True and False on Back Pain
Low Back Pain is Normal! No, I am not crazy!!
80% of people will experience low back pain in their lifetime.
It is a normal human experience, which we might not like, but most people will have some version of back pain. For many, it is a short fleeting experience, but most people know someone whose quality of life is greatly affected by back pain. But unfortunately, we do not yet understand the phenomenon well enough to predict or diagnose why low back pain is a persistent condition for some.
When low back pain strikes, the perfectly natural response is to try to find the “problem” or cause of the pain. Many will want to get a scan such as MRI or X-ray to “see” what the source of the pain might be. The problem with this is, it turns out that common “problems” spotted on MRIs such as disc bulges or “slipped discs” are as common as wrinkles – nearly everyone over a certain age will have some back degeneration, whether or not they have back pain (See the two graphs below as you read on). So, even if your MRI shows a herniated disc or other so-called “abnormality”, how do you know that it wasn’t there before the start of your pain? It may or may not be the true source of the pain, and we are now learning that you can recover from the pain without necessarily ‘fixing’ the ‘abnormality’. The story that we get from imaging is further confounded by a recent study where a lady was scanned by MRI at 10 different centers. There was little agreement in what the lumbar spine MRI showed, with the authors stating that the study “identified marked variability in the reported interpretive findings and an alarmingly high number of interpretive errors” 1.
On top of that, the emerging field of pain science also indicates that depending on how such ‘negative’ imaging findings are presented to the patient, they can even have a negative effect on pain and function all by themselves! So as clinicians we have to be very careful interpreting and communicating imaging. I like to compare many of these findings to wrinkles on the skin – just something that happens as we age, and not necessarily problematic or anything to worry about. I do want to take a minute to note that I am not anti-MRI, as there is a time and a place for it, especially when there is the possibility of serious pathology and loss of function. However, even in those circumstances, great care should be used in communicating the findings!
Another common misconception that I hear frequently from patients is the idea of something being out of alignment, subluxed, slipped, or whatever term you wish to use. In-part it is caused by popularized media reporting, but sadly is mostly due to various health professionals using this terminology. Why sadly? There is absolutely no quality research, including imaging studies, that shows this to be the case, except for a very small minority of patients in extreme situations (trauma, certain genetic conditions)2,3,4,5,6,7,8,9,10,11,12. Sure, perhaps we feel something is out of place and needs to be fixed. A manipulation certainly may make us feel better for a short period, however, this result is not due to something being put back in place. It is important to address this, as I have had many patients come into the clinic, and not necessarily for back pain, telling me that they have to be careful not to put their back out of alignment again. Or, they are telling me that they have to go periodically for something to be put back in alignment. This negative construct leads people to move less, and resultingly have more issues with their pain and health.
The video below provides a great example of what we have just discussed. Jack is a young guy from London and was told, based off of MRI, that he had the back of a 70-year-old! Doctors informed him that he needed to have surgery which had significant risks. He was fearful of movement, of surgery, and the future. But in the hands of a caring professional, Peter O’Sullivan (a world renowned back pain expert and researcher), Jack was able to experience some hope and trust in his back! Without having the recommended surgery he was able to recover to the point that he started his own company laying gas mains and piping (very manual, heavy work!). The video is 8 mins long, and you might need to re-watch a couple of sections as not everyone will be used to Jack’s strong London accent, but it is well worth your time! (His accent is strong, but I understand him well because I’m pretty sure he is from the part of London where I grew up!)
Having hit a couple of hot topics, I want to share with you let us consider three other common misconceptions, and then three little-known truths about back pain and its management.
3 more falsehoods on back pain:
- Bed Rest is good for you.
- If you have read any of our other blog articles you will see that typically in human injury (except for significant fractures, spinal cord injuries etc) we want a relative rather than complete rest from activity. Keeping active to some degree has been linked to better outcomes with back pain, whereas studies have shown that prolonged bedrest is detrimental to pain and health13.
- Increased pain means that more damage is occurring
- Modern science tells us that underlying anatomical changes do not always correlate to pain. This is why two people with the same anatomy/pathology can experience very different levels of pain. Pain is a perception by the brain of how much danger an activity or stimulus is to your body14. There are many things that affect this perception, giving our bodies the ability to either shut pain out or to amplify it. Certainly, what is going on locally with anatomy alters the stimulus that our brain perceives15. But, stress of current life (work, family, etc), the influence of previous experiences/perceptions, and various other things will contribute to how we perceive pain16. To see this complexity, ask why a papercut hurts so much, but someone suffering a traumatic amputation on the battlefield may not even realize it happened as their body tries to get them out of harm’s way.
