The Complete Guide to Low Back Pain

Even spondylolisthesis and stenosis — true dislocations of vertebrae, and narrowing of the tube that your spinal cord lives in — may not be the primary cause of pain in many cases.79 Until relatively recently in history, almost everyone (except John Sarno80) assumed that spinal stenosis was painful. It’s spinal-canal narrowing! Ouch! Right? That’s gotta hurt!

This is an MRI scan of a severe spondylolisthesis — a dislocation of the lowest lumbar joint. This patient has never had low back pain.

But in 2006, Haig et al published truly surprising evidence that spinal stenosis often does not hurt.81 In this study, about 150 people were assessed for back pain either with MRI alone or just with physical assessment. MRI can certainly detect narrowing of the spinal canal, but on the basis of MRI alone, doctors could not identify which patients were hurting, because many of the people who had stenosis did not have pain. These results also strongly imply that a narrowed spinal canal does not (alone) cause back pain.

Consider this striking case, of one of the most memorable clients I ever had as a massage therapist. The picture is an MRI of a type of dislocation, a bad spondylolisthesis (grade III) — her fifth lumbar vertebrae was basically falling off her sacrum, slipping down and forward. It was about 50% displaced. The degree of structural deformity seemed extreme, almost disastrously so. How could she even walk? And that has got to be painful, right?

Incredibly, this middle-aged client was not a back pain client; she sought my assistance for a minor foot problem. She’d never had significant low back pain in her life: only occasional minor episodes. As if that were not surprising enough, she also had severe scoliosis. This is not an isolated case of a serious but painless dislocation; there are other case studies of relatively asymptomatic dislocation and deformity.8283 I discuss them in more detail in an article about spinal manipulative therapy.

Of course, spondylolisthesis, spinal stenosis, and other extreme anatomical situations undoubtedly can cause pain. Stenotic pain, for instance, is responsible for the characteristic forward stoop of many elderly persons — because stenosis causes pain when you straighten up, it forces its victims to bend forward to escape it. It’s a real problem. But it’s also fascinating that they cause so much less pain (or other problems) than anyone previously thought.

Clearly something beyond the obvious is going on.

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You are getting older! But getting older is probably not the reason your back hurts. This is an important clue that back pain often cannot be blamed on biomechanical glitches.

Many kinds of pain are known to increase steadily with age. Any doctor with some experience knows this. And every person over the age of thirty-five can feel it. And it seems consistent with the common sense idea that spinal degeneration progresses with age and causes pain.

After the age of 40, perfectly normal vertebral columns rapidly become rarer and rarer. It is unusual after that age to see spines without x-ray evidence of aging, including thinning of disks and thinning of articular surfaces. The longer a man lives, the more impressive the radiologic changes in his vertebral column become.

College of Physicians and Surgeons of the Province of Quebec84

Yet young people — working people in their thirties and even twenties — get severe back pain in numbers so large that they are routinely highlighted for their economic significance.

And there is evidence that people actually get less back pain as they age! Certain types of back pain are relatively absent in the young and become increasingly common with age, especially some of the most severe kinds of back pain — more on these examples below. But those are the exceptions that prove the rule.

The overall trend is clear: most typical back pain occurs in the thirties and forties,85 either actually declining in the fifties and sixties,86 or at least not steadily increasing — exactly the opposite of what you’d expect if back pain was mainly caused by the degeneration that we know is occurring!8788 Just look at this camel-hump of a graph of one survey:89

Graph of the percentage of survey respondents who reported low back pain at different ages.

That’s a striking prevalence of low back pain in mid-life … and a striking decline later in life. Not every data set shows this so clearly — I confess to cherry-picking one of the most impressive examples — but even where there isn’t such a clear decline, any decline in pain with age, or even just a lack of increase, is sharply at odds with the conventional wisdom.

If low back pain were about spinal “wear-and-tear,” you would not only expect to see more back pain in older people, but worse back pain in older people — much worse. If spines were fragile, and if their fragility was driving low back pain, then the thirty-year-old back pain patient, on average, would be much better off than the sixty-year-old back pain patient. And yet this is decidedly not the case! Many younger patients with no history of injury suffer from extremely severe pain — pain that is well out of proportion to the degeneration that cannot possibly be significantly afflicting their spines at their age.

Degenerating, schmegenerating!

Although they aren’t immune, older people are actually relatively free of low back pain. It’s the thirty- & fortysomethings that generate the horrifying low back pain statistics.

None of this is widely known, but it’s not out in left field. We know that degeneration correlates poorly with pain, and is mostly determined by genetics and pathology anyway, and not “primarily through routine physical loading exposures (eg, heavy vs. light physical demands) as once suspected.”90 Although family doctors may not be aware of this research, they can learn it easily enough from medical experts, just like I have. For instance, Dr. Richard Deyo of Seattle, one of the world’s foremost medical authorities on back pain, knows full well that back pain is not usually structural, and he’s done much of the research that proves it. In his tutorial for doctors published in the New England Journal of Medicine in 2001, Deyo makes it clear to physicians that only a small amount of back pain has any structural cause, and the rest of it — about 70 to 85% — is just unexplained.9192

The nastiest types of back pain do increase with age

Certain types of back pain are relatively absent in the young and then surge with age. Deyo explains that “cancer, compression fractures, spinal stenosis, and aortic aneurysms become more common.” And Vlaeyen et al emphasized that “if only more severe forms are included, the prevalence steadily increased in individuals ≥65 years of age,”93 based on Dionne et al (which is actually a paper entirely devoted to this question).94

Cancer is a solid example, because it definitely gets more common with age, and it sure can cause severe back pain, so that’s going to drive up the number of cases of nasty back pain in older people. But if you subtract such cases from consideration, then the lack of any clear sign of non-specific back pain worsening with age is even more glaring.

Dionne et al. concluded that it’s “unclear” how age affects non-specific low back pain. My opinion is that the absence of clarity is precisely what’s interesting. If aging is bad for backs, why isn’t it more obvious?

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It’s hard to find biomechanical bogeymen — even when they do exist. Even when structural abnormalities that matter actually are haunting a back, healthcare professionals have an extremely difficult time accurately identifying them in an exam. The ability to pick up on subtle signs with advanced palpation skills and diagnostic cleverness and sophistication is something that essentially all physical therapists aspire to. It is almost the basis of some professions, like chiropractic, where the whole point is to “correct” spinal dysfunctions … which must first be identified, of course. Similarly, massage therapists cannot “release” knots if they cannot find them. And physical therapists cannot prescribe specific corrective exercises without picking a target.

The difficulty does not seem to stop anyone from guessing. If I had a buck for every time I heard something like this…

“It’s my sacroiliac joint. My physiotherapist told me.”

Patients get told this kind of thing a lot.

The sacroiliac joint is an especially popular scapegoat, but there are many reasons to doubt that the sacroliac joint is a cause of pain nearly as often as it is diagnosed, beyond the fact that there are just so many possibilities. For instance, consider its legendary toughness:

I talked to a trauma surgeon that had been to a workshop where they talked about the sacrum being “out of place.” He just said this is ridiculous: we see people who are in motor vehicle accidents with every bit of their body smashed but the sacroiliac joint is intact. It is so strong.

Peter O’Sullivan, Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, Australia

So patients are routinely given specific pathoanatomical explanations for their back pain, and it always sounds impressive … mostly just because it’s “specific” and “pathoanatomical.” It sounds good. Medical jargon makes things sound Serious.

Surely there are tests that can identify the problem tissue?

In a 2000 editorial for the Medical Journal of Australia, Dr. Nikolai Bogduk sassily wrote that many diagnoses for low back pain are “illegitimate, inappropriate, or fanciful”95 (italics mine) and explained that there is hope for more precise diagnosis … but only with specific medical tests, such as nerve blocks and provocative discography.

Is there really, though? There might be a little “hope” in such testing, but the evidence shows that common diagnostic tests for back pain just don’t work very well — not even the more hardcore options like nerve blocks.

In 2007, the European Spine Journal published an excellent paper about the ability of professionals to suss out the specific cause of back pain using a variety of “specific medical tests.” This scientific study of about 40 tests-of-testing studies put the claims to the test!96 (Yes, that sentence does actually make sense.) Can the pros really pinpoint where low back pain is coming from?

Nope. Some are surely better than others, but the average is just really poor.

At best, testing only modestly increased the odds of correctly identifying the source of pain. “Some diagnostic value” is the strongest positive assessment in the article — and that refers primarily to MRI being used to help confirm a disc as the source of pain (not eliminating it, which they cannot do).97

Facet joints are a common scapegoat for back pain, but (emphasis mine) “none of the tests for facet joint pain were found to be informative.”98 This makes me cringe, because I “tested” for facet joint involvement frequently during my clinical career. That was a couple minutes of my patients’ time and money wasted every time I did it (to say nothing of the misleading results). And the evidence that such testing is largely futile had already existed for years even back then, but had not trickled down to me through my texts, instructors, or continuing education. Yet another great example of how important it is for clinicians to keep up with their journal reading.

The effectiveness of common kinds of testing for spinal dysfunction was “at best moderate,” and that was only if multiple tests were used. The tests bombed when tested independently. No one test was any good by itself. Such testing involves a lot of skill and knowledge, so to get even “moderate” results you would also have to have the most competent testing, a top-of-class type of doctor or therapist — rare by definition.99

One would hope that common diagnostic tests for spinal trouble would produce reasonably unambiguous results which, when checked for their reliability, would prove to be correct most of the time. Instead what we have is a mess of underwhelming performance not much better than pointing at random anatomy while blindfolded.

Hancock et al added to the (already large) pile of evidence that “conventional investigations do not reveal the cause of [low back] pain”100 (that’s Dr. Bogduk again). In 2009, the American Pain Society also gave a thumbs down to provocative discography in their official guidelines for low back pain — reducing the diagnostic options even more.101

Similarly dismal results trying to identify bad facet joints in the neck

King et al piled on with similar conclusions about the reliability of tests for the source of neck pain — it “lacks validity.”102

They compared physiotherapist diagnoses of 173 people to more reliable testing done by blocking the joint. What they found was that physical therapists were good at identifying facet joints that were painful — which is great, good for them! — but they were also rather prone to diagnosing a facet joint issue even when there was no pain. In other words, they were over-diagnosing, telling practically everyone that they had facet joint pain, which was correct in some cases, but wrong in many others. In spite of this, “Manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination,” they wrote.

Can’t touch this

Maigne et al tested two physicians with training in manual medicine to see if they could detect the painful side by feeling for tension in the spinal muscles. In almost two hundred patients, they identified the correct side of 65% of lower back pain and 59% of neck pain — barely better than chance.103

And, if they couldn’t do it, most massage therapists would probably fail the same test — despite our legendary reputation for zeroing in on tissue problems with uncanny accuracy.

A little humility, please!

I went through a phase for a few years where I started to worry that other healthcare professionals were much smarter than I am, because they seem so good at identifying exactly where back pain is coming from. (Also, they still tell me they are.) But years of experience and study have taught me that humility and restraint may be wiser, and less wrong, than most of these “specific pathanatomical explanations.” From Ben Cormack, having a bit of a rant about pseudoscience and amateurism in back pain diagnosis:

“The worlds best researchers admit they can’t reliably diagnose [back pain], so why can you?”

People (patients and pros) do constantly talk like they “know” what causes back pain, or at least have a very strong suspicion, and it’s almost always delusional. The specific mechanisms of back pain are mostly as impossible to know as what Bilbo had in his pocketses. We cannot generally trust professionals to identify a structural origin for your pain, even there is one. Which there may well not be.

We need a lot more diagnostic humility.

None of this means that specific causes don’t exist, and I’ll be talking about this more soon in the chapter, “It’s not structure, except when it is: “specific” back pain.” But the evidence strongly hints that these causes you can point to on an anatomy chart are not present as much as anyone thinks … and even when they are, they’re fiendishly hard to confirm … and not as severe and consistently problematic as people assume and fear.

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The scary spine models are a great example of how old ideas in health care persist. And make trouble.

Model of doom & gloom

Lumbar spine models like this almost all show a herniated disc. Some go a step further & show discs slipped so far “they’ve completely left the spine”! (Hat tip to Dr. Lorimer Moseley.)

Many experts have made strong statements about the importance of reassuring back pain patients … and not horrifying them with ominous diagnoses like “herniated disc.” Such diagnoses are usually wrong — or hopelessly oversimplified at best — and needlessly intimidate patients … which is itself a risk factor for low back pain. Nervous low back pain patients tend to have more pain for much longer.

And yet it remains almost impossible for a clinician to buy an anatomical model of the lumbar spine that doesn’t have a little rubber disc bulging ominously from the spine … invariably coloured bright red, just to hammer the point home!

And it remains almost impossible for a patient to look at such a model without thinking, “Yikes! That’s what’s going on in my back?”

That little bulging disc looks bad. Or, God forbid, a disc that has “slipped so far out it’s sitting on its own”? Here’s pain researcher Lorimer Moseley making this point in a great TED talk. He’s talking about how pain is probably intensified by the belief that there is danger — the so-called nocebo, the opposite of a placebo — and plastic anatomical models of slipped discs are much too persuasive.

Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on its own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

(I laughed out loud at that, and then cheered. I’ve been bitching about these blasted models for many years.)

Such models also undoubtedly also influence professionals. Even if clinicians accept that it’s an oversimplified model, the prominence of herniated discs in most models and anatomical drawings constantly exaggerates their importance.

Anatomical models aren’t cheap, and once a clinician has purchased one, it will likely stay in his or her office for many years, even decades. I’m sure there are probably hundreds of thousands of these things in offices around the world that are at least twenty years old. And clinicians are still buying new ones today!

And so this is a great example of how hopelessly obsolete clinical ideas persist for years, even decades, after the field has moved on.

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The medical jargon for back pain without a specific explanation is “non-specific” back pain. It’s what we say when we can’t be any more specific than “it’s back pain!” It almost like saying “undiagnosed” or “baffling” back pain… and it’s not really clear why we don’t just say that.

This “non-specific” term is odd. It isn’t standard for any other medical condition; there is no non-specific headache, for instance. A headache without a specific diagnosis is traditionally called a “tension” headache, which is even worse, because it presumes a cause, which is probably usually wrong. Imagine if we called all puzzling back pain “tension back pain.”

Chronic low back pain is often classified as non-specific: that is, no organic cause of the pain can be identified. This happens a lot.

But it’s not the default! Back pain usually gets blamed on a specific cause prematurely, without actually knowing that it’s correct — much like the assumption that an undiagnosed headache is caused by “tension” (when we don’t even know for sure that tension can explain any headache, and there are many other known causes). Three common examples:

1. Many professionals still default to assuming that undiagnosed back pain is “degenerative” in some way, with variable specificity and vehemence, and that is the problematic assumption that I have mostly focused on so far in this book.
2. The most popular specific explanation for back pain among patients is probably “spasm,” which is more or less exactly the same as blaming headaches on tension. It isn’t terribly “specific,” but it is certainly more specific than “no bloody clue.” It is an idea! It is a specific hypothetical mechanism for pain. And it cannot be overstated how easily people take it seriously as the explanation for a new attack of back pain. I have personally heard people casually attribute back pain to spasm at least several hundred times in my career.
3. And then there’s a specific explanation beloved more or less equally by both patients and pros: the assumption of injury — that some relatively innocuous physical stress is the culprit. For a specific explanation, it isn’t terribly specific: exactly what anatomy has gotten hurt, and how, is often not specified by this specific diagnosis. “Something in the spine got hurt somehow” is as specific as it gets… or perhaps “slipped disc,” because that’s s the only specific injury that many people have even heard of.

All of these things are possible specific explanations for back pain, but none are them safe assumptions, not by a long shot.

That unsafe assumption has an evil twin: the equally unsafe assumption that there is no specific cause, which is implied by the label “non-specific back pain.” Rather than simply being unknown, too many people (mainly clinicians) slip into overconfidently assuming that no specific cause actually exists — or that it is so perfectly unknowable that it might as well not exist.

The other side of the coin: just because we don’t know the specific diagnosis doesn’t mean it is isn’t there

“…degenerative disc disease is undervalued as a cause of chronic low-back pain by clinicians, patients and society.”

Rustenburg et al, 2018, JOR Spine

Sometimes structure does matter. I have spilled a lot of “ink” in this book about the urgent need to back away from the pervasive idea that back pain is a structural problem (especially degenerative disc disease). I have demonstrated that specific, structural causes of back pain are over-emphasized, but not non-existent. Like violent crimes, they are far less common than the news makes people fear, but they do still happen.

In 2015, a perfect pair of papers by the same researchers pushed each way on this topic: one away from mechanical explanations… the other right towards them. The first was cited above (along with many other similar ones): Brinjikji et al looked at a whole lot of MRI pictures of spines, and presented evidence that signs of spinal degeneration are present in amazingly high percentages of healthy people with no problem at all. Good to know. It’s one of the best papers of that sort, highlighting the weird disconnect between back pain and spinal degeneration.

But Brinjikji et al didn’t stop there! Their second paper presented evidence that degenerative features visible on MRI are nevertheless “more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals.”104

Also good to know!

These papers aren’t actually at odds. The take-home message of the pair is just a nice, reasonable, and obvious compromise: degenerative changes matter less than many patients and professionals still assume, and are not an adequate foundation for many popular treatments… but they do still matter.

Duh? Surely no one is surprised by this!

Importantly, Brinjikji et al also showed that the disconnect between structure and pain is much less striking for some kinds of problems than others. Intervertebral joint dislocation (spondylolisthesis) is rarely asymptomatic! Some cases are, and that’s fascinating. But not most. 60% with bulging discs at age 50 are symptom free, but only 14% of 50-year-olds with spondylolisthesis are feeling no pain. It’s amazing that anyone can have a dislocated spinal joint and feel fine, but 85% do have symptoms.

So whether structure matters depends. Some spinal problems matter more than others. Some of them are worse than others. Duh again.

Neuroma: a very specific example of a very specific cause of back pain

Obvious sources of acute and/or ominous pain like infections, aneurysms, tumours, fractures, and inflammatory diseases are all causes of some back pain, but they aren’t of much interest here because they are so serious (and often relentlessly progressive) that they mostly do get diagnosed. They are the kinds of things that mostly qualify as “specific” back pain.

But what about specific problems that tend to drag on and never get diagnosed? Sure there are also specific causes of chronic low back pain that get missed? Of course there are. The only real question is: how often does that happen? No one really knows.

A friend of mine — let’s call him Alex — suffered for about five years from slowly but steadily worsening back pain before a wee little tumour was finally discovered: it was “benign” as far as tumours go, but it was growing on a nerve in his back (a “neuroma”), and it had just about ruined him. Neuromas are tumours, but they aren’t the kind that kill you … they just make you miserable. My friend had dropped out of the sport he loved, ultimate, the Frisbee sport, which is how I know him — we had played for years together on a team called Afternoon Delight. (Fun fact: Our team symbol was a pair of humping unicorns.)

At his worst, Alex could barely walk. Eventually, after an easy surgery, he was entirely cured, just like that. Boom. Specific as it gets.

Alex had seen many, many healthcare professionals who had failed to diagnose the real problem, thrown up their hands, and chalked it all up to non-specific back pain. I know, because I was one of those healthcare professionals.105

Before the diagnosis, “sensitization” had been a major diagnostic option, a classic pseudo-diagnosis that means the problem is a false alarm. Although Alex likely was suffering from the phenomenon of sensitization, it was probably a sideshow, a complication of the real source of serious irritation in his back.

A chiropractor finally suggested the right kind of spinal imaging, which easily identified the neuroma. Once everyone knew it was there, that was the end of any discussions about how strange and unexplained chronic back pain is! He just needed surgery to remove a little blob of uninvited tissue from a nerve root. And that surgery worked immediately and permanently.

That’s probably the single clearest example I’ve ever encountered of a specific cause of back pain, no fine print. The next example is also quite good, but it is not as cut and dried.

🎶 M-m-m-my Neuroma
M-m-m-my Neuroma
M-m-m-my Neuroma
M-m-m-my Neuroma
Ohhhhh my Neuroma
Ohhhhh my Neuroma
Ohhhhh my Neuroma 🎵

Cluneal nerve entrapment: another specific example, and another slam dunk surgical fix (maybe)

The cluneal nerves pass from the low back and sacrum into the buttocks, just under the skin, and they can get “tangled up” with ligaments and connective tissue on their way (nerve entrapment). The irritation potentially causes low back and leg pain. Most cases are probably relatively minor and are obviously related to a peripheral nerve in distress: that is, some cases probably don’t feel like classic back pain, but rather back pain with an obviously nervy quality (superficial, electrical, with some tingling and other distorted sensation). The location of the pain is probably also a little on the low side, less “back” than sacroiliac joint, butt pain, and a touch of sciatica.

In 2016, Aota reported on “a case of severe low back pain, which was completely treated by release of the middle cluneal nerve.”106 The patient suffered from nasty “back and buttock pain radiating to both legs” which was “continuous and severe,” and had come on gradually over a decade. She did also have some prominent tingling, however, so neurological involvement was probably always suspected. But she’d been operated on already — a clean miss, a pointless diskectomy to relieve nerve root pressure that didn’t exist.

She was lucky enough to have a doctor who figured it out and talked her into something that I doubt I would have agreed to: exploratory surgery to identify nerves “entrapped in adhesions.” Freeing it up definitely helped part of the problem, but it didn’t solve it. It took a second attempt to find the main problem, a leap of faith that I would definitely have avoided. But it’s a good thing she took it!

They found a tiny spot where the nerve passed through a ligament, cut it free, and that was the ticket: she was decisively cured. Which is pretty cool.

#1 marks the site of the superior cluneal nerves & where the first surgery freed nerves from “adhesions.” #2 marks the middle cluneal nerve, where the second surgery freed it from entrapment in the ligament. Click to embiggen

That’s about as structural a problem as we can imagine. Tissue in trouble! As physical as snarled sailboat rigging.

And yet it is still also completely possible or even likely that her problem was not the nerve “snag” per se but a biological vulnerability to feeling it. The physical predicament of the nerve may have been like kindling for a fire — a fire that was then lit by something else (and which then burned for years).107

Even if that was the case — and it would certainly be fascinating — diagnosing the vulnerability and solving it might be much trickier than just setting the nerve free. No kindling, no fire! Mostly this problem seems as straightforwardly mechanical as your legs falling asleep because a 40-pound terrier won’t get off your lap. Sure, maybe that dog will be a problem for you more and sooner than someone else… but it’s still easier to just shoo the dog off your lap than it is to figure out why it’s such a problem for you. If you can handle the sad puppy dog eyes.

There’s “no such thing” as non-specific back pain?

Back pain expert Dr. Stuart McGill has famously argued that there is “no such thing” as non-specific back pain: “there are only those individuals who have not had a thorough assessment.”108 He says this because of the tricky cases like neuromas, annular lesions, and cluneal nerve impingement. In a podcast interview, he gave the following interesting example:

MRIs are static, but when you watch dynamics of spine movement, things really change. The instabilities show up, the micromovements show up. In my last few years at the university, we did fluoroscopic investigations of whiplash patients. [X-ray “movies.” See digital motion X-ray. A powerful tool, rarely justified for a variety of reasons.] These were patients who were rather summarily dismissed by typical medical practice, the radiology reports said “oh, there’s nothing [specific] wrong with you.” Well, when we followed them and watched them move with fluoroscopy, we would see that they could move through the range of motion, and let’s say for example as they passed through 10 degrees of flexion they would get a shot of pain. We would watch and quantify on the dynamic fluoro image a sheer movement of the person’s neck. The legacy of the whiplash was a local joint laxity and instability and that would … cause pain.

So here was this poor person dismissed by MRI and yet they had a very specific and quantifiable mechanism for their pain. So you can imagine the cognitive dissonance that person was now in because some medical authority questioned the legitimacy of what they felt every day.

Dr. Stu McGill, interview for Evidence In Motion

Interesting! But again, just as with the nerve entrapment thing, maybe the problem in such patients was less “mechanical” than it looked, and could only be understood in a larger, messier context of physiological vulnerability. Everyone is easily seduced by the apparent explanatory power of a correlation on MRI. This story seems compelling, but it’s not really any different in principle from the well-established mistake of assuming that a picture of a herniated disc confirms the cause. The picture is compelling in both cases. A picture is worth a thousand words … but what if the words are lies? Both kinds of pictures seem to scream, “Look at me! I’m obviously the problem!” In one case we know it’s often misleading, so why assume the other is a slam dunk? It is a tighter correlation, but it’s still just a correlation. The inference of causality is reasonable, but it clearly ain’t a slam dunk either.

Dr. McGill believes a diagnosable biophysical cause is often there and can be found if we only look hard and smart enough. I admire his confidence! I have no doubt that some back pain mysteries can be found by a good enough medical Sherlock Holmes, but that leaves all the others: I doubt that anyone is actually capable of finding the problem in many other cases, and the quest to find a mechanical cause usually turns into a wild goose chase.

Unfortunately, I also know that it’s hard to find “a good enough medical Sherlock holmes.” In practice, even if all back pain is actually specific, it’s so hard to pin the specific tail on the diagnostic donkey that it barely exists as an possibility in the real world.

A large family of specific possibilities (with one major neglected one)

It may well be possible to find a proximate cause “if we look hard and smart enough” (like cluneal nerve entrapment), but those causes probably routinely not the only cause. That janky vertebral movement may be the specific trigger for pain, but it’s probably resting on other layers of causation (such as biological vulnerabilities, like being a little too inflamed… which is, for example, probably a fairly common and subtle complication of viral infections109).

I also think it’s obvious that many cases are in turn caused by something else. The true opposite to “non-specific” back pain is not a singular specific cause, but multiple causes, none of which can make much trouble all by itself… but put them together and you might get a rogue wave of pain that lasts until one or more of those something else’s backs off.

One of those something-else causes is, I believe, both extremely common and widely underestimated, something many professionals aren’t even looking for. I think that topic deserves a whole bunch of special attention, and so the next several sections will focus on “muscle pain.” But then I’ll return to a long list of other possible specific causes and factors: muscle strain, spasm, overuse injury, disc herniations, facet joint trouble, subluxation, sacroliac joint dysfunction, aligment problems like short legs, pelvic tilts, obesity, core weakness, foot wonkiness, pinched nerves, scoliosis, and — last but not least — the spectre of back mice. 🐭

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If we have to toss most of the conventional wisdom about back pain out the door, what replaces it? If most back pain cannot be explained with a specific pathology — or not just one of them, anyway — what can we attribute it to? If the usual suspects rarely actually hurt, or don’t hurt that much, then what the heck does hurting so persistently?

Ideally it would be something we could do something about. Or at least try. Without risking much expense or harm.

I propose that a fair bit of puzzling low back pain is either caused and/or significantly complicated primarily by “cranky” muscle tissue, which may respond surprisingly well to modest doses of massage (among a few other options).

This is not a hypothesis I make lightly, and I know (all too well) that this idea has been seriously criticized by some experts. But, happily, this hypothesis does not have to be proven to be helpful for many people: it is enough for it to be somewhat plausible and relatively cheap and safe to try. Experimental medicine, yes, but not dangerous (as long as you don’t do anything reckless in pursuit of relief).

The main Big Idea of this book is that a lot of low back pain is probably110 basically just muscle pain in the low back. The point is not that this is The Answer or the What Doctors Don’t Want You To Know About Back Pain or some such nonsense. I have chosen it as the major focus in this book because it’s one of the most useful hypotheses that many people are either entirely unaware of, or underestimate. It’s a good-bang-for-buck educational focus.

The idea is that the problem is not the spine, but around the spine. Not pinched nerve root pain, not herniated disc pain, not dislocation or subluxation pain, not arthritic facet joint pain, not torn muscle pain, not even a “muscle spasm” (even though all of these things can occasionally be the undiagnosed culprit). Not anything specific that is commonly diagnosed (or feared) by patients or professionals.

Just the humble muscle “knot” — a poetic and imperfect word for a quirky and controversial clinical entity.

Introducing trigger points

The more official word for a muscle knot is a “trigger point,” and a collection of particularly nasty trigger points is often (rather hand-wavingly) myofascial pain syndrome (MPS). Trigger points and MPS are important concepts and a major focus in this tutorial because:

• There are many well-established ideas about trigger points, at least partially supported by plenty of interesting scientific evidence slowly accumulating over decades. It’s definitely a half-baked mess,111 but it’s also not way out in left field either. It’s not even remotely as snake oily as homeopathy or psychic healing. For instance …
• The existence of unexplained sensitive spots in soft tissue is not in itself a matter for debate. Nearly everything else about them is hotly debated, but not their existence. The fiercest critics of the conventional wisdom concede that we are all studying what people subjectively experience as pain in muscle.112 There may be a great deal about them that we don’t understand, and they may be difficult to diagnose and treat, but they are there, and they have some distinctive properties (properties often observed in back pain).
• Trigger points seem to occur in the low back in unusual numbers and severity. Although there are several regions in the body where trigger points are common, the low back seems by far the most prone to it.113
• The clinical importance of trigger points is based on an unholy triple threat: they do not just (1) cause pain, they also (2) complicate any other pain problem, and (3) mimic other pain problems. And so they are likely to affect nearly every case of back pain at least a little, more or less regardless of whatever else might be going on. This cannot be said of other factors in back pain. For instance, discs do not herniate in response to muscle pain! But muscle probably does start to hurt due to disc herniations … and then continue after the herniation resolves, which they generally do.
• Best of all, trigger points are a Good News diagnosis insofar as their bark is worse than their bite: they are usually self-limiting and somewhat treatable, however clumsy and imprecise our methods. They may not be responsible for all back pain, but they are probably responsible for a bunch of it, and responsible for the part of it that we can work with relatively cheaply and safely.

The bark of trigger points may be worse than their bite, but they can bark very loudly. They can be amazingly painful — even frighteningly so, much worse and more persistent than an actual injury, probably far more painful than you would ever expect a mere muscle knot to be. This is one of their distinctive properties that is similar to back pain, which is so notorious for causing so much misery without any easily detected tissue trouble.

⚠️️ Anecdote zone: my professional experience treating back pain with trigger point therapy

I estimate that about trigger points are a major factor in “many” cases of mild to moderate unexplained low back pain. Much garden variety chronic back pain is probably just some trigger points that got a little out of hand. The relationship between trigger points and the pain is often so straightforward that the correct therapy is relatively easy — you find one or two key sensitive spots, stimulate them a bit, and bam, you’re a “miracle worker.”

And in many cases patients are just as capable of working this miracle as a healthcare professional with at least basic knowledge of trigger point therapy.

For instance, consider one patient who’d suffered from moderate, chronic back pain for several years. She’d been given several predictable structural misdiagnoses in that time, especially sacroiliac joint dysfunction, one of the classic back bogeymen. But she had a prominent sore spot in the top edge of her gluteus maximus that, when stimulated, produced the same sensation as her symptoms: a deep, sickly, nagging ache in the region of the low back and upper gluteals. In three appointments of moderate rubbing of that spot and a few adjacent ones, years of pain was completely relieved. Boom. This made me a “miracle worker” in her mind. She was quite surprised:

Just wanted to give you a quick update … my back has been absolutely fine. Unbelievable … or perhaps not, considering what I’ve learned from you! A big thank you for all your help.

Lois McConnell, retired airline executive, suffered chronic low back and hip pain for a few years

I have many such stories. In almost every such case, the pain was not terrible, but frustrating and persistent for years, then relieved by a handful of treatments — far sooner than natural recovery seems likely to have occurred. For a manual therapist, it doesn’t get much better than that. I’m shy about writing it down, because skeptics are absolutely correct to be skeptical of such anecdotes.

However, this whole idea is not too good to be true: it’s just ordinary good.

A willingness to focus on muscle seemed to give me the chance to help a surprising number of pain problems that would otherwise have defied me … but by no means was I actually working miracles, and failure was also common.114 I’m definitely not bragging that I was ever able to entirely fix any case of back pain in three appointments! A more realistic boast would have been: “I can significant improve about 60% of cases of moderate chronic low back pain of a certain type with two to six hours of massage. Ish.” (And I’m consciously correcting for all kinds of nasty biases that make clinicians overestimate their own effectiveness.)

Not miraculous, just good. Better than average.

And so it became my cautious suspicion back in the 2000s that back pain is often mainly about trigger points. And it has remained so even through the 2010s and now into the 2020s, as this idea came under real skeptical siege — in some cases from professionals that came to their skepticism because of my writing, an irony that fascinates me.

My belief is consistent with the much more famous beliefs of Dr. John Sarno. I don’t necessarily want to pride myself on being in agreement with Sarno, because he clearly got a lot wrong, and in particular he had cringe-inducingly poor understanding of trigger points. But, in this case, for whatever it’s worth (throwing a bone to the Sarno fans reading this), I am on the same page as Sarno.

How could so much pain be primarily caused by “just muscle”? Why would muscles and other tissues get into such an appalling state in the first place? If the back isn’t otherwise fragile, why is the muscle tissue? And why the back in particular?

All of these questions and many more need some kind of answers if we are to take trigger point therapy seriously.

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The wisest back pain experts all freely admit that we simply don’t know what causes most back pain, and they aren’t easily impressed by any attempt fill in that blank. Nevertheless, I am going to take a stab at it. One of the contenders is just cranky muscle. It could be a major missing piece of the clinical puzzle of “non-specific” back pain.115 This is not such a strange idea — although we are leaving the trunk of the tree of knowledge, we’re not going all that far out on a limb either. Remember, I am a quackery-hating curmudgeon, and I am not going to carelessly promote a pseudoscientific idea!

The first thing to understand is that muscle can really hurt. It can be a source of misery, and we know this from examples like the pain caused by an acute cramp, the more insidious and slow-motion agony of neuropathic spasticity, and especially the chilling example of the “MS hug.”116 And although we "know" these things — nothing controversial about the MS hug that I know of — it’s worth noting that the symptoms of the MS hug are often dismissed or misinterpreted. Because medicine is a mess.

For every clinically obvious example like that, subtler ones are likely legion.

Even patients themselves are often amazed to discover the sensitivity of their own muscle tissue. They feel the pain, but they have no idea how vulnerable the tissue feels until it’s prodded. Even moderate pressure can cause strong discomfort. Back in the day, my massage clients often asked me, “What is that?” (Or they just said a bad word.) They could hardly believe my “just muscle” answer. (And, no, I wasn't being brutal. I was never that kind of massage therapist.) They assume that such sensitivity must come from some more delicate anatomy. Plenty of muscle tissue does not hurt when you poke it, even quite vigorously — presumably because it’s healthier in some way. But some muscle, some of the time, sure is sensitive! Presumably because is un-healthy in some way.117

What’s going on? Why would mere muscle ever hurt so much?

Most of us take muscle for granted. We think it is relatively simple, dumb stuff. Nope! Muscle contains multitudes and miracles. It is one of evolution’s craziest inventions.

It is never “just” or “mere” muscle: it is a breathtakingly complex, sensitive, and volatile tissue.119 It’s got a complex, difficult, and unrelenting job to do, which it achieves through dazzling complexity and coordination of organic chemistry. And its behaviour is highly sensitive to our mental state.

All complicated systems can fail in complicated and subtle ways. Sometimes muscles behaves oddly, or poorly, or gets “sick,” and the pain can be agonizing. Dr. John Sarno writes: “ … it is highly unlikely that a structural derangement could produce pain equal in severity to acute muscle spasm [by which he meant trigger points].”120 I second that. I’ve both experienced and witnessed what I sincerely believed to be good examples of absurdly painful muscle.

What if there are rather a lot of sore spots?

“Myofascial pain syndrome” (MPS) was first studied by Drs. Janet Travell and David Simons in the 70s and 80s.121 In their notoriously incomplete and speculative explanation of MPS, physical and/or emotional stresses trigger a vicious cycle, and a trigger is basically a tiny cramp or spasm. A patch of muscle tissue clenches, choking off its own blood supply, resulting in oxygen and nutrient deprivation and stagnant tissue fluids that irritate sensory nerves and perpetuate the cycle.122 Some muscles seem to be more vulnerable to this phenomenon than others — the back muscles most of all. An updated version of this explanation, the “integrated hypothesis,” was spelled out in 2004 by Gerwin et al.,123 and is now the most widely known working theory.

For the purposes of this book, that working theory is what I will work with — with the understanding that it’s just a working theory, it has critics, and it could be wrong. Indeed, it almost certainly is at least partially wrong! Which Gerwin et al. have acknowledged.124 And which I also freely acknowledge, and even emphasize and explore at great length elsewhere.125

At great length. All of this is just highlights from my entire book about muscle pain, which is even larger than this one.

Only the explanation is controversial

Importantly, it’s only the explanation for sore patches of muscle tissue that is controversial. No one doubts that the sensitivity itself exists. The experts just argue about the why and the how and the what to do about it. Indeed, there’s a long, colourful history of arguing about this stuff: many people have tried to label/explain these mysterious patches of icky, achy muscle. The scientific literature was thick with theories long before the ideas of Travell and Simons started to dominate, and there are still several extant competing theories. A small sample:

• In his best-selling book Mind Over Back Pain (and in his more recent Healing Back Pain), Sarno described the same problem and calls it “tension myositis syndrome,” attributing it mainly to stress-induced constriction of blood vessels causing oxygen starvation.126
• Dr. C. Chan Gunn of Vancouver calls it “neuropathic pain,” and suggests another explanation: under-stimulated muscle may become extremely sensitive.127 Dr. Gunn’s ideas are also at the heart of one of the most popular and controversial treatment methods, “dry needling”: stabbing trigger points with acupuncture needles, basically! If that sounds painful, you’re right — it can be agonizing.
• Quintner, Cohen, and Bove proposed that the pain is caused by inflamed nerve fibres, and/or “referred pain and tenderness” from deeper tissues with unspecified troubles and/or “altered central nociceptive mechanisms.”128

Not all of these ideas can possibly be the whole truth. No doubt it’s a classic case of the blind men trying to identify different parts of an elephant. For the purposes of this book, I will work with expanded “expanded integrated hypothesis,” based generally on my opinion that is probably the "least wrong" of all the options.129

Trigger point referral

Discomfort from low back trigger points point spreads in somewhat predictable patterns into the buttocks & legs & occasionally around to the side. This trigger point can cause pain all the way down to the knee — sensation that can get mistaken for “sciatica.”

Here’s what can be said with some confidence about the clinical phenomenon of trigger points

Trigger points are patches of muscle tissue (and perhaps other soft tissues) that are “unhealthy” in some way (maybe “micro cramps,” maybe something else). Some muscles seem to be more vulnerable than others — and seemingly the back muscles most of all, for unknown reasons.130 They are not only painful to touch, but are also closely associated with aching pain and stiffness that spreads out from an epicentre of sensitivity. “Referred pain” is a well-documented phenomenon, and occurs with most visceral pain to some degree; the pain originates in one location, but is felt in other locations (in surprisingly predictable patterns).

For example, people with low back pain routinely have trigger points that “send” pain into the buttocks and down the legs. These sensations can be extremely similar to pain produced by irritated nerves, like lumbar nerve roots, the sciatic nerve, or the cluneal nerves in the buttocks — often resulting in misdiagnosis.131132 In most people with low back pain, trigger points causing these radiating sensations can be located quite easily. Although the pressure is nowhere near a nerve,133 the spot is sensitive and radiates in a familiar way — clients say things like “it shoots down my legs” and “that’s exactly what my pain is like.”

Unsurprisingly, sometimes the “pinched nerve” pain goes away when these trigger points are treated. This is an example of how muscle might be the main cause of low back pain, even when no spinal injury has occurred — including the cases that scare people, the ones that seem unusually severe, strange, or “nervy.” Massage therapist Clair Davies (famous for writing a simple guide to trigger points), writes, “Back pain always has a myofascial component, no matter the official diagnosis. Although arthritis, bad discs, and displaced vertebrae come quickly to mind when your back hurts, back pain is very often nothing but referred pain from myofascial trigger points.”134 (Though not necessarily referred, and indeed often not referred — just muscle tissue aching right where the trigger points live.)

Or consider the opposite scenario, in which we begin with a genuine injury or mechanical problem: despite the presence of a painful factor other than muscle, it may soon be the least of your worries as trigger points crop up and begin to overshadow the original problem, causing pain that is even worse and more stubborn.135 This may be a typical course of events.

It is the nature of trigger points to both complicate other kinds of back pain and cause more of it. Hypothetically, muscles full of knots aren't as functional — not as good at their jobs. If true, that would likely boost vulnerability to injury, re-injury. Pain itself is also probably a risk factor for more hurting in the future,136 and that might be more true of trigger point pain just because it tends to be so persistent: the more it drags on, the more likely it is to haunt people in the future, like a traumatic memory.

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This book is in the midst of extensive upgrades on the theme of the psychology of back pain (2023):

BEFORE — The book more or less embraced Sarno’s idea that back pain may often be “the new ulcer,” with some caveats, and aimed to persuade readers that one of the most important things any back patient can do is increase their confidence and optimism to achieve a “rational placebo” derived mainly from knowledge and (especially) “pain neuroscience education.” Although the importance stress relief was also strongly emphasized, the details of options like mindfulness and meditation, relaxation, and breathing exercises were all neglected, and mainstream psychology (mainly cognitive behavioural therapy) was completely missing.

AFTER: A more agnostic and modern perspective, with full reviews of all popular and mainstream ideas about the role of the mind in back pain, especially mindfulness and cognitive behavioural therapy. There will significantly less stress on stress, and somewhat less on PNE and the hope of top-down modulation as a major mechanism of relief. I do still think the "confidence cure" is an important and useful concept, but it will no longer be front and centre.

I am actively working on this transition into 2023. Some legacy content will remain for a while yet. I have already been working on this for months. I have a lot of background material prepared, and here’s what I’ve actually added to the book so far:

• There’s a new high quality chapter about mainstream psychotherapy (so mainly cognitive behavioural therapy).
• A full report on the study of pain reprocessing therapy that made headlines in the winter of 2022.
• Yoga for back pain is now thoroughly explored. For a long time I only had a chapter explaining why it’s “not for everyone.” True! But not really the whole story. 🙂
• This section!

Coming in time:

• Malingering and psychosomatic pain. (I haven't started writing on this yet, but it’s been on my mind routinely for over a year now. I am mentally prepared for it!)
• More about meditation/mindfulness, and especially the neurophysiology of relaxation and deep breathing exercises (drafts well underway).
• Vagus nerve “resetting” and polyvagal theory (mostly written, just need to adapt and transplant).
• Putting Sarno in his place a bit (but also still working with some of his better ideas).
• And more! It’s a ginormous theme.

The big psychological picture

Chronic pain in general is often hard to attribute to any one factor, and back pain is the ultimate example of this, such a “perfect storm” of many possible factors that it’s almost inconceivable that the mind has no role to play. Even when back pain originates in frank pathology or trauma — which certainly happens to some people (I am married to one) — it will eventually be complicated by psychology in some way. Probably.

But how? Almost every big idea about the role of psychology in back pain is on thin scientific ice — both alternative and mainstream.

On the mainstream side, cognitive behavioural therapy is highly over-rated, and everyone is appalled by the ubiquitous all-in-your-head vibe emanating from most doctors like hard radiation (even when disavowed), and experts cannot even agree on the existence of psychosomatic pain (yes, that concept remains amazingly unclear scientifically).

On the alternative side, the power of the mind over pain has been a fountain of quackery for a century! There are undoubtedly some good ideas in that mess, but trying to find them is like going to the landfill to search for some good drapes.

There are immense problems with all of the most influential ideas in mind-body medicine, and most of the major personalities are controversial. Sarno, arguably the most influential expert on the topic of the psychology of back pain specifically, was certainly full of good and compassionate ideas, and he was good at expressing them … but he was also obviously drunk on his own Kool-AID by the end of his career, pumping out books about the power of the mind to heal practically anything. We all know what the road to Hell is paved with.

