Back Pain Made Simple: Just the Facts

The Cleveland Clinic Journal of Medicine has a helpful, authoritative review of back pain, its causes, and advised treatments. Back pain is the second most common reason for doctor visits (after the common cold). I recommend sending it to anyone dealing with back pain.

Some of the key points:

  • Most back pain has no recognizable cause and is therefore termed “mechanical” or “musculoskeletal.” Underlying systemic disease is rare.
  • Most episodes of back pain are not preventable.
  • Confounding psychosocial issues are common.
  • A careful, informed history and physical examination are invaluable; diagnostic studies, however sophisticated, are never a substitute. Defer them for specific indications.
  • Encouragement of activity is benign and perhaps salutary for back pain and is desirable for general physical and mental health. Evidence to support bed rest is scant.
  • Few if any treatments have been proven effective for low back pain.
  • Low back pain should be understood as a remittent, intermittent predicament of life. Its cause is indeterminate, but its course is predictable. Its link to work-related injury is tenuous and confounded by psychosocial issues, including workers’ compensation. It challenges function, compromises performance, and calls for empathy and understanding.

I would highlight the fact that exercise is helpful. (You should also exercise when you have the common cold, by the way.)

The last point about empathy and understanding rings true. Last October I woke up one morning with searing, unexplainable lower back pain. It dominated my existence for a couple weeks and I was able to do almost nothing else. I grew more understanding of what some must deal with on a daily basis.

Also, I never do exercises in the gym that come anywhere close to hurting my back. This includes squats. Unless you're extremely well instructed on how to use the weights, avoid back-related movement and stick with bodyweight exercises.

(h/t Andy McKenzie for the pointer)

13 Responses to Back Pain Made Simple: Just the Facts

  1. I never thought I’d see a post from Ben Casnocha on lower back pain, at least before he was forty.

    I still can’t believe tumbling was required in our physical education at junior high school. We had to do rebounding– backward and forward flips on a mini-trampoline– with spotters, of course (I think the morbidly obese guy was excused, though, thank God).

    To give an example of the different ‘confounding psychosocial issues’ faced by back pain sufferers:

    A few year ago I had a continual pain in the upper right side deltoid muscle of my back. Not to brag, but I have exceptionally well-developed back musculature (I don’t work out– I think it’s attributable to my vibrant sex life;-).

    Anyway, after suffering for a couple weeks with the worsening discomfort of a nagging dull pain deep within the knotted strands of all that protein-mass, I made an appointment with an orthopedist.

    Imagine my chagrin when confronted by a haggard, gray-complected man in his mid-thirties who was at least forty pounds overweight. I thought, “What does this slob have to tell me? He looks like the walking dead.”

    As usual when it comes to character-reading, I was right. This charlatan told me that aspirin was not an anti-inflammatory, just before he prescribed the NSAID Vioxx, which was soon thereafter yanked from the market after it was found to endanger the heart.

    He also prescribed six month’s worth of therapy at the center next door, which I later learned he half-owned.

    Needless to say, I ignored his prescriptions and set about to find some simple mechanical explanation for my back problem.

    It occurred to me that I spent a lot of hours reading with feet outstretched transversely on my sofa, which is really a framed folding futon. In folded position, the ‘seat’ is at a fair angle from level, so my spine and whole back would be thrown out of perpendicularity to it.

    Thinking this might be the cause of my discomfort, I quit sitting that way, and voilà! the mysterious back pain disappeared.

    Lest any cynics out there think that a folding futon is not the best place to conduct a vigorous sex life, I assure you that I prefer the floor.

  2. Kevin says:

    Well, I’m glad the august Cleveland Clinic has nothing to say on the issue of back pain beyond ‘actually exercising may not hurt and might help’.

    Everyone wants a surgery or a pill to fix their back. I agree with first commenter, often times incorrect posture is to blame. Further, most backs are so weak that the spinal erectors don’t have the strength to hold proper posture.

    Most people address this by doing more crunches. Fantastic.

    I had low level back pain for years which I attributed to playing college football and lacrosse. Oh well, what can you do.

    Then I started deadlifting and actually strengthened my back.

    Sometimes, bodyweight exercises aren’t enough. If you have to, do superman’s on the floor to strengthen your back. Otherwise, load some weight on the bar and pick it up.

    Most people can strengthen their backs without breaking their form and being at risk for injury.

    As an athlete, Ben, I’m surprised you subscribe to the ‘workout lite’ philosophy of segregating mind-numbing cardio from machine strength training and calling it effective. Is that how they did it in bball?

