Myths & Facts of Low Back Pain
If you ask an osteopath, physiotherapist, or chiropractor what they treat the most in clinic, they will all quickly state low back pain. Low back pain is the most burdensome musculoskeletal disease in the world. In terms of years lived with disability due to a disease or injury, lower back pain has consistently been shown to lead the charts (Vos et al., 2017). It is also the most expensive health related condition. Research in the US found that $134.5 billion US dollars was spent in 2016 for the treatment of lower back pain (Dieleman et al., 2020)! The incidence of lower back pain is also on the rise, with the burden of this condition affecting more of the population. You would think that by now we would have better solutions to managing this disabling condition. So why is low back pain still on the rise?
The reason lower back pain has continued to rise is largely due to individuals seeking costly, ineffective, and often harmful care. Now this is not the general population’s fault, it is the health industry’s fault. Unfortunately, there are far too many health care providers and now with social media (influencers & personal trainers), providing nocebic information regarding low back pain. The scary thing is that the individuals who are provoking this unnecessary fear into the population, also have the largest following on social media! It is easy to make money by selling fear and problems that are not there, especially with social media in todays day and age. These unhelpful beliefs about low back pain, have been consistently shown to be associated with worse pain, disability, loss of work (income) and medication use (Main et al., 2010). This is why seeking and listening to an evidence informed practitioner is crucial. If you have read any of my previous blogs or seen me personally, you know I hate the BS and will provide you with information based off evidence. For the rest of this blog, I will highlight 10 myths and 10 facts about lower back pain. This blog was largely based off the information provided in the British Journal of Sports Medicine - Back to basics: 10 facts every person should know about back pain.
Myths about Low Back Pain
1. Low back pain is due to a serious medical condition.
Low back pain is mostly not due to a serious cause. In fact, a serious cause of low back pain is very rare! Some people fear they will end up in a wheelchair, this is extremely unlikely!
2. Low back pain will become persistent and deteriorate in later life.
This does not seem to be true based off the clinical evidence. Low back pain certainly can have its flare-ups (which is common), however individuals are able to live a life with minimal or no pain if they receive care and reassurance from a great practitioner. This practitioner will look to quell any fears or misconceptions you have on back pain and improve your strength and functional capacity.
3. Persistent low back pain is always related to tissue damage.
Persistent low back pain is unlikely to involve tissue damage. Our backs are strong and can tolerate a lot of load. However, when we sustain an acute injury perhaps there is some tissue damage. Thankfully the human body is capable of healing and usually anything that was damaged would have healed up. This time frame obviously varies, however it is usually 6-12 weeks. When pain persists past the natural healing timeframe, there is usually other factors at play. Stress, poor sleep, anxiety, fear, inactivity, poor load capacity or unaccustomed activity, fatigue and tension can influence the sensitivity of the back to movement. To reduce chronic pain from occurring, seeking a professional opinion from a practitioner who prioritises rehabilitation and movement is recommended.
4. Scans are always needed to detect the cause of low back pain.
A scan is only as good as the clinical symptoms associated with it. The majority of back pain and injuries in general for that matter do not require a scan. This information is largely unhelpful, and scan often creates more fear by revealing something that does not cause pain. In other words, you cannot see pain in a scan. A large proportion of scans will show pathological findings in asymptomatic individuals. This is one reason why seeing an evidence informed practitioner is crucial when managing your pain or injury. In the case of low back pain, a scan will likely show a disc bulge or disc related injury. These findings are common in asymptomatic people, and they also resorb (shrink) over time. A scan also cannot predict the level of your pain and how disabled you are.
5. Pain related to exercise & movement is always a warning that harm is being done to the spine and a signal to stop or modify activity.
Hurt does not always equal harm! Pain often is just a sign of your body being sensitive to stimuli. Especially if you have had a prior injury to the region, your brain will possibly predict a heightened response to movement that normally would not hurt. This is common, and if we exercise (rehabilitate) to a point of pain tolerance, this is actually a proven effective way to manage pain. I highly recommend you read my blog on ‘Pain & Exercise’ to learn more.
In summary though, tolerable pain inhibits the pain you normally experience. Repeated tolerable rehabilitation is one way of inducing a predictive processing error in your brain. Instead of predicting the movement as painful, it will eventually process that movement as safe. This is a major way I rehabilitate people at The Reform Lab. Rehabilitation in this way is an excellent way to improve function and confidence on movement, which ultimately plays a huge role in reducing pain.
