Although there is mountains of research into back pain there has been neither a simple cure nor cause present itself despite what you may read on social media and the internet!
The strength or ‘correct’ firing of a particular muscle or a collection of muscles to give us stability is clung on to by many in the world of fitness but with no real evidence to back up the mountains of mechanically based theory.
I have previously taken a bit of a look into the evidence behind the concept of 'core stability' *Click Here*
The medical world has been stumped by this problem for ages hence all the research and diagnosis such as ‘non specific back pain’. It is becoming more apparent that this is an issue that goes well beyond mechanics and simple binary thinking.
The number of factors that may play a role in back pain are many as we can see from the graphic below. They may all need to be taken into consideration in varying degrees based on the individual.
If the medical world has struggled to understand the problem over the last 20 years then attending a few weekend courses with a guru probably won’t give you an answer to this elusive question either, despite whatever it says in the course description!
You really don’t know what is causing the problem
The first thing a trainer can move away from is trying to find or treat a cause. Common gym based diagnosis’s such as its your core ‘instability’ or your posture are not supported by the available evidence.
This study *Click Here* compared the spine loading characteristics of those with and without back pain. Rather than displaying instability in the lumbar spine the pain group actually increased their muscular co-activation and increased spinal stiffness. This co-contraction was correlated with MORE compression and shear forces on the spine.
This study *Click Here* investigated lumbar curvature angles and there association to back pain. They picked an interesting population to study – coal miners! Miners will get into some pretty extreme postures repeatedly and under some heavy loads too.
These researchers did not find a correlation between the lumbar curvature and back pain of the miners. So the question is will the average persons tight hamstrings or hip flexors cause a lumbar curvature that is causing their back pain? That is a far from easy assumption to make based on current research.
If somebody proposes a ‘fix’ for back pain then they must produce some decent evidence that their cure has been implicated with factors involved in back pain or has had an effect on back pain. This holds true for the various claims surrounding breathing, vision, feet or how you rolled as a baby as the potential problem or cure.
Extraordinary claims require extraordinary evidence!
A theory is just a theory until it is supported with some evidence. The fitness world has long been dominated by theory often lagging well behind the available evidence or just simply not requiring people to provide any. This is a problem.
The problem with misinformation is it also drives our next problem, which is what clients get told by their trainers. A poorly thought out ‘diagnosis’ regurgitated from an internet guru might just do a little more damage than you think.
Words affect people deeply. The beliefs that people hold about their backs can influence how people perceive their ability to perform certain movements and may actually make their problems worse not better.
Telling people they may need lack core ‘stability’ as an example may imply more to someone than is actually intended. This piece on the language we use and how it is perceived *Click Here* explored the term, among many, ‘instability’.
The term instability was actually perceived as “the back could go at any time” or “Something's a bit loose ... It's liable to pop out”.
How would that affect your movement or function if you felt this way about your back? Increased muscular co-contraction and reduced relaxation are already associated with back pain so using these types of terms may actually INCREASE the pain, turning up the pain dial rather than helping turn it down.
Much as words can hurt they can also help. One of the leaders in the field of pain education Adriaan Louw looked at how helping people understand more about how pain works can have a positive influence. *Click Here*
His group’s systematic review “The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain” came to this conclusion.
“For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance”
So how can you help?
If we go back to some of the many factors involved with back pain at the top of the article, most of them can be influenced by a trainer.
Trainers are uniquely placed to offer help in nearly all of the areas bar pathology and diagnosis which are both tricky and contentious subjects for even the most highly qualified. Here is a good piece on the multi factorial aspects of back pain diagnosis *Click Here*
Pain and fear of pain or “throwing the back out” influences peoples activity level. What better way to increase activity levels than under the watchful eye of a qualified trainer?
Movement helps. Simple. Not just the movement itself but people’s perception of how much they can move and their confidence levels to do so. This has been referred to as the ‘locus of control’ and is important for good outcomes with back pain *Click Here*
Finding the right level of activity for your client with back pain is vital. This has been termed ‘graded exposure’ and may mean that just simply moving rather than 'training' as regular gym goers or professionals might see it is a real positive for some. We may not need to focus on specific lifts or increasing strength for specific muscles.
Sometimes people display specific movement issues such as a fear of flexing or pain when flexing as an example. It is important not to see these movements as problematic but instead try to reintroduce them. Explaining to someone that they will ‘blow out’ their disc if they squat wrong is really not helpful if we appreciate how words can hurt and is probably just not true! People squat with horrendous form on a daily basis and the vast majority never ‘blow out’ a disc.
Instead how to get people back to being happy to move in an unrestricted manner should be the main aim. Slowly introducing positions that have been previously problematic with the minimal amount of discomfort is paramount to increasing functional capacity.
We have a loading scale at Cor-Kinetic we find useful for when thinking about the right activity level.
One of the consistent elements observed is the ‘guarding’ of the lower back area that decreases the amount people are happy to vary their movement strategies. Pain can cause changes in movement that can then lead to further problems. Although we may not be able to identify the cause we can certainly be aware of the effects of pain on movement and try to reverse them.
Considering the multi factorial nature of pain this seems to be a little more sensible than trying to pin point a single and possible unrelated factor such as ‘core stability’
Simply helping people to relax and move in more varied ways maybe the best form of training input. The aim of this is to ‘recalibrate’ how someone perceives and subsequently responds to movement and movement tasks.
The level of damage likely to be caused by doing up your shoe laces is minimal. For some people though their reaction to this low level movement can be out of proportion to the level of damage it might potentially cause.
One of my favourite quotes is by V.S Ramachandran, an Indian neuroscientist.
“Pain is an opinion on the organism's state of health rather than a mere reflective response to an injury. There is no direct hotline from pain receptors to "pain centers" in the brain”
How to positively influence the opinion should be a key consideration for the trainer. Introducing varied movement and movement perceived as a threat in a graded manner and then progressively loading to desensitize would appear to be a sensible and pragmatic approach to back pain.
Movement variability is consistently shown in the research to be affected by pain and specifically in the lower back pain population and should therefore logically be a factor to be addressed in any remedial program.
I will hold my hands up to being biased in this area but my bias is hopefully based in the available evidence rather than my favourite pet theory.
Here we see a decrease in the movement variability at the joint level and intra muscularly (within a muscle) with those experiencing back pain *Click Here*
This study found that movement variability was affected by back pain and after the pain subsided these movement alterations still remained *Click Here*
This is important because you may have many clients who have experienced back pain and have subsequent altered cognitive perceptions & CNS adaptations in sensitivity levels and movement strategies that could contribute to future incidences.
Here is a summary of the key points in this article for helping with back pain
- Remember words can both hurt and help
- A specific diagnosis is hard to come by and unlikely to be tied to a single factor
- Movement helps
- Think variety rather than a specific movement, exercise or muscle
- Graded exposure & slow progressive loading
- Introduce relaxation rather than stabilisation and stiffness
This video is on some movement for back pain.
Here is a webinar on movement variability.
Please check out our courses for trainers *Click Here*