Lifting and Back Pain

Back pain is a complex, multifactorial, frustrating, and potentially debilitating situation that can really get in the way of training and life. Unfortunately it is going to happen and is a part of life no matter what you do or don’t do. There is such fear and avoidant behavior with back pain that the advice of lifting weights seems to align with insanity. However, this is not the case in reality. Lifting weights can be a very effective strategy to improve back pain as well as potentially decrease the occurrence and severity when it does happen.

Resistance training may be effective for reducing low back pain and easing discomfort associated with arthritis and fibromyalgia (1)

There is no way to completely prevent back pain from occurring and it cannot be distilled down to mechanical or structural issues as it is a very complex experience. There are a multitude of factors outside of physical issues that can contribute to it (life stress, previous experiences, personal and familial beliefs about pain, sleep, lifestyle, genetics, and many, many other factors). Lifting weights is not a cure all, and neither are any other treatments or interventions for it. However, lifting can significantly and positively impact the modifiable factors and contributors to back pain, potentially better than any other form of treatment or activity.

The fear and resulting avoidant behavior (reducing or stopping activity) can be a self-feeding and vicious cycle. Often, when someone experiences back pain, they will reduce or stop activity which can lead to becoming weaker and resulting in decreased activity tolerance. This can spiral into further weakening and decreased activity tolerance. Thus pain continues, potentially increases, and becomes even more limiting.

The disability associated with chronic low back pain may result in substantial losses in quality of life and posterior chain function, which may be related to the increase in pain and the fear-avoidance cycle that recurrently foreshadows the onset of pain (3)

We tend to view our back through a fragile lens and that it needs to be protected instead of seeing that it needs to be exposed to loading and lifting to build strength and robustness. The fragile and protective mindset causes a lack of trust and confidence in the back resulting in avoidance of movement.

Further, there could be a movement confidence and/or movement competency component that may also be important (3)

The fear of what may be the underlying cause or meaning of back pain can often be the most limiting and debilitating factor vs the actual pain experience. The fear of potential back injury alone can keep individuals from activity such as lifting weights without actually experiencing pain or injury. The deeply ingrained societal beliefs that lifting with your back and bending your back are dangerous are actually unfounded, but are extremely limiting due to imposed fear and perceived danger. Along those lines, the belief of having to move in an exact “safe” manner to avoid injury can also prevent individuals from lifting as they are fearful of not lifting “correctly”-another unfounded fear.

Pain beliefs inform coping behavior and perceptions of fragility based on pathoanatomical explanations are linked to an avoidance behavior that, in turn, can sustain pain and disability in a fear avoidance cycle. (9)

Our backs are meant to move and bend. This is ok and is something that can be trained and adapted to. Bending your back with lifting is not in and of itself a bad thing. Also, movement of the spine during lifts such as deadlifts, kettlebell swings, and squats is unavoidable and an inherent part of the movements even if the back appears to stay rigid. Back motion has been found to be up to 40 degrees during a squat. (15)

lumbar spine motion (specifically L1 to the sacrum) ranged from 26° in flexion at the beginning of the swing to 6° of extension at the top of the swing. (13)

Squat lifting was thereby characterized as lifting with the back kept as straight as possible and with mainly flexing the knees and the hips…The analysis of the lumbar lordosis angle RoM showed mean values of … 25.1 ± 8.2° for squat. (14)

-the back moved anywhere from  approximately 17 to 33 degrees during the squatting movement despite keeping the back as straight/rigid as possible

It all comes down to movement tolerance and programming: as long as you can tolerate the movement and you begin at an appropriate start place for you (appropriately dosed volume and intensity) then you can adapt to all sorts of movements and positions as well as get stronger with them over time.

Utilizing greater lumbar flexion during lifting (i.e. stoop lifting) is not a risk factor for low back pain onset, persistence, or recurrence. (5)

Pathomechanics (study of how movement can lead to injury or dysfunction) do not determine symptomatology (4)

-Implies that lifting technique is likely not the source of pain in and of itself, it is ok to move in various ways and there is no particular way of moving that guarantees you will or won’t get hurt

Neuromuscular and motor control variations are also normal. The body has surplus capacity to tolerate such variation without loss to normal function or development of symptomatic conditions. (4)

-Implies that lifting technique and movement can vary widely and still be tolerated well, thus does not need to be an exact “perfect” technique. If movements are tolerable, consistently repeatable, gradually loaded and progressed, you can adapt to all sorts of positions and ways to move.

