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Save Yourself from Low Back Pain!

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Thank you for your business. This section (blue border) is an introduction to this e-book just for customers. The complete e-book begins below this section. If you have any problems, read on for some tips and help, and please do not hesitate to contact me personally. ~ Paul Ingraham, Publisher

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Save Yourself from Low Back Pain!

Low back pain myths debunked and all your treatment options reviewed

updated May 3, 2018

by Paul Ingraham, Vancouver, Canada  bio

© 2001–2018 Paul Ingraham, Vancouver, Canada. Access to this document was purchased by Vladimir Stoyanov, София / Sofija, BG (customer #2422877). privacy Private sharing on a small scale is just fine — you can lend it to up to 3 people — but this ebook may not be shared widely by any means. Access may be revoked if this page is accessed from too many locations, too quickly. If you find this document posted publicly, it has definitely been pirated! If you did not borrow access personally from V. Stoyanov, please purchase access for $19.95 from the PainScience.com eBookstore. Thank you for supporting a small business and low-DRM publishing. what’s that? ~ Paul Ingraham, Publisher

TABLE OF CONTENTS

No matter where you are in the book, you can get back here with the button floating in the lower right margin.
- Top of Document

- Customer Introduction (Tips & Help)

- Start of Book

- BOOKMARK  ?

- Table of Contents

- • Introduction

- 1.1 A tragic low back pain myth

- 1.2 How can you trust this information about low back pain?

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

- 1.4 Who is this low back pain tutorial for?

- 1.5 Some cases of “incurable” chronic low back pain can still be cured!

- 1.6 Is this going to be one of those “it’s all in your head” theories about low back pain?

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

- • Diagnosis

Your low back is not fragile!

- 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

- 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 Other possible causes of low back pain, or “No, my low back pain is really serious …”

- 2.16 Could it be muscle strain? The muscle strain myth

- 2.17 From the frying pan of injury pain to the fire of trigger point pain

- 2.18 Could it be a vicious cycle of pain-spasm-pain?

- 2.19 Could low back pain be an overuse injury?

- 2.20 Could it be a herniated disc?

- 2.21 Facet joint syndrome and MIDs

- •2.22 Diagnostic numbing of facet joints

- 2.23 Is there such a thing as a “subluxation”? Can your back be “out”?

- •2.24 Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves

- 2.25 Do you really need to lose some weight?

- 2.26 Is it core weakness?

- 2.27 Is it all in your feet? Foot-o-centric low back pain theories

- 2.28 Your problem is that you’re having “too much fun”

- 2.29 Could you have a “pinched” nerve? The nerve pinch myth

- •2.30 The role of true nerve problems in low back pain

- 2.31 The strange case of scoliosis

- 2.32 Back pain and sneezing

- •2.33 Back mice (lipomas)

- 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 The confidence cure

- 3.3 What is the difference between a ‘confidence cure’ and a mere placebo?

- 3.4 Stress relief and the tyranny of meditation and yoga

- 3.5 Another %[email protected]&*!! personal growth opportunity

- 3.6 Yoga and meditation are still an option, of course

- 3.7 Beyond the confidence cure: what else can you do for low back pain?

- 3.8 Pain medications (and even alcohol) can be useful

- 3.9 Comfrey makes backs comfy, study claims

- 3.10 A tale of two tutorials

- 3.11 Introduction to treating your own low back trigger points

- 3.12 Limitations of trigger point therapy, and how to take advantage of them

- 3.13 Basic self-massage for low back trigger points

- 3.14 How do you know it’s working? Getting a trigger point to “release”

- 3.15 Massage tools are indispensable

- 3.16 The bath trick

- 3.17 Can you damage your nerves when self-massaging?

- 3.18 Don’t hesitate to recruit amateur help

- •3.19 The evidence for massaging back pain

- 3.20 Heat and ice both provide good bang for buck, but err on the side of heat

- 3.21 Act normal! Rest minimally and strategically, while maintaining as much normal activity as you can

- 3.22 Massage with movement and life in the Goldilocks zone

- 3.23 Some particularly useful mobilizations for the low back

- •3.24 Don’t worry about lifting technique

- 3.25 Traction: low back pain on the rack!

- 3.26 What about stretching?

- 3.27 Troubleshooting perpetuating factors

- 3.28 Fix your insomnia

- 3.29 Morning pain and sleep posture

- 3.30 Sitting, chairs, and ergonomics

- 3.31 Troubleshooting severe and persistent trigger points

- 3.32 Troubleshooting even worse trigger points

- 3.33 Less than a cure, but better than nothing: short term symptom relief options for low back pain

- 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 What about surgery?

- 4.9 The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries

- 4.10 Surgery for sciatica (microdiscectomy)

- •4.11 Needles for back pain: nerve blocks for facet joints and related treatments

- •4.12 Kill it with fire! Treatment by nerve destruction

- 4.13 Bogus Cures

- 4.14 Craniosacral therapy (CST) is often prescribed for low back pain but has no potential to help

- 4.15 The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests

- 4.16 Core strengthening has failed to live up to the hopes and dreams of therapists and patients

- 4.17 Scoliosis cannot be straightened without surgery

- 4.18 Facet joint and intradiscal steroid injections are not recommended for most patients

- 4.19 Prolotherapy: still popular, and for no good reason

- 4.20 Spinal decompression therapy: worth the money and risks?

- 4.21 Back bracing and stabilization contraptions (especially inflatable ones)

- 4.22 Antibiotics for back pain: a debacle

- 4.23 A few more snack-sized reality checks: brief comments on other treatments to avoid

- Now what?

An action-oriented summary of recommendations

- 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  ?

Welcome to one of the Internet’s saner sources of information about chronic low back pain.[NIH] This is a book-length tutorial, a guide to a controversial subject for both patients and professionals. It is not a sales pitch for a miracle cure system. It’s heavily referenced, but the tone is often light, like this footnote about being “shot by the witch.”[1] I will offer some surprising ideas — underestimated factors in low back pain — but I won’t claim that all back pain comes from a single cause or cure. It’s just a thorough tour of the topic, the myths and misconceptions, and the best (and worst) low back pain treatment ideas available.

Since I first started treating low back pain in 2000, there’s been an explosion of free online information about it — countless poor quality articles. Back in the day, we actually had to go to a doctor or buy a book to get shoddy back pain information — now it’s just a Google search away.[2][3][4] Even many better articles still have serious “attitude” problems.[5] But it’s worse than that: even professional back pain guidelines are often misleading.[6] For instance, despite overwhelming scientific evidence to the contrary, it’s extremely common to incorrectly portray back pain as a “mechanical” problem, as if the spine is a fragile structure which breaks down and causes pain.[7] This is based on decades old misconceptions about how backs work, and how pain works, which the medical world is only gradually learning to leave behind.

1.1

A tragic low back pain myth

This myth of “mechanical” failure of the low back has many unfortunate consequences, such as unnecessary fusion surgeries — a common and routinely ineffective procedure — and low back pain that lasts for years instead of months or weeks. The seriousness of chronic low back pain is often emphasized in terms of the hair-raising economic costs of work absenteeism, but it may well be far worse than that — a recent Swedish study shows that it probably even shortens people lives.[8] The stakes are high. “Tragedy” is not hyperbole.

Even more tragic is that good information exists, and not just here in this book: many medical experts do “get it” (the doctors doing the actual research). But they have fought a long battle trying to spread the word to their own medical colleagues on the front lines of health care. A 2010 report in Archives of Internal Medicine showed just how grim it is:

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

~ Williams et al, 2010, Archives of Internal Medicine[9]

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.

1.2

How can you trust this information about low back pain?

I apply a MythBusters approach to health care (without explosives): I have fun questioning everything. I don’t claim to have The Answer for low back pain. When I don’t know, I admit it. I read scientific journals, I explain the science behind key points (there are more than 440 footnotes here, drawn from a huge bibliography), and I always link to my sources.

For instance, there’s good evidence that educational tutorials are actually effective medicine for pain. ? Good information is good medicine!

You don’t need to take my word for anything — you can just take the word of the many low back pain medical experts that I quote,[11] and the hard evidence that their opinions are based on. At the same time, I am realistic about the limits of the science, much of which is pretty junky.[12] My own credentials are somewhat beside the point. My decade of professional experience as a Registered Massage Therapist does help me understand and write about low back pain, but what really matters is that I refer to and explain recent scientific evidence, but without blindly trusting it.

About footnotes. There are 449 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content, [1] and boring reference stuff. [2] Try one!

1.3

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

Why does the myth of mechanical back pain get repeated endlessly on the Internet and in health care offices around the world?

- Repairing spinal joint “misalignment” is an easy idea to sell … but it’s hard to actually do! Chiropractors often can’t even agree on which joints need “adjusting” — even with only five lumbar joints to choose from.

- Poor posture and crookedness is another popular scapegoat — it seems obvious that posture is relevant. Many professionals assume that back pain is some kind of postural problem that you can exercise your way clear of. Unfortunately, the evidence shows that no kind of exercise, not even the most hard-core core strengthening, has any significant effect on low back pain.

PRO  Strong enough for a pro…but made for patients. The main text is user-friendly, but oodles of footnotes provide extra info and citations.

I do criticize many common practices and beliefs. If you disagree, let me know—I can take it, and I’ve made many changes over the years based on quality feedback.

- The almost magical power of MRI to look inside the back gives both doctors and patients something to point at and blame, but most are unaware that MRI has been proven (many times) to be a lousy diagnostic tool for back pain. The things you see on MRI scans are rarely the real problem — and every radiologist seems to see something different!

- Orthopedic surgeons (especially American ones) profit handsomely from the most complex low back surgeries (especially spinal fusion), so they are strongly inclined to think of back pain as a mechanical problem in need of physical repair — in spite of piles of scientific evidence to the contrary. If all you have is an incredibly profitable hammer …

- Sports medicine specialists have great expertise about injuries, so they often assume that back pain involves some kind of damage — but the evidence clearly shows that low back pain often has nothing to do with tissue damage.

Is professional care for low back pain really this dodgy? Sadly, I believe so. I clearly remember graduating clueless myself. If I hadn’t spent many years doing post-grad study of low back pain, I wouldn’t know 98% of what’s in this document. All of the points above — and many more — will be explained and supported in great detail below.

1.4

Who is this low back pain tutorial for?

This book is overkill for new and acute cases. It’s best for patients with unusually stubborn low back pain and sciatica — and for doctors and therapists who want to help with it.

Most acute low back pain fades steadily — up to 90% of it, for uncomplicated cases.[13] So does a lot of so-called “chronic” low back pain![14] But when you don’t recover, many of the therapeutic options — things like surgery for a herniated disc — cause anxiety that is unnecessary and harmful. The purpose of this tutorial is to review and expand the options.

This tutorial is great for people who like to understand their problems. Its dorky, quirky thoroughness is unlike anything the big medical sites offer, and the lack of a miracle cure secret is rare among independent sources. My goal is “just” to empower you with education (without boring you to tears). When you’re done, you’ll know more about your back than most doctors. (Not that this is saying much![15]) I’ve spent years compiling this information from hard study, professional experience, and lots of your stories and feedback. I update the tutorial regularly.

But I will not just tell you what you want to hear. Understanding low back pain as well as possible is valuable, but it will not necessarily lead to a cure. Sadly, some low back pain cannot be fixed.

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

~ Pain, by Marni Jackson, p. 5

And yet …

1.5

Some cases of “incurable” chronic low back pain can still be cured!

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

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

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

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

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

I have never met a patient — no matter how experienced or self-educated — who could not gain at least some new insights and new hope from this tutorial.[16]

1.6

Is this going to be one of those “it’s all in your head” theories about low back pain?

Absolutely not!

Low back pain can certainly be sensitive to emotional state, just like an ulcer gets worse when you’re stressed. But both are real physical problems! All of this will be discussed in detail, and it’s important, but this is not a tutorial about treating back pain through psychoanalysis, stress relief, and positive thinking. Tools like yoga and meditation are great for those who enjoy them, but not required.

A weakness in Dr. John Sarno’s (otherwise interesting) writing about back pain[17] is that he tends to give patients the idea that recovery from low back pain is all a mind game. That’s going too far. “The biology of pain is never really straightforward, even when it appears to be.” (Moseley)

Over-rated?

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.

1.7

“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 gladitorial training. In fact, he had a tumour. It killed him in 2011.

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

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

The rule of thumb[19] 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:

When to Worry About Low Back Pain And when not to! What’s bark and what’s bite?       ~ 4,250 words

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

DIAGNOSIS

Your low back is not fragile!

2017 — Science update: Added a small but key new point and citation about genetic factors in degeneration; and an important new citation about the disconnect between imaging results and pain.

Spines haven’t changed in the last century,[20] and yet modern civilization suffers from a great plague of low back pain.[21][22] Yet the real causes of most back pain are obscured by medical mythology and misunderstanding.[23] Before I discuss what does cause most low back pain, it’s important to talk about what does not cause it. In this section, I will challenge the mythology in just a few paragraphs, supported by over thirty references to the best scientific information available — references you can check for yourself. This is quite different than most sources of patient-focused low back pain information, which tend to avoid discussing the evidence.

This is where the free introduction to the tutorial ended.

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.

I do worry there is a combination of side effects and unnecessary treatments and labeling people as being fragile when they’re really not. The combination of those kinds of things may actually be in some cases doing more harm than good.

Dr. Richard Deyo, low back pain expert[27]

Ignoring expert recommendations from their own colleagues,[28] doctors order too many fancy tests (especially MRI or “magnetic resonance imaging”)[29][30][31][32][33] to try to find evidence of mechanical failures — yet we know that doing such tests does not lead to better results,[34] may even cause harm,[35] usually shows problems in people with no pain,[36][37][38][39][40][41][42] and shows no problems in people who do have pain![43][44][45]

None of these means that the cause of pain can’t still be lurking in the spine — it could be.[46] But either causes of back pain that can actually be imaged are surprisingly rare, or hard to spot, or both.

Medical care for the Jetsons?

For many years now, MRI scans have been the ultimate in futuristic medicine. But while these machines are miraculous in some ways, they can be worse than useless for diagnosing low back pain & studies show that doctors recommend way too many of them … especially when they profit from it.

The overdiagnosis of slipped discs in particular

With and without MRI, disc herniations is the most overdiagnosed cause of back pain, probably one of the most overdiagnosed problems in the history of medicine. They are feared by patients way out of proportion to their frequency or severity.[47] Herniation severity does not correlate well with pain in the first place, but they definitely can’t be the cause of the trouble when they just go away on their own.

Once a spinal disc has “slipped,” it seems like it’s in a biomechanically awkward situation and can’t recover any more than a broken window can reassemble itself. And yet “slipped” discs usually un-slip! This is called “resorption” — a nifty back trick that most people are unaware of (including too many healthcare professionals still). Most herniations, roughly 60%, just go away, some of them surprisingly quickly, like a snail tucking back into its shell, according to about a dozen studies.[48] One of the best of those studies tracked herniations for eight years, finding that only 12% got worse.[49] You can see a good example of resorption in these reassuring before/after pictures (follow link in footnote).[50] And here’s another eyebrow-raiser: a study in New England Journal of Medicine showed that people with back pain and herniations actually recovered slightly better than those with “normal” discs![51] For every disc that recovers completely, more probably resolve enough to relieve a key symptom.

And yet it is almost impossible emotionally to see anything that looks “bad” on an X-ray or MRI and not worry about it. And it’s also almost impossible to get a completely healthy-looking scan of anyone! TV’s Dr. Greg House has commented on this…

House: Give him a whole body scan.

Cameron: You hate whole body scans.

House: Because they’re useless. You could probably scan every one of us and find five different doodads that look like cancer.

~ House, Season 1, Episode 17, Role Model, written by Matt Whitten

But even Dr. House wasn’t cynical enough: radiologists can’t even spot the same red herrings. If you send the same patient to get ten different MRIs, interpreted by ten different radiologists from different facilities, you will get ten markedly different explanations for her symptoms. A 63-year-old volunteer with sciatica allowed herself to be scanned again and again and again for science[52] — a sting operation. The results were all over the map.

The radiologists cooked up forty-nine distinct “findings.” Sixteen were unique; not one was found in all ten reports, and only one was found in nine of the ten. On average, each radiologist made about a dozen errors, seeing one or two things that weren’t there and missing about ten things that were. That’s a lot of errors, and not a lot of reliability. The authors clearly believe that some MRI providers are better than others, and that’s probably true, but we also need to ask the question: is any MRI reliable? This would be laughable if it weren’t so tragic.

Or like low back pain. And yet, most visible defects are clinical red herrings, about as scary as a birthmark, and signify nothing except the power of modern medical technology to scare you silly if you aren’t armed to the teeth with confident knowledge to the contrary.

Greg House: one of my critical thinking heroes.

(Cameron ain’t too shabby at it either.)

Continuing on the theme of over-medicalization of back pain, doctors also prescribe too much surgery and too many drugs,[53][54] even though we have evidence that these approaches to the problem routinely have disappointing results.[55][56][57][58][59][60] Even when surgery appears to work, the benefits may often be due to placebo effect rather than correction of a significant problem.[61]

Many years before when I had serious back pain from a sports injury, the surgeons said they would explore my spine and “figure it out.” Out of frustration I had impulsively opted for the procedure. They ended up fusing the vertebrae. It left me debilitated. In hindsight, I blamed myself more than the surgeons. I had pressed them for a solution when in fact none was apparent because the cause of the pain was obscure.

~ How doctors think, by Jerome Groopman

The truth is that your back is not fragile — it is a strong, adaptable structure.[62] Multiple spinal joints can be fused without causing pain or loss of function.[63] The big muscles around the spine can be quite asymmetrical with no ill effect.[64] The spine can heal from injuries as well as any other part of the body, and can adapt well to significant mechanical failures — study after study has shown that people also can have significant spinal degeneration, deformities, and injuries without any pain.[65][66][67][68][69][70][71] There is even strong and recent evidence that structural stability is not a critical factor in the pain of collapsed vertebrae — stabilizing those bones with injected cement doesn’t make them recover any faster, as surgeons had reasonably assumed for decades.[72]

2.1

Even serious structural problems in the low back are often painless

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.[73] Until relatively recently in history, almost everyone (except John Sarno[74]) 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.[75] 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.

Or consider the striking case of one of my own clients. The picture is an MRI of a grade III (i.e. “bad”) spondylolisthesis, a type of dislocation — her fifth lumbar vertebrae is basically falling off her sacrum, slipping down and forward. It is approximately 50% displaced. The degree of structural deformity seems to be extreme, almost disastrously so. One wonders, how can such a person even walk? It’s 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 had 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.[76][77] I discuss them in more detail in an article about spinal manipulative therapy.

Of course, spondylolisthesis, spinal stenosis, and other extreme anatomical situations probably 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. So it’s certainly a real problem. But it’s also terribly interesting and informative that they cause so much less pain (or other problems) than anyone previously thought.

2.2

Maybe you’re just getting older? Actually, no …

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 structural problems.

Many minor structural problems 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. This is 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 Quebec[78]

Yet young people — working people in their thirties and even twenties — routinely get severe back pain in numbers so staggering that they are routinely cited for their economic significance. In fact, there is evidence that people actually get less back pain as they age!

Although certain types of back pain are relatively absent in the young and become increasingly common with age,[79] it doesn’t affect the overall trend: most back pain occurs in the thirties and forties,[80] either actually declining in the fifties and sixties,[81] 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![82][83] Just look at this camel-hump of a graph of one survey:[84]

ZOOM

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

That’s a pretty striking hump of low back pain in mid-life … and a surprising decline after that. Not every data set shows it so clearly — I cherry-picked 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 caused or even much bothered by wear-and-tear on spines, 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! A great 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?

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 anyway, and not “not primarily through routine physical loading exposures (eg, heavy vs. light physical demands) as once suspected.”[85] Although your family doctor may not be aware of this research, he can learn it easily 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.[86][87]

With my apologies, this annoying message from the management is repeated 3 times in the book to discourage piracy. Online access to this book was purchased by Vladimir Stoyanov. If you did not personally borrow this book from V. Stoyanov, it is pirated! Please purchase your own copy. Thank you for supporting a small business and low-DRM publishing. what’s that? ~ Paul Ingraham, Publisher

2.3

Structural problems in the low back are hard to diagnose accurately

Even if you have structural problems with your back, and even if they actually are the source of your pain, doctors and therapists have an extremely difficult time accurately identifying where the pain is coming from. Not that it stops them from trying ….

“It’s my sacroiliac joint. My physiotherapist told me.”[88]

I hear this kind of thing all the time: low back pain explained with a precise anatomical reference. It sounds good. In fact, sometimes I start to wonder if other physical therapists are a lot smarter than I am, because they seem to be so good at identifying exactly where low back pain is coming from!

But years of experience and study have taught me that a lack of confidence about such things is probably wiser.

Nerve blocks numb the nerve supply to a single spinal joint to see if the problem goes away. Provocative discography is the injection of an irritant into a disc nucleus in an attempt to reproduce the patient’s typical pain. Both techniques will be discussed more below.

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”[89] (italics mine) and explained that there is hope for more precise diagnosis … but only with very specific medical tests, such as nerve blocks and provocative discography.

In 2007, the European Spine Journal published the best paper about this so far. This scientific study of about 40 scientific tests of testing studies put the claims to the test![90] Can therapists really pinpoint where low back pain is coming from?

Basically, no.

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).[91] Massage therapists, rather disappointingly, could not even identify the side of the body that back pain was on by feel alone — despite our legendary reputation for zeroing in on tissue problems with uncanny accuracy.[92] Being inaccurate even at finding the side of pain is kind of the palpation equivalent of missing the broad side of a barn in target practice, and rather strongly suggests that, even if there is a structural problem, it doesn’t even show up clearly enough for the “magic hands” of massage therapists!

Facet joints are a common scapegoat, but (emphasis mine) “none of the tests for facet joint pain were found to be informative.”[93] 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, to say nothing of the misleading results! And the evidence had existed for years. 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. 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.[94]

One would hope that diagnostic tests would produce reasonably unambiguous results which, when tested, 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 (cited above) added to the (already large) pile of evidence that “conventional investigations do not reveal the cause of [low back] pain”[95] (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 number of serious diagnostic options even further.[96]

You cannot generally trust professionals to identify a structural origin for your pain, even if you have one.

Which you probably don’t.

2.4

Those scary spine models

This is a great example of how old ideas in health care persist. And cause problems.

As you’ve learned above, although herniated discs do happen, they are less common and much less serious than most patients, doctors, and therapists believe. Meanwhile, several respected medical experts have made strong statements about the extreme importance of reassuring low back pain patients and not scaring them with ominous-sounding diagnoses like “herniated disc.” Such diagnoses are usually wrong — or hopelessly oversimplified at best — and needlessly scare the wits out of patients … which itself is a known risk factor for low back pain. Nervous low back pain patients tend to have more pain for much longer.

And yet it remains nearly 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! It is also nearly impossible for a patient to look at such a model without worrying.

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. Moseley.)

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 always worsened when you believe that there is danger … 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 it’s 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 years. Long before I’d ever heard of Lorimer, I’m proud to say.)

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 years, probably even decades. I’m sure there are probably hundreds of thousands of them 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.

2.5

It’s not structure… except when it is

2017 — New section: An important and interesting acknowledgement that mechanical causes of back pain do exist.

Mechanical explanations for back pain are not always wrong or useless. I have devoted several sections to demonstrating that structural causes of back pain are over-emphasized, not non-existent.

In 2015, a group of researchers published an excellent pair of papers making this point. The first is cited above: 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 its kind, demonstrating the weird disconnect between back pain and back degeneration.

But Brinjikji et al didn’t stop there.

They also published another paper[97] presenting 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.”

Also good to know. And quite challenging to my bias. 😜 But the take-home message is actually just a nice, reasonable compromise between two well-known viewpoints: 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.

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

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

For these reasons and more, Dr. Stuart McGill, a well-known low-back pain expert, argues that there is no such thing as “non-specific” back pain: “there are only those individuals who have not had thorough assessment.”[98] He believes the (mechanical) cause is there and can be found if we look hard enough.

I admire his confidence! And I have no doubt that some back pain mysteries can be solved by a good enough medical Sherlock Holmes. But I have a lot of doubt that we are actually capable of finding the problem in most cases. I think the evidence is overwhelming that most diagnostic searches for mechanical causes are barking up the wrong tree. I think it’s obvious that many cases are caused by something else. Something a lot of professionals aren’t even looking for.

2.6

So then what? The missing muscle piece

So what is going on with low back pain? If we have to toss most of the conventional wisdom out the door, what replaces it? If the usual suspects don’t actually hurt, or rarely hurt, or don’t hurt that much, then what the heck is hurting so much?

I propose that a lot of otherwise undiagnosable low back pain is either caused and/or complicated primarily by humble muscle tissue.

That is, a lot of low back pain is probably[99] muscle pain in the low back. 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.” Not anything commonly diagnosed (or feared) by patients or professionals. Specifically, most low back pain is probably caused or complicated by the humble muscle “knot” — a poetic and imperfect word for a quirky and controversial clinical entity.

The more official word for a muscle knot is a “trigger point,” and a collection of particularly nasty trigger points is often called 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, supported by plenty of interesting scientific evidence slowly accumulating over decades. It’s a half-baked mess,[100] but it’s not way out in left field either. 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.[101] 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 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 to by far the most prone to it.[102]

- 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. Trigger points are likely involved to some degree in virtually every case of back pain, regardless of what else is 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 is likely to start to hurting because of disc herniations (and even continue after the herniation resolves).

- Best of all, trigger points are a Good News diagnosis because they are mostly self-limiting and treatable, however clumsy and imprecise our methods … because their bark is worse than their bite. 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.

But trigger points can bark very, very loudly. They can be amazingly (frighteningly) painful — 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.

I estimate — opinion and guessing, not science — that about half of all cases of mild to moderate low back pain without any other obvious causes or complications are caused by these sensitive little spots. Most garden variety back pain is probably just some trigger points that got out of hand. The relationship between trigger points and the pain is often so straightforward that the correct therapy is nearly effortless — you find one or two key sensitive spots, stimulate them a bit, and bam, you’re a “miracle worker.”

For instance, a woman came to see me complaining that she’d had moderate, chronic back pain for several years. She’d been given several predictable “mechanical” misdiagnoses in that time, especially sacroiliac joint dysfunction, one of the classic back bogeymen. But she had a prominent gluteus maximus trigger point that, when stimulated, caused the same sensation as her symptoms — a deep, sickly, nagging ache in the region of the low back and upper gluteals. In three appointments, years of pain was completely relieved. Bam. “Miracle worker.” 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 stories like that. In almost every such case, the pain was not terrible, but frustrating and persistent for years, then relieved by a handful of treatments. 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. Working with muscle seems to have given me an opportunity to solve 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.[103] I’m definitely not bragging that I can fix any case of back pain in three appointments! It’s more like this: “I can improve about 60% of cases of moderate chronic low back pain of a certain type with two to six hours of massage.” Not miraculous, just good.

In most of the other half of all cases, trigger points are causing or complicate otherwise relatively minor spinal injuries, like mild muscle strain in a lifting incident. Some such injuries will get better, and some will mark the beginning of a long struggle with trigger points — ultimately, the trigger points are the more stubborn problem. Most chronic back pain would probably be less chronic and less serious if not for the tendency of trigger points to pile on and make everything worse, and create sensations that seem an awful lot like scarier things (nerve pain, chiefly).

That leaves only a small fraction — maybe 10%? — of back pain that is more completely mysterious.[104] But even in that puzzling remainder, the pain will still usually involve trigger points: they crop up like clockwork near any other major problem, and make a bad situation worse. Therefore, nearly anyone with low back pain probably also has some low back muscle pain.

But 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?

About your free companion trigger point tutorial

Some things just need to be described over and over again. The clinical significance of muscle pain is one of the most important ideas this website has to offer. Muscle problems are an under-estimated factor in many conditions, especially neck and back pain. Several PainScience.com tutorials introduce trigger points. Regular readers and boxed set owners may find all the introductions to be somewhat redundant, repetitive, and a lot like reading something over and over again. 😉

But it’s critical information for every new reader.

I do make an effort to “customize” every discussion of trigger points. This tutorial discusses the basics of trigger points as they relate to low back pain. But don’t forget that customers who purchase this book also have full access to a large companion tutorial about trigger points.

Trigger Points & Myofascial Pain Syndrome

The full trigger points tutorial covers the subject of trigger points in extravagant detail — it is a book-length document, the longest of the tutorials available on this website. The low back pain tutorial does not assume that you are necessarily going to read the entire trigger points tutorial, or any of it, so there’s enough information about trigger points here to adequately introduce you to the subject.

However, if you want to know all about trigger points, then the full trigger point tutorial is the document to read. Your interest in the trigger points tutorial should be proportionate to how much you think trigger points might be involved in your particular case of low back pain.

2.7

There is nothing “just” about muscle

While many medical back pain experts will only go so far as an acknowledgement that “no one really knows” what the cause of most low back pain is, some other experts suspect the same thing I do: that muscle may be a major missing piece.[105] And it’s not such a strange idea — we are leaving the trunk of the tree of knowledge, but we’re not going too far out on a limb here.

Muscle can be a source of major misery, and we know this from the pain caused by an acute cramp, or the less acute (but equally obvious) suffering caused by neuropathic spasticity. An excellent (and rather chilling) example of that is the “MS hug.”[106] And yet it’s worth noting that the symptoms of the MS hug are often dismissed or misinterpreted. And for every clinically obvious example, less obvious ones are legion. Muscle is a sensitive[107] and volatile tissue,[108] but it is also underestimated.

Even patients themselves — the people suffering — 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 when prodded. Even moderate pressure on some muscle tissue can cause strong discomfort. My clients often asked me, “What is that?” (Or they just said a bad word.) People can hardly believe that it’s “just” muscle — that it’s not some more vulnerable anatomy that feels like that. Healthy muscle does not hurt when you gently poke it, but unhealthy muscle sure can! What’s going on? Why would muscle hurt that much?

The answer is that muscle tissue is never “just” muscle tissue — there’s a lot of it, it’s biologically complex and chock full of nerve endings, it’s behaviour is highly sensitive to our mental state, and it’s got a difficult and unrelenting job to do. And sometimes muscles get “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].”[109]

“Myofascial pain syndrome” was first thoroughly studied by Drs. Janet Travell and David Simons.[110] In their explanation of MPS, physical stresses and/or emotional stress triggers a vicious cycle, a trigger is basically a tiny cramp or spasm: a patch of muscle 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.[111] 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.,[112] and is now the most widely known working theory. And, for the purposes of this book, it’s the theory I will work with — with the understanding that it’s just a theory, it has critics, and it could be wrong. Which Gerwin et al. have acknowledged.[113] And which I also freely acknowledge.[114]

... an appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points, despite their having been written about in medical journals for over sixty years.

~ The trigger point therapy workbook, by Clair Davies, p. 2

There’s a long, colourful history of arguing about this stuff: many people have tried to label and explain these mysterious patches of icky, achey muscle. The scientific literature was chock-a-block with theories before the ideas of Travell and Simons started to dominate, and there are still many competing theories today. Some examples:

- In his best-selling book Mind Over Back Pain (and in his more recent Healing Back Pain), Sarno describes the same problem and calls it “tension myositis syndrome,” attributing it mainly to stress-induced constriction of blood vessels causing oxygen starvation.[115]

- Dr. C. Chan Gunn of Vancouver calls it “neuropathic pain,” and suggests another explanation: under-stimulated muscle may become extremely sensitive.[116] 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 have 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.”[117]

Not all of these theories can possibly be entirely correct, of course. It’s probably a classic case of holding onto different parts of an elephant. But we’ll proceed with the main working theory.[118]

So, trigger points are patches of muscle tissue (and perhaps other soft tissues) that is “unhealthy” in some way. Some muscles seem to be more vulnerable to this phenomenon than others — seemingly the back muscles most of all, for unknown reasons.[119] They are not only painful to touch, but also spontaneously generate spreading pain and nervous system disturbances to nearby tissues. This spreading is a well-documented phenomenon called “referred pain.” Pain originates in one location, but radiates in surprisingly predictable patterns to other locations.

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 a pinched nerve — often resulting in misdiagnosis.[120] In most people with low back pain, trigger points causing these radiating sensations can be located easily. Although the pressure is nowhere near a nerve,[121] 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, when these trigger points are treated, the “pinched nerve” pain goes away. This is an example of how muscle can be the entire 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 his highly readable version of a classic medical text on muscle pain), 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.”[122]

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.[123] Indeed, this is a common course of events. It is the nature of trigger points to cause and complicate other low back problems[124][125][126] — to make a bad situation worse! — that makes it the most significant factor in the majority of low back pain.

2.8

Low back pain is the new ulcer

2017 — Science 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.”

Back pain is how many bodies say “no!” This phrase is borrowed from the title of a book about stress-induced illness by Vancouver physician Gabor Maté.[127]

Let me stop the groaning right away: 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 muscle pain is not a basket-case diagnosis. As I’ve already promised, I will not tell you that having back pain means that you are a hypochondriac or that it’s “all in your head,” and I will not recommend meditation and yoga as treatment. These are tired clichés that miss the point. Myofascial pain syndrome is a real, physical condition that just happens to be sensitive to mental states, much like high blood pressure, heart disease, asthma, or irritable bowel syndrome.[128]

Just as MPS both causes and complicates back pain, stress is both a root cause and a significant complicating factor in MPS.[129] Although it is under-researched, numerous studies have nevertheless shown connections between stress and low back pain.[130][131][132][133][134] It’s also significant that anti-depressants and sedatives have been found to be mildly helpful.[135] The likely potency of placebo in the treatment of back pain is also telling: nothing works magic on a stress-induced condition like optimism!

Many people are stoic, perhaps most, and do not believe that they are suffering from much stress. Or they may be aware that their lives are stressful but claim to have a “good attitude” or kick-ass coping skills. But “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”[136] (emphasis mine). Indeed, it is socially risky to express nervous tension or anxiety — no one wants to be perceived as jittery! And it is also often a verboten self-judgement as well. So stress often must find some other way of manifesting.

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 once an ideal way to be seriously stressed in a socially acceptable way. However, everyone now “knows” that ulcers are stress-induced, whether they really are or not, so ulcers are no longer an effective disguise for emotional stress — and perhaps this explains why the incidence of ulcers has decreased steadily since the 1970s.[137] (Aren’t ulcers caused by an infection? Yes, but…[138])

Instead, Sarno proposes, North Americans increasingly make back pain into a perfect “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.

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

Once an episode of back pain starts, pain itself, immobility, and the fear of more pain become a new and nasty source of stress. Thus, back pain can “cause itself.”[139] Although this process is self-limiting — muscles only get so dysfunctional in this way — pain, fear, and immobility constitute an axis of evil, each reinforcing the other.

Tragically, medical care for back pain often makes the vicious cycle even more vicious by frightening patients:

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

This reflects my own clinical experience: many back pain clients come to me in despair as well as in pain, often clearly upset by a medical diagnosis. Thus, a leading cause of back pain may be health care itself,[140] 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 & virtually guaranteeing the persistence of low back pain.

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

2.9

Pain and fear, together at last: an even simpler vicious cycle

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 stubborness 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, you will be more pain prone, regardless of whether or not you actually behave fearfully by immobilizing yourself, for instance. (See Woolf[141] — a particularly important reference.)

Bear with me for a moment for an amusing example. (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.)

All Finished 0:16

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:

Did it help? 0:25

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.”[142] 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 is probably 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 strategies (which is why I gave it special focus in the pain-fear-immobilization diagram). The next section is another great example…

2.10

Chronic low back pain is not so chronic: the myth of chronicity

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.

The window of time that conventionally distinguishes “acute” from “chronic” cases is six to nine weeks. There’s a widespread belief you are doomed to long-term chronic pain if you don’t recover by the end of that period. This is a myth: although chronic low back pain can last many years, there’s no way to know if your case will, because low back pain can disappear at random. You do not disastrously become an impossible case the moment you enter week ten.

