Lower back pain is an issue New Yorkers are confronted with in all walks of life. Whether you work long hours in an office or have to move around often, whether you're an athlete or are relatively inactive, whether you have small kids to carry around daily or were in a car accident a long time ago, whether you run miles and miles on NYC streets or do Cross-fit three times a week, chances are you’ve probably had low back pain at some point in your life. And if not, you definitely know more than one person who has. Right?
So how do I make it better?
The first thing I always emphasize to frustrated clients is that living with low back pain does not have to become your new normal. I encounter so many clients who have in some ways given up hope or stopped seriously trying. Either they've tried 'everything', been told by impatient medical providers that they just have to live with the back pain or they just run out of time and money trying to finally get rid of their low back pain.
In 15 years of practice I have encountered this easily more than a few hundred times. And it's not just with chronic back pain but with other sports injuries and chronic pain. It's very common for people to express the same frustrations with treatments for neck injuries and shoulder pain. Injury recovery specialist and sports medicine doctors often throw up their hands or push them onto the next provider. It can be very discouraging for a person suffering with daily pain and chronic injuries sidelining them form their favorite sports and basic activities of daily living.
Another initial point of emphasis is that - and this might sound cliche or too warm and fuzzy - but we are all unique and our bodies will respond to different treatments, so if one method of relief doesn’t help, don’t give up! Below is a list of several self-treatment techniques but for serious pain it’s best to consult your physician or an injury therapist.
What constitutes 'serious' pain depends on you and on many factors: on how long you've had the pain, what type of pain it is - aching, throbbing, sharp, dull, burning, numbing/tingling, tightness, etc., where the back pain is located, what makes it feel better or worse and when it bothers you the most.
You’ll first want to locate the pain and assess it before applying a treatment. Stretching or massaging an area can make it worse if you don’t know what’s wrong with it. Once you’ve found the regions that are painful and which may be caused by or causing the pain, it’s time to figure out why. Figuring out why is not often an easy task because there are so many causes of low back pain and reasons why you might have it. For this reason it is very helpful and many times essential that you get an assessment by an injury recovery therapist and/or diagnosis by a back pain doctor of some kind.
What can cause low back pain?
The short answer to this questions is, A LOT! Our low back is essentially the grand central station, so to speak, of our bodies. So much muscular, nerve, joint and bone traffic goes through here that is intricately interconnected that when one section or structure gets blocked or damaged, the entire region can get affected.
Muscles: From large, flat muscles such as the latissimus dorsi (the "las") to strong, short stabilizers like the multifiti to thin, long postural muscles know as the erectors, there are dozens of muscles that interweave and directly influence the low back. In a lot of cases of low back pain, the problem is simply muscular, in the form of a muscle strain or soreness from exercise. Simple self massage, stretching and/or clinical massage therapy can be the answer.
Joints: The low back is made up of many strong and important joints. This includes the small vertebral/spinal facet joints, the larger joints that contain the Discs and the Sacroilliac (SI) joint. Wear and tear on these joints occurs early and often. In fact, a large body of evidence suggests that degeneration, or arthritic changes, begin to occur at age 21 in the cervical and lumbar spine, both in the Facet joints and in the Discs.
Structural changes to the spinal joints in the form of arthritis or tearing can cause low back pain symptoms. It is, however, important to recognize that the existence of a herniated disc may not cause pain at all whereas slight arthritic changes that may look clinically insignificant on imaging can cause severe symptoms.
Regardless, if your pain has gone on for a long time and/or is severe and debilitating, you should see a low back pain physician such as an orthopedist, osteopath, physiatrist who specializes in low back care. This is primarily to screen for joint damage rather than muscular injury because in many cases the treatments for one versus the other can vary in significant ways.
Nerves: Low back pain involving nerve impingement will often manifest with unique symptoms and usually reflects a more serious injury than a simple muscle strain and even arthritis not involving nerves. When a nerve in the low back is pressed on either by an inflamed facet joint, a herniated disc or a narrowing of the spinal canal, it often means that those injuries are more serious and that treatments will differ in specific ways.
