I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about me • more about PainScience.com
Welcome to one of the Internet’s saner sources of information about chronic low back pain.[NIH] This is a book-length tutorial, a guide to a controversial subject for both patients and professionals. It is not a sales pitch for a miracle cure system. It’s heavily referenced, but the tone is often light, like this footnote about being “shot by the witch.”1 I will offer some surprising ideas — underestimated factors in low back pain — but I won’t claim that all back pain comes from a single cause or cure. It’s just a thorough tour of the topic, the myths and misconceptions, and the best (and worst) low back pain treatment ideas available.
Since I first started treating low back pain in 2000, there’s been an explosion of free online information about it — countless poor quality articles. Back in the day, we actually had to go to a doctor or buy a book to get shoddy back pain information — now it’s just a Google search away.23 But it’s worse than that: even professional back pain guidelines are often misleading.4 For instance, despite overwhelming scientific evidence to the contrary, it’s extremely common to incorrectly portray back pain as a “mechanical” problem, as if the spine is a fragile structure which breaks down and causes pain.5 This is based on decades old misconceptions about how backs work, and how pain works, which the medical world is only gradually learning to leave behind.
I am a science writer & amateur athlete in Vancouver, Canada. I’ve been writing about low back pain for over a decade, in part to understand & manage my own chronic pain problems, including rare but nasty episodes of back pain. ~ Paul Ingraham
About footnotes. There are 395 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.
This myth of “mechanical” failure of the low back has many unfortunate consequences, such as unnecessary fusion surgeries — a common and routinely ineffective procedure — and low back pain that lasts for years instead of months or weeks. The seriousness of chronic low back pain is often emphasized in terms of the hair-raising economic costs of work absenteeism, but it may well be far worse than that — a recent Swedish study shows that it probably even shortens people lives.6 The stakes are high. “Tragedy” is not hyperbole.
Even more tragic is that good information exists, and not just here in this book: many medical experts do “get it” (the doctors doing the actual research). But they have fought a long battle trying to spread the word to their own medical colleagues on the front lines of health care. A 2010 report in Archives of Internal Medicine showed just how grim it is:
Usual care provided by general practitioners for low back pain does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time.
Williams et al, 2010, Archives of Internal Medicine7
Experts have particularly struggled to get the word to alternative health professionals — most of whom don’t even read medical journals.8
In this tutorial, you will meet those medical experts and find out what they know and believe and why. Their ideas about low back pain are neither “conventional” nor “alternative” — they simply come from the best minds in the business.
The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).
You don’t need to take my word for anything — you can just take the word of the many low back pain medical experts that I quote,9 and the hard evidence that their opinions are based on. At the same time, I am realistic about the limits of the science, much of which is pretty junky.10My own credentials are somewhat beside the point. My decade of professional experience as a Registered Massage Therapist does help me understand and write about low back pain, but what really matters is that I refer to and explain recent scientific evidence, but without blindly trusting it.
How do so many health care professionals go wrong when they treat low back pain?
Why does the myth of mechanical back pain get repeated endlessly on the Internet and in health care offices around the world?
Repairing spinal joint “misalignment” is an easy idea to sell … but it’s hard to actually do! Chiropractors often can’t even agree on which joints need “adjusting” — even with only five lumbar joints to choose from.
Poor posture and crookedness is another popular scapegoat — it seems obvious that posture is relevant. Many professionals assume that back pain is some kind of postural problem that you can exercise your way clear of. Unfortunately, the evidence shows that no kind of exercise, not even the most hard-core core strengthening, has any significant effect on low back pain.
pro Strong enough for a pro But made for patients. The main text is user-friendly, but oodles of footnotes provide extra info and citations.
I do criticize many common practices and beliefs. If you disagree, let me know—I can take it, and I’ve made many changes over the years based on quality feedback.
The almost magical power of MRI to look inside the back gives both doctors and patients something to point at and blame, but most are unaware that MRI has been proven (many times) to be a lousy diagnostic tool for back pain. The things you see on MRI scans are rarely the real problem — and every radiologist seems to see something different!
