• Good advice for aches, pains & injuries

Save Yourself from Low Back Pain!

Low back pain myths debunked and all your treatment options reviewed

Paul Ingraham, updated

Large banner image of a vintage illustration of the lumbar spine from an oblique perspective, no caption, vaguely representing analysis of low back pain.

We can put a man on the moon, but back pain [NIH] is just as miserable as ever, and more costly to society than ever. Most information available online is awful.1 There are no miracle cures or back whisperers. Not one popular treatment has ever been shown to work well.2 When we are “shot by the witch,”3 it’s going to run its course like a head cold in most cases, or drag on much longer in a few, and there’s not much anyone can do about it.

There is room for improvement, however! We could, at least, not add insult to injury with pointless and expensive testing, therapies, and surgeries that are all about finding and fixing structural problems that are mostly not there, or not the real problem. Despite overwhelming scientific evidence to the contrary, it is still sadly routine for back pain to be seen as a “mechanical” problem, as if the spine is a fragile structure which breaks down.4 There is some truth in that old way of looking at it, but there are many other factors in back pain. It’s hard to treat because “it’s complicated.”

Has nobody noticed the embarrassing fact that science is about to clone a human being, but it still can’t cure the pain of a bad back?

~ Pain, by Marni Jackson, p. 5

A tragic low back pain myth

This pervasive myth of spinal fragility has many unfortunate consequences, such as unnecessary fusion surgeries — a common and routinely ineffective procedure — and low back pain that lasts for years instead of months or weeks. The seriousness of chronic low back pain is often emphasized in terms of the hair-raising economic costs of work absenteeism, but it may well be far worse than that — a recent Swedish study shows that it probably even shortens people lives.5 The stakes are high. “Tragedy” is not hyperbole.

Even worse is that good information exists: many medical experts do “get it,” but they have fought a long, losing battle trying to spread the word to their own medical colleagues on the front lines of health care.6 Back pain treatment in the real world is notoriously out of step with guidelines and best practices,7 and the average family doctor is just not educated enough.8

And as if that wasn’t bad enough, doctors who are more interested in back pain are even worse,9 probably because a little knowledge is a dangerous thing. Similarly, experts have particularly struggled to get the word to alternative health professionals — most of whom don’t even read medical journals.10

In this tutorial, you will meet those medical experts and find out what they know and believe and why. Their ideas about low back pain are neither “conventional” nor “alternative” — they simply come from the best minds in the business.

The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).

Lorimer Moseley, “Teaching people about pain — why do we keep beating around the bush?Pain Management. 2012.

How do so many health care professionals go wrong when they treat low back pain?

Why does the myth of mechanical back pain, the premise for so much ineffective treatment, get repeated endlessly on the Internet and in health care offices around the world? (All of these points above will be explained and substantiated in detail further along — these are just the highlights.)

Plus, of course, there are an almost unbelievable number of sketchier treatments for sale, easily marketed to desperate souls. Is low back pain treatment really this much of a mess? Sadly, I believe so.14 I clearly remember graduating clueless myself. If I hadn’t spent many years doing post-grad study of low back pain, I wouldn’t know 98% of what’s in this tutorial.

Typical stock photo of a guy in a suit meditating, sitting cross-legged in a field with a blue sky background, representing the common belief back pain might be helped by meditating and/or yoga and stress relief in general.


Yes, stress is a factor in low back pain, but meditation & yoga are over-rated & inappropriate options for many people. This tutorial explores more practical options.

The case for hope: some “incurable” chronic low back pain can still be cured

Most acute low back pain fades steadily — up to 90% of it, for uncomplicated cases.15 And so does a lot of so-called “chronic” low back pain!16

But not all. This tutorial is mainly for patients with unusually stubborn low back pain and sciatica, and for the doctors and therapists who want to help. (It’s overkill for new and acute cases.) Even for these really entrenched cases, there is hope.

While it’s true that most chronic lower back pain will not yield to any popular back pain treatment, it’s also true that some really stubborn “incurable” cases do eventually turn out to be curable. People who believed for years that their pain was invincible have still found relief. Not always, and often not completely — but sometimes any relief is far better than nothing. How can extremely stubborn pain finally ease up? Simple: because many cases weren’t truly stubborn to begin with, despite all appearances. So many health professionals are poorly prepared to treat low back pain that patients can easily go for months or even years without once getting good care and advice. When they finally get it, it’s hardly surprising that some patients finally get some relief from their pain.

And it’s always amazing to me how chronic pain can, with the right approach, finally melt away — it’s not common, but it does happen. Lots of people who thought they’d “tried everything” for lower back pain read this tutorial and then write to me and say, “Well, I guess I hadn’t tried everything!”

Similarly, many athletes with “career-ending” injuries are far from finished. Bret “The Glute Guy” Contreras, from You’ll Never Squat Again:

Numerous powerlifters over the years have come back following ‘career-ending injuries’ to set all-time personal records. Donnie Thompson is the only man to total 3,000 lbs (1,265 lb squat, 950 lb bench, 785 lb deadlift). Many people don’t know this, but several years back Donnie suffered a horrendous back injury and herniated three discs. He could barely walk, but he got out of bed and rehabbed himself every day. Within three months he was back to heavy squatting and setting personal records. Got that? Setting personal records three months following an injury that herniated 3 discs!

How could that be? It’s almost like herniated discs aren’t necessarily as scary as everyone seems to think. Hm!

I have never met a patient — no matter how experienced or self-educated — who could not gain at least some new insights and new hope from this tutorial.17

“What if there’s something seriously wrong in there?”

“How do you know I’m not seriously hurt?”

“Could it be cancer? A tumor?”