You’re not likely to catch a doctor actually saying that you’re doomed after week nine. This myth is sneaky: health professionals aren’t stating it directly or erroneously defending it. What they will do is simply fail to reassure their patients during the transition to chronic pain, conveying an attitude of deepening concern and defeatism as the weeks go by, as though you are becoming one of those patients, a “difficult case.” Other professionals may just slightly exaggerate the importance of the transition from acute to chronic. It’s not wrong for health professionals to start taking a case of low back pain more seriously over time — but it is wrong — possibly even tragic — to do so without carefully reassuring the patient.

Many health professionals are now educated enough about low back pain that they make a point of reassuring patients with fresh cases that most acute back pain disappears within a few weeks — and that’s great, because it’s true. Unfortunately, many of those professionals simply postpone the alarm to the ninth week. That defeats the purpose of reassurance by undermining patient confidence long before the ninth week. It is not at all reassuring to be told that “most cases go away” if it’s closely followed by “but you’re screwed if it doesn’t!” Patients given these conflicting messages will start worrying about whether or not their pain will go away by the ninth week, with rapidly escalating concern if it doesn’t!

Consider a hypothetical patient: our crystal ball tells us that she will recover by week twelve, a somewhat slow recovery, but far from the nightmare of chronicity that a few patients face. Her doctor wisely tries to reassure her that most back pain goes away by the ninth week, but he carelessly tries to emphasize his point by saying that only “serious cases” last longer, so they won’t discuss her surgical options until then. This physician used best practices while simultaneously setting this patient up for severe anxiety.[143] How is she going to feel in week eight with symptoms that are still prominent? She doesn’t have the crystal ball. She has no idea that she’s actually going to be just fine very soon. All she knows is that her problem is starting to look serious and surgery will be on the table as an option soon — yikes! Such anxiety could very well change the course of the problem.

Such anxiety perpetuates some cases that would otherwise fade away not long after the nine-week “deadline.” And it’s such a shame, because there’s not much more cause for alarm at nine weeks than there is at three weeks. The longer pain lasts, the more likely it is to last even longer: that is a sad truth. But it doesn’t mean that long-term pain is inevitable any more than a slow-healing fracture is never going to heal. Some people just recover more slowly! There is no magic line in the ninth week separating easy cases from difficult ones. In fact, you can have low back pain for three, six, or nine months — technically a “chronic” case — and more than 30% of those patients will still recover by one year. And although there’s no data to support it, it is my experience that chronic low back pain patients often recover at virtually any stage of the problem, even after suffering for many years.

These might seem like subtleties, except that we know that low back pain care is already rife with alarmism, and it’s a major problem because patient confidence and expectations are a critical part of rehabilitation. Low back pain patients are in real need of justified confidence, and lots of it, to combat the strong anxiety that is so common. Thankfully, we have good and recent scientific evidence that many patients recover from chronic low back pain — a strong basis for confidence, and some of the most encouraging research I’ve come across in low back pain science in a long time.

This evidence was published in 2009 in the British Medical Journal. Australian researchers concluded that the “prognosis is moderately optimistic for patients with chronic low back pain.”[144] This evidence is the first of its kind, a rarity in low back pain research, a field where almost everything has been studied to death — and it contradicts the common fear that low back pain that lasts longer than six to nine weeks will become a long-term chronic problem.

“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.” Their research differs from past studies of chronic low back pain, which tended to focus on patients who already had 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 likely to carry right on feeling rotten. But what if you study fairly new cases of chronic low back pain? How many of them fade away, and how many of them really drag on? Isn’t that what any low back pain patient really wants to know during their first few months of suffering?

So these researchers looked at patients who had not 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 pretty good number.

So, what’s the Australian connection?  Did the people who didn’t recover have anything in common? This 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 unwell.

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

And my favourite correlation: 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!

Yes, of course, that still leaves two-thirds of patients who continue to suffer past the year-mark — and that’s an unfortunate number. However, this is chronic low back pain we’re talking about here! The surprising and promising thing is that so many patients — almost 40% — actually do get better 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.

2.11

A trigger point checklist: does this sound like you?

There are several classic characteristic signs and symptoms of back pain that is caused mainly by muscle, or back pain with another origin that has come to be dominated by trigger points over time. 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 this simple. Check all that apply — if you have more than half of these, and no other apparent explanation for your pain, you probably have some trigger points.

- You have sore spots in muscles.

- Your pain usually occurs in specific areas of your body.

- The problem feels more like muscles than joints.

The checkboxes are for your visual convenience only. There’s no form here to “submit.”

- 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.

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 are probably not an important factor in your case. More than two thirds, and you can safely bet that trigger points are either the whole problem or a big part of it.

- 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 will be more sensitive to pressure. That is, it will hurt to 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 severeal locations.)

- Feels like muscle! Pain is a difficult sensation to interpret, but trigger points do often feel like a muscle problem. Many small clues can contribute to this subjective 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’s dull. If you’re pain is mostly aching, and nagging, with a strong “stiffness” component — and there are no obvious signs of 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 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.”[145] 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 more-or-less healed, and any continuing pain that you have is much 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 the frying pan, into the fire” phenomenon, discussed in another section and in a separate article, Into the Fire: Trigger point pain as a major injury complication, and how I finally “miraculously” healed from a serious and stubborn shoulder injury by untying the muscle knots.

- You crave stretch. You crave it because trigger points make you feel stiff and stuck. (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, it may feel difficult or even as though it amplifies the symptoms — like you are “pulling on the pain” — but it probably also feels somewhat relieving, offering a good pain, like scratching an itch. Similarly, muscle pain tends to make people generally squirmy: not only a craving for stretch, but for movement in general.

- … but stretch usually fails. Although it seems like a good idea, stretching trigger points usually fails to actually do much good. It’s not a very good treatment. Sometimes it might provide more relief, but most MPS sufferers will be underwhelmed by the benefits 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 biomechanically difficult to stretch,[146] 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,[147] 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, aching. Although nearly any quality of pain is possible, and particularly flared up triggers can get more focal and intense and toothachey, most trigger point pain most of the time is a dull ache. There aren’t many other unclear causes of pain that ache. For instance, arthritis usually has an aching quality, but it’s obviously joint pain.

- Similar pain in areas of the body. 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). Other kinds of problems would 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 points usually afflict just one or two regions of the body at a time (but sometimes more, of course).

- 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 stand out nicely.[148]

- Anti-inflammatories don’t help much. Since there is little or no inflammation per se involved in MPS, anti-inflammatories like Aspirin or ibuprofen (Motrin, Advil, etc) often have little or no effect. If they do help, that suggests the pain has a more “traditional” inflammatory nature (associated with tissue damage, such 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 benefits from other drugs are not very informative.[149]

- Wandering pain. One of the clearest signs 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. On the other hand, injury pain is much more predictable, and particularly tends to stay put. 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 exactly 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 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 an extremely common pattern with low back pain patients that their pain flips to the other side following some kind (any kind) of treatment.[150]

- You have the back-pain personality. MPS may be associated with a personality type. A good one, too: if you have MPS, there’s a good chance that you are a conscientious, caretaking workaholic. You are not necessarily “Type A”, because you try to have a life as well as earn a living, so you play as hard as you work — maybe even harder. But you are super-responsible: you strive to take good care of yourself as well as the people you care about, to do your job as well as possible without letting it take over, and to keep your home reasonably clean. You worry about stuff, you don’t sleep as much or as well as you’d like, and you feel bad when you can’t fit in all that good stuff. Your friends think of you as intense and responsible. And you have fits of howling back pain. Is this you?[151]

- 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).[152]

- A “numb” leg. Trigger points cause weakness in the affected muscles and a kind of numbness often mistaken for a nerve pinch — sciatica. But the 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 covered in much more detail below.

- Heat helps. Hot showers and baths and other forms of heating, even just warm weather, are almost always helpful. Many kinds of chronic pain are helped by heat,[153] but not all, and fibromyalgia pain is the most interesting exception: it is usually worsened by hot weather,[154] but MPS patients almost always prefer it. This is one of the clearest differences between these otherwise extremely similar conditions. Score a point for a trigger point diagnosis if you like to be toasty.

- Symptoms are aggravated by muscular effort and overexertion. Assuming that trigger points are some kind of muscle dysfunction, it follows that they will flare up when we demand more function from the muscle, and this is commonly reported. Muscles can be exhausted either by an obviously intense exercise like shoveling, or by less obvious postural strain — holding awkward postures. If you predictably have flare-ups of pain in situations where muscles are working, then muscle is probably the problem. Back muscles are particularly prone to postural strains — sustained positions like stooping over while gardening or cleaning a bathtub.

- 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 (arthritis and the progression of many subtle sources of inflammation that accumulate over the years, known as “inflammaging”). But relatively widespread stiffness in a younger person with no other known health issues, trigger points are a more plausible suspect.

2.12

3 Lessons From an Acute Back Trauma: Joint popping, muscle dominance, and the mind game

In early 2010, my wife had a motor vehicle accident while travelling alone in Asia. One of her vertebrae was badly crushed, plus she received a half dozen other fractures. Like all health professionals who face personal medical crises, I soon discovered that taking care of a spouse is nothing like taking care of a patient! Easier in some ways, much harder in others, it is a tornado of continuing education: hundreds of concepts that were only abstract professional knowledge are suddenly embodied in the pain of a loved one and pushed into my brain with an emotional battering ram.

All good health professionals are emotionally sensitive to their patients’ suffering … but not like this!

Here are three lessons about injury (especially low back pain) and recovery that I drew from the experience. None were particularly surprising to me. They were not so much learned as reinforced:

1 — Joints pop more after trauma! I’ve said this to patients for years without really being sure of it, but now I’ve witnessed it dramatically. Kim’s back barely popped before, but it now pops so much that she struggles to accept this as normal. It seems extreme.

2 — Muscle pain is king. Kim crushed one vertebra, snapped a tip off another, and had steel braces screwed into the bone above and below … but that’s not what hurt. She has had some back pain ever since, sure. But muscle pain in the area — especially the hip, many centimetres from the fractures — has consistently been by far the most significant source of symptoms. Again, muscle tends to get clinically underestimated!

3 — And neurology is queen. The evidence is overwhelming that what you think about your pain is a critical factor in your experience and recovery. Countless times I have observed Kim react to similar stimuli in different ways, depending on the mental context. Nervousness makes things hurt more! And confidence makes them hurt less. And the amount of physical damage correlates very poorly with chronic pain.

Most people reading this book have not had a serious injury, but instead have that exasperating kind of back pain that has no obvious origin. Nevertheless, we can learn from those who have been injured. How often does injury lead to chronic pain? According to one study, about 54% are still hurting at six months.[155] And what’s the difference between those who do and don’t? That’s murkier, but the study showed long-term pain was more likely:

1. if pain was acute at the beginning (independently of injury severity),

2. if patients felt responsible for the injury,

3. and if they were pessimistic or emotionally traumatized.

“Psychosocial factors strongly predicted persistent pain, pain-related work disability, and pain severity,” the researchers concluded, and noted that “many of these factors are potentially modifiable and should alert the clinician about the need for interventions in order to prevent the development of pain chronicity.”

Moving from the science back to the personal: my wife had a lot of luck and pluck. She recovered amazingly well. As I write this, she is travelling alone once again, in India this time, only a little less daring than she used to be.

2.13

“Out of nowhere”: seemingly random episodes of low back pain

“I just can’t figure out what sets it off!” Seemingly random flare-ups are one of the signature symptoms of low back pain, and of any pain problem dominated by muscle. This time-bomb effect is probably due to pre-existing painless vulnerability which can be pushed over into a more serious pain problem quite easily.

Trigger points exist in two states: latent and active. Latent trigger points are present but they don’t hurt unless poked. An active trigger point hurts no matter what. Latent trigger points can lurk unsuspected for weeks, months, or years, finally becoming active and painful with minor provocation — the straw that broke the camel’s back, the tip of the iceberg, pick your metaphor. 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.

A specific, common example of “outta nowhere” back pain is morning pain: waking up with it. This is discussed a bit in the sleeping position section.

This characteristic of trigger points powerfully explains the erratic nature of many cases of episodic back pain. John Sarno writes: “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.”

The “outta nowhere” phenomenon is typical of all chronic pain problems dominated by muscle, but it happens much more dramatically with low back pain. Low back pain seems to occur in much sharper spikes of intensity. (Neck pain does too, but not as dramatically.) Low back pain probably comes in sudden blasts because it’s scary; the fear factor is much more pronounced with low back pain than any other common area of pain.

Also, the intensity and rapid escalation may be due to the mass of the musculature involved. Not only is back pain alarming, but there is simply more muscle to hurt — a more dramatic vicious cycle of alarm, pain, and more alarm, and more pain.

2.14

Summary so far …

Let’s take a moment to review …

- The deepest roots of low back pain are in stress, which often does not express itself as nervous tension or anxiety, but rather as tissue dysfunction.

- Muscular tissue dysfunction may be a symptom of stress, both causing pain directly and potentially exacerbating existing issues in the spine, or making us vulnerable to new ones.

- However, injury and mechanical problems are themselves rare and probably do not cause much pain (or chronic pain) on their own.

It is the softer tissues that are more fragile and responsive to the mind than we guess. We hide our unacceptable emotions in them, safely disguised from ourselves and from others — and when the pain begins, people often receive a frightening diagnosis and ineffective treatment. A minor injury which might have healed well becomes a crisis instead … and then a series of crises over the years. Without good information, the fear, pain, and immobility can drive episodes of acute back pain for a lifetime.

Fortunately, there’s great information about breaking that cycle right here in this tutorial!

Message from the Management…

Enjoying the tutorial so far? I hope so. Here are some quick tips and reminders about your tutorial:

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2.15

Other possible causes of low back pain, or “No, my low back pain is really serious …”

I am often amazed to find that people can be so emotionally invested in their back pain that they are reluctant to give it up.[156] Or they are reluctant to believe that the pain is mainly caused by stress and muscle, both of which people tend to underestimate. So they tell me, “No, my back pain is definitely caused by a disc herniation,” or “That may be true for a lot of people, but I know that I just have bad arthritis.” People seem to almost want to believe that their back pain is “serious.”

For instance, those who’ve had surgery are particularly likely to use it as evidence that their back pain is serious — even when the surgery did not solve the problem! The seriousness of surgery leads people to believe in the seriousness of the cause of their back pain, and it takes a great deal of evidence to convince these patients that even a successful surgery does not prove a structural cause. Surgery can relieve pain without fixing anything, a complicated phenomenon that is discussed thoroughly below.

So the stress-muscle theory is a bit of a tough sell — and toughest of all to people who need it the most. All of this resistance and denial tends to suggest a diagnosis of low back muscle pain, of course. Basically, the more a patient protests the diagnosis, the more likely it is to be true![157]

It’s all the tougher to sell because, of course, this idea about muscle coexists and competes with dozens of other theories and possible causes of low back pain. 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 can not 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. So you may have signs of other back problems. Remember, what makes muscle such an important 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! So the presence of other problems, if they are there at all, simply means that it’s even more important to treat your trigger points. Trigger points are the most treatable part of the equation, because even “serious” structural problems may improve when the trigger point pain is eliminated or reduced.

So this isn’t just a matter of a going through a checklist of diagnoses that are “wrong, wrong, wrong, and also wrong,” but more a matter of putting them in perspective.

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 throw the baby out with the bath water.

As I’ve acknowledged, structural problems and real injuries in the back can happen, and you should still understand something about them. So, hopefully they are in perspective now and it’s safer to talk about some of them. 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 causes of low back pain, covering all kinds of theories: the completely bogus, the entirely legitimate (but often exaggerated), and the half-right.

2.16

Could it be muscle strain? The muscle strain myth

You have a muscle strain only if you tried to lift a car and then fell to the ground screaming in agony. Or something similar to that.

Although surprisingly rare — I’ve seen only a handful of cases in the last decade of working with low back pain — of course some people really do tear their back muscles. But it’s a myth that you can do this to yourself without knowing how. A strain is not a subtle injury! You can’t really miss a muscle strain. 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 bewildered when people are married to a theory of muscle strain, but say things like, “I’m not sure when I did it, though.” That’s like saying, “I’m not sure when I sprained my ankle,” or even “I’m not sure when I stubbed my toe.”

You cannot sprain ligaments or strain muscle without having a Very Bad Day. A true back muscle strain will flatten you, immediately, with absolutely no doubt about the moment that it occurred.

Muscle strain can occur only in the context of a massive muscular effort, and it causes severe pain immediately, almost instantly. (A mild strain may take a minute or two to become obvious.) Torn muscle will be red, hot, and swollen and possibly even bruised. Every slight contraction of the muscle will hurt, even just tensing the back muscles. A severe enough strain will cause some actual deformity — an obviously deformed (ripped) patch of muscle, very 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 muscle tears, and then you may have symptoms of two quite different tissue problems.

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.

2.17

From the frying pan of injury pain to the fire of trigger point pain

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 caused by trigger points can increase rapidly, even becoming 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, serious, and 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 feared out of proportion to their seriousness. (And it’s also a factor in serious injuries, of course.) Chronic symptoms following these injuries are almost always interpreted by the victim as a sign of the “seriousness” of the original injury, rather than as a minor (but chronic!) complication.

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 are. The “into the fire” problem is described in detail in the trigger points tutorial, and in a free article:

Into the Fire Trigger point pain as a major injury complication, and how I finally “miraculously” healed from a serious and stubborn shoulder injury by untying the muscle knots       ~ 2,750 words

2.18

Could it be a vicious cycle of pain-spasm-pain?

A popular idea is that muscles go into spasm after an injury to “protect” the joint. 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, it’s an obsolete oversimplification. Although the reactions of muscles do indeed complicate recovery from injury, as described above, it’s not due to a vicious cycle of protective muscle spasming. And although there are other vicious cycles involved in back pain, this isn’t one of them.

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.[158][159] 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 pretty stupid, actually — it would almost certainly deepen the wound. In fact, the severe pain of the strain strongly inhibits contraction of the damaged muscle.

If gross spasm was a player in low back pain, it would presumably make it relatively easy for experienced massage therapists to feel it — but evidence discussed earlier (see Maigne et al) showed that detection accuracy is quite poor, even when the therapists are just trying to identify which side is most painful.[160]

Of course, many professionals still believe in pain-spasm-pain, even though it’s obsolete, because it takes decades for dead ideas to disappear from health care. Odds are still excellent 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 fits in perfectly with the deep, irrational fear 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.

Certainly something like the old pain-spasm-pain vicious cycle is actually going on. Muscles do become “tight” and painful in the aftermath of injury. If they aren’t in “spasm,” what is going on? That question to be answered below.

2.19

Could low back pain be an overuse injury?

It could be an overuse or repetitive strain injury, but it probably isn’t — not in the usual sense, anyway. In general, back pain is definitely not thought of as an overuse injury. And yet there is some overlap and some sense in looking at certain cases of low back pain as if they were overuse injuries.

An overuse injury has a clear and specific meaning in sports medicine: the relatively gradual wearing out of a body part, instead of a catastrophic failure. Most involve a tendon becoming irritated by relentless, repetitive activity:

- Achilles tendinitis, tennis elbow, plantar fasciitis, and iliotibial band syndrome are all classic examples.

- Another familiar overuse injury is carpal tunnel syndrome, in which a wrist nerve gets pinched by swelling around inflamed tendons.

- Even bone can succumb to slow strain: stress fractures are the obvious example of that, and many cases of runners’ knee are basically the deep ache of a weary, irritated kneecap bone.

Nearly all overuse injuries occur in one of these predictable weak spots in human anatomy — and rarely anywhere else. 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. But the back is not vulnerable to this kind of failure, in much the same way that car axles don’t fail — they aren’t the car’s weak point. There are no structures in the low back particularly vulnerable to failure with 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. If anything fails, 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: contrary to expert assumptions for decades, the lumbar intervertebral discs actually adapt well to the forces involved in running, even at volumes greater than 50km/week — “overuse” by many people’s standards. They get fatter and juicier! There is a sweet spot, but it’s in the pacing: regardless of distance, the discs adapt best to a moderate speed, a just-right amount of impact found in slow running and fast walking.[161]

Overuse injuries are caused by obvious physical stresses. For instance, tennis elbow tends to crop up after playing a bunch of tennis, and it is painful to hit a ball again until it calms down. That situation does not involve much clinical confusion. But back pain is rarely so straightforward, particularly in recovery. Indeed, overuse injuries and back pain are basically at opposite ends of a spectrum, straightforward on one end and freakishly complex on the other. For instance, overuse injuries usually respond quite well to rest … for reasons as clear as their cause. If back pain were simply a matter of short term wear and tear, then rest would work marvelously. And yet rest is notoriously ineffective for back pain (as you will read about below).

So you can see why low back pain doesn’t get defined as an overuse injury.

And yet …

In some ways, in some cases, low back pain acts very much like an overuse injury. Most notably, it often begins like one: “I did something for a long time until my back hurt,” much like playing tennis leads to tennis elbow. Consider the case of 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. Cases like these are common and seem to be a great deal like overuse injuries in overall character.

Such cases may well involve some genuinely over-exerted back anatomy that is a bit inflamed and needs a rest. “Bed rest” is much maligned in low back pain science as a useless, discredited treatment — but who says you have to lie in bed like an invalid to give an exhausted back a break? For the gardener, pressing “pause” on the gardening may bring relief. For the nurse, a holiday from the hospital is probably needed to give the back a breather. Total bed rest would probably be a mistake for several reasons, but a period of simply avoiding whatever activity brought on the trouble is just sensible. (I will have more to say about resting in the resting section.)

But even in examples like these, it’s doubtful that inflammation is the main trouble, and possibly not trouble at all, for the simple reason that backs are extremely tough and flexible and it would be really difficult to cause any serious inflammation without doing something so absurdly, obviously, stupidly stressful that there wouldn’t be any debating about the cause or any need to have this conversation.

Once again, it’s more likely that muscle is the tissue with the issue. Most of the activities that seem to be a problem are the ones where back strength and endurance are required — activities that exhaust musculature. When muscle is pushed to its limits, you get a reaction that is only kinda, sorta like an overuse injury — a painful response to a lot of use, yes, but the symptoms otherwise have little in common with, say, a tendinitis.

So for the low back pain patient with a back-straining job or hobby, it’s probably best not to think of the problem as an overuse injury. Although it is possible that there could be some inflammation, it’s likely not much, and it is probably overshadowed by many other much more significant factors — such as exhausted, cranky musculature.

2.20

Could it be a herniated disc?

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

Intervertebral disc anatomy:    Spinal “discs” are soft, cushion-like pads of connective tissue, similar in design to a jelly doughnut, which separate the hard bones of your spine. Disc herniation is the bulging or rupture of these cushions.

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 back pain.

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 herniated disc bulges far enough 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 over your nerve roots is extremely unpleasant.

In the very worst cases of disc herniation, the bulging disc pinches the entire tail end of the spinal column, causing extremely alarming symptoms such as incontinence. Such cases are medical emergencies, and no one is likely to mistake them for anything else.

The most important thing for patients to understand about disc herniations is that they clearly have the capacity to heal. If you do clearly have a disc herniation, it should change surprisingly little about your approach to the problem. The real danger is not 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.

2.21

Facet joint syndrome and MIDs

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.

A MID story:  In one of the appendices to this tutorial, I tell the story of a woman with back pain that starts with a minor intervertebral derangement. If you suspect that your low back pain might have started this way, make sure you read that story.

This is one example of what we call minor intervertebral derangement (MID) — a slight, uncomfortable failure of facet joint mechanics.[162][163] 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!

2.22

Diagnostic numbing of facet joints

2017 — Major 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.

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 a specific anatomical structures with clear “edges,” much clearer than other tissues like muscle,[164] 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

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.[165] 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.[166] The evidence is similar for the thoracic[167] and lumbar[168] 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.[169] 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.

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.

2.23

Is there such a thing as a “subluxation”? Can your back be “out”?

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 — rotated specifically, which is interesting.

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, 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 a 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.[170]

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?

•

There can certainly be something wrong with your spinal joints — there are a few possibilities — but “subluxation” and spinal joints being “out” are not defined clearly enough to be useful, and are probably 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. Some chiropractors attribute great importance to subluxation. Most believe that subluxations cause neck and back pain, and — significantly — many also believe that they 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, actually 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:

Does Spinal Manipulation Work? Spinal manipulation, adjustment, and popping of the spinal joints and the subluxation theory of disease, back pain and neck pain       ~ 14,000 words

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.”[171]

2.24

Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves

2017 — Minor update: Added discussion of orthotics to treat leg length differences for back pain.

2017 — New subsection: Added content inspired by decades-old evidence of reduced spinal degeneration in “primitive” cultures where squatting is common. Some light editing of everything else in the chapter.

There are two broad categories of mechanical theories of low back pain: those that focus on degenerative changes and deformity, and those that focus on alignment, straightness, and posture. The “short leg” theory is the all-time classic example — and the most wrong common ideas about back pain. I have heard statements like “My last therapist told me I have a short leg” countless times over the years.

The therapist who saw leg length differences where there were none.  In 1999, I did an internship with an RMT here in Vancouver; I will call him “John.” John had been an instructor at the massage therapy college here for many years, and was popular and respected by many of my colleagues. Indeed, most of his clients were therapists.

On my first day in John’s office, he demonstrated a leg-length difference detection and correction in a patient, with great earnestness. I couldn’t see a difference before, and I couldn’t see a difference after. The only time I ever did see a patient in John’s office with an apparent leg length difference, I could still detect it after his “treatment” — despite John’s claim that he had “corrected” it. John was seeing what he wanted to see.

Usually the short leg is either trivial, less than a centimetre, or entirely imaginary. It was a routine professional experience for me 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 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.[172] Ruh roh!)

It’s all a moot point for low back pain, because a 1984 study published in English medical journal Lancet established clearly that leg length differences do not cause back pain.[173] 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.[174]

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.[175] The only studies with positive results have serious flaws.[176] (Orthotics don’t even prevent the lower limb injuries they are most often prescribed for.)[177]

The leg-length theory of back pain is representative of a wide array 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.

The lordotic curve is the curve of the low back. There’s a wide range of what’s normal. Lordosis refers to a 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 leg length differences. 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

There’s almost certainly a kernel of truth in the concerns 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 — show that there’s more signs of strain on the lumbar vertebrae.[178] 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.

Almost anyone who demonizes lordosis and hectors back pain patients to straighten up also paradoxically demonizes office chairs… and yet the conventional workstation posture actually eliminates lordosis almost as much as the “paleo” squatting posture that they romanticize. It’s well-established that sitting in chairs is not a back pain risk factor at all. This is an amusingly major inconsistency in the anti-curvature camp’s beliefs.

But even if “civilized” folks who stand more than “primitive” people 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.[179][180][181][182] Whatever weak correlation might exist could easily just be a postural response to pain, rather than the other way around.[183] This data torpedoes a number of back pain cure empires.

However, we will exploit pregnant women to make the point 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,[184] 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.[185]

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 more 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.[186]

2.25

Do you really need to lose some weight?

One of the most common, simple ideas in low back pain care is that extra weight is the problem. Do you need to lose some weight? Does it hurt to be heavy?

Let’s address this quickly and easily while the pregnancy stuff is fresh in your mind, because there’s an obvious connection. Pregnancy is a kind of “temporary obesity” — sorry, ladies, it’s an unkind phrasing, but quite factual — 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 back pain free. Lots of skinny people are also 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, actually. In 2010, Wright et al found that “obese twins were more likely to report low back pain.”[187] That may seem simple on the surface, but there are many variables involved. For instance, several other pain problems were also more likely: “migraine headaches, fibromyalgia, abdominal pain, and chronic widespread pain.” They found that weight was associated with more pain in general, not low back pain specifically, as you’d expect if the problem were simply due to compression of the spine.

Clearly the typical assumption about weight is not a safe one, and indeed the apparent connection between weight and pain weakened when the data were adjusted for common denominators like depression (a strongly confirmed risk factor for low back pain). In other words, if you factored out the depressed cases, the remaining subjects were not all that likely to have back pain. Given such complexity, the researchers made it clear that more and different research is needed to figure out what, exactly, is causing what.

No kidding!

An 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, 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.

2.26

Is it core weakness?

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!)

Wonder Core ad 0:29

Laughter is the best core workout.

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. 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 passage[188]). The word “core” seems to suggest something fundamental, foundational — it has a confidence-inspiring connotation. The belief in the power of core power is 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.

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 with perfectly good core strength, and lots of patients who’ve never had low back pain and yet they have never done a sit-up 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. The entire core strength fad is much ado about not much.

My experience is validated by the science to date. In late 2008, Physical Therapy published a review of all research on “motor control exercises,”[189] 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-do!

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 coordination[190][191] — and an impaired sense of touch,[192] 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).

2.27

Is it all in your feet? Foot-o-centric low back pain theories

High heels, flat feet, and bad shoes are all semi-regular scapegoats for low back pain. You can safely ignore them all with the same basic logic that we’ve used on several other theories discussed so far. These are probably a minor factors, yes. But a critical factor? You know the answer by now, but here’s an interesting recent example from high heel science.

A carefully done 2010 study showed that the body adapts effectively and minimally to high heels, producing similar functional results.[193] 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 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.”

2.28

Your problem is that you’re having “too much fun”

This topic is 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’s like the old joke:

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

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

Except that with low back pain, all too often this is translated into an ominous, hope-suffocating recommendation to avoid doing something you love:

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

“Well, then don’t play golf!”

In their ignorance of back pain and their conviction that backs are fragile, many health care professionals will treat your favourite activities — jogging, vigorous sports, golf, tennis, et cetera — as if they are a doomed way of life for you, so inevitably aggravating to your back pain that it is a foregone conclusion that you’ll have to give them up.

The weird part: this attitude can go so far 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 permanently quit a favourite activity. While a break is probably appropriate in many cases, it is almost never ultimately necessary — or wise — to actually give up your fun forever. In most cases, fun is a part of the cure … not the cause!

2.29

Could you have a “pinched” nerve? The nerve pinch myth

The importance of nerve pain in low back pain is exaggerated. People are so afraid of their nerves and of nerve pain that this important topic deserves particularly thorough treatment. A couple more minutes’ reading will ease most fears you have about mild and moderate nerve problems. Nerves can be injured, of course — and I’ll address genuine nerve impingement in the next section — but many of the times that people think their nerves have been injured, they really haven’t been.

I saw this full-page advertisement in National Geographic Magazine:

“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! For the reasons discussed above, the clinical reality is that the pain of a pinched nerve in the back is less common than nearly all patients and most doctors believe[194] — plenty of so-called neuropathy is probably caused by myofascial pain syndrome.

Nerves have a mystique

Nerves make people nervous! So to speak. The whole idea of nerves gets people anxious. Could it be a nerve? people ask. 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 is deeply embedded in the public consciousness, thanks to decades of excessive medical emphasis on the idea. Chiropractors especially have promoted this kind of thinking[195][196] to the point where many people think they can hardly get out of bed in the morning without pinching a nerve root.

I think the kind of advertisement with the stinging ants you see above greatly aggravates our society’s general anxiety about nerves. Pfizer and other pharmaceutical companies spend about a gazillion dollars on marketing that can create more worry about nerve pain in a year than I can counteract in an entire lifetime of low-budget public education! Bummer.

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!

And yet it’s amazingly difficult to actually pinch most nerves in the back. 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.[197] If you stretch or compress the spine, the holes do change size a little — as much as 70–130% in the looser neck joints,[198] a little less in the low back.[199] But, even at their most compressed, there’s still plenty of room.

ZOOM

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.

There’s so much space for nerve roots that even dislocations routinely fail to cause impingement.[200] Once again, I invoke the example of a patient 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.

I once helped with a young woman who had “sciatica” — the mother of all nerve pinches.

Allegedly, either her sciatic nerve or a lumbar nerve root was being pinched and sending hot zaps of pain down her leg. She came to me with this diagnosis already in place. 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 a nerve impingement problem. On the face of it, it did seem likely that something was being pinched.

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

I quizzed her very carefully about the quality of her pain. She assured me it was “zappy” and “electrical,” definitely “sharp” … just as you would expect of nerve pain. Yet something didn’t seem quite right. I couldn’t shake the impression that she was interpreting an intense non-neurological pain as a “zappy” pain simply due to her strong belief that she had a nerve problem. When you think a pain is nervy, you’re much more likely to interpret, feel, and describe it in nervy terms.[201]

So I did some experimenting, and clinched the case:

This young woman’s “nerve” pain could be perfectly reproduced by poking 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. This virtually eliminates a diagnosis of sciatic nerve impingement.[202]

In spite of spending most of my career trying to explain that this kind of thing is extremely common, I was actually surprised. The symptoms really did seem awfully neurological to me at first. Yet the evidence was hard to argue with, and — in retrospect — I realized that I had been fooled by “nerve anxiety” myself. In fact, her symptoms were strongly consistent with a diagnosis of myofascial pain syndrome (muscle knots). The only thing about her case the least bit unusual is that her muscle knots produced referred pain even more similar to nerve pain than usual, and even that may have been a by-product of my earlier leading questions (She was led into using terms like “electrical” to describe something she might have described in a less “nervy” way if she’d been given the proper chance).

Muscle knots are always doing this — fooling patients and professionals alike. Likely more common than nerve problems, and often more painful, muscle knots nevertheless get upstaged and misdiagnosed. Do you feel burning pain in your feet? Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you may have muscle knots!

Comparison of Nerve Pain and Trigger Point Pain

Nerve Pain

Trigger Point Pain

often causes tingling and pins and needles

almost never causes pins and needles

electrical, zappy, hot, burning

deep, aching, stabbing

often causes true numbness

may cause a “dead” or “heavy” feeling, but you will still be able to feel light touch on the skin

very specific pattern/locations

sometimes quite variable

injured nerves tend to produce continuous symptoms, or symptoms that occur predictably in response to a certain movement or position

trigger point pain, while it certainly can respond to position and movement, is usually more variable and unpredictable

only a few nerves in the body are commonly hurt

although more common in certain areas, trigger point pain also routinely occurs everywhere else

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

And yet, nerves do get pinched …

2.30

The role of true nerve problems in low back pain

May — Science 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.

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

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. Slightly more than one in ten people in the general population, not just back pain patients, have a pinched nerve root that can be confirmed electrodiagnostically, after all (that figure is from Braddom et al again). That may be lower a number than people expect, but pinched nerve roots are not exactly rare either.

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.[203] Back pain of this type is call “Bertolotti’s syndrome.” Specifically, nerve root compression occurs in about 13% of people with a transitional vertebra, and about 70% of those are symptomatic.[204] This is a pitch perfect example of how structural issues can certainly still be a source of trouble…even if their importance is generally exaggerated. And indeed there is also evidence that this problem is not much more common in people with pain, maybe even no more common at all.[205] I think probably it’s all true: it does cause some trouble, but not as much as expected and assumed.

More commonly, nerve tissue exiting the spine may be irritated by a bad disc herniation, and a variety of other relatively rare possibilities. The nerve roots that exit the spine divide into countless smaller peripheral nerves, supplying a stripe of skin that spirals around the body in elegant arcs called dermatome. Muscles supplied by nerves from that root are called the myotome. So every nerve root is responsible for a couple of “tomes,” and pain, weakness, numbness, and tingling within that distinctive “tome-zone” are strong indicators that somewhere a particular nerve root is being squeezed or irritated. Pain won’t necessarily “fill” the area precisely — they can be a bit fuzzy — so the pattern is not necessarily clear. Often patients only feel pain primarily in one section of the dermatome — for instance, they might have burning pain in the big toe, which lives in the dermatome for the bottom-most lumbar nerve root, L5.

Anonymous medical student does Halloween as a “dermatome” man — the stripes represent zones of skin innervated by nerves branching from a single nerve root.

