Like most injuries, when someone experiences low back pain, it typically resolves with or without medical intervention in a matter of weeks.
However, if you’ve had low back pain continuously for over 3 months, we in the medical community would say that you have chronic low back pain. Chronic low back pain is a very interesting phenomenon because while in some cases there is a true structural damage that would explain your symptoms; but in a lot of instances there isn’t. Or more likely, there was some tissue damage and it has since healed.
We know how long it takes for certain tissue to heal. Muscle…2-4 weeks. Tendon…4-6 weeks. Bone…6-8 weeks. Ligament and cartilage…close to 12 weeks.
When you see a doctor and have an x-ray, an MRI, or a CT scan they’re trying to find any damage to the tissues listed above. However, when they can’t find something concrete, it is then often referred to as “non-specific” low back pain.
While you might think this would be rare (because obviously if something hurts there has to be an identifiable cause, right?), non-specific low back pain actually accounts for 90% of all low back pain cases.1
Feeling Hopeful or Hopeless about Chronic Back Pain?
If you’ve ever gotten to this point, where the doctor tells you they can’t find anything wrong and they send you to a pain management specialist, things can certainly begin to feel hopeless.
The first thing I would want you to understand is that you’re not alone in this.
I’m sure everyone reading this article has had the common cold right? Well being that 80% of people seek medical treatment for low back pain at some point in their life, the common cold is the only condition that accounts for more doctor’s visits per year.2,3
Of all of those doctors visits and all of those people with low back pain, upwards of 73% experience a recurrence of symptoms within a single year…yet only 5% go on to develop chronic low back pain.1 While 5% may not sound like a lot, I assure you that is many thousands of people per year.
If you’re one of those in that 5% whose pain has become chronic, I want you to know that your situation is far from hopeless.
By the time you’re done reading this my goal is for you to feel hopeful about your situation through an improved understanding of the following:
- What causes chronic low back pain
- What may predispose someone to developing chronic low back pain
- Important take-aways from any imaging you may have had done
- And finally…what you can do right now and what physical therapy can offer you (Yes. Even if you’ve tried physical therapy before!)
What is Chronic Pain?
If we know that at most, the tissues in your body take around 3 months to heal, how then is it possible for pain to last longer than this?
Well, when most people think of how pain works they believe there is tissue damage somewhere in your body, for now we’ll say the lower back, and your lower back communicates to your brain that there is damage. This is not entirely accurate.
Your lower back communicates to your brain that it feels something, and your brain decides whether or not to make that experience painful. The physiological changes that occur in the brain are influenced by a host of factors such as:
- Previous experience- Have you had pain with this activity before? Is this how you injured yourself in the first place?
- Emotional well being- Are you stressed or anxious about something unrelated?
- Overall health- How is your diet? Your sleep? Are you a smoker? Overweight? Do you exercise?
- Beliefs about the pain– Do you believe there is some sort of catastrophic damage in your back?
Well, what we’ve come to understand is that these physiological changes that occur in the brain can sometimes persist far beyond when the tissue has actually healed.
What that means is that your body’s “alarm system” that alerts you to danger stays on even when the danger is gone. For a better understanding of how your brain and body process pain, check out these videos on understanding pain and chronic low back pain (video) that I frequently share with patients in the clinic.
Can You Trust Imaging?
Diagnostic imaging is certainly a wonderful tool. Yet whether your MRI looks like you were hit by a truck, or you’re the epitome of health, there does not seem to be a strong correlation with symptom severity.4 In fact, a large percentage of people as young as 40 years old who don’t have any symptoms at all, still exhibit common conditions like disc bulges (45%) and degenerative disc disease (68%) on their MRI.5 I would argue most of these are a normal sign of aging…wrinkles on the inside, if you will.
If so many people have these MRI findings, and a large percentage of those individuals have no pain at all, why is it some people experience debilitating and/or chronic pain by these same conditions?
