Debunking Misconceptions about Back Pain

This week in Spine Health Week, Sophie Fraser, Physiotherapy Team Leader, and Pain Management Coordinator at TVRC discusses common misconceptions about the spine and how to manage low back pain

Last Thursday after a day of working with patients in the VRC pain management program, I went to receive my second COVID vax. Jacqui, the nurse giving it to me was at the end of a ten hour shift and told me in passing how sore her low back was. She joked that at least now she can get her kids to empty the dishwasher, so she doesn’t have to bend. She also mentioned she was looking forward to having a few days off so she could rest her back, and that she should get back to doing her “core” exercises. She was great at her job - while we were chatting about her back, I didn’t even feel the jab. 

My conversation with Jacqui highlighted a few of the many commonly held misconceptions about what is a useful and healthy way to respond to low back pain. Low back pain is the biggest single cause of disability worldwide,  and its incidence is rising. Many people respond to it by resting, and avoiding movements such as bending, twisting and lifting, often on advice from a health care professional. This can be associated with the idea that pain equates to damage, and that minimising movement will prevent further damage. Braced postures and guarding movement are also associated with the widely held belief that having a strong “core” improves the strength and health of the spine and will reduce pain. 

It is important to know that the majority of cases low back pain do not reflect serious pathology. Degenerative changes and disc bulges or protrusions that often show up on scans are also very common in people who have no pain at all, and thus do not adequately explain how much pain or disability you will have (Brinjikji et al., 2015). A lot of back pain comes on with normal activity rather, than an injury, and can be related to stress, fatigue, or unaccustomed activity when the tissues may be sensitive to loading and movement.  Pain levels are often more reflective of how sensitive your tissues are, not how much damage you have, and flare ups can relate more to changes in activity, mood, stress and fatigue levels, rather than structural damage (O'Sullivan et al., 2020).

Avoiding activities and resting excessively can increase this tissue sensitivity and then likelihood of more pain on movement - further promoting further fear and avoidance. Having a “strong core” is not necessarily the answer; the research shows that core exercise are no more effective than general exercise for treating people with low back pain (Macedo et al., 2012). In fact, the majority of people with non-specific low back pain, have overactive trunk muscles, contracting the back and abdominal muscles simultaneously, leading to reduced variety of movement, stiffening up, and more likelihood of pain on activity. Learning to relax the trunk muscles, to breathe and move normally is important. You may be surprised to know that the shape of the joints in the low back mean it is actually designed for bending, and a large part of my treatment for people with chronic back pain, is to help them to feel they can relax, and bend safely, comfortably and without fear. It is also important to gradually load the spine to build structural resilience (O'Sullivan et al., 2020).

So, in terms of the best advice to manage low back pain, remember that less than 5% of back pain involves serious pathology. Resuming normal activity as soon as possible, and avoiding excessive rest is important; relax, breathe and try to maintain a variety of movements. The human spine is an amazing structure that remains healthy through a performing a range of different movements; any exercise that you enjoy and will stick to is better than specific exercise targeting certain muscles. If you have ongoing back pain consult your physio to guide you on how to move freely, gradually increase  your physical activity and loading,  and build confidence about your ability to maintain a healthy back. 

 
References

• Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., . . . Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811. doi:10.3174/ajnr.A4173
• Macedo, L. G., Latimer, J., Maher, C. G., Hodges, P. W., McAuley, J. H., Nicholas, M. K., . . . Stafford, R. (2012). Effect of Motor Control Exercises Versus Graded Activity in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial. Physical therapy, 92(3), 363-377. doi:10.2522/ptj.20110290
• O'Sullivan, P. B., Caneiro, J. P., O'Sullivan, K., Lin, I., Bunzli, S., Wernli, K., & O'Keeffe, M. (2020). Back to basics: 10 facts every person should know about back pain. British journal of sports medicine, 54(12), 698-699. doi:10.1136/bjsports-2019-101611