Hey readers! Welcome back! I’m so happy you are here. Today’s blog post is part II of my “Yoga for Low Back Pain” series. In the current installment, I will go over general information about chronic low back pain (CLBP) and pain in general, common causes for CLBP, and potential implications of CLBP. If you have not read part I of this series, I highly recommend that you go back and read that part first (click here). In part I, I went over the anatomy of the low back area, and while that information is a little dense, it is super helpful for conceptualizing CLBP.
Chronic low back pain (CLBP) is the most common cause of chronic pain and the leading cause of disability in the U.S. Globally, it is estimated that about 23% of the world’s population experiences CLBP. Y’all – that is almost ¼ of the entire human species. That is a lot of people! Sadly, CLBP is also becoming more common in both children and adolescents. Thus, CLBP is no joke. It is a real issue, costing a lot of money and affecting many human beings.
There is a difference between chronic LBP and acute LBP. Acute LBP lasts a few days to a few weeks, and it typically resolves on its own with self-care and usually no loss of function. CLBP, on the other hand, is defined as pain that lasts for 3 months or longer, usually with a loss of function. Individuals with CLBP may experience pain in the low back, lumbosacral, and/or sacroiliac regions. Unfortunately, CLBP is very persistent and has a high rate of incomplete resolution.
There is a huge variation in how CLBP symptoms present, and it really is individual-specific. The pain may be mild and somewhat annoying, or it can be severe and debilitating. The pain can start suddenly or slowly, it might come and go, and/or it can gradually get worse over time. The pain may feel dull or achy, contained in the low back. It might also be experienced as a stinging or burning sensation that moves from the low back to the backs of the thighs, sometimes even into the lower legs and feet. CLBP can also include numbness or tingling (sciatica), muscle spasms, and/or tightness in the low back and/or hips. An individual with CLBP may notice that the pain worsens after prolonged sitting or standing, or when changing position, such as in walking or moving from standing to sitting (and vice versa).
There are several ways CLBP is currently treated, including: surgery, steroid injections, pain reducing medicines, and education. Many people with CLBP seek out these options, but continue to experience pain, disability, and functional limitations. Thus, there has been increased interest in recent years for treatments that target improving the musculoskeletal system in general, including physical therapy, yoga, and other forms of physical exercise. It has been documented many times that yoga helps to help alleviate CLBP (more on this in part III of this series), and it may be a more cost-effective way to manage CLBP, particularly for individuals who cannot afford expensive medical care. Even though yoga studios can be too pricey for some people, there are so many free yoga videos on the internet and social media.
Overview of Pain Processing
The neurobiology of pain is complex, and the perception of pain can vary widely between, and within, individuals. The pain process begins at the cellular level in millions of nerve cells scattered throughout the body, known as nociceptors. When any of these neurons detect something that might cause the body harm, they transmit electrical impulses to the spinal cord. If the signal is strong enough, it opens a biochemical “pain gate,” allowing the signal to pass up into the brain, where the actual conscious experience of pain occurs. If the signal is too weak, the “pain gate” doesn’t open and the individual will likely not feel any pain.
If a pain signal does reach the level of the brain, your brain’s job is to assess the potential threat by analyzing where the pain is coming from and the potential damage and then compare that information with memories of similar scenarios and beliefs/thoughts/expectations currently held by the individual. Thus, your memories, beliefs, thoughts, and expectations can either intensify, or dampen, the transmission of incoming pain signals. Based on all of this information, your brain then sends signals, via the spinal cord, to the bodily area in question about how to proceed next.
There are ways that the conscious experience of pain can be altered. For example, pain signals can be dampened by the experience of doing something you enjoy. When you are doing a preferred activity, your brain typically releases “happy hormones,” such as endorphins, endocannabinoids, and serotonin, which can actually counteract the danger signals in the spinal cord, effectively closing the pain gate. Studies have also shown that thoughts and emotions strongly influence the perception of pain – with positive thoughts like joy and love “closing” the gate and dampening pain signals, and negative emotions like anger and fear “opening” the gate and heightening pain signals.
There is a lot of evidence that shows that patients with chronic pain may have anatomical alterations in the brain, including reductions in both the grey matter (i.e. where neuronal cell bodies are located) and white matter tracts (i.e. where neuronal axons are located). The good news is that several studies have shown that when a painful condition, such as low back pain, is eliminated, these brain matter reductions can be reversed, so that the affected brain regions become normal in size/density again.
