Back Pain Myth 1 – Something is broken

This is text will be the first in a series through which I want to address some myths that are still very prevalent in our society, be it in you, member of the general public, or among health care professionals.

Why am I focusing on back pain? The 2015 Global Burden of Disease Study identified that since 1990, low back pain has remained the leading cause of disability worldwide (Hurtwitz et al, 2018).

Now, let me explain why it is important we address certain myths, before we actually get to them.

It has been shown by research that throughout the general population of different countries, a lot of negative and often misinformed beliefs about back pain are still present (Christe et al, 2021b; Morton et al, 2019). These beliefs include things such as the back requiring protection, the back being vulnerable, the back being damaged and requiring special attention or treatment, or having to take time off from work to rest (Christe et al, 2021b; Morton et al, 2019)

Is this a problem? People can believe what they want, that won’t change reality, right? In this particular case, there is research indicating that having negative beliefs about back pain will make you experience worse pain, be more disabled by it and have a worse chance of improving and returning to your normal day to day (Burgess et al, 2020; Lee et al, 2015; Morton et al, 2019).

As I said, this problem is no limited to you, member of the general public. No, we healthcare professionals are also to blame. Looking at my own neck of the woods, beliefs about the back requiring special protection, good posture being important for protecting it, and that back pain requires special attention or treatment are still quite present amongst physiotherapists (Christe et al, 2021a).

This study by Christe et al (2021a) also suggests that physiotherapists with unhelpful beliefs are more likely to make their treatment plan and advice towards rest and avoidance of activities. This will contribute to poor care as it is likely to reinforce the aforementioned negative beliefs in people who seek treatment (Gardner et al, 2017), as well as being exactly the opposite of what is recommended in most clinical literature and guidelines (Lin et al, 2020; NICE, 2020).

So how do we tackle this problem? Using what I would argue to be one of the best tools we have to make the world a better place: education, of course. The importance and role of education, including the spreading of up-to-date messages, as part of the management of back pain has already been highlighted throughout the clinical literature (Buchbinder et al, 2018; Caneiro et al, 2020; Lin et al, 2020; Lewis and O’Sullivan, 2018; NICE, 2020).

Let’s get started by looking at one of the more prevalent myths surrounding back pain and how it has been shown to be incorrect.

Myth: Back pain is caused by damage in the back.

We can start addressing this myth by recalling that pain is not always associated with, and therefore, is a poor measure of the status of our tissues. If you want to learn more about this and the nature of pain in general, I’ve previously written a two part post about pain and its complexity. You can read both parts here and here.

Overall back pain is a quite common symptoms from younger to older age (Draheim and Hügle, 2018; Hoy et al, 2012) and it is rarely associated with a specific or serious problem. Historically, the percentage of people who have low back pain without it being caused by an injury or a pathology has been estimated to be around 90% (Koes, van Tulder and Thomas, 2006).

Putting this value under a different perspective, research looking at the amount of people who actually have a serious injury or pathology (medical problem) associated with back pain has estimated it to be lower that 1% of cases of back pain, ranging from 0.002% to 0.9% depending on the specific pathology (Finucane, 2020; Henschke et al, 2009) It is also important to note that in these cases, for a serious pathology to be suspected, other symptoms beside pain need to present, as mentioned above, pain itself is not an indicator of an injury, even if it feels very intense and severe.

Even these symptoms that are suggestive of something more serious – usually called ‘red flags’ by health care professionals – are often present, usually at least one, in people suffering with back pain, even if the person doesn’t actually have the pathology (Henschke et al, 2009).

Now, in no way this is me suggesting that this pain not be very disabling and limiting, quite the opposite. However it means that even if pain is very severe, the chance of it being life-threatening is very, very low.

Concluding, back pain is something very common throughout our lives and only very, very rarely caused by a serious problem, even when the pain feels very intense. I hope knowing this is helpful to you, either helping you understand a bit more about the pain you might be feeling, or if you are someone whose work involves helping people with pain.

Don’t forget that when in doubt, check with a certified medical doctor or a physiotherapist. When we next return to the myths surrounding back pain, I will explain why your doctor won’t always send you for a scan and why what you probably have been told about posture for most of your life doesn’t really matter that much. If you liked this text and feel you learned something from it, please share it around social media. If you want to make any remarks or ask any questions, feel free to do it in the comments.

References:

Buchbinder, R., van Tulder, M., Öberg, B., Costa, L. M., Woolf, A., Schoene, M., Croft, P., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., Anema, J. R., Chou, R., Cohen, S. P., Ferreira, M., Ferreira, P. H., Fritz, J. M., Genevay, S., Gross, D. P., Hancock, M. J., Hoy, D., Karppinen, J., Koes, B. W., Kongsted, A., Louw, Q., Peul, W. C., Pransky, G., Sieper, J., Smeets, R. J. and Turner, J. A. (2018) ‘Low back pain: a call for action’, The Lancet, 391(10137), pp. 2384–2388. doi: 10.1016/S0140-6736(18)30488-4.