Key points and highlights in the psychology of back pain

• Malingering — consciously pretending to have pain — probably does exist, but is fantastically rare compared to actual back pain, and not relevant to most patients or professionals reading this book. It is a consideration with back pain more than most other problems, however, because it is so often tangled up with legal battles about disability and injury. It’s also just an interesting sub-topic in its own right, so someday I may write more about it here.137
• Psychosomatic back pain might exist, but no one’s really sure about that, and it’s probably rarely “pure” or “all” in your head. It’s more likely that the mind can exaggerate seeds of truth about pain — minor injuries and pathologies — rather than gin it up from scratch. And there are plenty of such potential seeds in the spine! And yet even this (psychological pain amplification) is controversial and may not actually exist.
• Knowledge is power? An important neuropsychological perspective is that “pain is an opinion” generated by brains, a volatile perception based just as much on high level threat assessment as tissue insult. The pain “system” is an elaborate alarm system that leans towards better-safe-than sorry false alarms, with psychology as a major component. Spines in particular may be overprotected, which might partially explain the prevalence of human back pain — and reassurance, confidence, education, and an understanding of this principle (“Explain Pain” or “pain neuroscience education”) might all be helpful. But this is all hypothetical so far, with only scraps of direct evidence to support it.
• “Coping” rather than curing is never truly satisfying to any back pain patient, but nevertheless it is probably the only solid ground in this topic… and effective coping might actually support genuine recovery. No one wants a consolation prize, but it’s better than no prize at all.
• Lifestyle medicine — the pursuit of overall health, fitness, and happiness — is probably relevant to back pain by reducing biological vulnerability… and that in turn may call for psychological growth, maybe even a major mental makeover. The physiology of chronic anxiety, stress, depression and exhaustion is impressively toxic stuff, with loose but clear links to back pain, along with the social ills that obviously underly many of those problems — and hence the potential importance of a “biopsychosocial” perspective on back pain that includes essentially everything about people. Examples as simple as taking the edge off insomnia or blunting loneliness could be profoundly important to many chronic pain patients.
• Complex pharmacotherapy with psychological goals — anxiolytics and anti-depressants — has shown some limited but clear potential to help back pain patients.
• Cannabis (THC) is not usually thought of primarily as a psychotherapeutic treatment, but that might be how we should think about it: to the extent that it helps anyone with pain, its psychoactive effects are the most plausible active ingredient, rather than direct analgesia, which is does not appear to be capable of (although with cannabis there's a huge “it’s complicated” factor). See also things like ketamine and mushrooms and other mind-blowing substances that, while highly unpredictable, are notorious for their ability to radically shift mental state with occasionally impressive pain-relieving results.
• Yoga and meditation/mindfulness are “acquired tastes” that are aesthetically and philosophically objectionable to many people, and yet oppressively obligatory treatment options. For those that want to pursue them, they likely have some value — if you can separate them from the nonsense (especially the toxic positivity that is one of the primary outputs of the Wellness Industrial Complex, and the tragically mistaken belief that most back pain is caused by a weak/wonky “core”).
• Cognitive behavioural therapy is the 800-lb gorilla of modern psychology, over-hyped and over-rated, with shockingly weak evidence of efficacy for back pain. CBT is also the foundation of Smartphone apps like Curable, Pathways, and Ouchie — wildly popular and probably not useless, but also probably not revolutionary.
• There are several major branded mind-body medicine approaches to chronic pain, but the best known one focused on back pain is Sarno’s insightful and compassionate but flawed “mind over back pain,” which basically boils down to blaming back pain on repressed emotions and (more specifically) “avoidance of psychic conflict.” It’s probably not all wrong, but it’s pretty thin ice scientifically. Pain reprocessing therapy is another notable example, especially because of the notoriously positive 2022 trial.

Back pain is steeped in more ideas about the role of the mind than any other single common condition. However, the topic is even bigger than that! There are many more ideas about the psychology of pain that aren’t relevant or important enough to include here. For a more general tour of the theme, see Mind Over Pain.

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Back pain might be how some bodies say “no!” It could be the painful manifestation of an urgent desire and need for change — a reaction to stress. That turn of phrase is borrowed from the title of a book about stress-induced illness by Vancouver physician Gabor Maté.138

Back pain could also be how “the body keeps the score,” another phrase borrowed from a similar book.139

Let me stop the groaning: I know everyone is tired of hearing about the evils of stress, and the last thing anyone with chronic back pain needs is another reason to wonder if you haven’t somehow brought it on yourself. Low back pain is definitely not a basket-case diagnosis. Neither is back pain that is dominated by muscle. I am not telling you that having back pain means that you are a hypochondriac or that it’s “all in your head,” and I do not recommend meditation or yoga: those are tired clichés that miss the point.

Pure psychosomatic pain is probably as rare and exotic as hallucination (indeed, there are serious scientific questions about whether it’s even possible). While pain may be strongly affected by psychology, even disastrously amplified and prolonged, it is probably rarely “caused” by it. There isn’t even a pain-specific mental disorder defined for psychiatrists — there used to be, but it was eliminated because it was so problematic. There are so many hard-to-diagnose pathological causes of pain (an unfair share of which are in the back) that the experts judged there was too high a risk of prematurely diagnosing people with a mental disorder when there’s something actually wrong with them.140

The point here is that most pain begins with a seed of biological truth, some kind of injury or pathology, something that is objectively detectable in principle — but later it probably becomes increasingly sensitive to mental states to varying degrees and via various indirect mechanisms, much like high blood pressure, heart disease, asthma, or irritable bowel syndrome.141 Back pain is vulnerable to mental state.

The excessive sore spots of myofascial pain syndrome seem to disproportionately affected. Stress may be both a root cause and a complicating factor in MPS, much as MPS is both a root cause of some back pain and complication of nearly other types of back pain.142 Although it is under-researched, many studies have shown links between stress and low back pain.143144145146 The likely potency of placebo in the treatment of back pain is also telling: nothing works magic on a stress-aggravated condition like optimism!

The boiling frog problem

People often do not realize that they are suffering from enough stress to cause trouble. They have clear biological signs of stress — and this is an important premise for what’s coming here. The links between personality type and stress are a little murky and complicated, but they are certainly there:147

Your style, your temperament, your personality have much to do with whether you regularly perceive opportunities for control or safety signals when they are there, whether you consistently interpret ambiguous circumstances as implying good news or bad, whether you typically seek out and take advantage of social support. Some folks are good at modulating stress in these ways, and others are terrible.

Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 309.

There are two major personality types that not only involve a lot of stress, but some degree of obliviousness to it:

1. The stereotype of the “Type A” personality with its aggressive coping mechanisms, by eagerly tackling fears directly… and by seeing threats where there are none, just in case, which is why it becomes a problem. These people are likely to make a virtue of stress, re-framing it as though it were a good thing, eager to believe that “stress is your friend” (it’s not).148
2. The stoic, repressive personality — people who feel and act calm and methodical, and genuinely believe that they are, but they are actually conforming intensely to social norms, and controlling and organizing their lives to the point of suffocation. Dr. Robert Sapolsky: “It can be enormously stressful to construct a world without stressors.”149 Sarno: “one can be stressed without feeling tension” and “there are chronic daily stresses in people’s lives that are more insidious and more harmful [than crises] in their long-term biological consequences. Internally generated stresses take their toll without in any way seeming out of the ordinary”150 (emphasis mine).

And then there’s just straight-up avoidance, acting stoic because stress is the same as anxiety, and anxiety is stigmatized and many people want to hide it. It is socially risky to express anxiety — no one wants to be perceived as jittery! It can even be verboten as a self-judgement as well; some people perform stoicism for their own sake, trying to fake it until they make it.

Sometimes the source of tension is not obvious … I recall a young married woman who … denied being tense or nervous … she was known to be a very jolly, easygoing person. Only after a long discussion did she reveal that her strategy for coping with life’s problems was to put them out of her mind. This is a foolproof formula for generating tension. Putting things out of one’s mind doesn’t get rid of them …

John Sarno, Mind Over Back Pain, p53

Ulcers were a socially acceptable symptom of stress for a long time. Rather than being a nervous individual, you could be a hardass with an ulcer. But now everyone “knows” that ulcers are stress-induced, whether they really are or not, so ulcers are much less effective as a disguise for emotional stress — and maybe this might partially explain why ulcers have been declining since the 1970s.151 (Aren’t ulcers caused by an infection? Yes, but the devil is in the details, and the details are in this footnote:152 )

Instead, Sarno proposed, North Americans increasingly make back pain into a perfect new “hiding place” for nervous tension: a path of least resistance more than a choice. Because of the widespread belief that backs are fragile, people with back pain are readily seen as victims of biology, instead of stressed out basket cases. Perhaps in time, if the stress-mediated nature of back pain becomes a widespread idea, it won’t be as useful in this way.

Psychosomatic disorders are physical symptoms that mask emotional distress. The very nature of the physical presentation of the symptoms hides the distress at its root, so it is natural that those affected will automatically seek a medical disease to explain their suffering.

It's All in Your Head, by Suzanne O’Sullivan, 8

The vicious cycle hypothesis

Once an episode of back pain starts, pain itself, immobility, and the fear of more pain become nasty new sources of stress. Thus, back pain may “cause itself.”153 Pain, fear, and immobility constitute an axis of evil, each reinforcing the other.

Tragically, medical care for back pain often spooks patients, making the vicious cycle even more vicious:

The system generates great fear. I recall a woman who became terrified when she read in a well-known book on the back that if you had a mildly herniated disc and became active too soon it would fully herniate and then require surgery. Another patient was told by the doctor as she left the hospital after refusing surgery, “You will be back in two weeks screaming in pain and begging me for an operation.”

Dr. John Sarno, Mind Over Back Pain, p105

A leading cause of back pain may be health care itself,154 in part accounting for the increased frequency of low back pain in modern times and in industrialized nations. More generally, the fear is stimulated by the many common myths and misconceptions about the fragility of spines — which are perpetuated by nearly everyone, not just doctors.

Pain, fear & immobility constitute an “axis of evil,” each reinforcing the other & boosting the risk that the pain will drag on.

That’s a nice clear picture, but we can boil it down to something even simpler …

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The diagram above — the pain-fear-immobility cycle — is one of many similar ways of visualizing what happens in chronic low back pain. For dramatic effect, I’ve cast immobility and muscle dysfunction as the villains: very specific and physical parts of the vicious cycle. Immobility is a problem behaviour, for instance: something you do (or don’t do). That may not be quite right, but describing it in this way is no accident: I want to make it real. Something that implies action. Be more mobile! Keep muscles happy!

Immobilization is indeed a common way to show fear, and it’s much easier to work with the consequences of fear than fear itself. And it may well be a particularly important factor in muscle pain.

And yet fear itself is actually all we need to keep pain going in that diagram. Immobility is redundant. You don’t need that particular behavioural piece of the vicious puzzle to explain the stubbornness of back pain. You can take immobility out of the picture, and the vicious cycle carries on, powered by fear and pain alone.

We tend to assume that the persistence of pain means that there is damage and danger, assumptions that are in themselves direct causes of pain. If your brain thinks that the situation is injurious and dangerous, it has the ability to make sure it feels that way — regardless of whether or not you actually behave fearfully by immobilizing yourself. (See Woolf155 — a particularly important reference.)

Bear with me for a moment for an amusing example. (This is a bit of a reach, but it’s worth it to get a chuckle out of this difficult subject.) There’s an episode of The IT Crowd that has fun with massage: “Something Happened” (Season 4 Episode 3). Roy has terrible back pain, but he doesn’t particularly want a massage:

I’ve never enjoyed having massages. I don’t like being naked in front of strangers, and I can never relax if I think someone might play Norah Jones.

Roy, The IT Crowd, “Something Happened” (Season 4 Episode 3)

Nevertheless, he gives it a try and he’s actually kind of digging it, until the “something” happens: his therapist concludes the otherwise professional treatment with a quick kiss on the buttock! (News bulletin: this does not actually happen. This is amusing, fanciful satire.)

Yes, if you watch Game of Thrones, you have seen that massage therapist before. More seriously (and yet still funny!) is how Roy describes the results of his massage:

Roy attributes the failure to the extreme tension caused by a violating butt kiss — as one does — but there’s a deeper truth here: after a massage that seems to provide great relief at the time, many people do indeed soon end up right back where they started. Despite the nice clichés about feeling relaxed after massage, patients can actually get off the table feeling surprisingly unpleasant, wrung out in a not-so-good way: fragile, vulnerable, and tense. In Roy’s case, it was the kiss on the butt that did it! In real life, therapists of all kinds often unwittingly scare their patients with careless talk of what’s wrong in there, how serious it is, how they need more therapy, and so on, which can leave patients feeling more worried and anxious about their backs than they need to be. And that, in turn, is more than just a side effect: it actually perpetuates the problem.

It cannot be said enough: this is not an “all in your head” message. It’s an “all in your brain” message — not psychology, but neurology. Or, as Dr. Lorimer Moseley puts it, “Pain really is in the mind, but not in the way you think.”156 Here’s his description of this more purely neurological vicious cycle:

This is where our understanding of pain itself becomes part of a vicious cycle. We know that as pain persists the nociception [danger signalling] system becomes more sensitive. What this means is that the spinal cord sends danger messages to the brain at a rate that overestimates the true danger level. This is a normal adaption to persistent firing of spinal nociceptors. Because pain is (wrongly) interpreted to be a measure of tissue damage, the brain has no option but to presume that the tissues are becoming more damaged. So when pain persists, we automatically assume that tissue damage persists.

I think it goes like this: “more pain = more damage = more danger = more pain” and so on and so forth.

All of this strongly suggests that anything that reduces fear might be therapeutic. Reducing the fear part of the equation — not just empty reassurance, but good reasons for genuine, unforced confidence — is a recurring theme throughout the rest of this book. Refusing to be immobilized is probably one of the best specific strategies for rebuilding confidence (which is why I gave it special focus in the pain-fear-immobilization diagram). The next section is another great example …

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Famously, most back pain doesn’t last long: most people get better fairly soon. Specifically, at least half of people with back pain will improve or even recover completely within just a month.157 But then what?

What happens when back pain doesn’t go away within a few weeks? When does acute pain become chronic… and how long does chronic low back pain last? The duration that conventionally distinguishes “acute” from “chronic” cases is 6-12 weeks (depends who you ask). It’s an arbitrary number, not a data-based one — and it comes with the insidious, confidence-nuking insinuation that those who do not recover by that deadline are doomed to a much longer battle with chronic pain.

You do not disastrously become an impossible case the moment you hit week thirteen. In fact, if you’ve had chronic low back pain for less than a year, I’ve got great news for you: your ordeal may soon be over, no matter what you do about it. Or don’t do about it. There is good evidence about this, which this article will explore in detail.158159

Obviously low back pain can last for many years, sometimes constant, and other times coming and going (chronic episodic back pain). But these are a worst-case scenarios, and here’s the good news is that chronic low back pain is:

• chronic low back pain is less common than people fear
• chronic low back pain is less severe than people fear
• chronic low back pain is less chronic than people fear

The pseudo-myth of back pain chronicity

The pseudo-myth is that chronic back pain is common, severe, and rarely ever lets up. It’s not quite a full-strength myth for two reasons:

1. Chronic back pain is real and serious. The pseudo-myth is an exaggeration of the truth, not total departure from it.
2. No one is really out there “promoting” the myth, or erroneously defending it. You’re not likely to catch a doctor actually saying that you’re doomed after twelve weeks of back pain — but it might be implied.

Back pain is generally over-treated and over-medicalized with lots of medical drama with minimal benefit for patients (exhibit A: the infamous overprescription of imaging, too often and too soon). Part of that drama is a pervasive attitude of defeatism and alarmism about the prognosis of chronic low back pain. Most healthcare professionals know enough to reassure their patients that a new episode of back pain is likely to resolve quickly, but many of those same professionals simply postpone their pessimism and alarmism, defeating the purpose of their reassurances, and often undermining patient confidence long before chronicity actually arrives.

It is not at all reassuring to be told that “most cases go away with two or three months” if it’s accompanied by the strong implication that “you’re screwed if it doesn’t!” Patients given these conflicting messages are likely to start worrying that their pain will might not go away in time to avoid the spectre of chronicity.

There is no clear transition from acute to chronic pain, but pain that persists beyond 9–12 weeks is usually deemed chronic. The surprising thing? Most chronic low back pain doesn’t stay “orange” for a whole year.

Good news: credible evidence that plenty of chronic back pain backs off!

If you’ve had chronic low back pain for less than a year, I’ve got great news for you: your ordeal may soon be over. A good Australian study by showed that “prognosis is moderately optimistic for patients with chronic low back pain.”

“Many studies provide good evidence for the prognosis of acute low back pain,” the authors explain. “Relatively few provide good evidence for the prognosis of chronic low back pain.”

And the prognosis is better than most people would expect.

This research is different from other studies of chronic low back pain, which often focus on patients who already have a well-established track record of long-term problems: in other words, the people who had already drawn the short straw before they were selected for study, and are therefore much more likely to carry right on feeling rotten. But what if you studied fairly new cases of chronic low back pain? How many of them fade away, and how many of them drag on?

And isn’t that what low back pain patient most want to know? Especially after suffering for 3-4 months? Just how chronic is chronic back pain? No so chronic after all…

More than a third of chronic cases recover within a year — which isn’t very chronic

Costa et al followed patients who had not yet recovered from their new cases of chronic low back pain, and found that “more than one third” recovered within nine more months. That’s a quite a happy number.

Yes, of course, that does still leave almost two thirds of patients who do continue to suffer past the year-mark — and that’s not such a happy number. This is chronic low back pain we’re talking about here, after all — it’s not nothing! But the surprising and promising thing is that so many patients in this study — almost 40% — actually did recover by the one-year anniversary of their pain. These are people who didn’t get better in the first three months … and who would have been told by many doctors that they were officially “chronic” at that point.

This evidence is a great foundation for more substantive and lasting optimism about back pain. But wait, there’s more!

How did it go for 11,000 more people with chronic low back pain?

Sure, it’s great that a third of people recover entirely, but there’s still something important missing here: what happens to everyone else? Do they improve? Or do they get stuck with just as much back pain at a year as they had at three months? Obviously that does happen to a few unlucky souls.

But definitely not most people.

There’s surprisingly little hard evidence on the prognosis of chronic low back pain: as of 2023, there’s still just one other good study … and it also came from Costa et al. Busy researchers!

In 2012, they pooled a whole bunch of data about the progression of both acute and chronic back pain, generally validating their 2009 finding that chronic pain improves, and some of it resolves — further debunking the idea that chronic is permanent. Yes, lots of people still have significant pain and disability a year after being stuck with the “chronic” label… but not everyone, and almost everyone improves quite a bit. Costa et al. crunched the numbers on over 11,000 patients in 33 different studies of back pain patients, and split them up into acute and chronic (pain for more/less than 12 weeks). Here’s how pain in those groups changed in the year after their trouble started:

Whether pain was acute or chronic to begin with, pain declines in very similar way over a year. Although chronic is clearly worse than acute on average, it also declines slowly & significantly over the months — a striking contrast to the pattern that people fear about back pain chronicity.

Risk factors: who did well or poorly in the Costa trial, and why?

Did the people who didn’t recover in Costa et al’s 2009 trial have anything in common? The study also looked at risk factors, and found some patterns. The patients whose pain just kept going were those who had worse pain, more disability, and more fear (“perceived risk of persistent pain”) — no surprise there. They were also the patients with a history of previous sick leave — not for back pain, but for other things, people who may be generally unwell.

A little more surprising was that they had less education: better educated people recovered better.

And (my favourite) the patients with persistent pain also tended to be non-Australian. That’s right: native Australians in Australia get less chronic back pain than non-Australians in Australia! Not sure what to do with that information — don’t move to Australia and get low back pain, I guess? Sound medical advice.

Who does poorly with low back pain? Known risk factors for chronicity

Back pain chronicity is impossible to predict reliably, but there are some signs to be alert for. Although very complex, the oversimplified truth is so obvious it almost feels silly to say it: the worst and most intimidating cases of back pain are the most likely to last! But we can get more specific…

1. Anxiety and pessimism. Obviously more severe back pain tends to be more emotionally challenging, but there are other critical factors too, like how the pain menaces work and fun. (It is not clear whether anxiety and pessimism are a cause of chronicity, or merely a natural consequence of the severity that leads to chronic back pain. More on this below.)
2. Leg pain, pain in the neck and shoulders, and difficulty walking or getting dressed.
3. No position or movement eases the pain. This can change with time, so the more and sooner you can see relief with some movement or position, the better. This is the phenomenon of “centralization” — relief in response to specific repeated movements or sustained postures. We see this in roughly 40% of people with back pain, and it is quite strongly linked to better outcomes.161 It’s possible, maybe even likely, that centralization is just a sign of a milder case of back pain,162 but I’m including it because it’s such a famous signal. (See the centralization chapter for more.)

Back pain chronicity risk quiz

The STarT back pain questionnaire is a nine-question quiz that does a good job of identifying low, medium, and high risk of a poor outcomes for people with back pain.163 The full questionnaire is intended to be used by clinicians with patients, but it can be understood and used by anyone, and there’s an online calculator.

But scoring the official version is a bit tortuous (there’s literally a flow-chart for it, and worse164) — so I think the world could use a simpler version. This is my own slightly simplified self-serve quiz for patients. While the full quiz is scientifically validated, and that matters, it’s clearly not an exact science, and simplified version is just fine for getting a rough sense of your risk level.

The more of these statements apply to you, the higher your risk of chronicity, and the more likely you are to benefit from skilled and personalized care. Most people scoring three or less probably need not professional help at all, as long as the situation doesn’t get worse. If you score low initially, but then much higher three weeks later, you should seek out help.

In last couple weeks…

• My back pain has spread down into one or both legs.
• I have had some pain in the shoulders or neck.
• I am walking less and/or I’m dressing more slowly.
• I don’t think it’s safe to be physically active.
• I am worrying a lot about this back pain.
• I am struggling to enjoy things I normally enjoy.
• This back pain has been extremely bothersome.

The relationship of back pain and anxiety and/or depression

This sub-section probably contradicts other parts of the book! My views on this topic are evolving, and a large revision of the content on psychology is (still) underway in 2023.

Knowing that your chronic back pain probably won’t be as chronic as you fear is inherently valuable. But could that kind of reassurance actually help? And does being afraid of a bad outcome actually make it more likely?

Anxiety, pessimism, and depression might cause exactly what we fear — a self-fulfilling prophecy. And reassurance might actually scare the back pain away and, all other things being equal, produce a better prognosis than if you were freaked out.

That’s a very tempting idea, but No one actually knows that anxiety causes or exacerbates back pain, or vice versa, because the right evidence simply does not exist (despite some strong expert opinions to the contrary in both directions). All anyone can do is speculate. All we do know is that there is a some kind of relationship,165 and that there are indeed psychological risk factors for back pain … but correlations and risk factors are not “causes.”

It is plausible that anxiety and depression have can make back pain worse (at least). And if that’s the case, then reassurance and correction of the misinformation might be very valuable.166 Here’s a hypothetical case study to illustrate how all this might work…

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There are several classic characteristic signs and symptoms of back pain that might be caused mainly by cranky muscle, either from the start, or as a persistent complication of an original problem that has slowly faded away. This section provides a quick checklist to give you a rough idea, plus a slow checklist with more detail.

For most people, most of the time, confirming a trigger point diagnosis is simple enough. Check all that apply — if you have more than half of these, and no other apparent explanation for your pain, you probably have a trigger point or two.

• You have sore spots in muscles.
• Your pain usually occurs in specific areas of your body.
• The problem feels more like muscles than joints.
• Your pain is primarily dull, aching, and nagging.
• You feel a lot of stiffness as well as pain.
• Affected areas feel weak and heavy.
• Stretching is appealing (but not very effective).
• Hot showers and baths are usually helpful.
• Anti-inflammatory medications don’t really work.

And now for the slow checklist. This list is deliberately similar to the slow checklist for myofascial pain syndrome in the trigger points tutorial, but it is customized for back pain. Muscle pain in the back is a different critter than muscle pain in general — many distinctions are made throughout this section. Disclaimer: obviously this is not an exact science. Indeed, as some would argue, it’s not any kind of science, and they’re certainly right about this: this is all based on professional opinion and experience. We don’t know what trigger points actually are, just how they seem. And how they seem is bound to be unclear and overlap with other issues quite a bit. Any one checkmark in this list could be misleading, and even a whole bunch of them aren’t diagnostic, just “suggestive.” Check every item here, and what does it mean? The pain is more likely to be driven by muscle, but hardy guaranteed. You are bound to have some of these signs, regardless of the cause of your back pain. Roughly less than one third means that trigger points probably aren’t an important factor in your case. More than two thirds? There’s a decent change that trigger points are a significant factor.

• Sensitive under pressure. By definition, trigger points are sensitive patches of soft tissue. If you have a trigger point problem in the back, then your back muscles may be more sensitive to pressure. That is, it will hurt to firmly poke your low back and upper gluteal muscles, compared to muscles in problem-free areas of your body. These are big muscles, so they may not be sensitive to light pressure — use a medium to firm pressure and check in several locations. And it probably is possible to have deep trigger points that cannot be provoked by poking.
• Feels like muscle! Pain is a difficult sensation to interpret, but trigger points do often feel like a muscle problem in ways that may be hard to specify. Many small clues can contribute to this qualitative impression: a sense of moderate depth (deeper than skin, shallower than bone), for instance, or sensitivity to flexing and stretching. Muscle pain might be much sharper than you expect, but usually it is dull and aching. If your pain is mostly aching, and nagging, with a strong “stiffness” component — and there are no other kinds of pain, like stabbing or burning or electrical sensations — then muscle may be the source of your troubles.
• No other obvious cause for pain! And by “obvious” I mostly mean “injury.” One of the simplest ways to diagnose trigger points is simply by elimination: if there is no obvious trauma, then trigger points are somewhat more likely. Only a significant and recent accident qualifies as a possible traumatic cause of your back pain: a high-velocity sports injury, falling off a ladder, or a muscle strain while lifting a sofa-bed. Backs are pretty tough — they cannot normally be damaged by subtleties like “twisting the wrong way” or “more golf than usual.”167 There are other reasons pain might persist after healing, but trigger points are a strong possibility.
• You have back trauma, but it’s old. Perhaps you really did injure your back … once upon a time. However, backs heal like any other part of your body. If your injury happened more than twelve weeks ago, you have probably healed entirely or mostly, and any continuing pain that you have is therefore more likely to be caused by trigger points. (There are other reasons pain might persist after healing! But trigger points are a strong possibility.) This is the “out of the frying pan, into the fire” phenomenon, discussed in another section and in a separate article, Muscle Pain as an Injury Complication: The story of how I finally “miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had healed.
• You crave stretch. You crave it because trigger points are strongly linked to sensations of stiffness. For contrast, it is not an appealing idea to stretch a damaged spine. The nervous system usually strongly warns you away from that! When you stretch an aching muscle, it may feel difficult or even as though it amplifies the symptoms — like you are “pulling on the pain” — but it probably also feels relieving, like scratching an itch. Related: muscle pain tends to make people generally squirmy, a craving for movement in general.

• … but stretch usually fails. Although it seems like a good idea and often feels nice at the time, stretching trigger points usually fails to actually do much good. It’s not an effective treatment. Sometimes it might provide more relief, but most MPS sufferers will be underwhelmed by the results of stretching. However, because it does tend to take the edge off, stretch remains appealing.

  Unfortunately, the muscles typically affected in the low back are also biomechanically difficult to stretch very much,168 so it often feels futile, like trying to scratch an itch you can’t quite reach. Back fear can definitely be a factor here: stretch is also limited by the brain,169 so the anxious back pain patient may not crave stretch simply because of a freaked out nervous system.

• Aching, not sharp. Your pain is primarily dull, aching, nagging pain, as opposed to sharp, stabbing, burning. Although nearly any quality of pain is possible, and flared up trigger points can occasionally get hotter and stabbier, most pain of this type is just an ache. There aren’t many other unclear causes of pain that ache like this. For instance, arthritis can have an aching quality, but it’s often sharper and hotter.
• Similar pain in other areas. Trigger point pain is “patchy,” afflicting some predictable areas of the body, especially the meatier tissues of the trunk (neck, shoulders, upper back, low back, and hips). Different problems in those areas would probably cause different kinds of pain, or more widespread and uniform pain (like the diffuse all-over sensitivity of the flu, or muscle soreness after unfamiliar exertion, which always affects an entire muscle group uniformly). Trigger point pain usually flares up in no more than one or two regions of the body at a time. If you have one or two other similar pains in the other areas, it’s more likely that they are all muscle pain.
• Abnormal texture. You might be able to feel a lump in your muscle and a hard and ropy texture around it, but then again you might not. This is an unreliable way to diagnose trigger points, but it’s particularly tricky in the back, because there are many normal anatomical structures that feel like bumps and ropy structures, as well as common harmless abnormal structures, especially “back mice” (lipomas, more about them below). However, in some muscles in the area, bumps do tend to stand out nicely.170 But I want to be very clear that lump-hunting in the back is mostly a wild goose chase. But it might reinforce other signs and symptoms, so it’s worth being aware of.
• Anti-inflammatories don’t help much. Since there is little or no inflammation per se involved in muscle pain, anti-inflammatories like Aspirin or ibuprofen (Motrin, Advil, etc) mostly don’t help much. If they do help, that can mean that pain does have a more “traditional” inflammatory nature (associated with tissue damage, such as a wounded facet joint or a ruptured intervertebral disc). Some other conditions, notably fibromyalgia, also cause pain that doesn’t respond well to anti-inflammatories, so this sign is hardly a slam dunk on its own. Note that the effects of other drugs are not very informative.171
• Wandering pain. A classic sign of muscle-dominated pain is symptoms that change location, either moving to another area of the body altogether, or erratically shifting around and spreading out from a predictable epicentre. In addition to moving, trigger point pain also often changes quality, and comes and goes without much rhyme or reason (the “outta nowhere” phenomenon). Not all trigger point pain is so erratic, but it often is. For contrast, pain location is more consistent when it comes from injury, arthritis, or common kinds of neuropathy. Trigger points in the low back may be more entrenched and consistent than other areas of the body. Nevertheless, the pain is usually still less consistent than injury pain.
• Mirror image pain. Damaged anatomy is rarely neatly symmetrical. Trigger points, however, quite often have “evil twins” in the same location on the opposite side of the body. Many cases of muscle pain dominate a single side but will, occasionally, flip to the other side — and even a single instance of this is a near guarantee that injured tissue is not to blame, because injured tissues can’t change sides. So, if you do ever have symmetrical pain, it’s more likely to be caused by muscular trigger points than by injury. Also, it’s a common pattern with low back pain patients that their pain flips to the other side following some kind (any kind) of treatment.172
• There are signs of chronic or severe stress in your life. If the connection between back pain and stress is not obvious in your case — flare ups of back pain during crises — there may be many other signs of it. People who suffer from excessive muscle pain often have a medical history that includes other consequences of stress and stress-sensitive conditions (e.g. ulcers, panic attacks, insomnia, irritable bowel syndrome, etc).173
• A “numb” leg. Trigger points cause weakness in the affected muscles and a kind of numbness often mistaken for a nerve pinch — sciatica. But this numbness is a deep, dead, heavy feeling … not the more profound skin-numbness that you can get in specific areas when your low back nerve roots or sciatic nerve are in real trouble. This distinction is explained in more detail below.
• Heat helps. Hot showers and baths and other forms of heating, even just warm weather, are almost always helpful. Most kinds of chronic pain are helped by heat to some degree (ha!)174, with fibromyalgia pain as the most interesting exception (usually worsened by hot weather).175 But patients with ordinary muscle pain almost always prefer heat. If you like to be toasty, score a point for a trigger point diagnosis.
• Symptoms are aggravated by muscular effort and overexertion. Assuming that trigger points are some kind of muscle dysfunction, it follows that they might flare up when we demand more function from the muscle, and this is commonly reported. Muscles can be exhausted either by an intense exercise like shoveling, or by sneakier postural stress, like an awkward working posture. If you predictably have flare-ups of pain in situations where muscles are working, then muscle might well the problem. Back muscles seem especially prone to postural stresses — sustained positions like stooping over while gardening, cleaning a bathtub (but not just slouching lazily).
• The pain of stuckness. The discomfort of trigger points may be experienced as stiffness following periods of immobilization (e.g. hours in an airplane seat, or even a movie). This is a weak signal, because there are several other possible causes of stiffness, particularly in older people (the progression of many subtle sources of inflammation that accumulate over the years, known as “inflammaging,” which manifests in many ways but most obviously as arthritis). Relatively widespread stiffness in a younger person with no other known health issues makes trigger points a more plausible suspect.

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Being an adult is mostly about being exhausted, wishing you hadn’t made plans, waiting to take your bra off, wondering how you can fall asleep and stay asleep, missing someone or something, becoming forgetful, and wondering how you hurt your back.

source unknown

“I just can’t figure out what sets it off!”

Seemingly random flare-ups are one of the signature symptoms of many kinds of chronic pain, but particularly low back pain, and probably any pain problem dominated by muscle. This time-bomb effect is probably mostly attributable to pre-existing painless vulnerabilities, which can be pushed over into a more serious pain problems by surprisingly minor changes. There are a bunch of ways to be vulnerable before you actually notice, some of which we have little control over, others more so.

For instance, systemic inflammation (immune activation) is probably quite volatile, and waxes and wanes for our whole lives in response to physiological challenges, insults, and variables, many of which we are oblivious too. These changes are just too cryptic and messy to easily link to flare-ups.

Sneaky sources of physiological overload — stressing tissue more than we realize — are a factor we might be able to learn and manage more easily. Tissue can get into some trouble before it becomes obvious to us (stress fractures are a classic example), and then one day just a bit more activity pushes us over the threshold of injury. However, that rarely seems like pain truly out of “nowhere.” A lot of back pain flares up with essentially zero apparent provocation … and often disappears just as strangely. For that mercurial weirdness, you need to explain why pain would come and go quite easily, without any apparent provocation.

Latent trigger points

“Latent” trigger points may be a common form of pre-existing painless vulnerability. Trigger points exist in two states: latent and active, or quiet and loud.

1. Latent trigger points are present but painless … until provoked. Like a pimple that you don’t notice until pressure is applied to it.
2. An active trigger point hurts no matter what, throbbing like a severe pimple that hurts constantly.

Latent trigger points may lurk unsuspected for weeks, months, or years, finally becoming active and painful with minor provocation — the straw that broke the camel’s back. This creates the illusion that the symptoms have come “outta nowhere,” in response to minor physical and emotional stresses, when in fact the problem was developing for a long time before you felt it.

The “outta nowhere” phenomenon is a familiar feature of many chronic pain problems, and perhaps that’s because of the role of trigger points and the way they easily pop in and out of latency, like submarines surfacing and diving again.

Morning back pain

One of the best common examples of “outta nowhere” back pain is waking up with it. This is a major sub-topic, and there's a (very large) chapter about it: Morning back pain.

Sensitization and fear

John Sarno wrote: “How can severe back pain be started by incidents so variable in intensity? … In my view they are all triggers and have nothing to do with the basic cause of pain.”

Erratic pain seems to occur more dramatically in the low back than other areas. “Sensitization” is another possible explanation for this.

Sensitization is a normal process that occurs with even the tiniest wound: the area around a cut rapidly gets sensitive to stimulation, which encourages us to baby it. For simple, minor trauma, that’s all there is to it: hurt things get more ouchy until they heal.

But that effect can get chronic and abnormally excessive, probably for both psychological and physiological resons.

If pain is an alarm, pathological sensitization is a neurological problem with false alarms: bigger reactions to smaller provocations. Pain will be a worse experience — more intense and/or more of an emotional tornado — if we are convinced it represents a more dangerous problem than we actually have. And back pain is intimidating! So sensitization is probably often a major factor, lowering the threshold at which we notice tissue problems, and exaggerating them when we do.

Sounds awful, but the good news is that sensitization might also be eased by a wide variety of factors: anything that affects our overall sense of safety and well-being. This remains unproven, but plausible based on what we do know.

And so it is probably one reason why back pain seems to surge and ease unpredictably. It also might be one of the reasons that past back pain is a major risk factor for future back pain. Sensitization may be in place as a vulnerability long before a flare-up of back pain occurs.

When back pain suddenly shows up, we are tempted to blame it on the last minor stressor that affected it, such as a soft bed in a hotel. This is like blaming your bankruptcy on the last latte you bought before your account finally went into the red.

Todd Hargrove, Playing With Movement: How to explore the many dimensions of physical health and performance, 2019 p. 95, ch. 4: Stress and Adaptation

Trigger points might be a sign of sensitization — perhaps those sore spots are one of the things that happens because we’re sensitized. Maybe they are sensitization.

Regardless of the specific mechanism of pain — trigger point, irritated joint, whatever — low back pain may be volatile because it part because it’s emotionally overbearing, which is a powerful driver of sensitization. The fear factor seems to be more pronounced with low back pain than any other common area of pain, for a variety of reasons.

Another idea: the intensity and rapid escalation may be due to the substantial mass of the musculature involved, combined with the intimidating nature of pain in that region. There’s a lot of muscle in the thighs too, but pain there isn’t as worrisome … and pain in the neck can be very worrisome, but there’s a lot less muscle. The back has both a lot of muscle and it’s a scarier place to hurt.

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“I woke up with it” is an amazingly common description of how low back pain started. (And neck pain, and headaches, and even more.176).

Why? Is sleeping dangerous? Probably not: waking up with back pain rarely indicates a serious problem. Both mornings and backs are unusually vulnerable to some common minor sources of pain.

This is mostly about chronic back pain that’s at its worst in the morning, a common pattern. Even many people who are more or less pain-free during the day may still experience routine and significant irritation and stiffness first thing in the morning. But attacks of acute back pain are also much more common in the first few hours of the day,177 and that phenomenon may be related to why chronic back pain tends to be bad in the morning.

Morning back pain is a tough problem to treat because most of it probably has several subtle chronic causes, but there may be some opportunities for treatment.

Is pain & stiffness your alarm clock? Do you bail out of bed early every morning with low back pain, neck pain & more?

The 6 big causes of morning back pain

1. Inflammatory back pain: pathological inflammation from autoimmune disease, which is often serious, relatively rare, and fairly well known.
2. “Inflammaging”: slow but steady increase in chronic mild inflammation as we age.
3. Myofascial pain syndrome and/or fibromyalgia: back pain is often the hot spot in the body for muscle pain and otherwise unexplained widespread aches and pains, and there are some reasons why these conditions may be worse in the morning, but they are mysterious and controversial.
4. Insomnia and poor quality sleep is, of course, the most basic explanation for morning back pain. A good night of sleep is an effective painkiller, and a lousy one is the opposite.
5. Osteomalacia (vitamin D deficiency): vitamin D deficiency is probably quite common, is linked to chronic pain, and morning bone aching in particular.
6. Awkward sleeping postures: although this is the most “obvious” reason for waking up with a kink in your back, it might be worse than you expect.

3 myths about the causes of morning back pain

There are some popular ideas about what causes back pain that are probably wrong (or at least a lot more rare and trivial than believed):

1. Bad mattresses are generally over-rated as a factor in back pain.
2. Psychological factors are also often given too much weight. The mind is relevant to a lot of chronic pain, but morning back pain is particularly unlikely to be psychosomatic.
3. Intervertebral disc swelling is a popular specific scapegoat, but it’s highly speculative and quite likely wrong.

All of these causes are discussed below, along with many treatment options and suggestions. Click the green headings above to jump down to a section.

The scariest type of morning back pain: inflammatory back pain

The closest thing to back pain that is truly prominent in the morning is inflammatory back pain (IBP), or spondyloarthritis.178 Although IBP is well known to medical science, it often eludes diagnosis, its biology is mysterious, and morning symptoms specifically are a stumper, as unexplained as joints that ache before a storm. It’s just something IBP does.

But don’t panic! Although studies have confirmed that morning is a common time for inflammatory back pain to flare up, they have also shown that the connection is not strong or exclusive.179 In fact, most morning stiffness and pain is not pathologically inflammatory. It’s just that IBP is the only “official” morning back pain culprit.

The pain of IBP tends to be quite severe. If it’s not actually waking you up, it’s probably not IBP, or it’s a minor case.

When should you consider the possibility of IBP? Basically if your morning back is particularly bad: nasty and very consistent morning symptoms. The diagnosis is also more likely if you have other signs of this kind of back pain. Here’s a good inflammatory back pain quiz, and here’s my own quick checklist of reasons to ask your doctor about spondyloarthritis:180

• signs of inflammation in other body parts, especially tendons (where they attach to bone), eyes, fingers or toes, colon
• a family history of spondyloarthritis (although it develops slowly, it’s a serious disease, so you’ll definitely know if someone in your family had it), or other autoimmmune diseases
• you respond fairly well to NSAIDs (Aspirin, Ibuprofen, etc)
• an infection in the weeks before your back trouble began

Technically IBP causes night back pain, not morning back pain

The morning pain of IBP is actually a case of leftover nighttime symptoms, which wear off as you wake up and get moving. When the symptoms are milder, you will mostly sleep through them, noticing them only when you wake up. But these symptoms will usually be obvious while you are still in bed, as soon as you are conscious — or even waking you up early.

In contrast, pain that you don’t notice until you actually get up and start trying to move around is less likely to be inflammatory in nature. But these are rules of thumb only, of course — there’s always lots of exceptions in biology.

PATIENT: Doctor, my back hurts when I wake up in the morning.

DOCTOR: Wake up in the afternoon then.

Doctors, do not actually trying giving this advice with patients! Joke (with visuals) via 9GAG with a hojillion likes and shares on Facebook.

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Myofascial pain syndrome and/or fibromyalgia

There are two common types of widespread moderate body pain, both somewhat mysterious and controversial, both known for affecting the back more than other areas, and both known for their morning hijinks:

1. Myofascial pain syndrome (MPS) is an infestation of too many “trigger points” — sore, aching patches of soft tissue that often seem to ease with massage and heat, but which are mostly unexplained and difficult to treat.
2. Fibromyalgia (FM), a disease of increased sensitivity generally and decreased pain threshold, fatigue and sleep disturbance, and the “fibro fog” (mental confusion).

There’s likely lots of overlap between these conditions. Fibromyalgia isn’t really an explanatory diagnosis; it just labels a common pattern of symptoms that probably have different causes in different people. MPS is a hypothetical problem with muscle tissue that is a possible explanation for some body pain, and that type of pain is extremely common in fibromyalgia patients.

Fibromyalgia is associated with morning back pain because:

1. People with FM rarely feel rested. The condition either causes or is caused by fragmented sleep and a lack of deep restorative sleep. Fatigue makes any pain worse, and this is probably felt mostly acutely in the morning, gradually (and imperfectly) yielding to the stimulations of the day: exercise, sunlight, coffee, people, noise and so on. The morning-ness of fibromyalgia pain could also just be “one of those things,” an unexplained rhythm of the disease.
2. Although FM involves widespread pain by definition, back pain is a routine hot spot.

And trigger points may be associated with morning back pain because:

1. Tissue stagnancy and postural stress seem to be a major cause of flare ups of pain of this kind, and both are an issue at night: we are often pretzeled into awkward positions in our sleep for long periods.
2. The paraspinal muscles seem to be particularly vulnerable to trigger points. Whatever they are, they happen more in those muscles (and a few others).

The tendency of FM and MPS to affect the back in particular might be because they each affect it in their own special nasty way, or it could be two sides of the same coin. Perhaps fibromyalgia affects the back more than other areas because it causes vulnerability to trigger point … which seem to occur in the back muscles much more than other muscles.

Fibromyalgia and MPS both exist on a wide spectrum of severity. Fibromyalgia’s diagnostic criteria are notoriously tricky.182 MPS is barely even recognized as a clinical entity. Many people may have mild cases that will never be diagnosed, but morning back pain may be the tip of that iceberg — the most likely time and place for the symptoms to be felt, even if you are otherwise mostly fine.

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Chronic low-grade inflammation and “inflammaging”

Everyone over 40 knows that it gets more uncomfortable to get out of bed as we age. Most people chalk it up to “arthritis,” but that’s rarely a significant factor until much later in life. Conditions like fibromyalgia and myofascial pain syndrome, as common as they are, can’t account for all of it. So what’s the problem?

A little bit of inflammation spread all over the place is a likely culprit. This might happen as a consequence of “metabolic syndrome,” a set of biological dysfunctions strongly linked to poor fitness, obesity, and aging, and possibly linked to severe chronic stress as well.183

And aging itself seems to be inflammatory (no matter how fit, skinny, and calm you are), which is known as “inflammaging.”184 So, if you’re on the far side of middle age, or you’re younger but struggling with your weight and/or major long-term stress, chronic inflammation could be your issue.

Connecting inflammaging to the curse of morning back pain

This inflammaging thing is intriguing, but does it have anything to do with morning pain or back pain specifically?

The morning link isn’t much of a reach: for whatever reason, inflammatory diseases are notoriously morning-o-centric (like the more serious inflammatory back pain mentioned above), and so it’s reasonable to assume that less serious inflammation has a thing for the morning too. We also know — only just recently — that the body can suppress inflammation at night, pumping out an anti-inflammatory protein on a schedule,185 which probably accounts for some morning pain and stiffness as the suppression wears off. No one knows anything about how to actually control that effect, but at least we know it exists.

The back link is trickier. Being overweight is less of a risk factor for back pain than most people think, so there’s no obvious association with metabolic syndrome. If there is a connection, it might be that the spinal joints are among the first structures to be affected by inflammation — and not necessarily because they are more fragile or harder working than, say, knees, but perhaps because the brain seems to be quite over-protective about the back, and more likely to raise the alarm sooner, louder, and longer.