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

Despite the fact that real nerve-pinch pain exists, once again muscle tissue health may be an important factor. Although trigger points usually imitate nerve pain, they may be the underlying cause of true nerve pain. A nerve passing through unhealthy muscle tissue may soon be just as unhealthy as the muscle tissue itself! And that may be why treating trigger points can alleviate “real nerve pain” — which it sometimes does.[206]

Fun fact: healthy nerves can be pinched firmly without causing pain, but oxygen-starved nerves are sensitive.[207][208][209][210] There’s also some good evidence that damage to nerve roots has more to do with blood supply than mechanical impingement of the nerves themselves.[211]

So perhaps nerves that wouldn’t have a care in the world if it weren’t for the sick muscle tissue around them may start to complain in a way that resembles a serious pinched-nerve problem.

Once again, in yet another way, we see 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, discusses patterns he has observed in private practice as a massage therapist. My experience has been identical …

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 disks 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

There are mechanisms by which nerves can become pathologically over-sensitive after an initial injury … including genetics, unfortunately. Stubborn cases of real nerve pain may be at least partially explained by your genes,[212] so patients should be wary of therapeutic wild goose chases looking for mechanical causes of pain. Although chronic pain could be do to on-going irritation of nervous tissue, it could also be entirely due to a malfunction of the sensory equipment itself. A fascinating, bleak possibility.

2.31

The strange case of scoliosis

Yes, of course, scoliosis is a real structural problem, and it probably can be a major factor in back pain. But it’s also usually not the devil that so many therapists suggest. It is particularly silly to attribute severe low back pain to a minor scoliosis, which is very common. Scoliosis can be anything from a gentle abnormal curvature, barely detectable, to a severe deformity.

Severe scoliosis, but minimal low back pain

Becca Harlos 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 Becca should be crippled — but in fact she is more fit & active than I am.

The picture above is of one of my clients, Becca Harlos. Becca’s spine began spiralling out of control when she was quite young, and by the time she was twelve it was rotated to about 70˚. Her internal organs were being slowly crushed, and radical surgical intervention was required to save her life.[213])

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 Becca’s back (and the steel rods!) as she grew. Today she is rotated to about 40˚.

A particularly severe scoliosis

This scoliotic spine shows just how extreme the disease can be. This would be approximately 90˚ rotation — the vertebrae are turned to face approximately at right angles to where they should be — only about 20% more than Becca’s spine at age 11. This spine was preserved by “      plastination” — a fascinating technique.

This is a much more dramatic case of scoliosis than most people have even heard of, let alone experienced. But Becca’s story clearly shows that scoliosis can be a serious disease. Far from simply being “a bit crooked,” it can involve a severe deformity of the spine that can cripple and kill, and every severe case of scoliosis needs to be treated surgically. No one understands the cause of it. It’s basically a complete mystery why spines do this — a great example of how primitive musculoskeletal health science still is. Even cancer is understood better!

What’s remarkable about Becca’s case is that she is not a back pain patient. Not really. Not the kind of low back pain patient that buys this tutorial.

Like the client described above with the drastic spondylolisthesis — one vertebrae practically falling off the one below it — Becca is incredibly fit and surprisingly pain-free, considering what is going on in her back. She does have some back pain, and occasionally it is even strong. But she is nevertheless unmistakably better off than most of my low back pain patients. Her pain is relatively minor. She plays ultimate and other vigorous sports — she does not feel or act fragile.[214] By contrast, most people with serious and stubborn low back pain — the target market for this document — are typically “flattened” by nasty episodes of pain, or suffer almost unbearable constant nagging pain, like a toothache in the back.

Imaginative scoliosis diagnosis:  As if it weren’t bad enough that therapists tend to exaggerate the importance of mild scoliosis in low back pain, they often diagnose scoliosis where there is none. Many, many times patients have said to me, “My other therapist told me I have scoliosis,” and yet I can only see it if I squint and use my imagination. Although technically any spiralling of the vertebrae is scoliotic, mild cases just don’t matter — “the incidence of significant scoliosis is low” write the authors of a large 1999 study of scoliosis screening.[215] 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.

And yet one of the most common bogus theories of low back pain that I hear is that it is caused by a minor scoliosis — by the kind of scoliosis that you can hardly see! Patients routinely report being told this by other therapists. Some therapists apparently automatically screen for scoliosis, and blame even the most subtle curvature for any back pain the patient has.

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

Shouldn’t they be completely crippled?

Unsurprisingly, just as scoliosis is unjustly blamed for back pain, 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.

2.32

Back pain and sneezing

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.”[216] 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).

2.33

Back mice (lipomas)

April — New section: No notes. Just a new section.

“Back mice” is a cute name for a very common thing: little fatty cysts that form in the low back.[217] 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 do not. 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 impingement[218]).

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

Not everyone agrees with that. There are case reports of back mice that seemed to be more tightly linked to chronic back pain.[219][220] It’s not clear why this would be, but I’ll keep an open mind. 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.[221]

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!

PART 3

SELF-TREATMENT OPTIONS

How to save yourself from low back pain, or at least avoid getting hurt or ripped off trying

Confidently understanding the nature of back pain is probably more than half the battle. For that reason, this tutorial has already devoted a great deal of time to explaining back pain and debunking incorrect or over-rated theories of back pain. For the same reason, this part of the book kicks off with a thorough discussion of the special problem of psychological stress from a few different angles, and the surprising power of informed confidence to resolve low back pain — even some severe, chronic cases. After that, it will continue with a long list of other treatment strategies.

Educated low back pain patients can often manage their own problem well enough. In all my years as a writer and massage therapist, I have never yet met a back pain patient who really had “tried everything,” though many have claimed that. The vast majority had only just begun the journey, and often beginning with the worst options. Once they get more serious and focused about self-treatment, many previously chronic cases improve substantially.

Managing your own back pain has three major components:

1. The “confidence cure.”

2. Self-massage and other self-treatment of myofascial trigger points.

3. Finding good therapeutic help along the way — and a good surgeon if these efforts fail.

Here are the most interesting or important self-treatment options for low back pain, pretty tightly summarized. The rest of the tutorial is devoted to reviewing these and several others in much greater detail. Many are unique to low back pain, and I will review those more thoroughly. Many other treatment or management approaches are applicable to nearly any chronic painful condition or overuse injury, and in those cases I will usually summarize and then link to another article on the site.

- Given the complex “head games” involved in most chronic low back pain, pursuing greater emotional health and maturity in a general way is a surprisingly worthwhile approach to rehabilitation. There are countless possible approaches to this, but — for readers willing to try something a little odd — I particularly recommend bioenergetic breathing: a form of deep breathing that can provoke a lot of self-reflection and body awareness rapidly.

- Yoga is an appealing form of semi-recreational exercise for many low back pain patients. At best, you might discover and create the capacity to do things you simply did not know that you could do, either before back pain or since. However, it’s probably not a very effective treatment for most people, and you definitely need to beware of injury and overzealous poses.

- Meditation is definitely not everyone’s cup of tea, but it is proven to be a modestly useful way of coping with any kind of chronic pain. It might be a little more useful for low back pain because of the strong mental and emotional factors in back pain.

- Medications are largely futile except for short-term symptom control, and do not work nearly as well as we’d hope. There are some particularly disappointing surprises about medications, like the fact that muscle relaxants don’t actually relax muscle! Voltaren Gel and comfrey cream are noteworthy for being a little more promising and particularly safe. Also, bizarrely, painkillers can actually cause pain — and so getting off certain pain meds may be helpful.

- Self-massage (for trigger points) is an experimental treatment approach, with only indirect or deeply flawed support from science, but it is well-justified by low cost and risks and high plausibility. Much of the self-treatment section of this book is devoted to several key aspects of it and several tips for working on the low back.

- Heat and ice are covered in detail below, of course, because nearly everyone tries them. Both are mildly useful, and both can provide good bang for buck, but in general the evidence favours heat. Ice can go badly in some cases, and neither ice nor heat will cure anything. At best, heat might play a non-trivial role in relieving trigger points.

- Avoiding whatever makes pain worse is a no-brainer rehabilitation tactic. Although it’s obvious in principle, people often neglect a coordinated approach to identifying and eliminating aggravating factors. Insomnia is the most common, pernicious, and unsuspected culprit. Insomniacs should make sleep repair a top priority.

- Simple rest is the most obvious way of avoiding positions, movements and activities that aggravate the pain. But the evidence is strong that too much rest is just as much a problem as too little. I recommend pursuing a “life in the Goldilocks zone.”

- Mobilization exercises — thorough, gentle repetitive movements of the back and hips — are a way of systematically exercising in the Goldilocks zone: getting as much stimulation and light exercise as possible without pissing off your back. I provide four specific examples of ideal low back mobilizations.

- Traction — pulling on the spine in various ways — is something a lot of patients crave. It’s a mixed bag, and it’s too uncertain and risky to pay for it. But if you can keep it cautious and cheap and do it yourself, it’s definitely worth a shot. I will explain how.

- Stretching is one of the most disappointing of all the classic self-treatment methods. You’ll be hard-pressed to find stories of people who cured their tough chronic back pain with stretching. Stretching is over-rated in general, and seems to be particularly unremarkable for back pain. On the other hand, it can be pleasant and certainly won’t hurt you if you don’t overdo it.

- Addressing postural strains is often an easy way to make life a little easier for your back. Decent, comfortable chairs are the major example, of course, but there’s more. Sleeping position is a particularly important one to consider.

3.1

So what’s the plan?

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.

There’s actually some good    science news coming in a couple sections. No, really!

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.[222] 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, robust evidence of absence:[223] “The average effects of treatments … are not much greater those of placebos.” 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.[224] And, yes, there is plenty of room for big treatment effects to show up[225] — 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 guesswork 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 about this book: that I do too much “debunking,” and not enough prescribing of specific, promising treatments. Although I get few refund requests — way below industry averages — most of the requests I do get are caused by this specific concern: Where is the road map to cure? The step-by-step action plan? The savvy exercise regimen that will make the pain stop?

These things don’t exist, as I warned in the introduction. In particular, prescribing a treatment “plan” in a book is simply out of the question, because every case is different, and what works for one person isn’t going to work for the next. I promise that I’m not holding out on you. But 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 (and least of all the tough ones I write books about).

No plan survives contact with the enemy.

~ Helmuth von Moltke the Elder

Most people reading this probably think it’s all quite reasonable, normal, and even ethical (and this section unnecessary). But for your amusement, imagine what I hear from a few customers: some rather unreasonable expectations! For instance, the customer that 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?

I promise to review the treatment options, not endorse them. The disappointing truth is that there are only a motley assortment of mostly underwhelming options with complex pros and cons. Some are better than others. But quite a few are dodgy, for obvious reasons: hope sells. And so there are just generally far fewer good 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.)

Nevertheless, 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. There is considerable value in learning about the more dubious treatments, and avoiding the expense and distraction. 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!

Negativity 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 be an enemy of massage, and — my favourite — “advanced negativity,” a discussion of how cynicism is baked into science in the form of the null hypothesis.

Why So “Negative”? Answering accusations of negativity, and my reasons and methods for debunking bad treatment options for pain and injury.       ~ 5,000 words

3.2

The confidence cure

Knowledge is in every country the surest basis of public happiness.

~ George Washington, 1790

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 even devote an entire short chapter below to why you don’t have to bother with yoga and meditation — unless you want to, of course.

How about massage?  Good idea! Massage is extremely effective at reducing anxiety and depression — which is nearly synonymous with “stress relief.” Another chapter is devoted to this.

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.

Some good news. Finally!

What I’m calling the “confidence cure” is a more specific version of what’s more formally known as “cognitive-behavioural therapy,” which is 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.[226] But there are many ways to think and act differently! Until 2013, nothing quite like my “confidence cure” had really be tested properly. I’m pleased to report that it passed it’s first proper test handily.[227] Statistically and clinically significant results for a back pain treatment? Pinch me![228]

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.[229] 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.[230]

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 claims 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 can 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, few people are willing or able to do enough yoga and meditation to solve these problems through mindfulness and spiritual growth!

A more practical solution, therefore, is knowledge, acceptance, and awareness of the true nature of low back pain itself. In other words, education.[231] 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.

Simple, but not easy

Skeptical? Can it really be that easy? Isn’t this “too good to be true”? Well, 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.[232] 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![233] 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.

3.3

What is the difference between a ‘confidence cure’ and a mere placebo?

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).[234] 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:[235] 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.[236] 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.

3.4

Stress relief and the tyranny of meditation and yoga

What can you do about stress other than going here? Not that there’s anything wrong with going here …

Meditation and yoga appeal to lot of people for a lot of reasons, and they do have many possible benefits if you get serious about them. For example, a diligent meditation practice can improve sleep quality, which in turn can help back pain. Insomnia is one of the sneakiest factors in persistent body pain of all kinds.

However, the reputation and popularity of yoga and meditation are almost oppressively immense, eclipsing other options in many people’s minds. People feel that they must try them to reduce stress and contribute to a healing process, and many people have trouble thinking of any other way of responding to pain and stress.[237] They actually feel guilty for not trying them or for not liking them. Tyranny! Yoga and meditation may have their uses, but no one should be feeling guilty about passing on them, and there are other options.

For those who like the idea of meditation and yoga, I will discuss them, and their potential, in another section later on.

If you’ve never been interested in yoga or meditation before or never really tried it, it may not be a great idea to try to take them up just because you’ve got a new pain problem. Someone with low back pain who already has experience with yoga and/or meditating might find it more useful.

As popular as yoga and meditation are in North America today, they are still not mainstream.[238] (Indeed, they are part of the “popularity myth” of alternative health care.[239]) Most of my massage clients over the years 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.

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 and mindfulness particularly exasperating. Many are allergic to the many bogus claims associated with it (like reprogramming your DNA? sheesh). Even if they can get past the flaky stuff and like the idea, they may still have a sort of personality conflict with the slow pace and calmness required. If so, the 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.”

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.

Another large group of people who aren’t suited to yoga and meditation: the ones who never liked the idea to begin with! You know who you are, and you’re not alone. Plenty of you suspect that “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 a healing process. In fact, one the biggest stresses in your life may be the loss of exercise, which was the only stress-management strategy you took seriously.

When I was a massage therapist, many of my clients clearly identified this exasperating catch-twenty-two: they noticed that stress aggravated their back pain (or perhaps even triggered it in the first place) … yet they had to reduce the back pain before they could exercise again to reduce the stress!

That’s frustrating. Stressful, even!

Plus, you could crush your cat. So be careful…

Pets Interrupting Yoga 2:47

Please consider the option of studying yoga and/or meditation. They really are worthwhile pursuits, and they definitely can reduce stress and back pain and offer you a host of other benefits. But rest assured that they are not the only options, nor even necessarily the best options. (And they are not even completely safe).

I think it is important for people to realize that movement and a bit of quiet time are what everyone needs to feel their best. Often yoga and meditation dogma gets in the way of just basic healthy lifestyle concepts.

— Byron Selorme, Shavasana Yoga Centre, Ontario

3.5

Another %[email protected]&*!! personal growth opportunity

This is the most straightforward alternative to yoga and meditation for general stress relief. Particularly 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

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 they 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 in Why Do We Get Sick?, and I get more thoroughly practical in Pain Relief from Personal Growth. You might also want to read Dr. Gabor Maté’s excellent book When the Body Says No. There is also one extremely useful personal growth tool that you can start leveraging right away: The Art of Bioenergetic Breathing. However, the best thing you can do is just go straight to Haven.

With my apologies, this annoying message from the management is repeated 3 times in the book to discourage piracy. Online access to this book was purchased by Vladimir Stoyanov. If you did not personally borrow this book from V. Stoyanov, it is pirated! Please purchase your own copy. Thank you for supporting a small business and low-DRM publishing. what’s that? ~ Paul Ingraham, Publisher

3.6

Yoga and meditation are still an option, of course

Although I hope that I have made it clear above that yoga and meditation are not for everyone, and that you shouldn’t feel guilty if you’re not inclined to do them, they are worthwhile activities for a variety of reasons. Yoga and meditation probably constitute at least mildly effective self-treatment of low back pain — and perhaps also an antidote for many of the life-out-of-balance issues that often seem to accompany low back pain.

Sometimes the goal of healing is to get to a point where you can actually think about doing a yoga class — but sometimes a yoga class is how you heal. Of course, nearly any kind of exercise can become a useful part of a rehabilitation program, but I have a specific reason for singling out yoga and meditation for low back pain: for non-athletes who might not otherwise be interested in rehabilitative exercise, yoga is an excellent way to explore body awareness and safely test your limits with a variety of new challenges. Also, I believe that a social environment is helpful to most healing processes: seriously, injury loves company!

And meditation, of course, is a mental exercise — although it may challenge your body. Sitting still meditation, in fact, can be really uncomfortable for back pain sufferers. Although you should be open-minded to the possibility that you can work through the discomfort of sitting still, you also should be realistic about where you are in the healing process: when you are still learning about your back and about meditation, it may not be practical to torture yourself by sitting on a cushion for half an hour in a meditation class! So don’t. Discuss the issue with the instructor and choose a reasonable alternative. Any good instructor should be quite comfortable with workarounds such as lying down or meditating in a chair instead of the floor.

But do they work? I know you’re dying to hear about the science!

Meditation is almost certainly a little bit effective, but not all that much … as we might expect. A 2005 study showed this fairly clearly.[240] It’s a little more surprising that yoga is about the same: underwhelming and “better than nothing,” but probably no better than anything else you might choose to do. The most promising study showed fairly dramatic benefits, but only compared yoga to nothing at all — an easy win, you might say.[241] Another pair of yoga studies in 2005[242] and 2011,[243] both by the same authors (particularly Karen Sherman and Daniel Cherkin), made a point of comparing yoga to other therapies — ordinary stretching classes, and exercise therapy — with results that seemed less than impressive. It’s worth describing these in a little more detail.

The 2011 experiment compared how back pain might be affected by:

- yoga classes

- normal stretching classes

- reading an educational booklet

And the same research did almost exactly the same thing in 2005, with essentially identical results, but instead of the normal stretching class they used:

- conventional therapeutic exercise classes

Both yoga and stretching seemed to be somewhat effective, but neither was any better than the other — which is a blow to yoga pride. I feel a bit disappointed in that outcome myself. I rather like yoga, personally, and it would suit me just fine if it could kick some regular stretching-class buttinsky in a fair fight. Alas, no — apparently they are well matched.

The research has been widely reported as “stretching and yoga work,” with a few writers wisely emphasizing that yoga was no better. However, there’s an entirely neglected angle: I haven’t seen anyone report that both stretching and yoga are equally damned with faint praise by this research, and — worse yet — even that modest praise could be an illusion due to a significant weakness in the design of the study.

The impact of yoga was modest: barely detectable. A 2.5-point difference on a subjective scale to 11 is weak sauce. Some people might even say that it’s too much hassle to go to a bunch of yoga classes (or stretching classes, or conventional exercise classes) for such a modest benefit. May as well just take in a few extra episodes of Big Bang Theory while nature takes its course! Yoga isn’t entirely risk-free, and classes take time and money.

More subtle still — this science stuff is hard — a sneaky “frustrebo” effect could well account for the apparent modest benefit here. Subjects frustrated by being stuck in the dreary reading group of the study, deprived of either a lovely stretching or yoga experience, may have reported a more negative experience (see the note for a little more detailed explanation of that[244]).

So where does that leave us? Despite the distinct lack of encouragement from science so far, there are many reasons why people may choose to do yoga that have nothing to do with whether or not it speeds along the average case of chronic low back pain. A good list of other benefits — that it’s just good exercise, has low risks and costs, plus the potential for certain types of yoga to be more effective in some cases, all keep yoga in the “worth a shot” category. And remember, the science isn’t completely negative — just less positive than we’d like.

Nevertheless, yoga is definitely not proven effective for low back pain by this new study. Other writers are mentioning the problems with the study’s design like an afterthought, while they (or their editors) put the “good” news in the headline, while the flaws and concerns are pushed below the fold, if they are mentioned at all. Not only is there a significant weakness in the study, but that weakness could make both yoga and stretching seem more effective than they really are. This isn’t something I can ignore.

More about why yoga and meditation might be useful anyway

I see low back pain as a disease of sensory stagnation, bored and neglected postural reflexes — a lack of variety of experience. Yoga is an excellent way to stimulate your body, to remind yourself of what is possible in a way that going for a run or playing squash can never do. Yoga is playful, experimental. It is as though it was invented by people who wanted to know, “So what can we do with human anatomy? What’s possible?”

This experimentation can be challenging, even frightening at times. But if you practice, it is inevitably confidence-building. Slowly but surely you both discover and create the capacity to do things you simply did not know that you could do, either before back pain or since. And confidence, as we’ve discussed, is a crucial component of recovery from back pain.

Yoga is also a wonderful, perfect storm of mobilizing, stretching, and breathing … all three of which can contribute to healing from back pain. I have written about these three extensively throughout PainScience.com, with flagship articles for each:

- Mobilize!

- The Art of Bioenergetic Breathing

- Stretching for Trigger Points

In (extreme) summary, mobilizing and stretching might together constitute a self-treatment cocktail for trigger points, which are the actual mechanism of so much otherwise mysterious low back pain. And breathing exercises, by leveraging the body’s one great consciously controllable physiological rhythm, provide people with excellent leverage for changing their state, for getting out of a sensory rut.

And of course yoga is also meditative by nature. Some meditation practice is usually incorporated into yoga instruction, and the time spent feeling your body is also meditative. And meditation is useful because, straightforwardly, it is the art of soothing the mind — of taming the wild “monkey mind” that is both the curse and the blessing of the human animal. We possess vast frontal lobes that give us extraordinary executive power over our consciousness and our lives, but also torment us with their busyness, their second guessing and dithering and worrying.

Meditation is simply about practicing new ways of using that mental capacity to calm us down, to understand ourselves better — an odd sort of psychotherapy!

A few more considerations (like safety)…

Are yoga instructors qualified to teach people with back pain? Yoga instructors in North America are likely to be reasonably sensitive to back pain issues. However, people certainly do get hurt in yoga classes! I have seen numerous yoga injuries in my career. And people who go into yoga classes with a problem probably get hurt more often, and may have more faith in the safety of the class than it deserves. Many yoga instructors portray themselves as health professionals competent to do yoga “for” conditions like low back pain, but this is nonsense. Safe and competent care for low back pain is way beyond the competence of yoga instructors. It’s a good sign when yoga instructors limit themselves to simply safety alerts, saying things to their classes like, “For those of you with back pain” — just letting you know about poses that are more challenging for your back. That’s fine and good.

Private instruction is an interesting option to consider. Although I’ve already said “injury loves company,” there is a lot to be said for one-on-one instruction. Yoga classes particularly can be intimidating and dangerously competitive. They are often filled with 22-year-olds who can pretzel themselves and stand on the end of their baby finger. Yoga instructors will tell people to focus on “your own practice,” emphasizing that yoga is not a competitive sport … but people compete anyway. If you are an overachieving forty-something paying for your workaholism with your first episode of serious back pain, this can be a real threat to your success.

Private instruction seems extravagant to most people at first, but c’mon: if you wanted to learn to play the guitar, you’d pay somebody to teach you! At least consider starting with private yoga instruction or a blend of private and class instruction.

For a while in early 2011, the New York Times’ most-shared article was a “yoga bashing” article by William Broad, How Yoga Can Wreck Your Body[245] — an excerpt from a forthcoming book describing potentially serious yoga hazards, such as stroke. Broad raises a legitimate concern about a gap between a popular belief (“most yoga is safe and beneficial”) and the more likely reality: some fairly common postures and practices are a little dangerous, and there may well not be enough yoga-specific benefits[246] to justify even small risks. (Plus, the rationale for a lot of more extreme yoga is just total bollocks, and certainly deserves to be challenged on general principles.)

I don’t think Broad’s piece is particularly sensationalistic (as many yoga apologists[247] have asserted, of course), although I do acknowledge a couple serious flaws.[248] It’s a given that any athletic activity has both rewards and risks. (Look no further than head injuries in football for a prime example.) The problem is that any risks are a really rotten price to pay for many of the more ridiculous motives for bothering with yoga in the first place.

If you’re not too sure you even like the idea of yoga, the mild but real safety issues are well worth considering.

Meditation perils even?

Okay, admittedly meditation is much safer than playing in traffic or — shudder — running with scissors. It’s probably safer than taking a shower. However, even meditation is not without its hazards.

Some meditators succumb to an unpleasant psychological experience known as a “dark night,” which is like a bad drug trip: an emotional, existential crisis brought on by the mental rigours of seeking an altered state of consciousness. Blogger Gianna Kali explains that this “can be misconstrued as psychiatric issues,” which can lead to some tragic outcomes.

It’s an unlikely fate for the dabbler, of course, and I do not wish to sensationalize a trivial risk. Tord Helsingeng, a Norwegian massage therapist, points out that

‘dark nights’ are relatively rare even for practitioners who are ambitious with their practice, going to silent retreats with 8+ hours of meditation every day for many days or even months etc. If someone has come to such a stage that this would occur — which is essentially an integration problem with the no-self — they would have already managed a whole tool-box of techniques to deal with chronic pain.

“This sort of thing generally happens with more serious pursuit,” Kali concedes, “but the fact is one often doesn’t know who might become serious.” Her article on the risks of meditation is worth a look. It’s an interesting contrast to the widespread belief that meditation is totally safe and the only real option for coping with stress.

3.7

Beyond the confidence cure: what else can you do for low back pain?

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!

3.8

Pain medications (and even alcohol) can be useful

The commonly used over-the-counter medications are anti-inflammatories like ibuprofen, Tylenol, codeine, alcohol & muscle relaxants.

There is nothing wrong with using pain medications to help break the cycle of pain, fear, and immobility — as long as you know this is what you are doing. Here are the common medicinal options:

- Regular pain-killers, the anti-inflammatories particularly, may provide mild symptom relief, and to some extent this might suggest the presence of injury (as opposed to cramp or trigger points). However, they are usually ineffective, as there is rarely a significant inflammatory process involved in low back pain. All the over-the-counter (OTC) pain medications are fairly safe in moderation and work in different ways, so experiment cautiously.

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. acetaminophen is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers and it’s the least like 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.

- 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.[249] Scientists recently found evidence (in rats![250]) 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.[251] 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 there’s also virtually no down-side to trying.[252] Give it a try!

ZOOM

Voltaren Gel

Not exactly a magic bullet, but probably safe, reasonable & worth a shot.

- Opioids (the nuclear option)
Back pain is probably one of the most common reasons people want opioids — or think they do. Unfortunately, there’s surprisingly little evidence about the effect of opioids on back pain specifically.[253] A 2016 review of a dozen trials of short-term opioids for chronic back pain found that fully half of study subjects withdrew because of side effects or lack of efficacy, and for those who stayed the benefits were short-term and minor, leading to the sad conclusion that opioids are “not likely to be clinically important within guideline recommended doses”[254] — and you probably don’t want to try to improve on that with higher doses.

The infamous opioids are drugs like codeine (found in small does in Tylenol IIs and IIIs) and the more serious “hillbilly heroin” drugs like Oxycontin, Percocet, and Vicodin. They induce deep relaxation and euphoria and make you not care about the pain. Unfortunately, not caring is not a cure, and their efficacy is surprisingly dubious. And of course they also have grim risks like life-altering addiction and death by overdose, which is shockingly common. The danger can’t be overstated: more ordinary Americans have started to die from opioid overdose than car accidents. The CDC declared in early 2016 that opioids should not be an option for chronic musculoskeletal pain: there’s just too much danger, and too little evidence of benefit.

On the other hand, not everyone gets addicted and some people get real relief, so despite “the opioid crisis” — which is all-too real — there’s plenty of grey area here. If you have a good relationship with a cautious doctor who respects the risks, it’s not unreasonable to consider a short term opioid experiment: it could provide some much needed emotional relief from chronic pain, and maybe even break a vicious cycle. But the need for caution and medical supervision is as high as it gets.

For more information, see Opioids for Chronic Aches & Pains: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids for musculoskeletal problems like neck and back pain.

- Muscle relaxants come in several varieties, but only one that is widely available without a prescription: methocarbamol, as found in Robaxin, Robaxacet and similar brand names. The most famous muscle relaxant is diazepam — aka Valium, a benzodiazepene — along with several other well-known drugs (Klonopin, Ativan, and Xanax). Like the opioids, the benzos are another “nuclear option” — they interfere with muscle contraction, but they also interfere with a great deal else: like consciousness! Unfortunately, muscle relaxants are amazingly ineffective. They mostly cannot outperform a placebo in tests,[255][256] and even a prescription muscle relaxant like carisoprodol is so ineffective that patients will (this is bizarre) actually tense up if they are lied to and told that the drug is a stimulant.[257] Clearly the brain is the boss of your muscle tone. Even anasthesia doesn’t fully relax muscle![258]

- Alcohol is hard on your system in many ways, and hangovers actually increase muscle pain. Yet there’s also plenty to be said for a glass of wine or beer as a kind of medicine. In a world full of alcoholism and drug addiction, obviously this advice has to be offered and taken cautiously. However, as far as low back pain treatment is concerned, small doses of alcohol can be quite helpful — as is anything that relaxes you and reduces anxiety. Anecdotally, moderate usage seems useful for taking the edge off nearly any kind of pain via sedation and the “I don’t care if it hurts” effect. Combined with the confidence cure, alcohol can be effective. It’s one thing to be terrified of your back pain and to drink to take the edge off your fear — only to return to anxiety as the effect of the beer therapy wears off. It’s quite another to know that your back 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.

Best prescription ever?

“Perco-Bull (Red Bull laced with perrcocett) [sic]… Side effects include but not limited to: Wings.” Source unknown.

3.9

Comfrey makes backs comfy, study claims

ZOOM

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![259] 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.

3.10

A tale of two tutorials

Hopefully you know by now that you bought two tutorials for the price of one! (Some people actually do get to this point without realizing it. If this is you, don’t feel bad — this is strange and new-fangled stuff, this method of selling and publishing information!) You received the trigger points tutorial for free along with this one.

Trigger Points & Myofascial Pain Syndrome

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 all about the bath trick, and so it’s reproduced in full in both tutorials.

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!

3.11

Introduction to treating your own low back trigger points

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.

3.12

Limitations of trigger point therapy, and how to take advantage of them

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, 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.[260] 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).[261]

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 — our experimenting is expensive.[262] 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.[263]

3.13

Basic self-massage for low back trigger points

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.

3.14

How do you know it’s working? Getting a trigger point to “release”

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.

3.15

Massage tools are indispensable

Ah, the humble tennis ball

Best buddy to the common muscle knot!

It’s 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 was recently describing 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 tool massage 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.

3.16

The bath trick

From the Department of Why Didn’t I Think Of This Before: the bath trick! I discovered this while working on my own back muscle knots, which is a never-ending job — they are always under control, more or less, but always threatening to come back under the onslaught of chair work that I do, plus assorted other stresses.

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 — both my client trigger points and my own — 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 every other patient.

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!

3.17

Can you damage your nerves when self-massaging?

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.

Is there a difference?  Is there a difference between nerve pain and trigger point pain? You bet! Nerve pain is much “zappier” than trigger point pain. See the main nerve pain section again for more information about the difference between nerve pain and trigger point pain.

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.

3.18

Don’t hesitate to recruit amateur help

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.

Often I work with patients who have treatable cases of myofascial pain syndrome 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 may be all they ever needed! And no amateur can help them through that process. Only a confident professional who can put all 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.

3.19

The evidence for massaging back pain

2017 — Science 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.

2017 — Major 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.

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.”[264]

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.”[265] 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.”[266] 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:

Comparing massage to an “active” control is comparing it to another therapy that might be expected to have an effect, like spinal manipulation or TENS. An “inactive” control is more neutral: a true sham, a waiting list, or no treatment at all.

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 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 little review, leaving out things like trials of reflexology, and picking only the studies that I think are the most relevant to what I think is 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,[267] was a test of “comprehensive massage therapy” as delivered by well-trained Ontario therapists,[268] 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 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.”[269]

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 implicates: 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 nauseum, I get dorky in detail about the science of trigger point massage in that tutorial. Here’s just the bottom line…

Trigger point masssage is effectively still 100% experimental. It has rarely been directly tested and it has never been done well[270] and never for back pain specifically.[271] 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.[272]

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.

3.20

Heat and ice both provide good bang for buck, but err on the side of heat

Low back pain does seem to love heat! Low back pain patients are almost always heat seekers. It’s widely reported in the world of low back pain that heat is one of the only things that takes the edge off. This supports the notion that muscle pain is a key factor in most low back pain — it’s hardly a scientific conclusion, but an almost universal human experience that is at least consistent with a major role for muscle in low back pain.

However, I’ve never seen heat alone cure any case of back pain that was worse than the average, and it never seems to help much more than a stiff drink does. More scientifically, a 2010 study disappointingly showed that heat worked no better than ice, and neither of them worked all that well: they both provided only modest benefits.[273] (Granted, the people being tested had acute pain bad enough that they went to the hospital, so many of them may have been well beyond the help of a hot pack or ice pack.)

But a small, proven therapeutic effect is still valuable, and there are probably situations where it works even better. And heating is also a terrific self-treatment choice because it’s so easy and cheap. It offers a decent return on a minimal investment.

Thermophores are a “premium” heating pad — they are heavy, thick & produce a moist heat. Highly recommended!

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.

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 — quite a bit! — then hot soaks are more meaningful for low back pain patients than for the average person. 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 bath! I suggest several simple tips that can wring more therapeutic value out of the experience.

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. This section summarizes this tricky issue, but the topic is covered in much greater detail in a separate article, listed below.

Ice should be used on the back only by patients who clearly prefer it (for whatever reason), or when there is definitely a fresh, superficial muscle injury (a true tear, caused by a mighty exertion and/or trauma). 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 backfire. Most people clearly prefer to heat their low back pain, and a few have negative reactions to ice, particularly 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:

- PS The Great Ice vs. Heat Confusion Debacle — A quick guide that explains when to ice, when to heat, when not to, and why

- PS Heat for Pain — When and how to apply heat for therapy … and when not to!

- PS Icing for Injuries, Tendinitis, and Inflammation — Become a cryotherapy master

- PS (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.

3.21

Act normal! Rest minimally and strategically, while maintaining as much normal activity as you can

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. One study found that ordinary activity got better results than either bed rest or exercise.[274] Rest may be appropriate, but it should be minimal and tactical.

Bed rest, once a standard recommendation for anyone with acute back pain, is simply not effective.[275] According to an updated review of the science in 2005, bed rest may even cause more pain[276] — ouch! Unfortunately, I still hear from readers who have been told — at some point — 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. 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 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.[277]

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

3.22

Massage with movement and life in the Goldilocks zone

Do do do do, do do do do, do do do do…

Can you exercise to help beat trigger points in the low back? Yes. But you have to 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 muscles warm and happy … but not enough to irritate them.

Anyone struggling with trigger points 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 bunnies 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 that “massage with movement”

3.23

Some particularly useful mobilizations for the low back

Pelvic Circles — Stand and begin to swing your hips in a broad circle. Gradually expand the circle until you are pushing your pelvis as far as possible towards each point of the compass. If you have back pain, one part of the circle is likely to be extremely stiff or painful, so just keep it easy, do only as wide a circle as feels comfortable, even if that’s very small.

Stick-Yer-Bum-Out — 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.

ZOOM

Standing Forward Bend — 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 — 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.

ZOOM

Important note: 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 several 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.

3.24

Don’t worry about lifting technique

January — Major 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.

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,[278] and the number is probably even higher outside that profession.

They are all probably wrong. In this section, I argue that it’s not just incorrect, but 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.[280] 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.”[281] In 2002, physical therapist Leon Straker wrote:[282]

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:[283]

There is no evidence to support use of advice or training in working 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 Ergonomics[284] … and that paper supports nothing of the kind. It does not show that “heavy lifting increases the risk of back pain.”[285] 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.[286] A 2012 review found little to no evidence for any connection between back pain stooping over repeatedly or for long periods[287] — 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.[288]

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![289]

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.[290]

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,[291] 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,[292] three patients with VBRs did a bunch of lifting, and their implants measured the forces in squats versus stoops.

