Understanding Back Pain and other Chronic Pain Syndromes

My series of posts on chronic back pain and joint pain have been some of my most popular posts, and I’ve had lots of positive feedback from clients and readers who have followed the guidelines I outlined with great success.

Over the last year or so however, I’ve been doing a lot of reading and research into chronic pain, back issues and joint problems, and feel the need to revise much of what I wrote in those original articles.

My actual advice as to what to do if you are suffering from chronic back pain or knee pain actually remains pretty much unchanged – the lifestyle changes and exercises do seem to be effective: just not perhaps for the exact reasons I thought they were!

Before I get into the article though, I’ve just got to give a mention to four great sites which have been instrumental in making me totally change the way in which I think about, and approach, the treatment of chronic pain:

Chronic Pain: Is it all in your head?

To begin to understand back pain, one must first start to try and understand pain in general.

The fundamental concept which underpins my new thinking on the subject ofchronic pain is that “pain is an output of the brain”.

Now please understand, particularly if you’re currently in agonising and debilitating pain, that this is not my way of saying that it’s all in your head – at least not in the dismissive sense which the average overworked and under specialised GP might do. Neither is it meant to trivialise or belittle your condition.

Before I dive into the technicalities, here’s a little experiment you can perform on yourself:

First, take a 6 inch nail and hammer it into your hand (if you’re under 16, please seek adult supervision)

Now ask yourself, is the pain in your hand, or is it in your brain?

At this point you are probably fairly convinced it’s in your hand. It probably hurts a lot. Sorry, but bear with me, it won’t for much longer!

Next, take a chainsaw (if you don’t have one, a hacksaw or even pen knife will do), and cut off your arm (the one you just hammered the nail into).

Still feel the pain? Now I can’t guarantee you will, but it’s not uncommon for amputees to continue to feel pain in a limb which is no longer there! This well known phenomenon is known as “phantom limb pain”, it is well documented, and has been instrumental in helping shape modern thinking on pain.

To complete the experiment, cut off your head. I’m pretty confident you’ll no longer feel the pain.

OK, I know it’s not the most perfect experiment, as no one really knows if you can feel pain after death, it is a bit of an assumption. A better way would probably be to place a skewer through the relevant part of the brain, but I digress…

Pain is an Output of the Brain

The point of the above experiment is that pain, like all other sensations, emotions, and your experience of reality itself, is a creation of your own brain.

High Striker Image Courtosey of Wikipedia Commons

The picture to the left here depicts a sideshow sledge-hammer strength test – the one where the contestant has to hit the target with the hammer, sending a puck up the tower.

The harder the contestant hits the target, the higher the score registered on the scale.

There is a widely held belief that pain operates by a similar mechanism: there is a stimulus – stubbing your toe for example – which sends a signal travelling up the nerves to the brain, where it sets off an alarm bell. The stronger the stimulus, the greater the sensation of pain.

An ever growing body of research, however, is demonstrating that this is far from the case however.

Todd Hargrove provides a very nice and concise explanation here:

“Pain is defined as a conscious unpleasant experience designed to evoke a protective response…Although nociception is an input to the brain that often results in the output of pain, the brain considers many other inputs before deciding to create pain, some of which may be far more decisive than the level of nociception. In fact, nociception is neither sufficient nor necessary to create pain. In other words, you can have pain without nociception and nociception without pain”1.

Hargrove goes on to outline the four major inputs that feed into the brain which affect the resulting output:

  1. Interoception

Information relayed from “nociceptors” (high threshold nerve endings) which detect mechanical, thermal and chemical stimuli.

  1. Proprioception

Information from joints, muscles, tendons and skin about the bodies posture, position and movements.

  1. Exteroception

Information from the five senses – what you can see, hear, smell, taste and feel.

  1. Cognition

Knowledge, memory, belief, expectations, previous experiences, etc.

You more than likely actually know all this already. An example with which you are probably familiar is that of the dreaded paper cut: Chances are that at some point you have sliced open your finger, but not realised until you notice you were bleeding everywhere. It is only when you look at your hand, and see the deep gash in your flesh that all of a sudden your finger lights up with intense pain!