You’re not paranoid if they really are after you! Only about 1% of back pain has a nasty cause,18 and only a few of those are really scary. But it happens. Andy Whitfield, star of Spartacus, thought he just had back pain from his intense gladiatorial training. In fact, he had a tumour. It killed him in 2011.

The most dangerous thing about trying to reassure low back pain patients is the unnerving possibility that I might reassure someone who should not be. But reassurance is almost always appropriate. Most back injury feels worse than it is — its bark is worse than its bite.

But how do you know if you’re the exception? Can you recognize the early warning sign of cancer, infection, autoimmune disease, or spinal cord injury? These things often cause other distinctive signs and symptoms, and so they are usually diagnosed promptly. If you are aware of these red flags, you can get checked out when the time is right — but please avoid excessive worry before that.

The rule of thumb19 is that you should start a more thorough medical investigation only when three conditions are met:

  1. it’s been bothering you for more than about six weeks
  2. the trend is strongly negative — the pain is severe and/or not improving, or even getting worse
  3. there is at least one other red flag (see below)

And there are also two rare situations where you shouldn’t wait several weeks before deciding the situation is serious …

  1. significant numbness around the groin and buttocks and/or failure of bladder or bowel control
  2. if you’ve had an accident involving forces that may have been sufficient to fracture your spine

This free article explains in more detail (including a list of red flags) and is strongly recommended to anyone who feels nervous:

In all other cases, you can safely read this tutorial first. For instance, even if you have severe pain or numbness and tingling down your leg, you can safely read this first. Or, even if you have an obviously severe muscle tear from trying to lift your car or something, you can safely start here — rest and read. Your back is not as fragile as you probably think, and understanding why is a great starting place for healing in nearly all cases of low back pain.

Don’t confuse threat and risk. Working at the edge is a risk. But then again, so is walking out your front door.

~ Cory Blickenstaff, PT

Part 2

Low Back Pain Diagnosis

Your low back is not fragile! Most of what is supposedly “wrong” with spines is nonsense

Spines haven’t changed in the last century,20 and yet modern civilization suffers from a great plague of low back pain.2122 The real causes of most back pain are obscured by medical mythology and misunderstanding.23 Before I discuss what kind of things do cause low back pain, it’s important to talk about what does not cause it. In this section, I will challenge the mythology in just a few paragraphs, supported by dozens of references to the best scientific information available.

Most people — and most health care professionals — believe that back pain is usually caused mainly by structural problems, either injury or degeneration of the spine. This idea is not supported by the scientific evidence.24 Indeed, just the opposite is more the case: “The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).”25

When structural problems are exaggerated, you also get a plague of bogus explanations and solutions based on that. Spines do degenerate, but not for the reasons most people think they do: genetics is by far the biggest factor in degeneration,26 not your posture, your office chair or mattress, your core stability, or anything else that low back pain sufferers have taught to blame their pain on.

The idea that the spine is fragile is an unjustified but deeply held belief, based on ignorance of a complex subject and on an obsolete mechanical view of biology that has dominated medical thinking for centuries.


Unlock access to 105 more chapters for USD$1995 — much less than the cost of any physical therapy, and maybe more useful. Continue reading this page right after purchase. A second book about muscle pain is included free. See the complete table of contents below. Most content on is free.?

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132,500 words
111 sections
524 footnotes

