Podcast 31

The Causes of Lower Back Pain

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SHOW NOTES

Brian Cygan and Dr. James Fisher discuss the origins of lower back pain and why the vast majority of Americans will experience some form of lower back pain in their lives. Learn about the root cause of lower back pain and why most treatments only deal with the symptoms and the pain instead of solving the problem, which often leads to even worse issues down the road.

• Fisher is an academic and researcher in the UK. He’s published research on muscular strengthening as well as lower back pain.
• Lower back pain is a constant issue for a large swath of society. According to his study, somewhere between 70% and 90% of people will experience lower back pain in their lives.
• Lower back pain can be extremely debilitating to a person’s lifestyle and sleep patterns, and can have a major impact on their mental health as well. There is also an enormous cost to society in terms of productivity.
• At the Strength Coach, we’ve found that strengthening is an important strategy to improving the quality of life of someone experiencing lower back pain.
• Chronic lower back is when it occurs for longer than three months. At that point it’s important to seek medical guidance from a physiotherapist or general practitioner.
• About 10% to 15% of people experiencing chronic lower back pain have a specific reason for it like nerve issues or a slipped disc. The remaining 85% to 90% have what’s referred to as non-specific back pain which reduces the ability to mitigate the pain.
• For many of those people, the solution is often some form of painkiller or passive treatment like stretching and massage.
• The theories about the existence of non-specific lower back pain have to do with our evolution from quadrupeds in the past. The muscles around the lower back don’t tend to get much direct exercise and there seems to be a correlation between non-specific lower back pain and weak or atrophied lumbar muscles.
• The muscles that are more intrinsic to the spine over time, as we live a normal life, can atrophy as a result of not using them in a specific and demanding enough way.
• For most people, their gluteal muscles and hamstrings are very developed and do a lot of the work that the muscles in the lower back should do, and this can result in those lower back muscles becoming weaker, misfiring, and causing pain.
• With non-specific back pain, strengthening the muscles in the lower back should be the foundational approach to prevent future episodes of lower back pain.
• Specific lower back exercises are important for everyone in society to maintain their strength and muscle mass in that region and avoid the onset of lower back pain. Once something negative has happened, the road to recovery gets longer.
• Your lower back is central to everything you do. Without good control of your central muscles, you cannot throw or catch or jump or move well. From there it’s a downward spiral into the realm of disability.
• An imbalance between ab strength and lower back muscle strength can be part of the problem. We want all of the muscles surrounding the core of the body to be trained effectively, and it’s the lower back muscles that tend to be forgotten.
• The weak link is usually the lumbar muscles, and this can lead to a negative feedback process, where someone avoids exercising those muscles even more to avoid the pain resulting in greater muscle atrophy.
• We have other societal factors that are also contributing to the lower back pain that so many people experience as part of their lives.

One of the reasons why this is so important to you guys, the exercise coach, is because if people are experiencing low back pain, one of the things might be that their low back is weak or the muscles have atrophied and that’s causing discomfort when they then move or try to move.

Welcome to the Strength Changes Everything podcast, where you will get information about living a strong and healthy lifestyle. I’m Amy Hudson, exercise coach franchisee, along with my co -host, Brian Sagan, co -founder and CEO of The Exercise Coach. Today’s podcast episode is part one of a two -part interview series with Brian and Dr. James Fisher, researcher from the UK, who we’ve had on this podcast before, and they are discussing all things low back. If you are a person who deals with low back vulnerability, your low back feels achy, sore, pretty often you have some issues with that and it’s an area that you struggle with, you’re going to want to tune into this episode. In part one of this interview series, we’re going to talk about the prevalence of low back issues among adults and some of the known causes. And then in the second part of this interview, which will be the next episode, we will talk about what we can do to help strengthen and fortify that low back.

You’re going to pick up so much helpful information from listening in on this interview, and I trust that you will get as much out of it as I did. So without further ado, let’s roll part one of this interview.

Well, good morning, Dr. Fisher. Thank you so much for being here today to talk about the lower back.

Morning, Brian.

It’s great to be back to speak to you. Yeah, exciting stuff.