The mechanical stimulus – the actual cut in the finger itself – was there all along. The output of pain, however, was not generated until the visual input of seeing the blood, and the cognitive input of thinking “agggghhhhhr, I’m bleeding, this is bad, someone call an ambulance, mummy!” are added into the mix.

Pain is just one of many possible outputs the brain can generate in order to produce a change in behaviour intended to protect the body from (perceived) danger – other outcomes could be inflammation, a change in movement pattern (i.e. limping), or stiffness around a joint to restrict movement.

Hitting the Chronic

There are various definitions of chronic pain, ranging from pain which has persisted for more than 6 weeks, through to more than 12 months, with 3 and 6 months also being popular cut off points!

Personally, the definition which I prefer is that of “pain which persists for longer than the expected healing time“.

Just as with acute pain, chronic pain is also an output of the brain.

In the case of acute pain, interoception (i.e. some actual physical trauma) is usually (though not always) a significant input. In other words it is rare that one will suddenly experience pain out of the blue without any direct stimulation of the nociceptors.

Current research indicates however, that chronic pain is different, and that often there may be little or no actual stimulation at the nociceptors from any physical trauma, yet the sensation of pain is generated by the brain anyway!

Understanding that interoception is only one of 4 inputs which feed into the output of pain, it is easy to see how this scenario could occur:

While performing a specific movement – say lifting a heavy box at work – an individual causes a small trauma to the tissue in the lower back.

This mechanical trauma sends an interoceptive input to the brain. This information is then processed along with other inputs such as proprioceptive feedback (the lumbar is not in lordosis, perceived as a vulnerable position), exteroceptive feedback (the look of horror on your colleagues faces and the sound of something going ping in your back) and cognitive processing (preconceived ideas about the seriousness of back pain and the dangers of heavy lifting with bad technique).

All these inputs are processed within a split second, at an unconscious level. At the conscious level all that registers is that you were lifting a heavy box, when suddenly something went wrong in your lower back resulting in crippling pain.

The commonly held belief, is that once “the damage” (if indeed there actually is any!) is repaired, thus removing the interoceptive stimulus, the pain should go away, and the injured party should return to full, normal, healthy function.

In many, if not most cases, this is what happens. Unfortunately, however, not everyone is always so fortunate.

The problem is, that all these inputs feed back and forth into one another – i.e. the preconceived ideas about back pain, its causes and its seriousness are all reinforced by the sensation of pain they were complicit in generating.

Now each time this individual goes to pick something up, or just bends their spine in the same position, alarm bells start ringing and the brain may start to generate that output of pain again as it starts to perceive danger, even with no input from the nociceptors.

This situation is made worse by a phenomenon known as sensitisation where, yes, you’ve guessed it, the nociceptors become sensitised and take less and less stimulation in order to generate the same input.

I don’t want to delve into too much detail here, but what I did find particularly interesting was that the dreaded inflammation can be a major contributor to sensitisation. We know that bad diet, dysbiosis, infections and stress are all contributors to inflammation – could they also be having an impact on your chronic pain?

Imprecision is another related phenomenon, also exacerbated by inflammation, where adjacent nociceptors, or even those further afield, become activated along with, or instead of, those actually directly stimulated. This can result in what is often called referred pain, or in pain symptoms which seem to move around or cover a large area.

Common Back Pain Myths

So hopefully, now we have a little bit of a better understanding about what pain is, and what can lead to chronic back pain, or indeed chronic pain of any description. The next step is to look at what can be done to help it.

Before getting into this though, I thought it would be useful to dispel some common back pain myths, some of which I have been guilty of helping to perpetuate myself in the past!

  • Sitting Shortens the Hip Flexors

The story goes something like this: After 20 mins of sitting, a phenomenon known as creep begins to set in, where the shortened hip flexors begin to shrink. These shortened hip flexors register to the C.N.S as contracted, which prevents the glutes from contracting through a process known as reciprocal inhibition (where the contraction of a muscle on one side of a joint forces the relaxation of the muscle on the other side of the joint to allow smooth and fluid motion).

