We have all been exposed to “quick fixes for back pain.” Over and over again, you have been told to maintain “good posture”, sit less, avoid high heels, alter your sleeping position, so on and so on. These recommendations are a dime a dozen.
Can they help?
Absolutely, but I am guessing you are here because they aren’t or you actually want to know WHY your back hurts. In an effort to get relief fast we settle for the quick fix… we sweep it under the rug and move on. Pain exhausts your energy reserves. In order to be effective as a spouse, employee or in your hobbies you need to get a grip on pain, if not for your then for those that matter most in your life.
If you want to find long term relief keep reading...
Trying to help you understand ALL of the mysteries of back pain would likely turn into a book that you would undoubtedly fall asleep reading.
What I want to do today is explain an essential principle of back pain that most people do not understand.
… Something called “Position Intolerance.”
What is “Position Intolerance?”
To keep things easy we borrowed some terminology from Dr. Stuart Mcgill and Dr. Peter O’Sullivan to help categorize you into one of two groups. This will help you understand:
- What positions may be aggravating your pain
- What tissues are likely irritated
- How to use this knowledge to work toward a pain free back
So what is position intolerance? Just like it sounds, it is your body’s personal distaste for certain postures. Typically these fall into Flexion Intolerance (ROUNDED Back) and Extension Intolerance (ARCHED Back).
"Many of us mistakenly assume that we need to just “stand at attention” all day. If you are like most of my patients, this advice hasn’t gotten you very far."
Identify YOUR Clues
The “Clues” in each category will help you identify what positions may actually be worsening your pain.
It is possible that both Flexion (rounded) and Extension (arched) positions at the lower back increase your pain. If you are unable to tolerate either position to some degree your happy place will be in the “Neutral Zone.” Staying in the neutral zone will become easier when you learn how to:
- Fine tune your “Spine Awareness”
- Many people when properly tested are actually unable to put themselves in a neutral posture. Even worse, they tend to adopt the posture that actually increases their pain.
- Build Endurance around the trunk
- Lack of endurance, more than strength, is actually one of the most common findings in those with back pain.
*You may be asking yourself, "do I have to avoid these positions FOREVER?
The answer is NO. But similar to a stubbed toe, we want to stop irritating the tissues that are aggravated by your specific Position Intolerance. For example, people that fall into a Flexion Intolerance category tend to have more disc related pain. As the pain starts to subside we can gradually adopt these postures again. Intelligently though, spine flexion to tie your shoe is A-OK. Spine flexion to deadlift 500 pounds is not.
- You sit in a slumped, or rounded spine, position.
- Increased pain with sitting, especially long durations.
- Pain with bending forward.
- Pain worse in the morning.
- Pain in the morning may be attributed to a normal increase in fluid within the disc. This happens over night. For those with disc related pain, the mornings tend to be worse, as are rounded positions at the back.
- Pain in the morning could also indicate faulty sleeping postures or a mattress that doesn’t meet your needs.
- Reduction in pain with lying on your stomach or pain that stops radiating and “centralizes” to lower back.
- Centralize: This is when pain that is radiating, or traveling, down the leg stops and pain is only felt local to the back or not at all.
- History of sharp and/or shooting back pain while bending forward to lift a heavy object.
- You may have the tendency to sit in a more “arched” low back position.
- Pain with arching at your lower back while standing. You may experience more pain when reaching overhead.
- Wiping on the toilet (sorry, no better way to word this one).
- Pain with lying on you stomach or on your back if on a firm surface.
- In this position, the bed is too firm to support the natural arch in your back.
- Using a soft mattress may help relieve this problem, as well as training for proper spine control while sitting and low back support while sitting (lumbar roll).
"Remove The Nail."
I use the saying, “Remove The Nail” when discussing pain with my patients.
“If you had a nail sticking out of your head it would likely be ridiculous for us to sit here and wonder why you are having migraines, right?”
Well, we do the same thing when it comes to back pain. The only difference is we have a harder time identifying the nail when we cannot clearly see it. As mentioned earlier, we are going to make the invisible, visible. Finding the nail and removing it allows us to reduce the sensitivity of the tissues (muscle, joint, disc, ligament, bone, etc.) that are being stressed.
In order to do this we first need to identify the positions, or postures, that are contributing to your pain. Going back to “the nail,” it wouldn’t seem crazy to think that compressing the nail or tugging at the nail would worsen you headache. The same is true for your back. We often put undue stress on certain areas of the spine, wondering all the while why we are still in pain?
So after reviewing the clues in each section, which category would you put yourself in?
Flexion Intolerance (Rounded Back)
Extension Intolerance (Arched Back)
In our next article we will discuss the TISSUES (muscle, ligament, bone, disc, capsule, etc.) that are likely being aggravated based on YOUR Position Intolerance.
Disclaimer: Knowing exactly what tissues no longer "look pretty" when examined by expensive medical imaging does not alter our treatment. Just because the tissue isn’t pretty does not mean it is the source of your pain.
Michael Infantino, PT, DPT
Doctor of Physical Therapy
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