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Back Pain? Strengthen Your Brain

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    Explain Pain by D. Butler, L. Moseley
    Chronic pain, low back pain, physical therapy, herniated disc, fusion

     low back pain, chronic pain, low back pain, physical therapy, opioid, fusion, herniated disc

    Picture this: It started as an ache, a small discomfort in your low back after a long day at the office.  No biggie, you think, this will be gone by lunchtime.  But it doesn’t leave.  Two years and five doctor visits later you’re stuck in a cycle of chronic low back pain, wondering whether another round of cortisone injections is the solution.  Maybe you’re considering surgery, like a lower spine fusion or a discectomy.  Does this sound familiar?

    As a society, we have been taught to believe that pain, especially low back pain, is always the result of musculoskeletal damage.  Patients see X-rays that reveal arthritis and MRIs that contain bulging discs, and we falsely correlate our pain experience to these findings.  Often times as healthcare providers, we encourage this thought by promoting the idea that pain = damage.  It’s incorrect!  Butler and Moseley write, “(discs) degenerate naturally.  Degeneration is a normal part of aging of all tissues.  It does not have to contribute to a pain experience.

    At least 30% of people who have no low back pain have (discs) bulging into their spinal canal, sometimes markedly.

    This fact has been known for many years but it is still not common knowledge among the general public” (Butler & Moseley, pg. 54).  Additionally “In a systematic study that reviewed medical imaging, more than 90% of imaging in people over 60 years old showed degenerative changes of the spine.” (Brinjikji et. al, 2015) If the disc isn’t causing pain, then what is?  And why doesn’t my low back ease up with a warm bath and the latest Adele album?

    Great question!

    The pain experience is designed as a threat system: When the brain perceives a stimulus to be threatening, pain is experienced and the situation is (hopefully) avoided. With that said, the brain’s perception of a threatening situation is not always accurate, and can vary depending on a multitude of factors, including something as simple as your current mood or environment. The brain receives sensory information from the body and decides if the information received is currently a threat (could potentially cause damage). Imagine this: An accidental paper cut at your desk can be experienced as intense pain, while a gash when running from a grizzly bear may not be felt at all. In the second circumstance, the brain would be more interested in surviving the bear; therefore, feeling a painful gash in your leg would be irrelevant for survival and rejected as an appropriate perception at the time.

    “When pain persists and feels like it is ruining your life, it is difficult to see how it can be serving any useful purpose.  But even when pain is chronic and nasty, it hurts because the brain has concluded, for some reason or another, that you are threatened and in danger and need protecting – the trick is finding out why the brain has come to this conclusion.” (Butler, Moseley)

    A lot of times, (and this may seem simple, I know), pain is the result of fear of movement! We hear herniated/slipped/bulging disc or degeneration/arthritis, and, whether consciously or subconsciously, we no longer want to move at this location.  We fear further damage. We pick things off the floor, pretending we have a rod up our caboose that prevents us from bending our low back at all.  We brace extremely hard before lifting our kids, leading to muscle ache and fatigue. The goal is to remove this fear-avoidance behavior by gradually returning to the activities you love or want to do.  Doing so will allow the brain to decrease threat to movement, which will loosen muscles in the area and promote pain-free motion.  If movement is too painful at this time, take advantage of visual imagery to perform the movements mentally, and teach your brain to accept a non-threatening action as it should be – non-threatening. Rolling in bed is not a strenuous action. Sitting in a chair for one hour should not cause severe muscle aches and fatigue.  Here’s a simplistic guide to begin this progress toward recovery:


    Graded Imagery


    1. Lie on a comfortable surface with your eyes closed and place your hand on your low back. Close your eyes and picture yourself performing a bending motion at your back. How did your muscles feel? Did you tense up from the thought alone? If you need to regress this activity picture yourself sitting in a chair and bending.

    If your back is tense, how likely are you to move through those segments?

    1. Gradually increase the difficulty of this activity. Visualize yourself touching the floor. Perform deep breathing through your stomach for relaxation, and attempt to prevent lower back tightness during this imaginative process.


    Graded Exposure

    1. Rank how painful you think performing an activity would be (0-10 scale).
    1. Gradually increase the difficulty of this activity, rating your pain along the way.

    For example, for forward bending, begin in a seated position and attempt to touch the floor to the best of your ability. Participate in deep breathing along the way to prevent unnecessary muscle contractions of the lower back (three-second inhale, followed by a three-second breath hold and a three-second exhale). Once you touch the floor, raise your pelvis off the chair to the best of your ability.


    Stay tuned for more discussions related to pain science and how to get rid of your pain once and for all.


    Motion is lotion.



    Brendan Glackin, DPT, CSCS
    Glackin Physiotherapy, LLC


    Brinjikji, W., et al. “Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.” American Journal of Neuroradiology 36.4 (2015): 811-816.

    Physiopedia. “An interview with Prof. Peter O’Sullivan on the treatment of back pain – Sept 2015”. Youtube. Feb 4, 2017. https://www.youtube.com/watch?v=YWGSdRGQG-M&t=14s

    Butler, David S, and G L. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2003. Print.

    3 thoughts on “Back Pain? Strengthen Your Brain”

    1. This blog is fantastic! This is such a great way to get the word out to clinicians and patients about how to approach persistent pain. I do want to add that the example you posted is an example of Graded Exposure (to a fearful movement) graded exercise is more of a timed activity regardless of pain level. Keep it coming!

    2. Pingback: Back Pain: The Road to Recovery • Rehab Renegade

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