<>Once in a great while some cranky reader (always a guy) writes to tell me, “I didn’t learn anything from your book.” I’m a little skeptical about that, and it’s always tempting to start quizzing! There’s a great deal of information here, including analyses of recent research. Sure, readers who have already done a lot of reading about back pain might already be familiar with a lot of it — but you will know that going in, of course, and you’ll find the nuggets of new information and perspective that any keen reader is always looking for. BACK TO TEXT
<>Doctors used to prescribe bed rest for back pain. But now we know that lying still is one of the worst things you can do. It can make back pain worse and lead to other complications. Don't rest for more than a day or two. It's important to get up and slowly start moving again. Exercise has been found to be one of the most effective ways to relieve back pain quickly. Try swimming, walking, or yoga.
<>For instance, there’s good evidence that educational tutorials are actually effective medicine for pain.?Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902. Researchers tested a series of web-based pain management tutorials on a group of adults with chronic pain. They all experienced reductions in disability, anxiety, and average pain levels at the end of the eight week experiment as well as three months down the line. “While face-to-face pain management programs are important, many adults with chronic pain can benefit from programs delivered via the internet, and many of them do not need a lot of contact with a clinician in order to benefit.” Good information is good medicine!
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<>Low back pain can be caused by tumors, either benign or malignant, that originate in the bone of the spine or pelvis and spinal cord (primary tumors) and those which originate elsewhere and spread to these areas (metastatic tumors). Symptoms range from localized pain to radiating severe pain and loss of nerve and muscle function (even incontinence of urine and stool) depending on whether or not the tumors affect the nervous tissue. Tumors of these areas are detected using imaging tests, such as plain X-rays, nuclear bone scanning, and CAT and MRI scanning.
<>Physical activity. Exercise helps build strong, flexible muscles that will be less prone to injury. It can also help the healing process for an aching back, prevent problems in the future, and improve function. Work with your doctor to develop an exercise program, or seek a referral to another health professional who can. A good program typically includes the three major forms of exercise: aerobic activity, strength training, and flexibility exercises.
<>“The Pain Perplex,” a chapter in the book Complications, by Atul Gawande. Gawande’s entire book is worth reading, but his chapter on pain physiology is certainly the best summary of the subject I have ever read, and a terrific reminder that good writing for a general audience can be just as illuminating for professionals. Anyone struggling with a pain problem should buy the book for this chapter alone, though you are likely to enjoy the whole thing. Much of the chapter focuses on one of the most interesting stories of low back pain I’ve read, and it is a responsible and rational account — although Gawande, like most doctors, seems to be unaware of the clinical significance, or even existence, of myofascial trigger points.
<>Press-ups: While lying on your stomach, put your hands flat on the floor under your shoulders, like you are going to start a push-up. Press your shoulders up and let your hips and low back relax. Your hips should remain in contact with the floor as you press up. Hold the end position for 1-2 seconds and return fully to the starting position. Perform 10 repetitions. Bonus exercise: the Prone Press Up with Hips Off Center.
<>Aquatic therapy: Aquatic therapy and exercise can also improve flexibility and decrease pain for some people with chronic low back problems. It is especially beneficial for those patients who cannot tolerate land-based physical therapy.This is because the unique properties of water often make it a safe environment for exercising a sore back, providing gentle resistance, comfort, and relaxation. Fear of pain associated with movement is a major limiting factor for rehabilitation and exercises therapy. The support and warmth of the water enables a person to gradually introduce daily exercise into their treatment.
<>Nonsteroidal anti-inflammatory medications (NSAIDs) are the mainstay of medical treatment for the relief of back pain. Ibuprofen, naproxen, ketoprofen, and many others are available. No particular NSAID has been shown to be more effective for the control of pain than another. However, your doctor may switch you from one NSAID to another to find one that works best for you.
<>Infection of the discs (septic discitis) and bone (osteomyelitis) is extremely rare. These conditions lead to localized pain associated with fever. The bacteria found when these tissues are tested with laboratory cultures include Staphylococcus aureus and Mycobacterium tuberculosis (TB bacteria). TB infection in the spine is called Pott's disease. These are each very serious conditions requiring long courses of antibiotics. The sacroiliac joints rarely become infected with bacteria. Brucellosis is a bacterial infection that can involve the sacroiliac joints and is usually transmitted in raw goat's milk.