Lazy or inactive glutes which are intended to be the prime movers in actions such as hip extension, lead to the lower back muscles trying to take on more load than intended, thus resulting in pain and injury.

It all sounds great on paper, but is there actually any evidence to back this theory up?

Again, I have to point you back to another article by Todd Hargrove – reading this one was yet another “Doh!” [slap forehead with hand again] moment for me.

I had often pondered why if sitting, with hips flexed to 90 degrees is so bad, that squatting should be so much better, even though the hips are flexed to an even greater degree! A great example I guess of ignoring evidence which conflicts with an existing belief!

  • Posture

But of course bad posture causes back pain – everyone knows this! All you need to do is change your posture and you’ll be leaping around like a spring chicken again.

Hang on though – is there actually any evidence to back up this claim?

In his paper The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain Eyal Lederman’s research indicates that there is not. In his conclusion, Lederman argues that:

• PSB asymmetries and imperfections are normal variations—not a pathology.

• Neuromuscular and motor control variations are also normal.

• The body has surplus capacity to tolerate such variation without loss to normal function or development of symptomatic conditions.

• Pathomechanics do not determine symptomatology.

• There is no relationship between the pre-existing PSB factors and back pain.

• Correcting all PSB factors is not clinically attainable and is unlikely to change the future course of a lower back condition.

• This conclusion may well apply to many common musculoskeletal conditions elsewhere in the body (e.g., neck pain).2

This is not to say that there is no correlation between posture and back pain, or any other pain for that matter.

In one interesting Canadian study, researchers found a significant correlation between posture, lower back pain and personality type!3

The study size was relatively small, with only 100 people, but the results appear pretty robust – those with “ideal posture” were invariably extroverts and free from back pain.

People with “flat back posture” on the other hand were much more likely to be introverted, and suffer from CLBP.

This is fascinating, but unfortunately, doesn’t really have a great deal of practical application. Why? Because of course correlation does not imply causation!

While it is easy to jump to the conclusion that it is the “bad posture” causing the back pain, it could just as easily be the back pain causing the bad posture, or as we know that there is a large cognitive input involved in the output of pain, perhaps it is the personality type which is the driving force.

This is the advantage of the prospective studies (and larger sample sizes) which underpin Lederman’s post-structuralist position.

If you take a group of asymptomatic individuals, assess their posture, then follow them up at a later date in the future, those that had “bad posture” at the start will be no more likely to have developed back pain than those with “good posture”. Indeed, it could well be argued that much of what is considered as good and bad posture could in many cases actually be better attributed to anatomical differences.

That said, posture is not totally unconnected with pain. There have been studies that show that people in a dominant posture feel less pain than those in a submissive posture4. Assuming a dominant posture is a very different kettle of fish however than attempting to “fix” someone’s anterior pelvic tilt with some hip flexor stretches, bridges and core work.

  • Disc Damage/MRI Results

Your back hurts so you go to the doctors. He looks worried, sucks air through his teeth and shakes his head. This could be serious he says. He sends you for an MRI – a big scary noisy machine, all rather unsettling. After waiting for weeks for the results, they finally arrive, and the doctor regretfully tells you that your back is shot.

“Your vertebral discs have been squished and squashed so much, they have deteriorated to the state of an 80 year old’s. No wonder you’re in so much pain! Surgery is a possibility, but of course there could be side effects, and if it goes wrong you might be crippled forever”.

***DISCLAIMER*** I know this is a gross generalisation, so apologies if you’re a GP and take offence to this!

But hold on one second – what would happen if we were to take MRI’s of a cross section of people free from back pain?

A group of researchers did just that, and found that:

Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. With the results of the two readings averaged, 52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk…

…Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.5

In other words, once you get past a certain age, pretty much everyone has disc bulges and protrusions, and in many cases these cause no pain whatsoever.

Let’s go back to the hypothetical scenario of the individual putting their back out lifting a heavy object. They went to the doctors, got an MRI scan and get the standard Dr blurb above. They now have exteroceptive input that their back is damaged (they’ve seen the MRI and the model of the spine with the ruptured disc) and more negative cognitive input, all reinforcing the pain output.