Orthopedic surgeons (especially American ones) profit handsomely from the most complex low back surgeries (especially spinal fusion), so they are strongly inclined to think of back pain as a mechanical problem in need of physical repair — in spite of piles of scientific evidence to the contrary. If all you have is an incredibly profitable hammer …
Sports medicine specialists have great expertise about injuries, so they often assume that back pain involves some kind of damage — but the evidence clearly shows that low back pain often has nothing to do with tissue damage.
Is professional care for low back pain really this dodgy? Sadly, I believe so. I clearly remember graduating clueless myself. If I hadn’t spent many years doing post-grad study of low back pain, I wouldn’t know 98% of what’s in this document. All of the points above — and many more — will be explained and supported in great detail below.
Who is this low back pain tutorial for?
This book is overkill for new and acute cases. It’s best for patients with unusually stubborn low back pain and sciatica — and for doctors and therapists who want to help with it.
Most acute low back pain fades steadily — up to 90% of it, for uncomplicated cases.11 So does a lot of so-called “chronic” low back pain!12 But when you don’t recover, many of the therapeutic options — things like surgery for a herniated disc — cause anxiety that is unnecessary and harmful. The purpose of this tutorial is to review and expand the options.
This tutorial is great for people who like to understand their problems. Its dorky, quirky thoroughness is unlike anything the big medical sites offer, and the lack of a miracle cure secret is rare among independent sources. My goal is “just” to empower you with education (without boring you to tears). When you’re done, you’ll know more about your back than most doctors. (Not that this is saying much!13) I’ve spent years compiling this information from hard study, professional experience, and lots of your stories and feedback. I update the tutorial regularly.
But I will not just tell you what you want to hear. Understanding low back pain as well as possible is valuable, but it will not necessarily lead to a cure. Sadly, some low back pain cannot be fixed.
Has nobody noticed the embarrassing fact that science is about to clone a human being, but it still can’t cure the pain of a bad back?
Some cases of “incurable” chronic low back pain can still be cured!
While it’s true that some lower back pain just cannot be fixed, it’s also true that many “incurable” cases do turn out to be surprisingly treatable. People who believed for years that their pain was invincible have found relief. Not always, and often not completely — but sometimes any relief is far better than nothing. How can extremely stubborn pain finally ease up? Simple: because many cases weren’t truly stubborn to begin with, despite all appearances. So many health professionals are poorly prepared to treat low back pain that patients can easily go for months or even years without once getting good care and advice. When they finally get it, it’s hardly surprising that some patients finally get some relief from their pain.
Patients can easily go for months or years without good care and advice
And it’s always amazing to me how chronic pain can, with the right therapy, just suddenly end — it’s not common, but it does happen. Lots of people who thought they’d “tried everything” for lower back pain read this tutorial and then write to me and say, “Well, I guess I hadn’t tried everything!”
Similarly, many athletes with “career-ending” injuries are far from finished. Bret “The Glute Guy” Contreras, from You’ll Never Squat Again:
Numerous powerlifters over the years have come back following ‘career-ending injuries’ to set all-time personal records. Donnie Thompson is the only man to total 3,000 lbs (1,265 lb squat, 950 lb bench, 785 lb deadlift). Many people don’t know this, but several years back Donnie suffered a horrendous back injury and herniated three discs. He could barely walk, but he got out of bed and rehabbed himself every day. Within three months he was back to heavy squatting and setting personal records. Got that? Setting personal records three months following an injury that herniated 3 discs!
How could that be? It’s almost like herniated discs aren’t necessarily as scary as everyone seems to think. Hm!
I have never met a patient — no matter how experienced or self-educated — who could not gain at least some new insights and new hope from this tutorial.14
Is this going to be one of those “it’s all in your head” theories about low back pain?
Low back pain can certainly be sensitive to emotional state, just like an ulcer gets worse when you’re stressed. But both are real physical problems! All of this will be discussed in detail, and it’s important, but this is not a tutorial about treating back pain through psychoanalysis and stress relief! Yoga and meditation are good tools for those who enjoy them, but they are not required.
A weakness in Dr. John Sarno’s (otherwise interesting) writing about back pain15 is that he tends to give patients the idea that recovery from low back pain is all a mind game. It’s not! “The biology of pain is never really straightforward, even when it appears to be.” (Moseley)
Yes, stress is a factor in low back pain, but meditation and yoga are over-rated and inappropriate options for many people. This tutorial explores more practical options.
