"Hey everyone, look at my pain-free back!" - Arnold, probably.
9 Low Back Pain Myths
No fragile backs here...
Myth 1: Your back is a fragile structure so you need to keep it straight and be really careful moving it
This is wrong! Your back is stronger than you think. Most people will experience back pain during their lifetime. It can be disabling and worrying but it is very common and rarely dangerous. See, what you believe about your back pain influences your pain. The spine is a strong, stable structure that is not easily damaged! Your spine can handle well over 900kgs of pressure! Most physical things you do are far below the threshold where structural damage is done.
Not only this, but there's very little research to support the conclusion that spinal posture is causative, protective or preventative of back pain. While some positions of can be more painful to hold, this merely reflects the degree of sensitivity of the spine which is often strongly influenced by psychosocial factors (more on this later). Painful postures can also be linked with your habitual protective behaviours. For example, there's often a lot of bracing and protective guarding (i.e. ‘I need to sit up tall and engage my core’) in those with back pain. We know that this habitual protective strategy can actually increase spinal loads and feed into the pain experience and make it worse. For these individuals, relaxation and postural variability may provide pain relief.
“The strongest correlation to chronic back pain is whether the person believes the pain will persist.” - Peter O’Sullivan
Myth 2: You MUST have a scan
Only about ~1-3% of back pain is caused by serious disease or injury. If your back pain is connected with a traumatic event, this may be indicative of a fracture, which will need a scan. If back pain is linked with problems regarding urinary retention, loss of power, or loss of sensation in a limb, then scanning may also be needed. If back pain is associated with fever, malaise, weight loss etc., or if there's a history of malignancy, then its best to be screened first by a doctor. If none of these are present, then you are likely to be in the ~97% of people who are classified as having non-specific low back pain (NSLBP). We have some amazing technology to see inside the body. The problem with using this fantastic technology with NSLBP is that we can often find “abnormalities” (joint degeneration, loss of disc height in the spine etc.) and assume that this is the source of pain. The problem is that there is very poor correlation between “abnormalities” we find on imaging and pain. In fact, getting a scan can do more harm than good! Sometimes these normal age-related changes can cause people to be very fearful and avoid doing activities they need to do to get better. If you haven’t been recommended to get a scan, don’t worry, it’s a good sign that there’s nothing concerning going on!
A recent x-ray of the man himself...
“Structure is not destiny.” - Greg Lehman
Arnie, um, resting in bed...
Myth 3: Bed rest and time off work are good ideas
Rest in bed, take time off work and avoid normal activities if you want to experience higher levels of pain, greater disability and poorer recovery! Of course it’s sensible to temporarily avoid aggravating activities. However, the evidence is clear that staying as active as you're able and returning to usual activities is very important for recovery – and this includes remaining at work if possible! It’s totally normal to move a bit differently after an episode of pain, but it’s unhealthy to continue this long-term. (Foster et al., 2018)
“…most episodes of back pain are self-resolving, […] don’t need time off work, [and] most certainly don’t need surgery or injections. Instead what [The Lancet papers] tell us is back pain needs to be effectively and efficiently screened for the rare but serious causes and then managed with reassurance and advice to keep active and positive.” – Adam Meakins
Myth 4: Be extremely cautious when bending or lifting
While it can be painful to bend and lift with back pain, it's important that a person develops the confidence, mobility and strength to bend and lift. It is a common myth that bending and lifting is dangerous for the back, and engaging in these activities is an important function of daily living. If you're extremely worried about performing these activities, that could lead to fear and avoidance behaviours and actually increase your level of disability! Your spine is robust and is meant to bend! Being confident to bend, lift, twist, and move in lots of ways is important as this helps to de-threaten movement and de-sensitise the nervous system (O'Sullivan et al., 2018).
Arnold bending to pick up something heavy...
Pain is not necessarily a sign of damage but more an individual response to threat, real or perceived. Psychological factors are strong predictors of long term disability and chronic pain (Burton et al., 1995; Fritz et al., 2001).
Myth 5: Avoid exercise and activity, especially if it hurts. Exercising in pain is super dangerous.
The severity of back pain is a poor measure of tissue damage. This means that while an activity may be painful, this is not an accurate sign of doing harm. This is supported by a recent systematic review which highlighted that engaging in activities that are painful are safe and can result in greater benefits. Understanding that pain is a sign of tissue sensitivity rather than tissue damage is important to develop the confidence to return to valued physical activity in a graded manner and without protective muscle guarding. Start slowly and build up both the amount and intensity of what you do. Of course, it's a good idea to be reviewed by a physiotherapist or exercise physiologist if you're unsure where to start. While no one type of exercise is proven to be more effective than others, it's nevertheless important to pick an exercise you enjoy, that you can afford to maintain in the long-term and that fits in with your daily schedule.