Now perhaps the disc damage was caused by improper lifting technique, there’s a pretty fair chance however, that this person’s discs were damaged way before this incident, and they would simply never have known about it had they not experienced the pain and then gone looking for it.

An MRI is intended as a diagnostic tool to determine whether an individual suffering from back pain may benefit from a surgical procedure such as discectomy or laminectomy, however, there is very limited evidence that these interventions have any benefit6, and what little benefit they may have appears to be short lived, with patients undergoing surgery reporting less pain that those that don’t after a few months, but with the gap closing after 1-2 years7.

Is it possible that the more rapid improvement of symptoms from those undergoing surgery is actually down to new cognitive inputs – i.e. “my discs are now fixed, so I should have less pain”, rather than any change to interoceptive inputs – -i.e. quite possible the discs had been damaged long before the pain started and were completely unrelated?

It should also be noted that the non-operative treatments to which surgery was being compared were not exactly state of the art, evidence based interventions. They included chiropractic adjustment, acupuncture, magnets, orthotics, and all kinds of pseudo-scientific quackery. Factor in that much, if not most, of the physical therapy will have been based on trying to stretch people’s hip flexors, improve their posture and correct imbalances, and surgery is looking like it didn’t really pick a fair fight!

Considering the potential risks involved in surgery, the fact that in 1-2 years you’ll almost certainly be no better off than if you’d worshipped a crystal, and that simply seeing the MRI results might just make matters worse, my current feelings are that I would simply not go for an MRI scan!

The good news is that if you have had an MRI scan, and been told you have disc/nerve damage, you need no longer let this knowledge place any limitations on your ability to recover, and live a pain free life with full functionality.

If it ain’t broke, how do you fix it?

So back, joint and other chronic pain problems can be a far more complex issue than we may have once thought.

The old structuralist school of thought “there is something mechanically wrong with the body, we must fix this, in order that the pain will go away” appears to have significant flaws.

So what should one do to rid oneself of chronic pain? Is it as simple as telling yourself it’s all in the mind?

Perhaps in some circumstances, like the example in this video for instance, this change in the cognitive inputs alone might be enough to free someone from debilitating pain overnight – unfortunately I think the chances of this are likely to be very rare.

Mapping the Road to Recovery

Part of the route to recovery, appears to lie in the relatively new field of research into what is known as “body mapping”

Body Maps are what enable proprioception; that is the ability to sense the relative positions of your body parts in space. Each part of the body is mapped for by a different part of the brain, and it is these maps that enable us to coordinate our movements effectively and efficiently.

Where things get interesting is that these maps are not fixed or hardwired, but are constructed and continually refined and renewed based on new feedback supplied from special nerve endings called mechanoreceptors, of which we have millions dispersed throughout our entire body.

Mechanoreceptors work in a very similar way to nociceptors – if you rub an area affected by pain you will more than likely experience temporary relief – this is because the signals being transmitted to the brain are effectively competing for bandwidth.

We start to build these maps as a baby, exploring our bodies and finding out how to move and what is possible.

Each area of the body, has a different area of the brain devoted to its own individual map. The more we move, the better these body maps become, and the larger the brain area devoted to the relevant body parts and movement patterns.

A magician skilled in slight of hand, would have a relatively huge area of the brain devoted to mapping the hands for example, a keepy uppy expert to the feet.

Think of an an adventurer exploring and mapping out a jungle – the more time they spend in there making detailed maps as they go along, the more quickly and efficiently they’ll be able to navigate their way through again in the future.

The downside is, that these maps can also fade away if not used regularly or explored deeply.

Picture the intrepid adventurer returning to the jungle after many years of retirement spent relaxing in his comfy chair. The journey would be difficult, arduous and possibly dangerous (though no doubt he would still fair better than and individual who’d never travelled there before!)

Another interesting aside regarding body maps is that they can actually extend to include inanimate objects which an individual utilises regularly – such as a martial artist’s weapons or a tennis player’s racket – they literally become and extension of the body, at least as far as the brain is concerned!