“What if there’s something seriously wrong in there?”
“How do you know I’m not seriously hurt?”
“Could it be cancer? A tumor?”
You’re not paranoid if they really are after you! Only about 1% of back pain has a nasty cause,16 and only a few of those are really scary. But it happens. Andy Whitfield, star of Spartacus, thought he just had back pain from his intense gladitorial training. In fact, he had a tumour. It killed him in 2011.
The most dangerous thing about trying to reassure low back pain patients is the unnerving possibility that I might reassure someone who should not be. But reassurance is almost always appropriate. Most back injury feels worse than it is — its bark is worse than its bite.
But how do you kow if you’re the exception? Can you recognize the early warning sign of cancer, infection, autoimmune disease, or spinal cord injury? These things often cause other distinctive signs and symptoms, and so they are usually diagnosed promptly. If you are aware of these red flags, you can get checked out when the time is right — but please avoid excessive worry before that.
The rule of thumb17 is that you should start a more thorough medical investigation only when three conditions are met:
it’s been bothering you for more than about six weeks
the trend is strongly negative — the pain is severe and/or not improving, or even getting worse
there is at least one other red flag (see below)
And there are also two rare situations where you shouldn’t wait several weeks before deciding the situation is serious …
significant numbness around the groin and buttocks and/or failure of bladder or bowel control
if you’ve had an accident involving forces that may have been sufficient to fracture your spine
This free article explains in more detail (including a list of red flags) and is strongly recommended to anyone who feels nervous:
In all other cases, you can safely read this tutorial first. For instance, even if you have severe pain or numbness and tingling down your leg, you can safely read this first. Or, even if you have an obviously severe muscle tear from trying to lift your car or something, you can safely start here — rest and read. Your back is not as fragile as you probably think, and understanding why is a great starting place for healing in nearly all cases of low back pain.
Don’t confuse threat and risk. Working at the edge is a risk. But then again, so is walking out your front door.
Spines haven’t changed in the last century,18 and yet modern civilization suffers from a great plague of low back pain.1920 Yet the real causes of most back pain are obscured by medical mythology and misunderstanding.21 Before I discuss what does cause most low back pain, it’s important to talk about what does not cause it. In this section, I will challenge the mythology in just a few paragraphs, supported by over thirty references to the best scientific information available — references you can check for yourself. This is quite different than most sources of patient-focused low back pain information, which tend to avoid discussing the evidence.
Most people — and most health care professionals — believe that back pain is usually caused mainly by structural problems, either injury or degeneration of the spine. This idea is not supported by the scientific evidence.22 Indeed, just the opposite is more the case: “The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).”23
When structural problems are exaggerated, you also get a plague of bogus explanations and solutions based on that. Spines do degenerate, but not for the reasons most people think they do: genetics is by far the biggest factor in degeneration,24not your posture, your office chair or mattress, your core stability, or anything else that low back pain sufferers have taught to blame their pain on.
The idea that the spine is fragile is an unjustified but deeply held belief, based on ignorance of a complex subject and on an obsolete mechanical view of biology that has dominated medical thinking for centuries.
END OF FREE INTRODUCTION
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Free second tutorial! When you buy this tutorial, you will also get Save Yourself from Trigger Points and Myofascial Pain Syndrome! — a $1995 value. The low back pain tutorial makes the case that trigger points are a major factor in low back pain. However, trigger point therapy is not an easy skill to master — and it’s an enormous subject. PainScience.com publishes a separate tutorial about trigger point therapy. It’s offered as a free, essential companion to the low back pain tutorial. As a pair, they give you everything you need to know about helping most cases of low back pain.
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••••• dots before headings indicate updated sections ?There’s a detailed description of all updates at the bottom of the tutorial, and it’s nice to be able to see what’s new at a glance in the table of contents. Any section updated in the last 400 days is marked (hotter colours = fresher updates).
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This document and all of PainScience.com was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.
Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.
“The Pain Perplex,” a chapter in the book Complications, by Atul Gawande. Gawande’s entire book is worth reading, but his chapter on pain physiology is certainly the best summary of the subject I have ever read, and a terrific reminder that good writing for a general audience can be just as illuminating for professionals. Anyone struggling with a pain problem should buy the book for this chapter alone, though you are likely to enjoy the whole thing. Much of the chapter focuses on one of the most interesting stories of low back pain I’ve read, and it is a responsible and rational account — although Gawande, like most doctors, seems to be unaware of the clinical significance, or even existence, of myofascial trigger points.