And some of our listeners are aware that we’ve had you on the podcast before, but for those who have not heard from you before, could you give us just a brief background on yourself?

Yeah, of course. I’m an academic and a researcher here in the UK at Solent University. I’ve been in academia for 15 years or so, publishing research, predominantly on any area of muscular strengthening, whether that’s in clinical or athletic populations or the lay population. And we’ve looked specifically at some low back research, or we’ve published some specific low back research with low back pain patients and with elite powerlifters and an array of different athletes with an array of different sort of training protocols. So we’ve done quite a lot on the low back. So yeah, there’s a lot happening there.

That’s great.

That’s going to be some helpful experience to draw on for this conversation. So just to kick it off, I mean, I’m sure we have listeners who will have an answer themselves to this question, but what would you say is so significant about just thinking about and researching and addressing the problem of lower back health, lower back pain?

Yeah, so the low back is just a constant issue in sort of society. Statistically, 70 to between 70 and 90 % of people, depending on what literature you look at, will will experience low back pain in their lifetime, of which about 70 % of those people, it will become chronic and chronic low back pain is low back pain that’s occurred for more than three months or is that recur is recurring for more than three months. So it’s not just a twinge that we have that then goes away, it becomes constant. And it’s a huge factor. I mean, when we talk about low back pain, we often use the term of the lived experience because it can be incredibly disabling and debilitating to a person’s lifestyle and their lifestyle choices, everything from their sleep patterns. And that, of course, has a huge mental health implications as well.

And in terms of it’s incredibly expensive economically to societies for both absenteeism, people being off work, and also what’s called presenteeism, which is people being at work and therefore being paid, but not really being productive in their job. So it’s incredibly important because of the prevalence, really, Yeah.

And for some people, just tragic when you see the discomfort that they can be in and the way that can disrupt what they want to be doing in life, as you said. And so you define a few terms there. And I want to key in a little bit on that chronic low back pain. I want to make a statement here before we get into it too deeply at the Exercise Coach, which is the studio brand that we operate around the country and that we talk about quite a bit on the Strength Changes Everything podcast. We deliver cutting edge fitness coaching, personal training. And so I want to be clear that while you’re going to refer to pain at times today, but the exercise coach as a fitness establishment, we’re not diagnosing or treating pain in any way.

That would only be properly the purview of, of a clinician. And of course you are also doing research on pain in the lab, but we do, we do work with people who have gotten into this state of experiencing chronic low back pain. And while we’re not really treating them per se, based on research, we’ve we of course, have found that strengthening is a really important strategy for them just to improve their quality of life. So can you just reiterate again, what you mean by chronic low back pain?

Yeah, absolutely. So chronic low back pain is low back pain that has occurred for greater than three months. It’s that might be occurs in movement, occurs permanently, occurs from prolonged positions, whether that’s seated or driving and things like that can often cause low back pain. But if we experience it for more than three months, even from a position that we’re in, then that becomes termed as chronic low back pain. Now at that point I would encourage anybody who’s experiencing low back pain to go and seek medical guidance from at the least a physiotherapist if not a general practitioner.

About 10 to 15 percent of people who experience chronic low back pain there is a specific reason for it. There are an array of possible reasons. It might be things like fusing of the vertebrae, or there might be nerve issues, there might be blood flow issues to the discs, there might be a slip disc. So there’s an array of different kind of medical reasons that exist. But the rest, and that’s only 10 to 15%.

That’s a low number.

That’s a very low number, yeah. And what’s more interesting is that the rest of that group, that’s 85 to 90 % have what’s called non -specific low back pain. And that basically means that a physical therapist or a medical practitioner of any kind cannot diagnose a reason why this person is experiencing low back pain. And of course, without a reason why we’re experiencing pain, there’s very little that we can actually do to reduce this pain. And so what tends to happen is people fall into a couple of processes. They generally go down a medical pathway and they’ll start on things like non -opioid painkillers, NSAIDs, which is non -steroidal anti -inflammatory drugs like ibuprofen, and potentially even move on to harder drugs like opioid painkillers, because it can be that debilitating that these people need to take this medication to sustain any kind of life.