6. Low back pain is caused by poor posture when sitting, standing & lifting (poor technique).
Of course, posture and lifting technique such as in the deadlift were going to get a mention! Blaming posture and creating fear on a bent (flexed) spine when lifting is how terrible practitioners and fitness influencers make money and get lots of likes. Blaming posture/lifting technique and then creating an imaginary fix to these imaginary problems, is how you can be stuck on the revolving door of back pain. The harmful advice of “bad posture”, “bad technique”, “deadlifts are bad for your back” creates fear and barriers to function. When it comes to sitting or standing posture, slouching is actually more energy efficient! Our bodies are quite relaxed in these positions, which is why it feels more comfortable. They key with any position, is to change it up when a little bit of stiffness comes on. Posture is all about movement variation! Move more and often after periods of sedentary behaviour and you will notice you have less tension/pain.
There is no solid causal evidence between lifting technique and low back pain. Sometimes you can be injured on lifting (such as the deadlift), however we have more evidence that suggests it was not the lifting posture that caused the injury. It was load intolerance to that given weight you were trying to lift. In other words, you probably did too much too soon and were not accustomed to that load yet. Furthermore, your load capacity may have been reduced from poor sleep habits or increased stress. As a result, the threshold for injury reduced. Back pain is far more complex than a mechanical view.
Do I focus on lifting technique with my patients who experience back pain on lifting? I certainly do, however it is more about reducing fear on lifting after the injury. For some people a more neutral spine is preferred, however some prefer a more flexed spine. It really is to do with the individual in front of me. Everyone is unique and so is their low back pain. Once we have found the optimal technique that allows that individual to return to lifting, a graded exposure to lifting is implemented. This approach gets them active early and reduces fear and muscle guarding on movement.
7. Low back pain is caused by weak core muscles & having a strong core protects against future low back pain.
If your health practitioner is stuck in the 80/90s they will be blaming your “weak core” for your back pain. They may even blame a single muscle for the pain you are experiencing. Having a weak core has not been associated with low back pain. In fact, individuals who have back pain have an overactive or stronger core. This is one reason why individuals with back pain move slower and are more rigid. Your core muscles are always subconsciously activated at a low threshold, you do not need to consciously squeeze the core muscles as this is unhelpful. Performing core strengthening exercises can be helpful, however it possibly has more to do with the exercise and movement acting as a pain reliever and muscle relaxant.
8. Repeated spinal loading results in ‘wear and tear’ & tissue damage.
Movement is medicine. ‘Wear and tear’ is not a thing, as exercising in a graded manner results in our bodies tissues adapting and becoming more resilient. Movement provides blood flow and it nourishes our joints with synovial fluid.
9. Pain flare-ups are a sign of tissue damage and require rest.
Pain flare-ups are common with low back pain. However, it normally does not mean you have sustained a re-injury. Pain flare-ups in the presence of lower back pain are more commonly associated with poor sleep, stress, anxiety, unaccustomed activity, inactivity, or low mood. Seeing your health professional during a flare up is a great option to get reassurance and receive treatment for pain relief. Rest is typically the last thing we want during a flare-up.
10. Treatments such as strong medications, injections & surgery are effective/necessary to treat low back pain.
Injections such as cortisone, opioid medication and surgery are not strongly effective for low back pain in the long term. Cortisone shots are actually more harmful in the long run to your tissues health. All these options have harmful side effects and are not recommended in managing chronic low back pain. Seeking treatment and advice from your health professional is recommended, as they should provide you helpful options that put you in control of your pain.
Facts about Low Back Pain
Having a positive outlook on back pain has been associated with less pain and less disability (Beales et al., 2015). Sharing this blog with your friends is a positive way of reducing the global burden of low back pain. So after you have read the facts, please share this blog with your friends and family.
1. Low back pain is not a serious life-threatening medical condition.
2. Most episodes of Low back pain improve, and low back pain does not get worse as we age.
3. A negative mindset, fear avoidance behaviour, negative recovery expectations, and poor pain coping behaviours are more strongly associated with persistent pain than is tissue damage.
4. Scans do not determine prognosis of the current episode of low back pain, the likelihood of future low back pain disability, and do not improve low back pain clinical outcomes.
5. Graduated exercise and movement in all directions is safe and healthy for the spine.
6. Spine posture during sitting, standing and lifting does not predict low back pain or its persistence.
7. A weak core does not cause low back pain, and some people with low back pain tend to over tense their ‘core’ muscles. While it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren’t needed.
8. Spine movement and loading is safe and builds structural resilience when it is graded.
9. Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.
10. Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centred and fosters a positive mindset, and coaching people to optimise their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment).
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