Dr. Jerome Groopman has written brilliantly about back pain, from personal experience. In How Doctors Think he puts back pain in the context of how medical thinking is influenced by marketing and money, giving us a somewhat chilling insiders’ view of the surgical treatment of back pain. In The Anatomy of Hope, he tells his own story of super severe back pain. It has a happy ending! Both books are also otherwise worthwhile. “Marketing, Money, and Medical Decisions,” a chapter in the book How doctors think, by Jerome Groopman. Groopman, writing from personal experience with chronic back pain and a spinal fusion surgery, discusses back pain as intelligently as any medical expert I’ve come across, but he does so in a way that will fascinate patients. In this chapter, his discussion of back pain is placed in the context of how medical thinking is influenced by marketing and money, giving us a somewhat chilling insiders’ view of the surgical treatment of back pain.
What’s new in this tutorial?
This tutorial has been continuously, actively maintained and updated for 13 years now, staying consistent with professional guidelines and the best available science. The first edition was originally published in September 2004, after countless hours of research and writing while I spent a month taking care of a farm (and a beautiful pair of young puppies) in the Okanagan.
Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 113 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).
Most links to sections shown here work for customers only. For access to all sections, buy the tutorial for $19.95. You’ll get the full version right away.
— Minor update: Added discussion of orthotics to treat leg length differences for back pain.
— New section: An important and interesting acknowledgement that mechanical causes of back pain do exist.
— New subsection: Added content inspired by decades-old evidence of reduced spinal degeneration in “primitive” cultures where squatting is common. Some light editing of everything else in the chapter.
— Science update: Added a small but key new point and citation about genetic factors in degeneration; and an important new citation about the disconnect between imaging results and pain.
— Science update: Discussed important new review of SMT for acute low back pain. Significant revision of the section.
— Science update: Strong new reference to Andrade et al fully supports the main message of the section.
— Science update: Newer, better, evidence-based good news about disc herniation resorption.
— Science update: Updated references for debunking of TENS for back pain. Added ultrasound to the section.
— Minor improvement: Added a proper summary of Roffey et al, and a relevant personal footnote.
— Science update: Added discussion of a remarkable example of poor MRI reliability.
— Major correction: An evidence-based reversal of position and advice about sitting and back pain, correcting a long-standing error: my long-term assumption that too much sitting is a risk factor for back pain was never defensible.
— Science update: Added commentary on the “do not offer” acupuncture recommendation in the new NICE guidelines for back pain.
— Edited: Thorough revision and modernization. Although I revised this section just five years ago, it needed it again!
— Science update: There is now a good scientific concensus on the subject of spinal fusion, thanks to papers like Mannion 2013 and Hedlund 2016. Putting a spotlight on this called for some serious revision and editing. The whole section is greatly improved.
— Upgrade: Added much more information about non-Rx pain-killers, and greatly improved information about opioids (and linking to much more information).
— Correction: Removed overconfident statements about the clinical significance of the effects of psychoactive drugs, plus related minor updates.
— Science update: Some fresh citations that strongly reinforce the main point of the section, and a few entertaining new examples of weird placebo effects.
— Safety update: Updated opioid summary for consistency with new CDC guidelines.
— Update: Added new intro to section about distorted body image.
— Minor update: Clarification of the significance of some previously cited science, Ferreira et al.
— Science updated: New citations and more information about spontaneously resolving herniations.
— Science update: Beefed up the evidence that vertebroplasty is an ineffective surgical fix for an allegedly structural problem.
— Minor science update: Added a note about the odds of back pain having a serious cause.
— Science updated: Added some general explanation of cognititive-behavioural therapy, with a key reference.
— Science update: Added discussion of a popular acupuncture-for-back-pain paper, Cherkin 2009. Which is not fit to line a birdcage, in my opinion.
— Edited: Modernization of trigger point summary, more science, and more acknowledgement of controversies.
— Edited: Modernization of trigger point summary, more science, acknowledgement of controversies.
— Science update: Added surprisingly good news about methylene blue injections.
