An influx of patients suffering from lower back pain has prompted me to look at some misconceptions about back pain. Do you believe that bed rest is the best cure for back pain? Or that you always need an X-ray to determine the cause of your back pain? Read on to find out more about the many facts and fallacies about back pain.
True or false: Bed rest is always recommended for back pain
In the first few days after the initial injury, avoiding activities that worsen pain may help to relieve it, as it does with pain in any other part of the body, such as a sprained ankle. However, there is very strong evidence that keeping active and returning to all usual activities, including work and hobbies, is important in aiding recovery. Prolonged bed rest is unhelpful, and is associated with higher levels of pain, greater disability, poorer recovery, and greater absence from work. In fact, it appears that the longer you stay in bed because of back pain, the worse your pain becomes.
An increase in exercise and return to normal daily activity should be done gradually. Therefore, while performing some common tasks at work and home may initially be painful, early and gradual return to all these tasks is better for your back than prolonged rest.
True or false: Once you have hurt your back you will always have a ‘bad back’
While low back pain can be very painful initially, most people make a very good and speedy recovery within a few weeks with improvement continuing over a few months.
Most people can return to their work, sport and hobbies relatively quickly. They may have recurrent episodes which also settle quickly, but they do not experience any major changes in their quality of life. A simple clinical examination by a physiotherapist along with some advice is often enough to set them on the road to self-managed recovery.
However, some people do develop long-standing, disabling problems. It is most important that these people, who may be at risk of developing ongoing problems, are identified early.
Current research shows that there are a number of factors associated with an increased risk of ongoing back pain, such as the level of pain, distress, anxiety, and fears that movement will make the condition worse. These factors can be identified at an early stage by your physiotherapist and research has shown that your prognosis is greatly improved when these factors are targeted as part of the management of your low back pain.
True or false: The worse the pain, the more the damage
This may seem strange, but we now know that more pain does not always mean more damage.
People with similar back problems can feel very different levels of pain. The degree of pain felt can vary according to a number of factors, including the situation in which the pain occurs, previous pain experiences, your mood, fears, fitness, stress levels and coping style.
In fact, two individuals with the same injury can feel different levels of pain. Furthermore, the brain has the ability to ‘inhibit’ or turn down the volume and intensity of pain.
The tissue that has been injured cannot generate pain – it can only send messages to the brain to indicate a possible “threat”. It is the brain that interprets and processes these messages as ‘pain’ or ‘no pain’. So the brain plays an important part in regulating if you feel any sensation, such as pain at any given time and how much you feel.
If you have persistent low back pain it might be that your whole nervous system (including the brain), which is involved in sending and processing pain messages is relatively more ‘active’ compared to other people, almost like a burglar alarm that is set to a sensitive setting. This can mean you feel more pain when you move or try to do something, even though you are not damaging your spine.
In fact, there is clear evidence of changes in brain activity in people with long-standing low back pain. A person’s genetic make-up as well as environmental and personal factors are also important in determining how we each experience pain.
Thankfully, a number of strategies, including a gradual return to activities, exercise, and education about pain, can be used to help lessen the pain and disability experienced. Research shows that once people with low back pain understand that the pain or ‘hurt’ they are feeling is not causing further ‘harm’ to their back, it is easier to participate in activities and exercise.
True or false: You always need a scan or X-ray for back pain
X-rays do not help your pain or assist your recovery and may result in costly interventions. A simple clinical examination is usually enough to identify the small group of people who require scans.
Bulging discs and degenerative changes are commonly found in spinal x-rays and MRI’s, but often occur in pain free individuals as well as those with back pain.
Most people with long-standing low back pain have no significant spinal pathology, so their pain is referred to as ‘non-specific’ low back pain.
For those who do have a scan, findings such as ‘disc degeneration’ are not closely related to their low back pain or disability, and are possibly more related to factors such as genetics rather than spinal overloading. In fact ‘disc degeneration’ is a normal part of getting older – like grey hair and wrinkles!
True or false: Your back needs to be ‘put into place’
When your back is really sore you may feel out of control of the situation, and that someone else must ‘take the pain away’.
Massage, manipulation, heat or ice, and acupuncture are useful to ease the pain in the short term. You may have been told that there is a bone or joint in your back out of place, or that your pelvis is out of alignment, and that it must be “clicked back”. Having your back manipulated is not putting anything back in place – there was never anything ‘out of place’ in the first place!
Common beliefs that low back pain is caused by spinal subluxations, pelvic asymmetries, alterations in leg length and other simple structural issues, are incorrect. For most people with back pain X-rays and scans do not show any evidence of joints being out of place or that discs have ‘slipped’ out of place.