You may recall from earlier, that proprioceptive information is one of the four areas of inputs which feed into the brain’s pain centres, so it should therefore be no surprise that body maps can have a significant effect on the resulting output of pain.

When it comes to acute pain – i.e. when the nociceptors are physically stimulated – better body maps can result in a greater output of pain, poorer body maps a lesser output. Under experimental conditions, such as the rubber hand illusion, the “forgotten” real hand can not only become less responsive to nociceptive pain inputs, but even exhibits less of an inflammatory response!

In other experiments however, looking at and focusing on a hand being exposed to extreme heat stimulus actually lowers the pain output, and using video to increase the size of the visual of the hand amplifies this effect8 – so perhaps it might be better to think of improved proprioception equating to a more accurate pain output?

One thing for sure is that individuals suffering from chronic pain, have less accurate body maps than those that don’t, being less able to visualise the area affected by pain, sense it’s position in space, or differentiate between one or two point stimuli without visual feedback9.

Of course, this is still only a correlation – it could be possible that it is the presence of chronic pain, that results in the loss of proprioception, just as it may cause bad posture – perhaps the body attempts to distance itself from the problem area in an attempt to numb the pain?

Pain is a Sign of Weakness?

James Steele II is another researcher looking into chronic lower back pain, and his talk on the subject at for the 21 Convention is well worth a watch.

In the talk, James debunks many of the common back pain myths highlighted above, but takes rather a different track in his approach to dealing with it.

In his research, James has identified a strong correlation between chronic lower back pain, and weakness in the muscles of the lower back.

Further to this, James has had great results in treating lower back pain through strengthening the lower back using a high intensity strength training protocol on a MedX Lumbar Extension machine10.

It should be noted, that in the talk, James does acknowledge that although the results from the training group are fantastic, particularly in comparison to the control, equally good results can appear to be achieved through through things such as “general exercise” or salsa dancing!

James argues that the advantage of a HIT strength training routine on the MedX is that it is much easier to measure and quantify progress. While I may disagree that the ability to measure something automatically makes it a better approach, I must concede it appears to be a highly efficient and effective treatment.

Could it again be a correlation confusion however? Proprioception is essential for strength, as the ability to generate force with the muscles is a skill. Could poor body maps be the root of the weakness and the pain?

I think it is possible, that one of the advantages of HIT style strength training is that it encourages the participant to focus inward, and forge that mind-muscle connection.

Perhaps it could be renewed body maps which make the HIT protocol on the MedX so effective? This might explain why activities such as salsa dancing and Taichi, which aren’t associated with great improvements in strength, can also be effective in reducing chronic pain?

A Fresh Look at Old Advice

I stated at the beginning of this article, that although I had altered many of my beliefs surrounding the etiology of chronic pain, my general advice remains much the same, though perhaps the reasons that it works are slightly different than I first thought!

In part I of my original series, I recommended avoiding extended periods of sitting, and to wear minimalist footwear.

I would still recommend both of these lifestyle tweaks, but perhaps for slightly different reasons:

Sitting itself may not cause problems, but not moving naturally, and regularly, through a full range of motion may well do!

That is to say, it is not spending all day with the hips flexed that is necessarily the problem, it is that one spends little to no time with the hips in other positions, a subtle, but significant difference.

One has to be careful with analogies, as things are rarely so simple, particularly where the human body is concerned, but I shall use one nonetheless as I do think they can be useful, if for nothing else than provoking thought.

Think of a door – if it is kept permanently closed, it is likely to seize shut. Equally however, if it is left permanently open, it may seize open (hence perhaps the standing desk may not be the solution is was once cracked up to be!). Providing the door is opened and closed through a full range of motion on a daily basis, however, it should be fine.

Taking the analogy one step further – is it necessary to keep opening and closing the door over and over throughout the day, or is once or twice sufficient? Could over use of the door actually increase wear and tear on the hinges and reduce the longevity of its hinges?

