What Can You Do When You “Throw Your Back Out”? Applying Pain Science in the Real World

This is a repost of a Facebook post I put up last week. It garnered some very positive feedback on a few fronts, and given the length of it, I figured it’d be worth putting together as a more formal blog, including a few minor edits to tidy it up for better reading, along with some additional references.
Plus, with my writing on here currently at a virtual standstill thanks to new gym owner life at Melbourne Strength & Conditioning and all the time demands that brings, I’ll take any excuse to get a blog post up at the moment.

A little proviso in case you abandon this read before I again highlight this point at the end: I’m not a physiotherapist. I am not qualified to diagnose to treat or to diagnose pain or injury.
A big part of my job however, is to be able to find ways to train our members around pain, and as such, I stay reasonably abreast of the current evidence and trends with pain science and rehabilitation by networking with and learning from excellent medical professionals.

So without further ado, here’s my little “I fucked up my back” story.

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A little n=1 anecdote on back pain, pain science, and the like:
Yesterday I managed to put my back into spasm.

“Spasm”, to clear up any confusion, is when the surrounding musculature suddenly and involuntarily tenses up severely in a protective response, the result being that most movement becomes extremely difficult and painful.

It’s the first time it’s happened to me in years.

Several years ago I would have back issues and go into spasm way too frequently, particularly with BJJ/MMA, and whatever crappy strength training I was doing back then…which included Crossfit (sigh).
The initial rehab advice I received back then was entirely unhelpful, too (cupping, anyone?!).

This time, it happened when I lifted something like an asshole. Entirely my fault, as I know better.

I was moving a 64kg kettlebell from an awkward position, and got lazy with it. Now, 64kg is far from what I’d consider heavy, but it’s enough to warrant paying at least a little attention to my form, especially when adding a few other factors in:

– I lifted it with one hand. Nothing I haven’t done a thousand times before with complete comfort, but obviously one hand increases the risk compared to two hands.

– Because I was being lazy, I reached over two other kettlebells and supported myself against the wall, rather than getting my feet closer to the ‘bell I was lifting. Again, nothing I haven’t done tons before as it’s not a weight I would typically give much thought to, but it still increases the risk.

– I’m weaker in general right now than probably any time in the past five years, and haven’t been deadlifting very regularly.
Basically, thanks to the joys of new gym ownership, my own training sucks right now.
So less frequency of regular lifting makes the stimulus more novel, increasing risk further.
Plus, my max strength is down a little, which in turn means my relative submaximal strength is down. I’ve effectively decreased one element of my “physiological buffer zone“, to pinch a term from Patrick Ward.
I.e., more increased risk.

– And finally, a big one, I was about six hours into my work shift, coming off less than four hours of sleep, and no more than five hours of sleep for a few nights in a row.
I’m not sure exactly what the evidence looks like for the relationship between sleep and injury, but I’d bet my left nut that we could show a pretty good correlation between increased sleep deprivation and increased injury risk and pain sensitivity.

So all of these little factors, while very minor in and of themselves, added up enough to increase the risk of injury to the point of it actually occurring.

So what did I do?

Well first, here’s what I didn’t do:

– I didn’t freak out.

– I didn’t start thinking that my back was “out”. (I’m not sure what that’s even supposed to mean, but I imagine people who use this phrase think their spine has somehow moved “out of place”. It hasn’t.)

– I didn’t start thinking about a bulging or herniated disc, or a “slipped” disc (there’s no such thing), or that I should get any imaging done to check for such.
I’ve never had an MRI for my back before, but what would it show anyway? A disc bulge or three? Maybe even a full herniation? Oh well. So what? What would that tell me? How would we know that had anything to do with my acute pain right now?
For the first two thirds of my life, I participated in all manner of sports that included contact and twisting and bending , and then spent the last half of my life lifting (reasonably) heavy things.
Frankly I’d be surprised if any imaging didn’t show some discogenic abnormalities. The correlation with disc pathology and pain is poor(1,2) so any imaging might provide nothing but a red herring. There’s a time and place for imaging, but it’s very unlikely that this is it.
(I’ve had my back x-rayed before, and was told by the chiro I was seeing way back then that I had “degeneration” in my spine. Well, of course I did. That’s a product of being alive for a while (1)).

– I didn’t start catastrophizing, thinking about worst case scenario: Not being able to work/sleep/train/fuck properly for a long time. I knew it’d be a passing incident that will likely improve rapidly, and probably subside completely in a matter of days.

