Back pain steals your freedom, core connection, and healthy movement. Bring it back. So before we get started, I want you to strap your walking shoes on or better yet, no shoes at all.
Grab your headphones and get your body moving while you listen to the insights that helped me climb out of a decade-long struggle of debilitating lower back pain and led to the creation of core balance training, which has helped thousands of people climb out of the back pain spiral for good. Welcome to the Back Pain Podcast by Core Balance, where we share practical insights to address back pain at its root. I'm your host, Dr. Ryan Peebles, doctor of physical therapy specializing in spine and core rehabilitation.
Each episode brings you a recording of one of my live sessions with my students. We start with a focused topic on back pain, then move into a live Q&A where I answered real questions in real time. My hope is that these episodes get you on the path to climbing out of the back pain spiral for yourself so you can live life the way that you want to.
Let's dive in. This week's topic is pain. We're going to talk about some of the aspects of pain that are maybe not so well known and the psychology side of pain, the side of pain where it's not so much a physical stimuli that causes the pain.
I first started learning about this aspect of pain, the psychological side of pain in physical therapy school. They teach it to health care professionals, but I feel that it's not enough to the general population. And so that'll be one of my goals today is to just give you a better understanding of what pain is and the different factors that influence pain.
I will warn you, this topic could potentially be offensive. It could be interpreted as offensive. And so I want to start out by saying I'm not trying to minimize the significance of pain.
Pain is very real and it is, even if it's influenced by psychological factors, it's still real and you still feel it. It does not minimize the significance or the impact that pain has. So pain is not just about the tissues of the body, tissues being anything physical of the body, right? Bone, ligament, tendon, muscle, anything that is a physical cell would be considered a tissue.
And that's not the only thing that is what causes pain. Pain is actually completely created in the brain. It's an interpretation of signals that are sent from the cells of the body.
And the design of pain is to protect you from potential harm or damage. And so it is the last thing that happens. It is the end result, as I talk about in the master class.
And there are many factors that go into pain. So let's talk about some of those factors. The perception of pain is influenced by several, what they would say in the medical world, non-physiological factors.
I'm calling them non-tissue factors because I don't know if physiological really makes a lot of sense to everyone. So non-cell or tissue factors. So personality, your thoughts, your beliefs, socio-cultural variables, put a star next to learning.
I think learning is one of the most significant, in my personal opinion, influences on the pain that we feel and emotional reactivity. What I'd like to accomplish with you is to just help give you a better understanding of where pain comes from and why and what could be potentially magnifying your pain if it's chronic and with the goal of you being able to better understand that and empower yourself so that the pain may not be as significant to you or as scary as it potentially could. Just knowing that pain may not be an accurate reflection of tissue damage.
When pain persists, the brain cells that produce pain, they get better at producing pain. So persistent pain would be chronic pain, right? So they get better at it. They get stronger.
They get more sensitive to stimuli. So it takes less of a stimulant or less influence to create the same or potentially even more of a reaction. And another thing that happens is these cells lose their capacity to be specific.
So you could imagine they get kind of desensitized to the location or the specificity. And so when they become less precise, then the pain just gets more generalized and it spreads. And there's actually a name for this in the medical world.
In medical terminology, it's called central sensitization. It's a diagnosis that people can get when chronic pain persists. And it's just something that is unchangeable.
And so we're going to talk briefly about central sensitization. I just want to educate you about this so that you know it exists. And I'm, again, not trying to minimize the physical nature of pain where pain is created by what would be called a noxious stimuli or something that actually causes damage in your body.
That still is real and that does exist. It's just good for us to also be aware of this other side of pain where stimuli that are not harmful can have the same effect, especially if the pain's been going on for a while. All right.
So this is a journal. Last week, we got into a lot of research. I'm not going to do that.
Last week's topic was imaging. And we kind of showed that damage in the spine is not correlated with pain. People can have tons of damage in the spine and zero pain.
And people can have tons of pain, very little damage to the spine. So there's a very poor correlation between tissue damage and pain. That was very research heavy last week.
I'm going to try and stay away from that this week. So real quick, central sensitization is a generator of pain hypersensitivity. And this is in the brain, basically neuroplasticity.
It means changes in the brain. I'm going to just go to the summary here. And I wanted to emphasize this.
It says, because central sensitization results from changes in the properties of neurons in the central nervous system, aka brain, the pain is no longer coupled as acute nociceptive pain is, which is like immediate trauma. That would be coupled. But central sensitization is no longer coupled to the presence, intensity, or duration of peripheral stimuli or harmful stimuli.
