Making Sense of Unexplained Lower Back Pain

Low back pain can often be hard to explain, the most common story we hear in clinic is that the pain started without an obvious injury. It may have started whilst you were doing something very normal like putting on your shoes or picking a pen off the floor. You may have just woken up with it or you may not remember at all when it started. This can leave you feeling confused and worried, and in a search for answers we begin the blame game.

The blame game!

Is it my mattress, is it those trainers, is it the cold weather, is it my posture or is it that old injury that I had 20 years ago coming back to bother me again? You may start to blame things that have never been a problem to try and simplify the problem. This can often lead to wasted money and time focusing on the wrong things.

So how do we explain low back pain that came on without an obvious cause, where should we be looking for the answers?

What can explain low back pain?

X-rays or scans?

The answers unfortunately are not always found in scans, pain is not something that you see. There are of course certain rarer causes of pain that can be found on a scan but more often than not tissue changes in the back as seen on scans are often normal age-related changes that go unnoticed by the body.  

Tissue changes on scans are often normal findings and don’t always contribute or lead to pain and are therefore unreliable in explaining low back pain.

Posture?

People often blame low back pain on their posture, but human posture is so variable, for any one person you find with a certain posture and low back pain, there will be millions of other people who have that same posture and don’t get back pain.

There is no evidence to suggest there is an ideal posture or that certain postures cause low back pain.

Why is it so hard explaining low back pain?

Let’s take one commonly mentioned cause of low back pain, muscle weakness in the ‘core’. To be able to say that this causes low back pain you would need to observe consistently high levels of low back pain in people with a weak ‘core’. However, when this is researched this is not what we find, there are lots of people with weak ‘cores’ that have never had any problems with low back pain. It doesn’t matter which single factor you pick, it will never consistently cause low back pain.

 A single factor is unlikely to explain your pain, our understanding of pain has moved on through years of research which has shaped our view and understanding of low back pain.

A more useful perspective on low back pain

We need to get comfortable with the idea that finding one thing that caused our pain is unlikely. We can however start to highlight multiple factors in your life and situation that are likely to have contributed towards you developing low back pain.  This way of looking at things takes into account how complex and unique we are as human beings and is likely to be much closer to the truth.

A multifactorial perspective on low back pain

Highlight the different factors unique to you and your story, below are some examples and areas that should help expand your thinking on what can contribute to the development of low back pain:

 Physical stressors:

• Exercising at a higher intensity than you’re used to
• Not exercising at all
• Sudden changes in physical demands at home, house renovations
• Any sudden increase in physical demand

Your biology:

• Medical conditions
• Specific spinal conditions/ tissue changes
• Genetics
• Old injuries
• Obesity
• Pregnancy
• Physical fitness and strength

Work Factors:

• Job satisfaction
• Physical demands of job role
• Levels of stress and pressure in work
• Sedentary job roles

Mental stressors:

• Low mood, anxiety
• High stress levels
• Feeling overloaded and inability to cope
• Feeling run down

Social Factors:

• Home life and level of support
• Level of responsibility and demand from family life
• Lack of opportunity to do things you enjoy
• Family illness
• Moving house
• Relationship problems
• Amount of free time
• Money troubles

The diagram above shows how multiple factors (blue arrows) tend towards a person getting low back pain, when combined together they exceed the threshold (red line) and low back pain occurs. The different size arrows show how different factors can contribute more than others, but this will be different for everyone at different times. The green arrows are factors that tend towards low back pain not happening, however, in the scenario above, the overall power of the factors tending towards low back pain is much greater.

Viewing your problem in this way will enable you to now focus on strategies to address the factors on the right and also enhance the factors on the left. Writing out your own diagram as above can help provide a visual aid of all the factors you may want to look at addressing.

Make sure you focus your energy on addressing factors that are within your control.

So, have we made sense of unexplained low back pain?

Cancel the new mattress, there are other factors to consider here. Hopefully you will now view low back pain more broadly, considering factors from all 5 of the areas above. Even if it prompts you to think less simplistically about low back pain and to consider other factors then it is a step in the right direction. It may also save you money, time and effort looking in the wrong places.

References: ‘A novel clinical framework: The use of dispositions in clinical practice. A person centred approach’ Journal of Evaluation in Clinical Practice. Matthew Low.