-also, if you consistently move and are accustomed to loading in a variety of positions and movements and not only a rigid movement pattern, you will have higher tolerance to various positions and movements that occur in daily life. I can attest to this through personal experience: I have had times where I have sustained frequent back tweaks with deadlifts that seemed to occur when my back would start to round during a heavy deadlift. Well, this improved when I began training deadlift variations that forced me to lift in a more rounded position, thus improving my tolerance to this. My back was only accustomed to being in a rigid position, so I became very pain sensitive to any deviation from this under load. Improving my tolerance to positions outside of the rigid extension not only helped to improve my tolerance to inevitable alterations in position, but also markedly reduced painful tweaks while my deadlift strength improved.

Lifting weights in a manner that involves using, loading, and moving the back can improve trust and instill a sense of confidence in how much the back is able to handle, positively altering the perception from fragility to robustness. I personally think this may be the most important aspect when dealing with back pain. If you have been suffering from back pain that limits your activity and affects your daily life, imagine what can happen when you realize that same back you’ve always had pain and limitations from allows you to pick up something heavy despite the pain or perhaps with tolerable or no pain? Your whole perception of yourself, your back, as well as your pain experience changes in a positive way.

It has also been demonstrated that individuals with low back pain and greater pain-related fear change movement patterns in an effort to reduce lumbar spine motion during some tasks. While the use of resistance training may alter the fear-related aspects of low back pain, (2)

-back pain and/or the fear of back pain causes movement alterations to avoid using and moving the back, whereas lifting where you intentionally use and load the back can change the experience and perceptions in a positive way.

This needs to be undertaken with an emphasis on optimizing spine health, with care not to instill a belief in the patient that the spine is “at risk,” which may promote unhealthy attitudes and catastrophizing. (6)

Loading the back, such as with the barbell lifts, can actually help to improve pain as well as promote positive changes in spinal structures:

In line with other tissues, such as bone and muscle, specific types of loading appear to be beneficial to the intervertebral disc and will result in hypertrophy (build tissue up) or spontaneous regression of disc material. (5)

Sensitive tissues respond well to physical load (as seen in, eg, the management of knee and hip osteoarthritis). This is likely due to the involvement of endogenous pain inhibitory systems. (9)

The reduction in fat infiltration and increased cross-sectional area (muscle thickness) observed in the lumbar paraspinals are in line with changes found elsewhere as a result of resistance training. These changes, the opposite of which have been associated with low back pain, may have enhanced force generation capabilities in this area improving load tolerance and contributing to reduced pain as has previously been observed in resistance training interventions. (2)

Being stronger in general has positive impacts on back pain, even with lifting that does not directly load the back:

It is worth noting that two studies included in the meta-analysis that utilized correlational analyses reported significant relationships between bench press strength gains and a decrease in pain and level of disability in patients with chronic low back pain. Specifically, Jackson et al.  showed that ~ 64% and 59% of the common variance in the decrease in pain and disability, respectively, could be explained by increases in upper body strength. Consistent with the findings for other musculoskeletal injuries such as hamstring or rotator cuff strain injuries, whereby stronger individuals are much less likely to experience such injuries, such evidence suggests that clinicians should ensure that their rehabilitation programmes for individuals with chronic low back pain involve a progressive resistance training component to maximize their rehabilitation. (3)

Further research findings with resistance training/lifting weights and back pain:

This study demonstrates significant reductions in pain and disability (72% and 76% respectively) in patients with comorbidities presenting with low back pain following a 16-week resistance training programme. (2)

many of the concepts that would be commonplace in training sporting populations, including progressive overload and high intensity… it is possible to impact many of the factors that have been suggested to contribute to low back pain by applying basic resistance training practices. (2)

A review by Dreisinger concluded that resistance training was the only exercise intervention that significantly increases muscular strength, flexibility, endurance and balance in patients with chronic low back pain. (3)

Low back pain is associated with a deconditioning of the extensor muscles of the back and resultant loss of muscle strength, thus creating a potential target for resistance training in chronic low back pain rehabilitation. Resistance training has been shown to improve strength and reduce self-reported pain in patients with chronic low back pain, thereby serving as an effective therapeutic modality in this common condition. (7)

Recently, periodised resistance training, which is the most effective form of resistance training in a healthy population, has also been shown to be effective at increasing muscular strength, reducing pain and improving quality of life in patients with chronic low back pain. (7)

Don’t we need to specifically find, address, and fix any postural, structural, or movement issues?

Postural-Structural-Biomechanical (PSB) asymmetries and imperfections are normal variations—not a pathology… There is no relationship between the pre-existing PSB factors and back pain… Correcting all PSB factors is not clinically attainable and is unlikely to change the future course of a lower back condition. (4)

Should we find out what’s going on before we do any exercising or treatment? Don’t we need to do an X ray or MRI to see what is going on before doing anything?