Instead, central sensitization produces pain hypersensitivity by changing the sensory response elicited by normal inputs, including those that usually evoke inoculus, which would be not harmful sensations. And so really what I just imagine in my head is you have these highways or pathways. You can think of them just like highways where pain travels down nerves and the nerves are the highways and the pain is traveling down them.
And they get so commonly used, so trafficked that they grow bigger. The highways grow larger and they can hold more painful stimuli going down them and everything gets emphasized. So unlike nociceptive pain, which warns of potential damage in response to noxious stimuli, central sensitization creates a situation in which pain is elicited by inoculus or not harmful stimuli.
And so these highways, they become the default firing pattern and they just continue. They persist. Just like the pain, they continue to be the normal pathway of sensation.
Instead of, you know, a side road that you can take when necessary, it's the normal pathway. And so we're always feeling it. This change is protective because it helps healing by limiting use of an injured body part until the injury is fully repaired.
So that's the body's intention. And so what we end up doing is we limit the use of our back, of our spine, and it's right in the middle of our body. So we limit activity.
And so this is not a good thing for chronic back pain. And it's part of the cycle. We feel the pain, we limit use, and that causes the problem to get worse.
And so as with someone with chronic lower back pain or chronic pain of many types, needs to learn to continue to use their body despite the persistence of the pain. Because you've now learned that the pain is not an accurate reflection, that damage is still happening. Central sensitization becomes pathological if inflammation persists.
Something like rheumatoid arthritis is a really good example of this, in which no healing is occurring, but the pain continues. This is just a bunch of big words to say that there's no more stimulation, but the pain continues. Central sensitization represents not only a state in which pain can be triggered by less intense inputs, but in which the central sensitization itself can be maintained by a lower level or even a different kind of input.
It could be something as simple as being late for work that can trigger the pain in the because it's become so sensitive that very little stimuli can trigger it. So done with the research. There's one other thing that this is not research, but this is just a website I found and I thought that I read the whole page.
I thought it was very helpful. And so this is like, how do we address this? What do we do about this? And so I thought it was kind of practical to share. So interventions aimed at enabling patients to break out of this loop that they're calling it and change their perception of pain may be more effective than interventions that appear to endorse the patient's view that the pain is a result of a problem and that it needs to be solved with pain relief.
So we get ahead of the pain, we get above the pain, upstream of it, and we know why it's happening. We know that it doesn't make sense at a certain point. And so that itself, that knowledge, as I continue reading, you'll see can have a really big effect.
Psychotherapy, for example, can produce long term changes in behavior through learning, which generates changes in gene expression that alter the anatomical pattern of interconnections between nerve cells of the brain. So basically what that means is learning changes the brain. And just learning stuff like this can change your pain pathways.
It can have a really powerful impact, more effective than traditional pain management where you go see a doctor that's going to just treat the pain for the end result that it is. When we treat it with our mind, it can be more effective. So the regulation of gene expression by psychosocial factors makes all bodily functions, including the brain, susceptible to psychosocial influences.
So that's it on research. I did not want to spend too much time with this, but hopefully that was helpful to someone. If I can help one person, then I've done my job today.
I just shared my book list in the program. I'm not sure if you're in the program or not. But I had a discussion with a student in the program, and that book came up.
And that book, the one is Healing Back Pain, the Mind-Body Connection by John Sarno. It was a pivotal moment in my life. It wasn't the complete solution to my problem.
There were also physical components, as there typically are with back pain. But it had a pivotal effect on my life with just the pain itself. And so I'm glad that you're aware of that book.
I was going to spend a lot of time talking about that book on this stream, but I just highly recommend everyone read that book. So some conclusions from Lorimer-Moseley, the research, and just what we've learned is that pain, especially chronic pain, is no longer helpful. It's not accurate.
It's not informative. It just becomes a pattern of behavior. And there is definitely an element that may have originally caused the pain that still exists, but we can no longer trust the pain itself if it's been going on for a long time.
It's likely heightened, and it's likely spread, and it's likely highly sensitive, because that's what happens with nerve cells. They can become more sensitive. So chronic pain does not accurately reflect tissue damage.
You can have pain, you can be sitting there in pain right now, and have no damage happening to your body. That's what that means. And that's actually what we found last week too with the imaging, with the people who have lots of pain and little to no damage, and the people on the other end of the spectrum who have lots of damage in their spine and no pain.
