Physical Therapy Series: Low Back Pain

Low back pain affects 540 million people around the world, is the single leading cause of disability worldwide, and can be experienced at any age. The vast majority of people will experience low back pain at least once in their life. As I have mentioned before, there are a few areas in the human body where injury is almost a rite of passage in middle age. Among them, the lumbar spine would be considered the “granddaddy of them all”. Injury to the lower spine is so common I would prefer for everyone to spend a few minutes each week doing exercises to maintain a healthy spine and decrease the chance of injury. The goal of this blog is to give some insight into why the lumbar spine is so prone to injury, and to provide some helpful exercises to help prevent injuries or begin treatment at home if an injury occurs. At the end I will share my personal story of dealing with back pain. 

“Reasonable people can disagree”
-Frank Martin Ivey, M.D.

Keep this quote in mind as you read further as there are many different opinions on why back pain is so common. There are even more differing opinions on the best way to treat it. I’ll begin with discussing two theories that are worth considering when contemplating  back pain. The first is to consider the lumbar spine from an evolutionary biology standpoint. 

Basically, our back is similar to the majority of the animal kingdom, but has evolved to serve two very human functions. First, humans have evolved to walk upright with long strides. This results in spinal curves to give us a stable center of gravity. The problem is these curves cause significant shear forces that make the spine prone to injury. The second, unique aspect of of human spine evolution the need for wider pelvises to better distribute our body weight in our upright position. Women experience this especially due to the need to be able to birth big headed babies which causes further spinal issues. The evolution of the wide pelvises resulted in some loss of spinal muscle bulk leading to a decrease in spinal stability. These design issues result in modern humans suffering from back pain. The Ancestral Shape Hypothesis is an interesting subject regarding the evolutionary anatomy of the modern human spine. Essentially, some human spines are geometrically more similar to our ancient ancestors, who at the time more closely resembled apes and had not fully adapted to walking on two legs. These spines are more prone to disc herniations. However, spines that are less similar to these more “ape-like” spines are more prone to injury extension injuries such as stress fractures. On the other hand, one could argue our spine is perfectly designed for our human needs. This argument would point out that perhaps we just abuse our spines with daily human life.

These two videos illustrate how sitting is detrimental to our health. We also need to consider how poor posture and improper lifting techniques cause further abuse to our spine. Our inactivity often leads to weakened core and spinal muscles that increase our risk of low back injury. Our poor nutrition will not only result in chronic inflammation that commonly presents as back pain and in some will result in large abdomens which further strain the spine.

This is a fantastic video that I will quickly summarize. Low back pain is a serious issue and a major contributing factor to the opioid crisis. 80% of humans will suffer from low back pain, but 90% will recover with no treatment. When you are injured you need to avoid the aggravating issue, rest, and gradually return to activity. I would add this may be easier said than done. Many people cannot afford to miss work so they need to continue working which may further strain their back. This work may involve heavy lifting, repetitive motion, or even prolonged sitting. All of these activities can be detrimental to an injured back. Be mindful that for some people, missing work is not only a financial decision but can also be a blow to someone's pride. Others with a low back injury may continue their fitness routine even if they are further damaging their back. Again this may be due to pride but some people can not afford to take a break from their greatest stress reduction technique. I would urge the reader to plan ahead for potential injury and have some less demanding stress reduction activities as a backup plan. The video introduces a phrase that is new to me -  “VOMIT” which means victim of medical imaging technology. This is a subject I attempted to tackle in my blog post on 10/16/23 “Why you don't need an MRI”. Basically MRI and CT scans are a poor correlation with pain. 50% of middle aged patients have disc bulges and 90% have some degree of degenerative disc disease without any pain. When confronted with abnormal scans you should be cautious in concluding your pain is caused by the abnormality. Simply stated, your scan may have looked similar the day before the injury as the day after.  Up to 80% of disc ruptures will shrink or heal in time. Estimates are that only 2% of patients with back pain will heal from surgery. For this reason, patients should prefer spine surgeons with a more conservative approach. If they tell you to wait and give conservative care a chance, or that surgery will not help, they could be doing you a favor. The video also explains how mental health issues such as anxiety or depression can amplify the existing pain. In other words, the pain is not all in your head, the pain is real but education, mindfulness and cognitive behavioral therapy can all be helpful coping mechanisms. Finally, the author addresses how exercise and movement will help improve the pain. By exercise he means many forms of movement not just core and spinal exercises. Rest is beneficial but it needs to be an active rest. 

The majority of low back injuries will heal without medical intervention. The goal is to commit to back exercises to help prevent injury. If you are injured you can start these exercises and seek assistance if you do not improve. Some things do need more urgent evaluation. For example, if your back pain is associated with fever or chills, or you have any associated bowel or bladder issues you should be evaluated. If you have pain, numbness or tingling in your legs you should be evaluated if it does not improve. If these symptoms are associated with weakness or paralysis you should seek medical help immediately. 