— Science update: There’s been more study of the role of bacteria in back pain. And still not enough!
— Science update: Added information and references about transitional vertebrae and Bertolotti’s syndrome.
— Science update: Added 3 good references and a diagram about how much “wiggle” room nerve roots have.
— Minor update: Added a reference for reassuring data about recovery rates.
— Major update: The first complete professional editing of this book has now been completed. Although the difference will not be obvious to most readers, several hundred improvements and corrections were made, and it is definitely a smoother read.
— Minor update: Added Digital Motion X-ray.
— Minor update: Plugged a good quality microbreaking reminder app
— Minor Update: Some relevant humour: added a pretty funny video about a core strengthening product.
— New section: A minor topic, but one of the most overdue sections I’ve ever added to the book: I’ve been asked about these devices a lot over the years.
— Rewritten: Cleaned up and modernized, more information, especially a more useful and evidence-based self-treatment tip.
— New section: No notes. Just a new section.
— Minor update: Added some great backup from a terrific surgeon blogger — who advocates for the necessity of testing placebo surgeries, exactly as I have in this section for many years.
— Minor update: Added a (fascinating) footnote about the myth of anaesthetic paralysis.
— Expanded: Added subsection on electroacupuncture.
— Science update: Reporting on the greatest hits of back pain science (Machado 2009, a source of several important points here and in other sections).
— Science update: Some science showing that the effect of hamstring tightness on back function/pain isn’t exactly potent.
— Science update: Interpretation of a little junky new science about Pilates.
— Comedy update: Added an amusing, extended example from the TV show, The IT Crowd.
— Minor update: Added a quote that beautifully expresses the reason for treating chronic pain with … maturity.
— New section: An overdue upgrade! This way pain and fear power each other is now explained much more clearly and thoroughly than before. It’s noteworthy that, with this update, Dr. Lorimer Moseley’s valuable perspective on back pain is now fairly well-represented in this book.
— New section: Important new chapter about a hype-hot news item.
— New evidence: Rare good news: the first good quality scientific test of “the confidence cure” had promising results — which is just about the best thing that could have happened to this chapter.
— Minor update: Interesting, useful new reference.
— Minor update: Upgraded risk and safety information about Voltaren Gel.
— New section: No notes. Just a new section.
— Major update: All major professional treatment options now summarized.
— New section: New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan.
— Major update: All major self-treatment options now summarized.
— Edited: Nothing in particular has changed, but it’s definitely a better chapter now.
— Science update: Added (more) evidence showing the role of smoking in chronic back pain.
— Science update: New reference strongly supporting a key, controversial point.
— Minor update: Added an intriguing quote about evolution and the lack of back pain in hunter gatherers.
— Science update: Put “foot fear” in context with some reassuring high heels science.
— Science update: Added evidence that the stakes are high with chronic pain: it may even shorten lives.
— Minor update: Added a new suggestion for safe, pleasant self-tractioning.
— New section: No notes. Just a new section.
— Science update: Interesting evidence that massage therapists cannot reliably find the side of pain by feel.
— Minor update: Added a fine example of taking yoga very, very seriously as an option. See first footnote in section.
— Update: Editing, and several new paragraphs about safety issues.
— Minor update: Some simple revision for clarity and quality, and a bit more content.
— Science: More science, and a few substantial new footnotes fielding common concerns and questions.
— Science update: Clarified information about pelvic tilt, and beefed it up with some more science.
— Minor update: Important new, skeptical footnote about the dangers of the powerful narcotic drugs.
— Science update: More evidence of the exercise effects are limited and non-specific. See the paragraph starting “Does spinal function improve…”
— New section: No notes. Just a new section.
— Updated: Added scientific cases studies, examples, pictures and video of true dislocation and abnormal anatomy to help drive home the point that even significant spinal joint dysfunction can be surprisingly harmless … never mind subtle joint problems.
— Minor update: Minor, but fun — a great quote about models of slipped discs, and a good new image to help it along.
— Rewritten: Improved and expanded. In particular, intramuscular stimulation (IMS) was “demoted.” I am disillusioned with it and no longer want to promote it without strong caveats.
— Major science update: Detailed reporting on some new yoga science. Significant re-writing of the section ensued. Sometimes new science does not back up my preconceptions: I’ve changed my tune here somewhat.
