Myth=“Most back pain is caused by serious damage”
Actually, most back pain is not serious, but yes, it can be an incredible nuisance to your life. Less than 1% of all lower back pain is due to life-threatening causes. If you have had a recent fall or high-speed car accident (events that are called trauma) that resulted in lower back pain, seek some guidance. Even then, answers to our “red flag” questions that might be associated with serious conditions lead to many false positives. Diagnostic triage for low back pain: a practical approach for primary care (mja.com.au)
Most grumpy backs are due to either a contribution of a sore muscle, joint, ligament, or nerve, but our movement test can’t tell them apart accurately Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review - eClinicalMedicine (thelancet.com). Fortunately, the original source of pain in these cases doesn’t really matter, as all of them respond well to high-quality back pain management and commonly feel better within a week without even doing anything. Persistent low back pain might be due to particular adaptations from your immune and nervous system (created by our powerful pain thoughts, beliefs, poorer general health, and lack of exposure to progressive movements), making back movement sensitive Risk factors for low back pain outcome: Does it matter when they are measured? - PubMed (nih.gov). A good conversation with one of our physiotherapists can help you identify your risk factors for pain persistence or assist your concern if you believe your back pain is due to a rarer condition.
Myth=“My back pain is caused by a sore disc”
True disc herniation-related pain is not as common as diagnosed. True disc irritation occurs in less than 10% of all back pain cases Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain | PLOS ONE. It's very common to have disc changes that can be observed by imaging without having current or future pain, so discs are easy to blame but are the innocent culprit. https://pubmed.ncbi.nlm.nih.gov/6495024/. Think of most disc changes as grey hairs and wrinkles of the spine. Back pain plus imaging might make you think the disc is the cause of your pain, but this is most likely an incidental active aging-related finding. Diagnostic triage for low back pain: a practical approach for primary care - Bardin - 2017 - Medical Journal of Australia - Wiley Online Library + Red flags or red herrings? Redefining the role of red flags in low back pain to reduce overimaging | British Journal of Sports Medicine (bmj.com) + Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain - PubMed (nih.gov)
Myth=“I need an MRI to best manage my back pain?”
Pain levels don’t predict imaging changes. Changes on imaging don’t reflect the severity of your back pain, and imaging does not need to change in appearance for your back pain to improve Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome - PubMed (nih.gov). Imaging should only be sought if specific medicine (not including over-the-counter or prescribed pain medications), injections or surgery is/are likely to be beneficial. However, even when imaging is indicated, your imaging results on their own might not predict if you will benefit from surgery Prognostic value of magnetic resonance imaging findings in patients with sciatica - PubMed (nih.gov)
Imaging is overused (due to a often busy doctor wanting to meet the expectations of an person in pain) and often misused as it is “ordered” without appropriate indications or reported with empathetic reassurance of normal pain-free age-related findings commonly found which don’t match your pain experience. Imaging is often expected by people and health care professionals to validate a pain experience, which it often doesn’t reflect accurately. If offered to you without explanation of which imaging findings are relevant for your pain experiences and which findings are likely to be incidental normal age related findings (grey hair and wrinkles of the lower back) you might become VOMIT or another Victim Of Medical Imaging Technology.
If you have already received a back MRI, keep this next message in mind…
For more about imaging usefulness and uselessness see these resources:
Myth= “My back pain is because of nerve compression”
Nerves in a healthy back get compressed all day with movement and tolerate it well Symptomatic and asymptomatic abnormalities in patients with lumbosacral radicular syndrome: Clinical examination compared with MRI - PubMed (nih.gov). Nerve compression on imaging doesn't explain the severity of most nerve-related back symptoms Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression - PubMed (nih.gov), and often, it's the immune system reaction around a nerve (which can't be seen with an MRI but requires more fancy imaging) that causes more sensitivity to movement, rather than the degree of compression. However, the persistent activity of the immune system that is initially painful is responsible for the gradual improvement in nerve pain The inflammatory response in the regression of lumbar disc herniation - PubMed (nih.gov), so keeping your immune system healthy and active with stress management, exercise and sleep can improve recovery from nerve pain and reduce the chance of it occurring.