Also, we do know that metabolic syndrome is associated with at least some common pain problems, like neck pain.186

It could also just be simple overlap: maybe these problems often just all happen at once. Inflammaging gets to everyone sooner or later, and back pain is spectacularly common, so they probably co-exist in the same people whether they have anything to do with each other or not.

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Poor quality sleep and insomnia are probably major causes of morning back pain

Don’t get me wrong: some people sleep just fine and still have morning back pain. But poor quality sleep and pain tend definitely tend to go together,187 and mornings can be the roughest part of that link.

The more interesting question is the chicken/egg thing: which comes first? Pain or sleeplessness? Once you have both insomnia and pain, they surely cause each other, but one side of that equation is probably more important than the other, like a cyclist pushing much harder on one pedal than the other.

In 2017, Gerhart et al studied the which-came-first question of pain and insomnia in 105 chronic low back pain patients.188 Their subjects bravely filled out five detailed questionnaires per day for two weeks — that’s a lot of paperwork! — tracking and rating many aspects of their pain and sleep quality. The goal was to study “lagged temporal associations”: what tends to happen after what? Are bad sleeps often followed by bad days with back pain? Are rough days with back pain followed by lousy sleeps?

Yes and no to those two questions.

Poorer sleep was strongly linked to everything being worse — which is about as surprising as a dog barking at a squirrel. It’s the timing of that relationship that this study zoomed in on, and not only did a bad night clearly herald trouble across the board the next day — more pain, more disability, more doom and gloom (“catastrophizing”) — but “especially during the early part of the day.”

The relationship did not flow the other way. That is, bad nights were likely to be followed by bad days… but bad days were not followed by bad nights. The data shines a nice bright light on a simple old question. The answer isn’t much of a shock to anyone who struggles with both back pain and insomnia, but it’s important and rare to confirm this stuff with a good study.

And it gives us a compelling incentive for focussing on sleep quality as a major factor in pain generally, especially morning back pain. And almost everyone can benefit in many ways from upgrading their sleep quality. To drive that home, let’s take a closer look at the biology…

Inflammation, sleep, stress, and pain

The link between sleep and pain is based on some superficially simple inflammatory biology: bad sleep is inflammatory… and inflammation makes it harder to sleep, which is not widely appreciated. That means that sleeping badly can actually make it harder to sleep well!189 This is a vicious cycle every extremely frustrated insomniac is familiar with: being exhausted from a sleepless is not a guarantee that you will sleep well the next night.

And that vicious cycle is relevant to night and morning pain, which is known to be significantly mediated by the immune system signalling molecule interleukin-6. IL-6 and inflammation are almost synonymous — more of one means more of the other. Everyone knows that stress makes it harder to sleep, but how? It’s not just because your mind is racing — it’s because stress makes us produce IL-6, which is inflammatory, and inflammation in turn makes it harder to sleep! And then the bad sleep also makes us pump more IL-6…

And that’s why it’s important to get your sleep!

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Osteomalacia (Vitamin D deficiency)

Vitamin D deficiency is probably more common than once suspected — at least 1 in 20 people in the lowest estimates,190 and possibly many more.191 Vitamin D deficiency can cause subtle widespread pain that may be misdiagnosed as fibromyalgia and/or chronic fatigue syndrome. Most notably for the purposes of this article, it can cause bone aching, particularly in the back, that is worse at night (for no clear reason). Naturally, any night pain that doesn’t actually wake you up is often noticed upon waking.

This symptom is caused by osteomalacia, which is bone weakening from malfunctioning bone building biology. The Mayo Clinic describes osteomalacia symptoms like so: “The dull, aching pain associated with osteomalacia most commonly affects the lower back, pelvis, hips, legs and ribs. The pain may be worse at night, or when you’re putting weight on affected bones.”

Other symptoms of vitamin D deficiency include: fatigue and weakness, lower pain threshold, and more acute soreness after exercise that is slower to resolve, sweating, and depression. For more information, see Vitamin D for Pain.

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Awkward sleep postures

In 2015, Steffens et al found that most “back attacks” — episodes of acute back pain — occur in the first few hours of the day.192 They also identified an “awkward posture” in the two hours preceeding the attack as the second biggest risk factor (after “distracted during an activity”). Although their study wasn’t perfect, the results were too strong not to take seriously. Notably, just an “awkard posture” was quite a bit more likely to be associated with acute back pain than much more traditional bogeymen like difficult or sloppy lifting.

Based on this evidence alone, we can guess that morning back pain might be so common because sleeping is a rich source of awkward postures. In people with chronic back pain especially, it may be a routine source of minor irritation of their ongoing problems.

Awkward positions can be quite painful, even injurious. Sleeping often involves slightly awkward positions held long enough to cause sustained compression, pinching, and oxygen starvation of tissues (which may or may not have been vulnerable or irritated to begin with). The dose makes the poison: it doesn’t have to be a terrible spine position to cause trouble. Just a little awkwardness will do the job if you’re stuck that way for long enough. Although people can also carelessly tolerate postural stresses while wide awake — we generally move before they become a problem — it’s much more of a risk at night.

Sooner or later, any posture gets awkward — the trouble with tissue stagnacy regardless of position

Being still always gets uncomfortable, regardless of what position we’re in. We like to move, and sitting or lying down always gets uncomfortable in time. Forced immobilization is a potent torture method. Working in stagnant postures — like sitting in at a desk, no matter how well we do it — can start to feel more like a kind of torture as we age.193

Sleeping is an obvious potential source of tissue stagnancy, of course, but beds are more comfortable than chairs in every way, physically and psychologically. Healthy young people are relatively immune to simply being still in bed, but as we age and develop assorted vulnerabilities and sensitivities — things like fibromyalgia, myofascial pain syndrome, and chronic inflammation — it starts to become a problem.

Trigger points may be aggravated by stillness, for instance.194 Morning pain could be a wake-up call (ha ha), letting you know that you have a bumper crop of mostly asymptomatic (“latent”) trigger points that flare up overnight. In Lita’s case, trigger points could account for the consistency of her symptom timing, and for the peculiar way in which she is fine at 6am, yet can’t stay in bed past 7am, but then is fine again by 8am as she gets moving and her trigger points calm down.

Minor injury (or re-injury)

We may also cause minor injuries in our sleep, or aggravate existing minor injuries and vulnerabilities (like chronic minor back pain). Sometimes you just roll over and pinch something hard enough and quickly enough to hurt it — maybe not even enough to wake you up, but enough to feel the consequences when you do wake up. Usually this is going to be an isolated incident, but what if you keep pissing off the same vulnerable tissue?

For instance, suppose you already have minor intermittent back pain related to an old accident: it’s bothered you for years, off and on, and you’ve learned that leaning backwards is usually bad news. But then you do it in the middle of the night in your sleep, an extended lumbar spine for an hour when you weren’t even conscious — no fair! And so you wake up in moderate pain.

In other words, whatever is bothering your back in the first place can be easily and routinely aggravated — re-injured — by common sleeping positions.

I have no personal experience with back pain like this, but I know exactly what this is like from trying to sleep with a shoulder injury.195

Such incidents won’t explain all chronic, consistent morning back pain, because you’re unlikely to slightly but frequently re-injure yourself in the same way. Or maybe it’s not so unlikely: if bending your spine one way or the other is a problem, it might be easily avoided during the day, but happen to some degree most nights. Again, it’s the duration that’s the issue.

There’s much more reading you can can on PainScience.com about this topic. This book also has a chapter about “alignment” as a factor back pain, another about ergonomics, and another about optimization of sleeping posture (positioning, mattresses, pillows, and so on). And if you simply cannot get enough about posture, there also a large (free) separate article about posture in general.

Are there psychological factors that drive morning pain?

Probably not. The book Back Sense proposes that morning back pain is caused by “stressful night-time mental patterns manifesting as back pain.” I do not dismiss the role of psychology in back pain — quite the opposite! it’s a major theme in my writing about back pain.

But I think that author is indulging in a simplistic mind-body connection theory. I’ve written crankily about this kind of logic elsewhere (see Why Do We Get Sick? or Mind Over Pain). It’s a bit of a reach to say that you have such a problematic, pain-causing mental state like clockwork every morning between 6am and 7am exclusively. Applying How to Simplify Chronic Pain Puzzles to the problem, it is much (much!) more likely that there is simply a time limit on how long you can lie in bed without tissue crankiness.

What about nocturnal intervertebral disc swelling?

This is one of the classic theories about why people seem to be more vulnerable to back pain in the morning. Unfortunately, it’s too speculative to be really satisfying. But what’s the speculation?

Between every pair of vertebrae is a bit of padding, the infamous disc. They probably swell up a wee bit overnight. There are two studies that suggest this196197 (although one of them was a study of long term bed rest, and only barely applicable here). A 2016 paper speculates that disc swelling is why astronauts probably suffer from more disc herniations than they should.198 Weightlessness is undoubtedly like resting your spine, but it’s another long-term effect, so I’m not sure how relevant the astronaut angle is — it’s just a fun angle on the topic.

Discs may swell, but that doesn’t mean swelling discs hurt. Mild swelling is hardly a concern in itself, and most people don’t wake up in pain, so it’s unlikely that swelling alone is a problem. Swollen discs may hurt more in the morning if there’s already something wrong with them, such as annular tears,199 but such discs might well be uncomfortable regardless. Mildly herniated discs might swell and effectively be more herniated in the morning — but many herniations are painless, so that’s hardly a smoking gun.

It’s an interesting possibility that nocturnal disc swelling is a factor in morning back pain, but the truth is beyond our reach. For all we know, problems with discs might be much more aggravated by postural stress … or it could be a complicated combination, such as swelling that is exaggerated by postural stress but still only hurting when other problems are present.

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My big idea about the role of "simple" muscle pain in back pain coexists and competes with dozens of other theories and possible causes of persistent low back pain. Therapy is a minefield of irrational diagnoses and treatments. Patients with back pain are invariably walking around with a long list of half-baked theories in their heads about why they are in pain, worrying about other problems and complicating factors that are either mythological or wildly exaggerated: subluxations, short legs and tilted pelvises, obesity, nerve pinches, weak abdominal muscles and many others.

One of the most important things I can offer my readers is a guide to this messy list of dubious or exaggerated theories. Most chronic low back pain patients are sick and tired of the “battle of the experts,” of the many conflicting theories which cannot possibly all be correct. Nothing defines a case of “low back muscle pain” quite like the merry-go-round of theories and the treatments based on them that work only for a little while, if at all.

Almost every bad diagnosis for low back pain is a variation on the theme of fragility that isn’t so much wrong as just exaggerated. For instance, nerve impingement is a real phenomenon, but a lot less important (and scary) one than patients have been led to believe. Most people who protest that their back pain is really serious and can’t possibly be caused by “just muscle” are simply wrong. A few are correct, of course. But only a few.

The trigger points of MPS often do coexist with other problems. Indeed, they are often present because of other problems. What makes muscle such an common underestimated factor is that it complicates and mimics other problems, often even eclipsing them. It doesn’t matter what you’ve got going on, muscle is going to get involved and make it worse. So the presence of other problems, if they are there at all, means that it may be even more useful to treat your trigger points — not because they are the whole story or the "root cause" or the Big Secret to back pain, but simply because they are often the only relatively treatable part of the equation.

I’ve now worked hard to persuade you that many alleged causes for low back pain are either entirely imaginary, highly exaggerated, hard to be sure of, and/or greatly overshadowed by the more treatable and surprisingly potent discomfort of muscular trigger points.

However, I don’t want to throw the baby out with the bath water.

Disease and injury happen, sometimes they happen in the back. Hopefully they are in perspective now and it’s safer to talk about some of them. So what can happen in low backs? What goes on that’s not “just muscle”? Over the next several sections, I will address many other possible common ideas about what causes of low back pain, covering all kinds of theories: the completely bogus, the half-right, and the cromulent.

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When people have a sudden onset of back pain, especially during any kind of exertion, there are two classic knee-jerk interpretations:

• Must have slipped a disc.
• Must have strained a muscle.

But you can only have a muscle “strain” if you tried to lift something like a car and then fell to the ground howling in agony. I exaggerate, but not much. Muscles don’t tear easily.

Of course some people really do strain their back muscles. But the belief is far more common the reality. There cannot be much more than one genuine example out of a hundred claims of strain. The idea that "pulling" a muscle can explain lots of cases even when you don’t even know exactly how you supposedly did it is a misconception so common that it borders on myth.

A true strain is never subtle. It’s a trauma, and a nasty one: it involves ripped, shredded, torn muscle. That hurts a lot. It takes a lot of force to tear a muscle, and it’s a brutal experience. I’m fascinated and a little bewildered when people are married to a theory of muscle strain, but also say things like, “I’m not sure when I did it, though.” That’s like saying, “I’m not sure when I broke my leg,” or even “I’m not sure how I stubbed my toe.”

You cannot sprain ligaments or strain muscle without an obvious trigger followed by a Very Bad Day. A back muscle strain will flatten you, immediately, with absolutely no doubt about the exact moment that it occurred.

Muscle strain can occur only in the context of an intense muscular effort, and it causes severe pain immediately, almost instantly. (Mild strains may take a minute or two to become obvious.) Torn muscle will be red, hot, and swollen, and possibly bruised. Every slight contraction of the muscle will hurt, even just slight tension of the back muscles. A severe enough strain will cause some actual deformity — an obviously deformed (ripped) patch of muscle, extremely sensitive to touch in the early stages.

Muscle strain is difficult to diagnose only if it coexists with other injuries. For instance, it’s not uncommon for discs to herniate at the same time that a muscle tears, and in that awful situation you may have symptoms of two quite different tissue problems — each of them making the other less clear.

Another challenge to diagnosis is that muscle strains, even mild ones, often merge seamlessly into chronic muscle pain … long after the injury has actually healed.

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If injury is the frying pan, trigger points are the fire.

Muscle pain is a routine complication of most injuries, especially in the form of trigger points. In the aftermath of an injury, the pain and stiffness of trigger points often increases rapidly, and may become so severe that the original injury becomes the least of your worries. Muscle pain is more than just a “complication” of injury — it is a common, significant long-term consequence of physical traumas.

This graph shows how trigger point pain increases & then dominates, even as injury pain is fading away.

This is all particularly true of back and neck pain, where minor and moderate injuries are common and generally feared out of proportion to their seriousness. (And it’s also a factor in serious injuries, of course.) Chronic symptoms following these injuries are often mistaken for an indicator of how serious they were to begin with.

Many factors conspire to make back and neck pain seem more serious than they are, and this is one of the most important. Although chronic muscle pain triggered by an injury is no laughing matter, there is no question that it makes injuries seem worse than they actually are. Trigger points as a complication of injury are explored in detail in the trigger points tutorial, and in this free article:

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A perpetually popular idea about how pain works is that muscles go into spasm after an injury to protect the area. The alleged spasm in turn causes more pain, and then the pain causes more spasm — a vicious cycle. This is referred to as the pain-spasm-pain cycle. Unfortunately, this story is mostly an obsolete oversimplification. Although muscles can indeed complicate recovery from injury, it’s probably not due to a vicious cycle of protective muscle spasming becoming painful.

Contrary to popular professional opinion, it has been scientifically clear for decades that muscles do not “go into spasm” to protect an injured joint. Au contraire: they often go limp to protect nearby tissues.200201 The problem with pain-spasm-pain is particularly obvious in the case of a torn or “pulled” muscle — which is certainly one of the usual suspects in the back, and exactly the clinical situation where a patient is most likely to get told that. But if the muscle is actually torn, how smart would it be for the body to clench it? It would be foolish, actually — it would deepen the wound! In fact, the severe pain of a muscle strain strongly inhibits contraction of the damaged muscle.

If gross spasm was a player in low back pain, it would also presumably make it relatively easy for experienced massage therapists to feel it — but evidence discussed earlier (in "Diagnose, schmiagnose!") showed that detection accuracy is quite poor, even when just trying to identify which side is most painful.202

Odds are still good that you will hear about the pain-spasm-pain cycle if you take an injury to any kind of physical therapist today. However, the low back is the most fertile ground for the theory — the idea that the spine even needs “protecting” with spasm in the first place harmonizes nicely with our deep-seated fears of spinal fragility. And so the pain-spasm-pain is yet another in a long list of ideas about back pain that need to be debunked and discarded.

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Yes! But probably not. Maybe?

It’s weirdly ambiguous.

Some back pain probably does begin as an overuse or repetitive strain injury, but it’s almost a perfect mystery how common it is. It rarely seems much like it, and it may also not actually be much like it — or the seeming may just be because the back is a lot more complicated than a single fiery tendon. Even if gradual overloading is the original mechanism of injury, it may then get warped by all kind of weird back business that no Achilles tendon ever has to worry about. Once such an injury starts to hurt, it is may be hijacked by the peculiar character of back pain such that it doesn’t seem to resemble classic overuse injuries.

And some backs probably can also just become slowly but surely more irritated by an activity, and seem just as straightforward as other familiar overuse injuries do: “I did something for a long time until my back hurt,” much like playing tennis leads to tennis elbow. Consider:

• The gardener, who stoops and kneels until her back catches fire — and then cannot comfortably garden again for weeks.
• Or the nurse who must lift and move patients, awkwardly and often at the limits of his strength, whether rested or not, until the pain becomes overwhelming.
• The cashier whose relentless standing slowly but surely seems to make her back hurt more and more over the years, until — boiling frog style — one day he's in enough pain that getting off his feet no longer seems to help.

Cases like these are common and seem to be a great deal like overuse injuries in overall character.

Some quick review of overuse injury basics

Overuse or repetitive strain injuries are the end result of many small injuries over time instead of a more dramatic and sudden tissue failure. Achilles tendinitis, tennis elbow, plantar fasciitis, and iliotibial band syndrome are all classic examples. More technically, these injuries all involve the relatively gradual and progressively painful failure of anatomy to adapt to load, especially tendons but also (and often overlooked) ligament, bone, and other tissues.

Exactly what fails and how it goes depends on many details, so there is a spectrum of overuse injuries ranging from quite straightforward to complex and weird. For instance, carpal tunnel syndrome is pretty clearly an overuse injury, but the only major example of one that mainly does its dirty work by affecting a nerve — and so it has many differences from a typical overuse injury.

If back pain is ever caused by overuse, it is surely at weird end extreme of that complexity spectrum — so much so that it’s often not at all obvious what's going on.

Weak points and durability: why overuse injury of the back might be rare-ish

Spines are tougher than we give them credit for — a major theme of this book. And so they may not be much of a "weak point." They are highly modular, and load is well distributed across many redundant structures, a system that is highly evolved to "take a licking and keep on ticking." It probably doesn't injures easily with repeated mild to moderate loading. It seems hard to hurt without major trauma.

All the classic overuse injuries occur in some fairly well-known vulnerable spots in human anatomy. If you’re doing something strenuous, it’s probably going to be the inflammation or irritation of one of these weak spots that stops you first. For instance, a construction worker might be (speculating) quite a lot more likely to get stopped by carpal tunnel syndrome before their back becomes a big problem.

There are no structures in the low back that seem to be obviously vulnerable to failure with common overuse. If there were, we would see a clear pattern of injury in athletes with highly repetitive and high-impact forces on the back: endurance runners would presumably be dropping like flies from low back pain, but they don’t. In those folks, it’s almost always their feet, shins, or knees.

Of all back structures, the intervertebral discs have always been considered the least adaptable and therefore the most prone to succumbing to wear and tear in jarring spots. But that’s wrong! That is not what happens. Contrary to expert assumptions and popular belief for decades, the lumbar intervertebral discs actually adapt nicely to the forces involved in running, even at volumes greater than 50km/week — “overuse” by most people’s standards. They actually get fatter and juicier! There is a sweet spot, but it’s in the pacing: almost regardless of distance, the discs adapt best to a moderate speed, a just-right amount of impact found in slow running and fast walking.203

Meanwhile, there is one population of athletes that does tend to suffer from overuse injuries of the spine, and they might be an exception that proves the rule: serious power lifters. They do have to watch out for overloading injuries, in exactly the way that you would expect from such intense compressive forces on anatomy that did not evolve for that activity. The spine is robust, sure, but good grief! I’m not saying power lifting is "dangerous," it’s not — but it’s an example of a kind of back pain that does happen, and does seem like an overuse injury… unlike most other kinds of back pain.

All of this points away from chronic overload as a common cause of back pain.

For these reasons, I spent much of my early career thinking that overload was rarely the nature of the beast in most cases where it isn't obviously the nature of the beast — the legions of people with no obvious mechanism at all for their back pain, which is by far the most common flavour of chronic back pain.

On the other hand: maybe there are a bunch of overuse injuries of the back after all?

An overuse injury doesn't have to be obvious or clear to be true, and we should probably expect it to be non-obvious and unclear in the case of . The same modularity and complexity that makes the spine quite robust may just mean that, when it fails, it does it messily compared to, say, a case of tennis elbow.

I enjoy poking holes in my own arguments. It’s kind of a hobby. Why would I say that overuse injury of the back is unlikely because the "classic" overuse injuries are simple? Ridiculous! What kind of dumdum am I? Because clearly there are some non-classic ones that are not simple! They don’t all happen to the relatively obvious, single-point-of-failure "weak spots".

For instance, bone fatigue and stress fractures are routinely overlooked in the pelvis and upper femur, despite the fact that they are rather obvious examples of overuse injuries (obvious once you know, anyway). Part of the reason that these injuries are often not diagnosed is that the pelvis is such an anatomical maze that there are lots of variations in exactly how it can fail.

Much like a spine might fail.

All tissue will fail under load: that's just biological law. It’s just a question of how much and what exactly gives up the ghost first, which is why we don’t hear about a lot of overuse injuries of the nose. But make no mistake: just because noses usually aren't subjected to repetitive strain doesn't mean it isn't possible. The question here is: are backs like noses, only theoretically vulnerable to overuse, and rarely in practice? Or are they more like pelvises: definitely vulnerable, but poorly understood?

What if the first tissue to "fail" was muscle? One of the major ideas in this book is that muscle pain can explain a lot of back pain that would otherwise be rather tricky to explain. And there is a hypothesis — just a hypothesis, but a cromulent hypothesis — is that trigger points are basically overuse injury of muscle, and intermediate and uncomfortable state between "fine" and actually tearing muscle, highly analogous to what happens to what's going on in bone before a stress fracture.

It seems highly plausible to me that in the very robust and modular spine, with no specific structure all that vulnerable to structural failure, that muscle might very frequently be the (trigger) point of failure, the weak link.

Or we could be much more conventional and make this imminently reasonable guess: overuse injuries of the spine put a strain on many anatomical structures to varying degrees, with diffuse and complex results, creating discomfort that is literally impossible to blame on a single source, because there is no single source — unlike most repetitive strain injuries, but definitely an RSI in principle.

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What most people know about “discs” in their spine is that they “herniate” or slip. And it’s true — they do herniate and “slip”! Actual slippage not included — it’s just a figure of speech, and a somewhat problematic one.

And when they do herniate, they certainly can hurt, causing many symptoms.

However, disc herniations were introduced above as an over-diagnosed problem that is feared out of all proportion to its real seriousness. As you learned above, disc herniations may or may not actually be present or be the problem. They may be as trivial as a hangnail, or even painless. Even severe herniations, obvious on an MRI, may lack symptoms in some cases, and a surprising number of herniations are known to quickly resolve on their own with no treatment at all.

All of that was established above (references up the wazoo). Now that we’ve reviewed it, I still want to re-visit the topic in a different context: what if you do have a herniated disc, and it really is a problem? It’s not like they don’t exist or never hurt! They are clearly a factor in some back pain.

Click to embiggen. All the main kinds of trouble that intervertebral discs can get into. Mostly less of a problem than people fear… but not nothing either! The images are slightly exaggerated for dramatic effect & it’s “scary” to show them… but these are things that really do happen to intervertebral discs.The good news? It looks worse than it usually is & there are many surprising reassurances.

The lumbar spine is more vulnerable to herniations for the relatively obvious reason that they are at the bottom of a stack of vertebrae. The greater the weight on them, the more likely discs are to herniate under the pressure.

If a disc bulges or bursts enough, and in the right direction, it can give a hard physical pinch to the lumbar nerve roots, causing pain and altered sensation and function throughout the pelvis and legs. And/or the disc may actually burst, spilling out a gelatinous substance like a crushed jelly doughnut — this shock-absorbing gel, when spilled into the tissues around the joint, can cause severe, deep pain. Although it’s rare, it certainly occurs, and it is one of the best examples of low back pain that is definitely not primarily caused by trigger points! There is no question that having disc jelly sprayed on your nerve roots is usually very unpleasant.

In one of the worst-case scenarios, the bulging disc pinches the entire tail end of the spinal column, causing extremely alarming symptoms such as incontinence. That is as bad as it sounds: these are medical emergencies, and no one is likely to mistake them for anything else (although, as with all things medical, the variety in the obviousness of the symptoms is startling).

The most important thing for patients to understand about disc herniations is that they clearly have the capacity to heal — and much better than most people would ever guess is possible.204 If you do clearly have a disc herniation, it should change surprisingly little about your approach to the problem.

The greater danger may not be the herniation itself, but the risk that it will soon be overshadowed by a nasty case of chronic muscle pain.

Healing of the herniation might also be retarded by a failure to address general tissue health in the region. While many herniations manage to heal with no help, it’s possible and reasonable that some cases might not heal well or quickly without appropriate treatment. In particular, supporting muscle tissue health may make a difference. There is no way to push a bulging disc back into place. But since we know they often go back into place on their own, there may well be ways to encourage them. Muscle tissue health is a potentially relevant part of the equation you can work with.

So although persistent symptoms of a disc herniation may be cause to try surgery, it’s extremely important to consider the options presented in this tutorial first, because even an old and unhealed disc herniation has the potential to finally resolve.

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Bracketing each pair of vertebrae are a pair of dime-sized (they are always described as “dime-sized”) joints called facet joints. These are typical slippery joints: lubricated cartilaginous surfaces, contained within a capsule. These are the joints that pop, like knuckles do, in the spine. Any of these joints can become dysfunctional, “stuck,” irritated, injured, and/or arthritically degenerated. One common pain scenario is probably a minor insult to a facet joint — sort of like a toe stub, but in your low back. When you consider how painful a toe stub can be — without doing any real damage — it’s easy to appreciate how people might over-react to the same amount of pain in the low back.

This is one example of what we call minor intervertebral derangement (MID) — a slight, uncomfortable failure of facet joint mechanics.205206 By definition, MIDs are minor, and on their own they shouldn’t cause more than a few days of pain at the worst — like recovering from a bad toe stub. However, MIDs are probably routinely complicated by fear of low back pain and the flare-up of vulnerable latent trigger points in the vicinity. In this way, many an MID may be the “cause” — the precipitating factor — of a more serious acute episode of low back pain.

Is there such a thing as a major intervertebral derangement? Almost certainly — but we would just call it an injury! The vast majority of toe stubs are harmless, but of course sometimes people actually break their toes. Similarly, if it’s common to slightly strain a facet joint, it’s also possible to more severely damage it — possibly even to the point it’s difficult to calm it down. But we would just call that a facet joint sprain. The joint surfaces might be slammed together (a “compression” sprain), and/or the connective tissue (ligaments) holding the joint together may be torn, like a tiny ankle sprain in your back. If you’ve ever had an ankle sprain, then you know how long it can take to heal.

Like muscle strains, however, genuine facet joint injury is not common, and it tends to be obvious when it occurs: a sudden, severe pain in a particular spot and associated with intense movement or impact. Hard to miss that moment! (People with facet joint injuries usually don’t have the “I can’t figure out what I did wrong” problem.) Such an injury also tends to produce pain that can be provoked — every damned time — by a specific movement. Trigger points might simulate this to some degree, but facet joint injuries are really good at it: if the joint surfaces are bruised, for instance, then they are going to hurt every single time you twist or bend the spine in such a way that they are pressed together. Every. Time. Trigger points, by comparison, rarely cause such a clear pain-movement connection.

Now that we’ve discussed most (not all) of the common, “legitimate” causes of back pain, I want to remind you again to keep them in perspective. Maybe one of these little nasties is a part of your clinical picture, and maybe it’s not. We’ve already established that it’s extremely hard to be sure. Be skeptical of any professionals who seem overconfident about your diagnosis. And bear in mind that all of these problems can interact in devious ways with trigger points, complicating diagnosis and treatment. If you have a nasty little facet joint sprain, for instance, it would hardly be surprising if, six weeks down the road, trigger points in the region started to become more of a problem than the sprain (which slowly heals). So even though you really are (or were) “injured,” remember to consider the role of muscle pain.

For the next several sections, I’ll put on my skeptic’s hat and seriously criticize some other alleged causes of low back pain that don’t make much sense or are chronically over-rated — and yet remain popular and widespread!

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One possible source of back pain is the knuckle-like facet joints, as discussed above. In a sense it doesn’t even matter what, exactly, might be going wrong with a facet joint — not if you can numb the whole thing, turning off all sensation like flicking a light switch. Facet joints are specific anatomical structures with clear “edges,” much clearer than other tissues like muscle,207 so they have become the target of several minimally invasive diagnostic and treatment procedures that aim to temporarily or permanently silence any pain noise coming from them:

• injections of various pain-relieving substances into the joint itself
• nerve blocks which temporarily cut off sensation in the whole structure
• destroying those same nerves

Note that everything here applies strongly to diagnosing sacroiliac joint dysfunction as well.

These procedures are all provided by medical specialists, most likely either a physiatrist or an orthopedic surgeon. Do they work? Are they safe?

Nerve blocks as a diagnostic tool

Here’s an interesting (if somewhat drastic) way to find out if a facet joint is the wellspring of spinal pain: cut off the nerve supply to the facet joint! If your pain stops, voila: presumably that’s where the pain was coming from.

This is called a “medial branch block” (MBB), or just “nerve block.” The medial branch nerves are the wee nerves that send information to the brain about tissue condition in the facet joints.208 Without those nerves, the facet joint reports nothing to the brain, and so the brain assumes all is well — a nearly perfect numbing. It’s the same as getting part of your mouth “frozen” at the dentist.

Thus, if an MBB relieves pain, “well there’s your problem.” That provides some diagnostic confidence that the facet joint is the cause of the pain.

But it’s not exactly foolproof. This practice is supported as a diagnostic tool only by scanty, conflicting scientific evidence. Some authors call it “fair” evidence, but probably shouldn’t have.209 The evidence is similar for the thoracic210 and lumbar211 spine.

Nerve blocks as a flawed diagnostic tool

Many other factors tend to confuse this method of diagnosis, which is probably why it hasn’t been validated by research. For example:

• What if 60% of your pain is coming from one facet joint, 20% from another, and 10% from a third? And only one of them gets blocked? What if something else entirely is also causing pain?
• What if the injection just misses? It can be difficult to be accurate with these injections. It takes skill!
• What if the anaesthetic “leaks” into surrounding tissues and numbs the wrong thing?

It gets murkier: the amount of relief low back pain patients get from facet joint injections can be predicted by psychological factors.212 Why would that be? Numbing might provide strong enough temporary relief to create an overconfident “eureka!” And that confidence might itself deliver some pain relief, further clouding the issue, and adding up to a false positive: a misleading result that puts a spotlight on the facet joint that is actually innocent, or only part of the problem. Fortunately, the evidence suggests that this kind of confusion is probably rare, and clear relief probably means what it seems to mean.

All this complexity is also why “the effectiveness of a specific treatment cannot simply be reverse engineered to conclude what caused the pain.”213 So MBB results should be considered as a diagnostic tool for stubborn neck or back pain, but nothing is ever as simple as it seems.

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In the winter of 2015, I went through a phase of back pain where a joint in my upper lumbar spine felt jammed: like a neck crick in my back. Every time I turned to the right, it felt like trying to close a door with something hard stuck in it. Thunk/ow. I had the vivid sensory impression that the joint was out of place.

Specifically, I have the vivid sensory impression that the joint was rotated, which is odd, because it’s anatomically impossible for lumbar joints to “rotate.” They just can’t do it. They are clearly structured to allow bending forward and backward, plus a little bit of side-bending, but intervertebral rotation just isn’t in the cards.

When a spinal joint feels out of place or jammed, there may indeed be some kind of joint dysfunction. But one fascinating, plausible possibility is that the sensation of “out-ness” may be where the explanatory buck stops: that is, maybe the joint just feels wonky. Pain distorts body image — our mental image of our own anatomy. An odd little 2008 paper demonstrated that people with back pain really feel like their vertebrae are deviated to the painful side even when they aren’t.214

It’s a straightforward idea, so simple it probably isn’t satisfying, but this phenomenon could be potent and persuasive. We are used to more or less trusting our sensations. If it feels out, we assume it must be out. But it ain’t necessarily so: sensation can be incredibly deceptive. This could be the main reason spinal joints ever feel this way. (Its illusory quality doesn’t make it any less of a problem, of course: there’s still something wrong that’s powering the illusion.)

Or maybe that joint really is out of whack in some sense. Let’s deal with that directly now: what about more literal, non-illusory subluxations?

•

Spinal joints can get into a few different types of trouble, but “subluxation” and spinal joints being “out” are not defined clearly enough to be useful, and are quite misleading.

“Subluxation” is mainly a chiropractic idea of some kind of spinal joint dysfunction, with many shades of meaning — too many — depending on who is talking about it. However, it is inextricably entangled with the idea of a spinal joint being “out” of place, and it is this sense of the word that needs some debunking. Many chiropractors attribute great importance to subluxation. Most believe, at the least, that subluxations cause neck and back pain, but — significantly — quite a few of them also believe that subluxations cause a wide variety of other health problems and so they “use spinal manipulation to treat visceral disease” (Homola). Subluxation theory has been both popular and controversial for many decades now, and it has never achieved medical respectability. Many experts, including quite a few chiropractors, deny that spinal subluxations exist in any meaningful sense.

It’s problematic that spinal manipulative therapy — the umbrella term for all kinds of spinal joint “adjustment” — is so often based on such a confusing and controversial concept. Subluxation has too much baggage to be a useful term. Let’s use more modern and specific terminology, and get away from the idea of spinal joints being “out.”

The controversies about subluxation theory are described thoroughly in this article:

But I’ll include one particularly important and interesting point here. As I mentioned in the introduction, chiropractors have trouble agreeing on a diagnosis of which spinal joints need “adjustment.” I do enjoy reliability studies, and this is one of my favourites. Three chiropractors were given twenty patients with chronic low back pain to assess, using a complete range of common chiropractic diagnostic techniques, the works. Incredibly, assessing only a handful of lumbar joints, the chiropractors agreed which joints needed adjustment only about a quarter of the time (just barely better than guessing). That’s an oversimplification, but true in spirit: they couldn’t agree on much, and researchers concluded that all of these chiropractic diagnostic procedures “should not be seen … to provide reliable information concerning where to direct a manipulative procedure.”215

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The sacroiliac joint (or SI joint or SIJ) is the large, sturdy joint on either side of the triangular sacrum. The sacrum sits in the pelvic like a keystone at the top of a stone arch — it’s even the same shape. The SIJs connect the pelvic bones (the ilium specifically) to the sacrum, and support the weight of the whole upper body.

The SIJ is more like a seam than a joint. It is a synovial joint, which means it’s in a capsule and has slimy cartilaginous surfaces just like a hip or knee joint, but almost everything else about it is strange: two large, irregular surfaces that remind me of the two halves of an oyster coming together.

It also only moves about as much as an oyster . It does move, but only a couple millimetres of sliding and a couple degree of twisting.216 On the one hand, any functional movement has the potential to be uncomfortably messed up. On the other hand, people with fused SIJs suffer no obvious impairment (but might still be somewhat more vulnerable to arthritis in the adjacent joints).

Natural sacral joint fusions

Sometimes the sacrum is fused to the lowest lumbar vertebra: a lumbosacral transition vertebra. “LSTV is the most common congenital anomaly of the lumbosacral spine.” In about a thousand patients studied by Sekharappa et al, it was about twice as common in patients who had sought spinal surgery as it was in patients with no spinal complaint (about 14-16% of patients, instead of 8%).217 The study also identified a “definite causal relationship” with degeneration of the disc above the LSTV.

Fusion of the sacroiliac joint is closely related and even more common, as high as half the population by the age of 80, and freakishly more common in men than women for some reason, in 287 subjects studied by Dar et al.218

These joints — the lumbosacral, and the sacroiliac — are so sturdy and immobile that, in some people, they cross the line and develop into a solid block. Talk about a stiff back! Literally!

Angela’s story: “Like fine gravel or sand in my pelvis”

Angela Zaleski woke up one morning in her mid-forties, took a step, staggered, and sagged to the ground — surprised more than hurt, but unable to support her weight on her right leg. The trouble was in a very specific location, straight south of her low right back dimple, on the right edge of her tailbone. “It was like having a rock in my shoe — but instead of one rock in my shoe, but it was like fine gravel or sand in my pelvis. I couldn’t settle onto it. It didn’t hurt, but I could tell it was going to hurt if I wasn’t careful.”

It was out of the blue. She hadn’t hurt herself that she knew of, had never felt anything like this before, and didn’t have any experience with back pain.

She gingerly stood up on her left leg and started “basically just squirming and testing weight-bearing on my right”… and it felt like it calmed down and settled and started to allow weight within a couple minutes. It was like the joint had been temporarily screwed up. She thought that was probably the end of it, just one of those weird body things.

But it was back the next time she stood up from sitting for a while.

And it was back the next morning. And then all the mornings ever since.

She quickly learned that she could never be still for long without the problem “recharging.” But she also learned that it usually wasn’t a big deal — no one incident was hard to cope with. A little squirming and shifting around, and the joint would settle down and started working. She got used to the “crunchiness” of the joint. “I can pretty much just walk it off now. It’s still there, and the first few steps are a bit wobbly and careful, but it’s not that bad.”

Unfortunately, the discomfort spread. As the weeks dragged on and it didn’t go away, she began to ache all around the problem, but especially just above in the pit of the low back. That pain eventually ramped up to the point where it was more distressing than the grinding in her SIJ, which continued to be a constant minor annoyance. As of 2019, she’s been managing this for about two years, with no improvement. She seems to be able to substantially beat back her symptoms — the aching — with trigger point therapy, but the aching always come back … probably because the SIJ grinding never leaves.

It’s hard to account for an experience like this without concluding that her sacroiliac joint “might be screwed up somehow,” and probably in a hypermobile kind of way, but exactly how and why remains a mystery. Although I’ve encountered many similar stories over the years, hers is the direct inspiration for adding this chapter to the back pain book.

Is SIJ “dysfunction” a real thing?

Caution, reservation, and even skepticism should be exercised on the part of the surgeon attempting to diagnose (let alone treat) this condition. It is very difficult to invalidate a treatment for diseases that cannot be reliably diagnosed. Not surprisingly then, therapeutic options are varied, poorly objectified, and remain within the same twilight zone as the treatment of lumbar facet pain.

Lonser et al, 2017, Neurosurg Clin N Am219

I believe it is real, but there are also a lot of caveats.

An honest translation of the word “dysfunction” is usually just “screwed up somehow.” Broadly speaking, loose, stuck, and/or inflamed sacroiliac joints surely do happen, but there are a variety of ways to get into those states and most of them are poorly understood. For instance, knowing that it’s “hypermobile” isn’t half the battle. It might be hypermobile because of several quite different clinical situations:

• an injury
• a hypermobility disorder (a genetic condition, and quite common)
• pregnancy (which loosens ligaments)
• a postural habit that’s been yanking on some ligaments for thirty years

Many experts do indeed doubt the validity and reliability of a diagnosis of SIJ dysfunction. Most skepticism is focused on the dubious idea of SIJ subluxation, an SIJ that is “out,” which is even more unlikely in the SIJ than in the rest of the spine, because the joint is so massive and sturdy. Even when hypermobile, we’re still only talking about quite small movements. The joint might move too much, but it’s not likely to spend any significant time “out” of position. It’s worth quoting this again:

I talked to a trauma surgeon that had been to a workshop where they talked about the sacrum being “out of place.” He just said this is ridiculous: we see people who are in motor vehicle accidents with every bit of their body smashed but the sacroiliac joint is intact. It is so strong.

Peter O’Sullivan, Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, Australia

Skeptics are mostly concerned that the importance of SIJ dysfunction is exaggerated, not that it doesn’t exist at all, for several reasons:

• As with so much chronic pain, it may be just one factor in a stew of complex drivers of pain and pain chronicity, and subtle biological vulnerabilities may be the more fundamental issue.
• There are other likely causes of pain in the same area, of course.
• How reliably or meaningfully can it be diagnosed? For instance, while surgical fusion of the SIJ might be helpful for some back pain, you have to be able to identify the patients who need it — which seems to be a major stumbling block.220
• Even if you could diagnose it reliably, can you actually do anything about it? As with so many structural problems, even if it was a good idea to tinker, it might just not be possible. It pretty clearly cannot be “adjusted” manually.221 Even if you bolt it together with titanium screws, you can’t necessarily going to stop it from shifting around,222 any more than you can hold a squirmy puppy completely still. Life doesn’t like to be immobilized!

As we saw with Angela Zaleski’s case, however, sacroiliac joints do get into trouble and can become the well-spring of back pain.

Diagnosing sacroiliac joint pain

It is probably not possible to reliably detect abnormal sacroiliac joint movement by feeling or watching the joint move,223 or only in the most extreme cases. Remember, the joint can rotate only a couple degrees and slide only a couple millimetres.224 If you are diagnosed based mainly on a simple physical exam, be skeptical!

Despite all the uncertainty, it’s relatively straightforward to diagnose sacroiliac joint pain based on the clinical picture. First of all, the location is pretty consistent and revealing: if you have pain along the edge of the sacrum, there’s a pretty good chance that it’s sacroiliac joint pain. It’s most likely to be irritated by sitting and forward bending. And it is more likely to be SIJ pain if there aren’t any other major kinds of symptoms (e.g. numbness, tingling, shooting pain down the leg).

There are certainly several other possibilities to be aware of, and the big one is probably just muscle soreness in the immediately adjacent gluteals.225

Imaging can also fairly easily reveal SI joints that are in the greatest amount of trouble from chronic inflammation.

And the sacroiliac joint is a big target: it’s fairly easy to inject it with a pain killer, and see if that relieves a bunch of pain. Although I wouldn’t start with that, it’s definitely worth considering. See “Diagnostic numbing of facet joints” for more information about this approach.

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Nearly all backs could make an instant claim on the warranty, if there were one. If [God] were responsible for back design, you’ll have to concede that it wasn’t one of His best moments and must have been a deadline rush job at the end of the Six Days.

Unintelligent Design: Why God Isn’t as Smart as She Thinks She Is, Robyn Williams, 2007. p. 63

Poor posture and misalignment — especially short legs and pelvic tilts — are widely believed to cause back pain.

How does that work exactly?

There is really only one simplistic idea here: posture causes arthritis. Crookedness applies small stresses to the spine over long periods, eventually causing painful degenerative changes. Supposedly.

Make no mistake: when people talk about posture causing back pain, “arthritis” is what it boils down to. They are guessing that you are slowly ruining your spine by being a bit off-kilter, and it’s a garbage guess. Even if you actually are off-kilter, it’s probably mostly harmless, and definitely does not account for serious back pain.

We’ve already thoroughly established that arthritic changes have very little to do with back pain, so it wouldn’t matter even if posture did causes trivial arthritic changes.

But it doesn’t even do that! Crookedness probably isn’t the explanation for any back pain at all, let alone a lot of it.

Short legs: the all-time classic example of a crooked theory

The short leg thing is by far the best-known example of a cause of postural stress — and I think it’s also among the most wrong and common modern back pain pseudo-diagnosis, constantly foisted on patients by healthcare professionals and other patients. It sells a lot of orthotics and heel lifts. I have heard countless statements like “my last therapist told me I have a short leg,” and I am certainly not the only one. Dr. James Noake:

“Just had a patient who’s had 19 sessions of chiropractic treatment, and been told he has a 14mm leg length discrepancy. He’s not better obviously. Can we stop with this now? I’m tired of unravelling this BS in clinic, especially on Friday afternoon.”

I have been asking myself “Can we stop with this now?” since the early 2000s, so I guess the answer is “nope.” This leg-length of nonsense — from chiropractic or any other profession — isn’t going anywhere soon. No matter how many smart people gripe about it.

Why is leg length unimportant?

Usually the short leg is either trivial, less than a centimetre, or entirely imaginary. It was a routine professional experience for me in my massage years to be unable to detect a leg length difference diagnosed by other therapists. I do not think it was because I was any less talented or observant therapist. I think the diagnosis had more to do with therapists wanting to seem biomechanically savvy than detecting any actual differences in leg length.

It is not hard to detect leg length differences. This is not, as they say, rocket science. The anatomical landmarks are clear. Either the leg is longer or it is not. If the difference isn’t clear, it can’t possibly be significant.

(Or … maybe it is difficult? In 2016, a couple of veteran chiropractors were unable to produce the same results using two common methods of assessing leg length.226 Ruh roh!)