— New science: I stumbled across a fantastic scientific paper about the prevalence of nerve pinches (hint: it’s low). Excellent perspective.
— New section: A key concept covered in the trigger points tutorial long ago, but so relevant to low back pain that I decided it needed to be here as well.
— New section: This section is a summary of an important concept that’s been available in a free article since late 2008, but it really needed to be emphasized here.
— Minor update: A few new paragraphs summarizing an important new study of massage for low back pain with disappointing results.
— Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman et al.
— New section: More information about an important characteristic of muscle-dominated back pain.
— Major update: Totally renovated section: re-written, reformatted, expanded, upgraded. A few new checklist items were added, most were expanded, and all were clarified. A separate and handier “quick” checklist was added to the existing “slow” checklist.
— Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.
— Minor Update: Added evidence that spinal fusion surgeries are not just ineffective but often harmful (Nguyen).
— Minor update: Added a fascinating science item about the effect of anti-inflammatory gels on back pain (Huang).
— Minor Update: Long overdue, I finally added some science to this section, showing that the connection between low back pain and obesity is weaker than it seems (Wright).
— Minor Update: Added some interesting references about sensation (Luomajoki) and the relationship between back pain and a disrupted “body schema” (Bray).
— Upgraded: New artwork from PainScience.com artist Gary Lyons, plus some important new references.
— Minor Update: Added a fun and informative quote from the TV show House.
— Updated: Added some new evidence about back pain and aging, and a nice new graph.
— Minor update: Just added a link, but a really great link! The CBC show Marketplace did an amazing job last year reporting on spinal decompression machines. Well worth a look — the show and their show page is probably now the single best source of information on this topic.
— Like new: Re-written and significantly expanded.
— New section: No notes. Just a new section.
— Major Update: Rewriting and expansion of the Special Supplement on spinal manipulative therapy.
— Updated: Added a much more detailed description of the Hancock et al study, and in fact turned it into the main substance of this section.
— Updated: Added a very beefy footnote about some new research showing that muscle imbalance does not result in higher rates of injury. This almost should have been a new section, but I decided to just make it a ginormous footnote — footnotes are there for delving if you want to, that’s the idea! You can read a summary of the research in the bibliography (see Hides et al), but the relevance to back pain is spelled out in detail here. And it’s interesting.
— Upgraded: Section now includes discussion of that bizarre and already infamous paper in the New England Journal of Medicine (see Berman). I also make an important new point: exactly why acupuncture placebos are such a problem for low back pain patients in particular.
— Like new: Rewritten. I’ve lost track and can’t be bothered to go back into the archives to figure it out for sure, but I think that this section was brand new (but never announced) late in 2009, and then this past week I gave it a substantial upgrade: it is now one of the best-referenced chapters in the book, and it says as much as probably needs to be said on the subject — or more!
— New cover: At last! E-book finally has a “cover.”
— Minor update: Added a scientific thumbs down for transcutaneous electric nerve stimulation (TENS).
— New section: A surprising scientific thumbs up for comfrey ointment was worth a whole new small section.
— Minor update: Added clear evidence that family doctors don’t do a good job caring for patients with low back pain, and that a myth-busting ebook like this is still important.
— New section: No notes. Just a new section.
— New section: An important update: a major new section that goes a long way to substantiating one of the most important points of this tutorial.
— Major upgrade: Rewritten and significantly expanded information about medications.
— New section: Having debunked expensive spinal traction using expensive decompression machines, here are some ideas for cheaper and safer methods of tractioning.
— New section: No notes. Just a new section.
— New section: Today I found a way to say some simple things about the power of self-treatment that have been “on the tip of my tongue” for years now. It all evolved from writing about an important bit of research, showing that manual therapists cannot (reliably) diagnose trigger points.