The difference was negligible! Squatting is the supposedly “correct” and safe way to lift, but it caused only 4% less load on tissues. That’s even less difference that Kingma et al found measuring flexion:

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![293] 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.[294] 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.[295][296] •sad trombone•

Interestingly, even hard braces are amazingly ineffective at reducing the forces on the spine![297] See Spinal Fracture Bracing: 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.[298] For fun. With, science says, less injury than other sports![299]

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.[300] 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 matters 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.

Strongman stone lift, 555 lbs … with quite a bit of lumbar flexion. 1:11

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.

3.25

Traction: low back pain on the rack!

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? In a handful of cases, it’s possible that traction is genuinely, modestly therapeutic. In the majority of cases, however, it’s probably like getting off your feet when you have a rock in your shoe, but not removing the rock.

The science of traction is overwhelmingly negative. There is no evidence that traction is effective. 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.”[301] 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 — simply 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 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 — simple machines that dangle you upside down 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 at a slight loss 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 slightly, creating “continuous passive motion” — wiggling you while you relax, basically. 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 much of anything else that website claims, but I certainly do like the actual device, because it offers a little mobilizing and a little traction. It’s certainly a pleasing, novel sensory stimulation, which I think is a great way to respond to 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 is unlikely to help unless “compression” is the problem. And, even if compression was the problem, decompression can only temporarily and slightly relieve the problem — soon enough you have to stand up again.

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.

The next most likely 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 weight can only do so much.

3.26

What about stretching?

This section is a summary of a much longer exploration of the topic in the trigger point tutorial. This summary deliberately lacks a lot of footnotes and references. Most of the scientific evidence is presented in the trigger points tutorial. Note also that the topic has already been partially covered in the yoga section.

Stretching is over-rated: it enjoys a reputation far greater than it deserves, and I have extensively debunked stretching as an exercise ritual.[302] However, typical stretching habits are quite different than stretching as a treatment for low back pain. Stretching probably has some modest value for the average low back pain patient, but I definitely do not recommend stretching as a primary method of self-treating low back pain, and I believe that the mobilization exercises I’ve already recommended offer better bang for your buck. However, I do recommend that you understand stretching and its limitations a little better and that you experiment with it — evaluate its effect on your back pain. Some people get more benefit from stretching than others do, and probably almost everyone gets at least a little benefit. There are too many variables involved to say whether stretching “works” or not.

I haven’t yet heard of stretching alone curing anyone’s low back pain, yet many people report that stretching feels good and helps to some degree. That anecdotal evidence that stretching works at least a little is substantial. It may not come close to curing low back pain, but darned if it doesn’t also seem to take the edge off — at least enough to make it worth doing. So people in pain tend to stretch, and often they feel better, briefly. To the extent that this is true, it is probably because stretching can sometimes partially treat trigger points.

But why isn’t it 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 certainly 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.

The case for stretching as therapy in the low back gets even worse: there are several muscles in the low back and pelvis that are mechanically awkward to stretch — almost impossible in one case. Most notably, the gluteus maximus is impossible to stretch. It routinely contains one of the two or three most significant spots in low back pain (this is perfect spot no. 12). It is a surprisingly long and lanky muscle, and the hip just can’t flex enough to strongly elongate it. There is literally no such thing as a strong gluteus maximus stretch! Similar limitations apply to the gluteus medius and minimus on the side of the hip, the big thick columns of muscle on either side of the lumbar spine (erector spinae) — all of them are stretchable, but they are awkward to stretch. And the iliopsoas muscle, which is actually easy and possibly useful to stretch, is rarely stretched because very few patients have ever heard of it or know how to stretch it.

And so, most people who are enthusiastic about stretching end up focusing primarily on the hamstrings and/or the quadriceps, because they are easy. And the idea is strongly reinforced by many therapists, who tend to exaggerate the importance of the leg muscles pulling, like puppet strings from below, on the pelvis. But the quadriceps are also mostly impossible to stretch (yes, you read that correctly).[303]

Tight hamstrings, back pain, and movement

That leaves the hamstrings as the sole muscle group in the entire region that is straightforwardly stretchable … and the specific relevance of hamstring stretching to back pain is, well … a bit sketchy. For instance: is there any connection between hamstring flexibility and the amount of lumbar movement when reaching forward? You’d think so, and you’d be right … but only if you’re talking about healthy people. Not so much in folks with back pain! A 2010 study was so simple that the results are hard to argue with, even if it’s hard to tell what they mean: some low back pain patients use their lumbar joints when they reach, and some don’t, and good luck predicting which ones based on hamstring flexibility. You’ll fail if you try, this data says.[304]

So that’s how it is. Interesting. But why and what does it all mean? Well, that is much trickier, of course, but the likely upshot is that hamstring flexibility probably isn’t a critical factor in back pain.[305] This is nicely echoed in a 2009 paper by Marshall et al: “With no relationship to actual disability and contradictory findings in the literature for the relationship of the hamstrings to the mechanics of the low back, it is unclear whether decreased hamstring extensibility should be targeted in rehabilitation programs for axial lower back pain.” Nothing much has changed on this topic since a 2002 review in Spine (Phila Pa 1976), which was pretty scathing about the meaning of the most common test of hamstring flexibility,[306] the passive straight leg raise (lifting the straight leg up while lying down):

There remains no standard PSLR procedure, no consensus on interpretation of results, and little recognition that a negative PSLR test outcome may be of greater diagnostic value than a positive one. The causal link between LBP pathology and hamstring action remains unclear.

Unclear indeed. All these problems and uncertainties keep me from getting excited about the potential of hamstrings or any other kind of stretch[307] to resolve low back pain … despite the fact that it sounds good on paper. 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.

3.27

Troubleshooting perpetuating factors

Low back pain is often not so tough once you understand and eliminate the perpetuating factors — the forces in your life that cause low back trigger points to form in the first place — and then keep them going.

Typical perpetuating factors in low back pain are muscle fatigue or stagnation or alternating between them (weekend warriorism), awkward postures and working positions, sleep deprivation from insomnia or shift work, and the psychological stresses already discussed in great detail. A few low back pain patients also face more mysterious and difficult perpetuating factors, such as other health problems (obvious or not so obvious), structural factors (yes, sometimes they do matter), and more.

Unfortunately, there is a bottomless pit of possibilities in trying to understand, identify, and purge such factors from your life. Good low back pain therapy should aim to identify and eliminate your perpetuating factors.

So, please repeat after me:

- Trigger points come back for the same reasons that they formed in the first place!

- Trigger points come back for the same reasons that they formed in the first place!

- Trigger points come back for the same reasons that they formed in the first place!

Usually. Sooner or later.

What perpetuates low back trigger points?

Pain from any other cause, and other chronic health problems. Anything that stresses the system seems to increase trigger point pain, but there are conditions that seem to more directly aggravate trigger points. A classic example is fibromyalgia, which is usually complicated by many severe and stubborn trigger points. Some of the worst perpetuating factors are in this class. Nearly all fibromyalgia patients experience low back pain.

Muscle fatigue, over-exertion, over-stretch. Anything that pushes your muscle tissue to its limits may aggravate your trigger points, which is why taking your low back pain to the gym is a risky business. Serious athletics and intense manual labour may perpetuate trigger points. Nurses, for instance, routinely suffer low back pain that is related to lifting (transferring) patients, loads that are challenging in many ways; even without direct injury, nurses may find their back musculature pushed to the limits. Rather than being unusually healthy, people who repeatedly over-exert themselves often struggle constantly with muscle pain. “Fitness” does not necessarily mean “painless”!

Weekend warrior-ism. Yo-yoing between a sedentary life and intense muscular activity might be worse than the extremes themselves. If your muscle tissues are stagnant in an office chair all week, and then pushed to their limits for three hours on Saturday, low back pain might be more likely than if you’d only been a couch potato or if you worked out excessively every day.

Insomnia and shift work are the most common causes of serious sleep deprivation/disturbance, which are major trigger point generators. Since insomnia is such a common problem, it tops the list of serious yet manageable troubleshooting goals. I mentioned nurses a couple points back: nurses face both over-exertion and the sleep disturbances of shift work.

Psychological stress, especially anxiety about pain itself, which we’ve already covered in detail.

Poor posture and anatomical asymmetries (being crooked) may be important in some cases, but these are extremely difficult to troubleshoot. A firm diagnosis of the exact nature of your postural problems is usually almost impossible to obtain — professionals invariably disagree — and fixing the alleged problem is rarely straightforward (and often physically or neurologically impossible.)

Poor ergonomics or inherently awkward working postures cause problems for the same reasons as poor posture and being crooked, but they are much easier to troubleshoot, for the simple reason that only the most obviously poor ergonomics/postures are likely to be a problem.

Poor diet (and other medical issues) may result in minor nutrient insufficiencies, which are given great importance by Travell and Simons. “Patients with chronic myofascial pain syndrome [have] a remarkably high prevalence of vitamin inadequacies and deficiencies.” However, as complex and controversial as the subject can get (Travell and Simons go on for many pages about it), the entire subject can be boiled down to one simple “insurance policy”: take a multivitamin, and just make sure that you stick to daily intake recommendations. Travell and Simons endorse this approach, despite their preference for the ideal circumstance, which would involve better scientific understanding and better medical assessment.

3.28

Fix your insomnia

Myofascial trigger points are probably aggravated by insomnia or even by mild but chronic sleep deprivation.

Insomnia is both a more important part of chronic low back pain than you probably realized, and also easier to treat than you probably realized. Let’s take those points one at a time.

Myofascial trigger points are probably aggravated by insomnia or even by mild but chronic sleep deprivation. There is no direct scientific evidence to support this idea, but there is plenty of indirect evidence. If you’d like to know more about this subject, the trigger points tutorial is actually not the place to look (surprisingly). I wrote a separate article about this, looking at all of the scientific evidence that insomnia aggravates trigger points. This article is required reading for insomniacs with body pain! See Insomnia Until it Hurts

Sleep disturbance is worth addressing because, like low back pain itself, insomnia is both stress-induced and stress-inducing, which makes it great example of a mechanism by which stress and anxiety can significantly contribute to back pain without actually being the “cause,” per se.

Treating insomnia is therefore also a great example of how you can leverage treatment of psychological stress to treat back pain — even though that doesn’t mean your back pain is somehow psychosomatic.

And insomnia treatment is a great example of how “stress relief” can involve concrete problem-solving as opposed to the stereotypically vague approaches to stress relief.

Okay, so insomnia and even just chronic low-grade sleep deprivation are probably factors in stubborn low back pain. Now what? How do you fix your insomnia? Easier said than done, right?

Actually, most insomnia — like low back pain itself — is far easier to treat than most people realize. That may sound like a bold claim, but you can rest assured that I am speaking from extensive and painful personal experience. I have battled severe insomnia for my entire life. I am, tragically, both a morning person and a night owl, leaving me little time to actually sleep. And so I know that insomnia is both very tricky to solve, but also easier than most people think. It can be done, in the vast majority of cases. So, for detailed information on treating insomnia, particularly the all-important “sleep compression” method, see: The Insomnia Guide

If your problem is not insomnia but sleep disturbance from shift work instead, you have a more difficult problem. You should at least consider changing careers, and see the end of the next section for some more perspective on that option. If you truly can’t change your schedule or your career — some people can, some people can’t — then find some books on the subject. Reading a good book about how to manage shift-induced sleep problems is highly recommended therapy for your low back pain!

3.29

Morning pain and sleep posture

Sleeping is dangerous? “I woke up with it” is an amazingly common description of how low back pain started (and not just back pain[308]). Many people get their first acute episode of low back or neck pain during the night, and the AM effect is also a dreaded part of chronic low back pain. Even many people who are more or less pain-free during the day — people who would never think of themselves as victims of chronic pain — nevertheless experience routine and significant irritation and stiffness first thing in the morning.

Maybe there are opportunities for treatment in changing the way we sleep.

Lita Scruton of Ontario asked me for an explanation of her morning back pain, and it was the original inspiration for this chapter:

Every morning I awaken stiff and have to get out of bed. No sleeping past 7am for me, ever! I can’t take the discomfort. So why during the day I can do anything, even exercise, and have no discomfort? Why do my muscles get so painful while I am suppose to be relaxed and resting? If I awaken during the night to use the bathroom they feel great, but any time after 6am, it is a whole different story. Can you help me solve this mystery?

Sleeping is a problem for backs because (and this is educated guesswork — I’ve never seen a shred of research on this topic):

- It can result in sustained compression, pinching, and oxygen starvation of tissues, which may or may not have already been irritated, with or even without an awkward position.

- It often involves at least two of the most obvious aggravating factors for muscle pain: tissue stagnancy, and sustained shortening or stretch of muscles.

- There might even be a mysterious x-factor in sleep — something funky about inflammation biology. (And that’s even sketchier guesswork, based solely on the clinical observation that there are several common flavours of morning pain.)

Pinching. Imagine you have a minor hand injury. Now imagine sleeping funny on your shoulder, cutting off circulation to the injured hand — you know, one of those times when your whole arm goes numb, and it feels like it doesn’t even belong to you any more. Your hand would really throb and ache as it “woke up,” wouldn’t it? A more obvious example: you might simply roll over onto your injured hand and hurt it directly, causing a minor trauma, a sleep injury (or re-injury). The same thing can and undoubtedly does happen with backs. This is the most obvious explanation for morning back pain.

And yet I’ve seen and experienced many cases that don’t really fit that description.[309]

The bamboo cage.  One of my favourite chapters in the trigger points book is “The bamboo cage — what immobilization torture can tell us about the nature of muscle pain and massage.” It’s about the neurology of stagnancy pain, and how it might even be the main explanation for trigger points.

Trigger points specifically are probably the most common and serious mechanism of sleep-induced pain. There seems to be a time limit on how long you can be still before soft tissue becomes irritated by stagnancy, and/or by being held in shortened or stretched positions for too long. How comfortable you feel in your bed in general is relevant, but it’s not the main issue. Most people feel great in a cushy chair … for the first hour. Whether you’ve slept in a comfortable position or not, trigger points are little time bombs that go off by 7am. Or earlier. And if you went to bed in pain … well, it’s just going to get worse.

This reaction to sleep is a wake-up call. Aggravated symptoms overnight with no other obvious explanation are a good sign of a bumper crop of latent trigger points re-activating. In Lita’s case above, 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. There are other possible explanations — Lita asked about a couple[310] — but the smart money is on trigger points.

A healthy younger person — damn them! — can sleep for nine, ten, or eleven hours and feel just a little stiff after waking up. But everyone past their second decade has a limit. The longer we stay in bed, the stiffer we get, and eventually stiffness turns to pain as the trigger points fully activate. It happens sooner if we’ve been sleeping in an awkward position — and it certainly happens sooner if we’re 45 instead of 25. But it happens to everyone. How long we can sleep without pain is a pretty good barometer for muscle tissue health!

Why does sleep actually help  some people? Not everyone’s back pain gets worse at night! There are many possible reasons for a night that actually helps low back pain. Some people just “sleep well” — they naturally and easily assume and maintain more comfortable sleeping positions, and change positions at good intervals. Some people may have mattresses and pillows and other sleep gear that facilitate this. And/or sleep may constitute such a significant and important period of relief from emotional stress and anxiety that this outweighs other factors. Younger people are much less vulnerable to tissue stagnation (they are better at maintaining their circulation despite stagnancy), and so they are better candidates for pain-free sleeping. Getting the idea? There are many variables. If you get a few good ones lined up, you may have no problem with back pain at night.

My position on sleeping position

Sleeping position is clearly relevant to back pain. Unfortunately, I think it’s only a minor/erratic aggravating factor in low back pain, and nearly impossible to do anything about anyway. We can do a few things to minimize the chances of a problem position, but usually we don’t even suspect a problem with our sleep posture until it’s too late — we woke up in pain. For most patients, working on sleeping position probably does not offer much bang for buck.

The position you’re sleeping in isn’t really the problem, but instead it’s the duration of being stuck in almost any position at night. To the extent that we may get stuck at a particularly awkward angle, the problem will certainly be worse. If you fell asleep in a slouch in your work chair, for instance, you would certainly wake up feeling unusually stiff and uncomfortable! If you’d been awake and vigilant about avoiding awkward positions and shifting positions regularly, you would face only the usual discomfort of excessive sitting.

What positions might be a problem? And what to do about them?

There is no secret and magic sleeping position for me to reveal to you, of course, and no sleeping position that is an obvious problem for a majority of patients. Many people with low back pain are perfectly aware of which positions are a problem for them, and they tend to avoid them avidly. About all you can really do about sleeping position is strive to achieve and maintain a neutral-ish position, seeking comfort to the best of your ability.

The most likely position to cause trouble is sleeping face down. I do not think that sleeping face down is a universally evil sleeping position. I am not on that bandwagon, as so many therapists are. I sleep face down myself because it is the most comfortable position for my back. But, based on years of anecdotal reports, I think face-down sleeping does tend to bug a lot of backs.

But, of course, it’s difficult to control your own sleeping position. Arranging pillows can support a comfortable position and help us maintain it. For instance, putting a large body pillow in the way, making it more difficult to roll into an awkward position, may help. However, most people who toss and turn can make short work of any pillow arrangement in their sleep. Any pillow that’s in my way is kicked off the bed in about five minutes.

This is why I can’t get very enthusiastic about trying to change sleeping position as a prescription for low back pain — even if it was important, I don’t think it’s possible. But there is another possibility…

The anti-nap: take a sleep break

But here’s one weird, good trick: if you’re really struggling with night and morning pain, break up the night. Just like you need breaks from long stretches of sitting, you may need to take a break from sleeping.

If you’re actually sleepless and in pain, don’t stay in bed squirming in misery all night — get up and help yourself! Or if you are sleeping, set an alarm! Either way, get out of bed, and mobilize, heat, and self-massage your back — or whatever else you’ve found helpful. Or ignore your back and do something pleasant.

If you were in an awkward position when the alarm went off, you may really be doing yourself a favour by interrupting it. You can “reset” your sleeping position when you go back to bed.

Few people have ever thought of trying this, let alone taken it seriously or tried it consistently for a few nights. Understandably, people feel an emotional reluctance to interrupt sleep for the sake of self-therapy — we’re all over-tired, and that’s an issue too — but it may well be the lesser of evils, if sleeping is hurting your back.

Stranger still, it may even be unhealthy (as well as painful) to try to sleep all the way through every night. There is actually a natural wakeful period in the middle of the night, like a mirror image of afternoon naps, which most modern people are resisting — we think we’re supposed to be asleep all night![311] But that natural tendency to wake up for a bit may actually exist to prevent excessive tissue stagnancy! So try not fighting it for a while — you don’t have to do it every night, or forever. If it helps you get through a rough patch with your back, it’s certainly worth a shot. And it’s worthwhile if it helps you sleep when you go back to bed!

Final tip: try getting up and taking care of your back for a few minutes without turning on a light — staying in the dark will help preserve “sleep mode.”

3.30

Sitting, chairs, and ergonomics

What were the bodies like on the beach? Ugly and white and ruined by offices.

~ Leonard Cohen, The Favourite Game

This section, new in early 2017, corrects a major error, reversing an opinion I promoted for well over a decade. I believed the “obvious.” I believed the myth. A lot of time spent in chairs may be unhealthy in some ways, but they are just not the back torture device I once thought they were.

Scientifically, there’s not much wiggle room on this point: many studies have shown that people who sit a lot simply do not get more back pain than more active people. There is no link. It’s just not a thing.

A lot of time spent here may be unhealthy in some ways, but office chairs are not the back torture device I once believed.

This was already established as early as 2000 when Hartvigsen et al. looked at thirty-five different relevant studies,[312] 14 of them about sitting at work, 21 with otherwise physically “lazy” jobs, and 8 that had “a representative sample, a clear definition of LBP and a clear statistical analysis”:

Regardless of quality, all but one of the studies failed to find a positive association between sitting-while-working and LBP. High quality studies found a marginally negative association for sitting compared to diverse workplace exposures, e.g. standing, driving, lifting bending, and compared to diverse occupations. One low quality study associated sitting in a poor posture with LBP. The extensive recent epidemiological literature does not support the popular opinion that sitting-while-at-work is associated with LBP.

Seven years and several studies later, Lis et al. reviewed fifteen suitable studies.[313] Although they noted evidence of a link between back pain and awkward sitting postures and vibration — so helicopter pilots get a lot of back pain, apparently — they otherwise just confirmed Hartvigsen et al.’s findings, concluding that “sedentary lifestyle by itself is not associated with LBP.” This was then backed up again by two more reviews in 2009,[314][315] which are the most recent as of early 2017, which is when I finally caught up to the evidence, noticed my mistake, and updated this chapter and several articles.

How did I go so wrong? Easy enough: I just never checked.[316]

It remains remotely possible that back pain is more common in certain kinds of “chair warriors.” But if there is any link at all, it cannot possibly be a strong one.

Sedentariness in sitting postures is might be a risk factor for other health problems, and so there’s plenty of justification for trying to minimize it and compensate for it, but that is another whole topic.

The Trouble with Chairs The science of being sedentary and how much it does (or doesn’t) affect your health and back pain       ~ 8,000 words

What about a better chair?

The evidence that there is no link between professional sitting and back pain is equally damning to the idea that the problem is related to the chair — because there is no problem. Ergo, the there is no ergonomics problem that can be solved with a new chair.

A particularly bad chair is a problem (or anything else that forces an awkward posture). Citing Lis et al. again, we know that awkward sitting postures likely are a problem. But that’s an obvious problem with an obvious solution. Simply sitting in a typical chair does not constitute a postural strain. Sitting involves significant spinal flexion compared to standing, near the end of range, but not at the end of range, and not under load. It’s not a big deal — if it was, it would have showed up in the studies ages ago.

The value of extremely comfy and ergonomically dazzling chairs is not just overstated, it’s wildly exaggerated by the companies that make and sell such things. There’s never been a shred of evidence that the right kind of chair can prevent or treat back pain.

There’s nothing wrong with pursuing comfort in your chair, but that’s not a back pain treatment: that’s just a treat. A chair you don’t care for may add insult to the injury of back pain, but it’s unlikely to actually stand in the way of recovery.

What about standing desks?

Since there is no link between sitting and back pain, the standing desk — in terms of back pain — is a solution looking for a problem. It could even a solution that creates a problem, because obviously standing all day might constitute a risk factor for back pain.

But, as it turns out, standing probably doesn’t cause back pain any more than sitting does (although the evidence on this point is less robust).[317] I accept that evidence even though I have some personal experience with standing-aggravated back pain.[318] Back pain is prevalent in professionals who stand a lot, like nurses and teachers, but it’s highly plausible that this is due to other occupational factors like stress and job satisfaction[319] — yet another example of the importance of the mind.

There may be other reasons to stand at your desk, but not for back pain treatment and prevention.

3.31

Troubleshooting severe and persistent trigger points

Sadly, many people who come to suspect that trigger points are a major factor in their low back pain diagnosis are initially excited by the possibility of relief … and then disappointed as self-treatment and therapy seem to go nowhere fast. Even when you are “correctly” treating the right trigger points, or even getting them treated by a professional, sometimes they just won’t go, or they come back so fast you wonder why you bothered!

You may get very little relief at all, or you may get good relief but only for a short time, or none of the above. Treated trigger points may come back in a day, a week, or a month. Worse yet, treatment may even backfire — yikes! Some people do experience nasty negative reactions — aggravated symptoms, severe bruising, and nausea are all rare consequences, but possible.

The problem of trigger points that always come back, or never really go away in the first place, may or may not be fixable, depending on your story and your body. In general, the only way to find out is to try a lot of things. The secrets to advanced trigger point troubleshooting are creativity and persistence — to throw everything at the problem but the kitchen sink to take the edge off over and over again, frequently. There’s no single magic bullet, but many small lessons that slowly accumulate into more of a solution and better control than you used to have.

What are the most common problems with self-treatment of trigger points in the low back? Assuming that they are actually the problem?

1. missing the trigger point (in the low back, the most common specific mistake is neglecting the trigger points in the upper gluteal musculature)

2. excessive pressure

3. using ice or getting chilled (a problem with all trigger points, but especially hazardous in the low back)

4. exercising muscles too hard or too soon after treatment, often with the belief that “core strength” is important (this is greatly debatable)

5. sustained awkward positions after treatment (i.e. sleeping in an awkward position, a long commute, chair work)

6. failure to address “perpetuating factors”

The trigger point tutorial goes into great detail offering just about every imaginable self-treatment option. Here’s a bird’s eye view of the options, followed by several more sections about issues of particular importance to low back pain.

Poor massage technique. I’m sorry to say it, but your self-massage skills may simply not be up to par yet! Such problems are neither common nor uncommon. Good technique is not always important, because you get away with poor technique with most mild to moderate trigger points. They aren’t that picky. But some of those trigger points won’t respond to sloppy technique. And when mediocre massage tactics meet more severe trigger points, failure is almost inevitable. Although, as Dr. Janet Travell wrote, almost any kind of stimulation has the potential to help your trigger points, unfortunately there is virtually no scientific evidence to guide us in determining exactly what will work best for most people, most of the time. Figuring out what works for you is a personal matter of trial and error … sometimes a lot of trial and error.

Too many trigger points. Remember, a trigger point is just a trigger point — but when you have a lot of active trigger points all at once, we call it “myofascial pain syndrome.” It’s the excess of trigger points that makes it a syndrome. Low back pain can easily be either a case of a severe, isolated trigger point, or a case of myofascial pain syndrome — numerous trigger points, all perpetuating each other, spread throughout the lower trunk and upper legs (and likely beyond). Trigger points may be so numerous that treatment becomes a logistical nightmare. Where do you start? It isn’t an impossible situation, but it does require more effort and tactical savvy than dealing with an isolated trigger point.

A great example of slavish, single-minded devotion to an ineffective technique is the core-strengthening and postural school of back pain therapy. This is the kind of therapy advocated by the popular but dubious “Lose the Back Pain” program, widely advertised on the internet in infomercial style.

Patients really get hooked on this idea that if they are stronger in the gut and have a nice “neutral” lumbar curve, that will solve all their back pain problems. The devotion to the concept is so strong and apparently emotionally addictive that I routinely encounter patients who simultaneously believe that the therapy works … yet they still suffer regular episodes of severe low back pain and are hypervigilant about protecting themselves from their backs “going out.”

If that’s an effective therapy, I’d hate to see their idea of a failed therapy!

Core strengthening is discussed in two other places in this tutorial, here and here.

Slavish devotion to techniques that haven’t really earned your love. This one is from the Department of “If I Had a Buck For Every Time ______.” Irrational devotion to an iffy self-treatment technique is extremely common. With mild trigger points you can get away with it — your iffy self-treatment method of choice does the job temporarily, sort of, kinda — and you’re happy to have even a little relief. But too often I see people just hammering away on a more serious trigger point problem and not getting any meaningful results. This happens most often with stretching. “I have a regular stretching routine that works really well,” patients will say. “Really?” I reply, trying to be gentle. “Has it solved the problem? Why are you still having regular episodes of severe pain? How effective is the stretching really?” If you have a pet self-treatment technique, and you still more or less have a significant trigger point problem, please face the obvious: it ain’t that good a technique!

Negative reactions and anxiety about them. If you’ve had ominously bad responses to self-treatment, and especially if they freaked you out, you may struggle to get good results in the future. Fear and anxiety are powerful aggravating factors in low back pain. If you don’t know how to avoid negative reactions, there’s no way to deal with the fear, and everything is more difficult.

Avoidable perpetuating factors. Trigger points often quickly regenerate for the same reasons that you got them in the first place. These reasons are called “perpetuating factors,” and eliminating them is often the holy grail of trigger point therapy. There are many possible perpetuating factors: insomnia, smoking, stress, awkward working postures, or your entire job or career. Many of these are avoidable — even your career! The solution is to learn what causes and aggravates your trigger points, and work hard to eliminate those forces from your life.

3.32

Troubleshooting even worse trigger points

This is a depressing section, but necessary — and hopefully fascinating and strangely reassuring to those of you who feel like you are facing invincible trigger points in your low back. There’s just no getting around it: sometimes, trigger point therapy is not an effective treatment for low back pain at all, or it barely makes a dent in your pain. There are two general reasons why trigger point therapy fails in the low back:

1. Trigger points are not really the problem. Any that are present are either just typical low back trigger points, or they are being constantly regenerated and re-aggravated.

2. Trigger points are the problem, but there are serious barriers to treating them successfully.

The only thing worse than not being able to release your trigger points is not understanding why, not knowing what your chances are, or not having a realistic view of the situation (see the sidebar for more about this). Here are some more reasons that therapy fails that you may not be able to do anything about:

Inaccessible trigger points. There are plenty of muscles in the human body that are simply not accessible without a scalpel or some other extraordinary effort. Sometimes, muscles that are difficult to access can be reached by a skilled therapist with specialized skills. (See the end of this section for some examples.)

Adhesions and mild contracture. Quick review: after a few years of clenching, trigger points might (just a hypothesis) start to “freeze like that,” glued into place by connective tissues that have lost some elasticity and no longer slide freely across each other.[320] Although there’s no evidence of it, I suspect that this is more common in the low back and gluteal musculature than in most other regions, because of how little movement the area gets. Of course, it would be more difficult to treat such gluey trigger points.

Trigger points caused by another health problem. In some people, trigger points are simply a symptom of something much bigger going on in the body, such as fibromyalgia or an autoimmune disease. Obviously, if trigger points are being generated in this way, there may be little that you can do to treat them, or you may have to deal with other health problems first. Insomnia and smoking are excellent examples of underlying problems that might make trigger point treatment difficult. A serious disease like ankylosing spondylitis — an autoimmune disease that slowly destroys the spine — is a classic example of a health problem that generates so many secondary trigger points that it is simply not possible to deal with them all.

Unavoidable perpetuating factors. Some things that predispose people to trigger points are effectively or entirely unavoidable. Health problems are an obvious possibility, but we’ve just mentioned that separately. Here, I mean features of your life you can’t change or won’t change because the cure would be worse than the disease. I will counsel people to consider changing careers and make other drastic changes that might help their myofascial pain syndrome. Almost anything you do with your life is theoretically avoidable or changeable, but there are limits to what people are willing to do.

The most straightforward example of an unavoidable perpetuating factor is parenthood. Being a parent can directly and indirectly aggravate low back pain in a dozen different ways — stress, insomnia, and piggy back rides, for instance. Yet parenthood is a burden that is nearly impossible to put down. Families sometimes actually disintegrate under these pressures, but most people, of course, will not and should not leave their children just to cure their trigger points.

The majority of severe cases of low back pain occur in people who are trapped in circumstances that set them up for failure. Insult is added to injury by therapists who continue to offer false hope — and charge for the trouble. In these ways, advanced trigger point therapy can go way beyond technique, involving challenging personal, social, and even philosophical issues.

But don’t give up too easily. The good news is that, although these issues present serious barriers to complete success, many patients can still achieve good partial results, controlling and limiting the severity of back pain as opposed to completely resolving it. It just requires a lot of dedication and effort.

More detail about inaccessible trigger points in the low back

In low back pain, several potentially relevant muscles are hard or impossible to reach. The muscles of the pelvic floor are inaccessible unless someone inserts a finger through the anus. That’s a real thing — I’m not making that up. And for a few people with pelvic and low back pain, this is a vital medical service.

A small hip muscle, obturator internus, is particularly difficult to massage.

A large spinal muscle, the psoas major muscle, and its companion iliacus, are both awkward and difficult muscles to massage, and nearly impossible to self-treat — yet both are may be relevant to low back pain.

The deep gluteal muscles are all treatable and even self-treatable, but they aren’t easy to self-treat, as they are all covered by a thick layer of gluteus maximus … and usually some fat as well. 😉 If you have trigger point pain coming from one of these muscles, there may never be a way to prove it or to treat it yourself, even with medical intervention. Sometimes this explains why trigger point therapy simply does not and cannot work.

3.33

Less than a cure, but better than nothing: short term symptom relief options for low back pain

Don’t knock good symptom relief … if you can get it. There are many painful situations where the root cause is untreatable and unknown, and symptom relief is the best you can hope for. Unfortunately, sometimes even that modest goal is elusive. A reader recently asked me:

How can I get relief from low back pain right now? Forget cure: I’d settle for treating the symptoms right now. Can I at least do that? Is there anything that can relieve the pain in the short term?

There’s really no good answer to this question. “It depends” and “not really” came up pretty quickly as I searched for an answer. It depends on what the (usually unknowable) origin of the pain is, and no, there’s not much that is likely to ease the pain significantly … not even temporarily.

Still, even without a satisfying answer, it’s a good question to try to answer, and quite different than the question I’m usually trying to answer: how do we end low back pain?

Short term pain relief isn’t impossible, it’s just unreliable and unpredictable — a crapshoot. There are many interventions that might provide relief, but none that can be counted on. If we lower our standards, here are some of the interventions that have a fighting chance of providing at least some respite from symptoms.

Many of these options repeat things that have been said above, or will be said below — but I think it’s useful to review them in terms of the idea of “what can I do    right now that might make the pain better?” It’s an important persepctive.

Drugs. As made clear above in the medications section, medications are not an effective solution for low back pain — indeed, “it doesn’t even touch it” is a common comment from frustrated patients regarding even the most potent drugs. However, unreliable is not the same thing as useless. Some people, some of the time, can get a least a little relief from virtually any painkiller. All are worth cautiously experimenting with, and all are problematic and pointless in excess.

Ice or heat, whatever seems most appealing. Ice can backfire, aggravating muscle pain in particular, but it can also provide relief. Patients should choose what seems right: although odds favour heat, patient preference is always key. I am forever encountering patients who crave one, but have been told to do the other by a professional. Do what feels right. For instance, ice is most likely to be temporarily useful in patients experiencing acute, “hot” pain where they sense, perhaps not literally but aesthetically, that the region needs to be cooled down — so cool it down! But be ready to switch to heat when ice starts to feel less appealing. Or vice versa. Heat is more likely to appeal to most low back pain patients. Taking your time with a good hot bath or shower is one of the most reliable symptom relief tactics — although it’s virtually guaranteed to be minor and temporary, at least it has a fighting chance of taking that edge off. Heat is also virtually risk free.

Mobilizations, stretching, and traction. I collectively think of these as “wiggling and squirming therapy,” the common denominator being movement. All have the potential to relieve symptoms … but also considerable potential to worsen them, depending on the case. How far to push it is a difficult question, because breakthroughs are possible with persistence. Swinging your hips around in a circle 20 times may do absolutely nothing, but 50 times could both help or hurt. Intense, risky stretching has been known to succeed where moderate stretching failed … and, of course, it’s also been known to injure people. It’s a gamble.

Chiropractic adjustment (spinal manipulative therapy) has been proven to be modestly effective in the treatment of low back pain — roughly equivalent to drugs (for a good recent research example, see Jüni et al). Despite its underwhelming benefits for most people, it might be worth pursuing as a symptom relief option because a few patients do get greater relief. Remember that SMT’s benefits are infamously temporary — i.e. unlikely to “cure,” but perhaps helpful for managing symptoms. Unfortunately, this is the least convenient and most expensive of the options presented here, and there are risks: some people’s symptoms are worsened, not helped, and the danger seems to be greatest with the patients most likely to seek help (nasty, acute cases where anxiety is strong).

Self-massage has been discussed extensively above as a cure for low back pain. But it also has great potential for short term-symptom relief, even if it can’t cure the problem. If I had to choose just one pain relief strategy for low back pain, it would undoubtedly be self-massage. Like chiropractic adjustment, benefits of basic massage on tough cases of back pain are usually temporary — but a little relief is better than none, and at least it’s safe and cheap to try!

PART 4

GETTING PROFESSIONAL HELP

A consumer’s guide to buying therapy and medical care for low back pain

Ideally, every low back pain patient would have the aid of a health care professional acting as a coach and guide, encouraging best practices in self-treatment, keeping back pain myths and fears from growing like weeds in the patient’s mind, and also contributing some skilled hands-on therapy. Unfortunately, that help is hard to find — and finding it requires the same knowledge and skills that you’ll need for self-treatment. For many, by the time you’ve learned enough to know what good therapy for back pain even looks like … you don’t need it any more!