Potential Causes and Risk Factors for CLBP
CLBP is incredibly complex and can be caused by a wide variety of factors. In general, CLBP is categorized as mechanical (sometimes referred to as “nonspecific”), radicular, or nonmechanical. Mechanical pain is the most common cause of CLBP, and it arises intrinsically from the spine, intervertebral discs, or the surrounding soft tissues (ligaments, tendons, muscles, fascia). Mechanical CLBP is typically localized to the low back, buttocks, and sometimes the tops of the legs. The symptoms of mechanical back pain often change based on the motion, activity, or position of the body. Radicular back pain, on the other hand, occurs if a spinal nerve root becomes impinged or inflamed. Radicular pain may radiate down the leg with a sharp, electric, burning-type sensation and can sometimes be accompanied by numbness or weakness. It is usually felt on only one side of the body. Finally, nonmechanical CLBP is usually due to a systemic disease and can be accompanied by other “red flags” such as: motor or sensory loss; issues with urinating or defecating; history of cancer; recent invasive spinal procedure; and significant trauma. In this blog series, I will mostly be discussing and reviewing yoga as it pertains to mechanical CLBP.
So, what are some causes for mechanical low back pain? Well, my goodness the list is rather long. Mechanical LBP can result from:
Irregularities of the vertebral column, such as scoliosis, lordosis, kyphosis
Sprains (overstretched or torn ligaments)
Strains (tears in tendons or muscle)
Spasms (sudden contraction of a muscle or group of muscles – spasms in the QL are common in CLBP)
Traumatic injuries, as in sports, car accidents, and falls
Degenerative problems, such as disc degeneration, arthritis, osteoporosis
Herniated/ruptured discs
Muscle imbalances, such as over- or underactive muscles and poor static or dynamic posture
Spinal instability, usually as a result of a weak core
Decreased mobility and sedentary lifestyle
Being overweight or obese
Advancing age
Smoking
Repetitive trauma or overuse
It is estimated that about 65-70% of CLBP cases are attributed to muscle strain or ligament injuries, and small percentage (about 5-15%) of cases are due to degenerative joints and intervertebral disc issues.
Musculoskeletal Correlates for CLBP
The low back responds to practically everything else happening in the body above and below it, but it is especially influenced by the biomechanics of the core and hips. If your core and/or hip muscles are imbalanced, weak, or demonstrate delayed/altered activation, the vertebrae of your lumbar spine can get pushed and pulled until injury happens to the lumbar ligaments, muscles, or the spinal discs themselves. If the natural lordotic curve of the lumbar spine is not maintained as a result of these muscle imbalances, it can negatively affect the way that forces are transmitted across, to, and from the low back. Thus, while I will only go over a few correlations between low back muscles and the low back, please know that a muscle imbalance or issue anywhere in the body can negatively impact the low back area.
Core weakness has been increasingly recognized as a biomechanical deficit in patients with CLBP. Specifically, individuals with CLBP have been shown to have decreased activation, strength, coordination, and/or recruitment of the deeper core stabilizing muscles, such as the Tranverse Abdominis, Internal Obliques, and Multifidi. Several studies have also shown that strong core muscles are important both for proper posture AND prevention of low back injury. If the core muscles are weak, the spine may not be stabilized sufficiently, causing the low back vertebrae to get out of alignment. Also, other muscles may have to compensate to do the job of the weak core muscles, potentially causing musculoskeletal injury to those helper muscles.
It’s also been documented that individuals with CLBP demonstrate reduced activation, strength, size, and recruitment of the Gluteus Maximus and Gluteus Medius muscles. These muscles are really important for hip extension, such as when rising to standing from sitting, and hip abduction, such as when reaching one leg out to the side when getting in/out of your car. The gluteal muscles are prone to becoming weakened for most people based on our sedentary culture. I wrote an entire blog series about the gluteal muscles, so you can check that out if you are interested (click here). But in general, when the gluteal muscles are too weak to perform their jobs, the low back muscles often have to take up the slack (i.e. compensate) to achieve the motor pattern requested by the nervous system. Muscle compensation is not a good thing because it leads to incorrect recruitment of muscles for functional movements, AND it can pull joints out of alignment causing injury or pain.