If you experience numbing/tingling down the back of your leg(s) and foot, burning or shooting pain and/or a loss of sensation or strength anywhere in your lower body, a "foot drop" in which you have very little if any muscular control of your foot or shooting pain when stretching your hamstring, you should consult with your medical doctor who specializes in back pain and spine health.
Making sense out of it all:
As you may have gathered by now, back pain can be complicated, much more so than say a calf strain or shoulder soreness. There are many muscles, joints and nerves that can get injured in an isolated way or can get injured together. This can make safe and effective self-care tricky and difficult. So use your careful judgement and know when to ask for help. Stretching or foam rolling the wrong muscles or the right areas but in the wrong way can further complicate your low back pain. On the other hand, getting it right can be an empowering and expedited way of getting rid of your low back pain.
"Peggy came to me with severe low back pain and numbing and burning sensations in her legs, indicating a potential disc herniation and/or nerve impingement. I was very careful treating her, relying on gentle myofascial release and traction. She reported that her symptoms had completely resolved less than 24 hours after seeing me."
“Tight” versus “Short” Muscles
Regardless of whether your low back pain is purely muscular or not, the chances are you'll need to stretch specific muscles with regularity in order to improve that muscle's length and strength, thereby improving biomechanics in the entire low back region. Knowing which muscles to stretch, which ones to foam roll, which ones to activate and which ones to strengthen is very important.
Tight muscles may be short, meaning they do not fully lengthen, or they may be long and over-active due to weakness and over-use. A tight muscle can limit functionality and cause pain because it cannot relax and contract properly. A short muscle, on the other hand, specifically means that it does not fully stretch to a normal length. Short muscles may be over-active, too strong or weak. While short muscles must be stretched in order to allow for normal contraction and joint range of motion, tight muscles may not need to be stretched. Understanding this difference is very important to injury prevention and rehab.
A short muscle is always a tight muscle but a tight muscle is not always a short one.
Pain Relief from Stretching
For tight but not short muscles, stretching may actually make a problem worse, even if it temporarily feels better. For those who work a desk job, sitting all day is already a constant stretch of the gluteus maximus muscle and is a very likely contributor to the lower back pain. Continually stretching it often feels good and therapeutic but it may just further de-activate this very important muscle.
Shortened muscles, however, can and should be stretched. When stretching, be sure to hold the stretch for at least 30 seconds but no longer than 2 minutes in order to get the full benefit. Repeat throughout the day. For the typical desk-job New Yorker, the hip flexors and not the glutes are what need stretching although this is not always the case. So remember, the types of stretches you do should only be targeted towards the shortened muscles. Some of he most common back stretches have you bend forward such as touching your toes or backward like when doing cobras in yoga. A backbend could be great for stretching the hip flexors but might compress the spine too much. A forward bend could be great for stretching short and overactive low back but is not appropriate if you have had a serious disc injury.
If you’re having trouble figuring out which regions are short and which are tight, it might be best to leave treatment in the hands of a capable injury therapist. Here’s a full article on Injury Therapy.
Self Massage
You’ve probably heard some variation of the following terms: self-administered trigger point release, self-myofascial release, self-myofascial, foam rolling. They all pretty much mean the same thing or have the same goal: to break up the trigger points, scar tissue and adhesions in specific muscles and connective tissue (fascia). This combined with stretching will enable your muscles to fully lengthen and contract in order to maximize joint range of motion and strength.
There are several types of tools to help you hit your trigger points. Just be sure to hold it on the trigger point for 30-90 seconds without moving or only moving very little. Be very careful not to overdo it. The purpose of self-administered massage release is to melt away stubborn, specific trigger points in muscles. Going too deep or staying on a sport too long can cause unwanted inflammation, residual pain and delayed healing.
In combination with other treatments such as active release techniques, it’s even possible to rid yourself of lower back pain altogether. The best way to achieve this is to consult an injury therapist or back pain specialist.
"Alex came to me with a half dozen lingering injuries and problem spots, including her low back, lower leg, foot and shoulder. Her issues were the result of years of dead lifts, heavy squats, kettle bell swings and power lifting. Through corrective exercises, functional training, manual therapy and specific strengthening and stretching of muscles, Alex now has gotten control of her body back and has stopped living with chronic pain."