Imaging evidence of degenerative spine disease is common in asymptomatic individuals and increases with age. These findings suggest that many imaging-based degenerative features may be part of normal aging and unassociated with low back pain, especially when incidentally seen. (10)

Our study suggests that imaging findings of degenerative changes such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention. The finding that 50% of asymptomatic individuals 30 –39 years of age have disk degeneration, height loss, or bulging suggests that even in young adults, degenerative changes may be incidental and not causally related to presenting symptoms.  (10)

See the table at the top of this article which shows the prevalence of findings on imaging in people with NO SYMPTOMS from Brinjikji W et al. 

We don’t need to worry about what’s going on in the spine outside of red flags (alterations in gait, neurological deficits such as bilateral leg weakness, numbness, saddle anesthesia, urinary or bowel incontinence, fever, etc). How symptoms present, behave, and respond are going to dictate how we can lift and train vs imaging or diagnosis. Also, changes (or lack thereof) on imaging do not always correlate with improved outcomes with back pain, thus we do not need to change what we see on MRI to improve pain:

Many studies have shown patients with marked symptomatic improvements with little or no changes on MRI. (11)

We can train with disc bulges and sciatica. They will likely heal over time anyway so why not lift to get better and stronger now?

Patients with sciatica should be encouraged to be patient and submit to conservative treatment methods initially. In the presence of clinical progress, even very large disc herniations can be left to resolve naturally. Early access to surgeons and diagnostic imaging may result in unnecessary operative treatment. (11)

However, the association between findings on MRI and symptoms is controversial, with several studies showing a high prevalence of disk herniation, ranging from 20 to 76%, in persons without any symptoms. (12)

In this study of patients with symptomatic lumbar-disk herniation at baseline who were treated with either surgery or conservative treatment and followed for 1 year, the presence of disk herniation on MRI at 1-year follow-up did not distinguish patients with a favorable clinical outcome from those with an unfavorable outcome. A recent systematic review concluded that even in the acute setting of sciatica, evidence for the diagnostic accuracy of MRI is not conclusive (12)

Jensen et al  did not observe any correlation between improvement in symptoms and improvement of disk herniation and nerve-root compression on MRI at 14 months (12)

In summary, in patients who had undergone repeated MRI 1 year after treatment for symptomatic lumbar-disk herniation, anatomical abnormalities that were visible on MRI did not distinguish patients with persistent or recurrent symptoms of sciatica from asymptomatic patients. (12)

Being active is a great thing and can certainly help with back pain, however lifting weights can be more effective than just being active. A stronger back can tolerate more stress and strain, which helps to reduce risk of low back pain with activity:

The results of this study show that treating patients suffering with chronic low back pain within the recreationally active/sedentary population using posterior chain resistance training is significantly more effective than using general exercise. The results of this study show there are overall “strong” levels of evidence for significant improvements in pain, level of disability and strength with posterior chain resistance training. These results also showed no significant greater risk of adverse events, relative to general exercise or walking programmes, (3)

This may suggest that a key feature underlying the potential benefits of posterior chain resistance training over general exercise in reducing back pain in patients with chronic low back pain is the use of progressive overload within the posterior chain resistance training intervention. (3)

In a study by Kell et al, CLBP (chronic low back pain) patients engaged in either a 16-week wholebody periodised RT (resistance training) programme using an exercise intensity range of 53–72% of 1RM or a periodised aerobic training programme. Interestingly, only the RT programme resulted in a reduction of pain scores and improvements in quality of life parameters. In a follow-up study by Jackson et al, CLBP patients used an exercise intensity ranging from 55% to 79% of 1RM. Again, increased muscle strength, reduced pain and increased functional ability were evident after participation in the RT programme, which was well-tolerated by all patients. These results indicate that improving maximal muscle strength through an effective RT programme can reduce symptoms in CLBP patients and that such an approach may be considered a valid therapeutic modality. (7)

The Deadlift and back pain:

The deadlift has an interesting situation with back pain. It is frequently viewed as a potentially injurious lift and a cause of back pain. This is in fact wrong, with the opposite being true: the deadlift is a great exercise to improve back pain.

The deadlift, which is often demonized as a cause for low-back pain, should be considered for therapy. The benefits of the deadlift, when judiciously programmed, outweigh the risks. (8)

Shear force on the spine  involved in lifts such as the deadlift are thought to be a source of danger and potential injury, however: as long as the shear force is able to be tolerated by the athlete, there is no additional inherent danger or risk. (8)

By using the appropriate repetitions and load for the individual's ability, shear and compressive forces that exceed the limit of anatomical integrity can be avoided. The SAID principle can be utilized to initiate adaptation in the bone, muscle, and ligamentous tissue to adapt and become stronger and therefore increase the limit of anatomical integrity while reducing unnecessary risk. (8)

Further, when comparing injury prevalence, the deadlift does not appear to present any excessive injury risk. Despite the resultant compressive and shear forces affecting the lumbar spine during the deadlift, if repetitions and load are appropriate for the athlete's experience level, there is not ample evidence suggesting the deadlift results in excessive injury risk to the individual. (8)

Bottom line:

It is ok to lift weights with back pain and with such conditions as disc bulges and sciatica. Outside of red flags noted above, most experiences with back pain will likely improve over time and do not need imaging or surgical intervention nor a specific diagnosis to find out the cause. Your back can adapt to lifting, improve in tolerance to activity and have less pain over time from doing so. Also, a back that is stronger and used to lifting weights seems to respond better and more quickly to training when pain/injury do occur, in my experience. Pain is going to occur as this is an inevitable part of life whether you lift or don’t. Why not get stronger and use your back anyways?