And just taking this into account, that there may be an illusion happening, and this illusion is trying to protect you from something, but that thing, it may not need protection. Learning this can have a positive impact on your relationship with your body and with the pain. And all that said, pain is still very real.
We feel it. It's the end result of all these processes. Even if the processes are related to our past experiences, or our childhood, or heightened sensations, heightened, more sensitive nerves, it's still very real.
But I encourage you to empower yourself. The act of learning this stuff, the knowledge that you are gaining by attending this stream, or doing whatever else, reading the book by Dr. John Sarno, it can change your brain. And it can make your pain less scary.
It can give your pain less power. And what that can do is it can give you more power over your own body and your life, knowing that you're not hurting yourself. You're not causing damage just because the pain is there.
That's a lot less scary to me. I don't know about you. I'm going to get into some questions that we've had from core balance training students lately, this week.
I've had a lot of questions, kind of oddly, about hamstrings in the past week or two. So we're going to talk about hamstring cramping. It may not be relevant to everyone, but if you're in the program, it's probably something you've experienced when doing the bridge.
And so I'm not going to read all these questions. But basically, everyone in this post is saying, I'm having cramping while doing the bridge. And is that okay? And should I do something differently? And actually, one of the people, Bill, who posted this, is in day one getting hamstring cramping.
So I'm just going to give kind of an umbrella answer that hamstring cramping is okay. It's expected and normal when doing the bridge in the beginning, because the hamstrings, without getting too deep into the anatomy, the hamstrings are in a very shortened position in the bridge. You have your knees bent pretty far, and you have your hips extended, which puts the hamstrings kind of at a mechanical disadvantage.
And it's a very vulnerable position for them. They typically don't exercise in that position. If you can imagine, the bridge position is not a common position for strength training or exercise.
And so when muscles feel vulnerable, and they don't feel safe, oftentimes what they do is tighten up or cramp up. And so it's just kind of like a reaction. It's a protective mechanism that actually tends to go away pretty quickly if you continue practicing and doing the bridge, because they get stronger.
They get more comfortable in that unusually shortened position. And it could only take like two sessions or maybe a couple days, maybe a few days at the most for the cramping to go away. So my advice for everyone is just to stick with it.
Don't be scared of the cramping. D says spasms. I'm not 100% sure if this refers to cramping.
If it's spasms, because spasm could be referring to like a more of a neurological thing. And so I just wanted to clarify with you, D, that if it's not cramping, if what you're experiencing is not cramping, and it's spasms from like a nerve impingement, then my answer would be different to you. Is it cramping or is it spasms? I just assume it's cramping because it's doing the bridge, and it's obviously a very common thing.
So anyway, yeah, the cramping goes away pretty fast, pretty magically, and it's nothing to be worried about. Michael, I see that you said you're in the program. That's great.
Sounds like you're doing pretty well. I can definitely talk about cycling, and this next question will be about driving. So the topic is transportation.
Let me just read your question a little bit more thoroughly. So you're an avid cyclist. You love road cycling.
Any tips for what you should be conscious of? So cycling is repetitive, and it's also in a very closed down posture, very almost like the fetal position, right? If you took someone in the cycling posture and you laid them down sideways on a bed, it's pretty close to the fetal position, which is the pattern of posture that we are trying to reverse. And my advice to someone who spends a lot of time on a bicycle is to counterbalance those effects because you're exercising your body, you're training your body in this closed down position. So we want to do what some people call cross training to open it back up.
And the bridge is the perfect thing for that, right? So cycling, closed down hips, bridge, open up hips. So I would recommend doing that after cycling. And then during cycling, I call it core... Whatever I'm doing, I call it core fill in the blank.
So core cycling would be just in your mind, thinking about the movement that you're doing originating from your core. And so with cycling, the pedaling motion, the initiation of that motion starts in the core. It's your powerhouse.
And so trying to shift your center of energy into your core, and then the legs are more of a peripheral activity rather than the main focus. It's really effective. I do it with riding a bike as well.
It just gets that core a little more engaged and there can be less focus on the quads and the hamstrings. So I would say try that. I wouldn't suggest too many different things because that's a lot to focus on just right there.
I'm going to read your notes you just posted. So after 45 minutes of a hard ride, you get low back cramp. So it sounds like you fit the bill exactly.
So it's the tight hip flexors that are bothering you. Standing up on the bike is the relief. And so if you could figure out a way... And I know there's, you know, positional stuff like raising your seat and you can get the handlebars better.
