Neck & Upper Back Pain

Every year, thousands of people claim that they are going to begin working out. Each January, the gym is flooded with new members who claim that this will be their year and yet, each February the gym is empty again. Having good intentions is great, but unfortunately, good intentions are not good enough. It’s not enough to know that we need to exercise or to say that we are going to. You have to actually get up and do it. And you have to do it over and over again until it becomes second nature.

Why are so many people unsuccessful? Because its hard. It’s hard to set up, it’s hard to get started and it’s even harder to stick with. Our goal is to help you be successful. So, we’ve done some of the “heavy lifting” for you. We have set you up with an introductory exercise plan that includes both stretching and strength training (see “strength and endurance training” page), both of which have proven to be beneficial for reducing pain. Now, we’re going to help you implement it. Below we discuss several strategies to help you learn exercise programming, as well as address several common misconceptions and barriers to adherence.

Strength training is a crucial part of overcoming low back pain. The vertebrae and the vertebral discs are surrounded by musculature that either hinder or enhance pain mechanisms. The stability of the lumbar spine is largely dependent on supporting abdominal and low back musculature. The abdominal muscles provide initial stabilizing support by generating pressure within the abdomen, extending posteriorly to provide an anterior support column. The lower back muscles also act to stabilize and support. The stronger these muscles are, the less stress that is placed on the discs and joints of the spine.

There is no single, specific exercise program that has proven most effective for reducing back pain. This is great news because it means you have choice! If something is fun or tailored to your likes/dislikes, you are more likely to engage in it. So, incorporate things you like into your workouts and avoid the things you don’t. If you absolutely hate push ups, don’t do them. There are thousands of ways to train each muscle group and you are not restricted to any single one exercise. You can achieve a well-balanced full body workout in many different ways. Because of this, you can change up your workout routine on a regular basis to keep it new and interesting. This will keep your workouts fun while avoiding plateaus in learning.

There are many other ways to help you engage in exercise while still reaping the numerous benefits that come from it. For example, listening to music you like may help motivate you. Another option is to have a friend join you. Research indicates that finding a buddy or a group helps contribute to positive outcomes. Not only does this social environment increase motivation and adherence, but it also gives you an opportunity to receive feedback and support from another person.

Quite often, people have a tendency to start strong (like the new years resolution-ers discussed previously at the gym in January who have miraculously disappeared by February) and quickly burnout. To avoid this, exercise programs should be gradually scaled in intensity. It is important to smart small and to build as your functional abilities and tolerance increase. For example, clinicians have supported the development of an exercise program for individuals under fifty years of age with low back pain that encourages the performance of ten to fifteen repetitions per day. For individuals over the age of fifty, evidence based practice suggests that eight to twelve repetitions should be performed a day, two times a week. However, this may not be appropriate for beginners and should be adapted to accommodate new learners. As the learner progresses, this can be adapted until this goal is reached. Initially, it should include low intensity with gradual increases in both intensity and duration. A sample designed for the under fifty population is seen below. This is intended for use as a guideline only and should not be considered to be the gold standard for practice. When designing a plan, it is important to consider individual needs.

Table 1: A guideline for grading exercise intensity (sample)

It is better to do ten repetitions with proper form then it is to do one hundred repetitions with sloppy form. If you are using incorrect form, you are loading and placing strain on incorrect joints and putting yourself at risk for further injury. Focus on doing it properly rather than doing it exhaustively or rapidly.

In order to ensure that the exercises are done properly, there are a number of things you can do. One way to learn is to research the ways in which the movement is intended to be done. This may include reading about the movements occurring or watching. It may be beneficial to have an experienced learner show you the movement and then you can model what you have learned. If you are uncomfortable with this but prefer visual stimuli, Youtube may be a great source for demonstrations. In order to give yourself visual feedback, practice in front of a mirror. This will allow you to observe the differences between the desired state and the actual state. This feedback can then be integrated to allow you to make changes in your movement patterns.

Teachers should give positive feedback with specific information content. This encourages effective learning, fosters an appropriate learning environment and acts as a motivator. Instructors should recognize the client’s fitness level and use it to set specific and realistic goals. Exercises should be provided at the level of the client, with the aim of ensuring client success. When instructing, the best way to support the learning of new skills is to provide a blocked practice environment. This means that a single skill is performed repetitively, with variation in training minimized as much as possible. After this skill has been mastered, blocked practice of another skill may occur. This allows the learner to derive a general solution to the motor pattern before contextual variability is introduced. Once the learner has established and mastered that initial pattern, a more random practice schedule may be introduced.

Evidence suggests that one of the most influential factors relating to exercise performance is the individual’s beliefs relating to the activity. In this case, that means that what people believe or purport to “know” about back pain and exercise has significant effects on how they act. So, we’ve decided to educate you on some of the key research in this area.