Research shows that people who are most disabled by low back pain are those who believe their pain relates to a problem with the structure of their spine, as this leads to heightened levels of fear, distress, and anxiety. There is very little evidence relating disc bulges to low back pain, as many people without low back pain have disc bulges without experiencing any pain. However, no study has ever shown that these bulges can be ‘clicked’ back into place by spinal manipulation. Most disc bulges resolve and shrink again over time and do not require surgery or injections.
The pain relief from all these treatments results from a reduction of the sensitivity or ‘activity’ of the nervous system, which helps to restore normal joint movement and muscle activity, and NOT from ‘clicking’ anything back into place.
Reliance on a ‘fix’ for your pain creates a dependency, reducing your self-confidence in coping with your back pain. In some cases it may be unrealistic to believe that chronic low back pain will go away completely. There are many people who have ongoing pain, but do not allow it to affect how they live their lives.
If you think about your pain constantly it becomes far worse – like an annoying song that plays over and over in your head. Like any chronic disease, such as depression, diabetes, and cardiovascular disease, low back pain must be self-managed. This can be done through developing a set of beliefs that your spine is a strong and resilient structure, and that you need not constantly worry about damaging it further.
Positive thoughts and beliefs such as ‘I can be sore but safe’ – telling yourself that pain does not indicate damage, but rather a nervous system that is dialing up its intensity to get your attention – can help you manage your pain yourself.
How to treat back pain
If you develop low back pain for the first time your physiotherapist, doctor, or healthcare professional should screen you for signs of serious pathology.
Only in a very small number of cases are further tests required. Otherwise, you should try to return to your usual levels of physical activity as quickly as possible, and avoid bed rest. Your physiotherapist will educate you on the nature of the problem, and address any unhelpful beliefs about low back pain.
For the majority of people who first hurt their back, there is no need for lots of treatment, and often some simple advice is sufficient. This may include advice on some simple exercises to ease your back pain. Patients who have higher levels of pain, disability, stress, anxiety, fear or depression may require more, and other, treatment to reduce the risk of low back pain becoming a chronic problem.
For people who have had persistent low back pain for a long time, participating in a regular exercise program makes a big difference. This can be a Pilates class, a yoga program, or something as simple as taking your dog for a 20 minute walk every day. 140 minutes per week is the recommended duration of exercise for good health. The important thing is it must be something that you enjoy, so that it can become a regular lifelong habit. Your physiotherapist can advise you about this.
For patients with higher levels of disability, stress, anxiety, fear or depression, multiple disciplines (possibly including a psychologist) may need to work together with the patient.
Exercise and back pain
Many different forms of exercise seem to help low back pain, including aerobic exercises like walking, cycling and swimming, as well as exercises aimed at improving the posture, strength and mobility of the spine. The most relevant factor is whether people continue with their exercise program over time. Therefore you should consider which form of exercise you enjoy most, and which you can do with little or no inconvenience. Remember that many hobbies and daily routines can be considered exercise also, for example gardening, cutting the lawn, and using the stairs instead of the lift. Importantly, exercise is most effective when we also change the way we think about low back pain.
What if exercise increases your pain?
When you haven’t exercised for a while some initial soreness is common in people with low back pain at first. This can result in people with low back pain becoming fearful about exercise if they believe the pain is caused by more ‘damage’ to their spine. This initial soreness is, however, a relatively normal response to exercise, and does not indicate any harm being done to your body.
Instead, this can reflect the ‘over-activity’ of the nervous system in response to movement mentioned earlier, which can reduce over time. And remember if you haven’t exercised for a while your body needs to build up a tolerance to the new challenge!
Your physiotherapist can help you with a program to gradually increase your levels of activity and exercise tolerance – a bit like training for a marathon!
In conclusion, low back pain is a common problem affecting the quality of life of many people. It is now clear that the beliefs of people with low back pain can have a major effect on their prognosis. Low back pain patients who are most fearful about their future low back pain, who rest excessively, who cannot cope with, or control, their pain, or who believe there is a serious structural problem in their back are at greater risk of developing chronic low back pain.
These are understandable concerns when one considers common beliefs about low back pain. The good news is that most of these beliefs are incorrect and can be changed. International research shows that improving beliefs about low back pain can make a big difference to people with low back pain. Research shows that exercise is safe and effective in the management of low back pain, and that people with low back pain should not be fearful of exercise, and thus reap the important benefits of exercise.
There are many resources on the Internet that give good advice in an entertaining way, but based on current evidence about managing low back pain. A few are listed here:
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