References: 

1. Westcott WL. Resistance training is medicine: effects of strength training on health. Curr Sports Med Rep. 2012 Jul-Aug;11(4):209-16. doi: 10.1249/JSR.0b013e31825dabb8. PMID: 22777332.

2. Welch N, Moran K, Antony J, et al. The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI defined lumbar fat infiltration and functional crosssectional area in those with chronic low back. BMJ Open Sport Exerc Med 2015;1:000050. doi:10.1136/bmjsem-2015-000050

3. Tataryn, N., Simas, V., Catterall, T. et al. Posterior-Chain Resistance Training Compared to General Exercise and Walking Programmes for the Treatment of Chronic Low Back Pain in the General Population: A Systematic Review and Meta-Analysis. Sports Med - Open 7, 17 (2021). https://doi.org/10.1186/s40798-021-00306-w

4. Lederman, Eyal. (2011). The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. Journal of bodywork and movement therapies. 15. 131-8. 10.1016/j.jbmt.2011.01.011.

5. Washmuth NB, McAfee AD, Bickel CS. Lifting Techniques: Why Are We Not Using Evidence To Optimize Movement? Int J Sports Phys Ther. 2022 Jan 1;17(1):104-110. doi: 10.26603/001c.30023. PMID: 35024210; PMCID: PMC8720246.

6. Hodges, Paul W. and Danneels, Lieven,Changes in Structure and Function of the Back Muscles in Low Back Pain: Different Time Points, Observations, and Mechanisms,Journal of Orthopaedic \& Sports Physical Therapy,volume49,6,464-476,2019,10.2519/jospt.2019.8827,PMID: 31151377,https://doi.org/10.2519/jospt.2019.8827

7. Kristensen J, Franklyn-Miller A. Resistance training in musculoskeletal rehabilitation: a systematic review. Br J Sports Med. 2012 Aug;46(10):719-26. doi: 10.1136/bjsm.2010.079376. Epub 2011 Jul 26. PMID: 21791457.

8. Weber, A, and Fanning, M. Risk-Benefit Considerations for Deadlifting in Rehabilitating Low-Back Injuries. NSCA Coach 11(3):32-35, 2024

9. Thorvaldur S Palsson, William Gibson, Ben Darlow, Samantha Bunzli, Gregory Lehman, Martin Rabey, Niamh Moloney, Henrik B Vaegter, Matthew K Bagg, Mervyn Travers, Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area, Physical Therapy, Volume 99, Issue 11, November 2019, Pages 1511–1519, https://doi.org/10.1093/ptj/pzz108

10. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.

11. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl. 2010 Mar;92(2):147-53. doi: 10.1308/003588410X12518836438840. Epub 2009 Nov 2. PMID: 19887021; PMCID: PMC3025225.

12. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ, Van der Kallen BF, van den Hout WB, Jacobs WC, Koes BW, Peul WC; Leiden-The Hague Spine Intervention Prognostic Study Group. Magnetic resonance imaging in follow-up assessment of sciatica. N Engl J Med. 2013 Mar 14;368(11):999-1007. doi: 10.1056/NEJMoa1209250. PMID: 23484826.

13. McGill, Stuart M; Marshall, Leigh W. Kettlebell Swing, Snatch, and Bottoms-Up Carry: Back and Hip Muscle Activation, Motion, and Low Back Loads. Journal of Strength and Conditioning Research 26(1):p 16-27, January 2012. | DOI: 10.1519/JSC.0b013e31823a4063 

14. von Arx M, Liechti M, Connolly L, Bangerter C, Meier ML, Schmid S. From Stoop to Squat: A Comprehensive Analysis of Lumbar Loading Among Different Lifting Styles. Front Bioeng Biotechnol. 2021 Nov 4;9:769117. doi: 10.3389/fbioe.2021.769117. PMID: 34805121; PMCID: PMC8599159.

15. Potvin JR, McGill SM, Norman RW. Trunk muscle and lumbar ligament contributions to dynamic lifts with varying degrees of trunk flexion. Spine (Phila Pa 1976). 1991 Sep;16(9):1099-107. doi: 10.1097/00007632-199109000-00015. PMID: 1948399.