It’s all a moot point for low back pain, because a 1984 study — old but good, published in English medical journal Lancet — clearly establised that leg length differences do not cause back pain.227 While it is obvious that a significant difference in leg length might still be a factor in back pain, significant leg length differences are rare, and would still be only a factor in low back pain — a factor that would probably express itself primarily in the form of muscle pain.

What about amputees? Extremes are interesting and instructive, and back pain is indeed common in people who have lost a leg, and it’s common to try to treat it by adjusting their prostheses. These are people who basically have adjustable legs! But a 2015 study found that there was in fact no length difference to correct in amputees with back pain.228

Not that you need an artificial leg to adjust your leg length. If short legs caused back pain, surely it would be a slam dunk to treat the problem with orthotics or heel lifts? But orthotics have no obvious benefit for back pain patients.229 The only studies with positive results have serious flaws.230 (Orthotics don’t even prevent the lower limb injuries they are most often prescribed for.)231

The friends of leg-length differences

The leg-length theory of back pain is the best-known example of a whole bunch of similar and related diagnoses.

A close runner-up in popularity is the pelvis-outta-whack theory — tilted or twisted — which goes nicely with the leg length difference theory: each can cause the other, allegedly. Pelvic misalignment isn’t completely mythological, but its importance in back pain is. Several flavours of the crooked pelvis diagnosis are common — and equally suspect. It comes down to this: a pelvis tilt too small to reliably detect in a mirror is very unlikely to be a primary cause of low back pain. Backs are just not that fragile.

And then there’s lordosis.

Lordosis

The lordotic curve is the curve of the low back. There’s a wide range of what’s normal, and it’s also constantly changing — in most people, with or without pain, regardless of their age, sex, height, or weight. Measure it objectively with a curve-o-meter five times in a row, and you are likely to give five different results, as shown in a nifty little 2018 experiment.232

“Lordosis” refers to a prominent lordotic curve, but it’s unclear how much curve is too much curve. It’s a variation on the pelvis-outta-whack theory and nearly as popular a postural villain as a short leg. The Internet is awash with back pain cures based on this simplistic idea that flattening the back will help (with the alleged bonus of flattening bellies at the same time, which often gets advertised as perk). Rolfer Todd Hargrove shares my feelings about this idea and how pervasive it is:

The cure for pain is usually presented as involving one or more of the following elements: stretching the hip flexors, strengthening the glutes and abs, or making a conscious effort to suck in the gut or otherwise modify the pelvic angle in standing. There are many different variations on this prescription of course, but you can find some version of it almost anywhere you look in the world of manual therapy and corrective exercise.

A kernel of truth?

Bad ideas that have no truth in them at all usually don’t last. It’s the ones that have a kernel of truth in them that really have legs.

There’s almost certainly a kernel of truth in the concern about lordotic curve. Being bipedal probably is a little more challenging to spines than being quadrupedal. Old data from studying “primitive” people in societies where people squat a great deal — eliminating the lumbar curve for large percentages of their lives — showed fewer signs of strain on their lumbar vertebrae than our more “civilized” postures produce.233 The authors also note that degeneration is more prevalent in animal spines in the places you’d expect: right where the curves are sharpest, and where the gravitational strains are the greatest.

But even if people who stand up more really do have more spinal degeneration, by no means does this mean that they have more pain — there are other major factors in the mix. Nor does it mean that you could do anything about it by trying to adjust your posture now, short of switching to a squatting-based lifestyle for a decade — and even that might not work, for a dozen reasons.

There is enough evidence about the curve concern to put it out of our minds. Either there is no connection between lordosis and back pain at all, or it’s not enough of a connection to worry much about.234235236237 Whatever weak correlation might exist could easily just be a postural response to pain, rather than the other way around.238

And remember, Schmidt showed pretty clearly that you can’t measure it reliably, not even with an objective gadget — let alone the biased eyeballs of a massage therapist keen to find something to “work” on. And you cannot diagnose or fix what cannot be measured.

All that data torpedoes a number of back pain cure empires.

Spines are dynamic

Ask the same person to stand for a postural assessment several times in a row & that curve will spontaneously change to something measurably different at least a couple times, without rhyme or reason — regardless of pain, age, height, weight, or sex.

What about hamstring tightness? To be continued

The hamstrings are the most popular main scapegoat for a wonky pelvic tilt, and it motivates a great deal of hamstring stretching. I will cover that topic in full later in the guide, framed in the context of stretching as a treatment.

Why don’t pregnant women tip over?

I will now exploit pregnant women to make the point of this chapter in a more interesting way. In the quest to make this subject matter as amusing as it is informative, I ask you: Why don’t pregnant women tip over?

It is a nifty anatomical fact that women have larger, stronger posterior lumbar joints,239 which is almost certainly a biomechanical feature that evolved to cope with major combined stresses of a large, awkwardly off-centre weight and leaning backwards to keep from falling over.240

What are the odds that this evolutionary adaptation makes women immune to the back strain caused by pregnancy? Well … nil! Even today, even with tougher spines, pregnant women suffer high rates of low back pain. Ask any pregnant woman how her back feels.

What we take from this is that the importance of spinal curvature is moderated by evolution. We can clearly see that deviations from average spinal curvature are a factor in back pain, or women probably would never have evolved an adaptation to cope with it. On the other hand, the same adaptation shows that both men and women are probably adapted enough that spinal curvature alone cannot be a deal breaker — if it were, we would have evolved to cope with it.

Another way of putting it: evolution doesn’t care if you have back pain, just as long as you can breed … but it always makes sure that you can do that much. It is easy for nature to saddle us with biomechanical features that are uncomfortable and imperfect, but still keeping us mostly protected from biomechanical features that are routinely crippling. Here’s an interesting passage about this:

We often say the reason people get lower back pain is because we became bipeds and being a biped is a stupid way to use your back. But actually that doesn’t make any sense, because if back pain is so difficult, such a challenge, natural selection surely would have acted to lessen the prevalence and severity of back pain. [Indeed, it probably has: the Whitcome paper on women’s lumbar spines — with Lieberman’s name on it — shows pretty clearly that we do have such adaptations. — Paul] In fact, if you start asking people who work with hunter-gatherers, most people say yes, actually come to think of it, I don’t really recall anybody saying that they had back pain. I’ve never seen anybody have back pain in the hunter-gatherer context.

Dr. Dan Lieberman, evolutionary biologist, Brains Plus Brawn

This section just gives you a glimpse into a much bigger rant about “structuralism,” which is what I call the excessive emphasis on alignment, posture, and biomechanical factors in physical therapy. For much more information, see Your Back Is Not Out of Alignment. But it’s all summed up by this conclusion from a large scientific study that tried and failed to find connections between structural problems and back pain:

… structural factors such as the size of the lumbar lordosis, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles are not associated with the occurrence of low back pain.241

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One of the simplest of all idea about low back pain is that extra weight is a factor and losing it will help. Do you need to lose some weight? Does being heavier hurt backs?

It’s more likely that it hurts to be un-fit. Any trouble with weight is probably more metabolic than mechanical. (I’ll circle back to this.) But first, while the pregnancy stuff from the last section is fresh in your mind, because there’s an obvious connection …

Pregnancy is a kind of “temporary obesity” — sorry, ladies, an unkind but factual phrasing — so what applies to pregnancy probably roughly applies to obesity. And men are likely a little more vulnerable in the lumbar spine to weight gain, because they lack the impressive and handy spinal adaptations of women — if it helps women a little, it must harm men a little.

However, the differences are minor statistical differences in rates of back pain — perhaps so minor that they are difficult to even detect. There is no obvious epidemic of pregnant women and overweight people who are crippled by low back pain while their skinny friends and neighbours are blissfully back painless. Lots of skinny people are afflicted by back pain.

Leaving the useful example of pregnancy behind, what does the science say more directly about weight and back pain? Nothing conclusive — which is what you’d expect if it’s not a big deal. An obvious connection would be … obvious. A minor connection? Obviously harder, but still: you’d think researchers could work this one out. How hard can it be?

Amazingly hard, of course. It’s science. Science is hard!

Research on the link between back pain and obesity

Hussain et al found a clear link, but not for the reason everyone assumes.242 Dario et al found no link at all, despite looking extremely carefully.243

Hussain et al. shows evidence of the metabolic roots of back pain, and maybe other kinds of chronic pain as well. The majority (82%) of 5000 Australians reported back pain on a questionnaire, and in 27% of them it was bad enough to be disabling. When compared to their fat mass fat distribution — known indicators of metabolic disorders — a clear pattern emerged: back pain intensity and disability go up with measures of fat mass and distribution.

This data does not suggest that weight is a “mechanical” problem — greater weight causing greater stress on spinal joints — but rather that “systemic metabolic factors associated with adiposity play a major role in the pathogenesis of LBP.”

This is a great example of what I mean when I say (and I often do) that we need to look beyond biomechanics — way beyond — to the messy “wet” factors in chronic pain.

That sounds very much like the last word, but this is musculoskeletal medicine, where nothing is straightforward.

No link at all in a big twin study

Specifically because “current evidence remains unclear,” Dario et al. tried to get everything right: a long-term study of over a thousand initially healthy people, measuring both the overall amount of fat as well its distribution, and — this is important — using twins to control for “the possible effects of genetic and early shared environmental factors.” This is an advanced approach.

And the results? They found … nothing: “No increase in the risk of chronic LBP was found for any of the obesity-related measures.” They checked six ways from Sunday, and “obesity-related measures did not increase the risk of developing chronic low back pain.”

So where does that leave us? Still in the woods! The relationship between back pain and obesity has always been — and remains — a bit of a question mark. My best guess is that there is no link, or only a weak one, and it’s explained as much or more by metabolism than the stress applied to your spine by extra weight. This fits right in with many other counter-intuitive truths about back pain.

Despite a seemingly obvious connection between back pain and obesity, there’s nothing obvious about it.

A large example from life

I had a middle-aged client who was particularly large, about 200 kilograms — truly obese. She normally saw me for other issues, but one day came to my office with severe low back pain, notably the first she had ever suffered. Fortunately, she is a wonderfully self-aware person, and trusting — she didn’t leap to the conclusion that it had to be because she’s too heavy, and she immediately accepted the idea that her back pain was probably caused mostly by irritated muscle. I was grateful that she had come to me first, because a physician would almost certainly have alarmed her with grave warnings about her weight causing spinal degeneration or vulnerability to injury. While that is probably a reasonable concern over the long term, I did not believe that it was the most important or immediate cause of her pain. I treated her for muscle pain, and she was out of pain in one week. She remained pain free for at least three years before I lost track of her.

A point of anatomy

The importance of the spine as a weight-bearing structure is exaggerated. Although it does indeed bear weight, it’s not really a matter of “stacking” vertebrae. The strain of supporting extra weight is, in fact, significantly muscular — muscular action, via a concept called “tensegrity,” is actually a much more important principle of spinal support. In effect, the lumbar spine is more like a spring than a stack of bricks. For more information, see the (surprisingly fun) article Ten Trillion Cells Walked Into a Bar.

So is weight a factor? Almost certainly. Is it a critical factor? No. Weight differences within a reasonable range are almost certainly not a big deal.

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Is back pain actually a modern problem, a disease of civilization and modern lifestyles, like diabetes and heart attacks? Or is that just a cynical myth about the perils of modernity?

I started asking that in about 2005, a few years into my career as a massage therapist (and in the earliest stages of writing the first edition of this book). I had been busily telling my patients what every self-respecting alternative medicine practitioner was supposed to: sitting is evil, postural sloppiness is ruining us, your core is weak, and “primitive” people don’t have these problems.

I mean, duh, we evolved without chairs! Paleo-posture is obviously superior!

As a somewhat low-“ranking” healthcare provider, this seemed like a valuable pearl of slightly subversive wisdom that I could offer to my clients, something those “mainstream” doctors wouldn’t bestow upon them. Try to act more like a hunter-gatherer!

So practical! 🙄

As a side effect of my skepticism on other fronts, it occurred to me that I just had no idea if the claim was true. Do “primitive” people actually get less back pain? How did I think I knew that anyway? Well, because I had heard it, obviously.244

But I needed data! I will now take you on a five-minute tour of the fifteen-year journey I took to get a clear answer to this question.245 Happily, there is one.

Is back pain on the rise in recent history?

Many researchers do 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,”246 which shows some kind of growing problem, and that in turn might mean that back pain is worse now than it was in the more distant past.

A Spanish 2001 study showed that “serious” musculoskeletal complaints (including a great deal of back pain, presumably) had increased significantly from 1993.247

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.248 And they also pointed out that the appearance of a recent 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.” A great example of how hard statistics can “lie.”

You can’t confident extrapolate from those points to conclude that back pain is a modern problem, though.

I could probably update these citations with some more modern ones, but it’s too indirect anyway. This was just the only kind of data I could find at the time.

Evidence from related concepts

When I went looking for more direct and relevant evidence, I simply couldn’t find it. Maybe I didn’t have the research skills. Maybe the evidence didn’t exist! That seemed plausible. There’s not enough evidence about anything in musculoskeletal medicine, and virtually none about unusual populations.

Body pain + basic cultures = thin results in a PubMed search!

I did find clear evidence that excessive sitting is not a major risk factor for back pain, and I publicly reversed my position on that.

I also became a skeptic about the clinical significance of posture more generally.

And I became convinced that “core weakness” isn’t really a thing, and doesn’t doom us to back pain in any case. (The next chapter is all about that.)

All that strongly suggested that back pain probably isn’t a disease of modern lifestyles, but it was still all a bit tangential, "circumstantial" evidence.

And that was about as good a job as I could do for a long time. I still did not know, specifically, about the prevalence of back pain in cultures that didn’t spend their days sitting at computer stations. (And I had much else to think about.)

I needed even better, more directly relevant data.

Even better, more directly relevant data

Someone else did the work for me! Now I can just cite his work, like this: in 2017, James Steele, PhD, wrote a paper about how back pain is probably a human problem and not a modern human problem.249 He thoroughly reported on the evidence that I’d failed to find. Yahtzee! Thank you, James!

Surprise surprise, the data says that back pain is not a disease of civilization. Dr. Steele: “LBP is common to almost all populations examined and that outliers are easily explained by their reluctance to report pain and instead to rely on traditional healing methods.”250 The data isn’t perfect or complete, but it’s good enough for high confidence. There’s either no difference at all, or not a major one.

And it gets better. It’s not just most kinds of humans alive today that get back pain, it has probably been most kinds of humans ever:

We have focused on extant populations thus far, both ‘modern’ and ‘traditional.’ However, there is evidence of lumbar spine damage and degeneration potentially pursuant to LBP in many examples of extinct species of Homo and other early human populations. These include Homo erectu, Homoheidelbergensis, ancient Egyptians and Nubians, ancient Chinese populations and Ötzi the Iceman. This included disc herniation, spondylolisthesis, scoliosis, osteophytosis, rheumatoid arthritis, osteoarthritis, lumbar spur formation, and ankylosing spondylitis all of which have the potential to cause LBP.

… it would seem that the cultural environment, despite varying considerably between populations, has little impact upon LBP prevalence.

Intriguingly, for Dr. Steele, this is all just a premise for an interesting hypothesis about how humans are just biologically vulnerable to back pain.251 But it’s a major premise and supported well. Indeed, looking at the evidence he assembled, I am humbled by my failure, circa 2010, to find, um, any of it.

So that’s that. Steele 2017 will be my go to reference for this point for a long time to come. Back pain isn’t a modern disease? Steele 2017. Primitive people get just as much back pain as programmers? Steele 2017. Back pain is huge annoyance for all kinds of humans? Steele 2017!

Possible objections to this conclusion

How could I be wrong about this? Because, of course, I could be wrong about this!

The most likely objection that I am aware of is that modern hunter-gatherer populations are actually quite different from our actual prehistoric ancestors. I have no doubt that is a big deal for certain kinds of research questions. I am not so sure it’s a big deal for this one.

People trapped in chairs all day (hi there!) fantasize about how much more robust their backs might be if only we were much more active, if only we had a much greater diversity of physical challenges every day. And that absolutely exists in other modern populations! That comparison is possible, and that’s what the conclusion is based on.252

It also just seems somewhat unlikely to me that prehistoric populations would be protected from back pain by some X-factor that modern highly-active populations do not enjoy. But it’s untestable in any case.

If you are aware of any other objection to the claim that back pain is not a modern disease, please let me know.

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Before reading about the science, please get into the mood by watching this fine 29-second Japanese advertisement for a core strength training machine, the Wonder Core. It just keeps getting better as you watch! (Oh, and: earworm warning — that little jingle is infectious!)

Laughter is the best core workout. (If the video has been removed, which has happened several times over the last few years, just search YouTube for “wonder core ad” and you’ll find it easily.)

It seems everyone and their dog thinks that the root of all low back pain is a consequence of weak abdominals and other core musculature around the pelvis, which in turn strongly implies a deep-seated belief that spines are “unstable” if you don’t work hard to shore them up. But instability is just the presumed consequence of many of the biomechanical bogeyman we’ve already shown to be not so scary, if not entirely imaginary. And back pain isn’t caused by instability any more than by the things that supposedly make us unstable. Dr. O’Sullivan in 2021, summarizing his 2012 editorial in the British Journal of Sports Medicine:253

“I used to believe instability in the lumbar spine was a thing — even published about it — but the evidence just didn’t stack up.”

A nugget from the editorial:

“It is now clear that there is little evidence to support the view that ‘instability’ underpins the basis of disabling non-specific chronic low back pain. There are no studies that demonstrate a clear relationship between spinal or pelvic mobility, degenerative processes, pain and disability.”

Core strengthening is a fad that started in the mid-90s based on a reasonable theory, but it “came to dominate thinking as an accepted truth way before we had a good answer about whether it worked” (Neil O’Connell, a snippet of a terrific longer passage254). The word “core” seems to suggest something fundamental, foundational — it has a confidence-inspiring connotation.

The belief in the power of core power is now so widespread that it dominates all thinking about exercise therapy for low back pain: there are really no other serious contenders. Nearly every popular kind of exercise therapy for low back pain is some variation on the idea that your core needs training. It is the conceptual justification for basically all exercise prescriptions for the back, whether it is spelled out or not.

Therapeutic exercise for the back is core strengthening. They are effectively synonymous.

Core strength has a major logical problem

A lot could be said about this annoyingly persistent theory of low back pain, but I can dismiss the subject with one dollop of logic: I have seen lots of low back pain patients who clearly have perfectly good core strength, people who can do a lot more crunches than I can, and I have also seen lots of patients who’ve never had low back pain and yet they have never done a crunch in their lives. Thus, as with weight, “core weakness” in itself is probably a minor factor in low back pain, but it cannot possibly be a critical factor.

But that’s just my clinical experience. What actually matters is that it is validated by the science to date. In late 2008, Physical Therapy published a review of all research on “motor control exercises,”255 which are one particularly “fancy” way of working on core stability, physiotherapy exercises that try to teach you to improve the coordination of your core and low back musculature. It’s like trying to learn how to wiggle your ears — difficult, but fiddly! These exercises are a popular variation on core stability training. However, all the research that had been done up to then was hopelessly unexciting. When scientists have studied a therapy more than a dozen times, you hope to see nice clear evidence that it really does the trick! No such luck. The authors conclude that “motor control exercise is superior to minimal intervention,” a somewhat disingenuous phrase to lead with. What they are really saying is, “Motor control exercise is better than nothing.” Which it is. But guess what? It is also “not more effective than manual therapy or other forms of exercise”!

So, in other words, you could have done any kind of exercise and gotten roughly the same benefit. Whoop-de-doo!

What that tells me is that motor control exercises are not exactly laser-focused on fixing any root cause of low back pain. If low back pain was truly caused by poorly coordinated action of the core musculature, you would expect to see motor control exercises really make a difference — way more of a difference than “other forms of exercise.” But they don’t!

Undoubtedly people with low back pain do indeed have impaired coordination256257 — and an impaired sense of touch,258 interestingly — but that’s hardly surprising. Do you feel like you have good precise motor control of the centre of your body when your back is screaming? I know I don’t! Despite all the fuss, researchers have never been able to prove that poor coordination is actually the cause of low back pain — and I don’t think any sensible person is surprised by that, because obviously, it could easily be exactly the other way around.

This is just a taste of this subject. Because the perceived importance of core strengthening is so high, it will be discussed in more detail below in the context of treatments and the question, “Should you bother?” I’ve written about it briefly here just to introduce you to the disappointing reality, and to emphasize sooner rather than later in the tutorial that this chestnut of low back pain “wisdom” is blown way out of proportion. Neil O’Connell (again) put it like this in a short 2011 article:

The problem is that, whichever way you slice the data, the effects of exercise are small to moderate at best (kind of the therapeutic equivalent of beige slacks: better than nothing but underwhelming).

Core neck strengthening?

Core strengthening for the neck is called deep cervical flexor training, and it’s a scientifically bankrupt analogy to core strengthening for the back. It’s “based” on some weak evidence that people with neck pain have weak deep cervical flexors, which is an unproven premise that the weakness is a cause of neck pain rather than just a symptom, and a smattering of literally corrupt (actually fraudulent!) evidence that strengthening the DCFs helps. The state of DCF training is about as depressing an example of the shabby state of rehab science as you can cough up. Full details and references in my neck pain book (of course). For our purposes here, it’s enough to just say that it’s a train wreck, and suggests that “core” strength isn’t an important consideration in any part of the spine.

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High heels, flat feet, and bad shoes are all semi-regular but minor blame magnets for low back pain. You can safely ignore them all with the same logic that we’ve used on several other theories discussed so far. If we are generous, they might be a minor factor, yes. But the thing? The actual main problem? You know the likely answer by now, but here’s an interesting recent example from high-heeled science…

A meticulous 2010 study showed that the body adapts effectively and minimally to high heels, producing similar functional results.259 The most interesting implication of their results is simply that “muscle structure may adapt to a chronic change in functional demand” — which might seem obvious, but that little bit of science has been hard to nail down over the years, and this is a good piece of the puzzle.

Chronic high-heel wearers do have shortened calf muscles, stiffer Achilles tendons, and a smaller ankle range of motion, but these changes “seem to counteract each other since no significant differences in static or dynamic torques were observed.” In other words, high heel wearers are not progressively disabled: their ankles work fine, just differently. This doesn’t mean there’s no conceivable harm (for instance, Kerrigan found evidence of harm to the knees), but it does tend to downgrade concern on the topic.

Most women who wear heels probably will not notice any obvious connection with back pain. If you do, I would suggest taking a break from them — but I would also recommend that ultimately the problem is not that “heels are dangerous to the low back,” but that “the back is too vulnerable to a minor stress.”

For a specific and entertainingly bizarre example of a questionable foot-o-centric theory of body pain, see the appendix to The Not-So-Humble Healer, “I have been humble for 2 decades now.”

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This sub-topic is mostly unique to low back pain. There’s just something about back pain that makes doctors particularly likely to tell patients that they may have to stop doing the things they love to do. It comes up with some overuse injuries too, but back pain really inspires this attitude, like the classic medical joke…

“Doctor, my shoulder hurts when I lift my arm like this.”

“Well, then, don’t lift your arm like this.”

But with a sinister twist. With low back pain, all too often the “joke” is all-too-serious, transmogrified into an ominous, hope-suffocating recommendation to give up, to give up on something you love:

“Doctor, my low back hurts when I play golf!”

“Well, then don’t play golf!”

The weird part: this attitude can go so far wrong that your activities are actually blamed for your back pain, as if the activity itself were a diagnosis. In other words, your problem is that you’re trying to have too much fun.

Even worse, this kind of “diagnosis” is almost always packaged together with the insinuation that your problem may be in your head instead of your back. What a mess!

Please beware of any professional who counsels you to quit a favourite physical activity, assuming it’s not absurdly intense for your age. While a break may be appropriate in many cases (if you haven’t already been forced to do so), it is almost never ultimately necessary — or wise — to actually give up your fun forever. In most cases, recreational exercise is a part of the cure … not the cause!

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This was a full-page advertisement for Lyrica in National Geographic magazine back in the 2000s:

“Do you feel burning pain in your feet?” the ad asks. “Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you may have nerve pain.”

Yes, you might. But there’s an excellent chance you don’t. Science says so!

This is one of the most common and understandable concerns that people have about pain near any part of their spine, especially the top and the bottom of it, but it is also one of the most overblown of all common medical fears.

For all the reasons discussed above (and more below), the pain of a pinched nerve in the back is less common than most people think, both patients and pros. Many other common causes of pain and altered sensation routinely fool patients and professionals alike into suspecting “some kind of nerve problem.”

And a large percentage of that so-called neuropathy is probably coming from muscle, and is relatively treatable.

Nerves are notorious

I once had a nice older Italian client who would ask me, over and over again, in a thick, sing-songy Italian accent, “So, it’s-a nerve, eh?” No, I would say, it’s probably just a muscle knot, not a nerve. And then — as if we’d never discussed it — five minutes later he would ask again, “So, that’s-a nerve, eh?” He was obsessed with nerves!

Like everyone else is. Sometimes it seems to me as if modern civilization is still getting used to the whole idea of nerves. When people talk about their nerves, it’s like they’re talking about something just revealed by science early last year. They speak with some awe about something barely understood … and feared. Nerves! It could be my nerves!

Nerves just make people nervous. The whole idea of nerves gets people anxious. Could it be a nerve? people are likely to wonder of any puzzling pain. Is this a nerve problem? What if it’s a nerve? Is something pinching my nerve? Something must be pinching a nerve!

The idea of a pinched nerve root particularly is deeply embedded in the public consciousness, thanks to decades of excessive emphasis on the idea in both mainstream and alternative medicine. The fraudulent marketing of anticonvulsants for neuropathy is the most spectacular and fresh example, but chiropractors have promoted this kind of thinking consistently for over a century.261 And now many people think they can hardly get out of bed in the morning without pinching a nerve root.

Nerve roots actually have a lot of wiggle room

All the nerve fear is peculiar, because it’s amazingly difficult to actually pinch most nerves in the back. And, even when you do, they are usually surprisingly unbothered by it.

In the back, we’re speaking mainly of nerve roots, where they exit the spine. In general, nerve roots have generous “wiggle room.” For instance, in the lumbar spine, the holes between the vertebrae that the nerve roots pass through can be more than a couple centimetres at their widest, while the nerve roots themselves are only about 3-4mm thick.262 If you stretch or compress the spine, the holes do change size a little — as much as 70–130% in the looser neck joints,263 a little less in the low back.264 But, even at their most compressed, there’s still plenty of room.

Schematic of nerve root wiggle room

On the left are the approximate proportions of a healthy nerve root & the hole it passes through (intervertebral foramen). When the spine is pulled or compressed, the holes get a little larger or smaller, as shown on the right … but there’s still lots of nerve root room. Click to embiggen.

There’s so much space for nerve roots that significant arthritic deformation and even major derangements of the spine (dislocations, spinal stenosis) can fail to actually cause trouble.265266 Once again I invoke the example of a patient of mine with a severe lumbar dislocation … and no symptoms at all, not even symptoms of pinched nerve roots. Her nerves seemed to be fine, even in an anatomical situation most people would assume to be extremely dangerous.

X-Factors: pinching in itself is not enough to cause trouble (seriously)

The idea of nerve pain is almost synonymous with nerve root pinching … but it shouldn’t be. Physical impingement is only part of the equation, and maybe it’s not even the biggest part. There are other factors.

Like oxygen. You need it. Your nerves need it. And both you and your nerves get cranky without it.

Fun fact: healthy, fully oxygenated nerves can be pinched firmly without causing pain, but oxygen-starved nerves are sensitive.267268269270 Related: there’s also some good evidence that radiculopathy has more to do with blood supply than mechanical impingement.271

And why would blood supply to a nerve root be impinged? According to Jayson, “Vascular damage and fibrosis are common within the vertebral canal and intervertebral foramen.” Especially after surgery! But not only after surgery. The delicate capillaries around nerve roots seem to degenerate just like joints get arthritic, and that process is probably accelerated by biological factors like autoimmune disease, cardiovascular disease, and chronic low grade inflammation … which are in turn affected by diet, fitness, stress, sleep, etc.

Despite the fact that nerve-pinch pain is a thing, it’s clear that tissue health is probably the more important factor. The vulnerability of the nerve before it’s pinched is probably more important than the fact that it’s being pinched, or how hard. And how vulnerable the nerves are may be affected by factors that have nothing whatsoever to do with your back. Like your genes!

Nerve pain and sensitization

There are several mechanisms by which nerves can become pathologically over-sensitive after an initial insult, causing the pain to drag on and on. For a long time, no one had any idea why this happened to some people and not others, and it really does seem to be a binary phenomenon: either it happens or it doesn’t. Unfortunately, one likely explanation was identified in 2010: genetics.272 That is not great news, but it is interesting and at least a little bit useful.

So chronic pain could be due to on-going irritation of nerve tissue, but it could also be entirely due to a malfunction of the sensory equipment itself. A fascinating possibility (and a rather bleak one).

The point: be wary of therapeutic wild goose chases looking for mechanical causes of pain. Neuropathy is definitely not just about pinching. The extended suffering could be caused by continuing irritation of a nerve root, or it could be entirely due to a malfunction of the sensory equipment itself.

The relationship to trigger points

If nerve pain is more about biological nerve vulnerability and poor health of tissue around them than physical irritation, what does that say about the role of trigger points? Maybe they are just another symptom of poor tissue health, or could they be a form of “poor tissue health” themselves. Could a nerve passing through/near muscle tissue rotten with trigger points be affected by that? I’m not sure how plausible it is, but it’s not inconceivable.

Maybe this is why treating trigger points sometimes seems to alleviate actual neuropathy.273 If so, it’s yet another way that a back problem that seemingly isn’t about muscle may nevertheless be helped by treating muscle. In this articulate passage, Clair Davies, author of The Trigger Point Therapy Workbook (my review), discussed patterns he observed in private practice as a massage therapist. My experience has been similar over the years …

Interestingly, almost all the people who came to me had some kind of back pain along with whatever other pain complaint they had. Their previous treatments for back pain had always focused on the spine. I heard about injections of papaya or cortisone. People had usually been told they had arthritis or bad disks, or that their cartilage had been worn away. They’d been shown X-rays [or MRIs! — PI] that purported to prove it. Some had already had surgery, and frequently had as much pain after surgery as before. Typically, the surgeon’s last word was always that he was sorry but he’d done all he could. Then he’d renew their prescription for painkillers and dump them off on a physical therapist. I heard these stories over and over again. And over and over, I found that trigger point therapy gave them the relief they’d been seeking for so long. Had trigger points been the problem in the first place? Arthritis? Bad disks? In Travell and Simons’ Myofascial Pain and Dysfunction, I had read that you can have herniated discs and arthritis of the spine and still find that myofascial trigger points are the primary cause of your back pain.

The trigger point therapy workbook, by Clair Davies, p. 13

I will explore cluneal nerve entrapment in other chapters, an example of a neuropathy that is more likely to masquerade as trigger points than other neuropathies, but which also has clear symptoms of nerve botheration. And in the next section, an example of the reverse: pain that seemed a lot like neuropathy but probably was not.

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I once helped with a young woman who had “sciatica” — the mother of all nerve pinches. The sciatic nerve is the biggest single peripheral nerve in the human body. Allegedly, either her sciatic nerve, or one of the lumbar nerve roots it emerges from, was being pinched and sending hot zaps of pain down her leg.

That can happen, so it was a plausible diagnosis, and she came to me with it already accepted. She also had some tingling in her feet (much like in the magazine advertisement). The description of her symptoms did, indeed, sound a lot like nerve distress. On the face of it, it was likely that her sciatic nerve was irritated: true sciatica, a genuine neuropathy. Although nerve pain isn’t nearly as common as trigger point pain, it certainly can happen.

A couple things didn’t add up, though. For instance, she had no numbness at all — no dead patches of skin, which are highly characteristic of true nerve impingement. Instead, she had widespread “dead heaviness” in her leg, a different kind of numb feeling that is much more closely associated with trigger points than nerve pinches — and a lot more common.

I quizzed her carefully about the quality of her pain. She assured me it was “zappy” and “electrical” … just as you would expect of nerve pain, not knots. Yet something didn’t seem quite right. I couldn’t shake the impression that she was interpreting non-neurological pain as an electrical mainly due to her strong belief that she had a nerve problem. When you think a pain is nervy, you’re going to interpret, feel and describe it in nervy terms. Pain quality is an extremely flexible concept.

So I did some experimenting, and clinched the case:

This young woman’s “nerve” pain could be vividly reproduced by pressing on muscle knots that were nowhere close to any nerve tissue. Pressing on the side of her hip, on a gluteus medius trigger point several centimetres away from the sciatic nerve, she reported the same “electrical” pain flowing down her leg, even producing the weird, tingling sensations in her foot.

That largely eliminated a diagnosis of sciatic nerve impingement,274 and the symptoms were fairly easy to relieve. No more neuropathy.

A more likely story

In spite of spending most of my career trying to explain to people that pain has many possible causes, and that muscle pain is particularly common and sneaky, I was surprising myself — fooled, really.

The symptoms really did seem neuropathic to me at first. But the evidence was hard to argue with, and — in retrospect — I realized that I had been sucked in by “nerve anxiety” myself. In fact, her symptoms were strongly consistent with a diagnosis of muscle pain.

The only unusual thing about her case was that her muscle knots produced referred pain that was more similar to nerve pain than usual, and even that may have been a by-product of my leading questions when I still assumed it was probably a neuropathy. That is, I may have accidentally encouraged the use of terms like “electrical” by basically suggesting them to her: “Is it an ‘electrical’ sensation?” If allowed to describe her pain in her own words, she might have done so in a less “nervy” way.

I suspect that muscle knots are routinely doing this, fooling patients and professionals alike. Painful trigger points are definitely more common than neuropathy, and at least some of those muscle knots feel enough like nerve pain that they are easily mistaken for the more familiar bogeyman.

The take-home message of this section: do not underestimate the power of trigger points to cause pain that seems like a nerve pinch.

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Sometimes, when it feels like you really have nerve pain, it’s because you really have nerve pain! But so what?

I argued above that nerve pinches are actually not a common cause of back pain: they are hard to pinch in the first place, and often not bothered by it when they are.

But “you’re not paranoid if they’re really after you.” Sometimes, when it feels like you really have nerve pain, it’s because you really have nerve pain (neuropathy, one of the basic types of pain).

Slightly more than one in ten people (not just back pain patients, but everyone) have nerve root trouble that can be confirmed electrodiagnostically.275 That may be a lower number than people expect, but impaired nerve root function is not exactly rare.

Here’s a fascinating for-instance: sometimes the sacrum is fused to the lowest lumbar vertebra by a bridge of bone, creating a “transitional vertebra” — a vertebra that can’t decide if it’s lumbar or sacral. They are the most common congenital anomaly of the low back, found in a whopping 7% of the population (at least, possibly much more) … and they probably do cause some trouble, the pesky little buggers.276 Back pain of this type is called “Bertolotti’s syndrome.” Specifically, nerve root compression occurs in about 13% of people with a transitional vertebra, and about 70% of those are symptomatic.277 This is a pitch perfect example of how structural issues can be a source of trouble … but there is also evidence that it’s not as much of a problem as one might think: it’s not much more common in people with pain, maybe even no more common at all.278 So it does cause some trouble, but not as much as expected and assumed.

This is probably the case for most seemingly obvious causes of nerve root trouble: they just aren’t as “mechanical” and simple as they seem. Nothing in biology ever is.

Disc herniations are probably the most common of the “obvious” causes of nerve root trouble, and there are a variety of other relatively rare possibilities.

So if you suspect that your back pain is the tip of a neuropathic iceberg, it’s important to be able to work towards confirmation of that suspicion.

The three main kind of back-related neuropathy

The Big Three types of neuropathy are all about location, location, location. There are three locations where nerve tissue can be bothered, each of them associated with its own “pathy.”

• spinal cord → myelopathy
• nerve roots → radiculopathy
• nerve “branches”279 (peripheral nerves) → peripheral neuropathy

Radiculopathy is the disease of a troubled spinal nerve root. A pair of nerve roots splits off from the spinal cord at each vertebra, and exits through big holes on each side of the spine. They are about a centimetre or two long. The nerve roots quickly split into major nerve trunks, which rapidly split into smaller nerves branching out into the body. Bothering nerve roots usually causes pain, tingling, numbness, and weakness throughout the tissue those nerves penetrate, in a roughly “dermatomal” pattern (see below). “Radicular” pain (the pain of radiculopathy) is often like an electric shock.

Myelopathy usually refers to spinal cord impingement in the neck or upper back, causing complex problems “downstream.” In the lower back, the spinal cord ends fairly high up, where it then turns into a horsetail-like bundle of nerves, the cauda equina.280 Impingement of that is the same idea as cervical myelopathy in principle, but it’s usually clinically simpler (because there’s so much less downstream of it). Symptoms mostly only occur only when the spinal canal is narrowed quite a bit by significant degeneration, deformity, or injury. Narrowing of the spinal canal is spinal stenosis, and fairly common in older people. Interestingly, impingement does not lead inevitably to symptoms: as with any other nerve tissue, the cauda equina is not necessarily vulnerable to a bit of squeezing. “It depends.” So that’s nice to know.

Peripheral neuropathy is trouble with nerves out in the body, away from the spine. The nerve roots of the lumbar spine rapidly divide into a complex web of nerve trunks, reaching out and down towards the glutes, called the “lumbar plexus.” If the plexus gets into trouble, that’s a “peripheral” neuropathy (even though it’s happening very close to the spine). Despite that proximity, these injuries are rare (they are well protected) and rarely have anything to do with chronic back pain: they cause symptoms mostly in the buttocks and leg (sciatica).

Neuropathic symptoms

Both radiculopathy and myelopathy can cause chronic back pain! Neither problem is common, and they definitely don’t always cause back pain, but it is one of the standard symptoms. Exactly how often they cause back pain is unknown. And then they also usually cause symptoms “downstream” in the tissues affected by those nerves (practically anywhere in the lower body in the case of myelopathy). Really the only way to know whether your back pain is related to myelopathy or radiculopathy is if you have both back pain and other classic neuropathic symptoms. And so here’s an overview …

Classic symptoms of lumbar radiculopathy, which is insult to the nerve roots in the lower back (the bundles of nerves that emerge from holes in the spine):

• pain spreading into the hips, legs and feet
• especially “radicular” (zappy, shooting) pain (more on this below)
• muscle weakness and/or numbness or tingling, especially in the calves, feet, and toes
• feet slapping while walking, tripping

Classic symptoms of lumbar myelopathy and/or acute myelopathy (cauda equina syndrome):281

• back pain
• pain and/or weakness in either leg, but especially both
• pain that is “radicular”: hot, zappy, shooting pain (more on this below)
• “saddle” numbness (where a saddle would touch: inner thighs, groin, central buttocks)
• bladder, bowel, and sexual dysfunction (possibly quite subtle, such as difficult initiating urination)
• an awkward gait

More about the scary symptoms of cauda equina syndrome … which turn out to be different and less scary that widely believed

Everyone should know that an abrupt attack of pain and weakness in both legs is potentially serious. Numb plumbing that doesn’t work right is worrisome! Just in case that wasn’t super obvious.

These are the signature symptoms of cauda equina syndrome. But CES doesn’t have exclusive rights to them.

Since forever, saddle numbness has been considered the big red flag for CES. But modern data now shows that it’s just about as common in people without CES!282 In fact, all CES symptoms are like this to some degree: they all occur in lots of people who have no detectable compression (with MRI). Every last one of them.

The only ones that are somewhat more trustworthy — the best red flags possible — are pain and weakness in both legs. To a lesser degree, difficulty starting to pee is also a little more common with CES. But even these more predictive symptoms still can and do occur in people who have no CES (that can be confirmed with imaging). Which is probably why many if not most CES-ish symptoms turn out to be false alarms — perhaps as high as 80% of them.284

So don’t panic! It’s amazing how weird and bad bodies can feel without anything being too terribly wrong.

This does beg a rather interesting question though: if numbness isn’t CES, what is going on? Great question!285

Fortunately, CES is rare, something a typical physician will supposedly see only once in their career — but it turns out that is a classic “zombie statistic,” living on long after it should have died, based on some dubious old data.286 It is indeed rare, but the truth is probably more like “a few cases” per career, or even “several” for providers who see more back pain cases.287 So this is kind of like warning you about being mauled by a bear — it can happen, but the overwhelming majority of humans will never have the displeasure.

The first rule of neuropathy club: symptoms are unreliable

Even the most dramatic and scary symptoms of CES are often phantoms and red herrings, which means that all bets are off. No symptom of any kind of lumbar neuropathy is a diagnostic slam dunk — not even close.

It is possible to have radiculopathy and myelopathy with no clear classic symptoms at all for long periods. And basically all of the symptoms also have other causes!

For instance, let’s consider the classic case of sciatica, where “pain below the knee” is the closest thing to a signature symptom of sciatica… but not every patient with sciatica has that symptom, and some with that symptom do not have sciatica.288 The symptoms just don’t tell the whole story.

And so ultimately this review is intended only to inspire further medical investigation. If you have chronic back pain and you have some other neurological symptoms … then it’s worth asking a doctor about it.

Radicular pain: what nerve root pinching feels like

Radiculopathy can cause very boring pain — just standard aches and pains — but it also often causes a very distinctive type of pain called radicular pain. (That’s basically just Latin for “root pain,” where radix = root.) Radicular pain makes a strong impression on people. It’s not boring.

• It usually goes well into the legs, often past the knee and even as far down as the feet.
• The quality is “electrical” pain that feels like it “zaps” or “shoots.” Sometimes the pain may have a somewhat more “hot piano wire” feeling than electrical. In any case, the pain comes in dramatic blasts along the thin line of a specific nerve — nothing like the more typical nagging aches and throbs of most low back pain.
• Radicular pain is often associated with altered sensation as well:
• True tactile numbness, in which you have reasonably well-defined patches of skin that cannot feel the prick of a pin.
• Pins and needles — or “parasthesia,” which is Latin for altered sensation.
• Radicular pain mostly occurs in patterns, following one of the dermatomes. Sort of — it’s less predictable than I was taught to expect. Most nerve root pinching in the back occurs at the bottom of the back, in the L4 to S1 dermatomes: a broad, spiralling tripe down the outside and back of the thigh, the front of the lower leg, and most of the feet. More about these patterns below.

None of that nonsense is normal for non-radicular low back pain, of course. Most low back pain has only minor effects on the legs, if any at all. Trigger points (muscle knots) in the back and hips often do spread aching and burning pains down the legs, and can definitely cause some confusion — but probably not vivid pain and tingling and numbness along a clearly defined path. And muscle pain can also make the legs feel heavy and dead, which is kind of like numbness — but not at all like the true lack of skin sensation that nerve impingement causes. The pins and needles and crawling prickles of neuropathy are especially distinctive.

More about radiculopathy symptoms: Nerve root trouble is felt in interesting patterns … kinda

Lots of data and instructions pass through a nerve root, coming to and from the tissues it supplies. Trouble with the root (radiculopathy) causes trouble throughout the distribution of the root’s downstream nerves, which spreads out in curious patterns: the dermatomes, the stripes of skin associated with each nerve root. Dermatomes spiral around the body like ribbons, down and away from the spine. Pain in a roughly “dermatomal” pattern is one of the most distinctive features of radiculopathy.

Only certain muscles are powered by each nerve root, too — myotomes — so trouble with a nerve root results in weakness of specific muscles.

So every nerve root is responsible for a couple of “tomes”: a skin-tome and a muscle-tome. A dermatome and a myotome.

A standard dermatome diagram showing the curious spiralling stripes of sensory innervation around the arms & legs. The reality is much less tidy, with lots of fuzziness & overlap. A truthful dermatome diagram would look more like a child’s colouring book! Click to embiggen.

Pain, weakness, numbness, and tingling within a tome-zone are strong indicators that a particular nerve root is being squeezed or irritated. But pain and weird sensations usually don’t fill in the area of a dermatome precisely. Instead, they are filled in more like a child’s colouring book: lots of colouring outside the lines! A detailed dermatome mapping study back in 1998, in which brave subjects were subjected to deliberate provocation of their nerve roots — ouch! — finding strong trends but many exceptions: “symptoms were frequently provoked outside of the distribution of classic dermatomal maps.”289 In another study, less than half of patients with L5 nerve root compression identified symptoms in the L5 dermatome.290 In yet another, only about a third was non-dermatomal; in the back, about two thirds.291 It’s all much less predictable than I was trained to expect.292

But why? Probably mainly because anatomy is messy. “Although there is a regular and orderly progression of innervation within each individual, it is likely that innervation patterns differ considerably between individuals.”293 That variability was confirmed in a cadaver study in 2000: no two corpses’ nerves were quite alike. Although nerve roots themselves were quite consistent, they had a rat’s nest of random small branches connecting them, like the tangled roots of a tree.294

Another wrinkle: even when the pain is in a dermatomal pattern, it may not “fill” the pattern, and pain is often experienced mainly in one section of the dermatome, often the most remote part. For instance, burning pain in the big toe, which lives in the dermatome for the bottom-most lumbar nerve root, L5. Most of the dermatome feels fine, but oh, that toe!

