Walking on the long and winding road to a pain free back

So what can you do to make your back pain free, to really get that feeling of having a spine as strong and viable as a tree’s trunk? First thing: get to know your pain! I mean really. Get to know it. I like to think of pain as an old relative that you wouldn’t say you like, because she’s nagging and complaining way to much, but still, she’s a relative and you need to make sure she’s all right. Most importantly, you would never do anything to hurt her. It’s the same with your pain, you may think angry thoughts about it, but it’s still a part of your body and your body deserve nothing but your unreserved love, no matter how deficient it is and how bad it works and how much it hurts. Especially than, when it hurts and doesn’t work the way you want I to. 

In practice: Keep a pain journal. Take notice of when you feel pain and how bad it is. For instance you can do it three times a day, when you wake up, somewhere in the middle and before you go to sleep. This will allow you to recognise any patterns that your pain follows. 

The importance of movement for the back cannot be pointed out enough. While it is beyond doubt good to walk, bicycle, run, swim or whatever you like to do, you can also try to move through conscious, slow yoga flows with focus on the somatic experience of being in the body. The reason why mind-body techniques such as yoga works so well for treating back pain is because they include both body and mind, and back pain is a body and mind issue. 

What I believe has been most valuable for me was a new approach to yoga. I did a teacher training with Julie Martin, who applies a rather rebellious approach to yoga. She works with freedom in movement and moves away from the old understanding of what constitutes a yoga position, or asana. Instead of being based on static strength like traditional yoga, it’s soft, fluid, dynamic. By moving ni this way, I have reached a whole new range of motion in my spine and in my hip joints. I work my hips a lot, because – surprise! – it’s all connected. The spine is part of the pelvis so naturally the pelvis affect the spine. I also work my feet, or rather try to keep them healthy by not (not anymore) squeezing them into shoes that are too small. 

Building stability and strength, especially if you have a tendency of hyper mobility (that is, if your joints can easily move beyond a normal range of motion), can rally help easing back pain. One of my favourite things to do when I start to feel that pinch in my lower back is to go to the gym and do dead lifts. Check out this guide if you want to learn how to do deadlifts! http://www.styrkelabbet.se/marklyft/ (in Swedish.)

There is also a lot to say about posture. Having a ”bad” posture is not connected to having back pain. This seems a bit counter intuitive but as you may have noticed a lot of people walk around life slouching like question marks without ever having any trouble with their backs. However, just because there is no correlation between posture and back pain does not mean that posture is irrelevant in treating back pain. Having a good posture, which I define as finding support for the spine from the feet, legs, and pelvis, takes focus away from the back. Imagine never having to think about where you place your spine, no more arching and no more rounding to find ease, the back can just be there without you thinking about it. 

A good posture should be one that offers support and stability for the spine to be in its natural curve. 

Last but not least something needs to be said about the illiopsoas. The psoas muscle has been called ”the muscle of the soul” (by Liz Koch of http://coreawareness.com). I really don’t want to go into the discussion about the validity of this claim, but limit myself to saying that the psoas is important as it connects the upper body to the lower body, stabilises the back and life the legs. It is one of the deepest muscles of the body and it originates along the spine and joins to the thigh bone. Typically most people would benefit from strengthening the psoas, more so then to stretch it. typically, what most people do is stretching it…
This is the illiopsoas:

An easy exercise: stand tall, arms alongside the body and lift and bend one leg so that you draw your knee towards your chest. Stay for a minute or so and make little circles with your knee, while allowing the pelvis to move with the circles. Do the other leg. Repeat. 

And of course, I’m announcing a workshop on back pain to the held at May 20. Please join me for a possibly life changing event! (Check out separate post!)

Is it gonna hurt? Fear of pain and fear of movement

Pain and fear of feeling pain can interfuse so that sometimes it’s hard to distinguish the two. It’s the fear of pain that makes us grip to protect the part that hurts, to try to keep everything still, or at least within a restricted pain free range of motion. It’s like we want to build an imaginary fortress around the painful area, mobilise our own tissue to shield and protect. The mere thought of how it would hurt to make an uncontrolled movement is frightening and sends chills of discomfort down the spine. After a while this fear may lead to an altered pattern of movement. You learn to move around the pain and never have to go directly into it. Thinking that if you only keep everything absolutely still it will heal. This is useful when it comes to a broken arm, but not so much when it comes to back pain.