Burgess, R., Mansell, G., Bishop, A., Lewis, M. and Hill, J. 2020. Predictors of functional outcome in musculoskeletal healthcare: An umbrella review, European Journal of Pain (United Kingdom), 24(1), pp. 51–70. doi: 10.1002/ejp.1483.

Caneiro, J. P., Roos, E. M., Barton, C. J., O’Sullivan, K., Kent, P., Lin, I., Choong, P., Crossley, K. M., Hartvigsen, J., Smith, A. J. and O’Sullivan, P. (2020) ‘It is time to move beyond a € body region silos’ to manage musculoskeletal pain: Five actions to change clinical practice’, British Journal of Sports Medicine, 54(8), pp. 438–439. doi: 10.1136/bjsports-2018-100488.

Christe, G., Nzamba, J., Desarzens, L., Leuba, A., Darlow, B. and Pichonnaz, C. 2021. Physiotherapists’ attitudes and beliefs about low back pain influence their clinical decisions and advice, Musculoskeletal Science and Practice. Elsevier Ltd, 53(April), p. 102382. doi: 10.1016/j.msksp.2021.102382.

Christe, G., Pizzolato, V., Meyer, M., Nzamba, J. and Pichonnaz, C. 2021. Unhelpful beliefs and attitudes about low back pain in the general population: A cross-sectional survey. Musculoskeletal Science and Practice. Elsevier Ltd, 52(August 2020), p. 102342. doi: 10.1016/j.msksp.2021.102342.

Darlow, B., Dean, S., Perry, M., Mathieson, F., Baxter, G.D., Dowell, A. 2015. Easy to Harm, Hard to heal: patient views about the back. Spine. Wolters Kluwer Health Inc, 40(11), pp. 842-850

Draheim, N. and Hügle, B. 2018. Chronic musculoskeletal pain in children and adolescents’, Manuelle Medizin, 56(6), pp. 440–446. doi: 10.1007/s00337-018-0484-4.

Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., … Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy, 1–23. https://doi.org/10.2519/jospt.2020.9971

Gardner, T., Refshauge, K., Smith, L., McAuley, J., Hübscher, M. and Goodall, S. 2017. Physiotherapists’ beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies, Journal of Physiotherapy. Korea Institute of Oriental Medicine, 63(3), pp. 132–143. doi: 10.1016/j.jphys.2017.05.017.

Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., Woolf, A., Vos, T. and Buchbinder, R. 2012. A systematic review of the global prevalence of low back pain, Arthritis and Rheumatism, 64(6), pp. 2028–2037. doi: 10.1002/art.34347.

Lewis, J. and O’Sullivan, P. O. 2018. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain ?, Br J Sports Med, pp. 1–2. doi: 10.1136/bjsports-2018-099198.

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G. and O’Sullivan, P. P. B. (2020) What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review, British Journal of Sports Medicine, 54(2), pp. 79–86. doi: 10.1136/bjsports-2018-099878.

UK National Institute for Health and Care Excellence (NICE). 2020. Low back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59], December 2020. [Online]. Available at: < https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica-in-over-16s-assessment-and-management-pdf-1837521693637 >

Henschke, N., Maher, C. G., Refshauge, K. M., Herbert, R. D., Cumming, R. G., Bleasel, J., York, J., Das, A. and McAuley, J. H. 2009. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain, Arthritis and Rheumatism, 60(10), pp. 3072–3080. doi: 10.1002/art.24853.

Hurwitz, E.L., Randhawa, K., Yu, H., Côté, P., Haldeman, S. 2018, The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. European Spine Journal, [e-journal]27, pp.796-801. Available through: https://link.springer.com/article/10.1007/s00586-017-5432-9

Lee, H., Hübscher, M., Moseley, G. L., Kamper, S. J., Traeger, A. C., Mansell, G. and McAuley, J. H. 2015. How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain’, Pain, 156, pp. 988–997. doi: 10.1097/j.pain.0000000000000146.

Morton, L., de Bruin, M., Krajewska, M., Whibley, D. and Macfarlane, G. J. 2019. Beliefs about back pain and pain management behaviours, and their associations in the general population: A systematic review, European Journal of Pain (United Kingdom), 23(1), pp. 15–30. doi: 10.1002/ejp.1285.

Koes, B. W., van Tulder, M. W., Thomas, S. 2006. Diagnosis and treatment of low back pain, BMJ, 332, p. 1430-4. doi: 10.1136/bmj.332.7555.1430