all myths & controversies
all diagnostic issues
all treatment options
  • 1 Introduction
  • 1.1 A tragic low back pain myth
  • 1.2 How do so many health care professionals go wrong when they treat low back pain?
  • 1.3 The case for hope: some “incurable” chronic low back pain can still be cured
  • 1.4 “What if there’s something seriously wrong in there?”
  • 2 Low Back Pain Diagnosis
    Your low back is not fragile! Most of what is supposedly “wrong” with spines is nonsense
  • 2.1 Even serious structural problems in the low back are often painless
  • 2.2 Maybe you’re just getting older? Actually, no …
  • 2.3 Structural problems in the low back are hard to diagnose accurately
  • 2.4 Those scary spine models
  • 2.5 It’s not structure, except when it is: specific back pain
  • 2.6 So then what? The missing muscle piece
  • 2.7 There is nothing “just” about muscle
  • 2.8 Low back pain is the new ulcer
  • 2.9 Pain and fear, together at last: an even simpler vicious cycle
  • 2.10 Chronic low back pain is not so chronic: the myth of chronicity
  • 2.11 A trigger point checklist: does this sound like you?
  • 2.12 3 Lessons From an Acute Back Trauma: Joint popping, muscle dominance, and the mind game
  • 2.13 “Out of nowhere”: seemingly random episodes of low back pain
  • 2.14 Summary so far …
  • 2.15 Morning back pain
  • 2.16 Other possible causes of low back pain, or “No, my low back pain is really serious … ”
  • 2.17 Could it be muscle strain? The muscle strain myth
  • 2.18 From the frying pan of injury pain to the fire of trigger point pain
  • 2.19 Could it be a vicious cycle of pain-spasm-pain?
  • 2.20 Could low back pain be an overuse injury?
  • 2.21 Could it be a herniated disc?
  • 2.22 Facet joint syndrome and MIDs
  • 2.23 Diagnostic numbing of facet joints (or the sacroiliac joint)
  • 2.24 Is there such a thing as a “subluxation”? Can your back be “out”?
  • 2.25 The role of sacroiliac joint dysfunction in back pain
  • 2.26 Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves
  • 2.27 Do you really need to lose some weight?
  • 2.28 Is it core weakness?
  • 2.29 Is it all in your feet? Foot-o-centric low back pain theories
  • 2.30 Your problem is that you’re having “too much fun”
  • 2.31 Could you have a “pinched” nerve? The nerve pinch myth
  • 2.32 Case study: nerve pain completely resolved by massage
  • 2.33 The role of true nerve problems in low back pain
  • 2.34 The strange case of scoliosis
  • 2.35 Back pain and sneezing
  • 2.36 Back mice (lipomas)
  • 2.37 Should you get an MRI, X-ray, or other imaging?
  • 3 Self-treatment options
    How to save yourself from low back pain, or at least avoid getting hurt or ripped off trying
  • 3.1 So what’s the plan?
  • 3.2 Some important things to keep in mind about placebos
  • 3.3 The confidence cure
  • 3.4 What is the difference between a ‘confidence cure’ and a mere placebo?
  • 3.5 Stress relief and the tyranny of meditation and yoga
  • 3.6 Another %[email protected]&*!! personal growth opportunity
  • 3.7 Yoga and meditation are still an option, of course
  • 3.8 Beyond the confidence cure: what else can you do for low back pain?
  • 3.9 Over-the-counter pain medications might be slightly useful (and maybe even alcohol)
  • 3.10 Comfrey makes backs comfy, study claims
  • 3.11 A tale of two tutorials
  • 3.12 Introduction to treating your own low back trigger points
  • 3.13 Limitations of trigger point therapy, and how to take advantage of them
  • 3.14 Basic self-massage for low back trigger points
  • 3.15 How do you know it’s working? Getting a trigger point to “release”
  • 3.16 Massage tools are indispensable
  • 3.17 The bath trick
  • 3.18 Can you damage your nerves when self-massaging?
  • 3.19 Don’t hesitate to recruit amateur help
  • 3.20 The evidence for massaging back pain
  • 3.21 Heat and ice both provide good bang for buck, but err on the side of heat
  • 3.22 Act normal! Rest minimally and strategically, while maintaining as much normal activity as you can
  • 3.23 Massage with movement and life in the Goldilocks zone
  • 3.24 Some particularly useful mobilizations for the low back
  • 3.25 Don’t worry about lifting technique
  • 3.26 Traction: low back pain on the rack!
  • 3.27 Stretching for trigger points
  • 3.28 Stretching for the hamstrings in particular (and other naughty muscles)
  • 3.29 Troubleshooting perpetuating factors
  • 3.30 Fix your insomnia
  • 3.31 Sleep posture, mattresses and pillows, and other help for morning back pain
  • 3.32 Sitting, chairs, and ergonomics
  • 3.33 Troubleshooting severe and persistent trigger points
  • 3.34 Troubleshooting even worse trigger points
  • 3.35 Less than a cure, but better than nothing: short term symptom relief options for low back pain
  • 4 Getting professional help
    A consumer’s guide to buying therapy and medical care for low back pain
  • 4.1 An introduction to your care options
  • 4.2 Physiatry for low back pain
  • 4.3 Massage therapy for low back pain
  • 4.4 Buying trigger point therapy rather than back pain therapy
  • 4.5 Spinal manipulative therapy (SMT): Adjustment, manipulation, and cracking of the spinal joints
  • 4.6 Physical therapy (physiotherapy) for low back pain
  • 4.7 “Medical” treatment option for trigger points: dry needling (IMS), stretch and spray, and trigger point injections
  • 4.8 Prescription medications: opioids, sedatives, and anticonvulsants
  • 4.9 What about surgery?
  • 4.10 The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries
  • 4.11 Surgery for sciatica (microdiscectomy)
  • 4.12 Needles for back pain: nerve blocks for facet joints and related treatments
  • 4.13 Kill it with fire! Treatment by nerve destruction
  • 4.14 Bogus Cures
  • 4.15 Craniosacral therapy (CST) is often prescribed for low back pain but has no potential to help
  • 4.16 The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests
  • 4.17 Core strengthening has failed to live up to the hopes and dreams of therapists and patients
  • 4.18 Scoliosis cannot be straightened without surgery
  • 4.19 Facet joint and intradiscal steroid injections are not recommended for most patients
  • 4.20 Prolotherapy
  • 4.21 Spinal decompression therapy: worth the money and risks?
  • 4.22 Back bracing and stabilization contraptions (especially inflatable ones)
  • 4.23 Antibiotics for back pain: a debacle
  • 4.24 A few more snack-sized reality checks: brief comments on other treatments to avoid
  • 5 Now what?
    An action-oriented summary of recommendations
  • 6 Appendices
  • 6.1 Appendix A: Why don’t the experts know more about this?
  • 6.2 Appendix B: A low back pain story
  • 6.3 Further Reading
  • 6.4 Reader feedback … good and bad
  • 6.5 Acknowledgements
  • 6.6 What’s new in this tutorial?
  • 6.7 Notes
dots before headings indicate updated sections ?There’s a detailed description of all updates at the bottom of the tutorial, and it’s nice to be able to see what’s new at a glance in the table of contents. Any section updated in the last 400 days is marked (hotter colours = fresher updates).

Q. Is there a print version? A. Electronic only, sorry. (You can print it yourself, but I don’t recommend it (too much paper and ink.)

Q. Can I read this offline, like at the beach? A. Yes. Like any webpage, it can be saved for offline reading easily.

Q. Who sells this? A. is a small business in Vancouver, Canada, run by me, Paul Ingraham, sole author and publisher since 2007.

Q. Does the book offer a “cure” for low back pain? A. No. I sell education about a notoriously tricky condition, not false hope. There’s nothing “too good to be true” here.

Q. Buy more & save 50%! A. Get a “boxed” set of all nine tutorials for great savings.MORE

Q. Ack, what’s with that surprise price tag?! A. I know it can make a poor impression, but I have to make a living and this is the best way I’ve found to keep the lights on here. Of course many people turn away, but 60,900 people have gone for it.?This is a tough number for anyone to audit, because my customer database is completely private and highly secure. But if a regulatory agency ever said “show us your math,” I certainly could. This count is automatically updated once every day or two, and rounded down to the nearest 100. It includes all individual and bundled books for sale on since 2007, and excludes a trickle of earlier sales, donations, and gifts. If money is tight, I offer a 85% financial hardship refund.?Just send me an email after purchase to ask for a money-is-tight refund. I ask people to jump through the hoop of buying first because it’s a nice compromise between “completely free” and “no giveaway at all.” By paying for the book, you take care of the paperwork of becoming a customer. And by holding back 15% — just 3 bucks — I avoid actually losing money on the transaction. Do me one additional favour and tell me your story? Something interesting about your case, perhaps? Anything at all.