Well…at the risk of sounding like an elementary school teacher scolding a bully… words can hurt. If you see your primary care doctor and she tells you “yeah I bet you threw your back out (whatever that means), I’m going to send you to see a specialist”. And then the specialist tells you things like “you have the spine of an 80 year old”, “your MRI is a mess”, “you have 3 bulging discs in your lower back”, “your SI joint is out of place.” How can someone hear those things and NOT let it affect their function?
You’re told you’re broken and you begin to behave like you’re broken. But assuming you’ve been screened by a physician and/or a physical therapist and they’ve ruled out any “sinister pathology” – fancy term for scary things like cancer, neurological deficits, or other truly worrisome findings- I’m here to tell you that in most cases pain doesn’t mean damage.
Not only does having pain not necessarily mean that there is something wrong, but moving and behaving as if there was something terribly wrong oftentimes just exacerbates the pain. When you “baby it” you lose strength, get stiff, and develop poor movement patterns.
Taking Your Life Back after Chronic Low Back Pain
Any video or article you read online that says things like: “5 Easy Exercises to Cure Your Back Pain Forever!” is mostly nonsense. Back pain can come from many different sources, some physical and some not, and what you do to “cure it forever” depends on WHERE the symptoms originate from.
Imagine the following interaction with a mechanic for car troubles you’re having:
You: “You know, I’ve been having some trouble with my car an-”
Mechanic: “Oh yeah this is going to be really easy… make sure your parking brake isn’t on while you’re driving, inflate your tires to a higher pressure, and top off the oil. That will fix all of your problems.”
You: “Are you sure you don’t want to at least inspect the car?”
Mechanic: “ No need! Those are some of the most common fixes for car trouble.”
See where I’m going with this? While those articles and videos do go over some of the most common solutions to certain types of low back pain…the authors haven’t evaluated you, so there’s no way of knowing if those exercises are appropriate or inappropriate; helpful or harmful.
Now, if you have been evaluated previously and have a good sense of where your symptoms are coming from and you’re reading articles or watching videos specific to that condition, that’s a different story. But in general, it’s best to avoid broad sweeping advice on a topic as complex as low back pain.
If you’re sitting there right now thinking “you just made me read all of this nonsense and you’re not even going to offer solutions to fix my pain?!” I’ll ask you to hang in there with me for just another moment.
I do have suggestions on how to begin to turn things around for the back pain you’ve been dealing with for months or years now. Six suggestions in fact….though they may not be what you would expect.
1. Track Your Pain
A simple, yet effective way of identifying aggravating factors is to track your pain. It’s easy enough to do in the notes section of your phone. Just start writing down what you’re doing every time you experience an increase in pain.
You may find that it’s with physical activity like lifting heavy boxes, carrying your kids, sitting for prolonged periods of time at work, or doing household chores. Though, you may find that it’s related more to stressful events like running late for work, having an important deadline coming up, or stressful family situations.
The first step to addressing chronic pain is to identify these patterns of painful activities.
2. Improve Your Sleep/Rest
This may seem like common sense but I would be willing to bet a substantial sum of money that if everyone reading this article is honest with themselves, less than 30-40% of us are getting the recommended 8 hours of sleep per night.
This is hugely problematic as much of our body’s healing, not just the physical but also the neurophysiological, occurs during restful deep sleep.
Many of you may be thinking “but Mr. PTProgress blogger man, how am I supposed to get 8 hours of sleep when my pain is preventing me from falling asleep in the first place?” A valid point. Poor sleep is a vicious cycle. You can’t sleep because of the pain → lack of sleep prevents adequate healing → pain increases → increased pain makes sleep more difficult → so on and so forth.
It’s not easy, but it is important to make little efforts to give your body a fighting chance at good sleep. Start turning the lights off around the house at 7pm. Read a book instead of watching TV. Take a hot shower/bath. No late night snacking. And perhaps most of all…put. the. phone/tablet. away.
3. Small Dietary Changes
I’ll keep this one brief and basic, as I am not a nutritionist or dietician. I’m sure for many readers I’m not the first person to suggest diet changes; for good reason.
