Low Back Pain: Part One
A better understanding of back pain
Over the last 13 years I’ve been struggling with low back pain (LBP), which lead to seeing many (so called) professionals. Sports doctor, physio-, manual- and remedial therapists, personal trainers, sports masseurs and specialized low back pain centers. In most of the initial visits, some individual tests were done. But after the intake, a one-size-fits-all program was prescribed as the solution. Looking around and seeing how many people, including myself, still have pain in their backs, I kept on searching for more individualized programs. For such an approach it is important to first have a look at what the spine can do, to then be able to understand the mechanism of injury.
Why do we have a spine?
The spine is a brilliantly engineered part of our body. The spine can move, can be loaded, it enables us to walk upright, and transfers power from our hands to our feet and vice versa. Let’s start with going over the movements it can do.
Spinal movements: flexion, extension, lateral flexion and rotation.
The movements can be categorized by looking at the spine from different points of view. We can tie our shoes (flexion), look and get up while lying face down (extension), bending sideways (lateral flexion), and turning your head and shoulders to look and see who’s behind you (rotation).
Spinal loading: compression and shear forces.
Besides moving, the spine can be loaded so it isn't crushed when you lift your barbell or jump down from a box. We can split these types of loading into compression forces (squeezing the segments together, by gravity or picking up a weight) and shear forces (which are the forces that slide the segments forwards or backwards relative to each other). On top of gravity and weights, muscle activation also creates compression and shear forces. More on this later.
“Keep your back straight!”
A quick look at the spine should make you laugh the next time you hear someone providing this ‘advice’ to his or her trainee. The spine is built out of 24 movable segments called vertebrae. When these segments are in their neutral position the side view should provide a 'double-S' shape. In this position, the ability to bear load is optimal when the muscles around your spine are active. But without muscle activation, the spine buckles easily. A trainer is therefore better off cueing for a neutral spine, and not a straight one. Key point, the back can bear tons of load, but only in its neutral S-shaped position, and with minimal movement.
What your spine doesn’t like
Any deviation from this so-called neutral position of the spine will decrease its ability to bear load and thus make it more likely to fail. This can result in temporary or permanent damage. What your spine doesn’t like, is when you start combining the different movements and loading possibilities together.
For example, when you bend forwards, the lower front part of the vertebrae is pressed onto the top part of the vertebrae below. Some compression and shear forces occur, but it’s well within the safe range of a healthy back. When you add extra load to this position - like a deadlift with bad technique - you might exceed the tolerance limits of the structures and end up injured.
Choose your exercises wisely: risk vs. reward
The problem with most muscles around your lower back is that their contraction doesn't do one thing only: multiple things happen simultaneously. For example, the big back extensor muscles create extension, but while doing that they also create compression.
A practical example of this would be when doing sit-ups. This exercise activates the six-pack muscles (rectus abdominis), but also adds considerable shear forces in a flexed position. So yes, you are strengthening your abs, but you are also ruining your spine in the meanwhile. By the way, for what activity or sports do you need that explosive flexion movement anyway? Create a stiff core and let the power come from your legs and arms.
“proximal stiffness for distal athleticism” - Prof. Dr. Stuart McGill
Find your pain trigger
Once injured, the overall tolerance to certain movements and loads drops. You will be left with less safe range to move or load the spine. When you don’t respect this save range, it can’t restore.
When you are in pain, your first step should be identifying your pain trigger. This trigger is a movement, load, or a combination as described earlier. Maybe you are flexion intolerant and it gets worse with extra load. Or maybe you are in pain when you rotate to the left and simultaneously lean back. Guess what you should avoid to have less pain?
You’ll find the best protocols in Prof. Dr. Stuart McGills book ‘Back Mechanic’. It’s a must read for anyone dealing with LBP.
In your search of your pain trigger, also think the other way around. Which positions or even movements take your pain away? Maybe you enjoy lying flat on your back or on your belly. Maybe sitting helps and sometimes standing up or walking around takes the pain way.
I’ll bet there’s a position (like lying down) or movement (like walking) which takes away your pain for a bit. But are you getting into this position during your day? Do you take a break at work to lie down or take a walk?
Once you’ve found out what your pain triggers are, I will discuss how to train your back in my next article!