Unfortunately, low back pain is all too common. Studies indicate approximately 80% of people will experience a low back pain episode at least once in their life. Of that 80%, the likelihood of recurrence is high. Depressing, isn’t it?
But does it have to be this way? I think not, and I will share with you why but first I want you to understand the questions I am asked on a daily basis and how there are other factors at play than just focusing on your low back and the mechanics around it.
At the time of writing this, I have treated somewhere in the ballpark of 20,000 patients in my career, most having episodes of low back or neck pain. To put that into perspective, my patients would overflow the Keybank Center Ice Arena (for all my Buffalo Sabres fans). I have heard the cries, and I have been in their shoes, too. So when I tell you “I understand where you’re coming from”, I truly mean it.
There is an interconnectedness between our minds, our bodies, and our environment. I believe to really understand our low back injury, we need to understand that these three pieces are inextricable to one another.
Think of these three things – your body, environment, and mind – as legs of a stool. If I take one away, the stool collapses. But the stool is your back. And it doesn’t just collapse, it HURTS.
Below are some of the questions I answer on a daily basis, and usually multiple times per day. They are legitimate concerns, and they are what impact my patients from the perspective of past, present and future concerns. I will break down the thinking cycle to help you better understand and see what I see.
After reviewing others' thought processes when dealing with a low back injury, I will try to explain a problem-solving method to help you get your ‘answer’ to the questions below, and hopefully help you create a fundamental thought process to understand your pain, combat recurrences, and learn to live your life.
1. “Will I ever be able to do ___ again?”
Present concern. The patient has an agenda and a goal they are wanting to reach that has now become unattainable. This affects them in the following ways:
Body – they are used to a certain expectation in their sport or day to day activity. This activity may give them meaning and purpose, and has now become disrupted
Mind – taking away this activity because of injury has created more than just the concern of the activity itself. The patient is usually thinking about their invincibility/vulnerability, loss of a stress reliever, or maybe a social engagement with this activity
Environment – this activity is usually their “go-to” way of exercise. This has been taken away, so there is a “now what” moment. This activity may be a social outlet and now they lost a form of creating and maintaining relationships
2. “Why isn’t this just going away like it did last time?”
Past concern. This patient is comparing their current self to their past self, expecting each time an event occurs to them, it should be the same every time. There is typically poor accountability in this group of thinkers. This can become very concerning for them in the following ways:
Body – most are resilient to the idea that their body is getting older and if they are not an active person to begin with, their inactivity and lack of resilience to injury becomes more prominent and frequent as they age. Most are used to being young and bouncing back quickly, even if they did abuse their body with lack of/too much exercise, poor diet and habits, etc.
Mind – I find patients that ruminate and think in the past are the toughest ones to break their train of thought. Because they are stuck on what once was or what they used to do, they have trouble not only looking at the present situation, but even more so, trying to get them to buy in to making changes now for their future self.
Environment – Again, most times these patients have a tough time being in the present and assessing their current situation. They may not realize that they currently aren’t active, even though they used to be a Division I football player. They may not realize they currently have a poor diet, even though they claim they could eat and drink anything and not gain a pound in their twenties (they are sixty now, by the way). This unawareness of their current environment makes change hard, because they usually think it’s the environment that needs to change around them, and not the other way around.
3. “I didn’t do anything out of the ordinary, why did this happen?”
Present concern. This patient is trying to find an answer, but usually is not looking beyond the day or hours of the injury. They are not aware of changes over months to years that built up to that moment of injury. They believe that fate just made them have a back injury and cannot understand why. This will affect them in the following ways:
Body – they begin to believe their body is more fragile, and start to restrict or avoid movements all together. They believe that because a seemingly innocent episode started their low back pain, there is no way they can perform any other heavier load task without risking a flare up.
Mind – the fragility mindset kicks in. This group starts to display kinesiophobia (fear of movement), and becomes discouraged at their setbacks of pain. There is usually rumination on the event, but no constructive thought process to look at other risk factors that have been there for months and years prior.
Environment – Their world becomes smaller. These patients are usually okay with backing off from activity. They sometimes wanted a reason to not perform an activity, or to get out of the activity completely.
4. “How can I permanently fix this?”
Future concern. This patient may have dealt with back pain on multiple occasions and is frustrated with the recurrence. This person usually has a mechanical mindset or “black and white” thinking. They want a solution and then to never worry about it again. This can affect them in the following ways:
Body – they don’t understand that the body is not like a machine - you cannot just replace parts and expect to be injury and pain free the rest of your life. They have difficulty realizing that homeostasis is a state of balance and that the body will have times of increased stress and decreased stress and each day will bring a different load and strain to the body. They refuse to actively engage in maintaining homeostasis for their low backs.
Mind – the mindset of “black and white” disengages the patient and makes them a bystander to their care. They have difficulty taking responsibility for the reason things “broke” in the first place, and do not want to be involved in the “maintenance” that it takes to keep their spine in good shape. They may be frustrated because they think they have done everything right, but unwilling to hear that maybe, because they keep having recurrences of low back flare ups, that they are not as perfect with their regimen as they think they are. Their minds are very set, and typically this is a “Type A” personality.
Environment – they cannot be bothered by setbacks. They have a planned agenda and do not afford time to take a step back. They look at the stepwise approach as a concrete plan. There is no revisiting the “lower steps” of exercise rehab and reeducation. They are thinking surgery as a “fix” and are unaware of the implications afterwards. These are the ones usually re injuring themselves after surgical interventions are performed.