Nutrition plays a sizable role in tissue recovery and overall well being. A healthy diet (and I mean diet in the sense of the food you consume, not structured diets that restrict certain foods) can make the difference between proper recovery and the development of chronic pain. However, people are less likely to adhere to changes in their diet if too many are made all at once. It’s too difficult. Hence small dietary changes.
Poor diet is not the reason you have pain, but it can certainly be one of the reasons your pain lingers beyond what is considered a normal duration.
4. Don’t Fear Your Pain
If you’ve been screened for serious pathology, or what medical professionals would call red flags, and have been told there are no significant underlying issues, oftentimes there is no reason to fear the pain you’re experiencing.
We established earlier that pain is produced by your brain and does not necessarily mean that there is tissue damage or that you’re making things worse. On the contrary, after a very brief period of rest, it’s the individuals that take an active approach to recovery who are less likely to develop chronic pain.
5. Consult Your Physician or PT
This is sort of the purpose of the entire article. Can physical therapy really help?
I have no doubt most of you have already consulted a doctor…a specialist…a therapist…a Voodoo priest…anything to try and alleviate the pain. What I’m talking about though is further consultation based on trusted recommendations.
Before resorting to things like surgery or pain management with injections and prescription drugs, look for a trusted 2nd opinion. A doctor who a family member had success with in the past. A therapist who took the time and was invested in a friend’s rehab. Check out Google reviews. Find someone who is willing to take the time to adequately assess your condition and work with you to develop an appropriate treatment plan.
If you feel you’ve had a bad experience with therapy in the past, don’t automatically think “oh well, I tried therapy and it didn’t work, guess it’s time for surgery.”
To go back to my car analogy: if you went to a mechanic to get your car looked at and they came back and said, “We can’t really find what’s wrong…we think you should just go buy a new car.” What do you do? You don’t go buy a new car…or if you do you have more money than you know what to do with and I would love to talk to you about a wonderful investment opportunity in assisting a lovely physical therapist in paying off his student loans :). No, you say, “Thanks, but no thanks. You guys can’t identify the issue, so I’m going to find someone who can.”
Physical therapists are particularly skilled at treating chronic non-specific low back pain. So, lack of improvement in the past doesn’t mean things are hopeless. Most of the time it simply means that the people you’ve been working with haven’t found the right approach. Time to find someone who can.
6. Stay Active
Perhaps the most succinct advice I can provide is to stay active. Idioms like “if you don’t use it, you lose it” or “motion is lotion” are absolutely founded in reality.
Does this mean you should fight through the pain to try to run or lift weights? Not necessarily. Pain doesn’t always equal gain. However, finding tolerable levels of activity that you can participate in consistently is essential to breaking out of this chronic pain cycle and taking your life back.
A Final Word on Chronic Back Pain
Our bodies are made to endure a lot. They’re also amazing machines that self heal, build muscle at any age,6 and we’re also the only animal that has a chin (for whatever that’s worth). The point is that we don’t have to let chronic back pain define who we are and put an end to all the activities we enjoy. Yes, if and when we experience back pain that seems to last longer than the normal ‘tweaked back,’ you may have to modify your activities a little and remind yourself of the 6 tips above. But remember, your health is not defined by x-ray or MRI images and understanding how our bodies perceive and process pain can help us realize that we don’t have to be defeated by chronic back pain.
This article was written by Dan Murphy DPT, OCS. Dan graduated from Washington University in St. Louis in 2016 and lives just outside of Chicago with his wife two children. He enjoys playing board games and any outdoor activities with friends and family.
- Koes, B. W., van Tulder, M. W., & Thomas, S. (2006). Diagnosis and treatment of low back pain. BMJ (Clinical research ed.), 332(7555), 1430–1434. https://doi.org/10.1136/bmj.332.7555.1430
- Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-747. doi:10.1016/S0140-6736(16)30970-9
- Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine (Phila Pa 1976). 1995;20(1):11-19.
- Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005;5(1):24-35. doi:10.1016/j.spinee.2004.05.250
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173