I was told, by one of the numerous physiotherapists I have seen, that I had unstable shoulder blades and lack of strength in my upper back. The way I interpreted that information was that I had to keep everything stable and in place in order to avoid pain in my neck and shoulders. And so I gripped. I tried to move my arms without moving the shoulder blades, which is definitely not useful because the shoulder blades will have to move when the arms elevate above shoulder height. That, I have come to realise, was a non-constructive fear of movement. I have had it with my lower back as well, trying to keep everything stable and move slowly and carefully to avoid visiting that painful range of motion. 

Fear of pain, leading to fear of movement. There is even a term for it: kinesiophobia: an excessive, irrational and deliberating fear of physical movement activity.

Often what happens when we go to see a specialist, a physician or physiotherapist, is we get a diagnosis or some sort of explanation as to why we’re having pain. We may even be told to be careful, avoid heavy lifting or uncontrolled movements. Peter O’Sullivan, the radical physiotherapist, holds the view that health professionals should try to give patients a different view on the pain. Instead of talking about the back pain as being caused by structural damage, wear and tear, bulging discs, etc., the message should be that those things are normal and that there is no need to worry about them. Instead treatment should be focused on giving pain patients ways to know their pain better and ways to move out of their pain cycle. The back should be trusted to move in its normal way, according to Peter O’Sullivan.

I like to think of the spine as the trunk of a tree. Tremendously strong, stable and yet flexible.

Pain may create a sense of vulnerability. Your body is a piece of the world that is yours and yours only. Its home to your mind, your consciousness and perhaps even your soul and it is supposed to be a safe home. Your body is also the entity through which you interact with the rest of the world, you move around, walk, talk and dress. You express yourself through your body. No wonder we may experience some desperation when the body is not working properly. Having a painful body truly puts the entire world at bay. As a counter mechanism we try to move in such away that allows us to avoid pain. As long as we manage to live our lives around the pain we can keep the illusion that we have a well functioning body that does not hurt, and this restores a sense of security. However, it does not work in the long run. Instead of moving around the pain, we can try to move right into it, accept it and take care of it. the way we would take care of an old relative whose company we may not really like but who still deserves our love and care. This takes courage. And it takes guidance. A good yoga teacher is one that you can trust never to take your body to places that can be harmful. She will encourage you to enhance your range of motion slowly and to increase your knowledge about your pain so that you can handle it consciously and eventually become pain free. 

Pain is just in your head, or? The multiple reasons behind back pain

I believe that we, as humans, have a tendency to always look for the one single cause for every problem we encounter. Often though, and especially when it comes to back pain, there is not one single cause but more like an ocean of causes that contribute to the problem to varying extents. Back pain is one of the most puzzling conditions, and it is still being researched. What we do know is that back pain is complex and cannot be deduced to one distinguishable condition. Some interesting facts are that:

  • Only about 1% of all back pain occurrences have a really serious cause, such as a fracture.
  • 90% of all people would have degenerated discs detectable in a MRI scan.
  • 50% of the general population think pain means that the back is damaged. 

Back pain is not only connected to physical issues but also to psychological and emotional. 

So, most back pain doesn’t signify a serious injury, and injuries are common and usually not dangerous but still we tend to think that that it is precisely the opposite. 

Your prospects of becoming pain free are affected by how you perceive pain. 

The last time I experienced back pain I was working at a place I didn’t like, for a number of reasons. One reason was that I had to commute for one hour and forty-five minutes by train only to get there. This was at the same time as public health minister of Sweden declared sitting down to be the new smoking, i.e. really, really harmful and to be avoided at all cost. I had to sit for one hour and forty-five minutes and I hated it, I literally felt how my body degenerated during those commuting hours. And of course it was devastating for my back. From being located to the right side of the spine in the lower back the pain started to spread, affecting my upper back and my shoulders as well. Everything got so unpleasant I could barely sustain myself. Then on the weekends I usually took the train in the other direction to go for a hike in beautiful mother nature. Two hour train rides was not uncommon (oh lord, won’t you buy me a Mercedes benz?) and did I ever experience pain during those hours of sitting down? Well, I did, but it was much, much less, it was bearable and it didn’t affect my mood like it did when I travelled to work.

Peter O’Sullivan is a physiotherapist engaged in the field of back pain. He highlights the complexity of lower back pain and criticises traditional clinicians for still considering back pain to be directly related to structural damage, even though research prove, time after time, that damage doesn’t necessarily equate pain. Structural damage in the back may lead to pain, but a back with no structural damage may hurt as well. So even if its possible to detect one or a few causes for pain it’s not really interesting to do so, but instead to look at what we can do to feel better. Highlighting the psychological and emotional causes for pain does not mean that structural or physical aspects are completely irrelevant, however. For instance, while most people with bad posture will never experience pain, bad posture may for other people be one among several causes for pain. That is, a bad posture won’t automatically lead to pain, but if you have pain, working with your posture may be a relief. 