Hexenschuss is a German word for back spasm or lumbago, but translated literally it means shot by the witch (hexe = witch and Schuss = shot). Those Germans have a word for everything! Hat tip to reader Richard Moison for teaching it to me. BACK TO TEXT
Is “much” information really “just plain wrong”? I will establish this in the sections ahead with a steady supply of clearly explained references to the medical literature that patients can understand and professionals can respect. This extra layer of information in easy-to-use footnotes is available for any reader who wants to dig deeper and check my facts. For example, here’s a good start: In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
I like to kick off a topic with an example of a terrible website about it, just for the chuckle and a teachable moment. ThePain.net is one of the worst I’ve seen: a large, stale, ugly thing by Pekka Palin, MD. There are hours of terrible reading there! Dozens of blandly composed, shallow, rambling, and frequently irrational mini-articles on every imaginable pain subject, all 100% unreferenced, laid out in huge blocks of text without a subheading for many screens (a typographic travesty). There’s soooo much badness, but I really got a chuckle out of this perfectly pointless phrase: “The most common reason for temporary back pain is lumbago.” Now “lumbago” means “back pain” (see the definition of lumbago on Wikipedia), so Dr. Obvious has helpfully explained that the cause of back pain is, er, back pain. The Internet, at your service! BACK TO TEXT
Turns out that the committees that write these things do not necessarily know the science! One of the best reviews of back pain research ever published — Machado 2009, more on this one later — found something really interesting: “treatment recommendations from recent clinical guidelines do not align with the results of this meta-analysis.” In fact, quite a few disproven pain treatments are still cheerfully recommended in otherwise sensible professional guidelines. Eek.BACK TO TEXT
To kick off the referencing, here’s the first of many expert opinions and quotes about this, from a 2013 paper by Max Zusman, explaining why low back pain is still such an incredibly costly problem for society:
It is extremely difficult to alter the potentially disabling belief among the lay public that low back pain has a structural mechanical cause. An important reason for this is that this belief continues to be regularly reinforced by the conditions of care of a range of ‘hands-on’ providers, for whom idiosyncratic variations of that view are fundamental to their professional existence.”
Well said, but perhaps a bit wordy. Here’s the simple version: patients believe back pain is caused by structural fragility, and careers are built on catering to that belief. I would also say that it is difficult to alter that belief in anyone, patient or professional. This preoccupation with fragility isn’t just reinforced by the practices of many therapists, it’s a major reason reason for them.
I was an alternative health professional myself for many years — a Registered Massage Therapist, trained in Canada (which has unusually good training standards). Of course, some of my colleagues in alternative medicine were diligent students of medical science. However, in my experience, most were certainly not — indeed, many lacked even the most basic knowledge of how medical science works or how to keep current about recent discoveries with clinical implications. BACK TO TEXT
Don’t take my word for anything. Take this guy’s word for it. Dr. Richard Deyo has been busting myths about low back pain for longer than I’ve been alive.
Or this guy’s word. Dr. Nikolai Bogduk has authored dozens of scientific papers about low back pain. He also questions and challenges many common beliefs about low back pain, and is one of the expert sources this tutorial relies upon.
Or this guy’s. Dr. Siegfried Mense is the world’s foremost expert in muscle pain. He is the author of the most current and authoritative text on that subject, and one of this tutorial’s most important sources.
That’s a huge topic, but here’s one simple example of an extremely common problem with back pain science: control groups that don’t control. Rather than comparing a treatment to a good, carefully selected placebo, most studies use a comparison to a treatment that is allegedly neutral, underwhelming, or placebo-ish. That makes the results hard to interpret: if each works about the same, it could mean that the treatments are equally effective … or equally ineffective! So much back pain science has this problem — or any one of a dozen other weak points — that you can effectively ignore at least 80% of all back pain research, because it’s so far from the last word on anything. Good science is essential to solving these problems, but really good studies are also difficult to design and rare. BACK TO TEXT
This paper presents some unusually optimistic old data about low back pain recovery: in a sample of about 100 patients, “90% of patients recovered within two weeks and only two developed chronic low back pain,” which is “much higher than reported in other studies,” but the authors suggest some good reasons why their number makes sense.
There is an anxiety-producing myth that low back pain is serious and chronic if you can’t shake it after the first several weeks, when in fact many people recover just fine after that “deadline.” An entire section below is devoted to the strong scientific evidence about this. BACK TO TEXT
Once in a great while some cranky reader (always a guy) writes to tell me, “I didn’t learn anything from your book.” I’m a little skeptical about that, and it’s always tempting to start quizzing! There’s a great deal of information here, including analyses of recent research. Sure, readers who have already done a lot of reading about back pain might already be familiar with a lot of it — but you will know that going in, of course, and you’ll find the nuggets of new information and perspective that any keen reader is always looking for. BACK TO TEXT
Dr. John Sarno’s original best-seller about low back pain.