- I find that once someone better understands this pain science they are better able to work at rehabilitating. I think that this is typically not addressed enough, which is why I see people who have seen two or three different providers before they see me. It is then my challenge to unravel their pain experience, and help them find ways to change how their brain perceives their pain.
- Something is wrong and it needs to be fixed, therefore I need surgery!
Having been a PT for 13 years in various settings and locations, I have worked with many orthopedic surgeons. The best ones that I have worked alongside will try to keep the patient away from spine surgery for as long as is possible. The only time they will rush to do surgery is when there is a significant medical emergency, for example, the potential for loss of bladder and bowel function due to a nerve compression17. The reason that they are slow to consider surgery is that the results for many spine surgeries are no better in the mid-to-long term than other conservative measures. Couple this with increased complication rates for surgery, in some cases 25%, and you can understand why uncomplicated cases should be given sufficient time for a conservative approach18.
- Working in a town with many engineers, the mindset and educational framework can make surgery seem to be a sensible and understandable option. For example, You are told you have a disc bulge (or a slip…) and it needs to be fixed. However, although biomechanics and structures of the human body are important, we are not machines. Hence, the above graphs where we see “pathology” and no pain. Even if we try to fix the pathology, not only can we not create exact repairs of structures (replicating the tissues is very difficult), we also have a highly adaptive nervous system which does not always behave like we might want or expect. As such, even if we could do a surgery where we perfectly replicate normal anatomy, the nervous system can still adapt in an unplanned way leading us to continue our pain experience.
3 truths on back pain:
- Movement is good for you19.
- Often patients walk into my clinic moving in a very rigid manner (just like Jack!). As I talk to them, I find out (as I suspected) that they have been told unhelpful things in the past that we now know are not true. For example, “do not bend the back”, or “you have to sit up straight”. What we are realizing (and this returns to our first falsehood) is that being in any static position or making a movement with more load than we are used to and have strength for is problematic. So, you could sit up straight with “perfect” posture at your desk all day long, and still find yourself in pain at the end of the day. In so-called “text neck”, the problem is not so much the position itself, but that many people are in that position for extended periods. In bending to pick up an object, the problem is not necessarily the motion itself, but instead that the person doesn’t have enough strength/conditioning to take the load/strain9, 20, 21.
- Instead of demonizing movement and being relatively static, we need to encourage it! For example, a desk-based employee should try to change posture every 15-20min, which may include doing some work while standing, taking a bathroom break, or picking something up off the printer. We need to encourage movement under load so that we are acclimatized to it. If something in your life requires you to bend over, practice it and gradually increase the load. We do the same with sports, and we see injury when the practice/conditions have been absent, or less optimal. If you find a task that is not typical for you, but needs to be done, analyze it and try to do it in a way that reduces load22. But above all, keep moving and vary your posture and movement patterns!
- Exercise is safe
- Previously we thought that carefully prescribed specific exercises were the best option for someone in back pain. These certainly have a place, but general exercise has also been shown to have positive effects23. Specific exercises can be a little dull, and monotonous, whereas general exercises can be much more fun and social, and are more likely to be complied with. Going back to the first truth – that movement is good for you – exercise can be very powerful for reducing back pain and keeping it from returning – if done sensibly, allowing for a gradual progression in amount and difficulty. Compare the safety of exercise with the danger of surgery or opioids24, 25. Most of us know someone suffering from pain who has become dependent upon medication, adjustments, or whatever treatment they perceive gives them relief. Becoming dependent upon exercises is a much better option (except is some extreme and unusual psychological disorders). Exercise is free/cheap, and yields many additional health benefits beyond the reduction in back pain, and most of us could do with a little more of it than we’re getting! Jordan Metzl, a sports-medicine physician at New York City’s Hospital for Special Surgery sums it up nicely: “Exercise is the best preventive drug we have, and everybody needs to take that medicine”.
- You don’t have to live with your pain!
- This one is so huge, I want to say it again: YOU DON’T HAVE TO LIVE WITH YOUR PAIN!!
- Isn’t that great news?? While the above points might be surprising to you, hopefully, they have also been encouraging! If anatomy does not necessarily correlate with function, and pain is a perception in the brain that has evolved over time, it is possible to improve and even resolve. I am the first to admit this is not easy and each person’s path will be unique. However, the great thing about pain being a perception of the brain is that the brain can change. We call this ability to change neuroplasticity, and what is awesome is that it can change both positively and negatively.
