Chronic back pain and why physical therapy doesn’t always work

Back pain, who hasn’t had that? You might say “I haven’t” — well, just wait. This article is mostly meant for people who want to get insight into fixing their chronic back pain or preventing it from ever happening.

Back pain is like a million-billion dollar question in medical industry, anyone who could find an universal cure for it should earn at least that much, if not more. Wait? What’s so complicated about it? Don’t we just go to a specialist, like a physiotherapist, they give a nice massage, show some exercises and we’re well on our way to getting great again. If that were true, why does pain persist in so many despite treatment. First, let me tell you a short story..

Story time

You wake up in the morning, feeling somewhat stiff in your lower back but as you move around, the stiffness fades away and you go on with your life. It has been so already few weeks, sometimes comes and sometimes not. At one point you need to lift grandma’s furniture around and suddenly there’s a fairly loud pop in your back and your back stiffens all up. You panic and say “f***!! Oh gosh, damn, I pulled my back”. So eventually, you put a time to a doctor. They look at you and say “Well, your posture is not that good! You need to sit straight and not lift heavy items.” They order a x-ray. You’re worried and waiting. Next day the results come back and it’s all good! Nothing wrong with your back — according to the report. Well, the back is still hurting. You wait a week, try to stretch it to make it feel bit better but it’s still there. Doctor recommends you to go to a physical therapist. You do as requested and the physiotherapist teaches you some exercises to improve your spine’s stability. You keep doing them but your annoying pain still persists and sometimes even goes worse. “Maybe I’m doing the exercises wrongly or not enough or perhaps too much??”. Months go past with exercises, stretches and mobility work but not much success to show. Finally, you decide to go for testing to get an MRI of your back. After a while, it comes back and tells that you got a bulging disc! Now you’re really frustrated, thinking about that furniture that ruined your back and perhaps your life. Doctor tells that it’s all not that bad but you need to go to a surgeon to get it fixed.

Let’s take a look at this story

Doesn’t this sound like a standard solution to combating back pain? Patient didn’t even go to less mainstream methods like acupuncture. So firstly, why isn’t that person getting better despite physical therapy, is he not doing the exercises properly? His back is still “unstable” or not strong enough? Let’s go through the story again but in detail. Firstly, back pain is an incredibly complex issue and there’s often not much certainty in the treatment and much less in the exact cause. The patient, of course, thinks that the back pain started with lifting but in reality that rarely the case. We’ll come back to that later. Many doctors and also physiotherapist still till nowadays think that posture is causing back pain. Just because posture is a fairly easy thing to assess, doesn’t mean it’s absolutely related to back pain. I mean it could but it might just as well be not, there’s no certain correlation.

MRI shows a bulging disc, so what?

Second thing what doctors do, is order testing, like x-ray and MRI. Now these are more like elimination checks but they CANNOT diagnose back pain alone. Many people want these, so they could “finally” know the answer to their back pain just to find out they were probably the most useless things. Unless your herniated disc is pressing on spinal cord (or on a foramen), in which case it would likely be causing myelopathy symptoms and a specialist would know it without any imaging. Just to make things “worse”, majority of the people are walking around with a disc issue, eg: bulging disc, degenerative disc disease (not a disease, actually) etc. What’s most improtant is that, a lot of them don’t got any symptoms. There’s been a test done with doctors: they were shown imaging results of people’s spines to guess who have back pain and who don’t. Their guesses were, well, wrong. It used to be that surgery was a popular choice of “fix” after a “scary” find on imaging but luckily, this is finally changing. MRIs are prone to pick-up false positives which get painted as the reason for back pain, while they’re completely unrelated to the actual source of pain. Also, this can create an additional nocebo effect on the patient. Sometimes MRI results are also misread, so if there are actual more serious signs, like aforementioned myelopathy, MRI results should be reviewed with another specialist to confirm radiologist’s findings.

Some doctors might recommend bed rest, which is generally a bad strategy. It might sound logicaly to “rest” after an injury but it’s been shown, that movement is still adventagous and long bed rest is definitely obsolete. It doesn’t mean that some bed rest couldn’t be used but a patient should not stay in bed for many days. Why is that? Muscle atrophy? Yes and no, will address that soon.