You can also get partial and mixed radicular pain involving portions and combinations of different tome-zones, by irritating not the root itself, but major branches off the root. The classic example is the sciatic nerve, which consists of several major branches all bundled together. This results in something like radicular pain … but not confined to nice tidy ‘tomes.

Despite all that, I want to emphasize that the patterns are still mostly reliable: for instance, you don’t have to worry about finding the symptoms of a C6 radiculopathy way over in the C4 dermatome. But adjacent dermatomes likely do overlap more than most professionals think. And this stuff is why neurologists get paid the big bucks. Even the simplified concepts are difficult.

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Scoliosis is right out of the X-files of musculoskeletal medicine: an unexplained anatomical defect that gets multiplied over the many joints of the spine, producing an overall sideways curvature that is much greater than the glitch in any one joint. It often starts in childhood, but it can strike at any age. It can stay subtle and stable for a lifetime, or it can progress relentlessly to extremes of deformity, or almost anything between.

Sometimes scoliosis has an obvious trigger, like the spine being pulled out of shape by the powerful spasms caused by some diseases, or as a reaction to a serious spinal injury (as it did in my wife). Scoliosis can even be induced! It happened to almost everyone who ever had ribs removed (eek!) to treat the consequences of tuberculosis.295 It’s almost like the spine is trying to squirm away from trouble.

But most scoliosis just comes out of the blue, and then often keeps coming (primary idiopathic degenerative scoliosis). Not only is this as weird as snake sneakers, it’s actually common. Spines do this lateral warping thing rather a lot. People with a little of it are simply everywhere: at least one out of three older women, maybe even half of them… and certainly at least one human of any kind in every full train car, busy coffee shop, or classroom.296

Severe cases are not common, but hard data on them is just as scarce as the patients. Horrifically spiralling spines have been staples of cabinets of medical curiosities for centuries, but that is an exotic fate, and most medical professionals will never see anyone like that.

Nearly everything about why spines do this thing remains a mystery, and a fine example of how primitive musculoskeletal health science still is. Delving into the nature of scoliosis is beyond the scope of this document — or apparently any document297 — but the condition can at least give us an interesting perspective on the uncertain relationship between spinal structure and pain. There is also a chapter on treatment for mild to moderate adult scoliosis later in the guide.

An illustration of extreme scoliosis, from a 1903 text on obstetrics by Cameron. Scoliosis this severe is life threatening & has basically nothing to do with common back pain or this book… but I can’t write about scoliosis without showing a vintage image of an extremely deformed spine for “colour.” It’s in my contract, I think.

Does scoliosis cause back pain?

Is scoliosis a significant factor in back pain? That’s what this chapter is about, and the answer seems obvious.

It isn’t actually obvious, of course.

It seems that scoliosis must surely increase the stress on spinal tissues — how can it not? And maybe that can add up to a problem over time. Perhaps 60% of scoliotic teens have back pain, and if the scoliosis worse, so is the pain.298 (I have been unable to find stats on pain in adult scoliosis.) But that’s roughly the strongest reported link. Other data suggests that pain in scoliosis patients is quite bit less common than 60%, maybe only 30% over a lifetime299 — plenty of painful scoliosis, but even more that’s painless.

The link between back pain and scoliosis so murky that legendary spine expert Dr. Alf Nachemson wrote, in 1979, “From available long-term follow-up studies of untreated scoliosis, there seems to be minimal risk of disabling back pain in adult patients who have lumbar curves.”300 And nothing’s really changed, because the world of back pain research moves like molasses: in 2021, Yuan et al pointed out that there is “no consensus as to whether non-specific low back pain in scoliosis patients is related to scoliosis per se or is just a normal symptom that could happen in anyone.”301 Still.

If we still can’t agree on that, it’s unlikely that scoliosis is all that painful. If it was, there would be a consensus!

Modern evidence certainly does show some risk, but it’s just not the slam dunk of a link most people think it has to be. The pain is notably not clearly worse than other kinds of back pain (a bit different, causing more groin and thigh pain).302 There are so many other factors in back pain that are not “stress on spinal tissues,” and back pain in the scoliotic is indeed clearly linked to the same squishy factors (insomnia, depression) that contribute to any kind of back pain. So the scoliosis may not actually be the main problem in the scoliotic patients who do have pain.

It is particularly silly to blame severe chronic low back pain on a minor scoliosis, but this happens more or less constantly. If you have minor scoliosis, good luck getting out of a massage appointment without being told “well, there’s your problem.” Even when there is minor scoliosis and pain, the main clinical question there should be why is minor scoliosis a problem? Because it usually isn’t. So there’s probably something else going on.

Scoliosis the terrible: Becky’s back

Extremes are instructive. Becky was a patient of mine in the 2000s, and while her back wasn’t quite eligible for any cabinets of medical curiosities… it was pushing it. He spine began literally spiralling out of control when she was quite young, and by the time she was twelve it was rotated to about 70˚ — a very severe scoliosis. Her internal organs were being slowly crushed, and radical surgical intervention was required to save her life.303

Severe scoliosis, but minimal low back pain

My former client Becky has intervertebral joints rotated to about 40˚, despite having large steel braces surgically implanted at the age of 12. If minor scoliosis was a significant cause of low back pain, then Becky should be crippled — but in the years that I knew here, she was more fit & active than I was.

Even after implanting large stainless steel braces in her back — followed by a year of difficult recovery — the powerful process of scoliosis continued to bend Becky’s back and the titanium rods. But over the years the metal was slowly winning the wrestling match, and by 2010 she was rotated to “only” about 40˚. (I have lost contact with Becky in the years since, though I hope I will be able to find her eventually and update her story here.)

That’s all quite dramatic, but it’s not actually the amazing thing. What’s most remarkable about Becky’s case is that she was not a back pain patient. Not really. Not the kind of low back pain patient that buys this guide!

Like the client described earlier with the drastic spondylolisthesis — one vertebrae practically falling off the one below it — Becky was incredibly fit and surprisingly pain-free, considering what was going on in her back. She did have some back pain, and occasionally it was even strong. But she was nevertheless unmistakably better off than most of the low back pain patients I have ever known. Her pain was relatively minor. She played ultimate and other vigorous sports, and did not feel or act fragile.304 She did not even hire me primarily to help with her back (although it was a strong “as long as I’m here” bonus reason).

By contrast, most people with serious and stubborn low back pain — the target market for this guide — are often “flattened” by nasty episodes of pain, or suffer almost unbearable constant nagging pain, like a toothache in the back.

Becky’s back is about as bad as a back can get structurally. But she probably had less back pain than many of you do right now, with spines that look perfect by comparison. Weird, isn’t it?

As with all such stories, the general explanation is almost certainly that pain is more biological than mechanical and requires a combination of factors, including non-obvious ones. Even many super obvious spinal problems are routinely neither necessary nor sufficient for pain.

Minor and imaginative scoliosis as a scapegoat

Legitimate but clearly minor scoliosis is routinely blamed for back pain. Some therapists automatically screen for scoliosis, and attribute any back pain the patient has to even the most subtle curvatures of the spine.

This just doesn’t add up. I have seen numerous cases of severe scoliosis over the years — none as dramatic as Becky’s, but several that were obviously deforming. All of those patients had “annoying” low back pain and stiffness, but not one had a serious low back pain problem.

And so, like all the other common structural diagnoses, scoliosis fails a simple test of logic: if a minor scoliosis is supposedly responsible for severe low back pain, then why are patients like Becky still able to walk? Shouldn’t they be crippled?

As if it weren’t bad enough that therapists tend to exaggerate the clinical importance of mild scoliosis in low back pain, they often diagnose scoliosis where there is simply none at all.

Many, many times in my hands-on career I was told “my other therapist says I have scoliosis,” but I could only see it if I squinted and used my imagination. Although technically any spiralling of the vertebrae is scoliotic, subtle cases just don’t qualify for the diagnosis — “the incidence of significant scoliosis is low” write the authors of a large 1999 study of scoliosis screening.305 They also think a common screening test for scoliosis (a test I’ve used many times myself) is probably deeply flawed.

Low back pain patients have enough to worry about without being told that they have scoliosis when it probably wouldn’t be clinically important even if they actually had it. Worse, they may not have scoliosis at all, or it’s so mild that you could argue about whether it’s there.

Just as scoliosis is unjustly blamed for much more back pain than it probably causes, many therapists also bizarrely claim to be able to cure scoliosis — to straighten the twisted spine. This will be debunked further along in the tutorial.

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There is a connection between sneezes and some back pain, believe it or not. What does it mean when sneezes hurt?

Sneezes violently contract many of the muscles of the trunk and also dramatically compress the abdominal contents.  Pains that occur only or mainly with sneezes suggest a problem that is particularly sensitive to abdominal pressure, and/or a problem that is relatively minor, noticed only during the intensity of a sneeze.

Any pain easily triggered by spikes in abdominal pressure should be checked with a doctor. There are several possibilities. Many are no big deal. Some are a bigger deal. You may be able to recognize a big-deal problem by looking for the symptom in non-sneeze situations. For instance, coughing is less intense than sneezing, but still increases abdominal pressure: if you notice the pain when coughing as well as sneezing, it indicates a greater sensitivity to abdominal pressure. Straining on the toilet is another good example, and you can simulate that strain simply by “blowing on your thumb.”306 If these milder pressures duplicate your symptom, take note: something in your abdomen does not like relatively minor increases in pressure! That is worth running by your doctor.

On the other hand, the more this pressure-sensitive symptom resembles your familiar back pain, the less worried you need to be.

Because sneezing involves powerful contractions of muscles throughout the trunk, irritated muscles or other anatomical structures could be disturbed by this.  Most often, grumpy anatomy will be obviously painful before the sneeze, and the sneeze simply spikes the pain momentarily.  However, it’s also possible for a problem to be silent until the sneeze, and then yell when the sneeze hits.

In some cases, the spot will then fall silent again, only briefly irritated.  That pattern tends to indicate a non-muscular source: something irritable that is only a problem when directly stressed.

More commonly, the sneeze marks the beginning of a new pain: a brief spike of sharper pain, followed by a new, persistent ache.  This pattern usually indicates an activated trigger point. The muscle is irritated by the sneeze and then continues to hurt. It’s quite surprising how many back pain symptoms originate with a sneeze! Personally, I’ve had at least one notable episode of back pain that began with a sneeze.

Since a sneeze affects virtually the entire trunk, there is no way to deduce from this issue which specific trigger points to focus on. You should simply hunt for trigger points in the tissues where the sneeze causes pain (and, of course, in muscles that refer pain to that area).

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“Back mice” is a cute name for a very common thing: little fatty cysts that form in the low back.307 A lipoma is a lipid-filled cyst with the texture of gelatin. They can get fairly large, up to a few centimetres, and in very rare cases they get a lot bigger: mice elephants! Just do a Google image search for lipomas for some eye-popping examples. But nearly all lipomas are about the size of a kidney bean.

Lipomas usually feel separate from other tissue, a bit slippery, like a tiny, firm water balloon sliding around just under the skin.

Lipomas sometimes get labelled as back mice when they are symptomatic, which they usually aren’t. Once in a blue moon one of these little things will get a little irritated, usually because of minor mechanical pressure (against a chair back, say), or because it’s in a slightly awkward anatomical location (perhaps causing some minor nerve impingement308).

They are about as dangerous as actual mice, and are not very clinically interesting. Unless they are.

Not everyone agrees that back mice are trivial. There are case reports of lipomas that seemed to be more tightly linked to chronic back pain.309310 Dr. Harvey Austin wrote to tell me of his experience with them:

Early in my surgical career, I removed painful fatty nodules from the low back from eight patients and obtained relief in each. Personally, I have had multiple painful nodules removed nine times over 28 years. Each time my newly-occurring (and different) back pain either instantly disappeared or was markedly relieved.

My science-savvy readers will understand that a doctor’s experience is interesting-but-inconclusive. No matter how earnest, such reports are invariably filtered through beliefs and expectations and cannot be taken to the knowledge bank. Still, it’s a fair bit of anecdotal smoke, isn’t it?

It’s not clear why some back mice would be painful, but I’ll keep an open mind. (Dr. Austin believes that it’s simply a sub-type.311) But it’s almost certainly rare, and it’s possible — maybe even likely — that these case reports are simply wrong, and there is no such thing as a serious back mouse problem.312

Back mice might be of no clinical interest at all, except that they so often get mis-diagnosed, usually by patients. Patients often notice and fear them. They notice lipomas because they have back pain and go exploring, and lipomas are superficial and obvious and obviously abnormal.

So people think they are tumours. Which they are … technically. Just not the dangerous kind. Lipomas are basically just benign tumours.

And patients who have read anything about trigger points ever will usually mistake them for trigger points. And there’s nothing sadder than someone desperately trying to “release” a lipoma. Lipomas are one of the classic examples of common lumpy and bumpy things that fool beginners into thinking they’ve found a trigger point. Is there anything more sad than someone desperately trying to “release” a lipoma? I have lost count of the number of readers and patients over the years who have made this mistake, and this is a major motivation for finally adding this section to the book.

But a lipoma feels very different from how a trigger point feels. Trigger points feel embedded in the muscle, not something that can move around on top of the muscle.

For years I only knew of lipomas from my own work. But now I have one of very own back mice!

My pet theory about back mice

A pet mouse, in this case.

I suspect that back mice are more prevalent in a biological milieu of chronic low-grade inflammation and “inflammaging.” That phenomenon was thoroughly covered in the morning back pain chapter, but to briefly recap for readers who are jumping around: we all get a little more inflamed in a variety of ways as we age, for all kinds of reasons, some obvious, some mysterious, but generally ramping up over the years. The most prominent manifestations of this are the classic diseases of aging and poor fitness, but it’s now clear that there are many more subtle examples, such as the high prevalence of frozen shoulder in people most at risk for heart disease. I think it’s likely that there are a lot more examples yet to be discovered.

Like back mice, which definitely get more numerous with age. It seems plausible that back mice are both more common and more ferocious in people who are more inflamed. No one has tested this, of course. We’re way out in the weeds here. But it’s a solid hypothesis.

I am getting old and unhealthy. I have had a lot of serious problems with chronic pain since 2015. That drama is much bigger than this topic, but a huge increase in back pain has been part of my troubles, serious abnormal inflammation is a major suspected culprit, and I have developed three back mice — for the first time in my life — in the same period.

COINCIDENCE? I THINK NOT.

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MRI has come up several times already, always emphasizing that the tissue issues it reveals are not necessarily your problem. There is some repetition here, but I won’t re-hash the details. The point of this section is to sum up the role of MRI (and other back pain imaging) and provide some practical advice.

Short answer: yes, for severe, chronic, or otherwise ominous back pain. But there are major caveats, and a need for a longer answer.

When it comes to diagnosing most back pain, MRI machines are like Monty Python’s medical machinery that goes “bing.” For back pain, MRI and X-ray are medical machines that make false alarms.

They don’t always make false alarms, of course. MRI is a miracle technology, no doubt about it — the ability to get clear images of soft tissues deep inside the body is valuable, and extremely tempting for everyone involved.313 MRI can shine when it’s actually needed and done well.

But the sad truth is that it’s not needed anywhere near as much as it is actually used, and it’s especially not needed for most low back pain. And not doing it “well”? That’s just normal: radiology reports are usually written without clinical context, and frequently presented to the patient like diagnoses. But low back pain experts have long understood that you simply cannot reliably diagnose low back pain with MRI or with X-ray in isolation — and trying to do so reliably raises false alarms that actually do harm.314 Premature MRI is actually often worse than useless.

Wise use of MRI is great (and I’ll finish with a summary of best practices). But the common overuse and abuse of MRI is a disaster of over-medicalization.

The over-imaging debacle is official (and it has been for years)

The lameness of MRI point was pointed out firmly by the American College of Physicians and the American Pain Society in their 2007 guidelines for the management of low back pain. Bizarrely, that message has not yet reached many therapists and doctors. Scientific journals are still publishing (and re-publishing) guidelines like these — perhaps eventually the message will get through!

The most important recommendation was that doctors should avoid giving people X-rays and MRI unless the clinical situation is really rather bad, such as severe and persistent neurological symptoms. The authors labelled this recommendation “strong,” and believe the evidence to support it is “moderate.”

I think that the recommendation should now be “stronger than strong, very strong, really extremely strong,” and the evidence supporting it (already all reviewed above) can be considered “bulletproof.”

That image shows the full history of that persons life. It shows the fresh wounds that may be related to their current pains, but it also shows all of the scars that they’ve accumulated over the years. So in showing the wounds and scars, no radioloist should be giving opinons as to what features correlate with pain until they’ve seen the patient and assessed them and understood their pains. This is a general flaw in medicine. I don’t believe radiologists should write a report without the context of the pain that the person presents with.

Stuart McGill, interviewed by John Childs for Evidence In Motion podcast (2018)

The good news: it’s not actually hard to do MRI right (or at least a lot better)

Doing it right mainly means taking fancy pictures of our insides only when it’s actually needed — that is, when there are ominous signs and symptoms, or significant chronicity.

But it also means using better tools for the job as needed, especially positional and dynamic imaging, which can show problems that just won’t turn up on garden variety scans. And metabolic scans, which show inflammatory hot spots, which can highlight a joint that’s in trouble right now (versus one that merely has scars from an incident many year ago). Some of these imaging techniques have greater risks, and so the need must be even greater to justify them — but sometimes these are the only tools that will get the job done.

Most importantly, it means that imaging should be always be interpreted in clinical context. It’s not a “finding” until it connects in some way with a person’s case.

What’s the big deal? Why is it so important to actually avoid using X-ray and MRI to diagnose back pain?

No one wants a false alarm, but what’s the big deal about a few diagnostic red herrings? It’s a worse problem than you might think in (at least) two major ways …

First, you can’t un-see an MRI. X-rays and MRIs genuinely spook people! If you see something that seems like a problem on a scan, complete reassurance is nearly impossible, no matter how expertly and convincingly someone explains why it’s not actually a problem.

Second, imaging often just fails to clarify the situation, or it actually muddies the diagnostic waters. A mountain of scientific evidence clearly suggests that back pain correlates really, really badly with these test results. Many people with no pain have all kinds of things “wrong” with their backs, and vice versa. Many problems revealed by scans that seem like “obvious” problems are not. And so the diagnosis and treatment often goes spinning off in the wrong direction. This is a major part of the reason why there are such scary statistics about the economic costs of back pain.

There are exceptions — sometimes imaging finds something important — and that’s why these tests can be appropriate for some kinds of severe and persistent low back pain. But it’s just a generally lousy way to try to figure out why your back hurts.

More good news: patients can do a lot about this

Despite all the science and warnings, it is still routine for me to hear from readers who have been X-rayed by their chiropractors and MRI-ed by their doctors in the early stages of back pain. And it’s still routine for those people to be told that what was found on their MRI is conclusive evidence of the cause of their back pain. I have almost never heard of a patient who was told that signs of typical degeneration might be meaningless, even though that’s what every patient should be told.

Take matters into your own hands.

Ideally, better imaging is going to need better doctors and a better system, of course. But improvements can be surprisingly patient driven. With just a little bit of education, patients can…

• Cheerfully refuse premature imaging! If you get back pain, and someone tries to beam rays through you prematurely, just say, “Thanks, but no thanks. The American Pain Society says it isn’t necessary unless I can’t feel my legs.”
• Politely ask if other imaging options are appropriate. For instance, if you are being told that no cause for your back pain can be detected, but you have a clearly repeatable pain with a specific movement or position, ask if — perhaps, just maybe — you should be imaged in that position, or moving through it.
• Privately resolve to take radiology reports with a huge grain of salt, regardless of what the doctors say. You should also try to ask your doctor for a more nuanced interpretation of the results in clinical context, but that’s a lot trickier — many doctors won’t have any better idea of how to do that than you do yourself! The main thing is just to maintain a strong healthy skepticism.

The pros and cons of MRI for back pain (from an educated doctor’s perspective)

This is brilliant:

Comic by Patrick Lyons of Coogee Bay Physiotherapy.

This is a great comic, but not every reader is going to fully appreciate the humour in the doctor’s thoughts, so I’ll elaborate a bit:

• What’s a “bottom up understanding of back pain,” and why’s that bad? It’s the idea that back pain comes primarily from backs (bottom up), when in fact we have really strong evidence that back pain severity and chronicity is powerfully tuned by the brain (top down).
• “Greater disability scores associated with MRI utilization.” One of the most common ways of measuring the badness of back pain is “disability” as determined by a very carefully designed questionnaire. And disability gets worse (higher scores) when MRI is involved in the assessment of back pain, probably because it “medicalizes” and dramatizes. This is a nocebo effect (opposite of placebo). Basically, looking for things wrong with people’s spines makes people fear their spines, which ironically leads to hypervigilance, sensitization, and disability.
• “Reduced sense of well-being following exposure to MRI.” Very similar to the previous item! “Well-being” can be high even when you have a bunch of back pain … or it can be low. When back pain is over-medicalized — too much fancy diagnosis, scary treatment options bandied about — people feel worse about their situation. More worried!

GO TO TOP • CONTENTS • NOTES

I debated for a bit whether or not rib pathology belongs in a book about back pain, but I decided it was a no-brainer: it’s a near perfect example of an obscure but specific issue that is at the root of some cases of back pain. There’s even some cheap, safe, reasonable self-treatment options to try. Plenty of rib pain has nothing to do with the back at all, of course. Many disorders of the ribs cause discomfort only or mainly in chest, abdomen, or flank (and even lower abdominal and groin pain are possible).

But the discomfort does often extends to the back. It might even dominate it.

Rib pain also fits strongly with a major theme of this back pain book: muscle pain. One of the major ways that rib trouble turns into back trouble is probably the discomfort of exhausted muscle trying to stabilize those sloppy lower ribs.

Many patients will have no idea of the potential for ribs to cause back pain, and plenty of professionals will be just as surprised by the extent of it — because until 2023, the variability and instability of the lower ribs was simply unknown to science, let alone frontline clinicians. Ribcage anatomy is still advancing, well into the 21st Century.

Introducing slipped rib syndrome

The lower ribs are somewhat unstable, and they can slide under a neighbour and pinch an intercostal nerve (among other discomforts). This is known as slipped rib syndrome.

As I started to write about SRS, an old friend was coincidentally suffering through a nasty case of it. He had a classic and severe blaze of intense pain around one side of his lower ribcage and extending all the way into his low back. It had started suddenly with no apparent provocation a couple weeks earlier, as I was beginning my research, and it made his life hell for a few days:

“I was in so much pain I couldn’t sleep, couldn’t breathe properly, couldn’t lie down or sit, couldn’t really do anything.” So he just sweated and squirmed his way through. “It’s been backing off this week, but it’s still bad.”

This was a new experience for him, but he has a form of muscular dystrophy that has already given him a lot of back trouble, and it probably increases the risk of this rib nonsense (due to weakness of the trunk musculature). But there’s also a much more common risk factor that no doctor or physical therapist would have known about … because no one could have known about it without reading a recent study of the anatomy of the ribcage.

You’d think ribcage anatomy would be settled science, but nope! And that is what I was writing about: not only is the lower ribcage an anatomically chaotic area, but specifically there are far more floating ribs down there than we see in the textbooks … and they are slippery. It’s new anatomy that matters.

“The word ‘normal’ is probably an inappropriate word to apply to the human body.”

Dr. Ian Griffiths

Rib research that matters: a lot more floating ribs than anyone thought possible

It’s getting routine for scientists to personally tell me about their research, which is delightful. Dr. Evert Eriksson, Trauma Medical Director at the Medical University of South Carolina, read my article about anatomical variation — about all the ways that anatomy differs from one person to the next — and he thought, I should tell this guy about my rib study! Bet he’ll like that. And he did tell me, and I did like it. Very much.

One could hardly ask for a better example of an interesting and problematic body oddity. What Laswi et al. found, studying 8^th, 9^th, and 10^th ribs in forty cadavers, was a lot more free 9^th tips, and entire floating 10^th ribs, than they were supposed to find:315

1. A whopping 59% of forty cadavers had three fully floating ribs — 10^th, 11^th, and 12^th — rather than the officially standard pair.

2. And 86% of 9^th ribs had a free tip, even though they were not otherwise true floating ribs. The 9^th was always (100%) attached to the 8^th by cartilage, but … messily, and most of their tips were free floating. So the 9^th is kind of a hybrid (partly a “false” rib, partly a floater).

(Rib types: True ribs are directly joined to the sternum; false ribs are indirectly joined; floating ribs are not attached to the sternum at all.)

The general theme here is quite a lot more costal margin hypermobility and variability than expected. Even if their findings were exaggerated,316 they would still be important. The authors reasonably conclude that “the 9^th and 10^th ribs are not invariably attached to the costal margin as described in anatomy books.” Consistent with all that floating and messy looseness of the lower ribs, Laswi et al. also found plenty of subluxations and free and “upwardly hooked tips” — all potential sources of discomfort and pain, maybe downright likely sources. If free rib tips are more common than anyone realized? Well, then so are their problems.

The new normal: three floating ribs, not two

All of Laswi et al.’s findings may be anatomically significant, but the floating tenths is a bit of bombshell. The paper is respectably calm and professional about it. I can make more of a fuss about it here. This is kind of a big, fascinating deal.

No one should be surprised that there are a few 10^th ribs floating around out there — anatomical quirks are legion317 — but more than half? That’s the surprise. That’s not a “quirk”! If true, it clashes with the textbooks, and redefines “normal.”

Redefining normal is tight. (That’s a reference to a running gag on my favourite comedic movie review channel, “Pitch Meeting.”) It’s really neat when research challenges extremely long-term assumptions about anatomy!

Look at most model skeletons or anatomical diagrams and they will show just two floating ribs. I checked several standard sources, and they all described only an 11^th and 12^th floating rib, with the occasional mention of “rare” 10^th floaters. Above the 10^th, the 9^th rib is always depicted as a nice tidy false rib, merging with the cartilage that links it to the sternum.318 Extra floating ribs are often said to be common in the Japanese, a claim mentioned all over the internet, but supported with only one dubious old citation that I have not been able to find.319320 Wikipedia’s rib cage page mentions floater variation, but only barely — 10^th floaters occur “sometimes” in “several ethnic groups, most significantly the Japanese” — and citing just a textbook (not the Japanese study). But they do show the original, vintage version of Gray’s ribcage … which does include three floaters! Interesting.

Most anatomical diagrams of the ribcage show only two floating ribs — as is normal. There are probably exceptions, but this is the only one I know of: the original, vintage Gray’s Anatomy, plate 112. Notice how sharp they look! Eek!

But in all the modern renderings I checked, both the 9^th and the 10^th are tidy false ribs, with no free tips. The reality as reported by Laswi et al. is far messier and looser, with way more 9^th and 10^th rib tips roaming free than anyone has ever known.

I have to turn in my “freak” card: my weird ribs aren’t so exotic after all!

Bonus rib messiness (not covered by Laswi et al.): there’s sometimes even an extra floating rib: the 13^th!

Several years ago, I discovered that I have both a floating 10^th and a stubby little floating 13^th. I marvelled at how I’d missed those oddities for so many years — but who counts their floating ribs?! Not even me, not even with a long history of weird rib pain and a keen interest in anatomy. It simply did not occur to me.

Based on conventional anatomy, I assumed that my floating 10^th was relatively rare. But with the 60% incidence identified by Dr. Eriksson’s group, a floating 10^th is not just a quirk … it’s actually how the spine models should be built! It’s what should be in the texts! 🤯 Even if another study found “just” 40%, it’s clear that this anatomical bug/feature is actually much more common than red hair, hazel eyes, or having a tongue long enough to touch the tip of your nose. There are clearly a lot of floating ribs out there — probably a lot more than most physical therapists ever imagined.

I guess I have to turn in my “freak” membership card, because a 10^th floater is less exotic than having freckles.

But I have had many of the symptoms of “slipped rib syndrome” off and on for my entire life, gradually worsening over the years. Isn’t “normal” anatomy fun? It’s time to talk about pathology…

“59% of us float down here. You might float, too.”

Pennywise, AKA "It" (Stephen King)

What could possibly go wrong? More floaters = more pathology

Subluxations, slipped rib syndrome, and hooked tips, that’s what. ☹️ Slipped rib syndrome is the catch-all term for a variety of problems related to the looseness of the lower ribs and their stabby floating tips.321 (This is very similar to Tietze syndrome and costochondritis, but not quite the same thing.322)

These lower ribs aren’t exactly the most stable anatomy to begin with, and the floaters are especially wibbly-wobbly. The lower ribs are more chaotically and loosely attached to each other and the costal margin than conventional anatomy has ever suggested, probably even in healthy young people — and age no doubt makes it worse as their attachments to each other and to the costal margin loosen and break, the ribs sliding under and over each other, and the tips in particular making trouble by poking intercostal nerves.

The end result for many patients is back pain, flank pain, some abdominal, and occasionally even groin pain: “a complex pain response,” as Laswi et al. put it. Unsurprisingly, symptoms are triggered by practically any movement or position of the trunk. Almost any combination of consistency, chronicity, and severity seems to be possible, which makes diagnosis quite challenging. Some people experience dramatic episodes of severe pain, which may last minutes or hours or days, but they may be largely pain-free between episodes — or not! Others may live with milder and more erratic symptoms for many years, never knowing what’s going on.

The symptoms of slipped rib syndrome are as variable as the anatomy, because the pathogenesis equation is freakishly complex. There are at least four ways that these loose ribs can cause trouble:

• Subluxation (partial dislocation) is the most obvious and distinct thing that can go wrong. This is not joint subluxation we’re talking about, not a spinal issue,323 but displacement of the ribs themselves, which can cross over each other like fingers. Laswi et al. found this in 19% of 9^th ribs (despite not being true floaters), and 33% of 10^th ribs.324 That’s just as startling as the incidence of 10^th floaters, and much more direct evidence that associated pathology is probably also more common.
• Intercostal neuropathy occurs when a rib subluxation pinches an intercostal nerve. This usually feels like a burning pain in a stripe around one side of the torso, but it’s not always that simple. For instance, the twelfth intercostal nerve is linked to the first lumbar nerve … which results in bonus neuropathy: pain in the lower abdomen and groin! And so we get a sub-type of slipped rib syndrome: twelfth rib syndrome.
• Inflammation around rib tips. A rib tip does not have to pinch a nerve to cause trouble. Any rib with a pointy end — paging Arya Stark — can irritate the tissue around it.
• Cramping, exhausted, and sensitive muscle is another very likely factor — certainly as a complication, and possibly also a cause or perpetuating factor. The body probably tries to stabilize/immobilize painfully displaced ribs by tightening up the area, which might lead to fatigue and irritation as a consequence. The intercostal muscles in particular can become extremely sensitive. And muscle dysfunction (cramping and/or weakness) might also predispose someone to subluxation in the first place. How many ribs have been pulled out of place?

If there are more floating ribs than we thought, with more free tips… then all of these predicaments are probably also more common and more severe.

“Stick ’em with the pointy end.”

Arya Stark, Game of Thrones (George RR Martin)

Hooked tips on the tenths

Another interesting variation that Laswi et al. found was hooked tips on 10% of 10^th ribs — quite common. One in ten people is plenty of people.

The hook is a cartilaginous extension to the 10^th rib that curves upwards towards the 9^th.325 This is actually nicely depicted in the Gray’s drawing above: that wicked-looking curved extension to the rib!

The hook is clearly just an incomplete cartilaginous connection to the costal margin: rather than merging with the rib or cartilage above, it falls short of it to some degree, making the 10^th a floating rib rather than a false rib … but a floating rib with a barb of cartilage pointed directly at the underside of the 9^th rib! And free to slip over or under it.

Indeed, over 60% of 10^th ribs with hooks were also displaced. Do you know where the tip of your 10^th rib is?

Are rib subluxations “a thing”? Skepticism about the skepticism

I have seen several knee-jerk skeptical takes about rib subluxations over the years, overconfidently declaring that they are “not a thing.” Scoffing at the unknown is not exactly skepticism putting its best foot forward. Like so many other things in musculoskeletal medicine, it simply hasn’t been studied much. As Laswi et al. have shown, we didn’t even have the basic anatomy!

The skepticism is mostly aimed at subluxations of the joints between the spine and the ribs, and tends to ignore displacement of rib bodies. I have certainly had my own suspicions about those kinds of rib subluxations, mainly because of their conceptual and anatomical proximity to intervertebral subluxations and some of the worst chiropractic nonsense that has come from that idea. But I carefully, consciously curbed my skepticism until I knew more … and I wish skeptics as a group would do more of that. It might help a bit to undo our strong reputation for throwing babies out with the bathwater.

Granted, there are probably far more more chiropractors opportunistically exaggerating the importance rib subluxation, and profitably overstating their ability to fix it, than there are skeptics cynically underestimating it and rolling their eyes.

But I’m now “fairly” sure that the truth is in the middle: clinically significant rib subluxations of both major kinds probably do exist.326

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There’s a short chapter later on exploring self-treatment of slipped rib syndrome.

GO TO TOP • CONTENTS • NOTES

If there were proven treatments for back pain, there would be no point in writing this book, now would there? Therefore, debunking is inevitable. The science is firm: all popular treatment options are annoyingly weak.

The best review of back pain science I know is almost entirely bad news: a 2009 paper in Rheumatology (Oxford) by Machado, Kamper, Herbert, Maher, and McCauley.327 It’s a meticulous, sensible, and readable analysis of the very best studies of back pain treatments that have ever been done: the greatest hits of back pain science. (Clinicians with any interest in reading science should definitely read this paper. Many patients will probably find it a little too science-y.)

The results were sad and predictable, a robust evidence of absence:328 “The average effects of treatments … are not much greater than those of placebos.” They were also strong reinforced by another pair of similar studies, which showed not only the same thing, but also that people who participate in all kinds of back pain studies fare no better (or worse) than people who don’t.329330

All that science, and all we know is that nothing popular works well. Of course, this has been obvious for many years to all serious observers of the subject. It’s also obvious to most people with chronic back pain.

What if even these good studies are wrong? What if back pain science is missing perfectly good treatment effects? There are a couple popular theories about this, but Machado et al also did a good job crushing responding to those hopes. So, no, studying just the right patients (subgrouping) probably won’t redeem any treatments.331 And, yes, there is plenty of room for big treatment effects to show up332 — if only they existed.

So give up? Hardly

Given such discouraging science, what are we doing here? Why even bother? Simple: we have lots of latitude for educated creativity and guess work about what might help your low back pain! And almost no latitude at all for a definite treatment plan.

Before I dive into the treatment options, I’d like to respond to a common reader concern that I do too much “debunking,” and not enough telling you what works and exactly how to do it. Although I get few refund requests — way below industry averages — most of the requests I do get are caused by this specific concern: Doesn’t $20 get me a road map to a cure? A step-by-step action plan? The savvy exercise regimen that will make the pain stop?

These things just don’t exist, as I warned in the introduction. I have not sold you a book without mentioning that.

Even if they did exist, prescribing a treatment “plan” is simply out of the question, because every case really is different — that’s not just a platitude. What works for one person really is not going to work for the next. I promise that I’m not holding out on you. I am not a cure salesman, and I will not tell you what you want to hear. There is no specific method or series of logical steps that will reliably cure any kind of chronic pain problem, least of all the tough kind I write books about.

No plan survives contact with the enemy.

Helmuth von Moltke the Elder

Many people reading this probably think plenty of debunking is quite reasonable, normal, and even ethical. But imagine some of the unreasonable expectations I hear from a few customers. For instance, one woman asked me for a refund because my book offered her “only suggestions”! What else is there? What did she expect? Binding arbitration? Click this link for a cure? Free magic wand with every purchase?

Historical perspective and the Age of Hype

The disappointing truth is that there is only a motley assortment of rather underwhelming options with complex pros and cons, but usually more “cons.” Some are better than others, but quite a few are dodgy, for obvious reasons: hope sells, and so there are many more poor options than there should be. Please blame reality for this … not me.

And blame the people who have given you false hope and raised your expectations of musculoskeletal medicine far beyond what it can possibly deliver.

We are living in the “Information Age,” but sometimes it seems more like it’s the Age of Marketing and Hype. An almost unbelievable amount of the information we consume is generated to promote products and services. The result has been an unprecedented flood of being told what we want to hear about absolutely anything.

The reality is that musculoskeletal medicine is surprisingly primitive. Medicine has always had bigger, scarier fish to fry than treating mere aches and pains and injuries, which were barely studied at all until the 1980s. Musculoskeletal medicine is still a cocky teenager, just starting to come of age and figure out that it doesn’t know everything. Even sports medicine specifically, with so much potential funding and relevance to occupational injuries, has been bizarrely slow to build its evidence base.

The trouble with pseudo-quackery: treatments that seem way more legit than they are

The most prominent problem in musculoskeletal medicine today is the prevalence of what I call “pseudo-quackery”: treatments that are about as sketchy as any old-timey snake oil, but seem modern and scientific and mainstream. A few classic examples: laser therapy, ultrasound, platelet-rich plasma, prolotherapy, nerve and muscle stimulation. But there are many more.

These disguised quackeries are actually based mainly on surprisingly stale tradition, speculation, and authority. They generate more false hopes and wasted time, energy, money, and harm than more traditional quackery because they are vastly more popular and very much part of mainstream medicine, or very friendly with it — even many hardened skeptics aren’t expecting snake oil when they go to see a physical therapist or an orthopaedic surgeon.

So musculoskeletal medicine is a minefield, and a lot of debunking just goes with the territory. But it doesn’t mean there’s no good news at all.

The good news

Despite all the debunking and disappointing evidence, I do indeed have positive things to say about several of the options. I have started this part of the book with a summary of all the options, and I will conclude it with another summary of my recommendations, focusing on the positive as much as possible, and what to actually do. Many things are worth trying, even if they aren’t sure things or sitting on any solid science:

We’re told to strengthen this muscle or stretch that one, or inject this substance into an injury, or zap it with heat or electricity or ultrasound … and sometimes it really works, even though placebo-controlled trials fail to validate the treatment. I’m a big advocate of better science to really understand what causes injuries and how to treat them — but in practice, I also believe that sometimes it’s worth trying something, anything, just in case it successfully ‘reboots’ your injury.

Alex Hutchinson, Sweat Science

An encouraging perspective, but of course it doesn’t mean you should try any old nonsense. And you may save some time and money avoiding several others (or at least re-prioritizing them). You may even avoid the heartbreak of those that can do some harm. Knowing what not to do is half the battle, if not more! Understanding the topic well enough to prioritize the imperfect options is actually a huge win, the best you can realistically hope for.

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The “negativity” of ratiocination is a surprisingly big topic, often funny, and sometimes profound. I answer the accusation in more detail in a compilation of tales of outrageous hate mail, the ethics and tactics of debunking, what it’s like to (supposedly) be the #1 Public Enemy of Massage (a therapy everyone loves to love), and — my favourite — “advanced negativity,” a discussion of how cynicism is baked into science in the form of the null hypothesis.

GO TO TOP • CONTENTS • NOTES

A placebo is relief from belief: people often feel better simply because they believe they have been treated. More precisely, it is the appearance or illusion of a treatment effect that is not actually attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is over-hyped.

This is a standard section in most of my books, covering several key points about placebo that are important context for any thorough discussion of evidence-based treatment options. I do not substantiate any of these points here — all the references are in a more detailed article about placebo.

• Placebo is not just one phenomenon — “the” placebo effect — but miscellaneous illusions that can collectively create the appearance of an effective treatment. Placebo is complicated!
• Placebo has a special relationship with pain. Reassurance (placebo) has more potential to relieve pain than most symptoms, because pain is strongly modulated by perception. But that only goes so far.
• Placebo is not a magical mind-over-pain superpower and its effects tend to be minor and/or brief. It can’t affect injury and organic pathology; it can only tinker with our experience of them.
• Placebo can also backfire. When a placebo effect wears off — as it usually does — people often fear that they must be really screwed, and then placebo turns to nocebo, placebo’s evil twin: feeling worse because of belief.
• Placebo potency is driven by whatever impresses the patient with the seriousness and legitimacy of treatment: risks, costs, size, intensity, technology and even odd minutiae like the colour of pills. This is why we have the concept of “therapy theatre” — because so much therapy is all about putting on a show.
• One of the best ways to impress people is with novel and intense sensations, because the patient can feel the “power” of the treatment. This is the basis of most manual (hands-on) therapies: they are sensation-enhanced placebos (“interactive therapy theatre”).
• Placebo has been hijacked and re-branded for its public relations value to alternative medicine. If your treatment isn’t evidence-based, no worries: you can still sell the power of placebo! “The power of placebo” is widely, weirdly used as a justification for therapy that can’t beat a placebo.
• Placebo does not work when you know it’s a placebo, contrary to what many people have heard (based on a couple bad scientific papers). The popular idea of “placebo without deception” is just bullshit, based on an experiment that created a strong expectation effect by inflating the participants’ expectations of placebo. So it was just an odd way of getting to the same phenomenon.
• Many snake oils supposedly work on animals, and if animals are immune to placebo then the treatment must be legit. But animals (and their biased human observers and caregivers) are definitely not immune to placebo. In fact, with animals there is even more opportunity for an illusion of a treatment effect.

We have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo.”

Book Review, Unlearn Your Pain [Schubiner], by Scott Alexander

Is it okay to pay for a placebo?

Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And placebo can work! So why not? This is an extremely common sentiment, raised in most discussions about a treatment that failed to beat a placebo in a fair test (invariably overlooking the fact that neither the treatment nor the placebo actually work very well).

I have no problem with people paying for a placebo as long as their eyes are wide open, but the wider your eyes get the less likely you are to get even a minor benefit.

And paying for things is never completely harmless.

Treatments with unknown efficacy but some plausibility and low risks are the least objectionable placebos to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual effect, and I’m willing to pay a little for that chance. I’m gambling on getting a genuine benefit, with a bit of placebo as a consolation prize. So, for me, the plausibility has to be there.

Comic by Loren Fishman, HumoresqueCartoons.com.

What I want readers to take away from this is that placebo is not therapy. It’s mostly just an over-rated curve ball that accounts for an awful lot of temporary “success” stories.

GO TO TOP • CONTENTS • NOTES

In the classic science fiction novel, Dune, the Jedi-like Bene Gesserit use the “litany against fear” to focus their minds and calm themselves:

I must not fear.
Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear.
I will permit it to pass over me and through me.
And when it has gone past I will turn the inner eye to see its path.
Where the fear has gone there will be nothing.
Only I will remain

“The Litany Against Fear” (Dune, by Frank Herbert)

A lot of back pain patients could benefit from the “litany against fear,” because fear is also the back killer. And what’s good for fear? Confidence, powered by knowledge. Educational therapy.

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The “confidence cure” is both more than you expect and less than you’d hope. It is surprisingly powerful, but it won’t be enough for everyone. It’s easy in principle, but difficult in practice.

We’ve established that stress is probably a major factor in most low back pain — both life stress and stress about low back pain itself — but reducing stress is a stumper. How do you do that, exactly? Most people really don’t know how to “reduce stress” — the imagination falters after “meditation or yoga” and possibly “beach holiday.” I devote an short chapter below to why you don’t have to bother with yoga and meditation — unless you want to, of course.

So what does stress reduction look like? What actual practical steps can be taken to relieve both the stress of life and the anxiety caused by back pain?

You are already doing the most important thing: reading this tutorial, learning, and starting to master the subject is the number one thing that you can do to “reduce stress” about the low back pain itself, and reduce the impact of other stresses on low back pain. Simply being well-informed is a bit of a magic bullet for back pain.

Knowledge is in every country the surest basis of public happiness.

George Washington, 1790

Some good news? Education probably works, maybe

What I’m calling the “confidence cure” is a more specific version of what’s more broadly known as “pain education,” or more formally known as “cognitive-behavioural therapy,” an umbrella concept for many therapeutic approaches that boil down to the idea that you can break out of back-pain prison by thinking and acting differently. If that sounds a bit weak to you, science agrees: in 2010, a major review of all behavioural therapies had a predictable disappointing conclusion.333

But there are many ways to think and act differently! Until 2013, nothing quite like my “confidence cure” had really been tested properly. I’m pleased to report that it passed its first decent test handily.334 Statistically and clinically significant results for a back pain treatment? Pinch me!335

Specifically, researchers tested classification-based cognitive functional therapy (CB-CFT, or just CFT). You can see why I prefer to call it the “confidence cure.” They describe it as “person centred, body/mind approach to understanding and managing this complex problem” that “targets the beliefs, fears and associated behaviours” of patients. “This approach aims to build self-efficacy, confidence, adaptability and provides hope and opportunity for change for the person with pain.”

