The New Science Of Low Back Pain

Go online and you would think we have the solution to low back pain. You know, the problem that is one of the biggest causes of disability in the world, that cost just in the US around 134 billion dollars! That problem is fixed with just one or two exercises that you see on social media right? Man, that would be awesome for SOOO many reasons, but you can probably tell that just isn’t reality and the fact we overly simplify low back pain is one of the BIG reasons we don’t do a great job of resolving it for most people.

A 2009 study looking at those with non-specific chronic low back pain (no diagnosable structural reason for pain) found that only about 40% of people recovered in a year’s time frame from the onset of pain (you can read HERE). Muscle strains and ligament sprains account for as much as 97% of back pain complications (1), that means a rather small amount have actual spinal structural issues. Most people that have low back pain don’t even suffer from common things like sciatica as that tends to only impact about 5-10% of people that get low back pain (2).

This is all to say that the majority of people that get low back pain don’t have significant spinal issues, so why do we have such a difficult time in having more success in helping chronic low back pain? Probably because we don’t understand the complex nature of chronic pain which is a combination of being a product of biological, psychological, and sociological issues. This was coined back in the 1970’s by doctors as the biopsychosocial model. In many cultures, the idea of the mind and body being one has been around for centuries, but largely in Western cultures we have approached all body problems as very separate from the mind. Now science is validating that they are connected and it expands how we have to look in addressing many chronic health issues such as…

-IBS

-Fibromyalgia

-Cardiovascular Disease

-Diabetes

-Many Auto Immune Diseases

& Chronic Pain (3)

This is NOT to say that the issues and pain that are caused through looking at more than just purely physical issues. There is a saying in the pain science literature, “all pain is real pain”. Telling people that the low back pain they are experiencing, for example, is not real is also incorrect. What can happen is the brain starts to misinterpret the signals that it receives as pain. This often is the case with the people that are under chronic stressful conditions and have experienced longer term pain. At the same time, this is NOT to say that there is no physical relationship to cases of low back pain.

Our Fascia May Be A Low Back Pain Issue More Than Muscles

A LOT of pain we experience in movement may not be the spine or the joint, but research is now showing largely myofascial. That is the combination of the fascia (connective tissue) that covers your muscles AND your muscles. It is estimated that 85% of people will experience myofascial pain (Cleveland Medical Clinic), that is even MORE than those that will experience low back pain. This pain can be quite intense and even refer to unrelated parts of our body.

One of the big culprits when it comes to low back pain is the thoracolumbar fascia. This large bundle of fascia plays an important role in transferring forces among trunk muscles and the spine (4). In fact, a fascinating 2011 study found that those with low back pain 12 months or greater had a significant reduction in movement of the thoracolumbar fascia than those without low back pain (5).

What does that mean for you or your clients? Does that mean you start doing Jefferson curls to “stretch out” the thoracolumbar fascia? Probably not the best idea as loaded flexion can cause more pain for people and doesn’t address the fact that the thoracolumbar fascia doesn’t move just up and down. Due to its diagonal pattern, carefully and deliberately working different patterns is going to help give better elasticity to the tissue (6).

You are going to see some examples below, but the idea that to build better movement in the low back is just about stretching the low back is a misunderstanding of some of these key concepts of low back pain.

Predictive Coding & Kinesiophobia

Both predictive coding and kinesiophobia represent really interesting, but also problematic chronic pain issues that often originate in the brain.

Predictive Coding: “When you have chronic back pain, your brain becomes more sensitive to pain signals in that area. As a result, the brain may begin to generate more predictions about when and where pain will occur in the back, even when there is no actual tissue damage or injury present. These predictions can contribute to the experience of chronic pain by amplifying pain signals in the brain. However, by understanding how predictive coding works, researchers may be able to develop new treatments that disrupt these predictions and offer relief from chronic pain.” (6)

Kinesiophobia: “According to the fear-avoidance model, individual who experience acute pain may get trapped in a vicious cycle of chronic incapacity and suffering due to their cognitive, emotional, behavioral, and functional responses to pain. This model states that when a painful event is perceived as threatening, it can lead to catastrophizing thoughts that movement and physical activity will result in further pain and injury. One component of this model includes fear of movement, or kinesiophobia, “in which a patient has an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury” (7)

An overly simple explanation is that the brain starts to alter how we experience movement. The longer someone has had something like chronic low back pain, the MORE these can be very real challenges to overcome. Reducing the impact of these issues can be helped by methods like Pain Reprocessing Therapy that is often administered by qualified mental health professionals. However, there is evidence that exercise like I show below can reduce pain catastrophising and help with some of these issues. Just telling people that movements won’t hurt isn’t probably going to work and forcing people to try to perform movements that they believe will hurt isn’t helpful either.

I could write more (and will this week) about such a BIG topic, but I wanted to help people see that low back pain is more complex than most of social media will make you believe and the ways we can help improve such complicated issues may be different than you would have imagined!

You can get so much help with challenging issues like low back pain with our special online programs like our Masterclasses, online certifications, and DVRT Rx Courses” HERE

References:

1. Costa Lda C, Maher CG, McAuley JH, Hancock MJ, Herbert RD, Refshauge KM, Henschke N. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009 Oct 6;339:b3829. doi: 10.1136/bmj.b3829. PMID: 19808766; PMCID: PMC2758336.
2. Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ. 2007 Jun 23;334(7607):1313-7. doi: 10.1136/bmj.39223.428495.BE. PMID: 17585160; PMCID: PMC1895638.
3. Renoir T, Hasebe K, Gray L. Mind and body: how the health of the body impacts on neuropsychiatry. Front Pharmacol. 2013 Dec 18;4:158. doi: 10.3389/fphar.2013.00158. PMID: 24385966; PMCID: PMC3866391.
4. Gatton ML, Pearcy MJ, Pettet GJ, Evans JH. A three-dimensional mathematical model of the thoracolumbar fascia and an estimate of its biomechanical effect. J Biomech. 2010;43(14):2792–2797. doi: 10.1016/j.jbiomech.2010.06.022.
5. Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bouffard NA, Konofagou EE, Lee WN, Triano JJ, Henry SM. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskelet Disord. 2011 Sep 19;12:203. doi: 10.1186/1471-2474-12-203. PMID: 21929806; PMCID: PMC3189915.
6. https://www.sarnoclinic.com/what-is-predictive-coding/
7. Bordeleau M, Vincenot M, Lefevre S, Duport A, Seggio L, Breton T, Lelard T, Serra E, Roussel N, Neves JFD, Léonard G. Treatments for kinesiophobia in people with chronic pain: A scoping review. Front Behav Neurosci. 2022 Sep 20;16:933483. doi: 10.3389/fnbeh.2022.933483. PMID: 36204486; PMCID: PMC9531655.