Myth= “It's possible to find the exact cause of non-traumatic low back pain.”
It's probably impossible to only have or be able to know the one cause of back pain. With back pain, think of risk factors rather than causes. All risk factors sit on a spectrum and individuals have varied ability to tolerate them. In isolation, an increase or decrease in a single risk factor could appear as the trigger but is simply the match that lit the fireplace. Your “kindling” is the contributing spectrum of risk factors. Multiple risk factors or stressors at different spectrum levels accumulate to lead to back pain development. Can patients identify what triggers their back pain? Secondary analysis of a case-crossover study - PubMed (nih.gov) Risk factors can also both or neither contribute to the expected progression of recovery or increased disability. Identifying your risk factors for low back pain is the tricky part, as there are heaps of proposed risk factors for low back pain (expand the diagram below)
You might find a suspected primary risk factor for yourself, but your lower back pain likely results from at least one other equally important contributor from the myriad on this diagram. The complexity of back pain means that seeking one simple solution, hack, secret, or trick is unrealistic. This fact needs to be accepted by those with lower back pain as otherwise, the behaviour of seeking a quick fix leads to frustration, lack of trust in the medical system, and persistent pain.
Myth=“Flexibility and strength protect me from back pain.”
On their own, back or core strength and flexibility are unlikely to be a strong protector for low back pain. A systematic review of the relation between physical capacity and future low back and neck/shoulder pain - PubMed (nih.gov) + Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function - PubMed (nih.gov) Positively, you do not need to improve at these factors either to improve your symptoms. Remember that you are not a machine with degrading parts that must be strengthened or made more mobile to protect from pain Thinking beyond muscles and joints: Therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment - ScienceDirect + Core Stability - E3 Rehab. We might have once thought this until we started imaging people without pain or symptoms and seeing similar imaging results to those with pain. Long-term measurements of imaging changes also didn't reflect changes in symptoms over time. Strength or flexibility exercises can still be equally effective, but not because they improve strength and flexibility. Any mode of enjoyment and exercise perceived as worthwhile likely improves other more important pain mediators. This might include improving movement confidence, mood, social engagement, and pain self-efficacy (beliefs that you can still do things despite the pain). A range of physical brain and back-induced changes like increased blood flow and immune system activation that also improves strength and flexibility can be helpful for low back pain and is always recommended if you have a physical goal you wish to return to or want to maintain good general health Why is exercise prescribed for people with chronic low back pain? A review of the mechanisms of benefit proposed by clinical trialists - PubMed (nih.gov) + Changes in pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy mediate changes in pain intensity on disability in the treatment of chronic low back pain - PubMed (nih.gov)
Pick what you like for your back. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021: Clinical Practice Guidelines (jospt.org) They all seem equally helpful for low back pain at the moment. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis - PMC (nih.gov) However, make sure you are still meeting the Australian PA Guidelines
Myth= “Bad posture causes back pain.”
There is no perfect protective posture. Posture does not protect against back pain. Your back is not a stack of unstable blocks ready to fall over if you don’t “sit up straight.” “Sit Up Straight”: Time to Re-evaluate | Journal of Orthopaedic & Sports Physical Therapy (jospt.org) + Beliefs about back pain: The confluence of client, clinician and community - International Journal of Osteopathic Medicine + Easy to Harm, Hard to Heal: Patient Views About the Back : Spine (lww.com) + The science behind why assessing and blaming posture for pain is BS - Cor Kinetic (cor-kinetic.com) Exposure to newer prolonged positions might require some adaptation, but why haven't you adapted to the posture you feel is bad? Maybe because of other more relevant risk factors like poor sleep, lack of physical activity, reduced work satisfaction, and reduced mood. Do slumped and upright postures affect stress responses? A randomized trial - PubMed (nih.gov) Think, “My next posture is my best posture,” and stay active. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews - PubMed (nih.gov) Don’t worry about postural correction exercises either, even if they have helped you in the past. Exercise is helpful for pain despite not consistently changing resting posture Non-surgical interventions for excessive anterior pelvic tilt in symptomatic and non-symptomatic adults: a systematic review - PubMed (nih.gov). Maybe exercise makes us more tolerant of tolerating any prolonged posture.