An important concept in regard to the complexity of pain is the pain cycle. Just as it sounds, the pain cycle describes how pain or injury leads to behavioural changes, which in turn leads to reinforced pain or prevents healing. A perfectly normal reaction to pain is avoidance: the body moves to avoid pain, if moving normally hurts more then it does to move in a distorted way, then your movements will be distorted. The body starts to compensate so that over time muscles, ligaments and nerves adjust to a new movement pattern that makes some muscles weaker and other muscles more tense. This in turn leads to sustained or aggravated pain. Another version of the pain cycle concerns the emotional aspects of pain so that pain leads to various forms of emotional suffering, which in turn leads to the experience of pain being intensified. 

This is where fear comes into play. Increased levels of fear of pain correlates with increased pain. Reducing fear can also reduce the pain experienced. Honestly, it can even be that the fear is worse than the actual pain, because fear happens at so many levels. It is the physical level of ”whats happening to my body, am I ever going to move in an unrestricted way again?”-feeling, it is the emotional feeling sorry for yourself or just feeling worthless, a sense of there being something wrong that feels deeper and more profound than just an aching body part. In the upcoming post I continue to dig into the topic of fear in relation to pain.

There is nothing as practical as a good theory….

Since I’m a used to be academic and a theory nerd I have taken time to really dig into the subject of pain research. I would like to provide you the basic theoretical insights I have gathered about the topic, if you’re not into theory you can just skip this section and wait for the next post.

What is pain? For a long time, pain was seen as a sensation produced by injury, inflammation or other tissue damage. This is the ’old’ – the Cartesian – understanding of how pain occur. Nociceptors – pain receptors in the tissue send information about damage to the brain and thus we feel pain. In this sense pain is a sound reaction preventing us from causing more damage by not moving or touching the place that hurts. This view, however, has come to be altered with progressions in pain research. We know now that pain is utterly complex and there is more to it then just the physical, structural aspects.

”While sensory input may initiate pain or other bodily awareness, it is not the sole, or even the dominant, causal mechanism” (Chapman 1996).

Physical pain is tackled from many different academic fields, such as neuroscience, psychology and physiotherapy. I also look into non research-based knowledge in the area of back pain; the topic has been adressed by alternative practitioners of therapeutic body techniques, such as yoga. Neuroscience, the science of the nervous system, focuses on nerves and nerve impulses, hence it concerns a rather high level of abstraction of the body. Physiotherapy, on the other hand, is more practice-based in its approach and concerns a lower abstraction level of the body. While the two fields produce different knowledge output, one is not more right than the other, they complement each other in a nice way.

There are two theories that really pushed forward our understanding of the causes of pain. The first one is the gate control theory from 1965. The neurologists Ronald Melzack and Patrick Wall showed, through a number of experiments, that non painful input closes the ’gates’ to painful input, thereby preventing pain sensations from travelling to the central nervous system (the brain and the spinal cord). So by creating other sensations in the body we may prevent the nervous reaction causing pain. It is generally believed that the gate control theory provides evidence of the psychological aspects of pain perception.

Ronald Walzack continued to work on the gate control theory, however, and later developed the neuromatrix theory of pain. Basically Walzacks insights came from studying phantom limb pain, reflecting on the fact that patients experience pain in a body part even though there is no body part there to feel. The neuromatrix theory of pain states that pain is produced by the central nervous system instead of the peripheral nervous system. Nociception, pain signals, travel from damaged tissue, via the peripheral nervous system, into the central nervous system. These are one part of what causes us to experience pain. The matrix, however, is made up of a network of neurons that consists of loops between the thalamus and the cortex, as well as between the cortex and the limbic system. Hence, pain is caused by this network, and by a characteristic pattern, the neurosignature, defining all the nerve impulses within the neuromatrix.