The point has already been made many different ways, but let me say it again: many health care professionals think they know about back pain but actually do not. This creates problems for patients, who are often not armed with enough information to know when they are being told something nonsensical.

Professionals are just as likely to believe the standard (structural) low back pain myths as their patients are, if not more so. They are seductive, those beliefs! And professionals may be persuasive in presenting their personal approach to low back pain therapy, even when they haven’t ever read a scientific paper on the subject, let alone a recent one. Typically, most of the patients they’ve supposedly helped simply enjoyed a natural recovery that happened to coincide with therapy … or those patients aren’t truly better, still living in fear of their back “going out,” and still suffering semi-regular episodes of severe low back pain. That’s not cured!

Patients are amazingly tolerant of failure in therapy. They will admire — and pay — therapists who have not done a darn thing for them, or not done much, or not for long. I have had many patients tell me, with a straight face, that they have a therapist they “love,” who is “awesome” or “really good” … yet they continue to suffer from episodes of severe pain! And they’re sitting in my office because of it.

Alternative medicine for low back pain is not as popular as you might think. I was surprised myself when a 2010 American survey found that only about 6% of the US population uses any kind of alternative therapy for their back pain: about 75% chiropractic, 20% massage therapy, a few percent acupuncture, and a few percent divided among everything else.[321] Still, 6% of the American population is almost 2 million people annually looking for a crack, rub, or needle poke!

One of the most important goals of this tutorial is to help you get off the merry-go-round of conflicting theories and barely effective therapies, to learn to spot the myths and the sloppy logic yourself, to know enough that you are no longer impressed by health care professionals who don’t know … well, at least as much as you know after reading this.

Please beware of giving therapists credit they do not deserve!

Recently a low back pain patient regaled me with a tale of therapeutic genius: another massage therapist had greatly impressed him with effective treatment for an unrelated problem. She had “connected the dots”[322] and deduced an obscure connection between one part of his body and another. My patient was full of admiration for this. However, my patient was also still full of pain. His back pain — by far his most important complaint — had never actually been solved. Yet he still believes this other therapist was a miracle worker. Why?

Perhaps low back pain is just so disturbing and frightening — especially when we think it’s “structural” — that even just taking the edge off the pain has great value to patients. But I think it’s mostly because patients just don’t know how much to expect from therapy. It’s okay to expect it to work! Raise your standards!

Here are some standards you should be applying to manual therapy (meaning primarily physiotherapy, chiropractic, and massage therapy):

- Therapy that seems overly concerned with structure and posture is highly suspect.

- Expect at least some reasonably clear sign of benefit within 3-6 sessions.

- There should be some kind of trigger point therapy, and there should be a clear effort not just to treat you but to train you to treat yourself.

- There should be some effort to help you resolve the problem long term — not just help you “until the next time.”

Summary of the main professional treatment options

- Below I will devote a short section to each of the major categories of professional helper you might want to consider. Physiatrists are the least known and most useful medical specialists for the low back pain patient. Physical therapists (physiotherapists) can be excellent but are prone to rote, overpriced treatments with mainstream credibility but little value. Massage therapists can almost always make a valuable contribution, but it can be really hard to find a good one (training standards are all over the map). Chiropractors indulge in so many questionable practices and beliefs that consumers must be extremely cautious hiring them.

- Spinal manipulative therapy (wiggling spinal joints, basically) is one of the major manual therapies for back pain, available from both physical therapists and chiropractors (but often for extremely different reasons). SMT has one of the strongest reputations of all back pain treatments, but without much cause. While there is some potential for a few patients, clinical trials of this treatment have been thoroughly underwhelming.

- Some treatments for trigger point treatments can only be had from a professional, such as stretch and spray, dry needling, and injections. Although all seem to be helpful in a few cases, S&S is very hard to find, needling and injection have significant risks, and they all dial up the cost of treatment for rather uncertain benefits. It’s not clear that they are really an “upgrade.”

- Professional massage is probably well worth pursuing, if you can afford it. It offers good value and low risk. It is particularly attractive in that it has virtually guaranteed power to reduce depression and anxiety at the very least, if not also relief from muscle pain (more hypothetical, debatable). Although the profession is rife with flaky stuff, that doesn’t usually get in the way of a decent experience. It can also be a useful part of learning and experimenting much more economically with self-massage . About the only way to go wrong is to have an overly rough massage therapist — please avoid that. It is entirely too common.

- Surgeries are often oversold to patients, and it is not unfair to call the industry a bit of a racket (certainly in America, anyway). There are many types, a lot of risks, and high costs. Incredibly, none of the “popular” surgeries have ever really been properly, scientifically tested. But surgery cannot be eliminated as an option, because it probably can help a few patients. The trick is to be very cautious and cynical and accept a surgical recommendation only from a surgeon who is also cautious and cynical.

- Like surgery, medicinal injections into spinal joints are not recommended for most patients. The risks and costs are obvious and the evidence is poor.

- Craniosacral therapy involves alleged manipulation of cranium and sacrum and cerebrospinal fluid. It’s relaxing and pleasant, but extremely unlikely to help low back pain (at least, no more than any other peaceful experience).

- Acupuncture is a popular alternative therapy for low back pain, but not as popular as everyone seems to think — or as effective. In fact, this therapy has been studied extensively and well and been proven ineffective. The science news about acupuncture for back pain has been all bad for years now.

- Many people work on core strengthening on their own — a self-treatment — but there is also an industry of making “advanced” or “technical” core training into the centerpiece of rehabilitation. Alas, this is another dud: the evidence is overwhelming that it just doesn’t do much, if anything, that ordinary exercise would do without any of the pretensions … or cost.

- Many professionals (but particularly chiropractors and Rolfers) specifically claim to be able to treat scoliosis — leading to meaningful improvement in pathological spinal curvature. While much of this is just well-intentioned wishful thinking, a lot of it borders on irresponsible quackery (and some steps right across the line). Anything’s possible, but please take this claim with much more than a grain of salt — more like a brick.

- Prolotherapy is the injection of an irritating substance to “toughen up” ligaments. Although it has been around for 50 years and is still a common alternative option, it has been proven ineffective.

- Chiropractors (almost exclusively) sell and oversell spinal traction contraptions — absurdly expensive for the chiropractor, who passes that cost on to patients. This is quackery. Although a tiny fraction of patients may respond well to it, traction is possible much more cheaply and safely.

4.1

An introduction to your care options

March — Major 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.

There are hundreds of treatment options for back pain that you have to get someone else to help you with. They are provided by at least a dozen distinct professions and medical specialities, plus many more that may contribute in various ways. For instance, mental health professionals are not “spine specialists” in any sense, and they are definitely not the first choice for most people, and yet they are an important part of the mix, especially for many patients cruising into their second or third year of pain.

Bad reasons for seeking help

Maybe the answer seems too obvious, but in my experience almost everyone who hires help is hoping for identification of a specific problem, and for “repair” of that problem. I call that the “seek and destroy” model. Those reasons don’t even make it onto my list, basically because they are unrealistic goals.[323]

Please do not look for a “back pain whisperer.” It’s nearly impossible to tell the difference between a genuine expert and a charming bullshitter. People have often tried to cast me in the role of a pain whisperer. When I worked as a massage therapist, people often said to me, “Wow, you’re busy and expensive: you must be good!”

“Maybe,” I would reply. “Then again, I might also just be charming and a good businessman. You really have no way of knowing.”

The idea of the exceptional clinician is mostly a pernicious myth. Yes, some people were at the top of their class, and some actually are unusually talented… but they are rare, and even they are not really much better at treating back pain than anyone else. Health care is not like sports, with an elite class of gifted people that consistently win. It’s more like gambling or investment, where uncontrollable variables dominate the equation, and the elite are defined more by their restraint and wisdom than special skills or insight. If they are truly knowledgeable and talented, then their superpowers will mostly be disappoint the desperate: restraint, humility, good communication, and doing no harm with bogus diagnoses & treatments.

Back pain is much too multifactorial and mysterious for any clinician to have consistently superior results. To the extent that they do, it is almost certainly because of exceptional charisma, empathy, and the ability to reassure… not their methods or savvy.

Better reasons for getting help

I think there are three good reasons for a patient with chronic low back pain to find and work with a knowledgeable professional:

1. Screening for more serious problems, of course. As chronicity sets in with no apparent explanation, new worries and red flags inevitably pop up. When they do, it’s important to re-open the medical investigation — usually because the results are reassuring. And if they’re not reassuring, if something gets found, it’s even more important to know!

2. Coaching, training, brainstorming, reality checks, etc — “talk” therapy, working on the mind game. Anyone with the right attitude and level of knowledge will do for this purpose. Their profession is irrelevant.

3. Some hands-on help with trigger point therapy — potentially curative, routinely helpful, or at least just soothing (when it’s done right). And soothing is always important, for any chronic pain problem. Literally the only people this doesn’t apply to are the few people who just don’t care for massage — you’re rare, but you exist!

There are definitely some other possible reasons — like that “repair” thing, which is great if you can actually find it, but don’t hold your breath — but these stand out for me. I found that coaching was my primary role in helping people with low back pain: my hands-on skills as a massage therapist were always of relatively low importance. The main thing was always that I could help people understand the nature of their back pain, educating and reassuring people as they faced challenges or setbacks, helping them to stay focused, and troubleshooting self-treatment problems. To some extent I’ve been able to continue in this role as the author of this book, as an educator, for 8 years now after my retirement from massage therapy.

A knowledgeable physical therapist can slowly build up patients’ confidence by reassuring them that there is no structural problem and reminding them of the physiologic reason for the pain …

John Sarno, Mind over Back Pain, p92

•

So, how do you get the professional help? How do you find someone who will give you that kind of help?

It is usually a wild goose chase to find a professional who really “gets” low back pain. You could easily see a dozen professionals of all kinds, or any kind, without encountering any real low back pain intelligence. Finding someone to be that expert coach and guide is tricky. All of the sections below are intended to help you understand the options and choose more wisely.

4.2

Physiatry for low back pain

It’s good to have a physiatrist when you have stubborn low back pain. Physiatry, also known as physical medicine and rehabilitation (PM&R), is the branch of medicine most valuable to patients suffering from any kind of musculoskeletal pain and dysfunction. In Canada, this specialization involves a five-year residency (four years in the US) after medical school. Practitioners are qualified to screen patients for more ominous causes of pain — something many non-physician health professionals often fail at, for lack of training. In other words, if it turns out that your back pain is caused by a cancer or a developing case of rheumatoid arthritis, this medical specialist may spot it the soonest.

The best reason to seek out a physiatrist for back pain is that many of them are educated about muscle pain (yay!) and can find and manipulate trigger points manually, or with dry needles, saline injections, local anaesthetic, or perhaps even Botox (though the effectiveness of Botox, once considered something of a magic bullet, has been in doubt since a 2007 study in the European Journal of Pain[324]). So for patients with really difficult trigger points, a physiatrist will offer the most impressive array of trigger point treatment options.

However, like all other medical specialists, physiatrists can’t know everything, and they may be preoccupied with continuing education about severe conditions and be disinterested in or less informed about milder chronic pain problems. And, yes, they may perceive low back pain as a “mild” problem — compared to something like, say, muscular dystrophy. Since they deal with some extremely ill and injured people, some physiatrists may even be dismissive of low back pain. I have seen patients falling through that crack: hurting badly enough to be miserable, but not badly enough to be of interest to a physiatrist.

With my apologies, this annoying message from the management is repeated 3 times in the book to discourage piracy. Online access to this book was purchased by Vladimir Stoyanov. If you did not personally borrow this book from V. Stoyanov, it is pirated! Please purchase your own copy. Thank you for supporting a small business and low-DRM publishing. what’s that? ~ Paul Ingraham, Publisher

4.3

Massage therapy for low back pain

Despite some serious concerns and a near perfect lack of scientific support (thoroughly discussed above), I still believe massage therapy is probably the best of the manual therapies for low back pain. At worst, competent massage therapy may be ineffective, but it still offers substantial “consolation prizes.”

Despite the lack of evidence, massage has had many endorsements from experts over the years. Back pain expert Dr. Richard Deyo is openly skeptical about other back pain therapies, but has shown a persistent enthusiasm for massage for many years.[325] Another well-known medical skeptic and mythbuster, Dr. Edzard Ernst, found studies of massage therapy for back pain were poorly designed, but “ …massage seems to have some potential as a therapy for low back pain. More investigations of this subject are urgently needed.”[326] And Patrick Wall, eminent neurologist and pain researcher, writes just a single persuasive word about massage therapy in his seminal book about pain: “delightful”![327]

For whatever that’s worth. Such comments hardly constitute good evidence, but it’s nice that massage therapy is the only physical therapy for low back pain that actually gets a bit of a “thumbs up” from the medical experts and skeptics. It’s better than a thumbs down.

Massage therapy is also less likely to do harm than other physical therapies and treatments, all of which have real risks, more risks in the low back than with other parts of the body. Even after reading this tutorial, many patients still have persistent fears and doubts about the stability and structural integrity of their back. Low back pain is more intimidating, frightening, and demoralizing than most other common pain problems. And, in that emotional context, many other therapies are riskier — whereas massage therapy tends to be and seem gentler, safer, and more reassuring. There is such a thing as overly aggressive massage, but it’s relatively rare.

By contrast, many people are outright afraid of chiropractic adjustments for the low back. Done properly, spinal manipulations are unlikely to pose a problem for a confident patient — but combining a nervous patient with a strong chiropractic treatment is a recipe for disaster. I have heard many stories over the years about people who had terrible, painful chiropractic adjustments that really set them back. Massage compares extremely favourably with this.

Or consider that physiotherapists routinely prescribe many therapeutic exercises, all of which have the potential to be hazardous. Again, usually these prescriptions will be conservative and safe, but some patients do get hurt trying to follow them — either because too much exercise was prescribed for core musculature that was not ready for it, or because the patient was too gung ho in following the prescription.

So massage therapy is quite safe. The worst case scenario is a massage therapist who uses intense pressures, which can — like an aggressive chiropractic adjustment — exacerbate the problem rather than helping. However, such aggressive treatment happens more slowly, happens in degrees, and is easier for a patient to spot and limit. Do not tolerate excessively strong pressure in massage therapy.

The main advantage of seeking care from a massage therapist is that they are most likely to either know a little about trigger point therapy, or to treat trigger points by accident simply because any muscle stimulation tends to be at least somewhat helpful for trigger points. Like pizza, trigger point therapy is pretty good even when it’s not very good.

The main problem with massage therapy is simply that so many massage therapists are not very well-educated in general — standards for training and certification vary widely around the world — and even well-trained therapists tend to have only basic knowledge of trigger point therapy.

There is much more information about how to find a good massage therapist in the trigger points tutorial.

The effects of massage on anxiety and depression (and the relevance to back pain)

There is an entire additional layer of reasons to buy professional massage therapy.

Myths about the effects of massage abound. I describe many of them in my general review of massage science, Does Massage Therapy Work? Massage does not flush lactic acid out of cells, or meaningfully increase circulation, or reduce cortisol levels, or reduce inflammation. As you’ve read above), it is still not remotely proven that massage helps back pain, or that it does it by treating trigger points. That’s still just a promising theory.

But there are two clearly beneficial effects of massage that are really, truly proven.[328]

- massage substantially reduces anxiety

- massage substantially reduces depression

If all else fails, the right kind of massage is going to do at least that much. This gives a substantial boost to the value of hiring a massage therapist to help with back pain.

Anxiety and depression are clearly tightly woven into the story of most cases of chronic low back pain. At the very least, they are complications of a bad situation. At most, they could be root causes of back pain in the first place — and therefore treating them could constitute a cure. The truth is likely in the middle: they are not the ultimate cause, but they can make a bad situation worse as a key part of the vicious cycle. Therefore, anything that relieves anxiety or depression offers some real leverage over back pain. And it should be clear by this point in the tutorial that any unambiguously good news about low back pain treatment is quite precious! There’s just not enough of it.

It is even possible that one of the reasons massage seems to help back pain — the modest evidence presented earlier — is via the mechanism of relieving anxiety and depression. Unknown. But possible.

Obviously self-massage is unlikely to have this effect (although that’s just an educated guess). Most likely it is derived from the (social, neurological) power of touch — a “grooming” effect — and is probably a vestigial remnant of the absolute need that infant mammals have for tactile stimulation. Without it, they usually cannot survive at all. Adults are less vulnerable to tactile deprivation but apparently still benefit substantially from a surplus.

In short, if you can possibly afford professional massage therapy, you cannot lose: it is worthwhile for this reason even if for no other.

This effect is also why you must avoid aggressive, no-pain-no-gain massage therapy. If the experience is not satisfying and soothing, it will probably not reduce depression or anxiety. Fire any therapist who does not respect this equation: literally the only truly evidence-based effects of massage!

Sloth Cuddles Cat 4:15

The power of touch is strong in these two: a sloth lovingly, thoroughly grooms a cat. So affectionate that it’s almost creepy…

4.4

Buying trigger point therapy rather than back pain therapy

One approach to getting helping for back pain is to focus mainly on finding help with muscle knots only. Don’t go to a therapist and say, “I have back pain, what’s the answer? What can you do for me?” Instead, say, “Help, I’ve got nasty knots and spasms in my back, and I need trigger point therapy!” Don’t even call it “low back pain.”

In other words, approach this like you are buying plumbing services, like you already know what your problem is and you just need someone with the skills and equipment to do the actual work. Don’t go in and just hope they will do trigger point therapy — find someone who will supply that service. Be an assertive consumer! You need a specific service, period, not an all-knowing miracle worker, not a back pain troubleshooter. It is easier to find a health care professional who understands enough about myofascial pain syndrome to simply help you with your trigger points than it is to find one who will avoid structural diagnoses and the many red-herring treatment options for structural problems.

Unfortunately, “much easier” doesn’t mean it’s easy — just easier. Trigger points remain medically obscure — they are largely unknown to every category of health care professional. Even the one kind of therapist that seems most likely be able to help — massage therapists, professionals who work directly with muscle tissue every day — are often unprepared for challenging cases. I have received email from actual working massage therapists who confess that they didn’t know anything about trigger points until they stumbled on this website.

On the bright side, even severe low back trigger points may go away simply with increased confidence and the normalization of movement and activity that comes with it. The education you are getting in this tutorial will actually make it much easier for a therapist to work with your trigger points. If you go in confident and prepared, and you’re already working on good self-treatment, then the need for a truly expert trigger point therapist is reduced. An average one will do!

So, whom do you hire if your focus is on finding trigger point therapy?

Your first choice should probably be a massage therapist or a medical specialist called a “physiatrist” — ideally both. Physiatrists specialize in musculoskeletal pain, and they are the most likely of all medical specialists to be smart about low back pain. Massage therapists are the most likely of all professionals to be able to help you with muscle pain and trigger points (even if they don’t know much else about low back pain). Both kinds of professionals may not work out — a physiatrist might be focused on more serious medical problems, like rehab from severe neurological injuries.

You might also hire a chiropractor you like, if they practice a massage technique like ART®, and/or if you feel that back cracking and manipulation feels especially useful to you — some people really crave the crack.

Physical therapists are usually a poor choice for trigger point therapy specifically, particularly in North America where a “hands-on” style is less common. However, many of them do dry needling: lancing trigger points with acupuncture needles.

Another option: find a physiotherapist or doctor who practices “medical” trigger point treatments, such as dry needling, stretch and spray, or trigger point injections.

All of these options will be discussed in more detail in the next few sections.

Safety of the therapy options

Nothing is risk-free. Pain-killers can actually kill (rarely), even exercise can backfire (common, but rarely serious), and those costly trips to the massage therapist, chiropractor, or physical therapist? About 30% of them will cause some kind of unpleasantness — usually no big deal, but that huge percentage is noteworthy given the cost.[329]

The risks are probably even higher with trigger point therapy, because so many therapists have an unjustified belief that intense therapy is necessary to “destroy” trigger points. There’s a lot of overlap between “deep tissue” massage and amateurish trigger point therapy, and intense massage can backfire and make you feel worse, a well-known phenomenon call post-massage soreness and malaise.[330]

I’ll discuss some more specific examples of potentially dangerous styles below.

4.5

Spinal manipulative therapy (SMT): Adjustment, manipulation, and cracking of the spinal joints

2017 — Science update: Discussed important new review of SMT for acute low back pain. Significant revision of the section.

by Gary Lyons

Redundancy warning: the discussions of subluxation and spinal manipulative therapy are extremely similar in both the neck and low back pain tutorials. One key difference is the discussion of risks — SMT for neck pain may involve rare but serious risks (paralysis, death), while the risks for back pain are much more common but also less severe (mainly pain exacerbation and scaring patients).

The idea of “adjusting” the spine refers to many different manual therapies that wiggle, pop, and otherwise manipulate spinal joints. The official term for these treatments is “spinal manipulative therapy” or SMT. This is one of the most famous of all hands-on therapies and the foundation of the chiropractic profession, but it is also widely practiced by physical therapists and osteopathic physicians.

Expert opinions on SMT range widely. The treatment depends heavily on the strange idea that spinal joints can be “out” in some sense in the first place, especially in the low back. This is a dubious premise, but even if it’s true it’s doubtful that anyone can do anything about it with their bare hands. But there’s no need to speculate: this treatment is relatively well-studied for musculoskeletal medicine, and although technically still inconclusive due to a lack of truly good quality studies, it has become an argument over scraps. The research clearly show that SMT’s benefits are probably small and unpredictable at best, and there are also risks, even including paralysis and death in the case of SMT for the neck. No one should ever get their neck “adjusted” without some understanding of these issues!

To support that pessimistic summary, I’ll focus on two recent scientific reviews about SMT for acute back pain.[331][332]

Historically, SMT for fresh cases of low back pain has often been presented by proponents as the best example of evidence-based care routinely offered by the chiropractic profession, but critics have pointed out that even this “best” use of SMT has been damned with faint praise by the research. Both of these credible reviews back up the critical view. The first concluded that “SMT is no more effective in participants with acute low-back pain” than shams and placebos. Weirdly, the second has been loudly touted by SMT proponents as good news, which it isn’t. Claiming it as a victory is one of the best examples I’ve ever seen of making lemonade out of science lemons! The review actually reported trivial benefits only, just 1-point improvement on a 10-scale at best,[333] which is about the same as you’re going to get from Advil. And it gets worse! Paige et al also identified lots of treatment backfires — minor ones, but who wants to spend the time and money on spinal adjustment to get more pain?[334]

Such results make it impossible to be enthusiastic about SMT for low back pain, acute or otherwise. SMT fails the “impress me” test — it clearly isn’t working any miracles.

And yet spinal “adjustment” and joint popping specifically is something that people do have a curiously strong craving for, and most clinicians — including myself, and more credible skeptics like Sam Homola, DC — still believe that some forms of SMT can be helpful to some of their patients, some of the time. Something of therapeutic interest seems to be going on in SMT in at least some cases. At the very least, in the right situation, SMT seems to be able to provide a blast of novel sensory input that the brain can put to good use, reinterpreting the painful situation in a positive way: a purely psychological and neurological effect, but also more than a placebo.[335]

But that blade cuts both ways! Just as the sensations of SMT can be a relief and a comfort, they can also scare people. Some folks are naturally skeeved out by joint popping, like fingernails on a chalkboard; some are downright phobic about it; many more are vaguely uneasy about it, either regardless of back pain or because of it. So the main common risk of SMT is psychological: SMT often spooks patients, which is a serious risk factor for chronic neck and back pain. It’s not a life-threatening risk, but it’s not trivial either. The nervous patient has much to lose with SMT. Combining acute symptoms, minor potential therapeutic benefits, fear of your spinal fragility, and fear of the treatment could be a recipe for disaster. I have often seen patients in this state: traumatized by an experience with SMT that increased their pain, powerfully feeding their fears.

My advice to patients is to avoid SMT completely if the idea gives you the willies. Never submit to spinal adjustment if you don’t feel comfortable with the idea. Even if you do, make it a low priority treatment option, something to try when most other options have been exhausted. If you already don’t know a chiropractor whose judgement you trust, consider seeking out a physical therapist to adjust your spine, where you’ve got better odds of a more cautious and evidence-based approach. And learn more about it first: this section is just a summary. The topic is explored much more thoroughly in a dedicated article:

Does Spinal Manipulation Work? Spinal manipulation, adjustment, and popping of the spinal joints and the subluxation theory of disease, back pain and neck pain       ~ 14,000 words

4.6

Physical therapy (physiotherapy) for low back pain

Physical therapists — better known as physiotherapists many places — have a large repertoire of treatment methods for low back pain. Their training and licensing give them nearly unlimited options — everything but surgery and prescription drugs. This is both a strength and a weakness. As a general rule, they are much less likely to indulge in the crank theories and quackery so prevalent in the alternative professions. And the best PTs are superb generalists that any back pain patient would be lucky to work with. I personally know some extremely admirable physical therapists. But the best are also hard to find, and the services of average practitioners are … well, “uninspiring” is a gentle way of putting it.

I have trouble recommending physical therapy for back pain patients because of it.

Unfortunately, in North America particularly,[336] the profession of physical therapy is “still dominated … by its original, now obsolete, structure-based ‘bio-medical’ model.”[337] and by a rather bland selection of antiquated treatment methods. Specifically, physical therapy is often limited almost exclusively to:

- passive therapy (being manipulated by the therapist)

- exercise therapy (particularly strength/core training)

- therapeutic ultrasound

- transcutaneous electrical nerve stimulation (TENS)

- hot and cold packs

If I had a buck for every time a client reported that a physiotherapist just “stuck a TENS machine on me and left the room,” I could pretty much retire. These typical treatments are still so commonly offered that they basically define the profession. By no means are the typical treatments the only treatments offered by physiotherapists, but they do dominate.

For example, someone I play sports with asked me, “What do physiotherapists do? They use that little machine, right? Ultrasound, right?” That was sometime in 2012 — pretty late in history for physical therapy to still be defined by the use of ultrasound in particular. Almost any physical therapist (but particularly the more educated ones) would cringe to hear their profession reduced to that, but that public perception about physical therapy was created by using ultrasound on most patients for decades. And ultrasound is still common!

So how about those typical physical therapy treatments? Exercise therapy, ultrasound, TENS machines, and so on? Do they help?

The hardest one to judge is exercise therapy, because it’s a broad category. Exercise/activity can certainly be helpful with smart and minimal prescription and guidance. However, in my experience, exercise prescribed by physical therapists for back pain is overwhelmingly simplistic,[338] heavy-handed, and excessive — and often in a transparently self-serving way (to pay for an in-office gym, for instance[339]). Even prescribed artfully and minimally, exercise is hardly a one-way ticket out of back pain — as typically prescribed by physical therapists, an exercise prescription is a prescription for wasting time and money.

Hot and cold packs were covered above; although they are occasionally helpful, the idea that it’s worth professional rates to have them applied by a professional is absurd.

Ultrasound and TENS machines — stimulating muscles with sound waves and electricity — are both equally underwhelming therapies. Both of them have been undermined or damned with faint praise by one scientific review after another for more than a decade now. I’ve moved both of these treatments to the bogus cures section.

Note that TENS and ultrasound might be a little more promising if specifically used to treat muscle pain. (That is discussed in detail in the trigger points tutorial.) But it’s unusual for physiotherapists to use these techniques with that intention, without which results will probably be poor — and it’s not like they had much potential to begin with.

Typical physical therapy was slammed in an interesting way by a damning comparison to, of all things, acupuncture (this study will be discussed in detail below in the acupuncture section). In a nutshell, the study showed that common treatment methods like those listed above were collectively less effective than sham (fake!) acupuncture. The results tend to suggest that you could literally get better results receiving fake acupuncture than by going to see the average physical therapist.

There are many similar examples. A mixed bag of standard physiotherapy is often used as a basis of comparison in research, and it rarely performs well when compared to or combined with other treatments. For instance, a 2010 study in Physical Therapy showed no sign that treatment with physical therapy after a nerve block helped people to recover any better. That’s obviously a thumbs up for that kind of nerve block … but it’s a clear thumbs down for typical physical therapy for sciatica.[340]

This kind of evidence suggests to me that paying for physiotherapy is a crapshoot, far too dependent on the individual professional and his or her expertise and choice of treatment techniques — which can vary widely and be extremely difficult for patients to judge. If you can find a physiotherapist who likes to work with his or her hands — many are surprisingly hands-off, preferring to prescribe exercises and use hardware — who knows something about trigger point therapy, then by all means I encourage you to work with that therapist. If you can find him or her.

4.7

“Medical” treatment option for trigger points: dry needling (IMS), stretch and spray, and trigger point injections

There are three common “medical” treatments that may be effective for trigger points — all options to consider for low back pain. They all come up fairly often for low back pain patients, because so many people have such severe back pain and it often feels like a muscle pain problem. Those medical professionals who know about trigger points may well suggest one of these:

1. Stretch and spray — stretching musculature while simultaneously applying a cooling spraying, for an alleged neurological relaxation effect.

2. Dry needling (or intramuscular stimulation, IMS) — provoking or stimulating trigger points with an acupuncture needle or a fine injection needle.

3. Trigger point injection — treating trigger points with an injected medicine or even just saline solution to “dilute” them.

All three are discussed in considerable detail in the trigger point tutorial, and there is not much to say about them for low back pain specifically. None are particularly reliable treatment methods, and the needling methods tend to be very painful and have minor risks — especially to low back pain patients. Painful treatments are a potential disaster for all patients, but the risk is definitely dialed up for low back pain, where anxiety can play such a major role. Patients with particularly severe pain seem to respond better to dry and wet needling — but I’ve also seen the intensity of the experience terrify and intimidate patients, confirming their worst fears.

Also bear in mind that even practitioners of these therapies — who usually understand trigger points well, whose training and experience should lead them away from structural diagnoses and towards an appreciation of just how potent and insidious muscle pain can be — often still perpetuate the myths of back pain. One of my clients recently fired her IMS practitioner because she (the therapist) showed excessive zeal for trying to diagnose and treat trivial postural dysfunctions — she was more interested in the effect of trigger points on posture and biomechanics than their role as direct pain-causers. It wasn’t working, of course. Sadly, the only unusual thing about this situation is that my client was knowledgeable enough to walk away.

4.8

What about surgery?

For many years I avoided writing about surgery because it was too far outside my expertise. However, as I have consulted with hundreds and now many thousands of patients and readers, corresponded with many of the world’s experts, and studied the scientific literature day in and day out for years, I am comfortable “going there,” at least a little. Nevertheless, this section is still “under construction” — that old website cliché — and there is a great deal that could be said about surgery that isn’t included here yet!

For now, there are two subsections here: one about surgery for sciatica, which is just a straightforward, bottom-line guide for patients considering that option.

The other section is all about the placebo problem with surgery, which explains why we still have surprisingly little good surgery science to go on. It’s fairly philosophical, and many patients might find it a bit dense to read. But it’s also sprinkled with practical clues about the value of surgery, and it provides a lot of good perspective. For anyone contemplating back surgery of any kind, it is worth the investment of time to stare at it for a little while! And professionals should, hopefully, find it all quite fascinating.

4.9

The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries

Placebo is a fascinating phenomenon, and its role in back surgery says much about the failure of medical science to come to grips with back pain. It’s important to emphasize the surprisingly poor state of scientific knowledge about the effects of surgeries in general, especially orthopedic (“carpentry”) surgeries, and back surgeries most of all (references coming). Referring to surgeries for pain problems, Nikolai Bogduk said:

Proper research is rarely undertaken and typically comes late, often 10 to 20 years after the first invention of the procedure. This is opposite to the way scientists behave in other disciplines, where if the results are negative, that should lead to cessation of the procedure. This never happens. Once it’s established, despite the evidence, invasive procedures keep being perpetuated.

~ Dr. Nikolai Bogduk, at the 2003 American Pain Society AGM

Much more evidence will be presented below, showing that even the most common low back pain surgeries have still, as of 2016, not been properly studied. And here’s the placebo problem in particular: even when back surgery appears to be effective, it’s possible, even likely, that the benefits are due mainly to the power of wishful thinking.

Placebo is a therapeutic effect produced by belief in the efficacy of a treatment or medication, and is believed to be why faith healing and snake oil are sometimes effective. Placebo has been known to “cure” many conditions that don’t superficially seem to have much to do with the mind. My favourite example is hair growth. Apparently, you can grow hair by sheer force of optimism: a 1990 study right here in Vancouver showed that men who received a bogus hair-growth treatment grew almost as much hair as people who received a real treatment: a 25% increase over baseline, compared to 66%.[341]

The surprising effectiveness of the real treatment overshadowed the significance of the placebo effect: the men in the control group grew hair because they expected to! Sure, it wasn’t as much hair — but they still grew plenty of hair! Wow. That is weird. Other good examples of strange placebo effects:

- improving pilots’ vision

- helping people lose weight

- boosting IQ by a few points

- controlling blood sugar

The importance of fake surgeries

Another striking example — and now returning to surgery — is a now-famous study conducted by the U.S. Veteran’s Administration in 2002.[342] For this experiment, three hundred people with osteoarthritis of the knee were operated on. Half were given a standard knee surgery, widely considered an effective solution for a clear, mechanical knee problem. The other half were given a bogus surgery: a probe was inserted into the knee and removed. Incredibly, both groups experienced equal improvement in their knee pain. The lead author, Dr. Lorimer Moseley — a bit of a rock star of a pain researcher from Australia — was quoted after publication, “We don’t really understand the placebo effect.” Understatement.

That was only the first of several studies like this, all demonstrating that popular orthopedic surgeries cannot beat fake surgeries.[343]

Placebo is a force to be reckoned with, and researchers need to compare all kinds of treatments with placebos and sham interventions whenever possible — but especially when the treatment is expensive or risky. It’s unethical not to do the studies. Comparing an experimental group receiving a real treatment with a placebo group is the most important method of controlling a study. Wikipedia: “The importance of having a control group cannot be overstated.”[344] Scientists consider an uncontrolled study to be of lower quality, potentially meaningless or misleading.

But surgeons have been sloppy about this historically, typically doing “inbred” studies that compare only different kinds of surgeries to each other, rather than comparing them to sham surgeries and other kinds of therapeutic interventions, or to no treatment at all (another kind of experimental control).[345] This is the placebo problem with surgery. This same point is made in detail by an orthopedic surgeon. He has devoted a blog to it,[346] and now an entire (excellent) book, Surgery.[347] As he explains, you “need a placebo [surgery] trial when the outcomes are ‘soft’ (subjective: pain).” Need! It’s just the only way to know if a real surgery actually works on back pain. This is Research Methodology 101. And yet it doesn’t happen.

Incredibly, there has never been a placebo-controlled study of any kind of common back surgery. When I started researching for this tutorial, one of my primary goals was to find evidence — if it existed — about the effectiveness of surgery in treating back pain. What I found was a mess of inadequate evidence pointing in both directions … and simply no truly controlled studies at all. And none has appeared in the decade since I first started paying attention. Until someone has compared the results of real spinal surgeries with faux surgeries, we can never truly know if a seemingly effective spinal surgery is actually helping people … or if the hope it gives people just creates a positive outcome for some.

Time for a good specific example.

In the summer of 2007, The New England Journal of Medicine — arguably the most credible medical journal on Earth — published the results of an otherwise fine study of microdiscectomy[348] that was conspicuously uncontrolled. Because of its fine pedigree and good design, surgeons are likely to carrying on citing this study for many years when recommending surgery to their patients. For the most part, I think that’s fair. More important, so does back pain expert Dr. Richard Deyo, who agrees that this research “bolsters the case that surgery is effective for patients with sciatica owing to herniated discs.”

However, the failure to compare microdiscectomy to placebo is worth discussing in more detail.

The focus in this experiment was on the timing of surgery. Rather than trying to figure out whether or not surgery should be done in the first place, they started with the assumption that it should, and set out to determine the best time for surgery: ASAP? Or wait and see for a while first? They compared the results of 125 microdiscectomies that were performed sooner with 142 that were done later. Those who waited were cared for minimally by family doctors who reassured them that most sciatica goes away within a few weeks — true! “confidence cure” — and then offered them surgery if their sciatica persisted for six months. They found that “the rates of pain relief and of perceived recovery were faster” for those who had surgery promptly, even though almost everyone was fine after a year regardless of when they had surgery.