I no longer think there’s necessarily a need to adopt a standing desk, or take regimented breaks from sitting to “stretch out the hip flexors”, however, prolonged sitting is certainly correlated with many adverse health effects (even if this should more accurately be not moving enough), so taking every opportunity to get up, move around, and take a break from whatever you are doing can only be a good thing.

As for wearing minimalist footwear, and spending as much time barefoot as possible, who really knows if this may have any kind of impact on back or joint pain? There’s certainly no conclusive research to say that it does.

My current hypothesis is that if there is a benefit to be gained from ditching the shoes where possible, it most likely comes from improved proprioceptive feedback, enabling better body mapping. The soles of the feet contain huge numbers of mechanoreceptors, one might speculate that they evolved there with some specific purpose. Wearing cushioned soles has the effect of muffling and confusing those signals, which one might presume would have a knock on effect to the ability of the brain to effectively map the area? Who knows what potential effect this might have.

Does this mean you should go out and attempt to run the the Western States 100 in a pair of Vibrams?

No, probably not a good idea. But walking around your house and garden barefoot, and doing your warm ups, and indoor exercise/activity barefoot where safe and appropriate is likely a good idea.

The subject of barefoot running itself I shall save for an upcoming post all of its own.

In part II I recommend a combination of soft tissue work with a foam roller, and some basic mobility exercises.

I would say that I’m now a foam roller agnostic! I know many people swear by it, but other than anecdotal evidence, there’s really very little hard data to back up their efficacy.

The full body foam rolling routine in the first video of the above article certainly stimulates many mechanoreceptors (and a fair few nociceptors!) all across the body. Could any potential benefits arise from increased proprioceptive awareness, rather than any actual physical changes to the fascia or other soft tissues?

My recommendation now would be that if you feel like you get a benefit/find it a good way to relax/get focused before a workout, stick with it. If not, skip it and dive straight into the mobility moves.

Performing regular mobility drills, slowly and mindfully, are quite possibly one of the most important things you can do to help alleviate or prevent the symptoms of chronic lower back pain or other pain syndromes.

Whether you perform the movements in the videos in part II, simply make full range of motion circles with your wrists, shoulders, hips and ankles plus some bodyweight squats and lunges, crawl around like an animal, or perform some Tai Chi or Yoga sequences, the key is slow, mindful exploration of your body and its limits, with the aim of creating that mind-body connection, and creating and maintaining detailed body maps.

My final recommendation in Part III of my original series was to learn the deadlift – AKA how to safely and efficiently lift an object from the floor.

The reasoning behind this recommendation was, and still is, due to the effectiveness of the deadlift for improving proprioceptive awareness of the core muscles (in fact, the whole body), and developing lower back strength.

Let me make it clear, however, that this does not mean someone with severe chronic lower back pain should walk straight into the gym, load and Olympic bar with plates and attempt to wrench it from the floor!

Training could begin with the empty bar lifted from a rack set to knee height or above. Never forgetting that the goal is to banish CLBP, not break any power-lifting records!

Deadlifts v HIT MedX Lumbar Extension v General Activity

James Steele II has in the past pointed to research which shows that the deadlift (specifically the stiff legged style) is not as effective as the MedX Lumbar extension machine at developing lumbar extension strength11.

Could the MedX Lumbar extension machine be a more efficient way to tackle CLBP?

I would certainly concede that the MedX has some potential advantages:

  1. It is much easier to learn.

Though it is possible to teach yourself to deadlift, if you are lacking in proprioception, ideally you will require a qualified coach to help you learn the correct movement pattern, or at the very least a good training partner.

  1. It will develop lower back strength much more rapidly.

The fact that the exercise is easier to learn, and is much lower risk, means that you can rapidly up the intensity and train the lower back muscles to failure, something I would never recommend with the deadlift.

Having said this, however, the deadlift also has some advantages:

  1. It is more difficult to learn.

Just because something is difficult, does not necessarily mean it should be avoided. Learning to move naturally and efficiently can, and should be, an important part of forging a healthy and capable body.