Does it seem a bit too complicated to grasp? In short it means that pain is in the brain more than in the body. Internal nerve impulses may be nociception – nerves sending signals about tissue damage. Nociception is an internal stimuli, it comes from within the body, just like an inflammation, a slightly irritable bowel, or stress. But nerve impulses in the neuromatrix comes from internal as well as external stimuli, that is, from changes taking place outside of our bodies as well as changes inside of our bodies. External stimuli could be we hear someone tell us we are strong, or weak, or maybe we read about someone having a strange and paralyzing disease that started out with a sore lower back. It could also be that we engage in some activity that we love to do and that makes us forget about the pain. Each part of the neuromatrix contributes to various aspects of the pain experience, the sensory, the emotional, the cognitive, motoric, behavioural, and conscious aspects of pain.

In short, pain is a nervous system condition rather than a structural, physical, condition. In the next post, I will look deeper into the causes of pain from a yogic perspective, how can we make sense of the complexity of pain and its connections to our general state of mind and all other things that provide inputs into the neuromatrix?

Hello back pain, my old friend!

Being a somewhat fit and healthy yoga teacher with a bendable body does not exactly add credibility in the field of back pain. Have I ever had a sore back? The answer is a clear and loud -yes! I have, and its been bad. But I’ve moved my way out of it (literally and figuratively) and I’d like to share what insights I’ve learned from the journey to becoming completely pain free (knock on wood!). Firstly, recognise that pain can be a great teacher. It’s not meaningless and completely bad to experience pain, at least seeing it as meaningless and bad might be an obstacle to becoming pain free. I’d like to think of the relationship between me and my back pain as the relationship between me and an old, slightly too traditional, a bit stubborn and hard-necked professor in a tweed suit whose standards are too high and who forces you to tie yourself in knots in order to prove yourself, but who you still hold on to because you know deep inside that he has a lot to teach you, even thought he can be a real idiot sometimes.

Important note: I don’t identify myself with my pain. I’m essentially pain free, the pain is just a visitor.

However, the first round of back pain happened when I was a teenager. I remember seeing a physiotherapist and being diagnosed with sciatica. That just made feel like an old lady so I didn’t make much of a fuzz about it. The second round of back pain happened when I was 22 or 23. It was a nagging, dull pain and a feeling of stiffness, to such an extent I feared my back would actually brake if I forced it to flex. I could not bend over to wash my face, brushing my teeth was a challenge and to put on my shoes, I had to lie down on one side and slowly try to pull the shoes on without moving my back. The pain was so bad I literally cried. (And just a parenthesis about how some people don’t really have a tradition of seeking professional help when shit happens, so to speak, I’m one of those people. Most people would probably, and rightfully, have gone to the hospital when putting on their shoes had them crying of pain.) The pain came and went for some years. At this time I was a member of a large gym chain and they would have a campaign where a chiropractor visited the gym, giving brief examinations for free. I signed up for one and the first thing the chiropractor commented upon was my way of sitting in the chair, ”do you always lean forward like that?” he asked. This was the first time I came to reflect upon how my posture and my way of moving affected my body. He also recommended some treatments and that I worked on building strength in my back and in my abdominal muscles. I did and eventually got pain free.

The third round of back pain started when I was in my thirties. This time I had a regular yoga practice, I was doing weight lifting at a gym and I had developed a huge interest for anatomy and movement. During the second round of back pain I was really suffering from it, this time the suffering was not as bad, even though the pain was. Like someone wise once said: pain is inevitable – suffering is optional. I had learned so many things about my body during the years that had passed since the last time my back hurt and I believe that all that knowledge helped improve my experience of the pain. (It is scientifically proven that knowledge about pain helps aiding pain.) Also, I acted straight away in a desperate ”if I cannot move I’m gonna die!”-kind of fashion. I went to see a regular physician at the health centre, I went to a physiotherapist and a naprapat. The physician performed an x-ray and compiled a letter saying he did not recommend surgery in my case. The physiotherapist gave me some excercises to find stability in my core. She also taught me about the important difference between hyper mobile people and stiff people, more on that in a later post! The naprapat did some adjustments and suggested that I had a bulging disc that I could try to treat by bending my back backwards and slightly to the right. It all made sense, and I dare to say that all of it (except for the physician) helped in some way, yet nothing took the pain away completely.

In retrospect, and now that I know how to work it away every time I feel a little nag in my back, I can see that the most important features of my last round of getting well from back pain was my fearlessness and my wish to learn everything about pain. The second round I really thought my back was seriously hurt and that forcing it to move would most definitely be dangerous. The last round I was more into experiencing, I did quite intensive backbends and tried to bend and flex my back in every way possible, assured nothing was going to break, so to speak. I’d like to explore the theme of fear in relation to pain a bit more, but first we’re going scientific. The next post will be about what science has to say about pain, look for it tomorrow!