Training with Back Pain

This is a guest post from qualified physiotherapist Seamus O'Connor.

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Low back pain is a real pain in the arse.

Well technically it’s a bit higher than that, but you know what I mean.

Low back pain is the leading cause of disability globally, affecting around 619 million people worldwide¹. Training with back pain can cause a lot of apprehension in people, particularly if they feel that working out is going to do more harm than good.

It’s difficult for people to train with back pain, or any form of pain for that matter, and there is a lot of confusion around how to do so.

So, let’s explore back pain a little further in the context of training and give you some practical advice on how you can manage your symptoms while continuing to train.

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First of all, it is important to note that the vast majority of back pain episodes do not have a specific identifiable pathoanatomical cause².

Put simply, most back pain cases are not caused by a serious pathology or disease and treatment is typically conservative (i.e. no needles or scalpels for you!). 

However, despite this, it can still be anxiety-inducing and debilitating for many people, to the point where it ends up controlling their lives. 

So, if you’re reading this and you’re struggling with back pain, or even if you’re just worried about your back when training, then let’s start to cut through some of the bullshit and find a way to help you through. 

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Firstly, let me set the scene by telling you that as a human, you are strong, resilient, and adaptable.

Our bodies are quite amazing in what they have the capability to do.

You might have heard that your intervertebral discs (those things between the bones of your spine) are like jam donuts – if you squeeze them too hard, the gooey stuff in the middle will pop out (ala a disc bulge or herniation). 

WRONG!

Firstly, your discs are a highly robust and complex cellular structure. They're made up of interwoven collagen fibres on the outside, which are excellent at resisting tension, and a more malleable but solid nucleus on the inside, which does a good job at dispersing compressive forces across the structure³.

They are also alive and do not work in isolation. These structures have the ability to adapt, and unless your jam donut starts talking to you (get help if it does), then there are no similarities between the two structures. 

Why is this important to know? Well because we need to stop moving in a way that we think is preventative of damage.

Bending your spine once is not going to cause your discs to explode or your spine to combust.

I mean, good luck taking your dishes out of the dishwasher if it did.

So why do we train like this?

Life is messy. We do not always lift, pull, carry, squat or hinge in perfect biomechanical alignment. Yet when it comes to training, we think that if we round our back even slightly during a deadlift then our souls will be sent to the shadow realm. 

So, if you’re concerned about your back during training but you have no symptoms, then come back to this point: you are strong, resilient and adaptable.

Keep gradually progressing your training to ensure your tissues adapt to that training and can be even stronger and more resilient in the future.

But I can hear the rest of you yelling at me! “Ok, ok, so I get that my spine is strong and the human body is adaptable, but I’m in pain, so what do I do about it!?!”

Good question. Glad you asked. Appreciate you.

First and foremost, if you’ve been struggling with back pain for a while and have been cleared of any serious pathology, then you need to think about picking the low-hanging fruit first! 

1. Are you sleeping 7+ hours per night? That means good quality sleep, not just having a half dozen beers and passing out during a late-night run of Gordon Ramsay’s Kitchen Nightmares.
2. Are you managing your stress? Stress can turn up the dial on the pain setting for many conditions, especially low back pain.
3. Are you eating well? Are you managing your overall calorie intake and making sure you get a wide variety of foods, including fruits and vegetables?
4. Are you exercising? Just in general - are you doing some huffing and puffing a few times per week? Do you lift some heavy stuff from time to time?

If you are doing none of these things, but expect a massage from a physiotherapist, chiropractor or osteopath to magically make your back pain go away, then I’ve got news for you – It probably ain’t gonna help in the long term.

Again though, life is messy.

We can’t always be perfect. People have different issues and challenges and sometimes we just have to deal with periods where we sleep less, stress more, eat worse and stay sedentary.

What you can do in these situations with back pain is start gradually exposing yourself to spinal movements.

It might be as simple as starting with some gentle pelvic tilts.

You want to expose your spine to more movement over time and desensitise your body from becoming hyper-reactive when you bend, extend, twist, or turn your spine.

For the rest of you with back pain saying “Yeah, I exercise, eat well and sleep well, I’m just in pain when I do certain exercises. What the fuck do I do about it?!”, firstly I’d like to ask that you stop yelling at me. But also, here’s what you can do.

1. Keep training – start by doing whatever exercises do not give you pain. Often people with low back pain have no trouble with their upper body exercises, isolated joint lower body exercises, machine-based exercises, etc.
   
   If you don’t feel pain, then keep going.
   
   You might have to switch out the treadmill for some elliptical or stationary/recumbent bike for your cardio depending on your symptoms. But for your overall wellbeing, it is important to continue to exercise.
2. Respect your pain, but do not be controlled by it! For those exercises that give you symptoms, we need to make a judgement call on how much is too much to persist with. Generally, I give people a simple system for pain management:
   • If your pain is tolerable, less than a 3/10, and does not get worse BOTH at the time of exercise AND 24 hours later, then go for it
   • If your pain is not tolerable, more than a 4/10, or it gets worse EITHER at the time of exercise OR 24 hours later, then we need to back off
3. Regress your exercises to make PROGRESS! Okay, so deadlifting hurts you. We need to find a way to regress the exercise so that you are getting exposure to parts of the movement to aid with returning to the full movement. Typically we want to do one of the following things:
   • Lighten the load of the movement
   • Shorten the range of the movement
   • Modify the movement to something similar

An example of a regression for a deadlift might be to do a kettlebell hip hinge from an elevated block.

There are many ways to modify movements. If you’re not sure, work with a coach or trainer to help you with this.

Over time, you should continue to progress your load and range to be able to get back into the positions that you previously were unable to achieve. 

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Lastly, for everyone with back pain, it is important to manage the psychological components of your symptoms.

If you allow yourself to catastrophise about your back, chances are you are only going to make things worse.

We’ve all been there.

We have pain. It lasts a while. We worry and panic. Then, it eventually goes away and we wonder why we were being so hysterical.

It is up to you to take control of your back pain journey. This is your body and your life.

Work with professionals in healthcare and pain management when needed.

But please, make sure that you are tackling the full biopsychosocial (i.e. not just physical, but emotional, social, mental, etc.) gamut of needs.

You can’t just go in for a massage once per week for 3 months and think you are going to get better!

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Disclaimer: This blog does not replace medical advice. If you have concerns or uncertainties, please visit your healthcare provider.

References:

1. Chen, S., Chen, M., Wu, X., Lin, S., Tao, C., Cao, H., Shao, Z., & Xiao, G. (2022). Global, regional and national burden of low back pain 1990–2019: A systematic analysis of the Global Burden of Disease study 2019. Journal of Orthopaedic Translation, 32, 49–58. https://doi.org/10.1016/j.jot.2021.07.005
2. Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., Beneciuk, J. M., Leech, R. L., & Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of Orthopaedic and Sports Physical Therapy, 50(7), 350–372. https://doi.org/10.2519/jospt.2020.9971
3. Poulter, D. (2020). Intervertebral discs are they jelly donuts? Physio Network. https://www.physio-network.com/blog/intervertebral-discs-are-they-jelly-donuts-a-guest-blog-by-david-poulter/#:~:text=Human%20discs%20do%20not%20slip,of%20a%20predominantly%20cartilaginous%20nature