Upper and lower back pain: What you don’t know will hurt you

Difficulties with our backs can lead to a variety of problems—including pain in the upper and lower back, the sacro-iliac joint, and even the neck, as well as loss of work, large medical bills, and distress at not being able to live life in a comfortable way.  

The major contributors to back pain? Stress, poor posture, and a lack of body awareness.

Many years ago, I developed and conducted a back pain program for the University of California.  What I learned was that very few people sensed their back, how it moved, and how they used their back to do almost any activity.  In other words, there was a low level or even a completely absent sense of their back.  It’s as if pain was the only signal that provided the information that they even had a back.  

This lack of back awareness is understandable.  Most of us can easily see the front of ourselves and we might find it quite easy to touch the front or even the sides of our body with our hands.  We are naturally more aware of the front of our bodies.  But it’s difficult to see our back (barring eyes in the back of our heads) and for most people, not so easy to touch our back.  

What this means is that it’s difficult to notice when our muscles are overworking to simply sit or stand—or for many people, even to lie down.  I’ve seen this firsthand as a large number of people that I work with report waking up with back pain in the morning after a night that should have been rejuvenating their muscles.  

Over the decades, many exercises for the treatment of back pain have gone in and out of style.  Some decades ago, it was very fashionable in the world of medicine and physical therapy to promote the use of something called Williams’ Flexion Exercises (this involved folding the front of your body).  That worked for a small number of people, but for most people, it didn’t, and for some people, it worsened their condition.  Later the opposite idea took hold with McKenzie Extension Exercises (these involved bending backwards to wake up the back muscles and activate them more).  These exercises met with similar results: they worked for some people and they made some people worse.

The key insight: How we perform exercises is more critical than which ones we do.

No exercise, trendy or not, will be useful if you can’t feel what you are doing. Imagine you were told to walk in order to strengthen your back. You can walk around like you do everyday, but that won't improve the condition of your back; it will just strengthen your old habits of arranging your body in painful ways.  But if you sense what your back or body might be communicating-- "I'm holding my breath anticipating pain with each step" or "I'm not swinging my arms"-- you can begin to adjust the way you organize your body to move. You need to be attuned to the sensory information from your muscles and your joints, in exercise and in daily life.

A person who uses a lot of their back muscles while sitting and even more when moving may first receive signals from the back to the brain saying, “I feel tight, but I don’t hurt yet” and then “Now I hurt, but only a little ache.”  If those the messages from your back are ignored, if you don’t sense the amount of effort in your muscular use of yourself, your back will eventually signal, “Now I really hurt so badly that I am not going to let you move without pain.”

The best approach to back care is to provide as much sensory information as possible so the person can detect and change, for themselves, how much effort are they putting into their muscles when they move or rest.

Take, for example, sitting.

Electromyography (a measure of how much you are activating your muscles) has shown that some people at rest in a sitting position use only 2% of the muscle fibers in their back while others use up to 15%.  These people can go to workshops or meditation retreats for days—sometimes sitting in difficult positions, but experience no pain after a week of meditating.  Other folks drop out of these programs after the first day because of the pain in their back brought on by sitting.  

Once you start to move, there is no option but to use more of your muscles.  But how much more? or how little more do you need to accomplish your desired activity with ease?

My goal in working with people to deal with their back pain is to educate them to better sense their backs.

I’ve worked with many clients suffering from serious back problems.  I try to help clients sense whole new ways of moving while learning how to decrease effort with every movement. Rather than trying to relieve the pain, my approach has been to give them a heightened sense of the shape of their spine, the textures of their muscles, a clear feeling for how the spine is involved in movements of their body.  This may require first touching and moving the client in such a way that the person can feel the details of the shape of their back and the amount of effort their muscles habitually use.  

Very often, their back pain would disappear.  They would react with surprise at the results:  “But you didn’t do anything,” “I felt my bones and muscles so clearly,” or “I can’t figure out how the exercises you gave me would help, because they were so simple.  No hard stretching, no repetitive movements to strengthen muscles…but I feel so much better.”

I try to give another voice for the back to signal the brain with non-pain related messages like, “I feel myself more. I even feel good. I thought I needed to stretch and pull my muscles but now I know how to release excess tension because now I recognize it.”

The secret ingredient to dealing with back pain is to learn how to recognize and sense your back more thoroughly.  Without that, there’s not much you or any therapy can do on a lasting basis.

-Frank Wildman, PhD