My original inspiration for this tutorial was Dr. John Sarno’s 1984 book Mind over back pain. (His more recent Healing back pain makes too many empty promises. See my review.) However, as much as I respect Dr. Sarno’s early work, there are at least three reasons why this tutorial is better than his books: (1) I make a much more airtight case against the conventional medical myths of back pain than Dr. Sarno does; (2) I also build a much better case for the real causes of back pain, heavily referencing more credible sources than Dr. Sarno does; (3) and I offer many more practical suggestions than Dr. Sarno does, instead of focussing exclusively on the psychological factors. Although I have less experience and education than Dr. Sarno, I do have a lot more hands-on experience (and the useful perspective of a journalist). BACK TO TEXT
In older adults, about 6% of cases have a serious cause, but 5% of those are fractures — which are serious, but they aren’t cancer either. The 1% is divided amongst all other serious causes. For people under age 55, the odds are even better. BACK TO TEXT
This study of changes in spinal characteristics (in Swiss adults) since the late 19th century found… well, basically nothing. Spines are pretty much the same now as they were then. At least in Switzerland.
Dr. Richard Deyo, one of the great myth busters of low back pain research, believes that “low back pain is second to upper respiratory problems as a symptom-related reason for visits to a physician” — only the common cold causes more complaints. Hart et al puts low back pain in fifth place (lower because Hart oddly excludes chronic low back pain). Chronic low back pain is usually the kind that this book will examine. Andersson writes: “Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain ….” Indeed, it is almost impossible to measure how much chronic low back pain there is: for every time that acute low back pain is the main reason for a visit to a physician, how many times does a patient mention low back pain as a secondary problem? Or sees an alternative health care professional about it instead? (Answer: pretty danged often.) So it’s actually possible that low back pain is the single most common reason that people seek help.BACK TO TEXT
Many researchers seem to believe that low back pain is a modern problem. For instance, Waddell writes, “Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic ….” In 2008, Martin et al found that, “The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7%… to 24.7% … 1997 to 2005,” which certainly shows that it is a growing problem and therefore likely to be worse now than in the past. A Spanish study (Jiménez-Sánchez et al) showed that musculoskeletal complaints (including a great deal of back pain, presumably) increased significantly from 1993 to 2001, though the rates remained stable in the years after that. Finally, Harkness et al did a nice job in 2005 of comparing rates of musculoskeletal pain (including low back pain) 40 years apart in the northwest of England, and found a large increase. In his books, Sarno also strongly portrays low back pain as a modern problem — though he doesn’t defend it . It’s hard to say if back pain actually is a modern problem, or whether it just tends to be described as such. Remember that human beings have a strong tendency to sensationalize and dramatize! Harkness pointed out in her study that the appearance of an increase “could be partly explained by the ‘worried well’. The ‘worried well’ are those patients who are concerned about their health, and attend their GP to seek reassurance about their well-being.” This is a great example of how hard it is to really be sure of anything! BACK TO TEXT
Nachemson says, “Rarely are diagnoses scientifically valid ….” And Deyo: “There are wide variations in care, a fact that suggests there is professional uncertainty about the optimal approach.” Many other researchers have made this point, but Sarno states it most eloquently: “There is probably no other medical condition which is treated in so many different ways and by such a variety of practitioners as back pain. Though the conclusion may be uncomfortable, the medical community must bear the responsibility for this, for it has been distressingly narrow in its approach to the problem. It has been trapped by a diagnostic bias of ancient vintage and, most uncharacteristically, has uncritically accepted an unproven concept, that structural abnormalities are the cause of back pain” (p111). BACK TO TEXT
Battié MC, Videman T, Kaprio J, et al. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J. 2009;9(1):47–59. PubMed #19111259. “The once commonly held view that disc degeneration is primarily a result of aging and wear and tear from mechanical insults and injuries was not supported by this series of studies. Instead, disc degeneration appears to be determined in great part by genetic influences. Although environmental factors also play a role, it is not primarily through routine physical loading exposures (eg, heavy vs. light physical demands) as once suspected.” BACK TO TEXT
There are 371 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.