5. “How can I prevent this from happening again?”
Future concern. This is typically a patient with a more open mindset. They are motivated to do what it takes to reduce risk of reinjury. They sometimes have a fear of recurrence, but are open to the suggestions provided.
Body – most of these patients are willing to give rest and recovery a try. They are more open and willing to revisit the therapy rehab. Some early on have a fear of bending and moving, but are more willing to break out of that fear when pain reduces.
Mind – these patients, although frustrated with setbacks, are not consumed by it. They understand that there is a likelihood of recurrence and are motivated to reduce this recurrence rate and intensity. Fear of setback is the biggest motivator, but does not paralyze or consume this patient.
Environment – although these patients are looking to the future, they are engaged in the present. They are willing to make changes as necessary and understand what they do today will impact their tomorrow. They are motivated and teachable.
The way a question is asked is sometimes like interpreting a zodiac sign. There is more meaning behind one question than the question itself. The type of question asked, as displayed above, can provide me with insight of how a patient thinks and what the concerns really are – if you can read between the lines. It can also provide me with insight of who is willing to help themselves, or who expects me to do the “heavy-lifting” for them to get them back to “normal.”
Just like I broke the questions down into ‘past’, ‘present’, and ‘future’ – the way we problem solve can be done in a similar fashion.
Answers to the Past:
The planetary scientist and consultant for NASA in the 1950s, Carl Sagan, is credited with stating “You have to know the past to understand the present”. And although we are not landing a man on the moon, we are trying to figure out your back pain, which can sometimes feel just as hard as landing a man on the moon.
Majority of low back injuries occur insidiously, over months to years. Pain is typically the last symptom. As load and increased force is placed on the lumbar spine with movements such as bending, lifting, and twisting, that load is transferred from the muscle, to the joints, and intervertebral discs. If that load continues over time, and the muscle is not fully engaged to support the spinal structures (i.e. joints and intervertebral discs), breakdown starts to occur – joint arthritis and disc herniations, which leads to spinal stenosis. This is a result of what we call poor biomechanics (i.e. how the body moves). If you had a grandparent ever yell at you to “not lift with your back,” first, they are probably speaking from experience, and second, listen to them!
How do you know if this is the case? Well, I can tell you in 90% of the population, poor biomechanics is the culprit.
Answers to the Present:
Once we understand that the current situation is not just linked to the present, but also to the past, we typically have better control on how to proceed in the moment. Unfortunately, any injury, especially back pain, is inconvenient. But luckily, it can be fairly easy to fix – if we can be patient. The key to a current injury is allowing our body to do what it does best – heal. So, how do we do this?
Well, for one, we need to take away aggravating factors that are flaring up your pain. For example, if every time you bend to tie your shoe, or sit you notice pain flares, then we need to change these factors to reduce the flare cycle. Instead of bending, try kneeling. If you sit all day, set a timer and stand up and stretch for a minute. You may need to get creative to work around some of these daily tasks, or just end up avoiding them at all cost if you are able to (going #2 is something you cannot avoid, I'm sorry!) Ask yourself, if I cannot avoid “X”, how can I at least try to make it easier?
Answers to the Future:
So we understand hopefully at this point that the injury you experienced in the present has a lot to do with the past. So what about the future? Well, the definition of insanity is doing the same thing over and over and expecting different results. Once the flare up has subsided, we need to realize that there may be factors in our day to day that are causing increased mechanical force on our low back which is resulting in flare ups. Some of these activities include:
Prolonged positions (ie sitting too long, standing too long, walking too long, bending and kneeling)
Lifting technique (at the gym, at home, helping a buddy out on the weekend)
Not being ‘well trained’ for hobbies (ie golf, gardening, biking, kayaking)
Bending activities (ie loading/unloading dishwasher, making the bed, leaning forward to brush your teeth)
If you notice, this list includes nothing out of the ordinary. I do not recommend you cut out brushing your teeth or not doing a hobby or activity you enjoy, but what I do ask is you look at these activities as events that need training. An example I use is the NFL player. He plays 1 game per week during season. But what is he doing to prevent injury from getting hit repeatedly, and running at full speed with transitions in movement? You would think more would be blowing out their ACLs and spraining ankles. But the magic lies in the training. For the majority of in season and off season, these guys are training using weights, running, and giving their bodies adequate recovery between sessions. Even though most of us aren’t NFL players, the concepts still apply.
If you want to participate in an activity that requires movement, you first have to move well, then move often, and Gray Cook would say. The idea is we need to train for life. It is a habit and a journey rather than an end goal destination. On the two ends of the spectrum is a bell curve. On the low end is not exercising enough, and on the high end is exercising too much. The sweet spot is in the middle – utilizing different exercises and recovery techniques so when you are called upon to do a more strenuous activity, such as helping a buddy move a refrigerator, or go golfing 18 holes, your spine is ready to take on those forces. Even if you’re reading this saying, well I don’t do anything strenuous and my back still hurts. You may fall in the “not exercising enough” category. This is where simple tasks such as simply leaning or bending for any period of time is causing pain – like with making the bed, or brushing your teeth.
To return to my main theme, the back pain paradox has to include your mind, body and environment. If we can create a positive in all three, this will reduce the risk and recurrence of future injury. If only one is improved, but the other two are not, then the risk for recurrent and future injuries will continue.
If you want to learn more, check out my other blog posts or follow my instagram @andrealarsenpac for more content!
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