Low Back Pain? Here’s How Your Brain Can Help
Old advice: Pain pills, high-tech tests, shots, and surgery. The latest science: Harness your brain, lace up your sneakers, and go low-tech.
After Marty Huggins fractured her lower back four years ago, she says she spent “two years lying on a fuzzy brown sofa in our family room. I was afraid I would hurt my back if I moved even a little.” The pain forced the 65-year-old from Stafford, Virginia, to retire from her job as a physical education teacher and competitive jump rope coach, and she stopped going to the gym completely. But despite countless visits to specialists, who performed tons of tests, gave her dozens of steroid shots, and regularly offered her opioid pain relievers, nothing helped.
The brain and low-back pain
Huggins started by researching pain-management programs and ultimately found the Chronic Pain Rehabilitation Program at the Cleveland Clinic, which was near the home of one of her daughters. Huggins enrolled in several classes on how the brain and body interact. She learned how to relax with mindfulness meditation and to tame her fear and anxiety about her back pain with cognitive-behavioral therapy (CBT). She also discovered the importance of good sleep and overcame her hesitation to start exercising again. Huggins even began taking an antidepressant, not because she was clinically depressed but because the medication helped turn down the volume on the pain messages sizzling through her nervous system.
“Now I hike Shenandoah Mountain. I go boating and fishing on the Potomac River with my husband and our grandchildren,” she says. “You really can calm your body down and change your brain to lessen the pain. I’ve never spent another whole day on that sofa!”
Could the cure for chronic and short-term back pain start with simply changing your attitude? The idea sounds crazy. Back pain causes real agony for 58 million Americans and fuels an $87 billion treatment industry of high-tech scans, spinal cord injections, opioid painkillers, and surgery. And yet the evidence continues to mount that these approaches may not help—and could even make things worse.
In the first study of long-term opioid use for back pain, published in March 2018 in the Journal of the American Medical Association, participants who took opioids had higher pain levels a year later compared with those who took acetaminophen or a nonsteroidal anti-inflammatory.
“Long-term use of opioids can actually worsen pain, along with causing dependence,” says Xavier Jimenez, MD, medical director of the Cleveland Clinic program that helped Huggins. Meanwhile, the latest research from prominent pain experts is revealing how surprisingly effective low-tech strategies can be. In a 2016 University of Washington study, for example, 342 people with chronic lower-back pain were randomly divided into three groups. Patients in one group got “usual care”—whatever treatment and advice their individual doctors provided. Along with receiving any medical care needed, a second group practiced mindfulness meditation and yoga and the third went to CBT classes for eight weeks. About 44 percent of people in both the meditation and the CBT groups had felt better six months later, compared with just 26 percent of the “usual care” group.
“Mind-body therapies and physical therapy are often as effective as or more effective than surgeries and injections, despite seeming less ‘medical,’” says Dr. Jimenez. “They’re also safer.”
You can’t always outsmart low-back pain
Despite how well they may work, mind-body therapies aren’t recommended in every case, of course. Some pain requires more invasive methods and even emergency treatment. If your back pain comes with bowel or bladder problems, or if you have progressive muscle weakness in your legs—for instance, if your knees keep giving out or you keep tripping—call your doctor right away or go to the emergency room. These are the other signs your back pain is an emergency.
“If the pain radiates down your leg or causes numbness and tingling in your leg or foot, see your doctor. It could be a compressed nerve root that needs attention,” says back pain researcher Anthony Delitto, PhD, PT, dean of the School of Health and Rehabilitation Sciences and professor in the Department of Physical Therapy at the University of Pittsburgh.
Back pain that lasts 12 weeks or more is considered chronic. If the cause isn’t obvious (a fall or a car accident, for example), don’t just treat the symptoms with, say, a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen. It’s important to work with your doctor to figure out what’s going on. “Pain can be a signal of ongoing tissue or nerve damage or spinal problems that need to be addressed,” says pain scientist Beth Darnall, PhD, an associate professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine.
If your back pain is new, continue your daily activities, but take it easy when exercising. Most of the time, you’ll start feeling better within three days. Once you’re on the upswing, talk to your doctor about incorporating the following strategies to help you stay pain-free.
Exercise on your own or in physical therapy
Walking and other activities can improve your back by strengthening muscles, relieving tension and stress, helping with weight control, and—bonus!—triggering the release of feel-good brain chemicals. In a 2013 Israeli study of 52 nonexercisers ages 18 to 65 with lower-back pain, a treadmill-walking program did as much as back exercises to bolster supportive “core” muscles and improve the patients’ ability to perform day-to-day activities.
Don’t like walking? “Try an elliptical trainer, a bike, swimming, or any other activity that’s fairly easy on your back but lets you move,” Delitto suggests. “If you feel some discomfort, try to continue for 10 to 15 minutes. Then reassess how you feel a few hours later. Chances are, you’ll feel better than before your exercise session.”
Other research suggests that yoga may be as good as physical therapy for chronic low-back pain. In fact, yoga and tai chi are among the nondrug therapies that the American College of Physicians recommends back-pain sufferers try before turning to pain relievers, especially prescription-strength ones. In one recent national survey of people with back pain, 90 percent who tried yoga or tai chi experienced relief, compared with 64 percent who simply followed their doctor’s advice. (Here are some other lower back pain treatments that really work.)
If you’re nervous about exacerbating your back pain when you exercise, ask your doctor for a referral to a physical therapist. In a May 2018 study, researchers found that people with lower-back pain who tried physical therapy before other treatments were 89 percent less likely to need opioids and 15 percent less likely to end up in the emergency room.