The MedX Lumbar Extension may certainly help develop proprioception in the lower back, which could be a major contributor to its pain reducing effects, but the deadlift helps develop proprioception in the both the core musculature and the limbs, in a movement pattern which coordinates them all.

(NB I should point out the James is in no way against deadlifts, and does train them himself, he just doesn’t view them as an efficient way to train the lower back muscles for strength or pain reduction)

  1. It does develop lower back strength.

In the previously referenced study, Fisher et al determined that the Romanian Deadlift was not as effective at developing lumbar extension torque as the Medx machine. I would argue, however, that this is not surprising as the deadlift recruits the muscles of the core in a static contraction, they are not used to produce movement, but rather to transfer the force generated by the legs.

As we know that strength is very specific, it is common sense that a machine which trains lumbar extension should develop more lumbar extension strength than a movement that requires isometric strength.

Which exercise is best for developing the muscles of the lumbar spine is really a mute point however, as the discussion here is back pain. If lower back weakness is a causal factor in CLBP, how much strength does one need to develop in order to combat it? While it may not be primarily a lower back exercise, I am confident the deadlift still sufficiently increases lower back strength for our purposes.

  1. It builds confidence.

A major advantage of the deadlift in my opinion is its confidence building factor.

As we have seen above, cognitive inputs are a major factor in the output of pain. Many people may have originally experienced pain when lifting something heavy, or even if this was not how it started, be wary of heavy lifting and bending as these things are known to be bad for your back.

By learning to gradually move through larger and larger pain free ranges of movement, with ever increasing loads, individuals suffering from CLBP can change their beliefs about what they can and can’t do. If you can confidently lift a heavy barbell in the gym, those boxes at work, or piece of furniture at home are not going to pose a threat.

Work With What You’ve Got

When it comes to dealing with CLBP, or any other pain syndrome for that matter, I don’t believe that there’s any one magic bullet.

My major criticism of the MedX Lumbar extension machine is that they are like rocking horse faeces! The chances of there being one in your gym are slim to none. There might be another lower back extension machine, but can you guarantee it is biometrically sound? Many cheaper machines are badly designed and not congruent with natural joint function.

Barbells can be found in most gyms, which is a big plus for the deadlift – but then you need to find a coach or reliable training partner (and of course a gym!).

If you happen to have access to all of these (MedX, Barbells + coaching/partner) then lucky you! It doesn’t have to be a question of either/or, I would actually recommend doing both. Follow the Live Now Thrive Later minimalist training program, but add in the HIT lumbar extension at the end.

Don’t have access to a MedX? Don’t despair, as you can train the lumbar musculature HIT style with bodyweight alone. Here’s a great exercise from Doug McGuff. The super minimalist approach to CLBP could be to try just one set of this bodyweight move per week, and nothing else!

Keep on Moving

So it turns out that back pain, and other chronic pain syndromes are a pretty complex phenomenon.

It’s unlikely that any chronic pain you are currently enduring is actually attributable to some kind of structural issue or tissue damage, but it’s not just “all in your head” either.

I think that the most heartening thing from all the above research is that freedom from pain is a possibility for everyone out there – regardless of what they’ve been told about the condition of their discs, musculoskeletal asymmetries, or wear and tear on their joints.

I still stand by my prescription of moving regularly, going barefoot when possible, completing daily mobility drills, and learning proper lifting mechanics, before gradually increasing ROM and load, even if the means by which this method works are not exactly as originally envisioned.

In the light of new knowledge, however, it seems the above method is certainly not the only way in which one can bring about an improvement in one’s symptoms.

The take home message is the importance of regular mindful movement, performed with the intention of exploring, and gradually extending, the limits of your body’s capabilities.

Whether this movement is with the above program in the gym, rediscovering natural movements through Primal Fitness or MovNat type training, joining a Yoga, TaiChi or Feldenkrais class, or taking up Salsa, Zumba or Ball Room Dancing, is probably relatively inconsequential.

While HIT strength training the lumbar extensors may well be the most time efficient method, all the other modalities have numerous other benefits attached to them too, from building confidence, getting out in nature, relieving stress, making new friends and having fun!