<>A 2007 Cochrane review of opioids for chronic low back pain found that tramadol was more effective than placebo for pain relief and improving function.16 The 2 most common side effects of tramadol were headaches and nausea. One trial comparing opioids to naproxen found that opioids were significantly better for relieving pain but not improving function. Despite the frequent use of opioids for long-term management of chronic LBP, there are few high-quality trials assessing efficacy. The benefits of opioids for chronic LBP remain questionable. There is no evidence that sustained-release opioid formulations are superior to immediate-release formulations for low back pain. Long-acting opioids did not differ in head-to-head trials.9 Opioids are banned by the World Anti-doping Association.70
<>Preliminary research suggests that hypnotherapy may be of some use in the treatment of low back pain. For instance, a pilot study published in the International Journal of Clinical and Experimental Hypnosis found that a four-session hypnosis program (combined with a psychological education program) significantly reduced pain intensity and led to improvements in mood among patients with chronic low back pain.
<>Gentle stretches, walking, and periodically standing up at your desk can help stabilize your spine and prevent muscle imbalances. And despite how hard it is to imagine doing Downward-Facing Dog with a bad back, yoga can work in your favor, too. A 2013 review of studies found strong evidence it can help beat lower back pain. Any type works; one to consider is the restorative viniyoga style.
<>Having strong core muscles (we’re talking abs here) can help protect your back from injury. Do this core-strengthening pelvic tilt 2 to 3 times per week: Lie on your back with knees bent, feet flat on the floor, and lower back flattened. Pull in your belly button toward your spine, contracting your abs; your pelvis should lift slightly off the floor.
<>Among the issues a little downward dog can ease—such as anxiety, stress—yoga may also bring lower back pain relief, particularly if the pain is long-lasting. A 2017 study found that attending weekly yoga for three months was just as effective as physical therapy for alleviating symptoms, and far better than back advice alone. Yoga-goers were also more likely to stop taking medication after a year. Learn more about how yoga eases lower back pain.
<>Many researchers seem to believe that low back pain is a modern problem. For instance, Waddell writes, “Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic … .” In 2008, Martin et al found that, “The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7%… to 24.7% … 1997 to 2005,” which certainly shows that it is a growing problem and therefore likely to be worse now than in the past. A Spanish study (Jiménez-Sánchez et al) showed that “serious” musculoskeletal complaints (including a great deal of back pain, presumably) increased significantly from 1993 to 2001. Finally, Harkness et al did a nice job in 2005 of comparing rates of musculoskeletal pain (including low back pain) 40 years apart in the northwest of England, and found a large increase. In his books, Sarno also strongly portrays low back pain as a modern problem — though he doesn’t defend it . It’s hard to say if back pain actually is a modern problem, or whether it just tends to be described as such. Remember that human beings have a strong tendency to sensationalize and dramatize! Harkness pointed out in her study that the appearance of an increase “could be partly explained by the ‘worried well’. The ‘worried well’ are those patients who are concerned about their health, and attend their GP to seek reassurance about their well-being.” This is a great example of how hard it is to really be sure of anything! BACK TO TEXT
<>Kneeling Lunge Stretch. Starting on both knees, move one leg forward so the foot is flat on the ground, keeping weight evenly distributed through both hips (rather than on one side or the other). Place both hands on the top of the thigh, and gently lean the body forward to feel a stretch in the front of the other leg. This stretch affects the hip flexor muscles, which attach to the pelvis and can impact posture if too tight.
<>Chronic back pain is straining both physically and emotionally. To manage the frustration, irritability, depression and other psychological aspects of dealing with chronic pain, you may get referred to a rehabilitation psychologist. This specialist may recommend meditation, yoga, tai chi and other cognitive and relaxation strategies to keep your mind from focusing on pain.
