I turned 29 a few months ago, which means I have lower back pain. I’m not sure why it means that, but I think literally every man reading this will wince in agreement. This lower back pain has been coming and going intermittently since I was about 23. It gets worse when I sit for a long time or do Brazilian Jiu Jitsu (a hobby that, perhaps not coincidentally, I picked up at age 23), and gets better when I do active stretching and light exercise involving my core and legs.
This problem is annoying enough that I’ve paid a fair amount of money to see physical therapists to try to fix it. Unfortunately, the advice and fixes I’ve gotten haven’t been great. The diagnoses seem to be all around muscular imbalances: the right muscles are too strong compared to the left, the glutes aren’t strong enough compared to the lower back muscles, etc. Then, as the explanation goes, the strong muscles pull stuff out of position and the weak muscles can’t resist. This causes back pain. The treatment is then to stretch the strong muscles and strengthen the weak muscles, restoring muscular balance.
I’m not a fan of these diagnoses/treatments for a few reasons. First, the treatment seems to be the exact same thing that I’ve been doing on my own, so I’m not sure why I had to pay money to hear this. Second, I’m going to have to keep doing these stretches/exercises forever, apparently. And third, there’s no way to falsify these diagnoses, so they’re not really scientific. They’re more just a guess. If they stop working, or if my back pain gets worse, I don’t have any way of modifying them.
Over the past several years, I’ve been very interested in finding a quick, permanent fix for my back pain, as I don’t like relying on something that I have to do continually and I don’t really understand. One “permanent” fix that I’ve tried a couple times is chiropraxy, even though I’ve always had my doubts. There seems to be a very wide variation in the quality of chiropraxy, but the best chiropractors seem to rely on a theory of nerve compression. Funnily enough, this is also the theory that back surgeons rely on, so I thought it’d be worth looking into.
As the chiropractic/surgical explanation goes, back pain is caused by something compressing the pain nerves in the back. This can be caused by a “subluxation”, the displacement of a joint 1. Or it can be caused by a herniation, which is the bulging of a spinal disc out of its normal cavity. This is normally due to a tear in the casing that keeps a spinal disc stuck in its proper cavity. Either way, bone or cartilage ends up where it shouldn’t be, compressing pain nerves and triggering pain signals.
From there, chiropractors and surgeons differ greatly in their proposed solution. Chiropractors want to pop joints back where they should be, regardless of whether they’re discs, vertebrae, or anything else. Chiropractors believe that if you can force a joint back in its proper place, it’ll stay stuck there, at least until your next chiropractic visit. If you don’t force a joint into its proper place, it will stay stuck outside, causing pain.
Meanwhile, surgeons disagree. They don’t think that it’s possible to just force a joint back into place permanently. If you force it back in, they argue, it’ll just pop out the same way it did before. So the surgeons believe that if there’s a displacement of a spinal joint (a vertebrae), the surgeon needs to force it back in and then mechanically attach it to its fellow vertebrae using brackets, so it never escapes again. If there’s a bulging disc, on the other hand, surgeons will simply cut out the part that bulges, a procedure called “discectomy”, without worrying about forcing things back in.
I like the idea of forcing joints back into place, which is why I tried chiropraxy 2. As someone who recently dislocated and then personally relocated my knee cap, I can tell you that there is a profound difference in pain levels when a joint is out of position vs. into position. If a joint is out of position, it would make sense that it would cause pain. It would also make sense that pain levels could be drastically and permanently reduced as soon as the joint was popped back in.
I think that’s how both chiropractors and surgeons think about it, too. Every chiropractor has presumably seen someone undergo immediate pain relief when a joint that was out of position gets forced back in. Meanwhile, every surgeon is aware of what can happen when a disc bulges severely enough to cause something like cauda equina syndrome, in which a disc ends up compressing the cauda equina nerve bundle in the lower back so badly that people lose bowel control.
In retrospect, though, I’m not sure this was the right way for me to be thinking about my lower back pain. My lower back pain comes and goes and has no other obvious symptoms. That doesn’t fit in with my experience of having a dislocated joint, which was a constant, sharp pain that did not seem like it was going away anytime soon. I also experience no loss of mobility with my back, even when I’m experiencing lower back pain. Presumably, given that the entire purpose of joints is to allow bones to move relative to another, any dislocated joint should make it difficult to move the affected bones.
Unfortunately, this realization only came after I spent several hundred dollars on chiropractic treatments and got very confused going down the rabbit hole of controlled trials on treatments for back pain, very few of which actually try to segment people by cause of their back pain. Well, live and learn.
Anyhow, after my youthful experimentation with chiropraxy, I started to think that lower back pain like mine, which comes and goes and has no other obvious symptoms, would seem to require a cause that also comes and goes and wouldn’t cause any other symptoms.
Muscle strain would be one obvious option, of course. It gets worse when I overtrain my muscles (or the wrong muscles), and better when I rest my muscles, or retrain the right ones. But there’s another option here: the “nocebo” model of back pain, popularized by Dr. John Sarno.
This proposes that, in the same way patients receiving placebos can psych themselves into feeling the side effects they expect to get, Westerners can psych themselves into feeling the back pain that they expect to get. Specifically, Sarno argued that Westerners somaticize stress by turning it into back pain3. So, the way to fix back pain is to fix how we deal with stress.
When I first read this, it seemed plausible. I have experienced stomach pain from anxiety, so it doesn’t seem crazy that I could experience back pain from stress. However, when I thought about it more, it didn’t really fit into my experience. I get back pain most often after jiu-jitsu practice, which isn’t particularly stressful but does require a lot of back muscles.
I do occasionally get back pain when I’m stressed at work, to be fair, so there’s probably something to the nocebo effect. However, even if that is an accurate partial diagnosis, it’s even less helpful than muscle strain. I already try to reduce stress because it’s unpleasant in and of itself. That’s like half the reason I exercise, ironically. Transforming my problem from “find a quick, permanent fix to your back pain” into “find a quick, permanent fix for your stress” isn’t super helpful. Both are difficult.
So, at the end of it all, I just ended up being stuck back at treating everything as muscle pain. Now, whenever I experience back pain, I stretch my hamstrings, groin, and obliques, then do some “good morning” exercises with no weight. It seems to work ok for now. Hopefully it will continue to do so.
Both doctors and chiropractors use the term “subluxation”, but chiropractors are looser on their definition. Doctors believe that any displacement has to be visible on an x-ray in order to be considered a subluxation, while traditional chiropraxy doesn’t consider that a necessary condition. Instead, traditional chiropraxy basically says, “If we fixed your back pain with a spinal manipulation, it was a subluxation”, which is obviously problematic, given the placebo effect. Some modern chiropractors have moved more towards the medical definition, though.
I feel like surgery itself is too dangerous to be done without exploring every other possible option. I especially think surgeons discount the dangers of anesthesia, as up to 1 in 3 patients will experience some period of cognitive decline after anesthesia. Basically, I don’t want to go under unless I’m desperate and have no other options.
He also argued some other stupid stuff regarding pain being caused by decreased blood flow, but we can ignore that.