I shall leave you with some interesting videos on the subject and some further reading:

Targeting Cortical Representations in the Treatment of Chronic Pain: A Review G. Lorimer Moseley, PhD, and Herta Flor, PhD

1) Review of Moseley and Hodges Conference on Pain and Motor Control by Todd Hargrove on Better Movement

2) The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain Eyal Lederman

3) Intricate Correlation between Body Posture, Personality Trait and Incidence of Body Pain: A Cross-Referential Study Report Sylvain Guimond, Wael Massrieh

4) It Hurts When I Do this (or You Do that): Posture and Pain Tolerance Bohns, Wiltermuth

5) Magnetic resonance imaging of the lumbar spine in people without back pain. M C Jensen, M N Brant-Zawadzki, N Obuchowski, M T Modic, D Malkasian, and J S Ross

6) Surgical vs Nonoperative Treatment for Lumbar Disk HerniationThe Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial James N. Weinstein, DO, MSc; Tor D. Tosteson, ScD; Jon D. Lurie, MD, MS; Anna N. A. Tosteson, ScD; Brett Hanscom, MS; Jonathan S. Skinner, PhD; William A. Abdu, MD, MS; Alan S. Hilibrand, MD; Scott D. Boden, MD; Richard A. Deyo, MD, MPH

7) Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial Peul et al

8) Visual Distortion of Body Size Modulates Pain Perception Flavia Mancini, Matthew R. Longo1, Marjolein P.M. Kammers and Patrick Haggard

9) Targeting Cortical Representations in the Treatment of Chronic Pain: A Review G. Lorimer Moseley, PhD, and Herta Flor, PhD

10) Limited range of motion lumbar extension resistance exercise in chronic low back pain participants J. D. Steele, S. Bruce-Low, D. Smith, D. Jessop

11) A randomized trial to consider the effect of Romanian deadlift exercise on the development of lumbar extension strength James Fisher, Stewart Bruce-Low, Dave Smith

Thanks for reading, I hope you found this post of interest. I would love to hear your thoughts and comments below, or feel free to tweet me at @Simon_Whyatt


  1. Hi Simon. Thanks for this article on why your back hurts. Just recently I was at a big event providing massages to people there. I must say I was surprised at how many ‘walking wounded’ were there. I did find it interesting the way you touched on how back pain can cause poor posture. The majority of clients that I help all have back pain either in the lower region or the trapezious area. Moving is a great way to ease pain, due to all the endorphins released, but massage can also help and I have lost count of how many of my clients have benefited from a massage. In my opinion part of the solution is getting the blood flowing into areas, where aches and pains are prevalent

    1. Hi Lisa,

      I certainly agree massage can be part of the solution, though you are right I didn’t really touch on it much in this article.

      The only reservations I have with massage, is that often people use it with a “fix me” kind of mentality. That is to say that they want to spend an hour or two a week and some cash for someone else to manipulate them to sort the problem, but then continue doing (or not doing) all the things that are likely causing the problem in the first place.

      I think it important that people take ownership of their conditions, and are active in solving them themselves 24/7 – once they have made the necessary psychological and lifestyle changes necessary however, I totally agree that massage is a great tool for helping alleviate symptoms, improving proprioception, and possibly even facilitating recovery and repair, not to mention its benefits from relaxation and stress relief!

      What event were you giving massages at?

  2. Hi Simon,

    Great post and thanks for discussing and linking my work.

    Very difficult to tease out the direction of many of these relationships and I agree with most of what you suggest (though my view favours the specific muscular role as probably more influential).

    I’ve got a few things you might find interesting regarding the link between deconditioning and LBP. Some results from the study you cited that weren’t presented at the PhySoc conference but are in the full paper and also a letter to Spine discussing the topic in light of a recent paper by Willemink et al.

    Drop me an email and I’ll give you the published ahead of print copies.


    P.s. Some really interesting results from my gait research too describing the link between deconditioning, LBP and gait variability but in review at the moment. Will be presenting some of the results at the World LBP Congress in October though so hopefully they make that available if its not published by then.

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