Harness your mind
Pain scientists are looking closely at an all-too-common mindset known as catastrophizing. “It’s normal to protect your back when it hurts,” Delitto explains. “But for some people, this leads to worry that any movement will do more damage. So people stop exercising, stop going to work, stop doing everyday activities. That leads to weaker muscles, stiffer joints, weight gain, and depression and anxiety.”
Catastrophizing plays a major role in whether acute back pain becomes chronic and how well people respond to treatment. It has also been linked to greater dependence on opioids. Catastrophizing may even feed into “central sensitization,” a cruel feedback loop in which the brain interprets little twinges as agony. Your mind might be one of the surprising reasons your lower back pain treatment isn’t working.
“Research shows that when catastrophizing is treated, pain intensity decreases. Daily functioning improves. And the structure of the brain in areas involved with pain processing actually changes, so that the benefits persist,” Darnall says.
Mind-body therapies such as meditation, progressive muscle relaxation, and deep breathing help calm your nervous system so it doesn’t react as strongly to pain. CBT, which helps you spot negative thoughts and craft positive alternatives, can stop the cycle of fear.
“Thoughts like ‘I can’t do any of the things I love because of my pain’ can be replaced with thoughts like ‘There are many things I can do today despite my pain’ and ‘Even though I feel challenged right now, I can use several strategies to help calm and soothe myself,’” Darnall explains.
It doesn’t take much time to make a difference. In a 2014 study of 76 women and men with a variety of chronic pain problems, Darnall found that just one two-hour session of CBT helped participants catastrophize less within a month.
Make deep sleep a priority
Nearly six in ten people with back pain say it interferes with sleep, which sets off a vicious circle. “Sleep is our body’s way of natural recovery,” notes Kevin Ho, lead researcher of the University of Sydney’s Musculoskeletal Research Group. “Emerging evidence suggests that disrupted sleep may upset body processes, including pain sensitivity and inflammation in the brain and spinal cord.”
A recent University of Sydney review of 24 studies involving more than 1,550 women and men took a closer look at how much sleep can help back pain. It found that people who tried CBT or took melatonin or eszopiclone (brand name Lunesta) had a 35 percent improvement in sleep and a 14 percent improvement in pain.
Just adjusting your sleep position could help. In a 2015 Portuguese study of 20 women in their 60s with lower-back pain, those who slept on their sides with a pillow between their legs or on their backs with a wedge pillow under their knees reported significantly less back pain after four weeks than a control group that didn’t change their nighttime positioning. In other research, exercises that strengthen core muscles in the torso reduced back pain, improved sleep, and helped relieve depression and anxiety. Consider trying these expert-approved home remedies for back pain.
Add low-tech soothers
Recent research has confirmed that massage and heat not only feel good but also can deliver lasting relief for chronic low-back pain. In a study published in the journal Pain Medicine, participants got ten massages over the course of 12 weeks. Half reported clinically meaningful pain improvement during that time, regardless of the type of massages they enjoyed, and most continued to feel better at 24 weeks.
Similarly, by boosting blood flow to the area, heat wraps, patches, and creams help ease back pain caused by muscle aches, according to a 2016 analysis in the Journal of Chiropractic Medicine. In addition, studies have shown that massage and heat help people get and stay more active, which also eases pain.
Over-the-counter transcutaneous electrical nerve stimulation (TENS) devices use a low-voltage electrical current to increase blood flow. In a 2019 Harvard University study, back-pain sufferers who used a TENS device experienced significant drops in pain and improved quality of life.
- Journal of the American Medical Association: "Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain"
- Xavier Jimenez, MD, medical director of the Chronic Pain Rehabilitation Program at the Cleveland Clinic
- JAMA: "Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial."
- Anthony Delitto, PhD, PT, dean of the School of Health and Rehabilitation Sciences and professor in the Department of Physical Therapy at the University of Pittsburgh
- Beth Darnall, PhD, an associate professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine
- Journal of Pain Research: "From Catastrophizing to Recovery: a pilot study of a single-session treatment for pain catastrophizing"
- Kevin Ho, lead researcher of the University of Sydney’s Musculoskeletal Research Group
- Osteoarthritis and Cartlidge: "Sleep interventions for osteoarthritis and spinal pain: a systematic review and meta-analysis of randomized controlled trials"
- Work: "Effects of sleeping position on back pain in physically active seniors: A controlled pilot study."
- Pain Medicine: "Real-World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study."
- Journal of Chiropractic Medicine: "Effect of ThermaCare HeatWraps and Icy Hot Cream/Patches on Skin and Quadriceps Muscle Temperature and Blood Flow"
- Pain Practice: "Outcome of a High-Frequency Transcutaneous Electrical Nerve Stimulator (hfTENS) Device for Low Back Pain: A Randomized Controlled Trial."
- The Korean Journal of Pain: "The effect of stabilization exercise on pain-related disability, sleep disturbance, and psychological status of patients with non-specific chronic low back pain."
- Pain Research and Management: "Effects of a Pain Catastrophizing Induction on Sensory Testing in Women with Chronic Low Back Pain: A Pilot Study"
- Journal of Pain Research: "From Catastrophizing to Recovery: a pilot study of a single-session treatment for pain catastrophizing."
- Journal of Manipulative and Physiological Therapeutics: "Association Between Symptoms of Central Sensitization and Cognitive Behavioral Factors in People With Chronic Nonspecific Low Back Pain: A Cross-sectional Study."
- The Journal of Pain: "Cognitive-Behavioral Therapy Increases Prefrontal Cortex Gray Matter in Patients With Chronic Pain"
- European Journal of Pain: "Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial."
- European Journal of Pain: "Cognitive functional therapy in patients with non-specific chronic low back pain-a randomized controlled trial 3-year follow-up."
- European Spine Journal: "Prevalence of sleep disturbance in patients with low back pain."