Q. Can I read it on my iPad, Kindle, etc? A. Yes. Any Internet-enabled gadget works fine. (The e-Ink Kindles are not a good choice.)

Q. Satisfaction guaranteed, right? A. Of course—and no time limit.

Q. Can I buy this anywhere else? Amazon? A. Not yet. Maybe someday.

Q. Can I lend it? A. Yes, with a 3-person limit.

Q. Can I give it to my clients? A. I have a generous lending policy, but not that generous. 😉 Please recommend buying it, or consider my bulk purchase program.

Q. Why do you want my postal code? A. To prevent fraud (strongly recommended by my payment processor), and to identify customers for login and repeat business.

Q. Are you going to send me e-mail? A.  Just a receipt.

Q. Why should I trust you with my credit card? A. I will never see it: it goes straight from your screen to Stripe, a payment processing service with a great reputation for Doing Things Right. They handle all the high-tech security.

You can also keep reading more without buying. Here are some other free samples from the book, and other closely related articles on

Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
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The back pain misinformation explosion

I hope that this page is one of the saner sources of back pain information available online, while also being much more thorough and friendly than the big medical sources. Since I first started treating low back pain in 2000, there’s been an explosion of free online information about it, of course — countless poor quality articles (see Starman). Literally hundreds of thousands of them. Back in the day, we actually had to go to a doctor or buy a book to get shoddy back pain information — now it’s just a Google search away.

Over the years, I’ve collected some interesting examples of just how bad it gets. Here’s three, shared for the chuckles and the teachable moments…

Exhibit A: The worst possible website about pain

Dr. Greg House doing a “facepalm.” is one of the worst examples of I’ve seen: a large, stale, ugly thing by Pekka Palin, MD. There are hours of terrible reading there! Dozens of blandly composed, shallow, rambling, and frequently irrational mini-articles on every imaginable pain subject, all 100% unreferenced, laid out in huge blocks of text without a subheading for many screens (a typographic travesty).

There’s soooo much badness, but I really got a chuckle out of this perfectly pointless phrase: “The most common term used for general, temporary low back pain is lumbago.” Now “lumbago” means “back pain” (see the definition of lumbago on Wikipedia), so Dr. Obvious has helpfully explained that the cause of back pain is, er, back pain. The Internet, at your service!

Exhibit B: Awful back pain information from Consumer Reports

Dr. Harriet Hall, critiquing a recent issue of Consumer Reports about back pain:

I found the [Consumer Reports] articles on back pain very disappointing. I hope I can still trust Consumer Reports when shopping for a washing machine, but I have no confidence that I can trust them when looking for an effective medical treatment. They seem not to understand the difference between anecdotes and data, between a popularity contest and a controlled scientific study. These articles may do harm by encouraging readers to try treatments that don’t work and by suggesting that it is reasonable to prioritize testimonial evidence over scientific studies. On the other hand, these articles may do some good insofar as they may dissuade some patients from rushing to a doctor and demanding imaging studies or prescription drugs.

Well, at least there’s that! But most of what CR published was horrifyingly naive and misleading. I scanned this issue in a grocery store lineup and was rolling my eyes within seconds. And then fuming: it seems like the flood of misinformation about back pain is infinite! I’ve been actively debunking back pain myths for about 15 years now, and the need for it has barely changed in all that time. So-called information like this, reaching a massive audience, seriously exacerbates the problem.

I think Consumer Reports has made serious mistakes in other domains over the last few years, and they are quickly burning the credibility it took decades to earn. Sadly, they will still have a strong enough reputation for years to come to do plenty of damage with content like this.

Even many better articles still have serious “attitude” problems. Usually the attitude problem is unjustified optimism. For instance …

Exhibit C: A widely praised “high quality” article full of flaws

This extremely popular 2017 article on the “new science” of low back pain was praised by many because it superficially seems to be very modern and science-y, and it correctly dismisses a number of myths, but I think it’s an exasperating failure. It creates a strong impression of being scientifically rigorous without actually being so. It brims with promising science news about alternative treatments that do not actually stand up to more cynical and experienced analysis.

Adding to the façade of scientific credibility, many of the right caveats and disclaimers about the “new science” are technically there — warnings about small effect sizes, mixed evidence, and potential flaws — but these cautions are also belated and consistently understated. The tone is overwhelmingly sunny and naïve, as though we are on the verge of a revolution in back pain treatment thanks to … a bunch of stuff that has been around forever and has clearly not been saving the world from chronic low back pain.

The low point of the article is definitely the advice to try to find a “back whisperer.” Back pain is too difficult a problem for anyone to have that role, no matter how expert and experienced. I think the idea of a back whisperer dangerously promotes false hope.

So who can you trust?

You’d think that you might be able to escape this mess by reading medical journals, but that’s hardly guaranteed. Even back pain guidelines published in medical journals are often misleading. They are not all good. The committees that write these things do not necessarily know the science. One of the best reviews of back pain research ever published — Machado 2009, more on this one later — found something really interesting: “treatment recommendations from recent clinical guidelines do not align with the results of this meta-analysis.” In fact, quite a few disproven pain treatments are still cheerfully recommended in otherwise sensible professional guidelines. Eek. So I am realistic about the limits of the science, much of which is pretty junky. +The quality of science is a huge topic, but here’s one simple example of an extremely common problem with back pain science: control groups that don’t control. Rather than comparing a treatment to a good, carefully selected placebo, most studies use a comparison to a treatment that is allegedly neutral, underwhelming, or placebo-ish. That makes the results hard to interpret: if each works about the same, it could mean that the treatments are equally effective … or equally ineffective! So much back pain science has this problem — or any one of a dozen other weak points — that you can effectively ignore at least 80% of all back pain research, because it’s so far from the last word on anything. Good science is essential to solving these problems, but really good studies are also difficult to design and rare.