One of the most common reasons that people with back pain fail to exercise is due to the preconception that “rest is best.” Individuals often feel that when they are in pain, they should not work out. For individuals with chronic pain, this can lead to months or years of sedentary behaviours. However, numerous studies have cited that exercise is significantly more effective in reducing back pain than rest. In fact, chronic back pain is often associated with diminished muscular capacity in selected muscles. While exercise adaptation and rest may be appropriate for acute cases, it is not practical for more chronic patients. When back pain becomes chronic, pain may persist during workouts, but is not indicative of ongoing tissue injury. Simply put, you are not worsening your condition by exercising. In these situations, pain cannot (and should not) be used to guide workout intensity.  It is normal for sufferers of chronic pain to be fearful of exercising and to avoid activities that may cause pain. However, it is important to understand that exercise will not worsen your condition if done properly. (Note: if you are experiencing dramatic increases in pain, consult a doctor). The idea is to increase well being, prevent debilitation caused by inactivity, decrease the likelihood of future back injuries, stabilize the spine, teach good body mechanics and to increase muscle tone.

Below is a visual depiction of the chronic pain cycle that can be used to help emphasize the importance of increasing activity, despite the potential for the continued presence of pain. It explains how individuals who experience chronic pain have a natural tendency to want to “guard” their body from pain. If our back hurts, we try to protect it. When we do this, we cause atrophy of the muscles we are trying to protect. As a result, we often overuse compensatory muscles and decondition the injured muscles. The more a muscle becomes deconditioned, the more impairment we see. The more impairment we see, the more we continue to guard those muscles. In chronic pain patients, this cycle continues in a cyclical manner, causing increasing disability through physical and psychological mechanisms.

Once pain improves, it is important that you continue with the exercise program. Oftentimes, clients will receive the intended benefits and then discontinue their program. When training occurs, strengthening occurs that takes stress off the back musculature. If these muscles were to atrophy again, the stress would re-occur and pain would return. It is recommended that basic core and dynamic stabilization exercises are continued. You want to sustain strength gains and maintain muscle mass long term.

Even after implementing and taking into consideration all of the material explained above, integrating a new exercise program is hard. It is okay to reward yourself when you engage in desired behaviours. This is called reinforcement and is used to strengthen behaviours and motivate their occurrence in the future. In early stages, it is acceptable to use a continuous reinforcement schedule, in which a behaviour is reinforced every time it occurs. As learners progress, a partial reinforcement should be integrated as they prevent extinction of behaviours. In this type of schedule, responses are reinforced only some of the time. A fixed-ratio schedule may be ideal in these cases. In this situation, a response is reinforced after it occurs a pre-set number of times. For example, if you perform your strengthening program five times, you can buy those super cute shoes you saw at the mall yesterday. Schedules of reinforcement derived from operant conditioning can have a dramatic effect on your outcomes – and the cute shoes don’t hurt either!  

And finally, give it time. The habits of successful people allow the consistent performance of behaviors that foster successful outcomes. If you repeat a behaviour often enough, those synaptic pathways in your brain become enhanced. It becomes second nature for you to engage in that behaviour. Older research has noted that it takes twenty-one days for something to become a habit. That means that you need to engage in that behaviour on a regular basis, twenty-one times before it becomes more of an innate habit. While newer research refutes this, saying that this is highly dependent on both the behaviour and the individual, it is still evident that it takes time to develop a new skill and to turn it into a habit. Even after the behaviour becomes a habit, return to old behaviours is simple and compelling. The neural pathways of the old habit or behaviour weaken with lack of use, but never completely disappear. It is easy to fall back into old ruts. So, make a conscious effort to stick with it! 

References 

Evans, M. M. (2005). A Cognitive Cycle of Chronic Pain: Targeting Catastrophizing and Fear. Pain Management Nursing, 6(3), 115. doi:10.1016/j.pmn.2005.06.015

Murphy, E. S., & Lupfer, G. J. (2014). Basic Principles of Operant Conditioning. The Wiley Blackwell Handbook of Operant and Classical Conditioning, 165-194. doi:10.1002/9781118468135.ch8

Parmentier, H. (n.d.). Modified Visual Feedback in Rehabilitation. Hand Transplantation, 303-306. doi:10.1007/978-88-470-0374-3_38

Pengal, L. H. M., Ph.D., et. al. (2007). Physiotherapist-directed exercise, advice, or both for subacute low back pain. Annals of Internal Medicine, 146(11), 787.

Simmonds, M. J., Ph.D., PT., MCSP., & Derghazarian, T. P. (2009). Lower back pain syndrome. In J. L. e. a. Durstine (Ed.), ACSM's exercise management for persons with chronic diseases and disabilities (3rd ed., p. 266). Human Kinetics.

Thompson, W. R., Ph.D., FACSM, Gordon, N. F., MD, Ph.D., MPH, FACSM, & Pescatello, L. S., Ph.D., FACSM (Eds.). (2010). ACSM's guidelines for exercise testing and prescription (8th ed.). Baltimore: Lippincott Williams & Wilkins.

Van Middelkoop, M., Ph.D., et al. (2010). Exercise therapy for chronic nonspecific low-back pain. Best Practice & Research Clinical Rheumatology, 24(2), 193.

Zipp, G. P., & Gentile, A. M. (2010). Practice Schedule And The Learning Of Motor Skills In Children And Adults: Teaching Implications. Journal of College Teaching & Learning (TLC) TLC, 7(2).