And so I'm sure you're aware of that stuff since you're avid. But I'm going to focus more on how you're using your body. And if you can get yourself to shift... There's a shift that takes place if you can like harness this intention where the main focus, the main muscle group that you're using shifts into the core.
It can have a pretty powerful effect on letting the other muscles that may have been the main focus in the past just kind of let off a tiny bit. And over thousands of cycles, thousands of pedals, that can have a pretty large impact. So I'm going to stick with what I said.
It sounds like the hip flexors are the problem. I would be maybe doing the bridge before your ride as well to open those up. Because the bridge, what it does is it lengthens the hip flexors with a long-term effect.
Like it will last through your ride. And I'm guessing you have clip-on pedals. And that's if you're pulling up with your thighs, pulling up on the clip-ons, that's hip flexors.
So you're going to want to definitely have your core engaged to protect your spine. It's the same motion as the dying bug. You've been through that.
The back anchor challenge. It's week four, module four. It's that same motion where you're staying connected to your back anchor.
And this is true for everything. So if you're listening and you're not a cyclist and you don't ride bikes, it can be applied to any activity. I do it with paddling on a surfboard.
I call it core paddling. It's my arms doing the motions, but the origination of my movement is in my core. And it has a really powerful effect.
So maybe pull up a little less on those clip-ons, Mike, and do more pushing. Remember the push away concept. It's really powerful.
So I would shift to doing, if you can, and I know if you're like in races and stuff, I don't want to be messing with your time, but the pushing is a healthier motion than pulling or lifting. Pushing away. And even if you are lifting, think about from a push away perspective.
This question is from Michelle. Her biggest pain trigger is the car. And she wanted to know if I have any suggestions for the best way to sit while driving.
What she should be doing with the core when she's in the car. So I've had this question from other students as well. The position of a car is not ideal and that's not much we can do about.
The best thing you can do is get yourself a bike, Michelle, if we're talking about cycling, right? But if you can't get yourself a bike and even an electric bike, which is happening a lot in this town, in the town I live in, Santa Barbara, people are replacing their cars. I have several friends that have done it with electric bikes. And now they travel to work or school or wherever on their bike because it's awesome for many reasons.
But if that's not possible for you, you got to stay with the car. Then we got to make it as ideal as possible. And so the reason a car position is not good is because your butt is so low and your knees are lifted up and your legs are out in front of you.
So you're not really using your legs at all in sitting. It's just like all 100% of your body weight right on your butt and right on your spine, really. And so the way to balance that out would be to scoot your seat back as far as possible.
So this is more ergonomics. And then we'll get into the second part of your question is what to do with your core. So scoot your seat back as far as possible.
Actually, we're going to tilt your seat back as vertical as possible. And that's not so much for your lower back, but it's for your neck and your upper back because if you're leaning, if your seat back is reclined and then you don't want to look up at the sky while you're driving. And what that does is it causes really poor rounded shoulders, forward head posture.
And so by bringing the seat from reclined like this to vertical, we can have a much better posture for our upper back and our neck. And since the back and neck are connected with the lower back, then it probably has a positive impact on the lower back as well. So we've got the seat back as far as possible.
We've got the backrest as vertical as possible. And then if you do have a setting for elevating the seat, then I would recommend like I drive a minivan. And so they have all the cool amenities in minivans.
So I can actually raise my seat up a little bit. And so I do that. So that's another, for some people, another option.
All right. So that's positioning and what to do with your core. This is something I've been doing for a while.
I think it's pretty effective and it just, it's a little trick to kind of activate the core very subtly. Like we're talking 2%. Remember, I'm all about subtle.
And that's because the stuff we're learning, you need to be able to do all day long. And if you go high intensity, not only does it use the wrong muscles and contributes to the problem, but it's not sustainable. You can't do it all day long.
And driving, if you're on a long drive, I'm not going to be suggesting doing abdominal contractions for a two hour drive, right? So very subtle. And if you've got your hands on the wheel, so gently pulling on the wheel, like a very gentle one pound of pressure pull towards me. And that pull can have a bit of an activation on the core muscles.
It gives you a little bit of a tactile cue, some feedback, some tactile feedback that can allow you to better connect with your back anchor very subtly, very gently to the back of the chair, depending on the type of chair or backrest you have. And then the other thing would be the breathing. So there are things you can do at the end of the day.
Driving is not ideal, especially if you have a problem, a left to right imbalance. Using that right leg, always the hip flexor being active on the gas and the brake. There's another thing that's just not very ideal.