That’s the spirit of my confidence cure all right. (There are some hair-splitting differences from other kinds of cognitive-behavioural therapy, but that’s such a boring tangent I’m not even going to put it in a footnote.)

The results of the test were not amazing, but they were satisfyingly good. “Disabling back pain can change for the better with a different narrative and coping strategies.” In particular, CFT beat the benefits of manual therapy and exercise by a wide margin.336 So CFT is now the king of the back pain treatment hill: not necessarily the best back pain treatment, but the best as far as we can tell from the evidence so far.337

By far the biggest problem challenge with the confidence cure is making it practical, understanding and applying it. So, how is it working? What’s the mechanism? Here are three important ways in which educating yourself may directly help low back pain:

1. Most stress is caused by a lack of information and control. When we understand the nature of our back pain better, it becomes less threatening, and this interrupts one of the most potent parts of the vicious cycle. Stress may continue to be a significant force in other parts of your life — having information about back pain does not give you control over, for instance, your difficult job or your challenging marriage! — but it’s unlikely to continue to express itself as back pain when low back pain no longer seems all that scary.
2. One of the main reasons that we have back pain when we are stressed is that backs are a good “hiding place” for stress, because most people never suspect that back pain is often an expression of anxiety. It’s a sneaky way to be nervous and frustrated without seeming nervous and frustrated. But once we know what we’re up to, the back is no longer a good hiding place for stress — and the vicious cycle of fear, pain, and immobility is interrupted.

3. Good information taps into the potency of placebo — the impressive effects of belief and perception on a surprising variety of pain problems. John Sarno claimed that this is the rationale for his successful back treatment method: “ … placebo works at an unconscious level, depending on ‘blind faith.’ What I discovered was that faith or belief in a concept could have a powerful, permanent therapeutic effect if it was based on accurate information” (p89-90), my emphasis. Basically, when you actually understand that your back is not in danger, it feels even better than just taking it on faith.

So that’s how confidence alone might put an end to a lot of back pain. No meditation or yoga required. No heroic efforts — many of which are likely to be ineffective — to eliminate stress in your life (and the effort may be nearly as stressful as the stress you are trying to eliminate). Life is stressful, and there’s not actually all that much that we can do about it. Most people’s lives are full of unpleasant challenges to their peace of mind. Realistically, hardly anyone does enough good yoga/meditation to solve these kinds of problems!

A more practical solution for back pain, therefore, is the knowledge and acceptance derived from education.338 By reading this book, for example. The goal is not to cure all life stress — but to keep it from causing back pain, simply by being well-informed and therefore confident, unafraid, active.

So what does modern pain education look like? It is not reciting pages from a textbook or giving a patient ‘the pain talk’.

Moseley, 2018, British Journal of Sports Medicine

Simple, but not easy

Skeptical? Can treating back pain really be as easy as just learning about back pain? Isn’t this “too good to be true”? it is not actually “easy” at all. Most people require lots of convincing and education before this strategy can have much of an impact — there’s nothing easy about that at all. Most people start out not only not understanding what’s needed for reassurance, but cling to a long list of myths and misconceptions.

If you can actually work through all of that, confidence really does work quite well … and it is a heck of a lot easier than achieving inner peace. This is where the whole notion of “mind-body medicine” really starts to pay off substantively for large numbers of people. The mind has the power to aggravate myofascial pain syndrome and low back pain … but, with some training, your mind also has the power to treat it.339 And this is grounded in good evidence. How people feel about their back pain is an incredibly important factor in the course that it takes.

Jonathan Berkowitz is a statistician at the University of British Columbia whom I am happy to know personally. He is more articulate and more sensible than many members of that profession. He contributed to a large study of factors that predict how quickly people with back pain will return to work; his job was to crunch the numbers. Dr. Berkowitz described to me his amazement as he examined the data. He couldn’t quite believe what he was seeing. No matter how he worked the numbers — and he tried it every which way — the conclusion was unavoidable: the patient’s expectations were the single most significant factor in the duration of their recovery!340 All other factors were significantly less significant.

“Basically, what the numbers clearly showed is that, if you think you’re going to get better and go back to work,” Dr. Berkowitz explained, “you’ll probably get better and go back to work!”

This is why Dr. Bogduk, a very medical man, believes that the most important thing a health care professional can do to prevent acute back pain from becoming chronic back pain is to “treat the patient nice and convince him that there is nothing so horribly wrong” (referenced earlier). Low back muscle pain is all about vicious cycles: the tendency of injury to aggravate MPS, of MPS to aggravate injury, of stress to aggravate MPS, of MPS to cause pain and fear, of pain and fear causing immobility, of immobility causing tissue stagnancy, spasm and MPS, and on and on. Awareness works because it is a way to break the cycle. It gives us some leverage. So, you are likely to feel better if you know that:

• there is no structural problem
• you won’t need surgery
• stress is a root cause, but that doesn’t mean you have to fix your entire life
• muscles cannot be seriously damaged by MPS
• you don’t have to give up playing tennis (or squash, or golf, or whatever activity you would hate to lose)

And, therefore, confidence alone can significantly reduce or eliminate a lot of tough cases of back pain — even stubborn ones that have been going on for years. In fact, paradoxically, it may even work particularly well on the toughest cases — tough cases are often tough because of persistent anxiety and fear. Thus, those cases are particularly susceptible to the confidence cure.

It is interesting to speculate how the world got along without back surgery for so long. I suspect that even though the family physicians of seventy-five years ago were unaware of the existence of TMS, they tended not to take back pain or “sciatica” very seriously. Mustard plasters were widely used and probably brought about relaxation of muscle spasm through the heat generated by the plaster. Sometimes folk medicine is more sensible than “modern” medicine. In any case, I suspect that the low-key, non-threatening approach to back problems characterized by an earlier time helped to prevent the kind of long-term, disastrous courses that exist today.

Dr. John Sarno, Mind Over Back Pain, p32

If I were you, I might well be shaking my head by the end of this section. It might seem, yet again, like I am breaking my promise that this is not an “all in your head” theory of low back pain. I still swear that’s not what’s going on here. I’m still talking about how your mind and brain interact with issues in the tissues — genuine provocations, not phantoms.

But you still need more information. In particular, I’ve found over the years — after lots of questions by email — that readers need to understand that the confidence cure is not just a placebo.

If education works, why isn’t it a better known option?

In a 2018 editorial for the British Medical Journal, Dr. Lorimer Moseley explains that “education is universally recommended as first-line treatment for acute and persistent back pain, but it attracts little attention.”341 It’s “always first line but never headline.” Why? It’s not because healthcare professionals “just get it,” unfortunately. Dr. Moseley:

Most doctors (although there are precious exceptions) do not know what [pain education] is, do not know how to do it, do not have the content knowledge and, even if they did, do not have the time. Yet without education, the rest of best practice care— advice to remain active, to exercise or to seek psychological therapy—makes absolutely no sense. To the person with back pain, best practice care without education looks very much like, “we don’t believe you; there is nothing we can do; snap out of it, get back to work and see a shrink.” It is insulting, illegitimatising, and infuriating.

Dr. Moseley wraps up by concisely making the case for back pain education:

Contemporary pain education is potentially more powerful for persistent pain than drugs and as powerful as anything else we can offer. Education is a missing link that would actually make advice to be active, to exercise and to consider psychological therapy a sensible strategy for back pain. Research shows that when someone with persisting pain begins to understand their pain, they actually engage in active, psychologically informed strategies and can have drastic reductions in pain and disability over the next 12 months; for these people, recovery is back on the table.

Truly excellent outcomes are possible for those persistent pain sufferers who take on the journey of retraining their overprotective pain system to be less protective. Contemporary pain science offers compelling reasons to suggest that recovery is within the realms of possible for many persistent pain sufferers. There is genuine hope—not for a quick fix but for a pathway to gradual recovery. It is not for the faint hearted, but people with persistent pain seldom have faint hearts.

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The opposite of rational, informed confidence is “wishful thinking” — and it is the single biggest threat to the health care consumer. When you’re in pain, it’s easy to hope for a cure where there are only promises. Snake oil salesmen know this — in fact, they depend on it. They know that people are particularly vulnerable to wishful thinking when they’re suffering from low back pain, and they exploit it in a big way. It’s a particularly scummy flavour of intellectual dishonesty.

The most familiar example of a rational, informed confidence cure: frightened by a strange and unpleasant symptom, you go to a good doctor. She compassionately chuckles and authoritatively explains why you have nothing to worry about: the condition is common and easily treatable. She spells it out for you, and she’s probably right: she is speaking from plenty of direct experience. If she says it’s not a big deal, it probably isn’t! You walk away not only with some “real” medicine … but feeling much better before you even take it.

That’s not the “placebo effect,” even though similar forces are involved. A placebo is based on a deception. But there’s no sugar pill in this scenario.

The confidence cure works its magic on patients in pain in several ways, but the main way is that “pain is an opinion” (Ramachandran) and “100% of the time, pain is a construct of the brain.” (Moseley).342 No matter what is happening in our bodies, it is the brain that decides how dangerous it is and whether or not it hurts and how much. Authoritative reassurance changes the pain equation in a meaningful way. In fact, it literally changes the meaning of your sensations. This is why it is increasingly considered real therapy to educate patients about how pain works:343 to deliberately induce a confidence cure.

All pain problems can freak people out. Many common painful conditions are characterized by strong patient fear and anxiety that — sadly — does not get relieved, because so few health professionals understand pain well enough to offer credible reassurance. For instance, with low back pain, fear is usually way out of proportion to the true severity of the problem. And not only is reassurance tentative and ineffective, many health care professionals will actually scare the patient by reinforcing any number of common, ominous-sounding myths about low back pain.

So reassuring a patient in pain does not create a “placebo,” per se — it’s not fake medicine and a comforting lie. There’s a genuine therapeutic effect there, but it’s based on rational, informed confidence.

But placebo also has a “genuine therapeutic effect,” doesn’t it? Aren’t we always hearing about the “power” of placebo? In both cases, the patient has been led to believe that they are going to be fine, and that belief in turn can actually reduce pain and suffering. So what’s the difference? Why is it fine to aim for a confidence cure … but sugar pills are ethically verboten? It’s complex, but the medical ethicists have been working on that question for a long while now, and there’s a strong consensus: it’s not okay to fool patients. In treating pain, there’s a particularly good reason for that.

A placebo is not a long term solution!

Placebo is not so powerful after all.344 Much of what is labelled “placebo” is actually just the appearance of an effect created by statistical and research glitches. What remains is relatively trivial. Dr. Steven Novella:

Placebo effects are mostly just as much an illusion as precognition or talking with the dead. Pain is the notable exception, which makes physiological sense. Pain is a subjective experience, evolved to have adaptive features that are highly situational. There are times when pain should be very bothersome, and other times when it’s more adaptive to be able to ignore pain. So it is no surprise that mood and expectation have highly influenced the reporting of pain.

To the extent that you can really change people’s moods and expectations about pain, they really will experience less pain and suffering — but often that is still not much better than an illusion. The big problem with a placebo for pain is not just that it’s ethically wrong to get it by lying to patients, even for their own good, but also that it doesn’t work very well. The therapeutic problem with fooling people with a pure placebo is simply that most people rarely stay fooled for long! And when they wise up, they usually end up more hurt and scared than ever before.

And bitter.

But if you can get the same soothing effect on pain without lying, not only are you morally safer, but — and this is the important part — you also get a much more robust effect.

For instance, consider the example of a true snake oil, a therapy that is expensive and totally bogus. (It’s so tempting to give examples! But I’ll steer clear of that, so that the point isn’t derailed by controversy. Or manufactroversy.) Initially, a placebo effect will be powered by mostly the charm and conviction of the seller, and the desperate hopes of the patient. But most patients — even many of the suckers — have that little voice pestering them: “Is this stuff crap? Did I just waste my money?” Rather than true confidence, most people who’ve spent a bunch of money on questionable therapy are watching anxiously for the first sign that they wasted their money.

And of course those signs come quickly, because it’s a bogus therapy. That’s when hope rapidly turns to ashes — so much for that nice placebo effect.

The beauty of an ethical confidence cure is that you get a much more lasting effect — one that is much less likely to be taken away from you later by the discovery that you were being ripped off or just told what you wanted to hear. That’s the difference: a placebo is not a long-term solution, but rational confidence based on good information is. And it’s a huge difference. Therapy must not induce placebo through disingenuous means or use that weak sauce to justify treatments that have no other effect.

Knowledge reduces uncertainty, which reduces stress and anxiety, which reduces pain. It is the job of shamans, not health care professionals, to bullshit their way into a placebo effect for their clients.

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This chapter is about “coping,” which sounds kind of lame. But here’s the thing: when it comes to back pain (more than any other chronic pain condition I can think of), coping is actually a lot more potent and useful than it sounds.

From a 1998 paper by Hadler and Carey, “Low back pain: an intermittent and remittent predicament of life”:

The tragedy of the past 50 years of the approach to the management of back pain in advanced countries is that we’re treating the wrong illness. We hear the patient complain of back pain when we should be hearing the patient proclaim, ‘My back hurts, but I’m here because I can’t cope with this episode.’ If we could learn to listen to this chief complaint, perhaps we can tackle the impairment in coping, which is the illness that renders the predicament of back pain intolerable.

Is that really what the patient is proclaiming? I have a love/hate relationship with this statement. On the one hand, back pain is largely incurable, and there’s a lot to be said for focussing on the more achievable goals of symptom relief and better coping. “Just give me the good stuff, doc!” Whatever that is. (It’s obviously not opioids anymore.)

But I’ve also seen many people legitimately cured of back pain: diagnosed and treated competently, with a genuinely happy ending. Sometimes without any apparent change in their bodies. It’s not like anything anatomical got “fixed.” I have seen too many stories like that to be comfortable framing the desperate pleas of patients as a request for help merely “coping.” Why not both? I am sure that, in addition to coping, patients also want diagnosis and treatment — which is undoubtedly possible in many cases.

Perhaps the lack of widespread back pain expertise is a more serious problem than failing to “listen to this chief complaint.” We’re not “treating the wrong illness,” we’re treating it ineffectively, because we don’t understand it well enough yet: too many known unknowns and unknown unknowns. Too much of a tangle of factors in many if not most cases.

But then, on the other hand, maybe good coping is actually the road to a cure for some patients.

Wait, what? Did I just say that “coping” could lead to a “cure”? Come again?

The hiearchy of treatment goodness falls apart when applied to back pain

The best possible treatment for any condition is a cure — removing the problem, like pulling the thorn from the lion’s paw. A specific cure is routinely impossible in low back pain. It is only possible in a handful of cases where a treatable cause be definitively diagnosed. But we usually have no idea where the “thorn” is, and there may not be one at all, because it’s so clear that the injury model of back pain doesn’t explain most cases.

The next best thing to a “cure” is effective symptom relief, which doesn’t actually solve anything, but at least you feel better. This is goal of all pain medications. Symptom relief is the only goal in cases that are dominated by chronic pain, since the cause of the pain is usually unknown and/or incurable. Symptom relief often gets a bad rap just because it’s not a cure, but don’t knock a bit of good symptom relief if you can get it!

The next best thing after symptom relief is effective coping strategies: things that in no way improve the condition, but they do make you happier and more functional in spite of it. This gets a bit weird because “happier” and more confident people — as I explained in the last chapter — may actually feel less pain, and so effectively that gets upgraded to true symptom relief.

And then it gets even weirder, because maybe the root cause of the problem is actually sensitization — pain driven by fear, anxiety, stress, catastrophization — and so making that better could even get upgraded to curative.

In other words, what is typically seen as the bottom tier of back pain management, mere coping, might be very important. The entire field of occupational therapy is largely devoted to helping people be happier and more functional in spite of their chronic pain, but the great hope is that doing so will actually relieve symptoms or even solve the problem in some cases.

This is a wide-angle view of the justification for all kinds of squishy approaches to back pain treatment that are not obviously “curative,” but should still be taken seriously.

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Relaxing? Or scary?

Yoga classes are allegedly relaxing — in reality, they can be emotional pressure cookers, inflicting intense performance anxiety & self-consciousness about fat & fitness on the participants.

For those who like the idea of meditation and yoga as therapy for any chronic pain, there are other chapters for that:

• Meditation [work-in-progress, fall 2022]
• Yoga (new as of Oct 2022, and this chapter is particularly substantial)

But if they are not your cup of tea? This chapter is for you. If this particularly interests you (or you want to share it with someone), there’s also a longer, free standalone article about this, which tackles several more related topics: more detail about risks and harms, the bad attitudes and toxic belief systems of yoga and mediation, alternatives to yoga and meditation, and the “condescension” factor.

•

Mindfulness and contortions on a thin foam mat are not everyone’s cup of tea. And, although I know this will shock you, these activities are not as scientifically validated as the hype suggests — especially as treatments for back pain and other common musculoskeletal issues, where yoga looms particularly large.

The reputation and popularity of yoga and meditation are oppressively immense, eclipsing other options. People feel that they “should” try them to reduce stress and contribute to a healing process, and have trouble thinking of any other way of responding to pain and stress.345 They actually feel guilty for not trying them or for not liking them. Tyranny!

Yoga and meditation obviously appeal to lot of people for a lot of reasons. Yoga in particular may be good for our general health and fitness.346 But rest assured that they are not the only options — particularly for relief from stress and pain — and no one should be feeling guilty about passing on them. You have my permission to ignore them. And I think some people need that permission.

The original “dead or pretending” comic is by Spaceboy Can’t LOL: Facebook, Instagram.

People just cannot resist suggesting their favourite remedies to people who say they are in pain. Yoga & meditation may actually be the two single most popular choices.

Many people are poor candidates for yoga and meditation

Many productive, energetic people find it difficult — almost alien — to invest in subtle or indirect methods of self-improvement, and find the quiet challenges of meditation particularly exasperating. Many are allergic to the many bogus claims associated with it (like reprogramming your DNA? sheesh).

Mindfulness is particularly a mess: excitement about its potential reaches far beyond the evidence.347 Even for those who can get past all the bullshit and New Age nonsense may still have a personality conflict with the slow pace and calmness required, and their learning curve will feel steep; climbing it while coping with chronic pain, or acutely stressful life events, may not be a practical solution — and yet these are the very conditions when people are most likely to think they should “try yoga.”

But many people never liked the idea to begin with! You know who you are, and you’re not alone. Plenty of you suspect that all “that flaky stuff” is a cure that’s worse than the disease. You are more likely to be successful reducing stress the standard “Western” way, by “blowing off steam” with exercise! Which can be a great idea, except that blowing off steam is often not an option if you are struggling with pain and injury. In fact, one of the biggest stresses in your life may be the loss of exercise, which was the only stress-management strategy you took seriously.

Many people have noticed this exasperating catch-twenty-two: they noticed that stress aggravates their pain … yet they have to solve their body problem before they can exercise again as a way to reduce their stress! Exercise can’t be the solution to stress (or pain) when you’re in too much pain to do it.

That’s frustrating. Stressful, even!

Are yoga and meditation popular? Yes. Mainstream? Not so much

As popular as yoga and meditation are in the world today, they are still not quite mainstream.348 (Indeed, they are part of the “popularity myth” of alternative health care.349)

Even most of my massage therapy clients — several hundred of them from 2000–2010, and a “skewed sample” if there ever was one — had only dabbled in them, at best. (Nor did they ever report any success more significant than “taking the edge off” their stress or their aches and pains.)

When corporations start prescribing yoga and meditation

Y&M may not be truly mainstream, but it’s certainly not for lack of trying! This is a truly perfect example of what I mean be the “tyranny” of yoga, so good that I knew the second I saw it350 that it would have to be prominently added to this article (which hasn’t change much in years):

EVERY COMPANY: We’d like to promote mental health in the workplace.

EMPLOYEES: How about hiring more people so we feel less pressured? And maybe increase our pay a bit so we can keep up with the spiraling cost of living, so we’re not so stressed out?

EVERY COMPANY: No, not like that. Try yoga and meditation.

Hilarious and all-too-true. Don’t get me wrong, yoga can be great, but all normal people know it’s an irritating and inadequate default prescription for stress.

The potential harm of yoga and meditation

This is basically a chapter about why you shouldn’t feel obligated to try yoga and meditation, especially as rehab for your injury, or medicine for your painful problem. How’s “it could make things worse” for a reason?

Yoga in particular isn’t entirely safe, and even meditation has risks! Yes, seriously.

Independently of the direct safety issues, yoga and meditation instructors also aren’t exactly known for their love of science, medical knowledge, or staying in their lane — so you can get some pretty bad advice from them.

But of course the most likely risk is simply wasting your time and money on an activity you don’t actually even like, but you pursue anyway because you think you “should.”

Even weirder hazards of yoga and meditation: you might join a cult (oops)

“Maybe people who meditate for an hour/day are happier because they live a life that affords them an hour/day to meditate.”

Ginny Hogan, Twitter, Dec 17, 2021

Ginny made a good, basic point about self-selection and confounding factors. But the defensive and condescending responses! Yikes! They demonstrate the problem this article is about: too many fans of meditation are far too easily offended, ideologically overzealous, almost cultish. It’s a huge turn-off for most normal people. And it gets worse.

In early 2021, Cécile Guerin reported for Wired that the yoga world is riddled with anti-vaxxers and QAnon believers: “In my day job, I monitor the spread of online disinformation and conspiracy theories. I never expected to find them at my yoga class.”

Seems like one of the most obvious places for them in the world, based on my direct experiences with yoga classes, not to mention all the yoga nuts in my inbox over the years, demonstrating their spiritual sophistication by shrieking at me in all caps — the “Fuck you, Namaste!” phenomenon.

When you open your mind too far, all kinds of crap can get in there, and that’s why New Age bullshit is not harmless. Guerin’s findings are a textbook example of how magical thinking is a slippery slope to much more dangerous and all-consuming beliefs. If a place is badly polluted with pseudoscience, it’s not a “healthy” place — it can’t be. And it’s downright hard to avoid the flaky nonsense in yoga studios.

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Conventional self-improvement and life-improvement (problem solving) is the most straightforward alternative to yoga and meditation for general stress relief.

For people struggling with a difficult and slow healing process — low back pain or otherwise — I recommend that they “get personal” with their problem. Sometimes it’s a matter of just learning new coping skills for a pain. And sometimes people need to come to terms with the fact that years of self-sacrificial workaholism, for example, may be the primary factor in severe chronic pain. Usually the truth is in the middle: healing requires a complex mix of coping skills. Through this kind of learning, many people find long term relief.

Whilst the problem is superficially a physical one, the real challenges faced by someone with chronic pain are mental. Mental state is the biggest modulator of physical pain. Things hurt more when you’re stressed or sad, and the increased pain makes you both stressed and sad. The way out of this vicious circle is a wholesale change to how you perceive fear, suffering and setbacks.

How chronic pain has made me happier, by Rob Heaton

Psychotherapy has a role here to: not as therapy for back pain, but with the much broader goal of general sel-improvement Unfortunately, rare indeed is the low back pain patient who will even consider seeking psychological help as a component of treatment, even though it seems to be an obvious opportunity. Even when people do believe that emotional stresses are a major factor in their low back pain, the stigma against “psychological” and stress-related problems is strong! So strong that many people will avoid the most straightforward solutions to it.

But, gosh … ! If you are suffering from severe symptoms that are a physical expression of a life out of balance, it makes sense to see a mental health care professional! Doesn’t it? Food for thought.

Of course, there are nearly infinite ways of approaching this challenge, and I’ve written about it in several ways. I discuss the theory in detail Why Do We Get Sick?, and I get more practical in Pain Relief from Personal Growth.

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In my first year as a Registered Massage Therapist in Vancouver in 2000, I had not yet turned into a curmudgeonly skeptic, but there were early warning signs. I went to an Iyengar yoga class, billed as therapeutic for patients with pain. A mentor had told me it was an advanced class, ideal for healthcare pros, a kind of continuing education.

I was not impressed. I saw problems. I started nitpicking in my head, and I interrupted the instructor to correct her on a point of anatomy. “Actually…”

Yes, I was that guy: I tried to publicly mansplain anatomy to a yoga instructor the first time I attended her class. But it gets worse! I also got it wrong, despite warning myself to be careful. That memory still burns more than twenty years later.

But here’s the thing: I was right in spirit! Not about that anatomical detail — I surely did screw that up — but I was right about the big picture, right to be underwhelmed and annoyed by the “therapy theatre.” Because most of that “advanced” content was bogus and mostly irrelevant to any kind of pain.

If I’d said, “Actually, yoga has no special active ingredient that is good for back pain,” I would have been right. Obnoxious! But correct.

Does yoga help back pain? I have bad news and less-bad news

Most people assume that yoga is good for back pain, but is that true? Is it “clinically proven”? When tested rigorously, when you filter some of the noise out of the data, do back pain patients get results from yoga?

This question is plagued with a good-news-bad-news answer. Or maybe a bad and less-bad. The answer depends entirely on what you’re comparing yoga to.

If you mean “does it work better than nothing,” well… maybe. According to the science, yoga might be a little bit more helpful than doing no other kind of exercise or therapy, but it’s not nearly as clear as we’d all like it to be. That’s the less-bad news.

But if by “work” you mean “does it work better than other kinds of exercise” — is there something special about it — the answer is a major blow to yoga pride. Yoga doesn’t even get a lousy “maybe” from science on this question. The evidence is blunt: all exercise is equally mediocre as therapy for back pain.

Science isn’t even quite sure that yoga is better than nothing

Many scientific studies declare yoga effective compared to doing nothing,351 but the best ones aren’t so encouraging:

• A 2017 paper from The Cochrane Collaboration, purveyor of fine meta-analyses (pooling data from many studies), an organization that is notorious for pulling their punches.352 But on yoga for back pain? Cochrane crushed yoga hopes more than usual, concluding that it has no meaningful benefit … compared to nothing. There’s plenty more-study-needed uncertainty too, but the paper is a surprising bummer from this particular source: they acknowledge some short term benefits, but they also make it clear they were trivial.353
• A 2022 review reported the same small effects without bothering to say they were trivial, but it’s right there in the data. How much did yoga help with pain, temporarily, compared to “nothing”? Less than a point on a ten-scale.354
• Or there’s the 2020 meta-analysis that concluded that yoga “might” be helpful.355 Hardly a ringing endorsement.

Yoga versus other exercise/therapy

Millions of people assume that yoga is special in some way, better for backs than any other common form of exercise, or at least most of them. Alas, science unanimously declares yoga to be the loser here. No cherry picking required.

• The 2022 study above was quite positive about yoga-versus-nothing, but strongly negative on yoga-versus-exercise: “Not associated with any significant differences.” Translation: epic fail.
• A 2021 trial — a pretty good one in the journal Journal of Pain — compared yoga to both physio and eurythmy (a kooky movement therapy and/or performance art). All had equally trivial benefits.356
• But who needs quality and objectivity? Even the Journal of Alternative and Complementary Medicine — not exactly known for publishing discouraging words about alternative therapies — concluded that yoga is no better than other exercise.357
• One study even found that yoga didn’t even help anxiety and depression in back pain patients.358 This undermines the hope that the socialness of yoga is important.
• A widely cited 2011 trial found that yoga was no better than stretching for back pain … and neither was all that good.359
• Maybe yoga is better than pumping iron? Not according to the a 2017 trial.360

And so on. There are no important exceptions to this theme in the research.

Buts! The two main objections to the science

Yoga teachers, as a breed, are not known for their love of science, and many will scoff at the studies for two legitimate reasons:

1. Didn’t study the right kind of yoga. Researchers are not fools and don’t get their yoga teachers from a dollar store, and what they are studying is mostly pretty decent yoga. But of course it is possible that some yoga works better for back pain, and this has been missed.
2. Didn’t study the right kind of back pain patients. And of course it is also possible — almost certain, in fact — that yoga works better for some kinds of patients than others. In fact, we know it does.361 But the same people responded just as well to physical therapy. In other words, the study didn’t the “right people” for a yoga class, but people with back pain that was just easier to treat by any means.

These concerns about the research have serious theory-versus-practice problems. It’s not clear if the challenge/opportunity of “sub-grouping” is hope or hype. (There’s a scientific paper that addresses that question directly362 — which shares a lead author with one of the better reviews of yoga for back pain.363) It might pay off someday, but it could also be a wild goose chase.364 Back pain is just too hard to diagnose and classify.

For now, no one actually knows what the better yoga really is, or who the right sort of patients actually are. And, even if the smartest of smartypants did somehow know, they would be one voice in the wilderness. Most yoga in the real world would carry on being mostly the wrong yoga for mostly the wrong people, with mostly mediocre effects and just a sprinkling of both success stories and bad outcomes at the edges of the bell curve.

You can keep the hope alive by speculating that yoga is perfect for some back pain. Just don’t kid yourself that you’ll ever really know who.

Speaking of bad outcomes…

Yoga safety: exercise can backfire, and so can yoga

An awful lot happens in yoga classes that seems like it could be a bad idea if you have back pain, and people do get hurt. This is hardly a surprise in an industry so polluted with pseudoscience and myths. Some foolishness is inevitable.

But what cannot help much usually can’t hurt much either, and science confirms it unanimously: yoga is as generally safe as it is ineffective, and serious harm is extremely rare. Big backfires probably takes reckless and incompetent yoga instruction — which, to be fair, is definitely out there, and people need to know that.

But little backfires? Just getting somewhat worse instead of better? That is actually routine.365 In one trial, pain worsened in 12 of 156 people366 — and a rate of 10% means that one or two people in every class are going to get worse, and that is not great. Pissing off some of hurty backs is not what anyone wants.

Harm isn’t a deal-breaker. But you have to get something in exchange for the risk! So these risks, although they aren’t terrible, are hard to justify if yoga doesn’t deliver a clear win to everyone else — which is definitely does not. (Especially if you don’t even like it.)

And now consider the scale of the yoga industry: even if it was only 5% of cases getting worse, that translates into millions of people getting worse instead of better.

That yoga-bashing article in the New York Times

For a while in 2011, the New York Times’ most-shared article was a “yoga bashing” article by William Broad, How Yoga Can Wreck Your Body367 describing potentially serious yoga hazards, such as stroke. Many yoga apologists368 thought Broad’s piece was "sensationalistic." It’s not a perfect article by a long shot,369 but it raised legitimate concerns about a gap between a widely held belief (“most yoga is safe and beneficial”) and the more likely reality: some fairly common postures and practices are a little dangerous, and there not be enough yoga-specific benefits to justify even small risks. He also makes a very good point that many more extreme forms of yoga have truly ridiculous rationales.

All athletic activities have both rewards and risks. The problem here is that yoga’s benefits for back pain patients are uncertain long shots — and people also have many other sketchy ideas about what yoga can supposedly do for them.

The mild but real safety issues are well worth considering. Plus, you could crush your cat. So be careful!

Only one active ingredient of yoga is taken seriously: the core exercise

Yoga contains multitudes, and maybe it’s good exercise because of the prana, or the socializing, or the mindfulness, and people enjoy speculating about what the active ingredients might be. But almost all yoga for back pain is mostly very physical. You don’t see advertisements for Tantric or Jain yoga for back pain. You don’t see a half dozen yoga studios in every city claiming that Hindu spiritual teachings are what makes jivamukti yoga work for back pain.

No, it’s always the hatha yogas, the most secular and fitness-focussed, especially the Iyengar and Vinyasa traditions. Everyone thinks yoga is good for back pain specifically because it’s good for your core strength and coordination, and more generally the “optimization” of posture and spinal alignment.

This is why nearly all yoga studios preach the core exercise gospel, and the question “does yoga work” is basically the same as asking if core training works… and we already know the answer to that. We can infer it from all of the evidence about yoga, but there’s also an avalanche of data about “core” fitness achieved by many other means. See:

• Is it core weakness?
• Core strengthening has failed to live up to the hopes and dreams of therapists and patients

The gospel of core exercise is the solution to a largely imaginary problem, fear mongering about a mostly obsolete and simplistic view of back pain that has been debunked by back pain experts and undermined by the science for decades — mostly based on the strong evidence that people routinely hurt without spinal problems, and vice versa.

But the myth marches on, barely dimmed — thanks in large part to yoga!

Yes, some back pain is structural in character, and we shouldn’t throw those babies out with the bathwater. But the last thing most of those cases need is yoga. (And, even if spines needed changing, or more “support,” yoga does not do it.370) Meanwhile, there are many other more common and important drivers of back pain: messy biochemical and sensory factors instead of biomechanical. The most important thing to understand about back pain is that it rarely has one clear mechanical cause, and even more rarely one that can be helped by yoga — if ever.

Can yoga-for-back-pain classes still help people? Yes… but they can also hurt!

Yoga truly is a nice way to exercise, and that can help many people. It’s not gargling bleach or psychic surgery. And that is why I haven't relegated this chapter to the bogus cures section. It was a close call, but there's enough value in exercise we enjoy — regardless of any specific power to affect back pain — that I do think that people who like yoga should do yoga when they have back pain.

But they should do yoga with back pain, not for back pain. And cautiously. And ease up at the first sign of worsening back pain.

I do not think that teaching yoga as therapy for back pain is a good idea. Not enough people are helped, and too many get harmed, both directly and indirectly.

Are yoga teachers qualified to treat low back pain?

You can’t diagnose spinal tumours or infections from the front of a yoga class, which is basically why yoga instructors are only barely qualified to teach yoga to back pain patients, but never for back pain. There are many causes of back pain, and some of them are scary, so the minimum qualification to help people with back pain is being well educated about red flags (and also having the time for discussion and examination).

Is it possible to teach an evidence based “yoga for low back pain” class? Are you teachers qualified to treat back pain?

Yes. But it would be a strange and ironic class! Done right, it would undermine its own purpose, while providing what people actually need: some relief from the false hopes, red herrings, and nocebos provided by so many others. There are many back pain myths, yoga’s value for back pain is one of them, and debunking is effective.371 And why not have a class so humble that it’s almost laughing at itself? Seems rather Buddhist, actually. The right kind of students will find all this very refreshing… and yoga is still going to happen, and that’s still a good thing even if it’s not a “special for back pain” thing.

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I’ve now done all I can do to convince you that it’s all about the trigger points, and that the trigger points in the low back are particularly vulnerable to anxiety and stress and fear, and your first priority is to stop worrying about your back, and then perhaps address some of the broader emotional challenges in your life.

However, many of you will be relieved to know that, yes, there are other more tangible treatment options!

I have repeatedly promised that this tutorial does not subscribe to an “all in the head” explanation for back pain! And it does not. Trigger points are a real physical problem. As important as it is to have confidence and not be frightened and intimidated by your back pain, there are also many things you can and should do to help relieve trigger points and promote recovery.

And, in any case, no matter how true it might be that psychological factors are relevant, everyone needs something to do when they are treating any chronic pain problem. You need tasks, something to work at, because action is one of the best cures for anxiety. So the next several sections are devoted to many more specific and practical therapeutic recommendations. Most of them, one way or another, are about treating trigger points.

But please bear in mind that all of these other self-treatment methods are probably ultimately less important than knowledge, awareness, and acceptance!

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Funny thing about back pain: some patients, especially the ones that also have leg pain, will feel quite a bit better when they move or position themselves in specific ways. For example, you might notice that leaning backwards repeatedly eases your leg pain — either it stops shooting quite so far down the leg, or it even disappears for a while. In some cases, pain right in the back itself might back off.

This well-documented phenomenon is cryptically known as centralization — because the pain retreats from the periphery into the center of the body. It’s an odd term. A better term would probably be “focalization” (hat tip to David Poulter), but “centralization” is extremely well established.372

“Centralization” is a good sign (yuk yuk).

The centralization thing happily happens in roughly 40% of people with back pain — happy because it is strongly linked to better outcomes.373 You want to be a centralizer! If you experience centralization, that is an official Good Sign..

This-a-way feels better: the “directional preference”

Whatever repeated or sustained movement or posture triggers centralization is your directional preference. In other words, if your pain “centralizes” when you bend backwards repeatedly, then your “directional preference” is extension. You prefer moving in that direction.

Strangely cryptic terms for something that really boils down to feeling better when you move one way rather than another.

This simple concept has become a staple of physical therapy for back pain. It comes from the McKenzie Method of “Mechanical Diagnosis and Therapy” (MDT), created by New Zealand physical therapist Robin McKenzie (1931–2013) — one of the best known “systems” in the body-fixing business. I’ll address MDT more generally in another chapter. This chapter zooms in on the one thing that MDT is almost defined by: extension exercises.

Or flexion for a few people.

And maybe side-bending for a handful.

Dr. Stephen May is a researcher strongly associated with MDT (he literally “wrote the book” on it, with McKenzie). In an interview for PT Pro Talk (episode 95), he said:

“I don’t think there’s anything like it in terms of its high prevalance rate, its potential to indicate a good prognosis, and its potential to indicate a management strategy. And if a clinician doesn’t take such a gift into account they would seem to be shooting themselves in the foot in a very daft way.”

Later in the book I will dig into this a bit more and push-back against that cockiness in a more general chapter about McKenzie/MDT. For now, I think there’s enough truth in Dr. May’s opinion that some DIY experimentation is fully justified: it’s evidence-based enough, easy enough, cheap enough, and safe enough that it should be in everyone’s bag of tricks.

Yoga’s “cobra” pose is an excellent example of a simple back extension exercise — which might be your (directional) preference. Extension is the direction most back pain patients prefer, if they have any preference.

Simple self-help for back pain based on centralization and directional preference

Self-help, really? Based on this rather technical-sounding phenomenon? Well, McKenzie himself published self-help books about it: Treat Your Own Back. So I think it’s fair game.

A 2004 trial asked “does it matter which exercise?” Meaning, does it matter if you exercise in the direction of your directional preference, versus the other way? 72% of the people the researchers worked with had a directional preference, and those folks did better harmonizing with their preference than clashing with it… regardless of what that preference was. That is, if they preferred extension — as most do — then extension exercises produced much better results than flexion. But it was vice versa if they preferred flexion.374

There are three directions to prefer: back (extension), forward (flexion), or the side as illustrated here. Sidebending is the rarest directional preference & this image emphasizes its simplicity. Just… bend to the side!

Nifty little study. Unfortunately, it is also an isolated bright spot in a generally disappointing literature on the McKenzie method. But it’s something.

Patients can and should exploit this concept by testing themselves for centralization and a directional preference, and then spending time in moving and resting in that preferred direction. Obviously not everyone will succeed at this, but quite a few will, and it’s quite safe to experiment with. In more detail…

There is no step three

Step One: Test for centralization by cautiously experimenting with a variety of spinal movements and positions, looking for clear signs of your symptoms contracting into the center of the problem — less pain sprawl, and relief that persists for at least a little while. There is no need to do anything intensely, or to repeat anything that obviously makes you feel worse.

In the best-case scenario, this is easy and obvious and you can confirm it in minutes. In the worst-case scenario, it might take several sessions of experimentation over a few days to pick up on the signal. If there’s no sign of centralization after a few days, it’s time to give up: you are not a centralizer! (Not yet, anyway. It can change! You can re-test every week or two.)

Only centralizers should proceed to step two.

Step Two: Once you have determined that you have a clear directional preference… use it! Spend time every day moving your spine that-a-way. Or resting with your spine curved in that direction. If it hurts or makes things worse, just stop — the whole idea here is that you’re emphasizing something that makes your back feel *better*. Not worse.

That’s the basic self-serve version of exercise therapy for back pain based on centralization and a directional preference.

Of course you can also recruit professional help with this: a professional with MDT training and experience (and there are a lot of them around the world) obviously might be able to suggest many refinements, and that may be worth pursuing. But there’s also nothing wrong with experimenting yourself, and that’s going to be enough for many people.

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Photo by Jose Luis Sanchez Pereyra on Unsplash

Perhaps the most interesting & controversial plant in the world.

Cannabis is a plant, most notably marijuana (bred for its narcotic effects) and the major strain of hemp (bred for other purposes). It’s one of the most interesting plants in the world because it produces chemicals with interesting effects, the cannabinoids. The most interesting and famous of those are THC (tetrahydrocannabinol) and CBD (cannabidiol). All cannabis contains THC, CBD, and hundreds of other related compounds, but there’s a lot more THC in marijuana plants, and a lot more CBD in hemp.

THC gets you high (psychoactive effects), and CBD does not. Both are alleged to be pain killers: it’s their most popular medicinal use (either that or as a sleep aid), but CBD is much less studied.

The evidence for pain-killing

So, are cannabinoids effective pain killers? “It’s complicated”!

As a science journalist, I am honour bound to emphasize that cannabinoids are not proven pain-killers. “Proof” is a high bar that has not yet been cleared. A huge 2017 review of the scientific literature on cannabis concluded that there is “substantial evidence that cannabis is an effective treatment for chronic pain in adults.”375 But the review also explains that the evidence shows only modest benefits so far, there is uncertainty about every detail, and significant practical problems abound for both researchers and consumers.

And that was hardly the last or only word. Other reviews of largely the same evidence have been much less optimistic. In 2017, Nugent et al looked at 27 scientific trials of cannabis for chronic pain trials, and it was disappointing: weakly positive for neuropathic pain, and just inconclusive otherwise.376 In 2019, Häuser et al wrote “Cannabis medicines can be regarded to be third-line therapy for chronic neuropathic pain. There are signals of a lack of efficacy for all other chronic pain syndromes.”377

So that’s not great.

THC might have some bonus effects for some low back pain patients because it can function as a muscle relaxant. More about that in the muscle relaxant chapter. But it is one way that THC might be relieving pain indirectly.

A noteworthy new trial of CBD for acute back pain

Studies of pure CBD for pain remain rare, which makes a good 2021 Australian trial noteworthy.378 Researchers tested CBD in the same situation where doctors might normally prescribe powerful anti-inflammatories or opioids: in people who have gone to the emergency room with severe back pain. A hundred patients were given an ibuprofen and paracetamol plus either 400mg of CBD or a bogus pill that looked just like it.

This a fair test in several ways. If CBD actually has anti-inflammatory properties, the people who got a CBD booster should certainly have gotten some extra relief. Severe acute back pain is a tough pain-killing challenge, but we should expect anything touted as “good for pain” to help out at least a little in this situation.

Unfortunately, CBD made no difference at all: it was like it wasn’t even there. •sad trombone• The groups were identical on all outcomes: pain levels, how long the patient stayed, the need for “rescue analgesia” (the Oxycodone), and adverse events.

It is conceivable that CBD alone, or repeated doses, would have performed at least as well as standard meds, and maybe more safely — safer than NSAIDs anyway379 — but it’s a long shot. This was quite a fair test, and CBD just bombed.

Usage guidelines for beginners

If you’re new to marijuana, there’s a bit of a learning curve. Here are some tips:

• Pure topical CBD creams and oils are overall the safest and most convenient, so they should probably be your first priority to try. THC may be where it’s at, but it’s harder to use…
• Use caution with THC edibles! Dosing and duration of effect are huge wildcards. You can get way, way too high for comfort — not very dangerous, but scary.
• Avoid vaporizers that use oil infused with cannabinoids, due to scandalous, tragic safety issues because asshole manufacturers have added other dangerous, un-tested substances380. Dozens of people died in 2019. Died!
• Infused oils aside, vaping raw cannabis in moderation is quite safe.381 Just take it easy for at least your first three times — just one or two modest inhalations of vapour is just fine to start.

For more detailed information, see Marijuana for Pain.

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The commonly used over-the-counter pain-killers are Tylenol & anti-inflammatories like ibuprofen.

Nothing you can swallow is likely to significantly relieve back pain. There are so many possible causes and mechanisms involved in back pain that, in principle, one type of relief is probably not going to work well for a lot of people. But that complexity means that it’s also worth experimenting — you never know what might work for any given patient.

And even a little benefit is better than nothing. So it’s worth experimenting — as long as you know how to do it safely. There is nothing wrong with cautiously experimenting with over-the-counter pain medications to occasionally, maybe help tame the cycle of pain, fear, and immobility, as long as you know this is what you are up to. A temporary crutch.

If you do discover a specific pain-killer works even a little better than the others, that can be quite valuable over the years. It’s worth paying close attention to using each major type of pain-killer on at least three occasions. And that could take a while! I suggest you take notes — seriously.382

Prescription medications like opioids, anticonvulsants, and sedatives are discussed below in another chapter.

Regular pain-killers, mainly ibuprofen and acetaminophen

Basically, the regular pain-killers mostly don’t work all that well — which surprises no one.

But they can take the edge off. And that is not nothing. There are days when that is what you need.

Your typical sugar pill placebo is going to net you a drop in pain of 10%, which is also about where “minimum clinical significance” is usually defined. That is, less than a 10% reduction in pain just doesn’t matter — it’s too small. Guess how much pain relief people get from over-the-counter pain killers on average? Just that much. In a 2017 review of 35 studies, both placebos and common anti-inflammatories for back pain had a “smallest worthwhile effect” of about 10%.383 The authors think that “there are no simple analgesics that provide clinically important effects for spinal pain over placebo.”