Then I also stretch or massage or have other sort of what we call passive treatments. And if I can continue, one of the kind of theories around the existence of non -specific low back pain is the way that our bodies now function. And it’s actually quite fascinating. It’s almost an evolutionary movement from our origins as a quadruped, where we walked on our hands and feet, to a biped, where we now walk on just our feet. And we are very dominant in our hip extensors, so our hamstring and our gluteal muscles, and that leaves our lumbar extensors.

So the muscles around the low back don’t really get much direct exercise. And what we’ve tended to find is that there’s a very, very strong correlation between people who have chronic low, non -specific chronic low back pain, and having smaller atrophied lumbar muscles, and weaker lumbar muscles as well. Now, I’m not suggesting that that’s true of every person, but there’s certainly a very, very high correlation of those people. And with that in mind, a lot of my own research, and obviously one of the reasons why this is so important to you guys, the exercise coach, is because if people are experiencing low back pain, one of the things might be that their low back is weak, that the muscles have atrophied, and that’s causing discomfort when they then move or try to move.

That makes a lot of sense. So the muscles that we might say are more intrinsic to the spine, you’re saying over time, as we just live a normal life, can atrophy as a result of not using them in a specific and demanding enough way is that kind of a summary.

Yeah, absolutely. I mean, we have very intricate musculature around the spine based on the kind of importance of that anatomical region, and based on the specificity of the movements of each vertebrae moving. And our problem is that we tend to at best contract those muscles isometrically, or at worst, not really contract them at all. And and all of our movements when we bend forward actually comes from rotation of the pelvis and derotation of the pelvis when we straighten back up again comes from our hips, comes from our glutes and our hamstrings. Now we can walk around society and see we as a population have very developed gluteal muscles, you know, they protrude from the back of us quite a lot and they’re very, very strong. And they do a lot of the work that the low back should actually do.

And the more that they do, the more they take over. And there’s, of course, then the whole neurology of poor motor control. We don’t recruit our low back muscles very well. We just simply recruit the muscles that are the easiest ones to do the job we want. But our low back muscles are enduring some of this and not firing in the right way. And they’re they’re then producing pain and discomfort and so forth.

So for a large percentage of people that experience low back discomfort beyond three months, it’s non specific in terms of the origin of that back pain. And so we might consider strengthening, if not the root cause of much of chronic low back pain, at least a foundational consideration for developing an approach to helping people who’ve experienced chronic back issues, get healthier and maybe even also prevent future episodes of low back pain.

Yeah, absolutely. Absolutely. So this is really referred to as the Deacon’s hypothesis. And it’s basically saying that we don’t use our lumbar muscles properly. And so they decondition, they get weaker and they atrophy.

And so with that in mind, low back exercise or specific low back exercise is important for everybody in society. It’s not important for people with low back pain or older people, or people with or without a disability or any other medical condition. it’s important for everybody in society to maintain that strength and to maintain that muscle mass in that region to avoid the onset of low back pain because we already know that once something negative has happened it’s a longer road we have to go through the recovery process and then make the improvement but if we can make the improvements before there’s any negative implications then That’s a positive thing, right? So you’re saying we should be as excited about training our lower back as we are our biceps? Well, I would say we should be more excited because the reality is our biceps probably get a lot of stimulus in the things that we do day to day anyway. And whilst it might not be sufficient to grow sort of 20 inch biceps, that’s not going to impact this longer term.

It’s our low back that’s really going to be the central part of all of this. And we often use the term core or trunk. they kind of fall in and out of fashion as terms, but they’re not the wrong term because they are central to everything we do. Without good spinal stability, we don’t have good distal mobility. So without control of the center of our body and our low back and our abdominal muscles, we can’t move our arms and our legs and walk and run and throw and catch and lift and everything else that we want to do very well. And to be honest, from there, it’s really just a a downward spiral.

We’re really falling into the realms of severe disability at that point.