In short, the sooner these patients had surgery, the sooner they felt better.

Seems compelling. But although it convincingly shows that getting a microdiscectomy sooner as opposed to later is probably a good idea, this research can’t convince anyone that either surgical timing is better than a fake surgery, or better than nothing at all. It might be, but how can we possibly know from this evidence? That’s the placebo problem. Read on, and discover the significant problems with this research and that the same authors later did a better experiment with worse results… and they even admit the need for comparison to placebo.

Subjects who’d received no surgery at all might have recovered faster than either group, or at least no slower (exactly as with the knee surgery example above). But what if the study was only determining the lesser of two evils? There is no way to know without comparing those who received surgery to people who didn’t.[349] And a comparison to a sham surgery comparison would have been even more informative, because the benefit of prompt surgery might have been due to a placebo effect. Early intervention could well seem more decisive and proactive to patients, and therefore significantly increase their optimism for a good outcome, and decrease their anxiety. “We’re nipping this in the bud! Hooray!”

Expectations have been shown to be a major factor in recovery from back pain.[350] But patients who have already been in pain for months by the time they have surgery may be much more weary and cynical, and therefore have much lower expectations of recovery. Psychological forces were at work on these patients, we know that those forces matter — we know that placebo can be a large factor even in situations where no one expected it — and that they could invalidate the results. Yet the researchers did not design their study to check for this. And what a shame, because it would be nice to know!

In 2008, Peul et al went on to perform a better microdiscectomy experiment.[351] Those results were so much less impressive, showing much less benefit to sciatica surgery, that they wondered “whether surgery has any effect at all on the natural course of sciatica”! And then they directly suggested that this surgery should be compared to a placebo: “One may decide that a randomised trial of microdiscectomy versus placebo or sham surgery is needed to evaluate the effectiveness of surgery accurately.”

Did I call that or what?

I am not the only commentator who has noticed the lack of well-controlled surgical trials. Ironically, the very authors of the microdiscectomy study discussed above also wrote that “the only study, which compared surgery with conservative care directly in a RCT, was performed by Weber more than 20 years ago.” But they also make note of other weaknesses with that paper, and conclude that “it is impossible to extrapolate and generalize these results to the treatment policy of today.” They are saying that properly designed research of low back pain surgery has never been done.

Nachemson wrote in 1992, “ …the effectiveness of surgery [is not] proven by acceptable clinical trials.”[352]

Gibson wrote in 1999: “There is no scientific evidence about the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative treatment.”[353]

So, have things improved since then? No. Lumbar microendoscopic discectomy has been an increasingly popular form of surgical treatment for low back pain.[354] Although a considerable amount of research has been done, as of 2016, there are still no controlled studies of this technique — just a lot of studies comparing different methods of doing microdiscectomies.

Spinal fusion: the king of back surgeries

Evidence has been mounting that the most popular back surgeries are not just ineffective but actually dangerous, particularly the king of back surgeries — spinal fusion. A big 2011 study of hundreds of “victims” of fusion surgery found shockingly poor results from this incredibly common procedure.[355] Patients suffered “significant increases” in nearly every possible negative outcome in the two years after fusion surgery — significantly increased disability, opiate use, prolonged work loss, and poor return-to-work status. Even more recent evidence has piled on, clearly demonstrating that fusion is ineffective at best.[356]

I think the nail-in-coffin study arrived in 2016 with the publication of the results of long term experiment comparing spinal fusion to physiotherapy over more than a decade. At first glance, it doesn’t seem to contain the “last word” on spinal fusion: on the contrary, it seemed to produce contradictory and inconclusive results. By some reckonings (types of analysis) patients felt better off after fusion, even after many years, even though they didn’t “act” like it (as measured in terms of things like work status and medication use).[357] But this good-news-bad-news result was an illusion created by a summary of the paper that was “highly biased and selective.”[358] The authors cherry-picked the best possible sounding news from their own data. Call me crazy, but maybe that was because the paper was funded by a company that makes surgical instruments. Just sayin’!

The bottom line? Fusion is a terrible option for most people with back pain. Although “more study needed” is a cliché in medical science, it’s not always true. Saltychev et al produced such resoundingly negative results that they think it’s “unlikely that further research on the subject would considerably affect this conclusion.”[359]

But Hedlund et al.’s biased conclusions are still interesting to us, because they put a spotlight that glaring disconnect between post-surgical perception and reality. Subjects in their study really did believe they were doing well, even though the evidence is quite overwhelming that they were not doing well. Many of them may have even been doing worse. It’s yet another demonstration that patients get some significant benefits from wishful thinking… and nothing makes us wish harder than getting a big-deal surgery. If nothing else, we badly want it all to have been worth it.

John Sarno does not mince words on this subject. He makes it clear that back surgery has a strong placebo effect: “ …surgery is a powerful placebo, perhaps the ultimate placebo. The effectiveness of a placebo is directly proportional to the impression it makes on the patient’s subconscious mind.”[360] And this is undoubtedly why you can find positive evidence about fusion[361] … even in Hedlund et al.’s nail-in-coffin study!

This tutorial has already presented strong evidence that structural deformities like disc herniations are a much less important factor in back pain than doctors once believed. Yet all back surgeries, by nature, are intended to correct structural deformities. Given the mixed results of most back surgeries, it is reasonable to speculate that surgery, when it works at all, may do so more because the patient believes in the treatment than because it is inherently valuable.

At the very least, it seems essential to do some properly controlled research. The failure of medical science to do so — yet — is a serious limitation on our knowledge.

4.10

Surgery for sciatica (microdiscectomy)

Surgery for sciatica is only an option when it is caused by a herniated disc, as opposed to when the sciatic nerve is being impinged by the piriformis muscle, or (obviously) if sciatica-like symptoms are being generated by muscle knots alone.

Even when there is a herniated disc, surgery should be seriously considered only in the most painful and persistent cases. Bear in mind that herniated discs are not necessarily painful. Even if they have made an appearance on an MRI, that does not necessarily mean that they are related to your problem. Or it might be. The idea of microdeskectomy is to cut away the disc that might be irritating the spinal nerve roots that the sciatic nerve comes from.

In 2008, a group of Dutch researchers published the results of a good study of surgery for sciatica.[362] (This is the same study discussed in detail in the placebo section.) Although not perfect, it is certainly the best such experiment yet performed, and will be more or less the “last word” on the subject for a while, the new-and-improved conventional wisdom. This remains the case as of 2016. (It is also quite readable for a scientific paper, and keen patients or professional readers might want to browse the full paper, which is freely available.)

Peul et al found that operating relatively quickly — not long after diagnosis — “roughly doubled the speed of recovery from sciatica compared with prolonged conservative care.” However, that sounds a lot better than it actually was: the speedy recovery didn’t last for long. In fact, “These relative benefits of surgery, however, were no longer significant by six months’ follow-up, and, even at eight weeks, the statistically significant difference between treatment groups in primary outcome scores was not sufficient to be clinically meaningful.” In other words, the effect of early surgery was quite underwhelming. A graph shows this very clearly:

That pretty much says it all, doesn’t it? For your trouble of getting cut open, you get a modest dip in pain in the early days, but soon after, you’re back in the same boat as the fellow who didn’t bother. “Neither treatment is clearly preferable,” the researchers concluded. They argued that it might be time to stop recommending surgery based on physician preferences, and start asking patients what they think of the options.

This study is less positive about than some previous ones have been. However, it was a more carefully designed test, and gives us many reasons to put more stock in its results. In fact, the results are so conclusive that authors wonder “whether surgery has any effect at all on the natural course of sciatica.”

We’ll never really know until someone compares real microdiskectomy to a sham surgery. Refreshingly, Peul et al actually suggested this. Unfortunately, it still hasn’t been done.

Slightly faster recovery and relief of leg pain might be worthwhile for some patients. However, much of this eagerness (and probably some of the pain) is driven by fear. As you’ve learned from earlier sections of the tutorial, back pain and sciatica have a unique ability to scare the pants off patients!

The risks of microdiscectomy are low as surgeries — but even with low risks, there is still a considerable financial, personal, and social “overhead” any time people get cut open. We should avoid any kind of invasive medical procedure unless the benefits are extremely clear.

Like a charge of murder, it should probably be proven “beyond a reasonable doubt” that surgery is worthwhile. Such proof is simply not present in this case of surgery for sciatica!

4.11

Needles for back pain: nerve blocks for facet joints and related treatments

2017 — New section: No notes. Just a new section.

Earlier in the tutorial, I explained the diagnostic power of nerve blocks (specifically medial branch blocks, or MBBs). If cutting off the nerve supply to a facet joint significantly improves your symptoms, then maybe the facet joint is the source of the pain — it’s not as sure a thing as we’d like, but it’s a good clue.

The same idea can also be used to treat facet joint pain. Three common treatments all try to stop facet joints from hurting: injecting various pain-relieving substances into the joint itself, the chemical nerve block, and actual destruction of the nerve (using a clever, no-needle method). None of these treatments should be considered until a facet joint pain source has been suggested by the results of a diagnostic MBB.

Why the focus on facet joints? They are a well-defined anatomical structure, which makes it easy to target — a case of “looking where the light is” (streelight effect) or treating where it’s easy to treat.

Another section covers acupuncture and dry needling, which are based on very different principles. This is about wet needling — injecting medications — and other methods of anaesthetizing spinal joints.

The evidence for treatment efficacy is mixed — of course! Results are far from guaranteed, about two kilometres from it. Benefits may be temporary and/or partial, and it’s not risk-free. The value of injections right into the joint is particularly questionable. A treatment does not have to be perfect to be worthwhile, and there is probably some good being done with these procedures, but not a lot, or the evidence wouldn’t be so thin.

The journal Pain Physician has published a few studies of facet joint injection treatments for the cervical and lumbar spine,[363][364] and the thoracic spine.[365] The only major review was published by Spine,[366] which was the most discouraging: “There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain,” although the benefits of some types of injection therapy for certain patients “cannot be ruled out.” The others were more positive, but also not based on much actual data. So what do the more specific reviews in Pain Physician have to say?

Much of what’s positive in them comes from a 2008 experiment (done by some of the same researchers), in which they gave medial branch nerve blocks to 120 chronic neck pain patients, and found that they produced “significant relief and functional improvement” in “over 83% of patients.”[367]

This study has been widely cited as near proof that nerve blocks work, and it is the main source of enthusiasm about needles for neck pain in recent history. I think it is pretty decent evidence, and so MBB is an option chronic neck or back pain patients could consider. However, as always, you have to read the fine print. A more detailed look at this paper is quite educational …

6 reasons to curb your enthusiasm for medial branch blocks as a treatment option

I can see at least 6 reasons why the Manchikanti et al paper is not exactly a slam dunk, and MBBs are no miracle cure:

1. “Over 83%” of patients sounds awfully good — and it is, for a neck or back pain treatment — but it’s hardly everyone. More than 1 in 10 people were not helped, even after a facet joint was “confirmed” as the source of pain by an earlier nerve block.

2. In science, the words “significant improvement” do not mean “cured”: they mean statistically significant, which is highly problematic. Statistical significance just doesn’t mean much. Those who were helped were not necessarily helped a lot — just enough that we can say, “Yep, that treatment was better than nothing.” So many of those people almost undoubtedly had results that were somewhat less than miraculous.

3. These patients didn’t just get one needle in the neck and then walk out the door with their “significant improvement.” They walked out the door … and then came back again a few weeks later for another dose. And another. The average number of treatments over the course of the year they were studied was, wait for it … three and a half, plus or minus one. That’s off to the pain clinic with you three, maybe even four or five times per year to get your “significant results.” That’s a fair amount of getting stabbed in the neck, I have to say. Is this procedure starting to sound a little less awesome than it did at first?

4. As implied by the need for repeat treatments, the benefits were not exactly long term. The average duration of average pain relief was 14–16 weeks, give or take a lot. Some patients were getting their statistically significant but probably minor symptom relief for only half that time — about a couple of months. No wonder they needed repeat treatments.

5. And, of course, it’s a minimally invasive procedure, and all invasive procedures have higher costs and risks, and should be avoided unless absolutely necessary.

6. Last and definitely not least, these patients were not compared to patients receiving any other kind of treatment or no-treatment or a placebo, which I find really strange. It leaves us wondering how well they would have done with no treatment at all. Spinal pain is notoriously unpredictable. People who receive no treatment routinely experience “significant relief” for no apparent reason. Thus, this study just doesn’t fully answer the question it asks — it can’t.

And that’s the most “promising” evidence!

Epidural injections

Epidural injections are a similar-but-different needling treatment, and “one of the commonly performed interventions in the United States.” Unlike MBBs, they are not directed at the facet joint in particular, but just squirt a dose of anaesthetic into the space alongside the spine inhabited by the spinal nerve roots[368]

The higher you go on the spine, the smaller the epidural space gets, and the more difficult and risky it is to stick a needle into it. Because of this, epidural injection techniques have long been more common and more suitable in locations from the upper back down, and their reliability and safety for neck pain has been considered dubious. However, it is becoming more accurate, practical and safe with new techniques. Fluoroscopic guidance! Ask your surgeon if he’s using it (and, if not, why not).

So, here’s a shocker: “The underlying mechanism of action of epidurally administered steroid and local anesthetic injection is still not well understood.”[369] And yet, despite the predictable mysteriousness of it, there is evidence that it’s helpful. In early 2009, Benyamin et al concluded that studies of epidural injections show “that they have a significant effect in relieving chronic intractable pain of cervical origin and also provide long-term relief.”[370]

But there’s that damn word again: “significant”!

4.12

Kill it with fire! Treatment by nerve destruction

2017 — New section: No notes. Just a new section.

Another way to treat pain — closely related to nerve blocks — is to destroy the nerves that detect possible tissue threats (nociceptors). If you can’t numb it… wreck it!

They are usually destroyed with heat: “kill it with fire!” Specifically, this is known as electrocoagulation or radiofrequency ablation (and other names and similar methods). A tiny probe delivers high frequency radio waves to the tissues, a cousin of what your microwave does to food. It’s a precise way of burninating things.

In the case of the back, it’s usually the nerves to the facet joints or intervertebral discs that are targeted.

This treatment approach might seem simplistic and destructive and maybe even a Very Bad Idea…and you could be right. Certainly it’s understudied, but it has produced some promising results for wrist pain, back pain, and tennis elbow.[371] This “circumstantial evidence” is better than nothing. On the other hand…

So what could possibly go wrong with denervation?

It doesn’t always work, of course. Which is a little surprising. Why wouldn’t destruction of nerve fibres completely, definitely solve the problem?

1. Most importantly, it might not be complete destruction: the surgery might not destroy enough of the right nerves.

2. Pain doesn’t actually come from nerves: they merely deliver information about tissue condition to the brain for consideration. The brain has other ways of deciding whether or not a back hurts, and it can simply ignore the eerie silence of destroyed back nerves. If the brain thinks your back hurts… then your back hurts. (Remember the phenomenon of phantom limb pain: if people can feel missing limbs, they can certainly feel partially denervated joints.)

3. The procedure might seem to work at first due to the powerful placebo effects that surgery can generate, only to reassert itself later.

4. Back pain has many possible mechanisms. Depending on exactly what’s going on, denervating a facet joint could be a clean miss.

So should you ablate? It might be worth a try for desperate patients only after plenty of other options have been exhausted. It’s most likely to work at least a bit if there is a strong clinical suspicion of facet joint or intervertebral disc pain specifically, as opposed to other sources (that are difficult or impossible to treat in this way). But the evidence is too limited and mixed for any real confidence.

4.13

Bogus Cures

There is an huge commercial market for back pain therapies, “solutions,” products, and information that will miraculously fix you right up. Google searches for “low back pain” produce, of course, a ridiculous number of options: more than thirty million of them the last time I checked, and with a plethora of “sponsored links” to boot.[372]

Naturally, most of the products are too good to be true. These can easily be identified by the hard sell tactics. These products waste your time and money, which is bad enough, but more importantly they postpone real understanding of the problem. Being distracted from your real education is better than being harmed by a pointless surgery, of course, but I think most back pain patients would agree that being distracted from good quality, evidence-based therapy is a serious problem!

No one sets out to be a sucker. In my experience, nearly everyone who tries one of these hard-sold products is well aware of how distasteful the marketing is, and resents it even as they pay. But they pay anyway because they are desperate, having adopted the plucky (and understandable) attitude of “I’ll try anything once.” Thanks to the morass of medical confusion on this subject, patients are left thrashing around for years, grabbing at anything that looks like a life preserver. But most of these products and therapies are a mirage.

My mind is not truly closed to most of these. It’s more like what my wife and I call “cat closed” — our word for closing the door enough to keep the cat from getting in/out, but open enough for some air. If I label a therapy as “bogus,” it’s because my mind is cat-closed to it: I have no intention of changing my mind about it for now, but in principle I am always willing to entertain new evidence.

4.14

Craniosacral therapy (CST) is often prescribed for low back pain but has no potential to help

Craniosacral therapy is routinely prescribed to patients with low back pain. Even CST wasn’t seriously flawed in principle, it still wouldn’t likely have anything to do with back pain.

The modern incarnation of CST was founded by an osteopath, John Upledger, and it is mainly practiced by osteopaths, chiropractors, and massage therapists. CST is a “subtle” therapy that involves light holding of the skull and sacrum with almost imperceptible movements. The idea is that such manipulations affect the pressure and circulation of cerebrospinal fluid and have profound therapeutic effects for just about anything that ails you — not only back pain but also much more serious ailments and diseases.

However, CST has completely failed to establish any plausible mechanism of action, particularly one that would be the slightest bit relevant to back pain. Dr. Steve Hartman, as an osteopathic physician himself, harshly criticizes CST: “Craniosacral therapy lacks a biologically plausible mechanism, shows no diagnostic reliability, and offers little hope that any direct clinical effect will ever be shown … patients should invest their time, money, and health elsewhere.”[373]

While there is probably some legitimate controversy about aspects of CST, its proponents tend to reach far beyond even the most generous and optimistic interpretations of the relevant biology and evidence.

For a more detailed general review of CST, see Does Craniosacral Therapy Work?.

4.15

The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests

Acupuncture enjoys a general reputation for being “good for pain” and is a popular treatment option for low back pain in particular. It doesn’t deserve that reputation or popularity. I recommend against it, and I have been doing so for many years. In 2016, acupuncture was officially scorned in the well-respected NICE guidelines for back pain. Although there was a lot of argument and controversy about this, it was sad, bad day for acupuncture in the end: it is now on the official “do not offer” list.[374]

For a long time, evidence about acupuncture for low back pain seemed to fall into the “promising” category. However, virtually all of that old evidence has been called into question,[375] and rendered obsolete by better quality scientific experiments.[376] It is particularly worth noting that this has been acknowledged even by prominent proponents of acupuncture.[377] In January, 2009, the British Medical Journal published a new analysis of acupuncture for pain, with discouraging results. A dozen of the best scientific studies of acupuncture treatments for pain were carefully analyzed. The treatments were for conditions like osteoarthritis, headache and migraine, low back pain, fibromyalgia, and more.[378]

The authors of the paper found a statistically significant but “small difference between acupuncture and placebo acupuncture.” They concluded that “the apparent analgesic effect of acupuncture seems to be below a clinically relevant pain improvement.” Remember, in the context of treating pain, a “small analgesic effect” is worthless — hopelessly damned by faint praise.

Acupuncture for low back pain specifically has been studied well now. In 2007, a German research group noted that acupuncture had “never been directly compared” with a placebo or with conventional therapy (a great example of how old studies were of poor quality). So they did it, in a large and meticulous study of acupuncture for low back pain. The results were published in September 2007 in Archives of Internal Medicine.[379] And the results are fascinating! There were two clear and seemingly contradictory findings:

1. Both acupuncture and sham acupuncture were better than conventional physical drugs, physical therapy, and exercise.

2. Acupuncture was no better than sham (fake) acupuncture.

Yes, you read that correctly: acupuncture was no better than a sham (no surprise, totally consistent with other recent research) … but both acupuncture and the sham were better than conventional therapy. Ouch! Not good news for physical therapists! Or acupuncturists! Sort of? This research was a big, weird deal. It’s both a significant and strange package of good and bad news for everyone concerned. I’m afraid I have to admit that it is even discouraging for one of my own key theories about back pain — see the note for more about that.[380]

What about Cherkin 2009? This is a popular paper, heavily cited because the abstract reads like great news. Sadly, it’s hopelessly flawed and biased, and only weakly positive in any case. Once again, the data damns with faint praise… even if it could be trusted, which it can’t.[381] This paper is not fit to line a birdcage, in my opinion.

My interpretation of all this is simple: as we know perfectly well from a lot of other research, the expectation of positive outcome is by far the most significant factor in healing from back pain. People who believe they are going to get better, get better. (For instance, see Schultz, already discussed above.) And people who receive acupuncture — the real thing or a clever imitation — simply feel better cared for, while conventional therapies often fail to reassure.

Patients are cynical about conventional therapies. But now you should be cynical about acupuncture, too. The Germans wrote that the lack of difference between the acupuncture groups “forces us to question the underlying action mechanism of acupuncture and to ask whether the emphasis placed on … traditional Chinese acupuncture points may be superfluous.” Yes, indeedy!

Replication is important in science, so you’ll be happy to know that these results were echoed exactly by another good study in 2012, in a high-impact journal, Pain.[382] Just as with the German study, this part sounds good: “all 3 modalities of acupuncture were better than conventional treatment alone.” But that means only that people find the ritual of acupuncture gives good placebo. The real story is told by this: “there was no difference among the 3 acupuncture modalities [true/sham/placebo],[383] which implies that true acupuncture is not better than sham or placebo acupuncture.” In other words, it doesn’t matter if acupuncture is real, just that it seems to the patient like an impressive ancient Chinese healing ritual with needles.

What about electroacupuncture?

Electropuncture — zapping acupuncture points with a mild current through the skin — seemed to be the least unimpressive of the many slightly helpful treatments that Machado et al damned with faint scientific praise. (See the introduction to the treatment sections for my summary of this important review.) It topped their carefully prepared list: the best benefit out of 34 mediocre treatments! So said the data. But, like all of their top five, the electroacupuncture score was “based on just one small- or moderate-sized study,” so there’s a good chance it was an over-estimate.[384] It is possible that electroacupuncture is actually the best of the bunch, but you’d have to be an optimist (or an acupuncturist) to believe it.

Of course, electroacupuncture is not even acupuncture — it’s transdermal electrical nerve stimulation masquerading as acupuncture.[385] So the electroacupuncture data in Machado is a bit of a red herring.

What’s the harm?

Oh, there’s harm! If acupuncture gives a good placebo, what’s the big deal? There definitely is a problem with that, and particularly in the case of low back pain. You might well wonder why anyone would consider spending a bunch of money on a treatment that has been proven to be a placebo, but using acupuncture’s placebo effect is advocated routinely by apologists — even in the New England Journal of Medicine.

Consider the infamous case of the 2010 New England Journal of Medicine paper (Berman), in which the pro-acupuncture authors clearly admit that acupuncture does not work:

As noted above, the most recent well-powered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient

The statement “sham acupuncture was as effective as real acupuncture” is logically equivalent with “acupuncture does not work.” Let me repeat that:

sham acupuncture was as effective as real acupuncture = acupuncture does not work

But note that disingenuous word play to make acupuncture sound a little better, “as effective”! On this basis, the authors then went right ahead and recommended it anyway … you know, for the sake of a good placebo effect. Not only did they recommend it, they advised doctors to send patients to a “properly trained” acupuncturist.

Properly trained how, exactly? In placebo delivery at the point of a needle?

Bear in mind that we live in an age of such vigorously defended patient rights and robust anti-paternalism that it’s ethically verboten for doctors to prescribe so much as a sugar pill. And that’s (mostly) a good thing. But these pro-acupuncture doctors think it’s okay to send you to a “properly trained” acupuncturist for $1000 worth of placebo-inducing ritualistic needling?

Shame on you, NEJM![386]

My knickers are really getting into a twist over this trend of defending a placebo effect as though it is just pure goodness. And it’s especially nasty when it comes to low back pain, because there is such a mind game with low back pain.

Here’s the thing: when I was a massage therapist, I routinely saw significant harm done by acupuncture and other ineffective therapies. Far from enjoying a robust mind-over-matter placebo effect, most patients seemed to believe all the more in their back pain as an unassailable affliction that “even acupuncture” couldn’t help. Real life example:

I tried acupuncture, and it did absolutely nothing but make me feel dizzy. I went home traumatised, and thought: “that’s another treatment that didn’t work.”

reader Harry M

More tragic than simply wasting time and money on a treatment that doesn’t work is that so many patients conclude not that the treatment was ineffective but that acupuncture was defeated … defeated by an unusually serious case of back pain.

Patients are strongly predisposed to anxious assumptions that their problem is really bad, and the failure of acupuncture confirms it, even if it’s not really true. The acupuncturist is given the benefit of the doubt, while their back pain is elevated to the status of a fiercer enemy. A nice trap.

How’s that for a “placebo”? “What’s the harm,” indeed!

As you have seen throughout this book so far, the scientific evidence is overwhelming that emotional and psychological factors are of major importance in low back pain (and many other kinds of chronic pain). The pain is not “all in your head,” but it is powerfully affected by what’s in your head. This shift in perspective after a minor placebo effect wears off and painful reality sets back in is really problematic, significantly exacerbating people’s fear that they are “screwed.” Thanks, acupuncture!

For a more detailed look at acupuncture used as a treatment for pain in general, see:

Does Acupuncture Work for Pain?

4.16

Core strengthening has failed to live up to the hopes and dreams of therapists and patients

The mythology and ideology of core strengthening was sniffed suspiciously above and found wanting: a fad yet to be validated by evidence. But it’s an important topic that deserves more detailed attention, because both therapists and patients do love their core strengthening. It is so popular that it is nearly synonymous with exercise therapy for the low back, and exercise therapy in general is the foundation of physical therapy for low back pain. Huge numbers of low back pain patients are prescribed some kind of exercises, and most are core strength builders.[387] In and out of clinics, Pilates is massively popular. It is a widely and passionately held belief that back and abdominal strengthening will help back pain, and Pilates is the branded exercise system dedicated to core strengthening, so Pilates must be good for back pain, right? I used to believe all this myself — but mainly because I’d heard it repeated so often by my teachers and colleagues.

Sadly — and it really is sad — compelling evidence now indicates that this kind of specific, core-focused strengthening is not an effective prevention or treatment for low back pain.

That statement will cause of howls of protest from nearly every professional reader who has ever prescribed exercise therapy for low back pain, not to mention the countless patients who are convinced it makes a difference. As I will show in this section, the problem is clearly that, while it does work at least a little — the research does show this, and I do not deny it[388] — it does not work nearly well enough.[389] As with so many other treatments, core strengthening is damned with faint praise. When I say that it is “proven to be ineffective,” I don’t mean that the benefits are non-existent; I mean that they are too minor to be excited about. There is ample evidence that core training works, but works only poorly at best.

And of course the benefits might not exist at all. I’m trying to be nice here and concede that core strengthening does something, but it’s possible I’m being too generous.[390]

Keep reading and I think that you will be persuaded that core hype has never been justified. The evidence is compelling, and the verdict is as in as it needs to be.

See also!  Exercise and Back Pain – Hell’s own elephant , a good, short read summarizing more of the science from 2009 and 2010, by UK back pain researcher and fine writer Neil O’Connell (mostly for the excellent pain science blog, Body In Mind). He is mentioned a few times throughout this section (and the whole tutorial).

So what did fourteen studies say all put together? I’ve already referenced a 2008 review in Physical Therapy which came to the completely unexciting conclusion that motor control exercises (one variation on core strengthening) are better than doing nothing, but not noticeably superior to “manual therapy or other forms of exercise.” That was the net result of analyzing fourteen other tests of motor control exercises.

That should be enough to dampen your enthusiasm for core strengthening right there! But let’s look at more evidence just to be thorough. It’s important to slam dunk this.

First, about Pilates: it hasn’t been studied directly much, but it’s a dead loss insofar as it has. A small, junky 2013 experiment[391] showed not the slightest reason for excitement: small benefits completely indistinguishable from all other forms of exercise treatment. This theme continues …

Core strengthening is no different than “general exercise.” A more recent 2010 paper by Unsgaard-Tøndel et al in Physical Therapy compared core coordination and core strengthening exercises to general exercise.[392] Over a hundred participants worked with “experienced physical therapists” once a week for eight weeks — a nice fair test, a good approximation of what a motivated patient might do.[393]

Pain and disability were measured before and after, and again at a one year follow-up. Unfortunately, there were no differences: “This study gave no evidence that 8 treatments … were superior to general exercises for chronic low back pain.” Sure, perhaps more training would have yielded better results, but how much better? Would it be worth the additional expense and effort for what would probably be only a minor difference at best?

Does core strengthening prevent back pain? Another 2010 study of more than 1,100 soldiers found that specialized, “precise” core strengthening did nothing to improve rates of low back pain (or any other injury) compared to good old-fashioned sit-ups.[394][395] And a similar 2011 soldier study, almost four times bigger — really huge — found that although “core stabilization has been advocated as preventative” it provided “no such benefit when compared to traditional lumbar exercise.”[396]

That was a big, fat nil result. They didn’t find minor or modest prevention benefits — they found nothing at all.

Soldier studies are always great because you know they were forced to exercise way more than any normal person would. Of course, soldiers are also different from civilians — healthier, for instance. But what’s particularly important about these big military tests is that they found no effect at all. Soldiers are not that different from the rest of us, and they get back pain like the rest of us. How likely is it that core training would work well for us, but not at all for them?[397] Similarly, does a test of prevention prove that it can’t work as treatment? No, but prevention is well worth testing in itself (it’s part of the legend of core strength).[398] And I’m not so sure that prevention and treatment are so very different either.[399]

Does spinal function improve in low back pain patients who exercise? Does it improve in the way that it should? It ought to — that’s certainly one of the core assumptions of core training. A 2011 analysis of trials looked for correlations between clinical outcomes and spinal functional performance, but found little or none.[400] Even when patients felt better, their backs didn’t work better … not even in terms of spinal functions that were allegedly specifically related to the type of back pain they had. If well-designed exercise plans for the right kind of patients actually improved spinal function as claimed by advocates, there should have been much clearer signs of that here. As back pain researcher Neil O’Connell put it, this data “suggests that if there are specific subgroups for whom exercise therapies have benefits, then the improvement in those subgroups was not likely due to the suggested ‘active ingredient’ of the exercises given.”

Are people with low back pain even out of shape in the first place? A 2006 review of scientific literature published in Disability Rehabilitation[401] asked, “Does physical deconditioning … exist in patients with chronic low back pain, and are treatments specifically aimed to reduce these signs effective?” The evidence is “conflicting” and the paper is short on the answers — if there’s a smoking gun here, it’s a thin wisp of smoke at best.

Consider that the authors found that “no study examined the effectiveness of cardiovascular training specifically” — a frustrating gap in the scientific research. They also concluded that “general and lumbar muscle strengthening are equally effective as other active treatments,” meaning that strength training and core training aren’t likely to be any more worthwhile than any kind of active therapy.

That does not exactly encourage me to tell anyone to try to strengthen their backs! Especially when I know full well that some of them may have adverse reactions caused by irritation of their trigger points. The authors pointed out that there is “only moderate evidence” that intense strength training in the lumbar muscles is more useful than moderate training … another strange gap. The authors believe that all of this is so unremarkable that it is “more promising” to study “the interplay between biological, social and psychological factors.” Not exactly a resounding endorsement of going to the gym for your low back pain!

In a 2002 study,[402] the core strength of college athletes was tested carefully, and then they participated in “a structured core-strengthening program, which emphasized abdominal, paraspinal, and hip extensor strengthening.” I bet they did a lot of crunches, booyah! Too bad about the total lack of results, though: there was no change in the rates of low back pain after all those crunches. So the authors concluded that there was “no significant advantage of core strengthening in reducing LBP occurrence.” Rates of low back pain were low overall in these athletes to begin with, so this certainly isn’t the last word on this subject.[403] But, in this case, core strengthening clearly failed The “Impress Me” Test: and if core strengthening was anything to write home about, surely these athletes would have had less low back pain after all that core strengthening? Surely?

Going back a little further into the science archives, a 1984 study published in the journal Spine of about 900 people found no correlation between back strength and back problems, but did find evidence that “good isometric endurance of the back muscles may prevent first-time occurrence of low back trouble.”[404] Muscular endurance demands good blood supply, so this evidence may suggest that adequate circulation is a factor in preventing back pain — a point consistent with MPS as the cause of most low back pain.

Then back to 2002 again, when a study of 600 men found similar results: “Among all the factors tested, endurance (or lack thereof) of the back extensor muscles had the highest association with low back pain.”[405] However, this study also found that, “Other factors such as the length of the back extensor muscles, and the strength of the hip flexor, hip adductor, and abdominal muscles also had a significant association with LBP.” But not, you notice, back muscle strength! Shouldn’t it be the most important factor, by far, according to the mythology of core strengthening? So much for that idea.

Okay, that’s enough about specific science experiments: we could do this all day!

To wrap up, I want to share one final and more general bit of science: a 2010 analysis of six other studies like the ones above. Its title asks the excellent question: Can We Explain Heterogeneity Among Randomized Clinical Trials of Exercise for Chronic Back Pain?[406][407] Fingers crossed!

As we’ve seen above, studies of exercise for low back pain are often underwhelming: while some show a minor benefit, it’s never a big deal, and we’re left wondering if another way of exercising (or testing) might have worked out better. There are so many ways to exercise, and the science of exercise therapy is plagued by this complexity: no matter what the research says, there’s always the real possibility that you might get better results by dialing up a different combination of variables.

Ferreira et al tried to identify not only if exercise works for back pain, but (importantly) which variables matter. This is quite different than testing to see what kinds of exercise work (and we already know there is no obviously superior exercise for back pain). The point was to see which variables affect study outcomes, including things like customization of the exercises and supervision. In fact, they found only one: “only dosage was found to be significantly associated with effect sizes.” Nothing else mattered: just how much exercise was done. Specifically, the number of exercises sessions.

And even that didn’t matter much. The effect of exercise was small in any case — real, but small. In fact, the effect on pain was barely there: “arguably these effects were too small to be of clinical significance.” The effect on disability was a little more promising, thankfully.

These results suggest that second guesssing what kind of exercise therapy to do for what patients might be bit of a fool’s errand: it doesn’t much matter who does what, just that you do it. If you do enough, you’ll probably get a little benefit. But there’s a real problem of diminishing returns: a large dose of exercise doesn’t (usually) produce a large benefit. But it will probably secure a modest benefit, at least.

Conclusions and recommendations about exercise

Considering all that, it’s hard to imagine how anyone could maintain enthusiasm for core strengthening or any other “technical” or specific form of exercise for low back pain. Exercise is probably almost never a decisive factor, and many cases of chronic low back pain persist in spite of it. That said, there’s no reason not to take advantage of the modest benefits of doing whatever kind of exercise you can enjoy … and no need for expensive training. Modest benefits are modest benefits.[408] And there are plenty of other good reasons to exercise. So why not?

To the extent that exercise gets good results, it’s probably because it stimulates the health of soft-tissues, and because it is (or can be) a positive, confident, fear-busting activity.[409] That is, exercise probably helps because people believe and hope that it will help — because it makes people more optimistic and confident — and because most moderate exercise is safe and healthful.