- If you have been struggling with back pain (or any pain) for a while, it is likely that a better understanding of the puzzle of pain and pain science can help you to overcome the pain22, 26, 27. The solutions you’ve tried so far may not have taken this into account, and a new approach may be needed. It will take time; unfortunately there usually are no quick results in cases of long-standing pain. I discuss this idea of quick fixes versus time to heal in another blog, but your body has changed over time, and it may take a similar amount of time to change for the better. Nobody can tell you an exact amount of time to recover, and nobody has a real/true quick fix (If they claim to, it is my opinion that you would be wise to seek another opinion!).
To help someone unleash themselves from the shackles of back pain, and even past treatments, is a greatly fulfilling thing. In my career, some of my most joyful and rewarding moments have been watching a patient who came in hopeless or fearful, and help them regain hope and realize relief! If you have been struggling with pain, I would love to hear from you and explore what I can do to help you overcome the pain and get back to living the life you love.
- Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2016;
- Kibsgård TJ, Røise O, Sturesson B, Röhrl SM, Stuge B. Radiosteriometric analysis of movement in the sacroiliac joint during a single-leg stance in patients with long-lasting pelvic girdle pain. Clin Biomech (Bristol, Avon). 2014;29(4):406-11.
- Holmgren U, Waling K. Inter-examiner reliability of four static palpation tests used for assessing pelvic dysfunction. Man Ther. 2008;13(1):50-6.
- Schneider M, Erhard R, Brach J, Tellin W, Imbarlina F, Delitto A. Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study. J Manipulative Physiol Ther. 2008;31(6):465-73.
- Koppenhaver SL, Hebert JJ, Kawchuk GN, et al. Criterion validity of manual assessment of spinal stiffness. Man Ther. 2014;19(6):589-94.
- Grundy PF, Roberts CJ. Does unequal leg length cause back pain? A case-control study. Lancet. 1984;2(8397):256-8.
- Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. Eur Spine J. 2007;16(5):669-78.
- Hides J, Fan T, Stanton W, Stanton P, Mcmahon K, Wilson S. Psoas and quadratus lumborum muscle asymmetry among elite Australian Football League players. Br J Sports Med. 2010;44(8):563-7.
- Richards KV, Beales DJ, Smith AJ, O’sullivan PB, Straker LM. Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents. Phys Ther. 2016;96(10):1576-1587.
- O’sullivan PB, Smith AJ, Beales DJ, Straker LM. Association of biopsychosocial factors with degree of slump in sitting posture and self-report of back pain in adolescents: a cross-sectional study. Phys Ther. 2011;91(4):470-83.
- Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008;31(9):690-714.
- Haig AJ, Tong HC, Yamakawa KS, et al. Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Arch Phys Med Rehabil. 2006;87(7):897-903.
- Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated cochrane review of bed rest for low back pain and sciatica. Spine. 2005;30(5):542-6.
- Wiech K, Ploner M, Tracey I. Neurocognitive aspects of pain perception. Trends Cogn Sci (Regul Ed). 2008;12(8):306-13.
- Rio E, Moseley L, Purdam C, et al. The pain of tendinopathy: physiological or pathophysiological?. Sports Med. 2014;44(1):9-23.
- Zaina F, Tomkins-lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016;(1):CD010264.
- Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current low back pain guidelines: a review. Eur Spine J. 2016;25(9):2788-802.
- Thompson T, Correll CU, Gallop K, Vancampfort D, Stubbs B. Is Pain Perception Altered in People With Depression? A Systematic Review and Meta-Analysis of Experimental Pain Research. J Pain. 2016;17(12):1257-1272.
- Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317-32.
- Hallman DM, Mathiassen SE, Heiden M, Gupta N, Jørgensen MB, Holtermann A. Temporal patterns of sitting at work are associated with neck-shoulder pain in blue-collar workers: a cross-sectional analysis of accelerometer data in the DPHACTO study. Int Arch Occup Environ Health. 2016;89(5):823-33.
- Gupta N, Christiansen CS, Hallman DM, Korshøj M, Carneiro IG, Holtermann A. Is objectively measured sitting time associated with low back pain? A cross-sectional investigation in the NOMAD study. PLoS ONE. 2015;10(3):e0121159.
- Bowering KJ, O’connell NE, Tabor A, et al. The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. J Pain. 2013;14(1):3-13.
- Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for chronic non-specific low-back pain. Cochrane Database Syst Rev. 2016;(1):CD012004.
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- Louw A, Farrell K, Landers M, Barclay M, Goodman E, Gillund J. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. Journal of Manual & Manipulative Therapy . 2016 Sept: 1-8
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Photo credit: PracticalCures via Foter.com / CC BY
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