<>One of the new back pain remedies is a muscle stimulation machine. In the past, you would need to visit a chiropractor or physical therapist to receive the benefit of one of these machines, but they now sell them over the counter. However, they are expensive. They make the muscles of the back “twitch,” and this helps to strengthen them. After several sessions with the stimulation machine, your muscles are better able to handle the stress and strain of everyday life again. When a back muscle is hurt, it loses some of its primary strength, and the stimulation machine can restore that to a point. The over-the-counter versions are limited, though, and you may need to see a professional if your back pain persists.
<>Over-the-counter (OTC) pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve), might relieve acute back pain. Take these medications only as directed by your doctor. Overuse can cause serious side effects. If OTC pain relievers don't relieve your pain, your doctor might suggest prescription NSAIDs.
<>The outlook for low back pain absolutely depends on its precise cause. For example, acute strain injuries generally heal entirely with minimal treatment. On the other hand, bony abnormalities that are irritating the spinal cord can require significant surgical repair and the outlook depends on the surgical result. Long-term optimal results often involve exercise rehabilitation programs that can involve physical therapists.
<>Thirty-five randomized controlled trials did not allow firm conclusions for the effectiveness of acupuncture for acute low back pain.25 For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment in the short term only. Acupuncture is not more effective than other conventional or alternative treatments.25
<>I have had life-altering low back pain for more than 8 years. I’ve had the fusions at L5-S1. Prior to my first surgery I spent 18 months seeking relief through physical therapy, intense massage therapy, myofascial “release” therapy, a visit to Dr. Sarno himself, injections, dry needling of trigger points and massage from a physiatrist, chiropractic work and more. For years between surgeries I tried core strengthening, acupuncture, PT, more massage, two rhizotomies, and visits to the Mayo clinic and Johns Hopkins’ pain management in-patient programs. So I’ve been through a lot. And your book is the first thing I’ve read that dispassionately and entertainingly dissects all of the options and offers some realistic, pragmatic suggestions. It’s a gift to all back pain sufferers.
<>Acupuncture. Based in ancient Chinese medicine, acupuncture stimulates points on the body thought to correct the body’s “qi,” or life force. It is believed that proper qi decreases pain and discomfort in the body. During a session, thin needles are placed in the skin for about an hour. Acupuncture has been shown to provide significant pain relief for some people.3
<>One of the most common reasons people develop low back pain is posture. Postural problems, including spinal abnormalities, along with muscular compensations or inactivity put added pressure on the back. Although people of all ages experience low back pain — including both athletes and those who are sedentary — middle-aged to older adults (especially when they’re overweight) are most likely to develop severe symptoms and therefore can benefit from lower back pain relief treatments like chiropractic care, soft tissue therapy and regular exercise.
<>A randomized single-blind controlled trial compared manual therapy and spinal stabilization rehabilitation to control (education booklet) for chronic back pain.26 Spinal stabilization rehabilitation was more effective than either manipulation or the education booklet in reducing pain, disability, medication intake, and improving the quality of life for chronic low back pain.26 A systemic review found segmental stabilizing exercises more effective in reducing the recurrence of pain in acute low back pain; however, exercises were no better than treatment by general practitioner in reducing short-term disability and pain.50 For chronic low back pain, segmental stabilizing exercises were more effective than treatment from general practitioners but no more effective than exercises using devices, massage, electrotherapy, or heat.50 In a trial of 30 hockey players, dynamic muscular stabilization techniques (an active approach to stabilization training) were more effective than a combination of ultrasound and short-wave diathermy and lumbar strengthening exercises.41
<>Bony encroachment: Any condition that results in movement or growth of the vertebrae of the lumbar spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony encroachment of the spinal nerves include foraminal narrowing (narrowing of the portal through which the spinal nerve passes from the spinal column, out of the spinal canal to the body, commonly as a result of arthritis), spondylolisthesis (slippage of one vertebra relative to another), and spinal stenosis (compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal canal). Spinal-nerve compression in these conditions can lead to sciatica pain that radiates down the lower extremities. Spinal stenosis can cause lower-extremity pains that worsen with walking and are relieved by resting (mimicking the pains of poor circulation). Treatment of these afflictions varies, depending on their severity, and ranges from rest and exercises to epidural cortisone injections and surgical decompression by removing the bone that is compressing the nervous tissue.