So my current recommendation for exercising for low back pain: do it only if it particularly floats your boat — but don’t bother if it sounds unpleasant. If you do choose to exercise, focus on the endurance of your core stability muscles: that is, encourage good circulatory health in those tissues! And avoid intense strength training, especially in the early stages of recovery, because the risk of aggravating trigger points is too great.[410]

4.17

Scoliosis cannot be straightened without surgery

Earlier in the tutorial I explained that scoliosis is one of the few structural factors in low back pain that is both legit and common. Its effect on low back pain is probably mostly indirect and much less serious than many therapists believe. However, it undoubtedly does contribute to low back pain by causing and aggravating muscular dysfunction, and it would certainly be wonderful if it could be eliminated from every case of low back pain.

It’s a no-brainer that scoliosis can’t be treated. It’s particularly obvious that severe cases can’t be cured by a chiropractor. When you have been severely deformed by scoliosis from a young age, and you’ve had big steel rods implanted in your back, you are under no illusions that anything is going to fix you right up. On the other hand, if you have only mild or moderate scoliosis, you know it’s probably not that big a deal. So there are really only a few people who actually need to hear this: a handful of patients who have just enough scoliosis to have a reasonable worry that it might be a major factor in their back pain. There might also be a few people with mild scoliosis who have been told by a therapist that it’s The One True Cause of their back pain, and that it can be cured.

This section is for those few people. For everyone else, it’s really just interesting as (yet another) example of how misleading common therapeutic ideas can be.

Unfortunately, there is no evidence that scoliosis can be removed from the equation by any conservative (non-surgical) therapy. And, of course, surgery is completely out of the question for mild cases — no one is going to get stainless steel rods implanted in their back to correct a mild scoliosis that may or may not even be causing any pain.

Most studies of therapy for scoliosis go like this: forty-two subjects with moderate (6–12˚) scoliosis were treated by chiropractors for a full year. The result? “No discernible effect.”[411] A 2007 paper in the journal Spine reviewed all such science on treating scoliosis (spinal curvature) without surgery.[412] The conclusions were depressing: across the board, the available evidence is either discouraging or of such poor quality that no conclusions can be drawn.

For instance, there is only “Level IV evidence on the role of physical therapy, chiropractic care, and bracing.” Level IV evidence comes from “studies where there is a high probability that results are due to chance.” In other words, such research is so preliminary or poorly conducted that it’s good only for inspiring better research! So this paper confirms that we know nothing about fixing scoliosis without surgery, and that anything that health care professionals think they know about it is an untested belief.

And yet …

And yet one of the most common dubious ideas in therapy is that we can “straighten” a scoliosis! It is a particularly common idea among chiropractors, of course, because they often claim to keep your “spine in line” (a popular bit of chiropractic ad copy). I have been hearing it since I started school in 1997. You can see a particularly outrageous modern example of such claims at the website TreatingScoliosis.com, a slickly marketed chiropractic 10-day “boot camp” which claims to be able to “decrease existing spinal curvatures over 25º and eliminate the need for bracing or surgery.”

I have never once seen anyone with scoliosis get straightened out that much … or even enough to notice.

A story of failed therapy: I particularly recall an older woman — I’ll call her June — with a moderate structural scoliosis. June’s case is a perfect example for this tutorial because her scoliosis was minor enough that it might be treatable with therapy — if any scoliosis can be — and yet it was also severe enough that, if scoliosis is a major cause of back pain, it should be obvious in her case. However, June had only moderate chronic discomfort in her low back and hip on one side. It was certainly a real problem and frustrating to her, but (like Becca) it was nowhere near as painful as a typical case of low back pain.

As I worked with June, I had a ringside seat as an experienced chiropractor also worked on June, supposedly in collaboration with me — with my muscle work and his “adjustments,” he believed we would cure her. I spoke to him on the phone about it, and he was confident — he told us that the scoliosis would be eliminated, completely. I deferred to his experience. Hey, I thought. Maybe he knows something I don’t. So I held up my end of the bargain and did the best work I could on her muscles.

We didn’t do it.

After about six months of regular chiropractic and massage therapy — thousands of dollars worth — there was not the slightest change in her condition: June was still visibly deformed, exactly like she was at the start, and still suffered from constant aching.

(Worse still, she eventually fired the chiropractor because he appeared to be frustrated by failure, and he started manipulating her spine too aggressively, as though he could force the issue. Sigh. After walking away from his office in much greater pain a couple of times, she cut him off.)

June continued to see me intermittently for years, always getting a little temporary relief and reporting on other failed therapies for her scoliosis. Acupuncturists told her that needling would straighten her out. Naturopaths told her that detoxification would straighten her out — huh? She devoted a bunch more time and money to another chiropractor doing another kind of massage therapy.

And yet she didn’t get any straighter. Last time I saw her, two or three years ago, June was still as scoliotic as ever. And still trying new therapies — she gets full points for persistence!

If even a small fraction of therapies claiming to have straightening powers can actually do it, then lots of people with scoliosis would be getting cured. But that’s not happening. There’s a lack of cured cases of scoliosis out there.

So … without a shred of decent evidence and not even any success stories, what can possibly account for the claims? It’s just another case of healer syndrome, I’m afraid — therapists believing that they have more power than they do.

4.18

Facet joint and intradiscal steroid injections are not recommended for most patients

It’s easy to understand why injecting steroids into joints is a popular treatment: there’s just something satisfying about the idea of getting right in there with a needle and soaking an (allegedly) inflamed joint with a powerful anti-inflammatory agent. Steroid injections can certainly work extremely well for other painful conditions. For instance, in the common knee pain condition iliotibial band syndrome, an injected squirt of steroids can work marvels.[413] How about back pain?

There are two common candidates for steroid injections in the low back: the little facet joints, and the big intervertebral discs. Unfortunately, both approaches have been specifically shunned in the 2009 American Pain Society guidelines for low back pain interventions,[414] and another large and impressive scientific review from The Cochrane Collaboration also slams it.[415] Why? What’s so wrong about steroid injections?

Injection therapies probably have a lousy track record because too many cases of back pain involve too many factors that injection can’t hope to address.[416] If a case of low back pain could be confidently diagnosed as a case of “pure” facet joint inflammation, then there’s a much better chance that a steroid injection would do the trick. Unfortunately, such confidence is rarely possible: there are just too many ways that backs can hurt.

It’s not an irrational treatment, but its efficacy is greatly impaired by the typical complexity of back pain. There are reasons to believe that it would work in some cases, and it almost certainly does work in some cases. Some patients should probably still consider it for cases that seem to be particularly “jointy” — that is, if the diagnosis of facet joint irritation or dysfunction is particularly clear (an intervertebral disc problem is less likely to be obvious). The Cochrane reviewers may have been pretty negative about injection therapies, but they also wrote that “it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.”

But definitely handle this option with care. It’s bad enough that there is little to no evidence of efficacy — sticking needles deep into your back is a fundamentally risky activity. It’s certainly not as dangerous as surgery, but it’s hardly risk-free either, and it’s expensive. This therapy is really only for a handful of desperate patients with the strongest indications for it, and possibly not even then.

Maybe it depends on what you inject: the curious case of intradiscal methylene blue

Methylene blue is an interesting chemical with many uses. This is a big flask of the stuff. Purty.

At this point in the tutorial you are getting used to the relentless bad news, so you’ll appreciate how strange it is for a high quality test of another kind of injection to have super positive results. That just doesn’t happen. It’s cynicism-defying, for sure.

Methylene blue is basically just an anti-inflammatory medication well-tuned for the chemistry of irritated intervertebral discs. (Another theory is that it actually destroys some small nerve fibers that have overgrown in the disc.)

Peng et al concluded that the injection of methylene blue into a painful disc is a “safe, effective and minimally invasive” method for the treatment of discogenic low back pain, far more effective than any other known treatment for low back pain.[417] The surprising results — 19% completely free of pain, and 72% almost so — were published in April in the prestigous journal Pain, by a credible research group.

In an editorial in the same issue, low back pain expert Nikolai Bogduk (see Bogduk) expresses every reasonable caution against premature celebration, yet judges that “there are no lethal flaws in the study” and calls it “one of the most incredible studies of a low back pain treatment ever published.” He describes the results as:

astounding, unprecedented and unrivalled in the history of research into the treatment of chronic discogenic low back pain. The results of surgery, rehabilitation, behavioural therapy, and any other treatment for back pain pale into insignificance. If the results of Peng et al are true, this intervention will revolutionize the treatment of low back pain. Spinal surgery for back pain will be rendered essentially obsolete. Furthermore, and ironically, the treatment is not subject to any patent, and is readily available. Anyone who performs discography will be able to provide the treatment, at trivial extra cost. For ridding the world of back pain, this study would be worthy of nomination for a Nobel Prize; if the results are true.

Lofty talk!

So, that was in 2010. Any news since? Not much: as of late 2015, only one other trial has been completed — with more good news, though somewhat less dramatic.[418]

I think it’s too soon to actually recommend methylene blue injection, but it’s certainly worth discussing with a physician in tough cases.

4.19

Prolotherapy: still popular, and for no good reason

“Prolotherapy injections have been used to treat chronic low-back pain for over 50 years but their use remains controversial,” write the authors of a 2007 review of prolotherapy in The Cochrane Collaboration.[419] “The role of prolotherapy injections for chronic low-back pain is still not clear.”

Really? Still? After 50 years, the role of prolotherapy still isn’t clear? This just doesn’t impress — if clear results can’t be shown after five decades, how good can it possibly be?

The authors give such a good description of prolotherapy I’m just going to quote them. Prolotherapy, short for “proliferative injection therapy”), involves:

Oh, the irony.  Prolotherapy is intended to actually cause inflammation with the ultimate effect of “toughening up” connective tissues. In the previous section, we discussed steroid injections to reduce inflammation — and a well-known effect of corticosteroids is that they erode connective tissues. So two popular therapies do exactly the opposite things. One causes inflammation to strengthen tissues, the other reduces inflammation at the cost of tissue integrity.

Something is wrong with this picture …

… repeatedly injecting ligaments with compounds such as dextrose (sugar) and lidocaine (anaesthetic) to help restart the body’s natural healing process by causing controlled acute inflammation (swelling) in the areas injected. Proponents believe this leads to stronger ligaments that can better support the low-back.

So, let me get this straight: prolotherapy relies on the dubious hypothesis that low back pain is caused by “weak ligaments” that need to be toughened up. Assuming you’ve read the tutorial straight through to this point, I’m sure you can see some serious problems with that. Just the single fact that so many people tolerate “serious” structural problems with no pain suggests that something as vague as “weak ligaments” is pretty unlikely to be the key to back pain.

I bet Steve Austin got prolotherapy!

Ha ha. Funny, right? But the idea that prolotherapy makes you “stronger, better” is precisely the sort of emotional appeal that can power a placebo & make a non-treatment seem to work for thousands of people.

Whatever benefit anyone seems to have gotten from prolotherapy is almost certainly due to placebo — something we can say with great confidence now that many similar examples have been documented. We know that pain patients are highly subject to placebo, particularly when the treatment seems more “potent” — i.e. injecting medicine — and has an emotionally compelling rationale. Doubtless every prolotherapy patient ever has been keen to have “stronger ligaments.” Stronger, better, faster! They probably used prolotherapy on Steve Austin![420]

The 2007 Cochrane review concluded that “When used alone,[421] prolotherapy is not an effective treatment for chronic low-back pain.” It was dismissed again in a 2009 review of all kinds of injection therapy: “there is no strong evidence for or against the use of any type of injection therapy.” And the American Pain Society has officially given prolotherapy a thumbs down in their 2009 guidelines for low back pain: they do not recommend it.

You can do better than a fifty-year-old therapy that has not shown the slightest serious potential in many perfectly fair scientific tests. In short: don’t waste your time and money on prolotherapy. It’s a long shot, at best.

4.20

Spinal decompression therapy: worth the money and risks?

Interested in spending vast sums of money on a dubious therapy for your back pain? Well, boy, are you in luck! Nonsurgical spinal decompression therapy (SDT) — also known as “pulling on your back” or “traction” — is ready to drain your bank account. (This section concerns SDT performed with expensive machinery. Self-administered traction is a different story.) Various forms of spinal traction machinery have always been available to desperate low back pain patients, and four facts are clear about this therapy to date:

1. It might work occasionally, a little bit, for some patients.

2. But no one really has a clue.

Serious criticism from serious people:  This topic has been well-covered by several effective and credible critics. Good summaries include Dr. Harriet Hall’s article for LiveScience.com, a detailed critique by the formidable Dr. Stephen Barrett, a scholarly but readable article (ideal for professional readers) by a chiropractor, Dwain Daniel, in Chiropractic & Osteopathy, and a great TV episode about it by CBC’s Marketplace (and a great selection of links on the episode page, too).

3. It is often prescribed and promoted with unjustified confidence.

4. There is a risk of injury.

Chiropractors have found ways to make simple traction sound better and cost more than ever before by doing it with extremely expensive machinery (doubtless it goes “ping”) with names like (I am not making this up) the DRX9000 True Non-Surgical Spinal Decompression System™. (You have to love the “true” in there. From now on, everything I market is going to have “true” in it. No longer will I sell mere e-books on this website: I am going to start selling true e-books!) Imagine the pressure a chiropractor might feel to sell such a service to patients after investing as much as a hundred grand or more for the equipment.

A machine that goes “ping” — the DRX9000 True Non-Surgical Spinal Decompression System™.

The most recent incarnation of traction therapy is non-surgical spinal decompression therapy which can cost over $100,000 [the equipment, not the therapy]. This form of therapy has been heavily marketed to manual therapy professions and subsequently to the consumer.

~ Daniel, 2007, Chiropractic & Osteopathy

The Florida Attorney General’s office launched a lawsuit against the largest manufacturer for “false and misleading claims.”[422]Daniel again:

There is very limited evidence in the scientific literature to support the effectiveness of non-surgical spinal decompression therapy. Considering the cost-benefit relationship, many better researched and less expensive treatment options are available to the clinician.

A 2007 review of traction therapy for low back pain reports that experimental results “consistently showed that traction … as a single treatment for LBP was not more effective than placebo, sham treatment or other treatments.”[423] Regardless of a few modestly positive studies, traction continues to show poor results in other studies, like this one from 2009 in the European Spine Journal with a good, rigorous design that showed no difference at all between traction and placebo.[424]

Incidentally, traction for neck pain is similarly lacking any clear support from science (see Graham).

And what about risks? Obviously, if you are pulling on painful lower backs with machinery, there are risks. SDT has been promoted as a safe therapy. However, Daniel reports:

This was a case report of a 46 year old male with a three month history of radicular pain consistent with a S1 radiculopathy. During his 5th session he suffered a severe exacerbation of his pain with marked enlargement of the disc protrusion requiring urgent microdiscectomy.

Personally, I recall three cases of nasty reactions to SDT in my decade of clinical work. In the worst example, my patient described going for therapy with minor low back pain, experiencing rapidly escalating discomfort in the machine. This escalated to a pop, excruciating pain, and “screaming.” This extraordinarily poor outcome was followed by a long period of much more severe, chronic low back pain. I remember his case clearly because he attributed it almost entirely to the SDT. He considered himself injured by the machine and sought therapy for its long-term consequence many months after the injury.

Incidents of minor harm are always likely to be much more common than serious ones, of course.

None of this means that traction has no merit at all — it almost certainly does help the occasional patient. But it does mean that it doesn’t pass the impress me test (not by a long shot). The PainScience.com salamander says: spinal decompression therapy should never be sold assertively for a high price to desperate patients, without clearly explaining the significant limitations and risks.

To conclude, an email from an anonymous chiropractor, regarding another chiropractor he worked for:

I actually worked for a real snake that used the DRX9000 and charged patients upwards of $6k for a series of treatments. We sometimes had severe complications, sometimes good results, and sometimes no change. Needless to say, I didn’t work for this “doctor” long.

4.21

Back bracing and stabilization contraptions (especially inflatable ones)

Bracing itself is not actually bogus: its rationale is. The ideas and beliefs that almost always go with bracing are the problem — most obviously with popular inflatable devices. This question arrived by e-mail one day from a Vancouver fitness class instructor I know very well — my mother.

Q A friend and participant in my class has arthritis in the spine and low back injuries from several car accidents. She wants my opinion of Dr. Ho’s Back Relief Belt. He’s a chiropractor and acupuncturist and the “belt” simply goes around the lower back and then you put air in it. Looks to me like a scam, and certainly not good science. I found both good and bad reviews. I suspect it’s worthless. Do you know of it? And, if you do, do you have an opinion about it… such as “no good”?

A There are several of these inflatable support/decompression contraptions on the market, with prices ranging from $100–400, plus countless other braces and support belts. They mostly “work” (minimally) by providing 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 (and of course in some small sense it actually does). Unfortunately, it also strongly encourages the insidious idea that backs need stabilizing in the first place. But in fact only a small fraction of chronic back pain involves a problem that would benefit from stabilization.[425]

And that’s assuming that the back can be stabilized. And that is a curiously unsafe assumption.

Incredibly, it’s not even clear that major spinal fractures require any “support,” or that it’s possible. You might think, “Surely he’s exaggerating!” But the spine is an extraordinarily dynamic structure, and research has shown that it’s so difficult to stabilize the spine (from the outside, without bolts) that its clinical value in rehabilitation is ambiguous at best,[426] and surgeons are of two minds.[427] Worse yet, somewhat like slouching into a comfortable chair, a brace may actually cause some sloppiness of spinal function, rather than using muscle to support and control the spine. That’s not just speculation: someone checked, and the results were quite interesting.[428] For much more detail, see Spinal Fracture Bracing.

What about traction and decompression? The limited value of traction as a treatment idea is covered thoroughly above, but the main issue here is whether an inflatable belt can actually decompress anything in the first place.[429] And I doubt it, of course. I am sure there is a slight lifting of the thorax as the device inflates, filling the space between the pelvis and the ribs — but I am sure that the sensory effect is much greater than the physical effect. If you could could put a wee scale between two lumbar vertebrae while inflating this thing, I don’t think it would budge more than 2%. But you might feel 20% decompressed … and that might be worth something.

I don’t want to talk you out of a lovely sensation-boosted placebo: a firm, wide belt might just help your nagging back pain. But what you believe about what it’s doing for you is critical! Your belief has more power than the treatment itself, and spinal stabilization contraptions usually do more to reinforce self-defeating beliefs about spinal fragility than they reinforce spines — if that’s what you believe they are doing, which most people do, even when they should know better.

On the other hand, you certainly have my blessing … if you treat them as a minor reassuring sensory input, and not a miracle cure that is substituting the stability your own spine lacks.

4.22

Antibiotics for back pain: a debacle

In February 2013, a study in the European Spine Journal reported weirdly good results treating low back pain with … antibiotics? No, really![430] I heard about this a few weeks before the hype exploded. (I’m updating this book a couple months after that. Nimble digital publishing for the win!)

The study implied that some cases of stubborn and inexplicable back pain are caused by an infection. (Stranger still, the authors suggested that it was an infection with a wee beastie that may be getting into spines thanks to brushing your teeth. Talk about unintended consequences! If it was true, it was sure interesting. One of my mentors, Dr. Harriet Hall, an extremely skeptical writer, thought so too.)[431] At the time, I wrote:

It’s a marvellously eyebrow-raising and strange test result. I’ve always wondered if “the answer” to low back pain might be like this, something really odd (or, more like, several odd somethings). It’s the kind of answer that is inevitable-ish: all the “reasonable” candidate explanations for most chronic low back pain have been checked and found hopelessly wanting, and all that’s left is the odd stuff that no one’s checked yet. And perhaps it’s this: an infection! Which no one saw coming, any more than anyone “called it” in the 70s that stomach ulcers would turn out to be caused by Helicobacter pylori.

There were all kinds of caveats, though. Above all — the caveat to rule them all — it sounded too good to be true. (So easy! Pills!) A skeptical dentist I know immediately pointed out that they had no direct evidence of infection in the first place, and the mouth connection was pretty much pure speculation and somewhat distracting and sensationalizing. Also, the study focused on a specific sort of back pain in rather carefully chosen subjects — and so, even if everything else was copacetic, antibiotic therapy wouldn’t work on the average frustrated back pain patient. (This alone should have been enough to suffocate any hype.)

There was also “an almost total lack of a response in the placebo group suggesting no impact of placebo effects, natural recovery or regression to the mean,” wrote Dr. Neil O’Connell.[432] “Which is odd,” he added drily. Which is sure an understatement. It was a real red flag that there might be something quite wrong with the way the study was conducted. I know Dr. O’Connell and discussed this with him, and I suspect that what he meant by odd was “the whole thing is probably bollocks, but I don’t have enough information to say that yet.”

Boy was he right.

The May 7, 2013 headline in The Independent was as sensational as sensational gets: ‘The stuff of Nobel prizes’: Half a million sufferers of back pain ‘could be cured with antibiotics.’ That was outrageously premature and irresponsible, but no one knew the half of it yet. There were attempts at damage control, like a much more level-headed editorial in PubMed Health,[433] but it was much too little to stop the tide of excitement. I saw countless social media posts from professionals who swallowed the story whole, tweets like “important news!” and “this is huge!” I got a lot of reader questions about it. So did Dr. Lorimer Moseley, a pain scientist:[434]

I have already received a dozen phone calls asking if I am trained to do antibiotic therapy and I can almost hear the hope on the other end of the line and cringe as I suffocate it in the wet blanket of truth.

Conflict of interest

And then we learned that the study was — probably — afflicted with a serious conflict of interest.[435][436] Three of the four authors were likely to profit from the good news they had published: not only were they on the board of a UK company that certifies doctors in antibiotic therapy,[437] they failed to disclose this in their paper. Oops! Major ethical faux pas!

A conflict-of-interest is not necessarily a big deal,[438] but sometimes they are rather damning, and I’d say this is definitely one of those times. Too-good-to-be-true results from a study of a treatment done by people who could profit richly from the news? Probably not a coincidence. Assuming it is what it looks like.

One study can never prove anything, because there are so many devious and subtle ways that the results of a scientific experiment can be warped. The hype was unjustified even before we knew there was an ethical scandal. Now it’s just an infuriating story about bad science getting a huge boost from the mainstream media, and the pointless torturing of back pain patients with the false hope of an easy fix. Nevertheless, the story belongs in this book, of course, because so many people are wondering about it now. And hoping.

There’s not a scrap of good news about back pain here, only bad news. Antibiotics almost certainly do not treat low back pain. We cannot rule out the possibility that antibiotic therapy will be vindicated, but I sure wouldn’t bet on it.

Please, do not pester your doctor for antibiotics to treat back pain. (All the more so because over-prescription of antibiotics is a dire problem.[439])

Scientists found these little P. acnes buggers in most of the spines they checked. But were they already there causing a problem? Or were they contamination from the procedure?

2015 update: more smoke than expected, but still no fire

Surprisingly, the door does not seem to have completely slammed shut on bacterial involvement in back pain. A 2015 review of several more studies of the idea concludes that there is “moderate evidence for a relationship between the presence of bacteria and both low back pain.”[440] Most studies have found bacteria in the spine, mostly Propionibacterium acnes. Could P. acnes be the Helicobacter pylori of the spine?

I wouldn’t bet on it yet. “The mechanism by which bacteria may enter the lumbar spinal tissue is unclear,” wrote Urquhart et al, but it’s not unclear if it’s contamination! And there is already evidence that it is just contamination. And almost any evidence of contamination puts the whole business deep in the shadow of doubt.

Seems like the role of bacteria in back pain is still just a big question mark. It’s plausible and there’s smoke — much more plausible that I expected two years ago — but there could easily still be no fire here at all.

All together now: “more study needed”! As usual.

4.23

A few more snack-sized reality checks: brief comments on other treatments to avoid

ZOOM

A typical TENS device.

Nutraceuticals in general. There are several popular supplements — such as creatine, glucosamine (see next item), whey protein, turmeric/curcumin and bromelain — that allegedly reduce inflammation in a variety of ways. These substances probably do have some interesting biological effects and probably some anti-inflammatory action — for instance, there’s little doubt that bromelain does have anti-inflammatory properties. It’s more a question of whether these substances are more effective or safer than existing anti-inflammatories — which is unproven and somewhat unlikely. Some nutraceuticals are of particularly dubious value, due to obvious too-good-to-be-true marketing hype. It might be worth experimenting with such nutraceuticals, but cautiously: there is a real danger of wasting your money. Plus, as this tutorial has clearly demonstrated, inflammation is probably a fairly minor factor in most back pain. See Can Supplements Help Arthritis and Other Aches and Pains?

Glucosamine in particular. Glucosamine is mostly known for being good for cartilage and osteoarthritis, so it is widely used as a self-treatment for low back and neck pain — which makes sense if you believe that these problems are arthritic by nature. But otherwise, this makes no sense at all. Glucosamine is an abundant monosaccharide (amino sugar) and a building block of proteins and fats, especially in cell walls. It’s made commercially by extracting it from crustacean exoskeletons. It’s been heavily studied, but there is really no good science news about it, and in 2010 it bombed a particularly good, fair test published in Journal of the American Medical Association,[441] and then another one shortly after that.[442] Glucosamine just can’t be taken seriously any more.

Transcutaneous electric nerve stimulation (TENS). TENS has been wildly successful in the marketplace for decades, and is still widely utilized in lesser physiotherapy offices, particularly to treat low back and neck pain. Electrodes are applied to the skin to stimulate muscle contractions, allegedly with a pain-killing effect. Despite the superficial appearance of being scientific medicine, TENS is clearly no miracle cure and is probably almost entirely ineffective. Thus it may be one of the most profitable quack medical technologies in existence. Its use for back pain was debunked as early as 2001 in a large scientific review,[443] and then again in 2008 in a review that concluded that what little good evidence is available “does not support the use of TENS in the routine management of chronic LBP.”[444] As of 2017, there hasn’t been another high profile review of TENS for back pain specifically, but there is a litany of mostly negative reviews for other conditions. There’s a slim hope that TENS could still be useful with just the right settings for just the right patients, but almost certainly not most back pain patients. The only thing that can be said in its favour is that it’s cheap and safe to try. For a full review, see Zapped! Does TENS work for pain?.

Therapeutic ultrasound is the the use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries (sprains, tendinitis, bursitis). There is no persuasive evidence it actually does this, of course. Although specific flavours of ultrasound (like shockwave therapy for plantar fasciitis) show some real promise, when it comes to back pain, ultrasound is nearly a clone of TENS: a commercially successful but scientifically bankrupt cure that seems more “modern” than it really is, and which might (but probably doesn’t) still turn out to be useful for just the right sort of patient, with the knobs turned to just the right positions. Strangely, good quality evidence for ultrasound is even scantier than it is for TENS: in 2014, Ebadi et al was a technically inconclusive review of just seven shabby little trials, but even in those trials they found no cause for optimism.[445] If ultrasound helps any back pain patients, it’s not a robust effect. See my full ultrasound review.

Taijiquan and qigong. Like acupuncture, taijiquan and qigong are thought by many to be good for virtually anything, especially aches and pains. Unfortunately for wishful thinking, recent, specific, good-quality research evidence shows that qigong does nothing whatsoever for chronic neck pain.[446] I feel fairly confident concluding that it’s not likely going to work any miracles for low back pain either — at least, no more than any other form of gentle exercise. Like Chinese medicine in general, taijiquan and qigong are too complex to dismiss entirely — you might end up throwing out some baby with the bathwater. If nothing else, they are gentle and aesthetically pleasing forms of exercise for some people, and there’s certainly nothing wrong with that! I was a practitioner of taijiquan and qigong for many years. However, there’s not much point in doing them as treatment for low back pain. At best, I recommend them as a component in an overall wellness campaign, simply because it’s good to move.

Diagnosis with Digital Motion X-Ray. Digital motion X-ray (DMX) is an X-ray video: many X-ray images strung together to make a movie. The output is impressive. In theory, it can reveal serious problems that somehow eluded diagnosis otherwise. In practice, this unregulated and banned-in-Canada technology is primarily sold to neck pain patients by chiropractors, often for evidence in personal injury lawsuits, and is completely eschewed in medicine because of concern about radiation exposure. DMX undoubtedly has some potential to show important things, but is it worth an increased risk of cancer to diagnose conditions that, mostly, can and should be diagnosed any other way? It’s not completely out of the question, but you should get multiple medical opinions and think hard before resorting to this exotic diagnostic method. Read more.

PART 5

NOW WHAT?

An action-oriented summary of recommendations

If you have the impression after reading this tutorial that there’s nothing that really works for low back pain, that’s understandable. But it’s more true that nothing is a sure thing. There are reasonable options to try, and many of them have been discussed in detail above. In this section, I summarize them. What should you do about your low back pain? What are my actual recommendations? An outline of a plan? This section is my prescription, and I will tell you exactly what I think most people with low back pain need to actually do.

First and foremost, stop spending time and money on the more expensive and dubious therapeutic options, unless you have specifically already noticed that one seems to be working particularly well for you. But unless your results are clear, do yourself a favour and fire the therapists who aren’t helping. If you review the self-treatment and professional treatment options quickly, you might notice a pretty strong pattern: the professional options really aren’t great, most are riskier, and they all range from “expensive” to “ruinously expensive.” The self-treatment options are much more attractive and promising.

The vast majority of low back pain patients are suffering primarily from a vicious cycle of anxiety, fear, and pain all reinforcing each other. More than anything else patients need the confidence cure — you need to be effectively persuaded, by clear explanation of the extensive scientific evidence where applicable, that:

- The lumbar spine is not fragile!

- Scary problems like herniated discs, arthritic degeneration, and pinched nerves are almost certainly not the problem (or much less a problem than you thought).

- Almost no one has actually “tried everything” for the low back pain, and good, rational options are probably still available to you.

Once this confidence is reasonably well established, it needs to be reinforced by the reduction of life stress in general — not via the clichés of meditation and yoga, unless you like that sort of thing — but by solving problems in your life to the best of your ability. The low back pain patient should regard anything that has the potential to reduce life stress to be a superior therapy for low back pain than most so-called low back pain therapies. This is not to say that stress reduction is a cure, but it is an important foundation for recovery, possibly even a pre-requisite in many cases. Psychological counselling, personal growth, strengthening your personal relationships, and bioenergetic breathing exercises are all probably at least as useful as any kind of physical therapy, and often more so. A $2000 vacation — the relaxing kind, not an “adventure” — should definitely be preferred to $2000 of any kind of therapy.

Poor sleep quality is hopelessly tangled up with stress and pain. For insomniacs with back pain, sleep hygiene therapy is the single most important indirect treatment option. Also a key factor in bed: biomechanics. Sleeping in awkward positions and/or on uncomfortable mattress can be an unsuspected, insidious factor in low back pain and insomnia, so take pains to make sure you are sleeping as comfortably as possible.

Quit smoking. This is another vital general admonition for patients with any kind of chronic pain — such general advice that it is not even mentioned anywhere else in this tutorial, because it isn’t a back pain treatment, per se. If you smoke, you already know that you’re hurting yourself (I hope). But did you know that smoking literally hurts? There is strong evidence that smoking is a major aggravating factor in chronic pain[447] … even back pain specifically.[448] Smoking may partly explain why back pain becomes chronic in some people,[449] while fading away in others. So, if you smoke, you need to ask yourself if you really want to make it significantly harder to recover from chronic low back pain, or if it would be better to just quit smoking. See Smoking and Chronic Pain.

Those are some of the major general issues.

However, most patients will obviously also want to feel like they are doing something more definite and direct about their back pain. To the extent that therapy is useful, the first choice should almost always be trigger point therapy, particularly if there are multiple signs that trigger points are a factor in your particular case. Even if not, they are probably still present to some degree, and treating them will still be the most practical method of supporting tissue health in the region.

Just as vacations should be chosen over therapy, self-treatment methods should always out-rank paying a therapist to do anything. I’m especially referring to regular self-massage for muscle tension and knots, but I’m also including specifically and efficiently and safely stimulating low back musculature and joints with mobilization exercises; by regularly using heat therapy (and probably avoiding ice, although it’s fine if it appeals to you); and freely experimenting with other self-treatment methods.

Low back pain patients must also seek to understand and eliminate the factors that perpetuate trigger points, particularly wherever there is a “perfect storm” of such factors that have not previously been taken seriously, yet are both significant and practical to address. The most important general concept is to aim to live in the Goldilocks zone as much as possible, choosing to do as much normal, moderate intensity activity as possible even during a flare-up. Other important ways to avoid aggravating muscle pain: specifically and efficiently stimulating low back tissues with mobilization exercises; fixing insomnia (again!); implementing a microbreaking strategy at work; by reducing postural strain, especially by upgrading your workstation ergonomics, and avoiding extremes of tissue exertion or stagnation (especially weekend warriorism); and taking a multivitamin as general insurance against nutritional insufficiency aggravating your trigger points.

A big one is to consider changing careers if your work situation is just hopelessly irritating to your back and you can’t fix the postural strains involved. It’s understood that some perpetuating factors are truly unavoidable, but back pain patients must seriously consider options that previously seemed “impossible.”

Note that low back pain patients should be wary of eliminating favourite activities, because it’s so disheartening, rarely necessary, and tends to strongly reinforce the worst possible mental attitude about low back pain. If it is necessary, the deprivation should be as little and as temporary as possible.

Some miscellaneous self-treatment options with less significant but attractive benefits include ordinary pain medications, even alcohol in moderation. Two ointments — Voltaren Gel and Comfrey — both have a little more potential, and are so cheap and harmless that they are firmly in the “worth a shot” category. Also make sure chronic pain medication use is not actually causing pain: analgesic rebound is a problem many patients never even suspect. Beware of this odd but real risk, and eliminate it.

If it seems to help, do some stretching in moderation, but beware of wasting your time with it, because it just doesn’t work all that well for most people. But yoga and/or meditation have numerous benefits if you like those activities; lumbar traction (using an inversion table, for instance) is worth cautiously experimenting with. But avoid expensive treatments like the over-hyped “spinal decompression” machines chiropractors use, and do endurance training for the core musculature rather than core strengthening (which is a waste of time and energy).

Finally, patients with serious low back pain may still want professional help, but this desire should be pursued with great caution. Approach all professional help with skepticism. Do not assume that professionals are competent to treat low back pain, and do not be afraid to shop around. Try many different therapists if you haven’t already, but always be quick to stop wasting your time and money on any professional who perpetuates myths or one-true-cause theories, makes big promises, or shows a lack of respect for your preferences or a lack of interest in trigger points as a factor.

Massage therapy is your best bet, because massage therapists are the most likely sort of therapist to know something about trigger point therapy, and — even if they don’t — they are also the best bet if you want to train your therapist to do the trigger point therapy that you want done. You will also get a robust treatment of depression and anxiety from any series of reasonably good massages, and it can be a good way to help you get started learning more cost-effective self-massage. All of that makes it worth the investment to shop around for a massage therapist you like.

Chiropractic therapy in moderation may also be useful if you’re comfortable with the idea of being adjusted, but beware of chiropractors who recommend long term treatment or — even worse — pre-paid treatment plans. Do not buy into the idea that your spine needs “maintenance”!

Another option to consider is working with any professional (most likely a physical therapist or doctor) who offers other methods of trigger point treatment, such as stretch and spray therapy, injection therapy, or the less reliable (but possibly worth trying if focused on trigger points) transcutaneous electrical nerve stimulation therapy (TENS) or ultrasound. Just be aware that the costs and risks go up with these approaches compared to massage, with no clear additional benefit.

Surgery and even minimally invasive treatments should be considered only when you can honestly say that you have tried everything else first — meaning, all of the above. Fusion surgeries, the most likely prescription, should probably be avoided even then. But when you have truly given the confidence cure and trigger point therapy a fair shot, when you have already addressed the worst of your emotional stresses and anxieties and insomnia, when you have established a good microbreaking habit and you’ve self-massaged yourself extensively and spent many an hour mobilizing in a hot shower, when you’ve experimented thoroughly with other trigger point therapy … if, after all that, your symptoms have still not been eliminated or at least well-controlled, then it is finally time to shop around for a good surgeon and discuss your surgical options, especially (and first) medial branch nerve blocks, which are probably the most evidence-based diagnostic and treatment method.

…our diagnosis and treatment of tension myositis syndrome [muscle pain] represent yet another instance of what is possible when the power of the mind is mobilized for healing the body. It’s not magic; it is as scientific as the appropriate use of antibiotics, for science encompasses everything that is true in nature.