So why trust this tutorial? Well, don’t need to take my word for anything — you can just take the word of the many low back pain medical experts that I quote extensively, and the hard evidence that their opinions are based on.+ (At the same time, I am realistic about the limits of the science, much of which is surprisingly junky.)

And, most importantly of all, I’m not selling a cure: the purpose of this tutorial is “just” education. It’s best for people who like to understand their problems. Its dorky, quirky thoroughness is unique. I will not just tell you what you want to hear. Understanding low back pain as well as possible is valuable, but it will not necessarily lead to a cure. Sadly, some low back pain cannot be fixed.

Part 2.1


Further Reading

Other articles on about back pain (lots of them, as if this book wasn’t long enough):

Other good reading about back pain:

Reader feedback … good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

I was reading your info about lower right back pain and I love how you say not to worry about everything, and add that even if it IS serious, it can most likely be cured. While reading it, I realised later that my acute pain had slightly subsided.You’re doing such a great service for so many people. I’m almost glad I was in such pain (on a weekend, of course) that I had to look up medical information myself. Yours is readable, understandable, funny, humble, and....tight on!

~Elsie Ventura

Just to say thank you immensely for the best, most sensible and credible information on back pain. So glad you came up in my google search. Credible, reassuring and humorous too.

~Suzanne Henderson

Just wanted to thank you for your clear, well-organized, credible, and thorough information about back pain. I am experiencing back pain that’s barking loudly for the first time in my 72 years. I now have an idea of the possibilities and degrees of seriousness. Thank you again for making the time and effort to write well.

~Braydon Aldred

I stumbled upon your writings this morning, when I was wishing I was at the gym, where I would usually be. It was some kind of kismet, for sure, because everything I read made total, absolute sense. Thank you, thank you, thank you. You have given me the courage and resolve to sit out this sprain so I can get back up again intact, and stay that way. Your writings about joint mobilization also make me realize I have some tactics to improve my current state now, even though I am recovering. A huge lightbulb has gone off for me. Thank you, again! Finally, I love your statement about going and putting your 110% into something else while you are healing. Best advice ever.

~Stacey Simons

Thanks again for putting together all the back pain research — a good percentage of it anyway — into an easy-to-read publication.

~Nojus Proctor

Thank you immensely for the best, most sensible and credible information on back pain. So glad you came up in my google search. Credible, reassuring, and humorous too.

~Suzanne Haslett, Suzanne Haslett, Masters in Human Development (Oxford)

I purchased the low back tutorial recently and got the free trigger points one also. Many thanks. They are great! I had already accessed the perfect spot series and have been working on my trigger points. It is very pleasing to have the full discussion of the physiology, and I now have a much better idea about the whole ghastly business.

~Leah Brannen, Saskatoon, Canada

I bought two of your eBooks last week, and I’m enjoying going through them. Your presentation is excellent. It’s far too early too say, of course, but I think I’ve already begun to benefit from your approach. One of the things I like most about your approach is your respect for “science,” as opposed to “merchandising.” You've put so much into those two eBooks, it's going to take time to do them the justice they deserve.

~David Calderisi, Toronto, Ontario

David diligently followed up a month later with the following comment: “By now I’m convinced your research and recommendations are right on the money. Thanks. I’ve recommended you to a few people who, like myself, have had back problems on and off for years. Thanks for having provided such a useful tool.” ~ Paul

I spent seven hours straight sitting at my computer and my back didn't hurt at all! You’re a genius! Thanks so much.

~Isabelle Deguise, Graduate Student

I had suffered from undiagnosed and seemingly untreatable low back pain since late August last year. Three physiotherapists, my GP, two RMTs, and my generally excellent personal trainer failed to help me make any progress. At my last visit to my GP in late December, he maintained his insistence that I just needed to loosen up my hamstrings! The systematic approach you took to reviewing all the supposed cures and providing a clear analysis of each and no doubt saved me thousands of dollars and months of frustration. That gave me the focus to work on trigger points known to cause LBP (with the help of some additional books and a great TP therapy app for my phone). My back pain isn’t totally gone, but I’m 95% there and I’ve got a handle on it.

~Erin Banks

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:


Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. was originally created in my so-called “spare time” with a lot of assistance from family and friends. Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

What’s new in this tutorial?

This tutorial has been continuously, actively maintained and updated for 15 years now, staying consistent with professional guidelines and the best available science. The first edition was originally published in September 2004, after countless hours of research and writing while I spent a month taking care of a farm (and a beautiful pair of young puppies) in the Okanagan.

Regular updates are a key feature of tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 150 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

OctoberMajor revision: Although the bottom line remains essentially the same, this chapter is now much higher quality in every way. More information, clearer, and fully up-to-date scientifically. [Section: Stretching for the hamstrings in particular (and other naughty muscles).]

SeptemberRewritten again: This chapter was rewritten along with the chapter on causes of morning back pain, and is about double its previous size. [Section: Sleep posture, mattresses and pillows, and other help for morning back pain.]

SeptemberRewritten again: This chapter is vastly expanded. In fact, it is now one of the largest chapters in any of my books. [Section: Morning back pain.]

AugustNew section: No notes. Just a new section. [Section: The role of sacroiliac joint dysfunction in back pain.]

