Managing Low Back Pain

We’ve all heard the statistics: 80 percent of Americans are bound to experience significant low back pain in their lifetime (and, as an instructor of mine once said, “the other 20 percent are lying”). Hundreds of millions of healthcare dollars are spent on back pain every year. 

To make matters worse, we’re not even close to coming up with an agreed upon standard of care for low back pain. Currently, back pain is treated with every modality known to man. Ask twenty different clinicians how they would approach a given low back pain case and I guarantee you get twenty different answers. 

How your low back pain is treated is ultimately based on the belief system of the good people you go to for help. Speaking on behalf of physical therapists (like me), what you’ll get treatment-wise is based on that therapist’s training and body of knowledge, the culture in which they work, the colleagues they collaborate with, and even their geography. Some therapists treat solely based on what has been shown in the research and some treat using what is tried and true and makes perfect scientific and physiological sense.

Low back pain is a broad topic. While there is no “garden variety” of back pain, I am happy to say that there are a couple solutions that work in almost every case no matter the severity, the exact location, or the precipitating event.

Most back pain is associated with a postural position of extension through the lower thoracic and lumbar spine. This is an arched back with a lower front rib flare. Pain is most likely from back muscles and surrounding soft tissues that become short and tonic. They get overworked and eventually hurt. Pain can also be from the compressive forces on the joints and discs of this part of the spine. There are certainly other mechanisms of back pain, but this is the most common picture of a low back pain patient.
(Side note: A more chronic type of back pain needs to be distinguished from a more severe situation. Symptoms such as severe pain down the leg, obvious weakness of leg muscles, or diminished bladder or bowel control need immediate medical intervention.)

When your brain senses pain, it essentially perceives threat. How we perceive the threat that pain is causing differs in everyone and is based on many factors. Usually the perception of threat can be dampened and the physiological effects on our body (like muscle tension and changes in breathing mechanics) minimized. But in other cases the threat that pain causes can overwhelm us and we start to feel a lack of control over it. “Fight-or-flight” will run rampant, and this same primitive mechanism that ensures our survival when the threat is real continues to churn 24/7 and actually becomes a detriment to our health. This is just more stress and the last thing we need.

In these cases, the Sympathetic Nervous System (SNS) needs to be dialed down and some control needs to be regained by the patient. There are many ways to give a locus of control back to the patient. The main methods I use are ones that combine control of breathing rate and mechanics with pain relief positions that target muscle imbalances. SNS overdrive and a hyperventilatory state (whether purely mechanical or via altered blood oxygen/carbon dioxide levels) go hand in hand. And pain control is significantly improved when low back pain sufferers find that there are actually positions and muscles that can be used to give immediate relief.

The 90-90 Hip Lift with Balloon is one such exercise. This technique is a staple of the Postural Restoration Institute® (PRI) and incorporates a lot of the components I’ve mentioned. By placing the feet on the wall it will be much easier to tilt the pelvis back, thereby reducing the amount of arching of the lumbar spine. This is flexion, and decompression of the lumbar segments occurs when we flex. This position also allows us to find and feel the elusive hamstrings and glutes that we are so often unable to contract for correct positioning of the pelvis and hips. These muscles exert a posterior tilt on the pelvis (again flexion) and will have an inhibitory effect on hip flexors that tilt the pelvis forward (extension).

Slow, methodical balloon blowing is one of the best ways to calm the nervous system. When we are in pain our SNS kicks into overdrive. Heart rate, respiratory rate, blood pressure, and stress hormones in the blood increase. Breathing tends to be more shallow and breath holding is common. Front, lower ribs are usually found to be lifted and are unable to drop fully upon exhalation. Lower ribs in back are usually splinted by tight back muscles and held in, accentuating the arching of the lower back. Blowing up a balloon slowly has an inhibitory affect on these processes and emphasis is placed on full exhalation in order to come out of this rigid position.

This technique is performed by doing a full exhalation, emptying the lungs of all residual air that may not be expelled in the type of rigid, shallow breathing seen while in pain. Full exhalation means that the diaphragm will achieve a relaxed position and its influence on pulling the spine and ribs into an extended posture will be minimized. A balloon also serves as resistance to exhalation so that abdominal muscles can be more effectively recruited. Toned and coordinated abdominal obliques are vital in making the solid connection between your lower front ribs and your pelvis.

At the end of exhalation there is a pause—a signal to the nervous system to chill out and rest. This is followed by a normal-sized breath in and another full exhalation. This is repeated until the balloon is filled and numerous sets are usually performed, though the beneficial physiological and neuromuscular effects can usually be felt in as little as one set. 

This one simple technique brings key postural muscles back online, breathing under control, and a switch from Sympathetic Nervous System overload to a more Parasympathetic state. It is one of many techniques I use and is inspired by the Postural Restoration Institute®. It’s one that you can easily try at home to help reduce pesky low back pain.

Steve Cuddy was voted as one of the best physical therapists in Austin in AFM’s Best Of cover story.