Myths of Lower Back Pain, And What You Should Do About It
Back pain. Around 80% of us will experience it from one time to another. For some, it may recur, and for a small percentage, (10-40%), the pain will persist and may become disabling. It has been labeled as the most disabling disorder for the western world and results in a huge economic burden. Estimates on the cost of chronic back pain on our health care system revile that it is listed as number one on the Global Burden of Disease List. But on an individual basis, back pain can be scary, debilitating and frustrating. Patients with chronic back pain describe their lives being on hold, their relationships suffering, having no confidence and have lost the things that give their lives meaning. I’ve once heard the back described like the heart, “frightening to think of if something goes wrong”.
This article “The Myths of Lower back Pain and What You Should Do About It” will explore why lower back pain is so prevalent, often difficult to treat, so variable, as well as give practical tips and advice for patients on how to get lower back pain relief and offer back pain solutions.
Given that lower back pain is a costly, unpleasant, widely experienced human ailment, a lot of effort has gone into the diagnosis of the problem. Over the last 15 years we have seen an explosion in the different modalities used for assessing the lower back. Constant advancement and ease of access of medical imaging techniques such as X-ray, CT and MRI scanner, has lead to a significant increase in routine imaging of patients with lower back pain. However the problem is that only a small group of patients have back pain can be attributed to really serious stuff. Around 1-2% of lower back pain is caused by infection, fracture or an inflammatory disorder. As little as 8-15% of back pain can be attributed to “specific” changes that appear on a scan such as disc prolapse pressing on a nerve root, later stage central or lateral canal stenosis. These kinds of back pain are when imaging is useful, and usually come with some clear indicators for referral for imaging. But for the vast majority of patients with lower back pain, scan results do not correlate well to a patient’s pain or disability. This leaves a large portion of patient’s with a “non-specific” pain disorder.
The reality is that when you scan anyone’s back, 90% of people have degenerate discs, 56% have disc bulges, around the same have some degree of arthritis, and around 30% have annular tears, all of who report no pain with these findings. Now how can that be? Isn’t it common knowledge that a bulging disc is a serious pathology that we associate with persistent lower back pain? Well, these “pathologies” are just part of the normal age related changes that occur within all of our body’s tissues. We don’t look the same on the outside as we once have, why should we look the same on the inside? These results on scan findings can be likened to grey hair, or wrinkles. Our normal “kisses of time” that do not relate to pain.
Now the problem we have created within the health care system, is that we attribute lower back pain as being caused by these damaged/effected structures, and if we treat the specific structure appropriately then we will get rid of the pain. But we haven’t done a good job of it. Some of the work within chronic pain, involves patients who have had multiple spinal surgeries in an attempt to “fix” these structural problems with no changes to their pain and occasionally an increase in their symptoms.
As a health care system we are doing more and more imaging for lower back pain. More and more injection therapies. More and more fusion surgeries. Yet the disability for these patients continues to rise. Why?
Well we haven’t taken into account what else can predict and cause lower back pain. We know from population studies looking at healthy and painful populations that many of the scan findings do not predict pain and disability. However when we look at the cognitive, psychosocial and functional factors, we paint a very different picture.
We know that poor sleep, high stress, depressed mood, and anxiety are strong predictors of lower back pain. In fact depression alone is three times more likely to predict lower back pain than the presence of a disc bulges on a scan. It is also important to understand that negative beliefs on lower back pain result in higher pain intensity, increased disability, and correlate with increased time off work. Specific beliefs that independently result in an impaired recovery include: a poor perceived prognosis (“I know it wont get better”), a belief that hurt equals harm (“I’m pinching a nerve when I move”), and the activity should be avoided due to pain (“I need to stop and rest when I get pain”). These non-anatomical factors work to increase the amplification effect of the central nervous system on pain and sensitize the spinal structures, and when this is coupled with other provocative movement strategies we see a greater pain response to otherwise normal activities i.e. sitting, walking, bending. Its important to recognize that many of these beliefs around lower back pain can be driven by practitioners, and highlighting we need to be careful with the language that we use. Also important to note is that as therapist we rarely ask about these other aspects of pain and they are not often willingly given, so as patients and therapists we need to delve beyond the signs and symptoms to establish the whole story behind the pain.
We also know that there are certain movement characteristics in patients with persistent back pain that are not present in pain free populations. For certain patients with pain we observe high levels of muscle co contraction around the abdominals and lower back muscles bracing the spine. This is especially prominent with any spinal movement such as bending forwards. It is often correlated with a fear of movement, or a fear of re-injury or pain, or it is a protective response by the body that is never un-learned once the initial injury has settled. Other patients have a poor perception of what their body is doing in space and adopt extreme postures in the belief that what they are doing is normal. Common patterns are postures involving a hyperextended back, usually in sitting, and are over working the back muscles. Usually this is accompanied with the belief that it is good posture and beneficial for the spine. We also see people unable to utilize the hips to bend forward and use a movement strategy where they bend only through the back overloading the tissues in the lumbar spine. By normalizing these abnormal movement strategies and integrating them into daily function we provide an opportunity for positive change.
So in summary, the “Myths of Back Pain” are this:
- Scan results are rarely predictive of lower back pain
- A disc will never slip. Never.
- The back is strong and a region to be trusted
- It is unlikely that your back pain is due to serious damage, and is more likely to be that of a minor strain or the area is sensitized
- Back pain is multi-leveled and can be driven by many different things
- The influence of the psychosocial and cognitive factors must be considered and evaluated when dealing with lower back pain
- Hurt does not equal harm
Finally the “What You Should Do About It”. We know that most acute back pain is due to minor sprains and very rarely is there any permanent damage, or structural change associated with the pain. If you have a scan it is important to understand that (unless a “specific” pathology is present) most of the findings are the equivalent of grey hair and wrinkles. Nothing to worry about. We don’t recommend excessive rest for back pain. Some activity modification in the short term is fine, but getting back to movement and activity is far healthier for the back. So if you have suffered a recent episode of back pain, take into account what your thoughts and emotions are doing. Understand that they may play a role in the way you are moving and your pain experience. See your physiotherapist and they will guide you on whether it is worth obtaining a scan, and give you strategies for getting back to normal healthy movement.
Finally, back pain can be scary and debilitating, but the back is a strong structure that is built to last and built to move, so if you suffer back pain, evaluate your situation from top to bottom, from thoughts to posture, and there you will find a road to improvement.
If you are suffering from lower back pain and would like to talk to a qualified physiotherapy practitioner contact our skilled physiotherapists for a consultation.