It’s possible that they just don’t work at all, complete duds, and the only reason they have any effect is placebo — same as the sugar pill. Or maybe their effects are just weak and unpredictable. Everyone’s different, every case is different. These meds probably do more for some cases than others. Our reactions to drugs are surprisingly variable, from person to person, and day to day. This has been well-documented for treating tension headaches with these meds.384

Most drugs work on only about a third of the population, they do no damage to another third, and the final third can have negative consequences.

Craig Venter, extremely famous and spooky smart geneticist (public lecture, Vancouver, May 3, 2011)

To the extent that the anti-inflammatories provide any detectable symptom relief, it may suggest the presence of injury (as opposed to cramp or trigger points). But there is rarely a significant inflammatory process involved in low back pain, or at least not one readily controlled by these medications.

All the over-the-counter (OTC) pain medications are fairly safe in moderation and work in different ways. There are four kinds: acetaminophen/paracetamol (Tylenol, Panadol), plus three non-steroidal anti-inflammatories (NSAIDs): aspirin (Bayer, Bufferin), ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).

Don’t take any of them chronically — risks go up over time, and they can even backfire and cause pain (rebound headaches).385 Acetaminophen is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers and it’s the least likely to help back pain (at all?). The NSAIDs reduce inflammation as well as pain and fever, but at any dose they can cause heart attacks and strokes and they are “gut burners” — they can badly irritate the GI tract (even taken with food, and especially with booze). Aspirin is usually best for joint and muscle pain, but it’s the most gut-burning of them all.

Naproxen might be the best of the over-the-counter drugs for most back pain (without significant sciatica, which tends to be tougher to tame).386 The evidence isn’t exactly conclusive, but it’s enough to justify prioritizing naproxen in your testing.

The standard of care has definitely moved on from routine prescription of medication, but “many patients with persisting symptoms also continue to take medicines long-term despite the low likelihood of ongoing benefits.”387 Don’t be one of those people. I think the main point to take away about the medications is that, even if it’s okay to do some cautious experimenting, there’s definitely no point (and plenty of risk) in continuing to take them if they aren’t obviously helping.

Topical anti-inflammatory (diclofenac/Voltaren)

Voltaren gel is an anti-inflammatory medication in a gel that you rub on, and it has a little more potential than the same thing in a pill — but Voltaren is a lot safer.388 Scientists recently found evidence (in rats!389) that it might actually be able to treat pain coming from deep inside the spine — right in the centre — which means it could be a “convenient and safe clinical intervention” for a few types of back pain.390 So convenient and safe, in fact, that it lands in the clinical “why not?” sweet spot. An anti-inflammatory gel will probably fail with many kinds of back pain (the ones that involve no inflammation) … but, unlike with the pills, there’s also virtually no down-side to trying.391 Give it a try.

Voltaren Gel — not exactly a magic bullet, but probably safe, reasonable & worth a shot.

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“Muscle relaxant” is an odd category of drug. There are several drugs that are relaxing, but are not exactly “muscle relaxants” because they are not specifically interfering with the biology of muscle contraction. A true muscle relaxant is essentially a poison that messes directly with muscle physiology.

You really don’t want too much of a true muscle relaxant. It can cross into paralysis. Amazonians used a muscle relaxant … on their poison arrows. Curare poison relaxes you to death. European explorers encountered the stuff early in their visits to North America, and it led to some of the earliest scientific studies in pharmacology.

And yet, on the other hand, it’s not clear that the muscle relaxant drugs are actually interfering with muscle contraction! So it’s a tricky topic.

Muscle relaxants and back pain

Earlier in the book, I discussed the idea of “back spasms.” Refresher: it’s a hopelessly vague description of a sensation that probably doesn’t have much to do with actual cramping of back muscles. Or it’s something more specific, like trigger points — micro-cramps that do involve unhealthy contraction, but aren’t really anything like the popular mental picture of a whole-muscle clenching painfully.

If some kind of back spasm is not a cause of back pain, surely muscle relaxants are largely pointless. Some experts are very cynical about this, describing muscle spasm as a simplistic non-diagnosis with strong emotional appeal to both doctors and patients, and therefore cynically exploited by pharmaceutical companies to sell a treatment (muscle relaxants).392 Some muscle relaxants certainly are marketed specifically as remedies for “muscle pain.” For instance, King Pharmaceuticals claims that Skelaxin produces “fast relief for muscle spasms and back pain.” There are definitely plenty of pros who think that’s just a scam.

Maybe. I’m sympathetic to that point of view, but I’m also not so sure it’s settled.

If muscle spasm is a major factor in back pain, or even a significant complication, then muscle relaxants are obviously useful in principle — and in fact we do know that muscle relaxants are somewhat helpful for acute low back pain (evidence discussion below). But there are also reasons other than actually relaxing muscles why those drugs might work a bit.

And then of course there’s the unavoidable truth that there are many causes of back pain that really have nothing to do with tight muscles. Even an extremely potent muscle relaxant is not going to make any difference if tense muscles aren’t the problem in the first place.

But, if they help you, it’s actually diagnostic. Effective treatment isolates uncomfortable muscular contraction (of some kind) as a cause or clinically significant complication.

Muscle relaxant primer

Muscle relaxants come in many related varieties,393 but only one that is widely available without a prescription: methocarbamol, as found in Robaxin, Robaxacet, and similar brand names.

There are also several prescription muscle relaxants, obscure to most patients, but most notably carisoprodol (Soma), cyclobenzaprine (Flexeril), metaxalone (Skelaxin).

All muscle relaxants are tame cousins of the truly potent sedatives (also discussed below), and can cause significant drowsiness, dizziness, and a laundry list of other common side effects, but there’s also a surprisingly wide range of safe dosage (hard to overdose).

Methocarbamol and friends are not widely used because they are not super effective. It’s probably because they’ve been around forever, because the drowsiness they cause makes them feel more potent than they actually are, and because relaxing muscles just seems like such a good idea to literally everyone, both patients and pros. I think perhaps muscle relaxants have been grandfathered into modern, scientific medicine. Tradition-based medicine, rather than evidence-based medicine.

Muscle relaxants are surprisingly unstudied, like many other popular drugs.394 In particular, good luck finding any study of the effect of these drugs on muscle function. It’s not clear if muscle relaxants actually relax muscles, or if they just make us feel more relaxed.

What evidence we do have is not exactly high quality.395396397

An expert of my acquaintance thinks they are useless specifically at low dosages.398

Acute back pain is the only condition for which there is adequate data. Some muscle relaxants (including methocarbamol) do appear to be roughly as effective for acute back pain as common over-the-counter pain killers399400 — so they can help, but not all that much, and with great potential for side effects. It’s also damning that there doesn’t seem to be much difference between muscle relaxants: “Comparison studies have not shown one skeletal muscle relaxant to be superior to another.”401 So we have a class of drugs that shows little sign of effect, no matter which flavour you use. Whoop-de-do!

Even a prescription muscle relaxant like carisoprodol (Soma) is so impotent that patients will (this is bizarre) actually tense up if they are lied to and told that the drug is a stimulant.402 (The study was quite interesting — if you only read one footnote about a study in this book, this would be a good one to choose.) Clearly the brain is the boss of your muscle tone, and the drugs only nudge us towards relaxation. Bear this fun fact in mind for the discussion of alcohol and other psychoactive drugs coming up — it’s a ray of hope.

And here’s another fun fact: even anasthesia doesn’t truly “relax” muscle.403 It stops voluntary contraction, but it doesn’t eliminate muscle tone. Only death does that, and even in that extreme case the tenacity of the contractile proteins is demonstrated in the phenomenon of rigor mortis.404

Muscle relaxants clearly work at least a little for some people, some of the time, probably usually at higher doses. And they are relatively safe to experiment with, even at higher dosages. In fact, it’s so hard to overdose on them that I even feel comfortable endorsing cautious testing of a larger dosage than what’s recommended on the box. Just don’t go driving, don’t combine with alcohol, and be alert for significant side effects — they aren’t effective enough to bother with if they harass you with side effects.

Narcotic “muscle relaxants” (sedatives like Valium)

If our goal is to loosen up tense muscles that might be causing low back pain, is there any drug at all that will definitely do the job? Any drug that’s reasonably accessible?

Narcotic sedatives, mainly the benzodiazepenes, relax everything. Like the opioids, the benzos are another “nuclear option” — they do interfere with muscle contraction, while also interfering with everything else: like consciousness! Many drugs have highly unpredictable effects, but the benzos are as potent and predictable as cobra venom.

The most famous of all the sedatives is diazepam, AKA Valium, a benzodiazepene. But it is only the most infamous member of a family of rogues, like Klonopin, Ativan, and Xanax.

Just because they are potent — and they certainly are that — does not mean they actually work, or that they work by relaxing muscles. A 2017 study showed that “Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain” (they put the result right into the title).405 However, I suspect that the your-mileage-may-vary factor is huge with these drugs.

As with the milder muscle relaxants, it’s surprisingly unclear whether or not these drugs actually reduce muscle tone, or whether they achieve relaxation indirectly via their potent sedative and psychoactive effects. Those psychoactive effects are a huge wildcard that could account for a wide range of responses. They are primarily used to relieve anxiety and improve sleep, both of which could easily relieve pain on their own.

I don’t think there’s any question that benzos might be a useful tool for treating headache. It seems worth at least considering this treatment option, despite the hazards… which are a big deal.

Benzos really do involve dire risks of physical dependence and addiction, and withdrawal can be nightmarish, dangerous, and even lethal at the extremes. Although it is possible to take and stop taking benzos safely, many people do not get the information and help they need for that. Sadly, I have extensive personal experience with benzo withdrawal, and I’ve written about that in detail.406

However, benzos can be safe if used in moderation for short periods only. They are a dangerous tool, like a gun, which must be respected and used with great caution. If you’re interested in dancing with this devil, don’t just ask your doctor for a prescription: make a point of showing your prudence by asking for only a 2-week supply of a small dosage only (the exact amount varies with the specific drug).407

The curious case of alcohol as a pseudo-muscle-relaxant

Alcohol is hard on your system in many ways. It’s a myth that a drink every night is a tonic, and there really is no safe intake level408 — it is a poison, and it can make people more vulnerable to chronic pain. And yet…

There’s plenty to be said for a glass of wine or beer as a kind of medicine.409 Anecdotally, moderate usage seems useful for taking the edge off nearly any kind of pain. This may be because it’s functioning as a kind of muscle relaxant, or at least as a general sedative.

Let me be clear: alcohol is not a muscle relaxant per se,410 not in a biochemical sense (and warning: it also combines dangerously with actual muscle relaxants and sedatives). In a world full of alcoholism and drug addiction, obviously a “prescription” of alcohol has to be offered and taken rather cautiously. But it is highly accessible, cheap, relatively harmless in moderation, and it’s a psychoactive drug — and anything that bends your mind has the potential to be a mild, obliquely effective muscle relaxant.

Combined with the confidence cure, alcohol might be effective, after a fashion. It’s one thing to be anxious about your low back pain and to drink to take the edge off your nerves — only to get right back to it as the effect of the beer therapy wears off. It’s quite another to know that your spine is safe but grouchy, and to drink judiciously to help break the vicious cycle of tension and anxiety itself, instead of just temporarily escaping it.

All psychoactive drugs — anti-depressants, alcohol, marijuana, amphetamines, opioids, benzodiazepines — often seem to help almost any problem, but the emphasis is on seem, because they mainly affect mood: “It is my impression that ‘pain-killing’ drugs improve the patient’s mood rather than take away the pain.” (Sarno)

Mood isn’t nothing. If you are genuinely happy and relaxed… if that’s something alcohol can do for you…

THC as a pseudo-muscle-relaxant

Tetrahydrocannabinol (THC) is the most famous cannabinoid produced by cannabis (marijuana). It is another relatively safe and accessible psychoactive drug, probably the only other one that seems tame enough to take seriously for this purpose. (Sure, you could blow your mind with acid or ecstasy and hope for a muscle relaxant effect, but that seems like overkill.) Obviously its accessibility varies widely from place to place as the entire world grapples slowly and awkwardly with legalization.

Like alcohol, THC doesn’t zap muscle tone directly, but it probably can do it indirectly and erratically.

If you are happy and relaxed while stoned, it’s certainly possible that a tense back will get … less tense! Whether it can meaningfully affect the kind of fierce contractions (or trigger points) that can make you miserable in the first place is anybody’s guess, but it seems worth trying.

For this purpose, virtually any strain of marijuana will do, but ideally a THC-rich one (not CBD) because you want the psychoactive effects. Whee!

With pot, there is also the added potential for direct pain relief (discussed above, along with usage guidelines).

And so I do tentatively recommend THC as another “muscle relaxant” worth experimenting with.

Botox?

Botox is the infamous face-paralyzing drug of the stars! It’s a special case, quite different from the other muscle relaxants. Like curare on poison arrows, Botox is outrageously toxic and doesn’t “relax” muscles but just outright paralyzes them, even in small doses. It’s obviously related to muscle relaxants, but it’s a separate topic.

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A comfrey plant. I harvested a large pile of the stuff once, working for room & board on an organic farm in my wild & free hippie youth.

Here’s a well-I’ll-be-darned study showing the potential for good low back pain relief from a surprising source. These kinds of results are usually published in journals like Herbal Believer and The Journal of Cheering for Herbal Remedies No Matter What. But this is from the British Journal of Sports Medicine, a respectable publication.

Researchers not only found that ointment made from the root of the comfrey plant is an effective treatment for low back pain, but a “potent” one!411 Assuming the experimental results are sound and can be repeated by other researchers, this one’s a rare, clear win for a traditional herbal remedy.

“The results of this clinical trial were clear-cut and consistent,” the authors report. “Comfrey root extract showed a remarkably potent and clinically relevant effect in reducing acute back pain.”

At first glance this certainly looks like an adequate test of comfrey. I will be watching for confirmation studies. Meanwhile, my recommendation to patients is to give it a try: minimal risks and positive results in a credible journal put it firmly in the “worth a shot” category.

I wonder if comfrey has something in common with Voltaren gel (discussed above)? Both are seemingly pretty mild ointments, both with some evidence of effect on a stubborn pain problem. There may well be some overlap in how they work.

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PainSci also has a very detailed guide to trigger points.

The two guides have a close relationship. The trigger points tutorial was last mentioned several sections back when I was introducing you to the role that trigger points play in back pain. I’m bringing it up again because we’re now going to be talking about treatment options for low back pain — most of which are directly concerned with trigger points, and are quite similar in both tutorials.

This duplication is unavoidable: the subjects are woven together like the snakes of the caduceus. And this is why I sell the two tutorials as a pair. I have made every effort to reduce the duplication, and to discuss trigger point therapy concepts here as they relate specifically to low back pain. For instance, rather than discussing only the general principles of mobilization exercises (as in the trigger point tutorial), I provide some specific examples of mobilization exercises for the low back in particular.

However, it is impossible to eliminate the duplication altogether, and sometimes it is nearly word-for-word for several paragraphs at a time. For instance, a section of the trigger points tutorial about a self-massage technique I call “the bath trick” I reproduced here in full because it is ideal for low back pain. I want readers of both tutorials to know about the bath trick.

However, for detailed trigger point therapy information, please refer to that book-length tutorial, which is about three times the size of this one. The next several sections of this tutorial are an executive summary of the same sections in the book-length trigger point tutorial. It may seem like there’s a lot here, but, trust me, there’s a lot more in the trigger points tutorial!

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Massage might help back pain. No one really knows, because, surprise surprise, even garden variety massage for back pain hasn’t been studied properly yet, let alone trigger point therapy. It is supported only by indirect and flawed scientific evidence (thoroughly reviewed below). For now, the bottom line is that it’s an experimental treatment, but for many reasons it makes sense to try it — especially self-massage, because it’s free and safe.

In my opinion, most trigger point pain can probably be relieved with a surprisingly small amount of simple self-massage, or with a helping hand from the right therapist in those hard-to-reach spots! Although trigger points can be weird and stubborn at their worst, the majority of them are usually easy to get rid of with a just little rubbing.

Dr. Janet Travell wrote that “almost any [physical] intervention” can relieve a trigger point. And self-massage is usually the simplest, cheapest, and most effective intervention. How can so little be so effective? How can such a minor treatment work?

The vicious cycle taking place inside a lesser trigger point is not difficult to disrupt. The knot may not be all that tightly contracted in the first place. The accumulation of metabolic wastes is relatively small compared to a severe trigger point, and it’s fairly easy to squish out with gentle pressure. The neurological dysfunction is not usually particularly entrenched, and it’s fairly likely to change in response to minor stimuli. Adhesions (“scarring”) are not a factor in trigger points that haven’t been around for long. And isolated trigger points are much easier to manage than the large groups of trigger points that are typical of full-blown myofascial pain syndrome.

The pillars of self-treatment for low back pain trigger points are:

1. Self-massage — the creative, persistent stimulation of musculature in the low back with pressure, applied a little bit with thumbs and fingers and fists, but mostly with massage tools like tennis balls or a massage stick.
2. Mobilization, or “massage with movement” — gentle but precise rhythmic movements that stimulate the core musculature, preventing tissue stagnancy without overexertion.
3. Heat therapy — liberally using hot baths, showers, hot tubs, and heating pads.
4. Eliminating perpetuating factors — the factors that tend to cause trigger points to form in the first place. We’ve already discussed a major one (stress and anxiety), but there are several others.

If the “confidence cure” is the most original and important idea in this tutorial, self-treatment of trigger points is the other original and important idea. On the one hand, trigger point therapy is actually fairly easy to do, but on the other hand, it can be surprisingly difficult to get good trigger point therapy from therapists. And, even when you can get good trigger point therapy, it’s usually too expensive to get enough of it. Just a little skill with self-treatment can make up the difference, either supplementing or completely replacing professional therapy. Time and again over the years, I have seen low back pain patients improve with relatively minor upgrades to their self-treatment methods. This is a critical principle for both patients and professionals to understand.

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This section is duplicated almost verbatim in the trigger points tutorial, because it’s particularly important: it answers the question, “Why self-treat?”

As mentioned repeatedly above, trigger point therapy is an unproven treatment — experimental medicine — and even anecdotally it is notorious for being hit or miss. If you do it yourself, you may be less effective than a professional might be, but at least you won’t go broke trying. It’s best not to pay upwards of a buck a minute for trial and error when you can experiment on yourself at no charge, safely.

This is the raison d’etre of this website, actually: when the professionals are nearly as unreliable as you are, you might as well save yourself instead of paying for professional shots in the dark. Obviously there are limitations to self-treatment — some spots you just can’t reach! — just as there are limitations to professional therapy. The only dramatic difference between professional care and self-treatment is the cost.

The beauty of trigger points is that you can use the worst things about them to your own advantage. They may be tricky and stubborn and weird, but you have time to mess around. You can wait. You can experiment. You can fiddle. For free. For years, if necessary — as long as there’s evidence that you’re gaining ground.

There are three basic problems with trigger point therapy, for both the pros and their patients:

1. Locating trigger points can be tricky, and it’s hard to treat what you can’t find.
2. Even when you’ve found trigger points, they don’t necessarily go away just because you squish ‘em, stretch ‘em, heat ‘em, or any of the other common treatment themes.
3. And even if they do go away, they usually don’t stay away: trigger points have a nasty habit of coming back.

Fumbling around with diagnosis. Trigger points are not easy to confidently locate, and research has shown that even the professionals struggle to find them for you. At best, it’s possible but difficult; at worst, it’s a crapshoot.412 Thus, hunting for trigger points invariably involves expensive fumbling around. When I was a Registered Massage Therapist, I was painfully aware that $1.67 was flying out of my patient’s pocket every single minute as I hunted around for their trigger points — I ought to be damned good to justify that kind of expense, and the sad truth is that I wasn’t always, and I was supposedly unusually expert at it (the author of an entire book about back pain and trigger points).413

The right professional may be able to “fumble better,” and give patients good treatment ideas. But as your own patient, you definitely have an advantage: you literally have all day to find the right spot.

Fumbling around with treatment. And then there’s the mystery factor, the overall scientific cluelessness about why trigger points form in the first place — not what they are, but why they happen. Which means it’s impossible to be confident about exactly what flavour of treatment is going to make them go away. Professionals are definitely not privy to the magic trigger-point-begone formula, and while extensive hands-on experience undoubtedly leads to somewhat higher quality experimentation, it’s experimentation nevertheless. And — once again — the experimenting is expensive.414 But patients can and should experiment with different approaches willy nilly. As a patient doing self-treatment, you might or might not get results, but at least the insult of a great expense is not added to your injury.

Fumbling around with perpetuating factors. The third basic problem with trigger point therapy is that a trigger point comes back, like The Cat in the Hat. The forces that tended to lead to them in the first place routinely result in their resurgence. Even successful trigger point therapy is notoriously prone to being temporary. But once again, we snatch victory from the jaws of defeat thanks to the logic of self-treatment: if your benefits are going to be brief, better that they also be cheap!

It’s also up to patients to make changes in their lives that make them less prone to persistent trigger points. A good therapist may have excellent suggestions for things to try, but an educated patient is nearly as capable. How hard is it, really, to guess that your crappy, uncomfortable office chair may be the reason your trigger points just keep coming back? If stress seems to be a factor in the stubbornness of your muscle pain, that’s not particularly difficult to figure out — certainly not after doing a bunch of reading on this website. It’s also a deeply personal problem to solve, and the solution likely doesn’t have much to do with physical therapy or massage therapy.415

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Self-massage offers the best potential bang for buck of all treatments for back pain.

It is not difficult to apply pressure yourself to key trigger points in the low back, especially with the assistance of simple tools such as a tennis ball and other self-massage tools. For average cases of stubborn low back pain, a small investment in experimenting with applying pressure is surprisingly effective. People who’ve had intractable back pain for years may experience more relief than they ever have before. Some may even find that self-treatment of trigger points becomes the only thing they need over the long term to control their symptoms enough to feel “good enough,” if not actually completely symptom free.

Not every case goes quite that well, of course.

Some patients will need to experiment more and may find that self-massage is never a complete solution in itself. Some trigger points are definitely resistant to self-treatment, and there are fundamental limitations to self-treatment for trigger points, particularly in the low back. It’s an awkward area to work on yourself, and sometimes the tough, thick muscle of the low back requires much more pressure — and/or more accurate pressure — than you can possibly apply without assistance.

Nevertheless, it is well worth trying, and it is worth trying quite a bit, for quite a while. I would encourage every chronic low back pain sufferer to become well-versed in trigger points before giving up on self-treatment.

The following free articles explain in detail four of the classic, clinically important trigger points in the region of the low back. Although there is always more to learn, these four trigger points are more than enough for most beginners to work with for a long time.

• Perfect Spot No. 2 — Quadratus Lumborum
• Perfect Spot No. 6 — Gluteus Medius/Minimus
• Perfect Spot No. 12 — Gluteus Maximus
• Perfect Spot No. 13 — Lumbar Paraspinal Muscles

For an easy case, literally just a single session consisting of a few moments of gentle rubbing can be enough. For slightly more difficult symptoms, a day or two of applying small but frequent doses of rubbing will usually do the trick. An investment of about a half dozen mini-treatments per day, each about 20–30 kneading strokes, can dramatically reduce pain and stiffness.

Here are a bunch more specific tips …

Rub in what way? For simplicity, either simply press on the trigger point directly and hold the pressure still, or apply very small kneading strokes, either circular or back and forth across the muscle fibres.

Rub how hard? The intensity of the treatment should be strong, but easy to live with. On a scale of 10 — where 1 is painless and 10 is intolerable — please aim for the 5–7 range, and err on the side of gentler at first.

What should it feel like? Pressure on a muscle knot should usually be clear and strong and satisfying; it should have a relieving, welcome quality. This is “good pain.” If you are wincing or gritting your teeth, you may need to be more gentle. You need to be able to relax.

What if it backfires? It probably won’t. But if you experience any negative reaction in the hours after treatment, simply ease up. In basic therapy, you can always count on trigger points adapting to stronger pressures over the course of a few days of regular treatment. If they don’t, either the problem isn’t really trigger points, or they are worse trigger points than you thought!

Rub how much? Massage each suspected trigger point for about 30 seconds. This is actually enough for many trigger points — especially if you have several that need attention! Five minutes is roughly the maximum that any trigger point will need at one time, but there is not really any limit — if rubbing the trigger point continues to feel good, feel free to keep going.

Rub how often? As long as you aren’t experiencing any negative reactions, you should massage a key trigger point at least once per day, and as often as a half dozen times per day.

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The goal of self-massage for trigger points is to achieve a “release.” What is trigger point “release” and what does it feel like? How do you measure success?

Trigger point release is the relaxation of the tightly contracted muscle tissue that the trigger point is made of. Unfortunately, this happy change in state may not be obvious, even when it occurs! The problem is that the tissue remains polluted with waste metabolites even after a successful release. Release may actually involve or even require damage to the tissue of the muscle knots. This means that it will probably still be sensitive to pressure, even if you’ve succeeded.

For beginners, the way to cope with this problem is to just not worry about it! Simply trust that you probably achieved a release, or a partial release, and then wait for the tissue to recover. Over the next several hours, if you were successful, you will notice a distinct reduction in symptoms — mission accomplished.

With easy trigger points, successful release is associated with “good pain” — that clear, strong, and satisfying sensation that is somehow both painful and yet also relieving.

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Ah, the humble tennis ball

Best buddy to the common muscle knot!

It is possible to massage your low back with your thumbs and fingers, or perhaps your fist, but it’s not especially easy or effective. The low back muscles are thick and tough. Although they are hypersensitive to pressure in some patients, in others they are “numb,” and require enormous pressures to achieve a satisfying and therapeutic pressure. Tools are therefore indispensable in self-massage for low back pain.

One of my clients once described an experience she’d had with an orthopedic specialist:

He didn’t know about using tennis balls for massage! He asked what helped my back pain, and I told him I always lie on a tennis ball. He looked at me like he was going to refer me to a psychiatrist! How can an orthopedic surgeon not know about the tennis ball thing? Doesn’t everyone know about the tennis ball thing?

Unfortunately, no: not everyone knows about the tennis ball thing. But it is one of the most time-honoured simple solutions for chronic muscle aches and pains, running a close second to the hot tub thing.

Indeed, a tennis ball is a handy tool for self-treatment of knots in your muscle.

The basic idea of tennis ball massage, or any massage with any kind of ball, is simply to trap the ball between your body and something else: usually the floor, but sometimes a wall, another body part, or creative options like the back of the couch or the bottom of the bathtub. The point is to use the ball to reach spots that you simply can’t get to with your hands, and every other kind of massage tool is a variation on this theme!

Tennis ball massage is usually the most useful in the muscles of the back and the hips: places you can actually lie down on the tennis ball, pinching it between your body and the floor or wall. Many other locations are awkward (especially for beginners), and you may find it difficult or impossible to apply pressure effectively.

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From the Department of Why Didn’t I Think Of This Before: the bath trick! I discovered this long ago while working on my own muscle knots, trying to tame an episode of back pain, which seems to be a never-ending job — they are always under control, more or less, but also always threatening to come back.

This is what trigger points do, of course — they come back. It’s in their nature. And that’s why I’m always working on them, and always discovering new ways of doing it. It’s a creative challenge that never ends.

The Bath Trick

Run a hot bath, then trap a ball between your body & the bottom or back of the tub to rub your back muscles — your buoyancy allows for excellent control over moderate pressures.

The bath trick is a “together at last” trick: it came from combining two other classic tactics for releasing your own trigger points: the heat of a bath and the pressure of a ball. But the result is more than the sum of the parts, and it works better in some ways than anything else I’d come up with before. Suddenly I’m using the bath trick regularly myself and recommending it to readers.

1. Simply run a hot bath …
2. climb in and get nice and warm and comfortable …
3. … and then bring in a ball! Trap the ball between your body and the bottom or the back of the tub, and cheerfully crush your trigger points with relieving pressure.

Ah!

The bath trick works particularly well because the pressure is easy to control.

Often people find that the full weight of their body trapping a tennis ball against the floor is simply too much — the pressure is too intense, and they can’t achieve a relieving sensation. But in the bath, you are much lighter! You have much better control and a moderate intensity of pressure.

While the heat relaxes you, your buoyancy in the water allows finely tuned control over moderate pressure on your trigger points. Applying a little more or less pressure is as simple as rising up in the water a little, or submerging more of yourself.

The KONG® brand dog ball is perfect for the bath trick.

What sort of ball should you use? Some balls are better for the bath than others. Tennis balls, usually so useful for self-treatment, are not especially good for the bath trick. But a KONG® brand rubber ball is perfect — not the pyramidal KONG with the hole through the center (although it could work), but preferably the KONG ball, which is made with the same dense rubber. They don’t get soaked, and they have a nice neutral buoyancy — they don’t sink or bob up to the surface — so it’s nice and easy to move them around underwater, trapping them right where you want between your body and the bathtub.

By contrast, wet tennis balls are kind of a pain outside the bath, and they like to pop up to the surface!

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Is this a realistic scenario? Can you damage nerves with self-massage? Here’s the executive summary for this section: no. Case closed.

Fortunately, it is nearly impossible to damage your nerves with self-massage. In my years of clinical experience, I have never known of anyone doing it.

Nerves are well-sheltered from pressure at all locations behind and beside the spine. It’s possible to compress them enough to feel it, but it is nearly impossible to compress them enough to cause damage. Nor are nerves naturally sensitive to pressure. Most nerves, most of the time, can be compressed firmly without producing any symptoms whatsoever.

However, there are physiological circumstances where nerves can be more sensitive — such as low back pain. Lumbar nerve roots may be irritable due to the stagnancy of the tissue around them, or from exposure to the chemicals released from a ruptured intervertebral disc, to name two examples. In such cases, you may feel some nerve pain or other strange symptoms with relatively minor pressures in the low back. As long as the sensations are minor (no worse than your typical symptoms), it’s no cause for alarm. If your nerves were at any risk, you would feel much more severe, highly off-putting electrical or zappy pains long before you were at any risk of actually damaging the nerve.

Even if you did persist — increasing your pressure in spite of such symptoms, which you are no more likely to do than you are to stick your hand into a jar of irritable scorpions — any injury you would do would most likely be minor. Nerves can recover from an enormous amount of abuse, up to and including being mangled in nasty accidents, or being pinched hard for years. For instance, many people who have truly severe carpal tunnel syndrome — years of crippling median nerve impingement — recover just fine once pressure on the nerve is finally relieved by surgery.

In the rare event that you might cause a nerve injury, it would probably result in only annoying but trivial symptoms that would take a few days to resolve, or perhaps a few weeks at the worst. But I have literally never heard of this happening by self-massage — it takes a lot of pressure, and it hurts too much as you approach the point of injury to actually get there.

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Do not underestimate the value of amateur assistance! A creative and generous amateur can be just as effective a trigger point therapist as the average professional, certainly for easy cases — and even for difficult ones!

At least half the challenge of trigger points is simply recognizing their importance in the first place — getting to the point where you accept that trigger points are your problem, or a large part of it. Many people need a professional to help them get to that point, or a tutorial like this, or a popular book like Clair Davies’ The Trigger Point Therapy Workbook.

I have often worked with patients who seem to have readily treatable cases of muscle pain in the low back, but who have been given dozens of different diagnoses over the years, many of them scary. Such people are unlikely to believe, at first, that simple trigger point therapy might be all they ever needed. And no amateur can help them through that process: only a confident professional, putting the diagnostic possibilities in perspective, can guide a frustrated, cynical, and confused patient to that awareness.

But once you are there … the therapy itself can be quite easy! So easy that even an amateur can do it. As you’ve seen in the preceding sections, trigger point therapy is not difficult — most of the time it’s just a little rubbing.

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I am going to go into considerable depth here, because that is what I do, but in this case there is an extreme contrast between my lengthy delving and the simple bottom line. It’s all going to boil down to this:

error! insufficient data!

We just don’t know if massage works for back pain (let alone massage with a focus on trigger points). At best, what we have leans towards “promising,” for short term results especially. At worst, it’s already over: massage doesn’t seem to work any better than anything else, or it already would have shown up in the research (limited and imperfect as it is). But I suspect the truth is that we simply haven’t studied it well enough in the right way yet. I am not aware of a single study of massage for back pain that doesn’t have at least one serious flaw, and none at all that have studied massage the way I’d like to see it done.

Until we have better research, any kind of massage for back pain is experimental medicine.

If all that mattered was the bottom line, I could safely end this chapter right now. But I have to go on! It’s my job to fully understand the research, and “show my work” — you parted with $20 to read this not just for the bottom line, but because I promised to go all the way down the rabbit hole, and to make it as interesting as possible.

But rarely in my work has so much rabbit-hole-diving come to so little.

•

For many years I published my opinion on the efficacy of massage without the support of any good evidence. For a science writer, that was an uncomfortable position. This book devotes a lot of words to debunking treatment methods of dubious value, while massage is one of the only therapies that I have recommended. Although I’ve always been clear that it’s no miracle cure, I’ve recommended it as a good therapeutic option, “because reasons.”416

So, am I a hypocrite with a pet theory and a double standard, supporting one treatment on the basis of insufficient evidence while condemning others for the same thing? Or does the evidence back me up?

It’s probably closer to the hypocrite side of things. 😮

In my defense, for many years the best review of the science that was available, by Furlan et al., had a cautiously optimistic conclusion, declaring that “massage is beneficial.”417 Furthermore, of the dozen or so low quality studies they had reviewed so far, there was a reassuring pattern: the most positive studies also seemed to be the best studies. Always a good sign.

But then, in 2015, Furlan et al. added another dozen studies to the pool of data, and changed their tune: now they have “very little confidence that massage is an effective treatment for LBP.”418 And nor should they. Although there are scraps of good news, the evidence damns massage with faint praise — just like all other “promising” back pain treatments.

Furlan et al.…

 … in 2008: “massage is beneficial”

 … in 2015: “very little confidence that massage is an effective treatment”

The change from optimism to pessimism is fascinating, and caused some angst in the small community of massage therapists who pay attention to research. Dr. Christopher Moyer explains the flip-flop in an interview for Massage & Fitness Magazine:

I think it is more that they are circumspect than pessimistic. Speaking as a scientist, we are very careful to guard against declaring a finding if there is even a small risk of it being a false positive. We never want to say ‘we’ve found something’ and later have it turn out we were wrong when more data comes in. So, I think they are hewing to scientific norms in this regard, and I do not fault them for that; it is important to be careful in science.

In this case, they may have regretted saying “massage is beneficial” based on inadequate evidence in the past, because they did indeed have to walk their optimism back as more data came in. But was it because the results were less positive? Or just that the evidence is such junk?

Garbage in, garbage out

Despite their bottom-line pessimism, Furlan et al. also reported good results: massage actually appeared to be better than control treatments, especially in the short term. In fact, the results sound so positive that you might actually wonder why the authors “have very little confidence that massage is an effective treatment for LBP.” From the plain language summary of the paper:

Massage was better than inactive controls for pain and function in the short-term, but not in the long-term follow-up. Massage was better than active controls for pain both in the short and long-term follow-ups.

But the results are also not positive enough. A skeptic would argue that massage should have been more better, a stronger effect — not just slightly better.

And the evidence comes from pretty junky science. There are only a few dozen studies of massage for back pain at all, and most of them suck. Although Furlan et al.’s 2015 meta-analysis was competently conducted, it suffered badly from the “garbage in, garbage out” problem, and the authors knew it:

The quality of the evidence for all comparisons [studies] was graded “low ” or “very low” which means that we have very little confidence in these results. This is because most of the included studies were small and had methodological flaws.

A bunch of low quality studies with a high risk of bias — conducted by people with a dog in the fight, people who were probably trying to prove that massage works — should be able to produce much clearer evidence of efficacy. If the results are weak, then those results damn massage with faint praise. (That’s what I have concluded about many other treatments.)

But sometimes the results are weak not because there were no strong ones to find, but because researchers didn’t look in the right place. In fact, I do not think these results damn massage with faint praise.

Comparing apples to orange cars: 25 completely different massage therapy studies

The studies Furlan et al. studied were all over the map. It would be hard to imagine a more eclectic group of experiments that are ostenibly about the same thing. In my opinion, this was the biggest problem here. There’s not much point in analyzing pooled data about different things: you need to compare apples-to-apples. This review was saddled with comparing apples to … orange cars. Almost everything was different in every study:

• practitioner credentials and experience were different
• techniques used as a comparison to massage were different
• experimental methodologies were different
• types of back pain were different (not bad, but definitely some)
• and, worst of all, the massage techniques were very different

What a mess!

For instance, massage techniques in these studies ranged from traditional Thai massage to “one 30-minute session of deep cross-friction massage” to “acupuncture massage” to — *facepalm* — reflexology. Three papers used reflexology! That disappoints me: reflexology is not massage therapy, it’s quackery that is superficially similar to massage, a foot rub with snake oil. Even if reflexology actually worked, it still wouldn’t be representative of “massage” — massage for back pain almost never involves reflexology. Including these 3 reflexology studies was like throwing some dead fish into the data pool. It seems almost like sabotage, a guarantee that at least 10% of the evidence was out in left field, a glaring flaw in an otherwise excellent paper.

Meanwhile, where is “trigger point therapy”? Even loosely defined as massage that focusses on sensitive spots, trigger point massage was almost totally absent from any of the research, and wasn’t the focus of a single study. And yet I think it’s the most likely kind of massage to make a difference in low back pain, which is why it was the primary approach I used in my own massage therapy practice for many years. I’ll return to the evidence for this kind of massage below.

Clearly, this was not a tidy apples-to-apples review, not by a long shot. Most of the studies had almost little in common except that they were all experimenting with some kind of massage-like therapy for some kind of back pain.

Sometimes “more study needed” is a bullshit cover for the fact that the research so far has simply failed to produce the good news that someone wants. The lack of strong, clear positive results is the result.

But sometimes more study really is needed, and I think this is a great example. The low quality and great variety in what was studied undermine the results so much that they mean almost nothing at all, which is why I don’t think the results damn massage with faint praise. The right research simply hasn’t been done yet. Furlan et al.’s review, as competent as it is, simply cannot answer the question: garbage in, garbage out.

“Cherry picking” the best studies

Let’s leave Furlan et al. behind now. What do the best studies say? What if I do my own review, deliberately leaving out things like sketchy trials of reflexology, and picking only the studies that I think are the most relevant to what I think constitutes good massage therapy for back pain? Can I cherry pick my way to a happy ending?

Let’s see what happens …

One of the best studies, a Canadian experiment conducted by Michele Preyde way back in 2000,419 was a test of “comprehensive massage therapy” as delivered by well-trained Ontario therapists,420 in six sessions in a month for 25 cases of sub-acute low back pain (non-chronic, but not brand new cases either). Comprehensive massage included remedial exercise prescription and posture education (as would typically be provided by massage therapists in Ontario). This treatment regimen was compared to massage alone, remedial exercise and posture education alone, or some useless laser therapy. Massage alone had “considerable benefit,” just enough to be considered clinically significant; adding exercise prescriptions (and posture education, but that probably wasn’t a difference maker) improved on those results even more, pushing them comfortably into clinical significance.

Booyah! That passes the impress-me test, and I am rarely impressed.

But for all that, Preyde’s nice little study has a critical flaw: the frustrebo effect, a “frustrated placebo,” caused by a lack of blinding. That is, everyone recruited for this study knew full well that it was a massage study … and so the folks assigned to the non-massage group were likely frustrated by that, which can cause a negative placebo effect. People love massage, and being left out of it in this experiment would have been a bummer (plus they’re also suffering and actually hoping for help). And low back pain is notoriously sensitive to expectations! So this is a recipe for statistical disaster for the study: the massage patients are happier and the non-massage patients are less happy, and that could easily skew the results enough to explain away the modest benefits that Preyde supposedly found. And that would actually covert it into a negative study, finding confirmation of no effect of massage for back pain. And that was the sad conclusion reached by Dr. Lloyd Oppel in a short response paper for the Canadian Medical Association Journal: “this paper’s most powerful findings indicate a lack of effect for massage therapy when compared with nonmassage controls.”421

A frustrebo effect caused by a lack of blinding is also the critical flaw in the next notable study, a much bigger and higher profile one. It’s possible that no study of massage has ever avoided this problem — none I’m aware of. The frustrebo effect is a great demonstration of how tricky science is.

The largest ever controlled trial of massage for low back pain was published in 2011. (A separate article analyzes it in detail. See Massage Therapy Kinda, Sorta Works for Back Pain.) Unfortunately, the results were not encouraging, despite the fact that the authors thought so …

Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months.

A strongly positive summary, barely tempered by the word “may.” It would have been easy — so easy — for me to just take their word for it, to accept that interpretation, and to add it to my list of references supporting my enthusiasm for massage. Unfortunately, I could not help but notice that their evidence does not really support such a sunny conclusion. In fact, their data showed that the benefits of massage were minor to begin with, and barely detectable after six months. Worse still, there’s that lack of blinding thing again. They concede the flaw but fail to acknowledge its serious implications: if anything, as with Michele Preyde’s study, it flips the story, from good news to a depressing evidence of absence.

Never in a million years would I have summarized the way they did. I would have said, “A lot of expensive massage produced minor, temporary benefits at best, and maybe none at all.” That seems like a much more intellectually honest description!

•

So that’s two studies now that start out seeming like good news that any massage enthusiast could easily cite to show that “massage works for back pain” — but which actually prove no such thing. Is there any point in continuing? Is there any other good study worth “cherry picking”?

Not really, no. There are other candidates, but they all have major issues. I’ve made my point: it’s actually not possible to cite any evidence that is clearly, unambiguously promising. Not with integrity.

Maybe if we poke the trigger points?

Maybe! But don’t ask science — it’s playing hard-to-get here. Just as I’ve analyzed the massage-for-back-pain evidence in this tutorial ad nauseam, I get dorky in detail about the science of trigger point massage in that tutorial. Here’s just the bottom line …

Trigger point massage is effectively still 100% experimental. It has rarely been directly tested and it has never been done well422 and never for back pain specifically.423 As of late 2017, I’m aware of just 16 studies worth knowing about — if you keep your standards low — and all of them have serious flaws, all show signs of a high risk of bias, all claim to be positive while being contradicted to at least some degree by their own actual data.424

If you squint optimistically, you could call the best of this evidence promising. You could say that where there’s smoke, there’s fire. But it’s like the smoke from last night’s campfire — more of a smokey smell than a smoke where any fire might be hiding.

But dial up even a mild cynical impulse, and the evidence collectively looks more like a damning failure to produce any clearly good news.

Mostly there’s just no conclusion at all. We simply don’t know if it works, for back pain or anything else. Boo.

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Backs seem to love heat. Heat is one of the only things that reliably takes the edge off. The anecdotal "evidence" of this is overwhelming, while the science is almost nonexistent — especially for chronic low back pain. But the nearly universal human experience of being soothed by heat should not be dismissed. This is a useful tool, especially because it’s relatively cheap, easy, and safe.

Ceaveat! Burns happen! Although mostly quite safe, I’ve seen a few minor thermotherapy burns in my career (but never inflicted one). My own wife has managed to burn herself with overzealous use of a heating pad.

Heat may be a useful tool, but it’s also extremely unlikely to actually cure anything. Indeed, it never seems to help much more than a stiff drink. One of the few decent studies that’s ever been done on this topic disappointingly suggested that heat worked no better than ice, and neither of them worked all that well: they both provided only modest benefits.425 It’s not a great study, but a evidence of a modest therapeutic effect is better than nothing, and there are likely situations where heat helps more.

For heating the low back, use just about anything that lets you deliver heat directly and in a controlled way: heated gel packs, heating pads, Thermophores (a special heating pad), towels saturated in hot water, and so on.

The “Thermophore” electric heating pads from Battle Creek are high quality heating pads for the rehab industry that have gradually become consumer products as well. They are thick, cozy, large, and… moist? Moisture condenses on the fleece cover, which they call their “Moist-Sure™ technology.” Cheezy trademark, but it does what it says on the tin.

Full-body heating in immersive settings such as hot tubs, showers, saunas, and steam rooms use heat to treat low back pain and may work because of their stress-busting powers. To the extent that low back pain is a stress-aggravated condition — perhaps quite a lot — then soothing hot soaks may be more meaningful for low back pain patients. Unsurprisingly, there’s a lack of scientific research on this topic. See Hot Baths for Injury & Pain for tips on getting the most out of your bathtub or Jacuzzi — believe it or not, many people do not really know how to take a hot bath, and I have a bunch of tips that can help you wring more therapeutic value out of the experience.

The curious case of the Hydrocollator

For decades, Hydrocollator steam packs or hot packs have been a staple in the rehab business. No self-respecting therapeutic or physical therapy clinic would be caught dead without one: a hot water tank, roughly the size of a trashcan, filled with a set of heavy, clay-filled heating pads, keeping them toasty warm and ready for use. They produce a very moist heat, because they are soaking wet (but the clay retains the moisture, so they aren't excessively drippy).

