery, 120, 136-141. doi: 10.1016/j.clineuro.2014.02.013

Moseley, G. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, 12(3), 169-178. doi: 10.1179/108331907x223010

O'Sullivan, P., Caneiro, J., O'Sullivan, K., Lin, I., Bunzli, S., Wernli, K., & O'Keeffe, M. (2019). Back to basics: 10 facts every person should know about back pain. British Journal Of Sports Medicine, 54(12), 698-699. doi: 10.1136/bjsports-2019-101611

Saraceni, N., Kent, P., Ng, L., Campbell, A., Straker, L., & O'Sullivan, P. (2020). To Flex or Not to Flex? Is There a Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis. Journal Of Orthopaedic & Sports Physical Therapy, 50(3), 121-130. doi: 10.2519/jospt.2020.9218

Thielke, S., Sale, J., & Reid, M. C. (2012). Aging: are these 4 pain myths complicating care?. The Journal of family practice, 61(11), 666–670.

Thiese, M., Hegmann, K., Wood, E., Garg, A., Moore, J., & Kapellusch, J. et al. (2014). Prevalence of low back pain by anatomic location and intensity in an occupational population. BMC Musculoskeletal Disorders, 15(1). doi: 10.1186/1471-2474-15-283