For more on clinical massage techniques, you can take a look at the full article HERE.
Muscle Activation
This term has become very common in the injury recovery and personal training worlds although it is very often confused with strengthening. For example, doing squats, which is a strength training exercise usually will not activate gluteal muscles if the glutes are indeed under-active and not firing properly. In actuality, doing squats with improper glute muscle recruitment can contribute to chronic low back pain and hamstring injuries because those muscles have to work harder to compensate for the under-active glutes.
Strength means structurally changing the size of muscle cells so they can produce and withstand greater forces, increase in density and grow in size. Activation, in contrast, is in essence “waking up the muscles”, not structurally changing them.
Let’s use the Gluteus Maximus muscle as a quick case study because this muscle is very often under-active and can play a major role in chronic low back pain origin and treatment.
Too much sitting: When we sit for long periods as so many New Yorkers do these days, the Glutes are in a stretched position. This constant over-stretching shuts the nerve impulse to a muscle down because the muscle isn’t being used and because the opposing muscles, in this case the hip flexors, are short and overactive (reciprocal inhibition).
Foot/Ankle shape and mechanics often have an impact all the way up the legs into the spine. So it is important to understand if and how these muscles and joint structures are contributing.
Under-active Glutes causes and is caused by over-activity of the hamstrings, low back musculature and hip flexors. When the Gluteus Maximus is under-active, the hamstrings and low back muscles have to pick up the slack, causing excess stress to these muscles and wear and tear on the spine.
If the Gluteus Maximus and Medius are under-active, the low back will bear much of the force during squats, dead lifts, running, walking up stairs and hiking up steep hills or mountains, thus worsening lower back pain.
Often time with lower back pain, the intrinsic abdominal and pelvic muscles are also under-active and weak. Specific exercises to activate these muscles are often required to resolve low back pain.
Activation usually involves very small, slow and specific movements focused on an individual muscle or muscle group in order for the body to reactivate the nerve impulses.
Activation exercises can be tedious and boring because they need to be performed slowly, precisely and aren’t exactly fun or impressive-looking exercises. But they are fundamental to injury prevention and recovery, especially for low back pain. Once muscles are active again, that’s when strength training becomes vital.
Strength Training: Getting It Right!
Once you have activated your glutes and other abdominal, upper back and lower body muscles, it's time to begin a safe and smart strength training program for your legs, low back and entire torso geared at low back pain prevention and post-injury rehabilitation. If you have had serious low back injuries and pain, you should consider embarking on this strength training program with a certified and experienced personal trainer or physical therapist. In my 13 years of experience as a clinical massage therapist, Active Release Techniques practitioner and Certified Personal Trainer in New York City, this is where I see and hear of people getting it wrong.
Slow, safe and smart should be your guide. Meaning, if you haven't done squats in 6 months and/or still have some low back discomfort, then you should begin with no weight or very light weight and work your way up in intensity gradually. You'll get back to your old self if you are smart and strategic. But you'll take many steps backwards if you try to do too much too fast.
Cardiovascular Exercise
There is a link between cardiovascular exercise and a decrease in low back pain. It’s not necessarily a cause and effect relationship but rather a correlation. There are many reasons for this, including improved neuromuscular coordination, stability and strength, an increase in blood circulation to muscles and a general reduction in overall stress that aerobic exercise has been proven to create.
Choosing the appropriate aerobic exercises will depend on several factors, especially the stress it creates on the low back if there is already an injury. It may be a trial and error process to figure out what works best for you. In general, low-impact activities are recommended when in the midst of lower back pain or injury.
Don’t be afraid to seek medical help too!
Self treatment can actually be very difficult to do on your own since most of us aren’t experts on anatomy and muscle function. That isn’t to say that it’s impossible, but it’s best to consult a specialist who can advise you on what types of stretches you can do and which areas should be massaged and addressed. Here in New York City, you have easy access to some of the best therapies available.
In combination with professional help, you can administer stretches, self-massage and muscle activation safely in order to cure the root problem leading to your back pain.