A photo of Mr Schwarzenegger presumably in some degree of pain...
Myth 6: Painkillers will speed up your recovery
While there is a common belief that strong drugs such as opioids provide effective relief for back pain, the evidence suggest that their effectiveness is similar to non-opioids drug such as NSAIDS and they carry significant health risks. There is also evidence that taking opioids long term can suppress the body's natural opioid system and result in increased sensitisation of the nervous system. The exploration and management of modifiable factors that can increase pain sensitisation utilising self-management strategies helps to build your self-efficacy and put you in charge of your pain. The use of medication can be a useful adjunct in this process where levels of pain are a barrier to self-management. Pain killers do not speed up recovery.
Yeah, this image has nothing to do with painkillers...
Disclaimer: specific patient advice regarding the use of medication is dictated by health care practitioners’ accrediting body within their country. For example, in Australia, this role lies with medical practitioners and pharmacists.
Myth 7: Sleep isn’t very important
Arnie prioritising his sleep.
The importance of sleep in tackling back pain has become increasingly clear in recent years. This is because it reduces stress and improves your overall feeling of wellbeing, making you less susceptible to the triggers of pain in the first instance and helping you to cope when it does occur. Aim for 7-9 hours a night and try to aim for a regular routine, as far as possible. It is also very important to know that there is no best position or type of mattress – whatever feels most comfortable for you is best. Cuddly toys are optional, but encouraged.
Myth 8: Back pain is all in your head
While we know that our thoughts and feelings about pain influence the severity of pain and its impact on a person, nevertheless your pain is NOT all in your head! This is clearly not helpful. I would like to validate your back pain, it's real, and your spinal structures are sensitised. However, being aware of the role that your thoughts and emotions have on your pain experience is important in having greater awareness of your condition. Many physical or psychological factors can cause back pain and often a combination of these are involved..
When physios tell Arnold his pain is all in his head!
Myth 9: Massage, manipulation, cracking etc. are great for chronic low back pain
While passive therapies such as spinal manipulation, massage, needling, spiky balls, rollers etc can provide short term pain relief, it does not change the natural trajectory of back pain. Exploring effective long term self-management strategies to build confidence when engaging in valued activities should be the primary objective. This builds self-efficacy and reduces dependency on passive therapies.
Arnold lies prone for leg curls, not rubs!
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Belavy DL, Quittner MJ, Ridgers N, Ling Y, Connell D, Rantalainen T (2017) Running exercise strengthens the intervertebral disc. Sci Rep, 7:45975. doi: 10.1038/srep45975
Bigal ME (2018) Opiods vs nonopiods for chronic back, hip or knee pain. JAMA, 320(5); 507. Doi:10.1001/jama.2018.6949.
Campbell A, Kemp-Smith K, O’Sullivan P, Straker L (2016) Abdominal bracing increases ground reaction forces and reduces knee and hip flexion during landing. J Orthop Sports Phys Ther, 46(4): 286-292. doi:10.2519/jospt.2016.5774
Dankaerts W, O’Sullivan P, Burnett A, Straker L (2006) Differences in sitting postures are associated with nonspecific chronic low back pain disorders when patients are subclassified. Spine, 31(6):698-704. doi: 10.1097/01.brs.0000202532.76925.d2
Juurlink DN (2017) Rethinking “doing well” on chronic opioid therapy. CMAJ, 189(39): E1222-E1223. doi: 10.1503/cmaj170628
Lewis J, O’Sullivan P Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med (2018) doi: dx.doi.org/10.1136/bjsports-2018-099198
Maher C, Underwood M, Buchbinder R (2017) Non-specific low back pain. Lancet, 389(10070): 736-747. doi: 10.1016/S0140-6736(16)30970-9
O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K (2018) Cognitive functional therapy: An integrated behavioural approach for the targeted management of disabling low back pain. Phys Ther, 98(5): 408-423. doi: 10.1093/ptj/pzy022
Smith BE, Hendrick P, Smith TO, et al Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med (2017) doi: 10.1136/bjsports-2016-097383
Staples, M. P., Kallmes, D. F., Comstock, B. A., Jarvik, J. G., Osborne, R. H., Heagerty, P. J., & Buchbinder, R. (2011). Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis. Bmj, 343. doi: 10.1136/bmj.d3952
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