– I didn’t chastise myself for not doing enough “core” work, or mobility work, or whatever else. Nor did I jump to the conclusion that I obviously need to do more in the future.

– Basically, I didn’t think about anything in terms of *damage*.
I’m well versed enough in this area to be aware that my body had just gone into a state of protection because of a perceived threat (The muscle spasms will stop me moving at the spine too much for now, and the feeling of pain will stop me from doing anything else that my brain has decided it doesn’t want me to do. Again, protection, not damage).

What I did do:

– I assessed the situation. What movements increase the pain and spasming? In my case, it was pretty much just flexion (“rounding” the lower back, or bending forward in a relaxed manner, for the non-fitpro following along).
So step one, avoid that spinal flexion for the immediate future. Think about where this will affect me – picking things up, putting shoes and socks on/off, sitting at my desk/in the car with a slumped posture, bending over the basin to clean my teeth, demonstrating grappling technique with my clients when we’re really supposed to be training, etc. So be extra careful in performing those actions for a little while, to avoid a flare up.

– More assessment. Where can I find relief? In my case, as expected, in extension. So my posture naturally adapted to a hyperextended one for a while. When I did need to bend forward, I’d use a hyper-strict technique, arching hard through my lower back. Spending time arching over a foam roller. Spending time in a cobra pose (lying prone, and pressing the top half of my body up to arch my back).
I did these in frequent short bouts, because I knew that regular, pain-free movement was going to be key in my recovery.

– Some focused, deep breathing from a comfortable position on my back.
It’s one thing to tell yourself to be calm, but physiologically, breathing – especially focusing on long exhalations – can certainly help decrease sympathetic tone (the stress response, basically).

– Not be a moron. I had to get my client to load his own plates for the rest of session, and had my MSC co-owner, Sia, loading anything heavy and doing all the demonstrations during our group sessions this morning (my coaching was all verbal today!).

– Popped a couple of Voltaren. Not some “natural” hippy-dippy bullshit anti-inflammatories. The real stuff. The stuff that you actually have to take with food, and that might give you stomach ulcers if you take it too much and for too long. That’s the shit I want.

– Bit by bit, I started to increase my movements. Walking more. Taking gradually longer, less protective strides. Moving my arms around more. Rotating more. Hip hinging more, and even eventually letting myself go into a little bit of flexion.
This is part of the process I know as “graded exposure“. Basically, feeding the body some of the previously painful movements bit by bit. Kind of letting the brain know that we’re chill, it’s ok to move, so we can lower that threat response now.

The result:

– Within the first few hours, the total area of spasm had localised down to just a specific spot in my lower back, whereas it had been really my entire low back and sides initially.

– I found enough comfortable positions in bed that I actually got a really good sleep.

– By this morning, the feeling of having a knife in my spine was gone for the most part, except when I occasionally pushed a little too far, too fast.

– I had moments during this morning’s sessions where I even briefly forgot about my back altogether. Briefly.

– By now, a little over 24 hours later, my pain is down significantly and my movement capability has increased dramatically. The pain and general protective tightness is still there, but I’ve got a much larger range of movement before it threatens to spasm again.

– I’ll probably pop the Voltaren one more time, and that’ll be it.

– I expect that this improvement will continue, and that by Monday or Tuesday it’ll be virtually unnoticeable unless I do something like a heavy deadlift, which I expect to be able to do within about a week. So we’ll see.
(Update: I’m at 6 days at the time of this repost, and this prediction has been pretty much on point).
If for some reason it doesn’t continue to improve like this, or especially if it was to get worse again, then I’d definitely get myself to a physio to ensure that nothing more sinister is going on. But I’m pretty confident I’m safe.

Anecdote over

This is just my experience. It’s not necessarily intended as advice to anyone else. Though, I think a fair bit of it could be taken as such and be useful for many – especially the “what I didn’t do” section – the next time they unfortunately do something that they’d probably describe as their “back going out”.

I don’t think any good physio would have any major concerns with my overall approach here, and for the most part would probably encourage a lot of it.

Take from this what you wish.

References:

1. Brinjikji et al. 2014 “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations” AJNR Am J Neuroradiol. 36(4): 811–816.

2. Jensen et al. 1994 “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain” N Engl J Med 1994; 331:69-73. 

Thoughts, questions, hate mail, or anything I missed? Feel free to drop a comment below. And of course, sharing this article will naturally help you jump the queue in your wait for karmic justice to start paying out.

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