Hydrocollators are an interesting case study in tradition versus science in rehab. They have a distinct old-timey vibe. They entered the marketplace in 1947, when they were first sold by the Chattanooga Pharmaceutical Company (now Chattem). They remain for sale today, with tanks ranging from a few hundred dollars to thousands (seriously).

On the one side of the equation, this product can easily be defended (or forgiven) as a pleasant and convenient way to deliver the best possible version of a classic folk remedy to back pain patients. What’s the big deal? Let people enjoy things! Seriously, I’m not being snarky here. If I had a home big enough to have a bathroom with some spa features, I’d probably want one of these things around — one of the smaller models, anyway — because heavy moist heat is just nice.

The interior of a Hydrocollator tank. It doesn’t really look like luxury, but these things really are quite pleasant.

On the other side of the equation …

The continued popularity of this product obviously has a lot to do with tradition, momentum, and — most obnoxiously — business model, because it’s one of the most passive of all the “passive therapies,” and it’s literally valuable for therapists to apply steam packs to patients while they they go work with other patients, a practice pattern that has been gradually going extinct. Other than “it feels nice,” which it clearly does for most people, almost all of the other assumptions underlying this usage are rather dubious,426 there is basically zero science to support any of it, and the benefit is clearly minor at best.

And so perhaps it’s rather embarrassing for the physical therapy profession that they were ever used, let alone that they continue to be widely used.

And what about ice?

One of the most common issues for low back pain patients is confusion about ice versus heat. Heat is almost always preferable, because it is what almost all back pain patients prefer. Low back pain patients are usually heat seekers — but there are exceptions!

Ice should be used on the back only by patients who clearly prefer that (for whatever reason), or when there is definitely a fresh, superficial muscle injury (such as a true tear, when a significant exertion causes a sudden onset of strong pain). Ice will not usually do any harm, and context certainly matters: if you like the idea of ice or just believe (for whatever reason) that ice will help, like the patients in the ER study mentioned above, it will probably help.

But ice should never be imposed on a reluctant patient, because it can absolutely backfire. Most people clearly prefer to heat their low back pain, and a few have negative reactions to ice, when it’s unwanted. Consider this “chilling” example of an “ice backfire”:

I was receiving a pleasant massage from an RMT for a low back or sacroiliac joint problem. Everything was going well, and I was feeling quite a bit better, when suddenly she put an ice pack directly on my skin. She gave no warning at all, just put it on. It was so startling and unpleasant that my back muscles started to spasm, and all the good she’d done was completely reversed. It was a disaster! Obviously, I never went back there ...

anonymous client

Talk about terrible technique and bedside manner! Alas, ice is often prescribed and delivered carelessly for the patient’s own good, without regard for their preferences. And that’s exactly when it tends to backfire, and why I want patients to feel free to choose!

For more on ice, heat, and ice vs. heat, see also:

• Ice versus Heat for Pain and Injury — When to use ice, when to heat, when not to, and why
• Heat for Pain and Rehab — A detailed guide to using heat as therapy for acute and chronic pain and recovery from injury
• Icing for Injuries, Tendinitis, and Inflammation — Become a cryotherapy master
• (Almost) Never Use Ice on Low Back Pain! — An important exception to conventional wisdom about icing and heating. Note that this is also highly relevant to neck pain patients, and there is a section specifically about neck pain.

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Normal activity levels — or as close to normal as you can get — are the best general course of action in response to most acute episodes of back pain.

It doesn’t sound like much, does it?

But there’s more to “act normal” and light general exercise than first meets the eye: finding and loitering in the activity Goldilocks zone is actual pretty good challenge. One study found that ordinary activity got better results than either bed rest or exercise.427 Some rest may well be appropriate, but it should be minimal and tactical.

Rest in peace, bed rest

Bed rest, once a standard recommendation for anyone with acute back pain, is just not a good idea.428 According to an updated review of the science in 2005, bed rest may even cause more pain429 — ouch!

Unfortunately, I still hear from readers who have been told that they must get flat and stay that way. This just exacerbates the idea of spinal fragility, reinforces the fear of disability, does little or nothing for pain, and results in making stagnant and understimulated tissues even more so.

However, it’s sensible to beware of activities that obviously aggravate your low back pain, and avoid them. What if your “normal activity” is unhealthy? I made it clear above to beware of advice to entirely quit favourite activities, but taking breaks from your routine may make sense when you suspect certain activities are part of the problem. An irritating activity or position — or even stagnancy — may contribute to the vicious cycle of back pain, and so it may be helpful to remove it from the equation briefly, experimentally, to see if it makes a difference.

The main challenge here is to decide whether any activity avoidance is actually called for in your particular case of back pain. How much do you think your back pain was caused by a specific activity or continues to be aggravated by it? That can be surprisingly difficult to figure out. The more confident you are about that, the more you should consider taking a break. Just remember that connection should be obvious — anything less than obvious, and it’s doubtful that the activity is actually a key factor.

One way I often see this thinking going wrong: blaming a harmless activity. Usually it’s a case of rapid onset where the patient doesn’t actually know what triggered the pain (that outta nowhere phenomenon again), and is trying to fill in that blank with whatever activity they happened to be doing at the time (or earlier that day or week.) “I was playing a lot of golf, so it must be the golf, therefore I must take a rest from the terribly stressful activity that is golf.” Probably not. If you are blaming an activity that does not seem particularly hard on the back, then it probably isn’t.430

If the need for rest isn’t obvious, then you probably don’t need much rest. Rest is obviously warranted in the case of the construction worker who had to repeat a particularly back-beating chore several hundred times in a row, with the pain getting worse and worse as he goes. It’s obviously a good idea in the case of the farmer who planted 400 yards of eggplant seedlings. It’s obvious in the case of the bodybuilder doing entirely too many dead lifts but still pushing on when he knew better. And it’s obvious in the case of the office worker putting in 12-hour days in an ill-fitting chair.

But it’s rarely that obvious. In the majority of cases where getting worn out is the main problem, rest is an equally obvious solution, and that patient never needs to read this book. For most back pain patients, it’s a more complicated mix, and resting is a little trickier — possibly helpful, but also potentially harmful. Consider a more complicated and typical example:

I had a client whose back pain was probably aggravated by a distinctive slightly flexed position that he assumes at work, a simple postural over-exertion. I advised him to continue to be an active person, getting any kind of exercise that pleased him. I also suggested that he find another way of positioning himself at work for a while and to make a point of taking some shorter days and maybe a long weekend at the same time that he worked on other therapeutic angles. In short, I told him to rest temporarily from that awkward posture, but not rest in general. I think it would actually have been quite harmful to tell this patient to permanently change his working posture — to advise total rest from that posture. Why? Wouldn’t some posture improvement just be wise? Well, maybe … but it can be extremely difficult to change postures, and meanwhile I didn’t want him to feel bullied by his back pain into thinking that he couldn’t handle something as innocuous as a slightly stooped posture.

It may benefit you to work on a specific posture, but there is also virtue in taking a stand and saying, “I should really be able to sit this way without it being a big problem.” And that is absolutely possible! Many people tolerate their lousy postures just fine. So for this patient, I quite deliberately placed the emphasis on getting some exercise and some temporary caution with the working posture.

Warnings to completely rest from or avoid a posture can sound like this to the patient: “Your back is so weak and pathetic that you can’t handle sitting. You are screwed if you don’t stop sitting in a particular way. You’re in awful pain now, and you always will be unless you can figure out how to pull off the seemingly impossible challenge of a permanent change in your posture. You might succeed for a while, but chances are you will backslide … and it’ll hurt!”

I’m exaggerating a little to make a point, of course. But I have seen quite a few patients and readers who have somehow — in most cases, they got the idea from a therapist with good intentions — developed a long-term paranoid hypervigilance about avoiding (“resting from”) activity X or factor Y. Even if they are out of pain, I’d call that a failure as far as quality of life goes. All this is bad enough, but it’s far worse still if the posture wasn’t actually even a relevant factor to begin with — which is definitely a possibility.

Ideally, you should use rest cautiously and temporarily to break a cycle of pain-causing-pain. However, remember that you should be able to resume activities that were previously problematic. And that you should focus on choosing to “act normal” — it’s an excellent, evidence-based strategy, especially for acute episodes of back pain where there’s no obvious connection with any particular activity. However, you can do even better! If your normal activity isn’t healthy, how about simulating or imitating a “normal” activity level? You can proactively target the affected tissues with the best possible exercise strategy: mobilizations …

Bourne concentrated on rest and mobility. From somewhere in his forgotten past he understood that recovery depended upon both and he applied rigid discipline to both.

The Bourne Identity, by Robert Ludlum, p. 137

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Do do do do, do do do do, do do do do …

Can you exercise to help beat chronic back pain in the low back? Maybe. But you must enter …

… The Goldilocks Zone.

One of the pillars of trigger point therapy is regular, easy exercise. Exercise intensity that is “just right.” Just enough stimulation to keep your tissues warm and happy … but not enough to irritate them.

Anyone struggling with back pain must (must, must) embrace life in the Goldilocks Zone. This is probably particularly true in the low back. The low back is almost never adequately stimulated by normal activity alone. Our modern lives do not lend themselves to moderate, regular stimulation of our back joints and muscles. We tend to live at the extremes, either standing or sitting for hours at work and at home, or pushing our limits in athletic recreation.

For maximum back health, you must regularly but gently stimulate your body. Weekend warriors need to let the ski slopes go for a while and take up a walking habit instead. Hardcore power yoga practitioners need to switch to a gentler class. Office workers have to learn to take regular breaks from the chair. Gym rats have to ease up on the “reps to failure.” And so on.

You can easily take the idea of the Goldilocks Zone and run with it yourself. It’s not hard to understand the principle. But the idea that absolutely everyone needs — the perfect embodiment of the Goldilocks Zone — is the idea of mobilizations.

Mobilizations are rhythmic, repeated movements that alternately stretch and contract musculature and other soft tissue — massaging your tissues with movement. I prescribe at least one or two key mobilizations to nearly every client, usually in preference to stretching. Mobilizations are more neurologically interesting than stretching, and they stimulate more metabolic activity in the tissue while remaining gentle. They are more practical and efficient than stretching in many ways, especially because they can affect more tissues more quickly. They also constitute both a better warm up and a better warm down for more intense activity.

Immobility is a major part of the vicious cycle of low back pain, but also one of the easier ones to break — once you start to trust that your back is not fragile, and there is no danger in using it.

Movement inspires confidence: as you move more and more, both you and your overprotective nervous system learn to trust the health of your spine again. I strongly encourage clients to emphasize the mental part of this exercise, treating every repetition of a movement like a message to your back: “everything’s cool, everything’s good, no problems here … ”

Mobilizations teach the back to behave like a back again, to do spinal things, to do what backs do.

Mobilizations stimulate low back tissues with much greater safety and precision than other common approaches to exercise therapy for the low back. By using your pain-free range of motion systematically, you can provide much more variety of stimulation to your low back musculature than you ever could simply by getting up from your chair regularly to run errands around the office — and, as long as you only do whatever movement is mostly painless and only in modest doses, it’s also nearly impossible to hurt yourself.

For more general information about mobilizations, see Mobilize! Dynamic joint mobility drills are an alternative to stretching, a way to “massage with movement”

Some nice mobilizations for the low back…

Stick-Yer-Bum-Out

Summary: Stick your bum backwards and out to one side while twisting the spine. This reaches deep into one side of the low back. Then reverse the motion, and do the other side.

This unusual mobilization reaches the low back and gluteus maximus in a way that no other exercise can, stimulating that hard-to-reach spot in the very bottom “corner” of the low back, just above the dimple. Stick your bum out as though you are going to sit down on a stool that is well behind you and off to one side. Your knees must bend. Round your low back like the top of a ball, lean your torso in the other direction (i.e. bum goes left, torso goes right), and twist your shoulders to face back towards the middle. (The further you lean and twist, the further the stretch will “reach” into your upper back.) To conclude, stand up and lean back a bit, clenching your gluteal and low back muscles firmly. Now alternate from side to side: left, clench, right, clench, left, clench, etc.

Standing Forward Bend

Summary: Straight from yoga: touch your toes and then stand up with a rolling motion of the spine.

Stand with your feet shoulder width apart and toes pointed slightly inwards, knees unlocked — this is not a hamstring stretch. Breathe steadily for the duration of the exercise. Begin by lowering your chin to your chest and continue to flex your intervertebral joints one at a time. The lower parts of the spine should remain erect for as long as possible. Continue until your entire upper body is hanging from your hips, and make sure your head is a relaxed dead-weight at the end of the spine. At this point, you have two choices for getting back upright: for the first 3-5 repetitions, you should (a) squat down, slowly straighten your back, and then stand up using the strength of your legs; but once you are warmed up a bit, you can (b) simply reverse the spinal movement instead, rolling up instead of down, lifting the vertebrae back into place one by one, starting with the low back and moving upwards.

Deep Gluteal Mobilization

Summary: Sit, cross one leg over the other, and lean forward. Then spread the feet and push the knees in and down. Far superior to a common physiotherapy stretch prescribed for sciatica and piriformis syndrome.

Starting from a seated position, place your ankle on the stretch side over your knee on the other side. Let your lifted knee relax downwards for a moment, and then begin to lean forward from your pelvis. Avoid simply slumping forward, which is useless. Visualize pushing your belly button between your legs. Now do this on the other side, to even yourself out, even if you have symptoms only on one side. Now, to complete the mobilization for both sides, place your feet widely on the floor, and drop your knees straight down towards the floor.

Mobilizations are not a life sentence. I recommend that you do them only on an as-needed basis. When you begin to self-treat low back pain, begin conservatively with only 10–20 repetitions of a given mobilization exercise per day, but then build quickly up to 40+/day of the most relieving exercises for a few days. Thereafter, you can do all the exercises “as needed” — whenever you think they might feel good or useful. The idea here is to do a lot up front, but not much later on. In my experience, almost no one is good at doing therapeutic exercises for long, so I don’t prescribe them as a constitutional or preventative: just a bunch of them at first to kick-start tissues that have forgotten normal function, and then trailing off rapidly. But they are always in your bag of tricks if you need them again.

Many people should use these exercises when taking “microbreaks” at work. They are an ideal way to quickly and efficiently stimulate stagnant low back tissues, to keep your back in the Goldilocks zone. More about microbreaking below in the section about managing low back pain when you work in a chair all day.

But even if you aren’t a “chair warrior,” microbreaking is a useful concept. For instance, mail carriers also experience a kind of stagnancy in their low back pain tissues, a sensory boredom with the same slight low back muscular contractions with every step, all day, every day. Mail carriers can benefit just as much from stopping every three blocks to take a microbreak of 30 seconds and do three standing forward bends or “stick yer bum out” mobilizations.

Another intriguing option is passive mobilization — that is, getting moved by something instead of moving yourself. However, this needs a partner or equipment. In the traction section (next) I give the example of spinal “jostlers” (like the Back2Life tool) that offer a little mobilizing and a little traction simultaneously — a fine, simple idea.

And finally, of course, get your heart rate up in whatever way pleases you

In addition to stimulating the spine and back specifically, you should also just stimulate everything and anything whenever you can — without obviously irritating your back. Some of your are groaning already, but bear with me: this is a good-news-bad-news thing.

The bad news is that this isn’t going to fix anyone’s back pain in the short term.

The good news is that it’s a fantastic investment, and it takes amazingly little exercise to be way better than nothing. You do not have to become “hardcore.” You do not have to do crunches or pull-ups like you’re in a training montage. You do not have to embrace the stereotypical lifestyle of the amateur athlete.

Just take the stairs more often. Jog two blocks now and then. Seriously. That’s all we’re talking about here. And this is evidence-based advice.

The calorie-counting stairs (click to zoom). Stairs are the most ubiquitous, accessible “gym equipment” in the world

Skeptics have been pointing out for years that exercise may not “fix” anything but a lack of fitness, and a lack of fitness is not a cause pain. Not directly anyway. Not in the short term. But exercise in general? As a “tonic” that improves health in a many ways, almost certainly boosting your “immunity” to chronic pain or failed healing ? Exercise remains rather amazing for that. It probably does improve your odds in all kinds of good ways over time.

For instance, we know that we can reduce inflammation with long-term daily exercise. Klasson et al is a good 2022 trial linking long-term daily physical activity to clear reductions in systemic inflammation (as measured by major biomarkers).431 They found “evidence for both systemic metabolic effects via thyroid hormones and in specific systems via reduced inflammation and immune cell counts.” This is a promising clue for many people with unexplained chronic pain who feel “inflamed” a lot. Some of them probably are, and doing as much exercise as you can is one of the only evidence-based strategies for solving that over the long haul (along with avoiding junk food and sleep loss and other lifestyle medicine basics).

And also for instance, we know that mini workouts, short but strong, are absurdly good bang for your exercise buck. Ahmadi et al did one of those morbid mortality studies, a big one cross-referencing deaths with fitness gadget data for tens of thousands of people.432 People died less if they did frequent small doses of vigorous exercise — less than 2-minute sessions, and only one or two per day. Intense and regular, but just little blasts of action. The benefits became measurable at 15-minutes per week, and continued to improve up to a total of an hour per week (or 4 mini workouts per day).

Four mini workouts per day sounds easy, almost like a slam dunk — and it definitely is easier than getting to the gym for 30-minutes per day. But it’s trickier than it sounds! I have tried to hit this goal a few times in recent years, and always failed. It’s a tricky habit for me to build.

(Note that “all-cause mortality” definitely overlaps with the “reduced systemic inflammation” measured by Klasson et al. taming inflammation was probably partly how mortality was reduced.)

Take the stairs!

Every chance you get, as often as your body can handle it, for the rest of your life, with or without any current back pain. Every stair climb is a gift of a minute or two of exercise. Little bits of oomph won’t “fix” back pain any more than regular putting $100 in a savings account will fix poverty… but they add up & the benefits start to reinforce each other. Over the long term, it’s a truly great way improving your odds of minimizing any kind of pain.

General exercise for back pain isn’t “random” or “miscellaneous”

In scientific studies of back pain, "general exercise" has often been shown to compete just fine more specific and allegedly "corrective" exercises. This has resulted in a common misconception that any exercise will do, just as long as you get moving. Todd Hargrove:

General exercise isn’t “random” exercise. It is exercise that a patient chooses to do, and that choice often involves a screening process that may have some wisdom to it. People are more likely to choose exercises that are non-painful, fun, that fit into their schedules, that their friends do, and that relate to meaningful functional goals. Exercise that meets this criteria is far more likely to help with pain than some exercise chosen at random. And maybe more likely than exercises prescribed by movement therapists.

Great advice.

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Resting peacefully in a position of comfort for a minute or two may ease chronic low back pain for much longer. There are a variety of techniques that exploit this idea in different ways, but “strain-counterstrain” therapy is the most common label for treating pain essentially just by positioning limbs for patients. It’s kind of a strange name.433 Most massage therapists call it “positional release.” I’ll mostly use SCS here. It has a surprisingly long history, which I discuss in more detail in the SCS chapter of the trigger points book.

We have here yet another odd treatment approach of unknown and probably low value at best. And also free. And also particularly harmless, since the point of it is to do almost literally nothing, like a form of meditation. At worst, SCS is just a comfortable, peaceful waste of time.

SCS is almost comically simplistic, but I can put a modern pain science spin on it: if it works, it’s probably because it exploits the principle that chronic pain often has a strong component of excessive sensory alarm (sensitization, previously discussed). I wouldn’t recommend this to a patient with runner’s knee, even though sensitization can be involved in any kind of chronic pain — the advice here is justified by the particularly important role that sensitization plays in low back pain, combined with the fact that low back pain is often highly sensitive to position/movement.

It’s certainly not justified by evidence! There is no direct evidence for the efficacy of this approach to the problem. It’s just pure plausibility and safety.

“But I’m always trying to spend time in the most comfortable position. How is this different?”

Fair question! SCS is more deliberate and methodical. We do naturally seek out positions that reduce our pain, but most of us can do a better job of it, more precise and thorough. It can be a “treatment” instead of reflexive pain avoidance, which is often:

• too brief and erratic
• distracted and agitated
• only partial avoidance

For instance, if you are avoiding pain while still trying to work, you may adopt a position of greater comfort in your chair… but it’s still painful. That’s not a position of actual comfort, it’s a compromise, the least painful position that allows you to keep working.

It’s like the difference between falling asleep on the couch and meditating.

It’s also like the difference beween unconscious squirming and deliberate pain free range of motion exercises.

A back pain example

Let’s pretend to be a fly on the wall observing a man with back pain aggravated by postural stress at a desk. This fellow feels quite a bit better when he sits up a little straighter and actually uses the chair’s lumbar support (not an endorsement of lumbar support, just how this patient’s pain happens to work). Our subject can be seen doing this dozens of times per day, seeking relief, but not really finding it, because that position of greater comfort is never complete or sustained.

No matter how long we watch, all we see is reflexive and rather desperate and disorganized pain avoidance, which quickly succumbs to postural habit.

It’s also not completely comfortable. It’s less uncomfortable than his habitual slouch, but it’s not truly comfortable.

What really feels good to him is lying down with lumbar support. What if that person were to take a ten minute break and lay down, with lumbar support, relaxing in a position where the pain is truly the mildest, or even absent entirely?

And what if he was mentally calm and focused on that experience, rather than a barely conscious adjustment while preoccupied with stressful work? Is it possible that this patient might emerge from that more deliberate rest feeling far better?

You can bet your boots it is — hardly guaranteed of course, but “possible”? Sure.

What does it mean if it doesn’t work?

Failure doesn’t mean much. Although success is probably an indication that sensitization is a factor, with failure the interpretation could go either way:

1. There’s still something wrong with your tissues.
2. The false/excessive alarm is still false/excessive.

There’s no reason to think that genuine tissue distress will be helped much by positional release. If you have a small cyst pressing on a nerve root, or a slow-healing overuse injury to a intervertebral disc, the pain will probably resume as soon as the comfortable position is abandoned and the vulnerable tissue is disturbed.

But other kinds of low back pain may not resume hurting again — or not so fast — because there may not be much wrong with the tissue to disturb, or not so much as there was originally.

Level up: resting at the edge of the comfort zone

Another way to do positional release is to find the edge of a comfortable position and hang out there. Hanging out in the middle of your comfort zone is saying to your nervous system, “Hey, see? We’re just fine!” But we can move to the edge of the zone and add this: “We’re fine even over here where the alarm starts to pipe up!”

For instance, let’s say that you begin to experience back pain with a disconcertingly tiny degree of flexion: the pain starts at just 5˚ of unsupported stooping. So hang out at 4˚, probably with some support. Stand in front of a counter or table, give yourself some support to make sure your nervous system feels safe, add another degree, maybe another, until you can just start to hear the pain-alarm starting to blare… and pause there.

Just spend time there not having much of a problem.

Positional release as “exercise”

Rehab exercise can be divided into a hierarchy of intensity: pain-free range of motion, mobilizations, endurance, and strength training. Although neutral positioning barely registers as an “exercise,” it fits in nicely at the easy end of that spectrum.

Positional release can be considered the first stage in a rehab journey back to normal activity levels: just comfortable stillness instead of gentle painless movement, but both with the goal of gently reassuring the nervous system and “practicing” being pain free. Even as you progress with more challenging activity and exercise, you can also periodically interject a little positional release, to continue reassuring your central nervous system.

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The risks of poor lifting technique have been exaggerated.

The conventional wisdom is that we must not stoop to lift heavy objects. To avoid injury, we should squat down and then lift with our legs, not our backs. About 75% of physical therapists believe this,434 and the number is probably even higher outside that profession. It’s just as common for professionals to blame awkward and uneven lifting of lesser loads, as in this perfect example from a reader:

Every doctor and chiropractor and physiotherapist I have seen for months has told me that I have back pain because I’m carrying around my baby son. I don’t buy it! I had the same back pain for years before he was born. I don’t understand why they can’t understand that logic. It comes and it goes and I just don’t know why, but it isn’t my son, or it’s not just my son.

Her logic was solid: if the pain pre-dated motherhood, then baby-toting is a daft explanation for it.

All those pros who believe in the importance of good lifting technique are probably wrong. I will argue that this is worse than wrong — it’s actually counter-productive. The truth is undoubtedly in the middle, but decades ago the pendulum of public opinion and “common sense” swung all the way to one side and got stuck there; I think it needs a firm (evidence-based) push back towards the centre.

For a more thorough and technical review of both sides of this topic, see Greg Lehman’s excellent review, “Revisiting the spinal flexion debate: prepare for doubt.” This article focusses just on making the case that the conventional wisdom is a myth: stooping to lift is not a significant risk factor for back pain, and most people don’t need to be taught how to lift simple heavy objects “properly.” Several sub-topics are not covered here, especially the athletic extremes (like powerlifting), special occupational challenges (like nursing or piano moving), or lifting during rehab.

Your back isn’t fragile and you already know how to lift things

Although we can’t lift heavy things just any old way, we don’t really need to be taught either. What matters most is so obvious that it’s hard to get wrong: just keep objects close to the body.436 As long as we do that, there’s not much we can do to improve on it, and in particular neither stooping nor squatting has an obvious safety advantage (the science coming below).

Although some of this still sounds a bit contrarian and radical today, the value of trying to tinker with people’s lifting habits to has been under fire for a long time. In 1997, Dr. Nortin Hadler wrote a paper for the journal Spine with the subtitle: “what you lift or how you lift matters far less than whether you lift or when.”437 In 2002, physical therapist Leon Straker wrote:438

Little evidence supports the effectiveness of training programs to change workers’ lifting habits and any attempt at change may just increase risk as workers lose the protection of well practiced and conditioned movement patterns.

That opinion was backed by a 2008 review of several years’ worth of evidence about lifting technique and low back pain:439

There is no evidence to support use of advice or training in [lifting] techniques … for preventing back pain or consequent disability. The findings challenge current widespread practice of advising workers on correct lifting technique.

(I’ll review some more specific and recent evidence below.)

I think that training people to lift “properly” probably doesn’t work because backs are actually tough as good boots, and what makes backs hurt (or get injured) isn’t influenced all that much — if at all — by how you lift things. The conventional wisdom is based on an assumption of a fragility that just doesn’t exist in the back, so it’s not too surprising that the training doesn’t make much difference: there’s no vulnerability to avoid.

And that’s not the only bogus assumption in this mess.

Does heavy lifting actually increase the risk of back pain?

If lifting heavy things at work leads to back pain, then it would make more sense to be careful about how you do it. If.

As much as I appreciate their conclusions, Martimo et al. begin their paper with a whopper of another unjustified assumption, in the first sentence: “Heavy lifting at work increases the risk of back pain.”

If that assumption isn’t correct, the entire discussion is a moot point, right? And yet the authors support it with only a single reference to a 1999 paper published in an obscure journal, International Journal of Industrial Ergonomics440 … and that paper supports nothing of the kind. It does not show that “heavy lifting increases the risk of back pain.”441 It’s a bogus citation! I am not making this up.

But that’s now ancient data in any case. Much more recently, a 2010 review concluded it’s “unlikely” that lifting was a cause of back pain in workers.442 A 2012 review found little to no evidence for any connection between back pain stooping over repeatedly or for long periods443 — a different angle on the same problem. Not enough reviews for you? Okay: a 2011 review of eight reviews “did not support” the conventional wisdom either.444

Never mind the weight: how about just the amount of time spent bending over? The stoopage factor? A 2015 study of 198 workers not only failed to find a link between the amount of back flexion and higher pain intensity, they found the opposite: more time spent flexing beyond 30˚ was linked to lower back pain intensity!445

None of this means that no one will ever hurt their back lifting something at work, but obviously the connection is nowhere near as obvious as everyone assumes. (Even the experts assumed it until quite recent history.) Likely there are major X factors.446

There’s no real smoke around lifting, so there’s probably no back pain fire.

Does stooping even put more load on the spine?

It is almost impossible not to flex your spine when lifting something off the ground, and there is remarkably little difference between spinal loading in different lifting techniques. Kingma et al measured 40˚ of spinal flexion even in a pure squat lift,447 the theoretical ideal lifting technique as understood by most people. Meanwhile, the lumbar spine flexed only ten degrees more when lifting the same way.

Or what if we could measure spinal forces directly? Imagine a pressure meter implanted in your back, completely replacing one of your vertebrae. What would it tell you, if you stooped over to pick up an object instead of squatting down to lift with your legs instead of your back? The nearly universal assumption is that stooping puts much more strain on the spine.

But if that was a safe assumption, I wouldn’t be bringing it up here. Just as Kingma et al found, there’s not much difference.

Those meters are actually a thing! Instrumented vertebral body replacements (VBRs) are high-tech gadgets installed in place of a vertebrae. Very cyborg! (Stronger, faster, more … measured?) In a 2016 experiment,448 three patients with VBRs did a bunch of lifting, and their implants measured the forces in squats versus stoops. Not only was the difference was negligible… it was actually in favour of stooping! Squatting is the supposedly “correct” and safe way to lift, but it actually caused 4% more load on tissues. Not a big number, but it’s in exactly the wrong direction if you were trying to support the conventional wisdom.

The current in vivo biomechanical study does not provide evidence that spinal loads differ substantially between stoop and squat lifting.

This is not perfect evidence, or the only evidence, but it’s enough to cast a lot of doubt on the value of advice to “lift with your legs, not your back.” And that’s all we need to make the case that the importance of lifting technique has been exaggerated.

What about back braces and support belts?

No one lifts more than bodybuilders and powerlifters. And bodybuilders must wear those big thick belts for some reason!449 If it makes sense for them, it must make sense for occupational lifting too. Surely.

Unless it doesn’t make sense for them. Siewe et al found that the use of weight belts increased the injury rate of the lumbar spine in powerlifters.450 Ruh roh!

And major recent reviews of the science have shown that there’s little or no prevention benefit to such belts in the workplace.451452 •sad trombone•

Interestingly, even hard braces are amazingly ineffective at reducing the forces on the spine!453 See Spinal Fracture Bracing and Fixation: My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace — fascinating topic.

Supports, braces, and belts mostly just provide some novel sensory input that reinforces the idea of security and stability — a sensation-aided placebo. That is, you don’t just hope that it supports your back, it feels like it does. Unfortunately, this also strongly encourages the insidious idea that backs need stabilizing in the first place. And that’s how you lose The Mind Game in Low Back Pain.

Another lesson from powerlifting

Deadlifts do not remotely look like a “safe” way to lift something heavy with your back. And yet the sport of powerlifting demonstrates that it’s possible to do deadlifts regularly without any obvious pattern of vulnerability to back pain. These guys and gals are stooping over and picking up dramatically more weight than anyone is ever going to lift at work.454 For fun. With, science says, less injury than other sports!455

Most powerlifters try to minimize spinal flexion, especially lumbar flexion, but it’s not clear that many of them are actually succeeding … and for sure many amateurs definitely fail, either because of poor training and/or because it is biomechanically difficult to achieve. Remember, it is nearly impossible not to flex your spine when lifting something off the ground.456 And so most deadlifts and strongman lifts bear a striking resemblance to how people are not supposed to lift, and yet the sport is amazingly safe.

But this isn’t about powerlifting: I’m just using powerlifting as an example to make a point about saner loads. I am definitely not saying that it’s safe for an untrained person to try to lift huge loads willy nilly — technique does matter when you’re trying to get several hundred pounds off the ground! It’s a completely different thing than schlepping stuff around in a warehouse. I am only saying that the range of what it’s possible to do surprisingly safely is just huge. If backs were actually prone to injuries when lifting 20-40 kilos with poor technique or training, it’s unlikely that people could ever safely multiply that by 3-10 times in deadlifts, but they clearly do, even with imperfect elimination of flexion, if that is even possible.

The point is that backs are naturally sturdy and non-fragile, and powerlifting is a great demonstration of that.

Don’t worry about how you lift … but don’t be a fool either!

Obviously you can hurt yourself if you are reckless with heavy loads. And obviously technique does matter for extreme loads (the kind of loads no one would ever be expected to deal with at work). Strain hard enough and you will get a muscle strain (a tear), or worse. And although disc herniations may be less common and less serious and less related to either lifting or back pain than people think, that doesn’t mean you want one.

But training for lifting technique is probably not important because heavy lifting itself probably does not actually increase the risk of back pain significantly in the first place — and so there’s no problem to solve with better technique, and no evidence that there is even any way to significantly improve on our technique. Doubtless heavy lifting is at least a little bit of a factor in back pain, just not a major one — not the kind of factor that generates a nice clear statistical signal.

Back pain that starts with a lifting trauma probably occurs less than most people think, and isn’t as severe, and when it does occur it probably often seems worse than it is due to the common problem of trigger points.

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Traction sure sounds like a good idea! Most people with low back pain feel as though their vertebrae are jammed together, and crave relief from that sensation. Gravity relentlessly presses vertebrae together — wouldn’t it feel nice to go the other way?

And it does. Nearly everyone seems to appreciate the feeling of lightening the load. But does it actually solve anything? Or is it just a temporary relief, an itch scratching? It may feel “as if” vertebrae are jammed together, but is that really the problem? In a handful of cases, it’s possible that traction is genuinely biomechanically relevant and modestly therapeutic. But even at best it’s probably analogous to getting off your feet when you have a rock in your shoe, without actually removing the rock — that is, a brief reduction of loading on sensitive tissue, but you don’t actually solve anything.

The science of traction is overwhelmingly negative, decent evidence that traction is effective for the average back pain patient. Like an aspirin that works only 5% of the time, it’s not a very useful treatment. And yet people crave it, and will do it, and maybe a 5% chance isn’t so bad when you’re desperate.

Just don’t pay too much for it. That’s the key.

There are a lot of ways to pull on your back, ranging from the cheap and easy to expensive and elaborate and pretty obviously scammy. Because traction often feels good, and because it might help, it’s probably worth cautiously experimenting with the cheaper and safer options.

But it’s probably not worth experimenting with the more expensive and risky options, such as “non-surgical spinal decompression therapy” (SDT) machines — the rack. Mechanical traction pulls harder and longer on your back, draining your bank account more and increasing the risks, all without any evidence of benefit.

These machines are well-studied, and most of the evidence about the effectiveness of back traction in general comes from studies of SDT. For the purposes of debunking, I report on that evidence in detail in a separate section devoted to criticizing SDT machines and claims. The bottom line is clear, though, hammered home in a major review of the subject in 2007 that looked at all the science up to then: “ … traction as a single treatment for LBP is probably not effective.”457 That certainly doesn’t exclude all hope — what about multiple treatments? — but it is discouraging.

For the remainder of this section, I will focus on the cheaper, simpler, and safer methods…

Seated lumbar pulls. The simplest method of low back traction is incredibly easy and free — just sit somewhere where your knees can hook firmly over the edge (i.e. a firm bed), lean back a little, place your hands flat beside your hips, and push backwards. You’re simply using your arm strength to push your upper body away from your hips, using the edge as an anchor. Hand position matters — you may have to tinker a bit, placing them farther forward or back. But if you have the principle in mind, you should be able to easily apply a gentle stretch.

Therapist-powered traction is another good option to consider. Although a therapist’s time is not inexpensive, traction can be just one inexpensive (fairly brief) component of the session. Therapists apply traction primarily by pulling on legs or hips, sometimes with the assistance of straps and other simple tools. One of the virtues of therapist-powered traction is that it there is only so much force that can be applied, making this a safe way to possibly relieve some discomfort. If it seems helpful, you can also graduate to an inversion table for a stronger traction.

Inversion tables are simple machines that dangle you upside down. They are a reasonably good compromise approach to traction, providing a middlin’ degree of traction at a middlin’ cost with middlin’ safety. Although they still require an investment of around $200 and some floor space, the expense is one-time only, and the equipment can be returned or sold if it doesn’t work for you. The cost is worth it if it works, and trivial if it doesn’t.

An inversion table

The inversion table allows good control over the intensity of traction as you slowly tilt yourself upside down.

There are many different models, but I emphatically recommend the table design of inversion machinery, in which you lie on a tilting platform that allows you to gently and slowly lower yourself into an increasingly inverted position. Being supported and having control are important when you’re experimenting with a treatment that could cause problems. By contrast, there are inversion machines which involve simply hanging loose from boots. These might be appropriate for someone who’s already established that they like to hang upside down … but what a bad way to figure it out!

Spinal “jostlers” like the Back2Life tool. The idea is that you lie on your back, hook your knees over supports that slightly lift your butt off the ground, and then the machine oscillates gently, creating “continuous passive motion” — wiggling you while you relax. I certainly don’t care for the style of the marketing for the product, and I definitely don’t think it “aligns the spine” or really anything at all that the website claims. But I do like the sensations produced by the device, and the combination of a little mobilizing and a little traction. It’s a pleasing, interesting source of stimulation, and I think that is often useful for back pain. It’s also mild enough to be extremely safe, and it’s not super expensive (about $200 USD).

Inflatable belts, like Dr. Ho’s Decompression Belt. “As the belt inflates with air, it expands vertically, gently stretching and tractioning the lower back.” But can it actually push apart spinal joints? It’s a little doubtful. I discuss the mechanics of bracing in another section.

Why doesn’t traction work better?

How come traction doesn’t pass scientific tests with flying colours? Decompression of intervertebral joints and discs is unlikely to help unless “compression” is the problem. And, even if compression was the problem, decompression can only temporarily and slightly relieve it. You’re going to have to stand up again soon.

However, many lines of evidence show that compressed and pinched structures are probably much less likely to be the explanation for back pain than most people think. By far the most common alleged compression in low back pain is the pinching of nerve roots — which this tutorial has already thoroughly debunked as an important factor of low back pain.

Another candidate for cranky compressed anatomy is the facet joints. However, facet joints have also been shown to be a factor only in some cases of low back pain, and they are not significantly load bearing. They do bear load — just nowhere near as much as the intervertebral discs. Thus temporarily relieving the back from vertical loading can only do so much for the facet joints.

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Stretching is over-rated: it enjoys a reputation as a pillar of fitness and a staple of rehab that it does not deserve.458 And people certainly believe stretching helps back pain, in large numbers.459

Stretching may have some modest value for some low back pain patients, but the benefits are probably erratic and minor, and in general you’ll get better bang for buck just from doing exercise and physical activities you enjoy, or anything that’s just more active — like mobilization exercises I’ve already recommended.

Nevertheless, I do think it’s worth dabbling in stretching. The stakes are high with back pain, after all. And it’s easy to experiment safely with stretching. So it’s probably worth some experimenting.

The science of stretching for back pain is some of the worst in all of musculoskeletal medicine

Stretching for back pain is both under studied and badly studied — like everything else in this business only more so. Despite widespread public faith in stretching as back pain medicine, making it a fine topic to focus on, unfortunately researchers usually fail to focus on it.460 So don’t expect much data-driven enlightenment here, but I’ll do my best. The literature is littered with studies that seem “promising,” without ever being decisive. Most of these seemingly positive results evaporate like water on a hot sidewalk when examined more closely. Here’s three telling examples:

1. A 2010 experiment described in the Archives of Internal Medicine comparing yoga, a stretching class, and an educational booklet.461 This study has been widely reported as “stretching and yoga work,” and it is indeed a good-news trial on its face. What has not been reported is that both stretching and yoga are equally damned here with faint praise: the effect size was modest, just 2.5 points on a scale of 11, which is just barely clinically meaningful. And even that modest benefit could well be an artifact.462 Not only is it not persuasive, I think it backfires and convinces me that yoga/stretching really didn’t do much.
2. In 2014, Chen et al reported “significant” benefit for nurses with back pain who stretched three times per week after work for six months.463 The results are right in line with what people optimistically expect of a stretching habit: that it’s at least as good as popping ibuprofen. Isn’t it great when Science tells us what we already believe? Unfortunately, it’s a terrible study, just complete garbage, in several ways.464 I only cited this paper so I could point at it and laugh before pivoting to the disappointing reality.
3. In 2019, Pourahmadi et al reviewed 12 studies and reported happy news about “slump stretching” for back pain465 — which looks like seated toe-touching, but with a couple extra twists to really crank up tension on the spinal cord, like tucking the chin. This is a fine example of a not-so-positive-after-all test in two key ways. First, it’s not actually a muscle stretch: its explicit target is “neuromeningeal structures within the vertebral canal” (neurodynamic stretching) and so even if the study was believably positive, it’s not validating anything that most people would ever intentionally do for their back pain.466 Second, even if it wasn’t obscure, the quality of the evidence they reviewed “was very low.” There’s never any justification for writing a positive-sounding result based on limited, lousy evidence. For all I know, slump stretching might truly work, and could be a ray of hope that some back pain can be treated with stretch (presumably the kind of back pain that involves the spinal cord, so definitely not all), but we cannot know that based on a few scraps of shabby data.

I am unaware of any study of this question that is actually promising. Meanwhile, there is plenty of actual “evidence of absence.” Three examples:

• In 2014, Sihawong et al showed in a roundabout way that stretching doesn’t prevent back pain, even in people with poor trunk flexibility.467 They studied hundreds of office workers with poor flexibility and trunk muscle endurance, but no back pain (yet), and followed them for a year while half of did exercises and half didn’t. That’s a fine design in many ways, so it’s a shame that they didn’t isolate their variables: like so many other studies, they combined stretching with other kinds of exercise. Unsurprisingly, the exercise group got less than half as many new cases of back pain. We already know that exercise is helpful … and that almost certainly accounts for the entire risk reduction. Not the stretching.
• An interesting 2021 study compared stretching unfavourably to a more elaborate exercise therapy, “motor skills training.”468 Stretching lost (and so did strength training). Not by a lot, but it didn’t have to. The point is that stretching failed to outperform some other exercise approach most people have never even heard of — which wasn’t impressive either. Even with unimpressive competition, stretching was not a contender.
• A 2020 review of studies of exercise for back pain — a good quality one in British Journal of Sports Medicine — concluded that stretching doesn’t work.469

That’s enough science of general stretching for back pain. Let’s get more specific now.

Could some of the apparent benefits of stretching be attributable to helping trigger points? And could we get more benefit from stretching with a more specific focus on muscle imbalance? The next two chapters will cover these ideas.

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This chapter focusses on one of the main reasons to consider stretching despite the underwhelming evidence presented so far: as a treatment for muscle soreness specifically, as a way to loose the muscle “knots.” It’s a summary of a much longer exploration of the topic in the trigger point tutorial, which is why this summary deliberately lacks a lot of footnotes and references. (Note also that this topic has already been explored in a different way in the yoga chapter.)

I have rarely even heard anecdotes about stretching actually “curing” back pain — major, lasting relief just doesn’t seem to be a level of potency that gets claimed very often. But many, many people report a “takes the edge off” effect. So people in all kinds of pain tend to stretch, and often they feel better, briefly. To the extent that this is true, it might be because stretching can sometimes partially treat trigger points. It’s an interesting idea to explore. In particular, if it works at all, I think it’s interesting to ask why it isn’t more effective.

Simons and Mense write (in their text, Muscle Pain), that stretching “by almost any means is beneficial” for trigger points — a ringing endorsement from the world’s leading authorities on trigger point pain. That sure sounds good!

But they also emphasize that (1) it has “not been firmly established” that stretching trigger points is helpful, and that (2) it works primarily for “newly activated, single-muscle” trigger points (which leaves out a lot of trigger points that are serious problems), and they also caution that (3) the stretch must be applied “slowly and only to the onset of discomfort” … which is a complete contradiction to their supposition that a trigger point must be “fully elongated” to deactivate it!

Folks, there is no hope of “fully elongating” most muscles by applying stretch “slowly and only to the onset of discomfort.” People with truly nasty trigger points can’t fully elongate a Slinky without an onset of major discomfort, let alone their trigger point-riddled muscles. Trigger points are tough — they are a tiny patch of spasmed muscle tissue, after all. And the muscle on either side of them is relatively elastic and already under strain from the trigger point. This could present a real obstacle to stretching serious trigger points. How do you elongate a patch of muscle that’s much harder and more tightly contracted than the tissue around it? Indeed, some trigger points are clearly aggravated by stretching!

So, basically, stretching is imprecise and inefficient! Trigger points are small and numerous and tough as nails, while stretches are big and imprecise and slow and awkward. And stretches may not be capable of elongating trigger points even when the stretch is strong and easily sustained.

Stretching probably does have at least a small therapeutic effect on milder trigger points some of the time. And this probably explains why it often feels so good and partially, temporarily relieves pain and stiffness. But that modest benefit falls way short of the goals I have for my patients — and it falls short of your goals, too, if you have serious low back pain.

So, feel free to experiment, but beware of wasting your time! For most people, there are other treatment methods that are almost certainly more useful!

Once again, see the trigger points tutorial for the full discussion of stretching for trigger points, which is about five times longer than this section and gets into all the nitty gritty detail.

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