The tone, or tension, of the hamstrings and psoas muscles can negatively impact the biomechanics of the low back, but in opposite ways. If your hamstring muscles are too tight, they can tug on the hip bones, pulling them down and back, creating a posterior pelvic tilt. This in turn pulls on the muscles of your low back, potentially reducing, or flattening, the natural lordotic curve of the lumbar spine. Conversely, if the psoas become too tight (which is common for many people because of chronic sitting), it can pull the lumbar spine forward and down, toward the lower abdomen, creating an anterior pelvic tilt. This can exaggerate the natural lordosis of the lumbar spine. If natural lumbar lordosis is not maintained because it is hypolordotic (i.e. too little lordosis) or hyperlordotic (i.e. too much lordosis), it can have ripple effect on the entire body, but especially on nearby areas (e.g. upper back, hips, etc.). For example, if your low back is out of balance, your body will adjust to “balance” around it. Your thoracic spine can become hyper-kyphotic, and the neck gets in on the act too, by overarching forward and bringing your head with it. This can result in muscle imbalance in the ribs, chest, shoulders, neck, and head, contributing to headaches, migraines, etc.
The tone/tension of the diaphragm can also affect the low back area since it has attachments sites in the lumbar spine. Studies have shown that lower activity of the diaphragm muscle (often caused by repeatedly using a shallow breath pattern, known as clavicular breathing - click here to read more about breathing) is associated with CLBP. Also, diaphragm fatigue, sometimes observed when deconditioned individuals engage in physical activity, can lead to reduced stability in the lumbar spine, potentially causing pain.
Potential Implications of CLBP
CLBP can lead to other issues in the body and mind. First, as discussed above in the section on pain science, those with chronic pain, such as LBP, can have reductions in the density of the neural tissue of the brain. Second, people who experience CLBP have a higher risk for anxiety, depression, and reduced quality of life (QOL). Often, the reduced QOL is the result of functional limitations that limit participation in activities of daily living (ADLs; e.g. cleaning the house, driving kids around, etc.). Third, CLBP can cause injury or pain elsewhere in the body, especially in the thoracic and cervical spine, shoulder, wrist, and hips, essentially putting the entire body in an uncomfortable and misaligned posture. Fourth, individuals with CLBP experience a lot of fear about the possibility of reaggravating the symptoms, leading to reduced participation in daily movement activities, such as ADLs and physical exercise. And this becomes a vicious cycle of more inactivity - e.g. "I am afraid it will hurt to exercise, so I don't." But this leads to deconditioning and eventually more pain and discomfort, causing the individual to abstain from physical activity even more. Lastly, individuals with CLBP are significantly more likely to sustain additional low back injuries. In fact, this is true for almost any injury to the body – once you injure an area, it is highly more likely to get reinjured. However, that is NOT a reason to avoid physical exercise and daily movement. Rather, if you experience CLBP, mindful movement is essential to reduce your pain and the damaging neurological effects therein.
Summary
Thank you so much for hanging on with me until the end of this post. As this post describes, CLBP is very complex, with many possible causes and consequences. Pain in general is detected by nociceptors scattered throughout the body. The nociceptors relay this information to the spinal cord, and if the pain signal is large enough, the spinal cord sends the signal up to the brain for further processing. Once the pain signal reaches the brain, various brain areas integrate the pain signal with your beliefs, attitude, and past experiences to determine the best possible outcome for you. On the other hand, if the pain signal reaching the spinal cord is too weak, it likely will not be transmitted to the brain, and the person will likely not experience the sensation of pain. It is important to note that a positive attitude and feelings of joy and happiness can actually dampen the intensity of a pain signal, while a negative attitude and feelings of anger or sadness can actually amplify the intensity of the pain signal. Mechanical CLBP can be caused by a myriad of variables, and it is often associated with issues in the musculoskeletal system, such as core weakness, limited diaphragm mobility, and muscle imbalances in the hips and thighs. CLBP can also lead to several negative consequences on a person's daily functioning, but this functioning can often be restored when the pain resolves. Part III of this series will go over some of the research that shows how beneficial yoga is for reducing the symptoms of CLBP. Thank you so much for reading this post!
As always, the information presented in this blog post is derived from my own study of neuroscience, human movement, anatomy, and yoga. If you have specific questions about your low back, please consult with your physician, physical therapist, personal trainer, or private yoga teacher. If you are interested in private yoga and/or personal training sessions with me, Jackie, email me at info@lotusyogisbyjackie.com for more information about my services. Also, please subscribe to my website so you can receive my weekly newsletters (scroll to the bottom of the page where you can submit your email address). This will help keep you "in-the-know" about my latest blog releases and other helpful yoga and wellness information. Thanks for reading!
~Namaste, Jackie Allen, M.S., M.Ed., CCC-SLP, RYT-200, RCYT, NASM-CPT
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