<>Spinal manipulation: Osteopathic or chiropractic manipulation appears to be beneficial in people during the first month of symptoms. Studies on this topic have produced conflicting results. The use of manipulation for people with chronic back pain has been studied as well, also with conflicting results. The effectiveness of this treatment remains unknown. Manipulation has not been found to benefit people with nerve root problems.
<>Bed Rest. Bed rest should not be recommended for patients with nonspecific acute low back pain. Moderate-quality evidence suggests that bed rest is less effective at reducing pain and improving function at three to 12 weeks than advice to stay active.46 Prolonged bed rest can also cause adverse effects such as joint stiffness, muscle wasting, loss of bone mineral density, pressure ulcers, and venous thromboembolism.37
<>Activity modification. One variant of resting is to stay active but avoid activities and positions that aggravate the pain. For example, if long periods of sitting in a car or at a desk make the pain worse, then set a timer to get up every 20 minutes and walk around or gently stretch. If standing makes the pain worse, avoid chores that require standing such as washing dishes at the sink. Avoiding, or minimizing, activities and positions that worsen the pain will help prevent or reduce painful back spasms and allow for a better healing environment.
<>I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.
<>This stretch is designed to help lengthen the piriformis muscle over time. This muscle is often the source of sciatica, or radiating leg pain. Sitting with a straight back, cross your left leg over your right leg placing your foot next to your thigh and tuck your right leg in towards your buttocks. Place your right arm on your leg as pictured and slowly ease into a stretch. Be sure to keep your back straight and chest lifted. Hold for 20 seconds and alternative sides, three times.
<>CBT: If you consult a psychotherapist for cognitive behavioral therapy (CBT), your treatment may include stress management, behavioral adaptation, education, and relaxation techniques. CBT can lessen the intensity of back pain, change perceptions about levels of pain and disability, and even lift depression. The NIH considers CBT useful for relieving low back pain, citing studies that show CBT to be superior to routine care and placebo.
<>“Stretching of the back and legs can help maintain or improve movement for everyday functions. For example, being limber will help you lift objects off the floor or put on shoes without increased stress to the back,” says Jiang. “Additionally, physical activity [like stretching] can help increase back resilience, so that one can perform more activities without increased pain.”
<>A randomized single-blind controlled trial compared manual therapy and spinal stabilization rehabilitation to control (education booklet) for chronic back pain.26 Spinal stabilization rehabilitation was more effective than either manipulation or the education booklet in reducing pain, disability, medication intake, and improving the quality of life for chronic low back pain.26 A systemic review found segmental stabilizing exercises more effective in reducing the recurrence of pain in acute low back pain; however, exercises were no better than treatment by general practitioner in reducing short-term disability and pain.50 For chronic low back pain, segmental stabilizing exercises were more effective than treatment from general practitioners but no more effective than exercises using devices, massage, electrotherapy, or heat.50 In a trial of 30 hockey players, dynamic muscular stabilization techniques (an active approach to stabilization training) were more effective than a combination of ultrasound and short-wave diathermy and lumbar strengthening exercises.41
<>Endorphins are hormones made naturally in your body. What most people don't know is that they can be just as strong as any manufactured pain medication. When endorphins are released in your body, they help block pain signals from registering with your brain. Endorphins also help alleviate anxiety, stress, and depression, which are all associated with chronic back pain and often make the pain worse.
<>Physical therapists can teach you how to sit, stand, and move in a way that keeps your spine in proper alignment and alleviates strain on your back. They also can teach you specialized exercises that strengthen the core muscles that support your back. A strong core is one of the best ways to prevent more back pain in the future. Studies show that when you increase your strength, flexibility, and endurance, back pain decreases -- but it takes time.

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Medical Disclaimer: The material on this site is provided for informational purposes only and is not medical advice. Always consult your physician before beginning any exercise program.

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These back pain movements really did help me with my chronic back pain.
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