JulyScience update: A minor science update, long overdue. No change to the bottom line, just more evidence that yoga isn’t exactly curing most people’s back pain. [Section: Yoga and meditation are still an option, of course.]

JulyMajor revision: Thorough science update and much more detail. Prolotherapy has gotten a bit of a revival in the last few years, and it’s persistence in the marketplace justifies more detailed coverage of the topic. Unfortunately, the bottom line hasn’t budged: still not recommended for back pain. [Section: Prolotherapy.]

MayUpdated: Added some good expert quotes and optimistic perspective on pain education from Moseley. [Section: The confidence cure.]

MayScience update: A particularly disappointing, predictable update on 2010’s overhyped news about methylene blue. [Section: Facet joint and intradiscal steroid injections are not recommended for most patients.]

AprilUpgrade: Modernized the trigger point content and added several paragraphs about sensitization as well. [Section: “Out of nowhere”: seemingly random episodes of low back pain.]

MarchScience update: Pure reinforcement: cited Artus 2010 and Artus 2014, backing up Machado. [Section: So what’s the plan?]

MarchMore information: Added content about personality types and the prevalence of concealed stress and anxiety, inspired by Sapolsky. [Section: Low back pain is the new ulcer.]

FebruaryNew section: No notes. Just a new section. [Section: Should you get an MRI, X-ray, or other imaging?]

JanuaryExpansion: Today I added a little depth on a couple key points, and commentary on a really interesting example of specific spinal pain from Dr. Stu “There’s No Such Thing As Non-Specific Back Pain” McGill. [Section: It’s not structure, except when it is: specific back pain.]

JanuaryScience update: Finally added hard evidence of the obvious — over-the-counter pain meds don’t really work — and got into some nuances. [Section: Over-the-counter pain medications might be slightly useful (and maybe even alcohol).]

2018Expansion: Continued the process of making this section into a more substantive exploration of the idea of specific back pain, and added a new example, a case study of back pain caused by a tumour on a nerve root. [Section: It’s not structure, except when it is: specific back pain.]

2018Example added: New sub-section, “A perfect example of a structural problem: cluneal nerve entrapment,” based on a fascinating case study reported by Aota. [Section: It’s not structure, except when it is: specific back pain.]

2018Substantial editing: Merged content from the back and neck pain tutorials, resulting in major upgrades to two important sections in both books. [Section: The role of true nerve problems in low back pain.]

2018Substantial editing: Merged content from the back and neck pain tutorials, resulting in major upgrades to two important sections in both books. [Section: Could you have a “pinched” nerve? The nerve pinch myth.]

2018Minor improvements: Discussed potential harms of strength training in a little more detail. [Section: Core strengthening has failed to live up to the hopes and dreams of therapists and patients.]

2018New section: A new standard chapter for most tutorials summarizing several key concepts about placebo. [Section: Some important things to keep in mind about placebos.]

2018Important update: Added an important new sub-section about anticonvulsants. [Section: Prescription medications: opioids, sedatives, and anticonvulsants.]

2018Major science update: New key new citations and thorough analysis. [Section: Do you really need to lose some weight?]

2018Upgraded: Added much more detail about the basics of neuropathy and revised everything else quite thoroughly. Expanded the discussion of implications of Jayson as promised last month. [Section: The role of true nerve problems in low back pain.]

2018Science update: A science update … with quarter century old science about blood supply and radiculopathy (see Jayson). This is just a quick drop-in for now, but it’s fascinating, so I’ll be elaborating more in another update. [Section: The role of true nerve problems in low back pain.]

2018New section: No notes. Just a new section. [Section: Back mice (lipomas).]

2018Major revision: Phase 1 of a reboot of this part of the book. Today I’ve added much more detail to the intro, emphasizing good and bad reasons for seeking help. [Section: An introduction to your care options.]

2018Major new section: Well, new to the book anyway. It has been available as a free article for quite a while, and it will remain so indefinitely. Although this content is not exclusive to the book, it definitely does belong here. [Section: Don’t worry about lifting technique.]

2017New section: No notes. Just a new section. [Section: Kill it with fire! Treatment by nerve destruction.]

2017New section: No notes. Just a new section. [Section: Needles for back pain: nerve blocks for facet joints and related treatments.]

2017Major upgrade: The section has been re-written and expanded significantly, with a key change in position. After reviewing the same scientific papers previously cited more carefully, I decided that they were much less promising than I originally thought. The section has flip-flopped from optimism to pessimism about nerve blocks without a single change in what’s actually cited, just a change in the level of diligence in interpreting the science. [Section: Diagnostic numbing of facet joints (or the sacroiliac joint).]

2017Science update: Added a substantive footnote explaining the relationship between ulcers, stress, and H. pylori infection as one of the best examples of a “stress-sensitive condition.” [Section: Low back pain is the new ulcer.]

2017Science update: An important follow-up on August’s major massage evidence update, I’ve now added a summary of the evidence for trigger point massage. Although the topic is not covered in detail here, much study went into making this summary possible. [Section: The evidence for massaging back pain.]

2017Major update: Rewritten and updated. I revisited all the evidence on massage for back pain, especially integrating Furlan et al (a major 2015 meta-analysis on this topic). The bottom line is now that the science is inconclusive and discouraging instead of optimistic. Sorry, everyone. [Section: The evidence for massaging back pain.]

2017Minor addition: Added an excellent recent example of awful back pain information. [Section: Introduction.]

2017Minor update: Added discussion of orthotics to treat leg length differences for back pain. [Section: Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves.]

2017New section: An important and interesting acknowledgement that mechanical causes of back pain do exist. [Section: It’s not structure, except when it is: specific back pain.]

2017New subsection: Added content inspired by decades-old evidence of reduced spinal degeneration in “primitive” cultures where squatting is common. Some light editing of everything else in the chapter. [Section: Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves.]