Now, I would like to pass along some helpful exercises that can both prevent back pain and be the first line of treatment if pain occurs. My goal here was to find short videos of 5-15 minutes because I believe that is a reasonable time for people to commit to improve their spinal health. There are many other programs at your fingertips. Take a look at these but consider taking a deep dive to find the program best for you.

The following is an effective program to maintain back mobility.  It can be used as a preventive program and to treat a strained or stiff back.

The following is an effective program to maintain or develop back strength. The first 4 minutes review common exercises that could harm your back if not done correctly. The last 4 minutes describe safe alternatives. 

1.Cat/Cow

2.Hollow body crunch

3.Bridging

4. Quadruped Arm and leg raise or bird dogs

5.Knee to chest stretch

If I could only choose one exercise I would choose bird dogs

The following are some gentle exercises that can help relieve low back pain. Notice many back exercises target the hips and hamstrings because tight hips and hamstrings are associated with back pain

Now for those with a Yoga background, they may be familiar with gentle back stretches they can incorporate on their own if injured or use as a maintenance program.

A quick YouTube search will give you a whole menu of programs you may like, but he following are some videos I have used for back pain, back mobility, and back strength.

My Low Back Pain Story

For any of those who are interested, you can keep reading for my own low back pain story and how I improved it after 15 years. The pain started in August 1986 when I was 17 years old. I was named to the county summer league lacrosse All Star team and during the one and only practice before the tournament with other surrounding counties I was injured. I was running up the sideline with the ball and the attackman dove to knock me out of bounds but he was a step late. He hit me in the back instead of on the hip. That night my back tightened up and  pain started going down my leg. Of course I likely only needed rest but I was excited to play in the tournament so I limped through a few games. It improved somewhat over the next 2 weeks but was quickly aggravated as football season started. I missed the first half of football season and ultimately had an epidural steroid injection so I could play. Nearly 40 years later this would be an unusual treatment for a teenager. On a positive note I had a successful end to the season and salvaged my senior year. Now I headed into wrestling season and again hurt my back the week before one of the biggest matches of the season. Again all I needed was rest but I got a second epidural steroid injection and again had a successful end to the season but my back never truly recovered. This led to my senior year of lacrosse and college lacrosse. My back was constantly stiff and often painful. I took NSAIDs almost daily. The first few weeks of running to train was always painful. I was cautious lifting weights because I was concerned with aggravating my back. The most important exercise of all for athletes is likely squats but I did not do them because one mistake would have hurt my back for weeks. In my mind the back and hip stiffness limited my speed and my ultimate success. I then proceeded to medical training where I intermittently tried to get in shape. Every time I started a lifting program my spine would set me back. Every time I started running again the first few weeks were painful. I needed my 10/6/23 blog “ I ran today” because I thought running slowly for 3 miles was the only way to run which pounded my back. Long surgeries standing or sitting and bedside dressing changes were painful as well. Through college and medical training I never considered I needed back therapy exercises. I just assumed I had a bad back and that I would likely need surgery in my 40s. I tried sit ups but they only worsened my pain.

 Then by dumb luck everything changed. In the summer of 2001 at age 32, 14 years after my original injury my back improved. I started my hand surgery fellowship in Kentucky while my wife and at the time 3 kids spent the summer in Maryland. With the rigors of orthopedic residency behind me I was able to start running and lifting consistently. I saw my wife’s Abs of Steel VHS tape( 10 years after its release) and decided to give it a try. My goal was to get a 6 pack but instead I cured my back pain. After a year of doing this tape my back pain completely resolved. I could lift and run with no back pain. In a few years I started doing P90x with no back pain and was a faster runner at age 40 than I was in college. 

I recently reviewed Abs of Steel and it's actually a perfect program for core strengthening without putting strain on the low back. I can see now with 20 years of orthopedic experience why it worked so well for me.

I then graduated to P90x ab ripper. This is a great program but the first few minutes would strain my hip flexors. My daughters were field hockey players which often puts a strain on the low back. The family joke is when their classmates came to the office with back injuries they were prescribed medicines and physical therapy but my own daughters were told to do ab ripper.

Ab ripper can be found on YouTube if you want to check it out for yourself.

Ab/core Plus- This is an even better program that does not strain the hip flexors. The program is long, but in it is some great exercises to try.

Now I am in my mid 50s. I get occasional back pain. When I do back exercises 2-3 times a week I’m pain free. When I have a strain I keep moving and do gentle stretches or gentle yoga moves. I have made it 15 years past when I expected to have back surgery. Both my parents had surgery with a great surgeon and they both had excellent results. There is no guarantee these exercises will keep me from needing surgery, but they greatly improve my chances and my lifestyle. Now that I have been sitting at the computer way too long it is time to get up and move my spine.