How can exercise and therapy help with chronic lower back pain?

If you are one of the millions of people in the country living with chronic lower back pain, it might feel that the last thing you want to do is take up exercise. You might also be wondering what the point would be in talking about the pain with a psychotherapist – what difference will that make?

NICE, the National Institute for Clinical Excellence (the body which recommends best practice treatments, based on high-quality research evidence, to the NHS) however, recommends both exercise and psychotherapy for the treatment of chronic lower back pain, especially where more traditional treatments have been tried but haven’t worked.

In this article, I explain how these two approaches can make a significant difference to someone living with chronic lower back pain. Let’s begin with understanding the three different forms chronic pain can take:

1. Nociceptive pain - this is pain resulting from an injury or tissue damage. 
2. Neuropathic pain arises from damage to or over-sensitization of the nervous system.
3. Functional pain is pain as the physical expression of emotional distress or pain as the physical memory of a traumatic event.

Stress, depression, and anxiety can make pain worse by reducing the amount of serotonin (one of the body’s natural painkillers), in the bloodstream, making the body more sensitive to pain. Reducing stress, anxiety and depression through psychotherapy can therefore have a direct and beneficial impact on pain.

How can exercise and psychotherapy help with these different forms of pain?

Nociceptive Pain

Exercise is often the best treatment if there is a physical reason for the pain. Lower back pain is often caused by inactivity – if you don’t exercise much, and spend most of your day sitting down huddled over a computer, the muscles in your lower back which stabilise the spine and help it to absorb the impact of force become weakened, meaning more of the work to hold you upright falls on the bones and joints of the spine. Vertebrae move closer together, putting pressure on the intervertebral disks, which can squeeze out of shape, pressing onto spinal nerves. This is what causes the pain.

Regular exercise, to improve your fitness in general, improve core strength, stability and endurance, helps you use your deep core muscles to stabilise the spine, keeping it in correct alignment with the pelvis and lifting the vertebrae up to take pressure off the disks. A personal trainer with the right experience can also show you how to stand and sit with good posture and how to move and lift heavy objects in ways that protect the spine.

Just being more physically active will always help, but core stability exercise, such as pilates is probably best. Stretching and mobilising the spine should always be part of the programme and your daily activities and a daily brisk walk is highly recommended. If you stand tall when walking, using your core to lengthen your spine and striding out, your body will use the elastic energy in your muscles, generated by walking, to support the spine, taking the pressure off the joints and stabiliser muscles. High impact activities involving jumping or running or lifting are best avoided until you've done the work on your core stability.

Neuropathic Pain

When nociceptive pain persists, the pain sensors in the brain and nervous system become over-sensitised and send out pain signals to the body, even if the impulses they receive from the cells in the affected area are getting weaker or have even stopped firing entirely.

Although you feel pain in your lower back, sensors in the muscles and joints in that area are signaling the pain sensors in the brain to alert it to possible damage in that area. The brain then analyses the information and if it decides there is a problem, sends pain signals back to the lower back to tell it should be hurting, to draw attention to the problem and find a resolution. The more information is sent, the more the system will expect to be told about potential damage and, eventually, it signals pain even though there is no longer any damage. This is chronic pain.

EMDR (Eye movement desensitization and reprocessing) is a wonderful therapy for addressing neuropathic pain, as it works at the level of the nervous system. EMDR was designed for use with trauma originally, using bilateral stimulation (directing the client’s attention from left to right, using eye movements, tapping and other methods, while remembering an aspect of a traumatic memory.)

This helps to process trapped or 'stuck' memories by alternating between left brain and right brain engagement and stimulating the brain’s natural memory processing system. This can move the memory into the brain’s library, the hippocampus, which understands time and place and can tell the difference between now when you are remembering the traumatic incident and two years ago when it happened. Problems are often caused by trauma if the memory gets stuck in the amygdala - the brain’s alarm system, which doesn’t understand time or place. If something happens to remind the amygdala of an earlier incident, it thinks it’s happening again and sends out the same stress hormones into the body to trigger the fight or flight mechanism.

It’s as if, even though in one part of your mind you know the incident is over and you’re safe, in another part, you are still in the middle of the trauma and can’t get away from it. EMDR connects the part of you that knows you’re safe with the part that still feels in danger, so that part can be reassured and helped to feel calmer and safer. This is called “adaptive information processing (AIP).”

AIP works with chronic pain too. Although the nervous system still thinks the lower back is damaged and should be feeling pain, another part of the brain / nervous system knows that the damage has healed and the body should be pain-free. Focusing on the pain, while undergoing bilateral stimulation helps these two parts of the body 'talk' to each other so that the areas of the brain sending out the pain signals can be calmed and the pain reduced.

Pain relief visualisations are used to relieve neuropathic pain, because of the posterior parietal lobe (PPL) area of the brain. This area processes pain and visual information, but can’t do both at the same time. Flooding the PPL with soothing, healing, pain-relieving information forces it to engage with the visual information and switches off the pain signals.

Nick Potter, an osteopath, in his book 'The Meaning of Pain' recommends learning to breathe properly (deeply and diaphragmatically) as a way of reducing pain. Many people, especially when stressed or anxious, tend to breathe into their chest, rather than deeper into the diaphragm, which alters the oxygen/carbon dioxide balance in the blood, making the body more sensitive to pain. Diaphragmatic breathing restores the correct balance and helps reduce pain. Stretching and relaxing the body, in combination with breathing can also help to calm pain -another good reason to take up pilates or yoga.

Functional Pain

A psychotherapist can help you with functional pain by helping you understand the buried traumas, memories and experiences which have become stored in your back and are causing the pain. Once these are brought to light, they can be worked through, talked about, and processed, which can have a beneficial impact on the pain.

We know anxiety and depression also make pain worse and working through these conditions in therapy also influences chronic pain. There is actually a high level of co-morbidity between depression and lower back pain, with perhaps as many as 30-50% of people living with depression also experiencing lower back pain. This could be because the pain itself is so difficult to live with it causes you to become depressed, or because, in serious cases of depression, you might be moving a lot less, due to having less energy and losing fitness and muscle tone.

Another view is that lower back pain and depression are the same thing - they are both expressions of distress, with one being the physical manifestation and the other the emotional manifestation. Whatever the link, moving more and talking about your physical/emotional pain will help.

A way to explore the meaning of your pain is to sit comfortably, with both feet on the floor, close your eyes and start to breathe slowly and deeply. Focus on the area where you feel the pain, and listen to it. What would your pain say if it could speak? What would it tell you about the stresses in your life, the traumas trapped in your body? Let your mind wander and see what comes up.

Exercise and movement also relieve depression and anxiety. Even if your pain is functional, the stiffness and discomfort your experience will feel physically real and could stop you from wanting to move. The right forms of movement will help relieve the discomfort directly by strengthening muscles and loosening joints and indirectly by acting on depression and anxiety (by increasing levels of serotonin in your bloodstream.)

What kind of pain do I have?

There is no difference in how these different forms of pain feel physically, so if your lower back pain is chronic (lasting for more than twelve weeks), the best place to start is to consult an osteopath or physiotherapist to check whether there is a physical explanation or a more serious cause of the pain. An osteopath or physio can also advise on what kind of exercise would be suitable. If no physical cause is found or the recommended exercises don’t make much difference, it could be time to consult a psychotherapist to explore whether there are any emotional or psychological issues contributing to the pain and how therapy could help address them.

Whatever the cause, working on the physical causes of the pain and talking about the experience can both help – move more / talk more!