Physical therapy to the rescue

So to combat muscle atrophy, we do what? Yes-yes, physical therapy! Physical therapy has been praised by research quite somewhat and it seems to be effective to quite a good level. So why does it even fail? Maybe we should first ask why does it succeed? Hey, that’s obvious, it’s because your muscles get stronger! Hold on tiger! I can already romanian deadlift 100kg with my “broken back” but I still got back pain, when I’m not even lifting!? It just doesn’t make sense. Many people, who barely can lift heavy weights, don’t got back pain. So, why don’t they? How does a person with a stronger musculature have back pain while weaker doesn’t? Now the tides change. Pain, is not really related to muscle strength. It’s just not that simple. Especially chronic (low) back pain, with its myraid of reasons, tends to need a complex solution. Sadly, even famous physiotherapists still think that skeletomuscular pain is always related to a mechanical cause. Really? So what physical “cause” causes skeletomuscular pain in fibromyalgia patients??

If it’s not the disc, what causes chronic back pain?

Lately, there has been a move away from physical model of back pain. We’re not only speaking about blown discs, spondylolisthesis or any other possible physical back pain cause. Back pain can be mental. Yes, you read that right. There might be nothing “physically” wrong with your back but with your thoughts. Ever wonder why placebo effect gets (back) pain better? Why a random massage or acupuncture fixes back pain? It feels good! Hey, it can’t be that simple…oh yeah? Why not? Dr John Sarno was one of the first to popularize the idea, that the pain is caused by the mind. While the mainstream medical world back then of course ignored him, its finally starting to catch up. More and more it is understood, that factors like stress, anxiety, loneliness, aimlessness, poor diet can cause or contribute to back pain. Basically it’s like scale, if life stress gets heavier than your capability to handle and recover from it, pain appears. Just like a weightlifter, who tries to snatch 100kg every day will exhaust muscles, tendons and nervous system till pain arrives. Coming back to physical therapy and this is purely my opinion, I do not believe that physical therapy just “fixes” chronic back pain because it strengthens your spinal erectors or that doing McGill big 3 stabilizes your back but it likely gives you a mental confidence, that your back is fine and it calms your brain to stop signalling pain. Sometimes physical therapy is not enough, likely a stress trigger has not been removed. Eg: stressful your work might be causing your back pain.

The ultimate back pain fix strategy

Firstly, there’s no one single magic pill, you gotta try out stuff to see what works for you.

If your back pain didn’t got better by itself and there’s no obvious cause (it’s, as they call it, “unspecific back pain”), then you should try the following things.

Try to reduce chronic stress and negative thoughts in your life, this is extremly important in beating chronic pain. This is also often completely overlooked by physical therapists, chiropractors. The main thing is just to enjoy, think positively, not to overly worry. Limit negative news, people etc. Eat healthily, try to remove sugars from your diet as they’re linked to increased stress and anxiety. Going keto/intermittent fasting might a good thing to try. Give Wim Hof method a try, it can improve your stress tolerance. Also slow meditation might help you feel relaxed. If you’re feeling lonely, join some activity group or try to meet with friends more often. Also, an illness might be causing your back pain, so curing it might also fix the back pain. Dr John E. Sarno works are worth looking into.

Training (physical therapy) is definitely something to do, IF you enjoy it. If you hate it, don’t do it. It’s likely not going to help you then, unless you change your mentality about it. Other passive treatments like chiropractic, massage, dry needling might help you, emphasis is on word “might”. Most importantly, if you feel your stress lowers and you feel more joyful inside, keep doing it.

As you can see, chronic back pain should be addressed with multiple tools. I believe that stress and anxiety might be one of the main culprits of non-specific chronic back pain.

Closing thoughts

Cycles

The negative cycle — if you get injured and don’t get better fairly fast, you get stressed. Chronic stress weighs you down. You don’t want to go outside anymore, then you start to feel more lonely. You also avoid movement as you might get “hurt even more”. And down and down the rabbit hole goes.

The positive cycle — resurrection, you realize you will get better, you start to believe that. You go out with your friends, which lifts up your mood. Now you slowly start to train again and see your spine is not that “fragile”. The more you do it the better you feel and the less pain you got. Less pain boosts your mood even more. Eventually, your pain disappears.

Disclaimer

It’s bla-bla not medical advice, as if actual medical advice would be any better but whatever! Obviously there is much more detail into back pain! I didn’t even cover compression/flexion/extension/rotation intolerence or red flags testing what a PT/doctor should test.

Goal revisited

I just wanted to give an overview of an overlooked aspect to chronic back pain and its possible fixes, which is not always PT. Also add some common mishaps by medical professionals.