Myth=“Recurrence is not normal and means my back pain is getting worse”
Recurrent episodic back pain is common for 30% of those that will have back pain and reflects the complicated recovery system of our body, so is often not a sign of worsening of the causes of back pain. Our body's structure, strength, and flexibility don’t fluctuate in a relevant manner that predicts flare-ups and pain changes. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review - PubMed (nih.gov), but our immune and nervous system do. Our immune and nervous system tolerance to all forms of stress might set off flare-ups, and previous pain might have lowered this threshold for flare-ups. It's unlikely these flare-ups are a sign of worsening back pain but instead indicate a very active immune system that you can help calm down with your thoughts and behaviour and by improving your general health (think of how to modify daily sleep, stress, fun, and movement) What have we learned from ten years of trajectory research in low back pain? | BMC Musculoskeletal Disorders | Full Text (biomedcentral.com)
Myth= “Rest is best.”
Actually, the worst thing you could do is be careful. “Motion is lotion.” Spending some time in bed on the first couple days of back flare-up might be helpful Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica - PubMed (nih.gov) but should be limited. Add gradually progressive movement that hopefully has some fun social aspects to it.
Myth=“Bending my back causes back pain.”
If the spine was not meant to bend, it would be a long, straight bone like your thigh bone. The “bending is bad for the back” belief originated from dead pig research in the 90’s that showed that non-living tissue does not adapt to movement To Crunch or Not to Crunch: An Evidence-Based Examination of... : Strength & Conditioning Journal (lww.com). Obvious right? This was then applied erroneously to living, adaptable humans. We also found out later that the changes we noticed in dead pig spines were also incidental age-related changes seen on imaging that can most often happen without pain or symptoms in living humans, but it was too late. The well-intended recommendation to not bend your back was too strong to easily reverse in our society. New and old but not popularised evidence suggests 1) the spine adapts to our movements just like any other joint and doesn't wear out like a machine, 2) we can’t stop the back from bending even if we tried with “good technique,” or cues to “keep the back straight” or “core tight”. The back joints still move under the skin 3) You might be more efficient or stronger when you bend your back while lifting 4) Fear of injury is a large risk factor for injury, so lifting while trying to brace against injury is not protective of injury.(PDF) Getting out of neutral: the risks and rewards of lumbar spine flexion during lifting exercises (researchgate.net) + To Flex or Not to Flex? Is There a Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis - PubMed (nih.gov) Also, it is likely that if you have or have had low back pain, you already bend your back slower, with less variability and with more muscle activation than someone without lower back pain, so you don’t need to work on increasing these factors with core stability or motor control exercises Spine loading characteristics of patients with low back pain compared with asymptomatic individuals - PubMed (nih.gov) + Are there differences in lifting technique between those with and without low back pain? A systematic review - PubMed (nih.gov) + Motor control exercise for chronic non-specific low-back pain - PubMed (nih.gov) It's also more common to have back pain spontaneously rather than after lifting or bending tasks (see graph below) Can patients identify what triggers their back pain? Secondary analysis of a case-crossover study - PMC (nih.gov) + Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode? A Longitudinal Case-Crossover Feasibility Study + Inciting Events Associated with Lumbar Disk Herniation - PMC (nih.gov) Yes, you still need to slowly progress your bending across time to allow adaptation, just like any other movement, to attempt to reduce the risk of injury and/or pain. You can still have pain after an innocuous back-bending movement like deadlifts or picking up keys off the ground, which might make you feel pretty fragile. However, just like any other joint, like after an ankle or shoulder sprain, gradually progressive, confident, full movement will help you recover while being overprotective and afraid of movement makes your pain system more active. 'I am afraid to make the damage worse'--fear of engaging in physical activity among patients with neck or back pain--a gender perspective - PubMed (nih.gov). Thinking of your back sprain as like a paper cut or cold, a temporary nuisance not threatening your overall happiness that you expect to heal with time, might be a more optimistic and helpful mindset to quickly assist your back pain recovery.
