Low Back Pain (LBP) is an epidemic in our modern society. LBP is reported as the #1 reason for missed work and #2 reason for seeing a doctor. According to National Institute of Neurologic Disorders and Stroke (NINDS), Americans spend over $50 billion each year on the evaluation, diagnosis, and treatment of LBP. It is the second most common “neurological ailment”; second only to headaches. Many clinicians and researchers estimate that 70-85% of people will experience LBP at some point in their lifetime.

AN ANATOMICAL APPROACH TO THE PROBLEM

LBP is a “catch-all” diagnosis. There are many structures in the spine that can cause pain. It is important to see a physician for a diagnosis and a good physical therapist or chiropractor to address your particular movement impairments and functional limitations.  Here is a list of the most common causes of LBP:

• Intervertebral discs: There is a disc between each vertebrae.  These discs allow for smooth movement and shock absorption.  Discs are frequently injured as a result of repetitive activities and trauma and can degenerate with age (more on bone loss).  Terms used to describe disc injuries include “herniated disc” or “bulging disc”.  If a disc is the source of LBP, the pain is usually aggravated by bending and twisting motions. Activities such as reaching down to tie your shoes or sitting for a long period of time can increase pain.  Also, quick movements such as a cough or sneeze can be painful.  Pain may be felt on one or both sides of the spine, and can be accompanied by nerve root irritation.
• Facet joints: These are the joints that, along with the discs, connect adjacent vertebrae.  Often these joints become dysfunctional and restricted into certain movements.  Facet-induced LBP usually affects one side of the spine more than the other.  It generally stays more localized than disc pain.  Painful movements include extending the back, leaning towards the side that is painful, or twisting.  Activities such as walking, running or reaching behind you to pick something up may be painful.
• Soft tissue: This includes fascia, superficial muscle, deep muscle (read about muscle strains).  Pain associated with soft tissue restrictions can present in any number of ways depending on which tissue is involved.  Generally, an active contraction or stretch of the affected muscle will elicit symptoms.
• Nerve roots: This is often referred to as a “pinched nerve”.   Nerve root pain can be experienced locally in the back, but it can also radiate down into the buttox and legs (sometimes called radiculopathy or radicular symtpoms. “Sciatica” is an example of this.)  As aforementioned, an injury to the intervertebral discs can precipitate nerve root pain as well.  Nerves from the spinal cord exit the spinal canal thru foramina (holes) between each vertebrae.  If a disc is injured it can impinge upon a nerve (“pinch”), and this prolonged compression creates pain both in the spine and down the length of the nerve (some of these nerves go all the way to the feet!).  This pain can be aggravated by similar activities as were mentioned above in the section on intervertebral discs.
• Degenerative Changes: Discs can degenerative over time.  The vertebrae also can become compromised by degenerative changes such as arthritis.  Pain from “Degenerative Disc Disease” is variable.  EVERYTHING can cause pain; bending forward, leaning back, twisting, anything!  A common arthritic condition affecting the vertebrae is termed “Spinal Stenosis”.  This is a narrowing of the spinal canal or the foramina (“holes”) through which the nerve roots exit the spinal canal.  Stenosis often causes pain both in the back, and radiating into the lower extremities.  It is generally made worse when the back is extended (or fully erect to neutral) and thus leaning forward tends to ease the pain.
• Fracture: Compression fractures can occur due to a fall or impact injury.  A spondyloslisthesis can occur as a result of a fracture in a particular part of the vertebrae.  Pain from fractures varies.  Generally a compression fracture will result in pain with bending and twisting, while pain from a spondylolisthesis occurs while extending the back.  Diagnostic imaging is needed to confirm these diagnoses.

OTHER THINGS TO RULE OUT:

Only a physician can rule out other, potentially more serious causes of back pain. These include:

• Cancer: Some common questions used to determine a person’s susceptibility to cancer / likelihood of having cancer are: Do you have a prior history of cancer?  Do you have a family history of cancer?  Are you over 50 years old?  Have you experienced recent, unexplained weight loss?  Do you have a constant fever or night sweats?  Does the pain remain constant, even while resting?  If you answer yes to any of these questions it is typically a red flag, and a clinician will want to rule out cancer, using diagnostic tests.
• Referred Pain From Internal Organs: Some organs that can refer pain to the area of the lumbar spine include the ovaries, uterus, testes (pelvic organs), kidneys, urinary bladder (retroperitoneal organs), pancreas, large intestine, and the sigmoid colon (digestive organs).
• Abdominal Aortic Aneurysm (AAA): This is a sac formed by dilation of the wall of the aorta.  Pain associated with AAA has been described as throbbing and pulsating.  No postural or positional changes alleviate the pain.  This is a medical emergency!
• Endometriosis: A condition in which the tissue that normally lines the uterus (endometrium) grows in other areas of the body.  Signs and symptoms include pain, irregular bleeding, and possible infertility.
• Psychological Factors: Some say that the the mind induces physical pain to serve a psychological purpose (Dr. Sarno).  Under this theory, the pain serves to distract the mind from some more disturbing, repressed psychological conflict.  It is a form of self-preservation.  On the other end of the spectrum are those who believe that pain is purely physical.  The majority of health care practitioners recognize both the physical, structural mechanism for pain and the psychological and emotional factors that affect the pain.  A good definition of pain addresses both the mind and the body: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (from IASP, Subcommittee on Taxonomy, 1979).

LBP is an epidemic that is complex in nature.  Diagnostic and treatment approaches vary.  In Part 2 we will discuss some conservative treatments that can help manage LBP and hopefully alleviate the symptoms.

Benefits of Active Release Techniques

• Increased Flexibility. Muscles are easy to stretch, fascias are not. Sometimes your flexibility is limited by tight fascia tissues and soft tissue work can help loosen these tissues.
• Increased Muscle Quality. Higher quality muscles perform better and endure longer with less pain.
• Less Injuries. Increased muscle quality and flexibility naturally prevent injuries from physical activities.

What You Need

• Foam roller. I previously had a cheap foam roller (~$20) that is entirely made out of foam. It worked great until it got too soft after 4 months of daily usage. I recommend getting a foam roller with a PVC pipe inside, such as the Foam Roller Plus, The Grid Foam Roller, or a high density foam roller that is extra firm. That way your roller will last you a lot longer and not crap out quickly like mine. Also, if
• Tennis ball/Lacrosse ball. Cheap yet effective. These are used for smaller muscle areas (e.g. glutes) or muscle areas that need more pressure. You can even substitute it with baseballs if you want.
• TheraCane. Used for increased precision. This is for when you have really specific pressure points and you need lots of pressure on that point to release. It is especially useful for reaching places that are hard to get to (like your upper-back).

How to Perform Active Release Techniques on Yourself

Here are a couple free PDF guides on how to perform soft tissue workouts: first PDF, second PDF. There are also a few books out there on Amazon (I recommend The Trigger Point Therapy Workbook), but I personally just follow the following routine by Eric Cressey.

Conclusion

I do about 10 minutes of soft tissue work and 10 minutes of stretching before I exercise. That is my daily exercise routine. The reason why I spend so much time taking care of my muscles is because I do not want to get injured. Injuries can take you out of commission for weeks, months, or even years. Soft tissue work can help prevent it so it seems like a no brainer to me! Start rollin’ now!