And so if you're on a highway, a long drive, if it's not raining, then I would suggest using the cruise control whenever you can. Let's just be safe with it. You're not supposed to use it when it's raining, right? People don't know that in California because it doesn't rain here or Southern California.
But I'm sure if you live somewhere where it rains, people already know that. So yeah, that's it. Gentle core activation with a slight pull on the wheel, and that can help you just connect to your back anchor, and then breathing into the back.
Sending the breath down. In the first lesson of the program, we teach sending the breath into the lower back, but you can actually get a lot of decompression by sending the breath down into the pelvis. It's more of a vertical reaction than the expansion in the lower back, and that can help with driving.
Take frequent breaks, and then if you can, I can't be recommending stuff like this, but I'll just say that I've done this on long drives. You can do the figure four stretch, where you get one ankle over the knee, and just do different movements. The body loves variety.
The body loves movement. So figure four stretch over the knee, and get creative with some other movements you can do as well. We'll get on to the next.
Does sleeping position matter? Yes, it matters. Is it something I'm going to recommend? I try to avoid it, because sleeping is very personal, and I wouldn't want to recommend something and have an impact on somebody's, a negative impact on somebody's ability to sleep. I would say just do what feels best for you.
If I said, like, in a perfect world, what is the best sleeping position is probably on the back on a firm mattress, but I don't do that, because I try to, but I don't all the time, because I tend to like sleeping on my side. Side sleeping is a little more comfortable on a softer mattress, because of your shoulders, and sleeping prone on the belly is probably pretty cool for the lower back, but not so cool for the neck. So there's no clear obvious answer.
If you can sleep on your back, and you have a firm mattress, then you're probably winning, but if you have a soft mattress, I don't think sleeping on your back is ideal. If you think about where we came from, and a long time ago, before mattresses, we probably slept on a firm surface, and because of that, we probably more often slept on our back. So mimicking what we did for hundreds of thousands of years is probably the most natural.
Guillermo, we've got a follow-up question on driving. We've got, while in the car as a passenger or driver, is doing any back anchor recommended? Yeah, so that's what I was talking about with just the gentle pull on the driver's wheel that can help you to connect to your back anchor. It just provides like a little change.
I find that trying to connect your back anchor while driving, without giving a little pull on the wheel, it's just hard to get that feedback, and so adding that little gentle, it's just a little feedback from the steering wheel, can allow you to connect to your back anchor. So yes, I think that's great, but very subtle, you know, two to five percent, and breathing. Breathing you can be working on all day long, and I don't have a problem, you know, the amount of time that you spend working on that, or even the intensity.
Okay, here's my conclusion. To me, it's the most important thing, is just to be aware that pain is not, when it's chronic, when it's persistent, it's not trustworthy anymore. It may not be a reflection of damage, or harm, or danger to the body anymore.
It, in many cases, very commonly, may be just heightened sensitivity of nerves, due to prolonged pathways, firing patterns of nerves, that have, it's been going on so long, it became the default sensation that you feel all the time, or nearly all the time, because that's the way that the electricity fires through your body. And so it's up to you to determine that. There are certain types of pain, like sharp pain, and certain neurological type pain, like sciatica, that can be reflective of a physical thing, a nerve being impinged.
So that's for you, or if you're with your doctor, you can talk to them about it. That's for you to decide. But if you feel intuitively, like your pain could just be something that's been going on for five years, or not even, doesn't have to be that long, and it's just kind of spread out, and just very persistent, then I would consider this idea, that we know from the research now, that it might not be a reflection of any damage to your body.
And that is less scary. The pain is less power when it's not hurting you from a structural perspective. So that's all I'll leave you with.
Michael, the weakness is not an illusion. Numbness and weakness together is not an illusion. I believe that is a nerve being pressed on, compressed, or impinged.
I would reflect on when that happens. After what? What did you do before that happened? Maybe in the hours before. And I would reflect on that, and then I would try to learn from that, and avoid those triggers that cause the weakness, because that's real, and that's a reflection of a physical thing happening in your body, especially if it's temporary.
And that's what can become heightened through simply increased sensitivity. And so again, that's called central sensitization, and it's a real thing. It's a real diagnosis.
You can look it up. I believe personally that it's a lot more common than what is reflected in the number of people who have it. I think it's extremely common in the back pain population.
So I hope this information helps you. So I'm super grateful that you're all here. Thank you for showing up for yourself.
And until next time, get down on the floor and give some love to your body. That does so much for you.