2017Science update: Added a small but key new point and citation about genetic factors in degeneration; and an important new citation about the disconnect between imaging results and pain. [Section: Low Back Pain Diagnosis: Your low back is not fragile! Most of what is supposedly “wrong” with spines is nonsense.]

2017Science update: Discussed important new review of SMT for acute low back pain. Significant revision of the section. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation, and cracking of the spinal joints.]

2017Science update: Strong new reference to Andrade et al fully supports the main message of the section. [Section: Even serious structural problems in the low back are often painless.]

2017Science update: Newer, better, evidence-based good news about disc herniation resorption. [Section: Low Back Pain Diagnosis: Your low back is not fragile! Most of what is supposedly “wrong” with spines is nonsense.]

2017Science update: Updated references for debunking of TENS for back pain. Added ultrasound to the section. [Section: A few more snack-sized reality checks: brief comments on other treatments to avoid.]

2017Minor improvement: Added a proper summary of Roffey et al, and a relevant personal footnote. [Section: Sitting, chairs, and ergonomics.]

2017Science update: Added discussion of a remarkable example of poor MRI reliability. [Section: Low Back Pain Diagnosis: Your low back is not fragile! Most of what is supposedly “wrong” with spines is nonsense.]

2017Major correction: An evidence-based reversal of position and advice about sitting and back pain, correcting a long-standing error: my long-term assumption that too much sitting is a risk factor for back pain was never defensible. [Section: Sitting, chairs, and ergonomics.]

2016Science update: Added commentary on the “do not offer” acupuncture recommendation in the new NICE guidelines for back pain. [Section: The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.]

2016Edited: Thorough revision and modernization. Although I revised this section just five years ago, it needed it again! [Section: A trigger point checklist: does this sound like you?]

Older updates — Many older updates are listed in a separate document, for anyone who cares to take a look.


  1. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
  2. Machado LA, Kamper SJ, Herbert RD, Maher CG, McAuley JH. Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology (Oxford). 2009 May;48(5):520–7. PubMed #19109315.  PainSci #54670. 

    This is the best single reference showing the lack of efficacy from all popular back pain treatments, but there’s lot more to say — much more information about treatment efficacy will be presented later on in this tutorial.

  3. Hexenschuss is a German word for back spasm or lumbago, but translated literally it means shot by the witch (hexe = witch and Schuss = shot). Those Germans have a word for everything! Hat tip to reader Richard Moison for teaching it to me. BACK TO TEXT
  4. Here’s the first of many expert opinions and quotes about this, from a 2013 paper by Max Zusman, explaining why low back pain is still such an incredibly costly problem for society:

    It is extremely difficult to alter the potentially disabling belief among the lay public that low back pain has a structural mechanical cause. An important reason for this is that this belief continues to be regularly reinforced by the conditions of care of a range of ‘hands-on’ providers, for whom idiosyncratic variations of that view are fundamental to their professional existence.”

    Well said, but perhaps a bit wordy. Here’s the simple version: patients believe back pain is caused by structural fragility, and careers are built on catering to that belief. I would also say that it is difficult to alter that belief in anyone, patient or professional. This preoccupation with fragility isn’t just reinforced by the practices of many therapists, it’s a major reason for them.

  5. Jansson C, Mittendorfer-Rutz E, Alexanderson K. Sickness absence because of musculoskeletal diagnoses and risk of all-cause and cause-specific mortality: A nationwide Swedish cohort study. Pain. 2012 May;153(5):998–1005. PubMed #22421427.  BACK TO TEXT
  6. Williams CM, Maher CG, Hancock MJ, et al. Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010 Feb;170(3):271–7. PubMed #20142573.  PainSci #55582. 

    “Usual care provided by general practitioners for low back pain does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time.

  7. A series of 2018 back pain articles in The Lancet (see Foster, Hartvigsen, Buchbinder) expressed what has become almost standard outrage at the useless back pain treatments still constantly provided by all kinds of professionals. This has been going on for decades now: the experts bemoaning the pitiful state of the standard of care for back pain. The experts just keep saying it, seemingly with more force every year — more presitigous journals, citing better evidence than ever — while the average clinician remains largely oblivious. BACK TO TEXT
  8. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.
    Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

    Cartoon by Loren Fishman,

  9. Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine (Phila Pa 1976). 2009 May;34(11):1218–26; discussion 1227. PubMed #19407674.  BACK TO TEXT
  10. I was an alternative health professional myself for many years — a Registered Massage Therapist, trained in Canada (which has unusually good training standards). Of course, some of my colleagues in alternative medicine were diligent students of medical science. However, in my experience, most were certainly not — indeed, many lacked even the most basic knowledge of how medical science works or how to keep current about recent discoveries with clinical implications. BACK TO TEXT
  11. Moseley GL. Whole of community pain education for back pain. Why does first-line care get almost no attention and what exactly are we waiting for? Br J Sports Med. 2018 Jul. PubMed #29982226.  BACK TO TEXT
  12. Moseley 2018, op. cit. Dr. Moseley again. He notes that “education is universally recommended as first-line treatment for acute and persistent back pain but it attracts little attention … Is this because health professionals intuitively know what education is and how to do it? Our research suggests not6—most doctors (although there are precious exceptions) do not know what it is, do not know how to do it, do not have the content knowledge and, even if they did, do not have the time.” BACK TO TEXT
  13. [Cover of Mind Over Back Pain, by Dr. John Sarno]

    Dr. John Sarno’s original best-seller about low back pain.