Makes sense and I can certainly appreciate what you’re saying about the importance of the core for mobility and functionality and performance. I do have a question though, related to the abs, let’s say. You’ve already said that the muscles that we’re really discussing here and that are in question and we’re concerned about related to lower back health are intrinsic to the spine. You’ve mentioned the lumbar muscles and that’s a collective term for a variety of more specific musculature that is intrinsic to the spine. I would say meaning it attaches to the spine and it functions.

These muscles function to directly move and stabilize or protect the spine and the intervertebral discs and the ligaments of the spine. But we hear a lot about the abs. Over the years, a lot of people have said, well, if you want a healthy back, then you need to have strong abs. Based on your experience and research and the research out there, would you just comment on that perspective?

Yeah, so, I mean, there’s a couple of approaches to this. If we say strong abs, abdominal muscles produce the opposite movement to our lumbar extensors. Abdominal muscles, we typically say are rectus abdominis, which is kind of the six -pack muscles at the front. They produce abdominal flexion or trunk flexion. Now, we tend to use those quite a lot in society anyway. And one of the problems with low back pain is we tend to have much stronger abdominal muscles than we do a lower back.

So it’s that imbalance that can be causing that problem. One of the other things when we talk about abs is we can talk about the core, the trunk muscles as a whole. And the best way to think of it is as a tent or as a flagpole. So if we imagine, if we take the example of a tent, we have guy ropes all the way around the tent holding it up. And if one guy rope is tight and the other one is loose, then the tent will fall over. So we have all of these muscles around our trunk.

We have our transverse abdominis, which runs in a belt around our midsection. We have our abdominals at the front, our obliques at the side, and our lumbar extensors at the back. And we also have our pelvic floor and our diaphragm as a bottom and a top, respectively. And really, we want all of those muscles to be able to contract upon demand and to be strong enough to counter the opposing muscles. And a lot of the time, it’s the low back that’s fallen prey to not being trained and not being exercised, not receiving sufficient stimulus. Most people will have done some abdominal exercise in their life or will have used their abdominals, even if it’s things like when they get out of bed in the morning.

But it’s the low back that tends to be disused, I guess. So, we definitely should have spinal stability. It’s probably a product of a lack of lumbar strength that’s preventing good spinal stability.

I think that’s so well said. All of the musculature of the core is important. However, based on I think what we see in research, we know that a large percentage of people who experience chronic low back pain do have a specific weak link and the weak link isn’t relatively speaking the abs versus the lumbar muscles, but rather it’s the lumbar muscles that are the weak link relative to the other musculature of the body.

Yeah, and it becomes a bit of a vicious cycle. So what tends to happen is I mentioned before the lived experience, we fall into what’s called a fear avoidance model. So my low back hurts. So now I do less exercise, or I do less things that I think will hurt it. And therefore, it only hurts more because it falls into greater atrophy and greater muscle weakening. If I take painkillers, or if I go for massages,

or whatever it might be, or acupuncture, it’s really just a passive treatment. It’s there just to abate the symptom of low back pain, but not the cause of the low back pain, which is really the weakness of the muscle. When we talk about the lived experience, there’s a huge amount of kind of research around cognitive behavioral therapy within the low back. And that talks about people who have low back pain making sense of their pain and making lifestyle changes. So it’s understanding why it hurts and then making the changes accordingly. And this is not rocket science.

This is something that should be relatively easy for most people to kind of get a hold of. But our bigger problem is, with all of this, is that we then end up with, in society, you and I are both sat right now, which means we have shortened hip flexors. Now, in society, that’s a common thing. Well, when I stand up, if my hip flexors stay shortened, they pull the front of my pelvis down. So it creates what’s called an anterior pelvic tilt. Now that creates a more extreme curve in the low back, which is called the lordosis, an extreme lordosis, which doesn’t help with people with low back pain.

So this is why people with low back pain might have it aggravated when they spend a lot of time sitting because they are in this position. So we then have all of these other kind of societal factors that really don’t help us to treat the cause of the low back pain.

And that’s where we will wrap it up for part one of this two -part interview series between Brian and Dr. James Fisher on the low back. Make sure you tune in next week for part two of this series, where we will be discussing what we can do about the low back issues that so many of us face. I can’t wait to see you next week on the Strength Changes Everything podcast and have a great day.