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Back pain is an enigma. The treatments are endless: massage, physiotherapy, even surgery.
But is the back pain really happening due to damage in the back? Are the symptoms a part of the bigger picture? Are invasive methods really necessary and will massage help the underlying issue or just band-aid the solution? Why, with all of the treatments out there, do you still have back pain?
This article will guide you through the best available evidence to help your client kill their back pain and get back to training.
There's Always an Assumed Cause
If you ask your client why they think their back hurts, they'll probably answer with something like:
- "I blew a disc in college."
- "I strained a ligament deadlifting."
- "I slouch at my desk."
Logic seems to infer that if there's pain, the cause needs to be directly related. But a direct cause and effect is rarely the case.
Most of the time, their backs aren't damaged.
Back pain is rarely caused by tissue damage or some kind of biomechanical problem.(1)
Unfortunately, most people still think it is, including medical professionals.(1,2) That's why many of your clients have probably been told they shouldn't squat, they need to get surgery, or that they need to go through elaborate strengthening and corrective exercises to fix their back pain.
How many people have you seen that have uttered the phrase, "I've tried everything?"
Most treatments are based on the idea that your client's back is "out" or damaged in some way, and are designed to "correct" or heal their backs.(1) Despite this idea being so common, it's still unproven and probably false.(1,3)
Is Damage Synonymous With Pain?
If back pain were caused by damage, you'd expect people with the most damaged backs to be in the most pain. That's not the case.
Depending on the data you look at, around 22-40% of healthy, pain-free people will have herniated disks. The same studies show that around 21-93% of people have bulging disks, and 56% can have tears in the connective tissue around their spine.(4-8)
One study found that "... even spinal canal stenosis (narrowing) is routinely painless."(9)
Remember, these people have absolutely no pain, despite obvious damage. Pain is often in the brain.
Other studies have also found that people with minor and severe spinal deformities often have no back pain.(10-14)
It's still possible that some of your clients with back pain do have tissue damage, but that's not the norm. We'll come back to them in a second.
First, let's talk about some of the most common, and unproven ways people often try to heal back pain.
Are Corrective Exercises, Core Strengthening, and Stretching Overrated?
It's tempting to recommend special exercises to correct your client's posture, balance their muscles, and make them more flexible. Extolling the "benefits" of these are also a trap that many overzealous trainers fall into as they try to get a client to purchase training sessions.
These methods are cheap, easy, and safe. In fact, physical therapists recommend core strengthening and corrective exercises more than anything else when they have a patient with back pain.(15)
Unfortunately, these activities are also probably a waste of your client's time.
Core strengthening and "motor control exercises" will sometimes make people feel slightly better, but the benefits are very small and not reliable. Most studies have shown that these activities are no better than manual therapy or other kinds of exercise.(16-21)
Even when people feel better after doing corrective exercises, their backs don't function any differently. The benefits were probably due to feeling more confident, and a placebo effect, than from any physical change.(22)
The same thing is generally true with drugs.
Drugs Aren't Very Effective for Treating Back Pain
Medication can offer a band-aid solution, but it doesn't solve the issue. Do you really want your clients to be medicated for the rest of their lives?(23)
There's still very little research on the best drugs, drug combinations, dosing amounts, or dosing schedules for back pain.
Non-steroidal anti-inflammatories (NSAIDs) like Ibuprofen, and acetaminophen (e.g. Tylenol) seem to work well for acute back pain, but don't help much with chronic back pain. Even then, the results from most studies are mixed, and we're still not sure how effective these drugs are for any kind of back pain.(23-25)
Surprisingly, muscle relaxants are almost completely ineffective for treating back pain. They're generally no more effective than placebos or other cheap drugs like NSAIDs and acetaminophen.(26,27) In fact, people will actually tense their muscles if they're told a muscle relaxant is a stimulant. (28)
What About Surgery?
Doctors are often quick to tell people with back pain they need surgery. When you have a client who's tried everything else, you've probably been tempted to tell them the same thing.
Unfortunately, surgery is remarkably ineffective.(8,29-32)
Most surgeons still view back pain as a structural problem that needs to be fixed, and are often more likely to recommend surgery before exploring other options. As we saw above, a large percentage of people will present with an abnormality in their spine if scanned. It doesn't mean that there's an issue.
As a result, "Rarely are diagnoses scientifically valid, nor is the effectiveness of surgery proven by acceptable clinical trials."(29)
If your client has had surgery, it's likely they can exercise like a normal person. People who get spinal fusion, where a surgeon connects several vertebrae, are often able to function as if their back was completely normal.(33)
Considering the cost, risk, and time it takes, surgery might be one of the worst choices for treating back pain.
Now let's look at the best possible explanation for what causes back pain, so you can help you clients feel better.
What Causes Back Pain?
The most recent and comprehensive studies indicate that back pain is largely caused by a hyperexcited nervous system.(8,34,45)
When the nervous system becomes sensitive it will either:
a) overreact to small stressors that shouldn't be very painful, or
b) create the sensation of pain even if your body isn't damaged.