Inciting Events Associated with Lumbar Disk Herniation - PMC (nih.gov) Most back pain did not start with a lifting event (only 8.5% of all triggers in this study) which would challenge the common opinion of the causes of back pain.
Myth=“Massage or getting my back cracked is the only way of improving bad back pain” Although most forms of manual therapy can be helpful for back pain, it’s unlikely that this is due to changing tissue. Pain reduction with manual therapy seems to work through many mechanisms, including the release of naturally brain-made opioids within your body induced by the touch of a caring person Unraveling the Mechanisms of Manual Therapy: Modeling an Approach | Journal of Orthopaedic & Sports Physical Therapy (jospt.org) + How Manual Therapy Works | Mechanisms & Effects (youtube.com) This explains why many types of manual therapy have similar effects on pain relief despite having a different narratives to their effect. Exercise can be equally helpful through similar mechanisms to manual therapy through an effect called “exercise-induced analgesia.” If both exercise and manual therapy are 1) enjoyable, 2) expected to make you feel better, 3) guided by a healthcare professional you trust and 4) provided an opportunity to complete activities you enjoy after, you will likely have an equal pain-reducing effect from either. If you think increased blood flow and reduced inflammation are good for pain, exercise is 10x better than either massage, spinal manipulation, needling, or cupping. At Method Health, we are biased toward exercise for back pain relief as exercise also offers vast other secondary benefits to every tissue in the body, including the back. The E3Rehab Podcast: 143. Assessing Reactive Approaches to Pain w/ Marc Surdyka (libsyn.com) + What manual therapy can and can’t do with Dr Mark Bishop | Listen
Myth=“Pain is all in the brain”
Pain is not made up by the brain but is a real experience influenced by brain activity, especially mood and thoughts, and how these might lead to certain behaviors like avoiding movement or fun social activities. If you look at brain activity during a pain event, heaps of the brain involved in memory, mood, and movement planning are highly active The Cerebral Signature for Pain Perception and Its Modulation: Neuron (cell.com). Evidence accumulating across many recent years suggests these areas in the brain and along the nervous system pathways adapt to get really good at having a bidirectional influence on pain, such as a change in mood, fear of making pain worse or remembering previous pain memories. These can increase feelings of pain and vice versa, which can explain confusing feelings of sudden extreme pain when “only” bending over. What is positive is that these areas can “unadapt” or change again not to be so sensitive, which might explain why persistent pain is not inevitable. You do not have “pain nerve endings”, you have “danger nerve endings.” Reducing persistent back pain takes time and practice - completing fun and social activities while practicing “de-threatening” your perceptions of painful movements or what is thought of as “danger” and becoming aware of all the other lifestyle and cognitive factors that can increase pain outside of “more pain equals more damage.” We are not trying to remove pain. It's an important function, we just want to increase the movement threshold before pain perception. Talk to our physiotherapist about this, as it is a highly individual journey. Cortical function and sensorimotor plasticity are prognostic factors associated with future low back pain after an acute episode: the Understanding persistent Pain Where it ResiDes prospective cohort study - PubMed (nih.gov) + How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain - PubMed (nih.gov)
What have I missed? Many of the public's confusion and misbeliefs come from well-intended healthcare professionals. Let us know if you want to clarify something confusing that you have heard, e.g., from a public health speaker about back pain. We can help provide an optimistic guide to living well with or without back pain. Home - Live Well with Pain
Note: This blog is aimed at individuals who have not gone through back surgery. If you are post-surgery and still experiencing pain, much of this is still relevant to you but there are some additional nuances to discuss either through an in-person visit with Method Health Physiotherapy or with future written articles.
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