  3. Sean says:

    I agree with Kevin that deadlifts, squats, and other compound lifts – when done correctly and slowly phased in – can effectively build back strength. I had lower back pain in high school but for the past few years have been regularly lifting weights and stretching (first classical stretch and now yoga) multiple times a week. I haven’t had any back pain for years and my back feels stronger than ever.

  4. Ben Casnocha says:

    Kevin,

    Good comments. The question comes to down your last use of “most people” who can do exercises correctly. I question this. In average to below average gyms, people are doing all sorts of exercises wrongly. And they’re seriously putting themselves at risk.

    No, that’s not how we did it in basketball. But I’m talking about what the average non-sports player should be doing fitness wise — not people looking to get jacked, work out at Crossfit, or play college athletics should do.

  5. Reader in Sweden says:

    Come on, squats and deadlifts are harder than most* bodyweight exercises but not THAT hard. It depends on your goals, of course, but bodyweight exercises are not going to make you REALLY big and strong, although they will suffice for general health, fitness, and also fat loss.

    * Exceptions would be advanced gymnastics stuff like pistol squats, planches, handstands, etc.

  6. Reader in Sweden says:

    In average to below average gyms, people are doing all sorts of exercises wrongly. And they’re seriously putting themselves at risk.

    That’s because they have too much ego to lower the weights and practice proper form under supervision of someone knowledgeable.

  7. I used to go to America’s Back for my low back pain and it was amazingly effective. I had tried lots of other things (chiropractic, accupuncture, exercies), but this worked in just 15 minutes per week. Unfortunately their business model didn’t work and they shut down.

    Now I do a combination of stretching and full-body isometric workouts. In my case the source of the pain is diagnosable shows up on an x-ray.

  8. Tyler says:

    Squats strengthen the knees, the back, and everything in the legs. The squat places the MOST stress on the body, and in response to this stress, testosterone is release, which you know is a muscle-building hormone. Squat to improve everything. It’s the single best exercise for the human body.

  9. Shefaly says:

    Extraordinary that the research/ study does not deem it worthy to say that lower backpain can also have psychosomatic bases in which case exercising the body isn’t going to help. That said I agree that too many people exercise wrongly but social norms prevent us from interrupting a huffing-puffing muscle man to tell him he is doing it all wrong. (It usually is a man; more women take help from trainers in the gym than men, in my experience).

  10. Brice Stacey says:

    Back pain is definitely tricky. I was in a terrible car accident at age 18, which did all sorts of damage to my back. The MRIs showed nothing of course, but that doesn’t explain the pain I felt nor occasionally being absolutely paralyzed out of no where.

    I think strength training worked best for long-term recovery. Massages were amazing for several days of relief. And there was this electric gun thing that felt like a bee sting that the doctor used on my legs and lower back that was absolutely amazing and made the pain disappear immediately, but the effects only lasted a day or two and resistance was a serious concern.

    You’d also be amazed at how much you use your back while running, but probably only noticeable in people with existing back problems. It’s my primary mode of exercising my back now and I’m doing fine.

  11. Goat Rogers says:

    I have hurt my back several times because of a reckless desire for excitement, sometimes bad enough to see on x-ray that my vertebrae were not straight and intense pain was occuring at that site. I have been bedridden for weeks and in so much pain that I could not turn over IN BED!

    A good chiropractor is the only thing that has worked, and thank god, it works instantly. Crack! Instant 80% reduction in pain. Come back a few days later and get another 80% improvement. After a few visits I am back to challenging my brother in law to jump off a bigger cliff or doing a surprise take down to my brother.

    I get injuries around periods of stress at work as well. I think the physical tension in the upper back and neck from stress takes its toll on the spine, and then you go to the gym and do something you do every week for years and all of a sudden major debilitating and persisting pain.

    The only thing a doctor has done for me is write me a script for pain drugs and steroids that severly affected my cognitive abilities and tempted my addictive streak.

    Chiropractors, know a good one.

  12. Paulcollins says:

    If someone has back pain, it doesn’t stop when he/she go to bed at night. There is a vicious cycle of back pain with sleep problems that contribute and related to each other. It is quite difficult to sleep well if one’s back hurts. And many times back hurts more because not well sleeping. In such situation one can give emphasis on several sleeping accepts like sleeping position, bed, mattresses and pillow etc. No doubt organic mattresses and pillows are best supplement.

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