It's possible that this will happen after a real injury. Say your client really does hurt their back in the gym. Their injury heals in a few weeks, but the pain remains or gets worse.
Your client's emotional and mental state will also affect how much pain they experience. Stress, whether it's caused by feeling overwhelmed, lonely, tired, or scared, will make their back pain worse.(35)
A number of studies have shown that simply educating your clients about what really causes pain, can make them feel much better.(36-41) Even when people don't exercise, they still feel better after learning about how pain isn't necessarily caused by structural problems, but by their nervous system.(42)
At this point "... 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."(36)
Cognitive functional therapy, which "targets the beliefs, fears and associated behaviours" with back pain, is thought to be more effective than manual therapy and exercise.(43)
Basically, this approach focuses on educating people about the real causes of low-back pain to ease their stress and fear around their condition. (Admittedly an over-simplification but adequate for this discussion.)
Studies have also shown that people who "catastrophize" their pain tend to have a slower recovery.(44,45) These are the clients who assume they're never going to get better, will never be able to squat again, and generally assume the worst. It's more important than ever that you help educate these people and calmly walk them through what really causes pain.
In short, telling clients what's really going on inside their body is one of the best ways to help them recover from their back pain.
Your Quick Start Guide to Helping Your Clients Overcome Back Pain
1. Ask your client about their history.
When your client says they have back pain, ask them the following questions and let them talk through the answers. Be careful not to interrupt them; nod your head and take notes as they speak:
- Where does it hurt?
- How long have you been in pain?
- When did it start?
- Have you been to see a doctor? If so, what did they say?
- Have you had any recent accidents that might have injured your back?
- Is the pain constant, or does it wax and wane?
- Are there any activities that you know make your pain worse?
Your goal at this point is to get a clear view of their condition, and help them stay as active as possible without causing them pain.
Phrasing is important. Don't ask a bunch of leading questions that reinforce the idea that their back is damaged.
For instance, if you ask "Have you had any scans of your low back?," "does your back ever make a 'popping noise,'" they're more likely to assume they're suffering because of some structural problem.
Resist the urge to immediately tell them to do a bunch of stretching and strengthening exercises. While it might make them feel a little better in the short-term, it still implies their back is damaged, misaligned, tight, or weak, which is probably not the case.
2. Educate them about the real causes of pain.
This is probably the most important thing you can do to help your clients feel better.
Read this article or print it out, and break the information down into simple chunks. Spread out the lesson over a few different personal training sessions.
In the first session, you might explain how pain is controlled in the brain, and that your tissues just send information about whether or not the brain should start making your body hurt.
The next session, you could talk about how stress and other issues affect their pain tolerance.
If you feel like they're not "getting it," then repeat yourself and use multiple examples. It's crucial they understand this information, as it's probably the best way for them to recover.
3. Encourage them to keep moving, even if they have low-back pain.
Most studies indicate that your clients will recover faster if they stay active, rather than resting.(49,50)
It doesn't matter what kind of exercise they do, as long as they're moving. Help them find activities that don't cause pain, but still give them a workout. It might be as simple as taking a walk every morning.
If they have pain all day, still urge them to workout a little. Complete rest tends to make back pain worse.(50)
4. Help them identify and cope with stress.
If you aren't asking your clients about their home life, start. Here are a few questions that will help you find what's stressing them out:
- "How much sleep have you been getting recently?"
- "How's work?"
- "Are you and still dating?"
- "How was moving into your new apartment?"
- "When was the last time you took a day off?"
People often feel better just talking about what's bothering them, even if you don't offer a solution. (Or in other words, "it's not about the nail.)"
If your client is a type-a personality who rarely takes breaks, it's possible they need to add some more play to their life.
5. Suggest they get a massage.
There's a little evidence that massage might help people with back pain.(51)
Most people find massages relaxing, and if it can fit their budget, it's worth trying. If nothing else, it acts as a relief of the stress that could be leading to some of the symptoms.
6. Ask them to be patient, and reassure them they will get better.
Most cases of back pain, even "chronic" ones, go away with time.(52)
Even if they have a herniated disk, those usually correct themselves, too.(53)
As cheesy as it sounds, there's strong evidence that if your client believes they can get better, they will.(54-56)
Remind them of that fact.
Recommend they see a doctor... if they meet the following criteria:
- They've had back pain for more than 6 weeks.
- They've had an obvious accident that might have been traumatic enough to fracture their spine, like a car crash.
- Their pain is extremely severe, and getting worse instead of better.
- They have numbness around their butt or groin and trouble staying continent.
Otherwise, it's best to stick to the above methods first.
Chronic back pain is frustrating. It's poorly understand, often misdiagnosed, and over-prescribed. Help your client understand what's really going on. Alleviate their concerns, listen to them, and help them find ways to move that don't cause pain.
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