    My original inspiration for this tutorial was Dr. John Sarno’s 1984 book Mind Over Back Pain: A radically new approach to the diagnosis and treatment of back pain, which is generally excellent, but a little too radical, too excited about one big idea. His more recent work (Healing Back Pain: The mind-body connection) makes too many empty promises and has serious flaws. See my Sarno review. BACK TO TEXT
  14. Why is musculoskeletal medicine such a mess? Many reasons, but mainly professional pride and tribalism, ideological momentum, and screwed up incentives (certification rackets, freelancing, insurance, huge profits). Also, the love of “advanced” and technological treatment methods, ignorance of the history of science and critical thinking skills, and the obscurity of newer and better ideas, especially the major neurological and biological factors that we’re still learning about, which many frontline clinicians are still oblivious to. I explore the trouble with modern musculoskeletal medicine in more detail in A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta. BACK TO TEXT
  15. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ. 1994;308:577–80. PainSci #57081. 

    This paper presents some unusually optimistic old data about low back pain recovery: in a sample of about 100 patients, “90% of patients recovered within two weeks and only two developed chronic low back pain,” which is “much higher than reported in other studies,” but the authors suggest some good reasons why their number makes sense.

  16. There is an anxiety-producing myth that low back pain is serious and chronic if you can’t shake it after the first several weeks, when in fact many people recover just fine after that “deadline.” An entire section below is devoted to the strong scientific evidence about this. BACK TO TEXT
  17. Once in a great while some cranky reader (always a guy) writes to tell me, “I didn’t learn anything from your book.” I’m a little skeptical about that, and it’s always tempting to start quizzing! There’s a great deal of information here, including analyses of recent research. Sure, readers who have already done a lot of reading about back pain might already be familiar with a lot of it — but you will know that going in, of course, and you’ll find the nuggets of new information and perspective that any keen reader is always looking for. BACK TO TEXT
  18. In older adults, about 6% of cases have a serious cause, but 5% of those are fractures — which are serious, but they aren’t cancer either. The 1% is divided amongst all other serious causes. For people under age 55, the odds are even better. BACK TO TEXT
  19. This is my translation/interpretation for patients of the somewhat more detailed information for physicians published in “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society”. BACK TO TEXT
  20. Ruhli FJ, Henneberg M. Clinical perspectives on secular trends of intervertebral foramen diameters in an industrialized European society. Eur J Spine. 2004 Apr 1. PubMed #15057552. 

    This study of changes in spinal characteristics (in Swiss adults) since the late 19th century found … well, basically nothing. Spines are pretty much the same now as they were then. At least in Switzerland.

  21. Dr. Richard Deyo, one of the great myth busters of low back pain research, believes that “low back pain is second to upper respiratory problems as a symptom-related reason for visits to a physician” — only the common cold causes more complaints. Hart et al puts low back pain in fifth place (lower because Hart oddly excludes chronic low back pain). Chronic low back pain is usually the kind that this book will examine. Andersson writes: “Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain … .” Indeed, it is almost impossible to measure how much chronic low back pain there is: for every time that acute low back pain is the main reason for a visit to a physician, how many times does a patient mention low back pain as a secondary problem? Or sees an alternative health care professional about it instead? (Answer: pretty danged often.) So it’s actually possible that low back pain is the single most common reason that people seek help. BACK TO TEXT
  22. Many researchers seem to believe that low back pain is a modern problem. For instance, Waddell writes, “Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic … .” In 2008, Martin et al found that, “The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7%… to 24.7% … 1997 to 2005,” which certainly shows that it is a growing problem and therefore likely to be worse now than in the past. A Spanish study (Jiménez-Sánchez et al) showed that “serious” musculoskeletal complaints (including a great deal of back pain, presumably) increased significantly from 1993 to 2001. Finally, Harkness et al did a nice job in 2005 of comparing rates of musculoskeletal pain (including low back pain) 40 years apart in the northwest of England, and found a large increase. In his books, Sarno also strongly portrays low back pain as a modern problem — though he doesn’t defend it . It’s hard to say if back pain actually is a modern problem, or whether it just tends to be described as such. Remember that human beings have a strong tendency to sensationalize and dramatize! Harkness pointed out in her study that the appearance of an increase “could be partly explained by the ‘worried well’. The ‘worried well’ are those patients who are concerned about their health, and attend their GP to seek reassurance about their well-being.” This is a great example of how hard it is to really be sure of anything! BACK TO TEXT
  23. Nachemson says, “Rarely are diagnoses scientifically valid … .” And Deyo: “There are wide variations in care, a fact that suggests there is professional uncertainty about the optimal approach.” Many other researchers have made this point, but Sarno (p. 111) states it most eloquently:

    There is probably no other medical condition which is treated in so many different ways and by such a variety of practitioners as back pain. Though the conclusion may be uncomfortable, the medical community must bear the responsibility for this, for it has been distressingly narrow in its approach to the problem. It has been trapped by a diagnostic bias of ancient vintage and, most uncharacteristically, has uncritically accepted an unproven concept, that structural abnormalities are the cause of back pain.”

  24. Sarno J. Mind Over Back Pain: A radically new approach to the diagnosis and treatment of back pain. Trade paperback, red/blue cover ed. Berkley Books; 1999. p. 27. BACK TO TEXT
  25. Moseley L. Teaching people about pain — why do we keep beating around the bush? Pain Management. 2012;2(1):2–3. PubMed #24654610.  PainSci #54762.  BACK TO TEXT
  26. Battié MC, Videman T, Kaprio J, et al. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J. 2009;9(1):47–59. PubMed #19111259.  The once commonly held view that disc degeneration is primarily a result of aging and wear and tear from mechanical insults and injuries was not supported by this series of studies. Instead, disc degeneration appears to be determined in great part by genetic influences. Although environmental factors also play a role, it is not primarily through routine physical loading exposures (eg, heavy vs. light physical demands) as once suspected.” BACK TO TEXT

There are 498 more footnotes in the full version of the book. I really like footnotes (and I try to have fun with them).

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