John Sarno, Mind Over Back Pain, p109

Good luck with your back.

PART 6

APPENDICES

How was that for you?

Thanks for reading. If you were not satisfied with the tutorial, please write to me about it. Constructive criticism is always welcome. And you’re welcome to a refund — all you have to do is ask.

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<a href="https://www.painscience.com/tutorials/low-back-pain.php">low back pain tutorial</a>

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6.1

Appendix A: Why don’t the experts know more about this?

They do, actually — the problem is that only the experts know about it. The ideas presented in this tutorial are supported in part or entirely by many of the world’s leading authorities on pain in general, and back pain in particular.

Yet it is easy to get the impression that this isn’t so, because front-line general practitioners, therapists, and even medical specialists seem deeply confused, or simply ignorant, about the treatment of low back pain. This is because the expert opinions, while available, have not been widely disseminated to non-specialists the way that good ideas usually are. There are many reasons for this, but I think it’s mainly because the real causes of back pain are difficult to square with the mechanistic philosophy of health care so prevalent in the world today.

Here is a sampling of expert opinion on the subject:

- Dr. Nikolai Bogduk, a medical expert without the least tinge of the unconventional about him, knows that back pain isn’t structural. At the Ninth World Congress of the International Association for the Study of Pain, he concluded that “Preventing acute [back] pain from turning into chronic pain was often a matter of ‘treating the patient nice and convincing him that there is nothing so horribly wrong.’” (Jackson) (You can read more about his comments by clicking the link.)

- Dr. Richard Deyo of the University of Washington is a highly credible mainstream physician and researcher. Although Deyo does not appear to know about the importance of muscle in low back pain, he does know that it is rarely caused by structural abnormalities. Deyo is also known for publishing the “back pain myths,” which are entirely consistent with the spirit of my own back pain writings.

- Drs. Janet Travell and David Simons, physicians and researchers, are the world’s foremost experts on pain of muscular origin, and have spent their careers trying to educate health care professionals about its clinical importance. If you read Travell/Simons and Deyo (see previous item), you pretty much have the back pain problem surrounded. They should really get together for lunch!

- Dr. John Sarno of New York concludes from his own clinical experience that most back pain must be caused by stress and muscles, and he has reinvented a basic version of myofascial pain syndrome that he calls “tension myositis syndrome.” Although he attributes too much to the power of the mind to heal, he explains some important aspects of low back pain very well to a popular audience. And I admire his many audacious but valuable insights and the power to express his ideas.

- Dr. Chan Gunn, a Vancouver physician and medical researcher, has devoted his career to understanding pain of muscular origin. He proposes a cause of muscle pain that contradicts Travell and Simons, and I don’t think they can both be right. However, just like they do, he certainly does an excellent job of explaining exactly how muscle can cause a lot of pain.

- Dr. Gabor Maté, another Vancouver physician, is not a back pain expert, but he is an expert about stress. He writes extensively about the mechanisms by which stress can wreak physiological havoc, helping reduce the stigma of psychophysiological ailments.

This is an incomplete list, of course. So many experts do understand — just not enough of them, and far too few clinicians do. Unfortunately, while the experts know better, the real causes of back pain remain unknown to most health care professionals.

6.2

Appendix B: A low back pain story

A typical low back pain story begins with gardening …

Imagine a professional woman who sits all day — a chair warrior — and enjoys working in her garden on the weekends. Her back muscles don’t get a lot of stimulation or movement. She is also conscientious, hard-working, and has relocated three times in the last two years for promotions — giving up a relationship for the most recent move. However, even though moves and relationship changes are consistently ranked by psychologists as among life’s most stressful events, she doesn’t think of herself as stressed out because she is skillful at ignoring and hiding most of the symptoms of stress. This is a common survival skill in our society.

Naturally, because of the long days in a chair and the suppressed stress, she already has some unhealthy back muscles, a mild case of myofascial pain syndrome. She hasn’t really noticed it, though. The knots in her muscles are what we call “latent” — that is, they are mostly painless unless someone presses on them. It’s been like this for years, and all she’s ever noticed was a bit of stiffness.

Then one weekend in the garden, she spends some extra time weeding, stooped and crouched for at least an hour longer than usual. While she works, she notices a minor stab of pain, and then feels unusually stiff for the rest of the evening. A tissue insult has occurred: what we call an MID or minor intervertebral derangement, the spinal equivalent of stubbing your toe. The MID is less painful in this case — all she’s done is pinched some small joint surfaces together, something she would probably forget in a few minutes if it had happened anywhere else in her body. But during the evening and throughout the night, the trigger points in her vulnerable back muscles begin to flare up into painful activity, reacting as much to their own sensitivity as to anything else. A vicious cycle has begun.

At this point, all her spasming muscles really need is some slow, confident, moderately stimulating movement — mobilizations — and perhaps a warm bath or a hot pack. Unfortunately, she doesn’t know that. When she wakes up, she finds that her back is throbbing and the slightest movement causes a stabbing pain that seems dangerous to her. In fact, the pain may be no worse than a bad headache, but it’s her spine, and she believes — like most people — that backs are fragile and back pain is frightening — so she makes an appointment with her doctor.

The doctor is unusually competent and cautious: he is reassuring and careful about what he says, knowing that most back pain resolves spontaneously within three weeks. However, he is not careful enough with his communication: trying to be helpful, he uses the “s”-word … “surgery.” Although he tells her that she will probably be just fine, he also tells her that she should report back to him if the pain persists or shoots down her leg, because “that could indicate a disc herniation and possibly the need for surgery.”

He does not tell her — because he does not know — that only a tiny fraction of back pain is caused by herniated discs, and even when it is, most disc herniation does not significantly benefit from surgical repair. She has heard of herniated discs. Her friend was flat on her back for six weeks with a “slipped disc,” a horrifying experience. This possibility really spooks her, and the vicious cycle is now compounded on all fronts: pain, fear, and immobility are all reinforcing each other.

Within forty-eight hours, every trace of her original minor “injury” has undoubtedly disappeared — like a stubbed toe, an MID can be painful at the time but is quickly gone without a trace. But her muscles, which were a bit sickly to begin with, are now howling with a flare-up of undiagnosed trigger point pain (the “into the fire” problem). Unless she is reassured and starts moving more confidently … there is no particular reason for the cycle to break.

And it doesn’t.

The muscle pain, which is so intense that it confirms her worst fears at every turn, comes and goes in waves for three weeks, when it could have been over, like a crick in the neck usually is, in about three days. She speculates endlessly about what she could possibly have done to herself. She can only guess that the cause was “gardening,” an idea that will haunt her for years, reinforcing the idea that her back is fragile and can be seriously damaged by an activity as mild as gardening. All this serves to poison her favourite recreational activity, which was formerly her major self-defense against life stress.

Our heroine has now become one of millions of people who are going about their lives in fear of “twisting wrong” or straining their backs. Once this attitude sets in, I call the condition “scaredy-cat back syndrome”: where myths and fear are the dominant aggravating factors in chronic or episodic low back pain.

And, like so many people with low back pain, things get worse for her.

Just when she thinks she might be getting a little better, pain begins shooting down her legs — just what the doctor told her was a “warning sign” of pinched nerves and disc herniation. In fact, that shooting sensation is a common feature of painful but harmless trigger point pain and has nothing to do with pinched nerves. But the doctor orders an expensive, high-tech test — magnetic resonance imaging, or MRI — in the hopes of finding a mechanical explanation for her pain. There’s a long waiting list (a Canadian problem with our medical system): while she waits, there will be nothing but more doubt and fear.

Meanwhile, he sends her to a physiotherapist, who reassures her that she probably won’t need surgery (thumbs up), but who does tell her that she needs months of expensive physical therapy, and that her back is hurting her because of a short leg and a misaligned pelvis — thumbs down! Although there may be some truth in these diagnoses, it’s irresponsible for a therapist to be so confident in them, or to pretend to know how important they are, or to prescribe months of therapy — all of this just perpetuates the idea that her back is really messed up.

Of course, therapy fails. The exercises are numerous, tedious, and feel like a life sentence. The diagnosis of crookedness is half wrong — two other therapists she sees later on give her completely different biomechanical explanations — and in any case they are fighting upstream against her fear and despair, which are much more relevant to her low back pain and much more treatable! Of course, all the fear and anxiety are greatly exacerbated by the failure of the therapy, the continuing pain, the loss of gardening, the effect on her career. She gains weight because she copes with the despair by eating more. Almost everything about her life gets worse.

Her back pain story continues this way for three years. Without good information and an accurate diagnosis, how can it end? She rides a merry-round of misdiagnoses and specialists and therapists. Sometimes she tries new cures, and sometimes she just puts up with the pain. When she feels like she’s tried it all, she gives up and has surgery. It seems to work well at first, and the surgeon is her hero. Life seems to get a lot better. Until the pain comes back six months later …

And that’s when she calls me.

And somehow I have to convince her that her back was probably never really damaged in the first place. That she never needed surgery. That the disc herniation was a red herring. That the main reason she never got better was because no one told her that her spine isn’t fragile. It is a nearly impossible task. Patients who have been through this — and much worse — are invariably exhausted, fed up, cynical, their heads spinning with contradictory opinions and advice. The best and the worst thing anyone could possibly tell them is that it didn’t have to go that way.

That’s my job. And that’s why I wrote this article. The bad news is that you probably didn’t have to go through this. The good news is that there’s a good chance that it can finally end now.

6.3

Further Reading

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

- PS Back Pain & Trigger Points — A quick introduction to the role of trigger points in back pain

- PS Massage Therapy Kinda, Sorta Works for Back Pain — It works, but not very well, and “advanced” techniques are no better than relaxation massage

- PS Do Nerve Blocks Work for Neck Pain and Low Back Pain? — Analysis of the science of stopping the pain of facet joint syndrome with nerve blocks, joint injections, and nerve ablation

- PS (Almost) Never Use Ice on Low Back Pain! — An important exception to conventional wisdom about icing and heating

- PS Morning Back Pain — A thorough review of possible causes for this frustrating symptom

- PS A Guide to Sciatica Treatment for Patients — A guide to buttock and leg pain (which may or may not involve the sciatic nerve)

- The “perfect spots” to massage back pain:

- PS Massage Therapy for Low Back Pain — Perfect Spot No. 2, in the erector spinae and quadratus lumborum muscles in the thoracolumbar corner

- PS Massage Therapy for Back Pain, Hip Pain, and Sciatica — Perfect Spot No. 6, an area of common trigger points in the gluteus medius and minimus muscles of the hip

- PS Massage Therapy for Low Back Pain (So Low That It’s Not In the Back) — Perfect Spot No. 12, a common (almost universal) trigger point in the superolateral origin of the gluteus maximus muscle

- PS Massage Therapy for Low Back Pain (Again) — Perfect Spot No. 13, The Most Classic Low Back Pain Trigger Point

- PS The Bath Trick for Trigger Point Release — A clever way of combining self-treatment techniques to self-treat your trigger points (muscle knots)

- PS Spinal Subluxation — Can your spine be out of alignment? Chiropractic’s big idea has been misleading patients for more than a century

- PS Spinal Fracture Bracing — My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace

- PS Natural Imperfection — Evolution doesn’t care if you have back pain … just as long as you can breed

- PS Does Spinal Manipulation Work? — Spinal manipulation, adjustment, and popping of the spinal joints and the subluxation theory of disease, back pain and neck pain

- PS Does Posture Correction Matter? — Posture correction strategies and exercises … and some reasons not to care or bother

- PS The Trouble with Chairs — The science of being sedentary and how much it does (or doesn’t) affect your health and back pain

- PS Psoas, So What? — Massage therapy for the psoas major and iliacus (iliopsoas) muscles is not that big a deal

Other good reading about back pain:

- Mind over back pain: a radically new approach to the diagnosis and treatment of back pain, a book by John Sarno. A classic in the field, flawed and aging still but worthwhile, written before Dr. Sarno started to treat his approach like a panacea. The book emphasizes a lot of right ideas for the wrong reasons.

- “The Pain Perplex,” a chapter in the book Complications, by Atul Gawande. Gawande’s entire book is worth reading, but his chapter on pain physiology is certainly the best summary of the subject I have ever read, and a terrific reminder that good writing for a general audience can be just as illuminating for professionals. Anyone struggling with a pain problem should buy the book for this chapter alone, though you are likely to enjoy the whole thing. Much of the chapter focuses on one of the most interesting stories of low back pain I’ve read, and it is a responsible and rational account — although Gawande, like most doctors, seems to be unaware of the clinical significance, or even existence, of myofascial trigger points.

- Dr. Jerome Groopman has written brilliantly about back pain, from personal experience. In How Doctors Think he puts back pain in the context of how medical thinking is influenced by marketing and money, giving us a somewhat chilling insiders’ view of the surgical treatment of back pain. In The Anatomy of Hope, he tells his own story of super severe back pain. It has a happy ending! Both books are also otherwise worthwhile. “Marketing, Money, and Medical Decisions,” a chapter in the book How doctors think, by Jerome Groopman. Groopman, writing from personal experience with chronic back pain and a spinal fusion surgery, discusses back pain as intelligently as any medical expert I’ve come across, but he does so in a way that will fascinate patients. In this chapter, his discussion of back pain is placed in the context of how medical thinking is influenced by marketing and money, giving us a somewhat chilling insiders’ view of the surgical treatment of back pain.

6.4

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.

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

I love what you do, I read your site often, and I recommend it to friends. I bought the boxed set because I read the studies you linked to, because I decided since my back hurts and so does everyone else’s in my family, I want it all. Plus my best friend has wicked iliotibial band syndrome, so I figured I’d pass along that info to him. Anyways, dude, you rock socks off, keep on fighting the woo woo, you’ve made a reader for life! Thanks more than you know.

~Dave Falloon, Systems Administrator, Winfield, Canada

I have had life-altering low back pain for more than 8 years. I’ve had the fusions at L5-S1. Prior to my first surgery I spent 18 months seeking relief through physical therapy, intense massage therapy, myofascial “release” therapy, a visit to Dr. Sarno himself, injections, dry needling of trigger points and massage from a physiatrist, chiropractic work and more. For years between surgeries I tried core strengthening, acupuncture, PT, more massage, two rhizotomies, and visits to the Mayo clinic and Johns Hopkins’ pain management in-patient programs. So I’ve been through a lot. And your book is the first thing I’ve read that dispassionately and entertainingly dissects all of the options and offers some realistic, pragmatic suggestions. It’s a gift to all back pain sufferers.

~John Ford, veteran of severe chronic back pain

Your low back pain tutorial is refreshing. I’d gotten tired of hearing the same old explanations for my back pain, which are obviously wrong simply because the back pain was around before the things that supposedly caused it! It was nice to read something clear and logical that is actually consistent with my experience.

~Jean Gallagher, low back pain sufferer, California

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 PainScience.com 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:

- Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.

- Too negative specifically. Some are offended by about a treatment option that they personally use and like. Or sell.

- Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.

- Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.

6.5

Acknowledgements

This document and all of PainScience.com was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

6.6

What’s new in this tutorial?

This tutorial has been continuously, actively maintained and updated for 14 years now, staying consistent with professional guidelines and the best available science. The first edition was originally published in September 2004, after countless hours of research and writing while I spent a month taking care of a farm (and a beautiful pair of young puppies) in the Okanagan.

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 124 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

May — Science 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.]

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

March — Major 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.]

January — Major 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.]

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

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

2017 — Major 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.]

2017 — Science 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.]

2017 — Science 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.]

2017 — Major 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.]

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

2017 — Minor 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.]

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

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

2017 — Science update: Added a small but key new point and citation about genetic factors in degeneration; and an important new citation about the disconnect between imaging results and pain. [Section: Diagnosis: Your low back is not fragile!]

2017 — Science 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.]

2017 — Science 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.]

2017 — Science update: Newer, better, evidence-based good news about disc herniation resorption. [Section: Diagnosis: Your low back is not fragile!]

2017 — Science 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.]

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

2017 — Science update: Added discussion of a remarkable example of poor MRI reliability. [Section: Diagnosis: Your low back is not fragile!]

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

2016 — Science 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.]

2016 — Edited: 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?]

2016 — Science update: There is now a good scientific concensus on the subject of spinal fusion, thanks to papers like Mannion 2013 and Hedlund 2016. Putting a spotlight on this called for some serious revision and editing. The whole section is greatly improved. [Section: The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries.]

2016 — Upgrade: Added much more information about non-Rx pain-killers, and greatly improved information about opioids (and linking to much more information). [Section: Pain medications (and even alcohol) can be useful.]

2016 — Correction: Removed overconfident statements about the clinical significance of the effects of psychoactive drugs, plus related minor updates. [Section: A trigger point checklist: does this sound like you?]

2016 — Minor update: Some editing and new caveats. [Section: Diagnostic numbing of facet joints.]

2016 — Science update: Some fresh citations that strongly reinforce the main point of the section, and a few entertaining new examples of weird placebo effects. [Section: The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries.]

2016 — Safety update: Updated opioid summary for consistency with new CDC guidelines. [Section: Pain medications (and even alcohol) can be useful.]

2016 — Update: Added new intro to section about distorted body image. [Section: Is there such a thing as a “subluxation”? Can your back be “out”?]

2016 — Minor update: Clarification of the significance of some previously cited science, Ferreira et al. [Section: Core strengthening has failed to live up to the hopes and dreams of therapists and patients.]

2016 — Science updated: New citations and more information about spontaneously resolving herniations. [Section: Diagnosis: Your low back is not fragile!]

2016 — Science update: Beefed up the evidence that vertebroplasty is an ineffective surgical fix for an allegedly structural problem. [Section: Diagnosis: Your low back is not fragile!]

2016 — Minor science update: Added a note about the odds of back pain having a serious cause. [Section: “What if there’s something seriously wrong in there?”.]

2016 — Science updated: Added some general explanation of cognititive-behavioural therapy, with a key reference. [Section: The confidence cure.]

2015 — Science update: Added discussion of a popular acupuncture-for-back-pain paper, Cherkin 2009. Which is not fit to line a birdcage, in my opinion. [Section: The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.]

2015 — Edited: Modernization of trigger point summary, more science, and more acknowledgement of controversies. [Section: There is nothing “just” about muscle.]

2015 — Edited: Modernization of trigger point summary, more science, acknowledgement of controversies. [Section: So then what? The missing muscle piece.]

2015 — Science update: Added surprisingly good news about methylene blue injections. [Section: Facet joint and intradiscal steroid injections are not recommended for most patients.]

2015 — Science update: There’s been more study of the role of bacteria in back pain. And still not enough! [Section: Antibiotics for back pain: a debacle.]

2015 — Science update: Added information and references about transitional vertebrae and Bertolotti’s syndrome. [Section: The role of true nerve problems in low back pain.]

2015 — Science update: Added 3 good references and a diagram about how much “wiggle” room nerve roots have. [Section: Could you have a “pinched” nerve? The nerve pinch myth.]

2014 — Minor update: Added a reference for reassuring data about recovery rates. [Section: Who is this low back pain tutorial for?]

2014 — Major update: The first complete professional editing of this book has now been completed. Although the difference will not be obvious to most readers, several hundred improvements and corrections were made, and it is definitely a smoother read.

2014 — Minor update: Added Digital Motion X-ray. [Section: A few more snack-sized reality checks: brief comments on other treatments to avoid.]

2014 — Minor update: Plugged a good quality microbreaking reminder app [Section: Sitting, chairs, and ergonomics.]

2014 — Minor Update: Some relevant humour: added a pretty funny video about a core strengthening product. [Section: Is it core weakness?]

2014 — New section: A minor topic, but one of the most overdue sections I’ve ever added to the book: I’ve been asked about these devices a lot over the years. [Section: Back bracing and stabilization contraptions (especially inflatable ones).]

2014 — Rewritten: Cleaned up and modernized, more information, especially a more useful and evidence-based self-treatment tip. [Section: Morning pain and sleep posture.]

2014 — New section: No notes. Just a new section. [Section: 3 Lessons From an Acute Back Trauma: Joint popping, muscle dominance, and the mind game.]

2013 — Minor update: Added some great backup from a terrific surgeon blogger — who advocates for the necessity of testing placebo surgeries, exactly as I have in this section for many years. [Section: The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries.]

2013 — Minor update: Added a (fascinating) footnote about the myth of anaesthetic paralysis. [Section: Pain medications (and even alcohol) can be useful.]

2013 — Expanded: Added subsection on electroacupuncture. [Section: The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.]

2013 — Science update: Reporting on the greatest hits of back pain science (Machado 2009, a source of several important points here and in other sections). [Section: So what’s the plan?]

2013 — Science update: Some science showing that the effect of hamstring tightness on back function/pain isn’t exactly potent. [Section: What about stretching?]

2013 — Science update: Interpretation of a little junky new science about Pilates. [Section: Core strengthening has failed to live up to the hopes and dreams of therapists and patients.]

2013 — Comedy update: Added an amusing, extended example from the TV show, The IT Crowd. [Section: Pain and fear, together at last: an even simpler vicious cycle.]

2013 — Minor update: Added a quote that beautifully expresses the reason for treating chronic pain with … maturity. [Section: Another %[email protected]&*!! personal growth opportunity.]

2013 — New section: An overdue upgrade! This way pain and fear power each other is now explained much more clearly and thoroughly than before. It’s noteworthy that, with this update, Dr. Lorimer Moseley’s valuable perspective on back pain is now fairly well-represented in this book. [Section: Pain and fear, together at last: an even simpler vicious cycle.]

2013 — New section: Important new chapter about a hype-hot news item. [Section: Antibiotics for back pain: a debacle.]

2013 — New evidence: Rare good news: the first good quality scientific test of “the confidence cure” had promising results — which is just about the best thing that could have happened to this chapter. [Section: The confidence cure.]

2013 — Minor update: Interesting, useful new reference. [Section: Diagnosis: Your low back is not fragile!]

2013 — Minor update: Upgraded risk and safety information about Voltaren Gel. [Section: Pain medications (and even alcohol) can be useful.]

2013 — Major update: All major professional treatment options now summarized. [Section: Getting professional help: A consumer’s guide to buying therapy and medical care for low back pain.]

2013 — New section: New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan. [Section: So what’s the plan?]

2013 — Major update: All major self-treatment options now summarized. [Section: Self-treatment options: How to save yourself from low back pain, or at least avoid getting hurt or ripped off trying.]

2013 — Edited: Nothing in particular has changed, but it’s definitely a better chapter now. [Section: The confidence cure.]

2012 — Science update: Added (more) evidence showing the role of smoking in chronic back pain. [Section: Now what?: An action-oriented summary of recommendations.]

2012 — Science update: New reference strongly supporting a key, controversial point. [Section: The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.]

2012 — Minor update: Added an intriguing quote about evolution and the lack of back pain in hunter gatherers. [Section: Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves.]

2012 — Science update: Put “foot fear” in context with some reassuring high heels science. [Section: Is it all in your feet? Foot-o-centric low back pain theories.]

2012 — Science update: Added evidence that the stakes are high with chronic pain: it may even shorten lives. [Section: A tragic low back pain myth.]

2012 — Minor update: Added a new suggestion for safe, pleasant self-tractioning. [Section: Traction: low back pain on the rack!]

2012 — New section: No notes. Just a new section. [Section: Back pain and sneezing.]

2012 — Science update: Interesting evidence that massage therapists cannot reliably find the side of pain by feel. [Section: Structural problems in the low back are hard to diagnose accurately.]

2012 — Minor update: Added a fine example of taking yoga very, very seriously as an option. See first footnote in section. [Section: Stress relief and the tyranny of meditation and yoga.]

2012 — Update: Editing, and several new paragraphs about safety issues. [Section: Yoga and meditation are still an option, of course.]

2012 — Minor update: Some simple revision for clarity and quality, and a bit more content. [Section: Stress relief and the tyranny of meditation and yoga.]

2012 — Science: More science, and a few substantial new footnotes fielding common concerns and questions. [Section: Core strengthening has failed to live up to the hopes and dreams of therapists and patients.]

2012 — Science update: Clarified information about pelvic tilt, and beefed it up with some more science. [Section: Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves.]

2012 — Minor update: Important new, skeptical footnote about the dangers of the powerful narcotic drugs. [Section: Pain medications (and even alcohol) can be useful.]

2011 — Science update: More evidence of the exercise effects are limited and non-specific. See the paragraph starting “Does spinal function improve…” [Section: Core strengthening has failed to live up to the hopes and dreams of therapists and patients.]

2011 — New section: No notes. Just a new section. [Section: What is the difference between a ‘confidence cure’ and a mere placebo?]

2011 — Updated: Added scientific cases studies, examples, pictures and video of true dislocation and abnormal anatomy to help drive home the point that even significant spinal joint dysfunction can be surprisingly harmless … never mind subtle joint problems. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation, and cracking of the spinal joints.]

2011 — Minor update: Minor, but fun — a great quote about models of slipped discs, and a good new image to help it along. [Section: Those scary spine models.]

2011 — Rewritten: Improved and expanded. In particular, intramuscular stimulation (IMS) was “demoted.” I am disillusioned with it and no longer want to promote it without strong caveats. [Section: “Medical” treatment option for trigger points: dry needling (IMS), stretch and spray, and trigger point injections.]

2011 — Major science update: Detailed reporting on some new yoga science. Significant re-writing of the section ensued. Sometimes new science does not back up my preconceptions: I’ve changed my tune here somewhat. [Section: Yoga and meditation are still an option, of course.]

2011 — Minor update: Added a couple great points/quotes from doctors about overuse of MRI, as reported by Gina Kolata for the New York Times. [Section: Diagnosis: Your low back is not fragile!]

2011 — New science: I stumbled across a fantastic scientific paper about the prevalence of nerve pinches (hint: it’s low). Excellent perspective. [Section: Could you have a “pinched” nerve? The nerve pinch myth.]

2011 — New section: A key concept covered in the trigger points tutorial long ago, but so relevant to low back pain that I decided it needed to be here as well. [Section: Could it be a vicious cycle of pain-spasm-pain?]

2011 — New section: This section is a summary of an important concept that’s been available in a free article since late 2008, but it really needed to be emphasized here. [Section: From the frying pan of injury pain to the fire of trigger point pain.]

2011 — Minor update: A few new paragraphs summarizing an important new study of massage for low back pain with disappointing results. [Section: The evidence for massaging back pain.]

2011 — Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman et al. [Section: Introduction.]

2011 — New section: More information about an important characteristic of muscle-dominated back pain. [Section: “Out of nowhere”: seemingly random episodes of low back pain.]

2011 — Major update: Totally renovated section: re-written, reformatted, expanded, upgraded. A few new checklist items were added, most were expanded, and all were clarified. A separate and handier “quick” checklist was added to the existing “slow” checklist. [Section: A trigger point checklist: does this sound like you?]

2011 — Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

2011 — Minor Update: Added evidence that spinal fusion surgeries are not just ineffective but often harmful (Nguyen). [Section: The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries.]

2011 — Minor update: Added a fascinating science item about the effect of anti-inflammatory gels on back pain (Huang). [Section: Pain medications (and even alcohol) can be useful.]

2011 — Minor Update: Long overdue, I finally added some science to this section, showing that the connection between low back pain and obesity is weaker than it seems (Wright). [Section: Do you really need to lose some weight?]

2011 — Minor Update: Added some interesting references about sensation (Luomajoki) and the relationship between back pain and a disrupted “body schema” (Bray). [Section: Is it core weakness?]

2011 — Upgraded: New artwork from PainScience.com artist Gary Lyons, plus some important new references. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation, and cracking of the spinal joints.]

2011 — Minor Update: Added a fun and informative quote from the TV show House. [Section: Diagnosis: Your low back is not fragile!]

2011 — Updated: Added some new evidence about back pain and aging, and a nice new graph. [Section: Maybe you’re just getting older? Actually, no ….]

2011 — Minor update: Just added a link, but a really great link! The CBC show Marketplace did an amazing job last year reporting on spinal decompression machines. Well worth a look — the show and their show page is probably now the single best source of information on this topic. [Section: Spinal decompression therapy: worth the money and risks?]

2011 — Minor update: Some editorial cleanup on core strengthening, and I a link to a good summary of recent research. [Section: Is it core weakness?]

2010 — Like new: Re-written and significantly expanded. [Section: Act normal! Rest minimally and strategically, while maintaining as much normal activity as you can.]

2010 — New section: No notes. Just a new section. [Section: Could low back pain be an overuse injury?]

2010 — Major Update: Rewriting and expansion of the Special Supplement on spinal manipulative therapy. [Section: Is there such a thing as a “subluxation”? Can your back be “out”?]

2010 — Updated: Added a much more detailed description of the Hancock et al study, and in fact turned it into the main substance of this section. [Section: Structural problems in the low back are hard to diagnose accurately.]

2010 — Updated: Added a very beefy footnote about some new research showing that muscle imbalance does not result in higher rates of injury. This almost should have been a new section, but I decided to just make it a ginormous footnote — footnotes are there for delving if you want to, that’s the idea! You can read a summary of the research in the bibliography (see Hides et al), but the relevance to back pain is spelled out in detail here. And it’s interesting. [Section: Diagnosis: Your low back is not fragile!]

2010 — Upgraded: Section now includes discussion of that bizarre and already infamous paper in the New England Journal of Medicine (see Berman). I also make an important new point: exactly why acupuncture placebos are such a problem for low back pain patients in particular. [Section: The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.]

2010 — Like new: Rewritten. I’ve lost track and can’t be bothered to go back into the archives to figure it out for sure, but I think that this section was brand new (but never announced) late in 2009, and then this past week I gave it a substantial upgrade: it is now one of the best-referenced chapters in the book, and it says as much as probably needs to be said on the subject — or more! [Section: Core strengthening has failed to live up to the hopes and dreams of therapists and patients.]

2010 — New cover: At last! E-book finally has a “cover.”

2010 — Minor update: Updated with a summary of a bizarre experiment with muscle relaxants that had quite surprising results. [Section: Pain medications (and even alcohol) can be useful.]

2010 — Minor update: Added a scientific thumbs down for transcutaneous electric nerve stimulation (TENS). [Section: A few more snack-sized reality checks: brief comments on other treatments to avoid.]

2010 — New section: A surprising scientific thumbs up for comfrey ointment was worth a whole new small section. [Section: Comfrey makes backs comfy, study claims.]

2010 — Minor update: Added clear evidence that family doctors don’t do a good job caring for patients with low back pain, and that a myth-busting ebook like this is still important. [Section: A tragic low back pain myth.]

2010 — New section: No notes. Just a new section. [Section: Less than a cure, but better than nothing: short term symptom relief options for low back pain.]

2010 — New section: An important update: a major new section that goes a long way to substantiating one of the most important points of this tutorial. [Section: The evidence for massaging back pain.]

2010 — Major upgrade: Rewritten and significantly expanded information about medications. [Section: Pain medications (and even alcohol) can be useful.]

2010 — New section: Having debunked expensive spinal traction using expensive decompression machines, here are some ideas for cheaper and safer methods of tractioning. [Section: Traction: low back pain on the rack!]

2010 — New section: No notes. Just a new section. [Section: Spinal decompression therapy: worth the money and risks?]

2009 — New section: Today I found a way to say some simple things about the power of self-treatment that have been “on the tip of my tongue” for years now. It all evolved from writing about an important bit of research, showing that manual therapists cannot (reliably) diagnose trigger points. [Section: Limitations of trigger point therapy, and how to take advantage of them.]

6.7

Notes

1. 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

2. Is “much” information really “just plain wrong”? I will establish this in the sections ahead with a steady supply of clearly explained references to the medical literature that patients can understand and professionals can respect. This extra layer of information in easy-to-use footnotes is available for any reader who wants to dig deeper and check my facts. For example, here’s a good start: In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT

3. Exhibit A: The worst possible website about pain

I like to kick off a topic with an example of a terrible website about it, just for the chuckle and a teachable moment. ThePain.net is one of the worst I’ve seen: a large, stale, ugly thing by Pekka Palin, MD. There are hours of terrible reading there! Dozens of blandly composed, shallow, rambling, and frequently irrational mini-articles on every imaginable pain subject, all 100% unreferenced, laid out in huge blocks of text without a subheading for many screens (a typographic travesty). There’s soooo much badness, but I really got a chuckle out of this perfectly pointless phrase: “The most common reason for temporary back pain is lumbago.” Now “lumbago” means “back pain” (see the definition of lumbago on Wikipedia), so Dr. Obvious has helpfully explained that the cause of back pain is, er, back pain. The Internet, at your service!

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4. 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.

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5. 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 Vox.com 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.

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6. Turns out that the committees that write these things do not necessarily know the science! One of the best reviews of back pain research ever published — Machado 2009, more on this one later — found something really interesting: “treatment recommendations from recent clinical guidelines do not align with the results of this meta-analysis.” In fact, quite a few disproven pain treatments are still cheerfully recommended in otherwise sensible professional guidelines. Eek. BACK TO TEXT

7. Zusman M. Belief reinforcement: one reason why costs for low back pain have not decreased. J Multidiscip Healthc. 2013;6:197–204. PubMed #23717046. PainSci #54554.
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.

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8. 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

9. 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. 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. Don’t take my word for anything. Take this guy’s word for it. Dr. Richard Deyo has been busting myths about low back pain for longer than I’ve been alive.

Or this guy’s word. Dr. Nikolai Bogduk has authored dozens of scientific papers about low back pain. He also questions and challenges many common beliefs about low back pain, and is one of the expert sources this tutorial relies upon.

Or this guy’s. Dr. Siegfried Mense is the world’s foremost expert in muscle pain. He is the author of the most current and authoritative text on that subject, and one of this tutorial’s most important sources.

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12. That’s a huge topic, but here’s one simple example of an extremely common problem with back pain science: control groups that don’t control. Rather than comparing a treatment to a good, carefully selected placebo, most studies use a comparison to a treatment that is allegedly neutral, underwhelming, or placebo-ish. That makes the results hard to interpret: if each works about the same, it could mean that the treatments are equally effective … or equally ineffective! So much back pain science has this problem — or any one of a dozen other weak points — that you can effectively ignore at least 80% of all back pain research, because it’s so far from the last word on anything. Good science is essential to solving these problems, but really good studies are also difficult to design and rare. BACK TO TEXT

13. 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.

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14. 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. See “Chronic low back pain is not so chronic: the myth of chronicity.” BACK TO TEXT

15. 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 by Loren Fishman, HumoresqueCartoons.com

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16. 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

17. ZOOM

Dr. John Sarno’s original best-seller about low back pain.
My original inspiration for this tutorial was Dr. John Sarno’s 1984 book Mind over back pain. (His more recent Healing back pain makes too many empty promises. See my review.) However, as much as I respect Dr. Sarno’s early work, there are at least three reasons why this tutorial is better than his books: (1) I make a much more airtight case against the conventional medical myths of back pain than Dr. Sarno does; (2) I also build a much better case for the real causes of back pain, heavily referencing more credible sources than Dr. Sarno does; (3) and I offer many more practical suggestions than Dr. Sarno does, instead of focusing exclusively on the psychological factors. Although I have less experience and education than Dr. Sarno, I do have a lot more hands-on experience (and the useful perspective of a journalist). BACK TO TEXT

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.

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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 states it most eloquently: “There is probably no other medical condition which is treated in so many different ways and by such a variety of practitioners as back pain. Though the conclusion may be uncomfortable, the medical community must bear the responsibility for this, for it has been distressingly narrow in its approach to the problem. It has been trapped by a diagnostic bias of ancient vintage and, most uncharacteristically, has uncritically accepted an unproven concept, that structural abnormalities are the cause of back pain” (p111). BACK TO TEXT

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

27. Dr. Deyo is quoted here by the New York Times in Back Pain Spending Surge Shows No Benefit regarding this paper published in Journal of the American Medical Association: “Expenditures and Health Status Among Adults With Back and Neck Problems” BACK TO TEXT

28. Chou R, Qaseem A, Snow V, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478–491. PubMed #17909209. PainSci #56029.The American College of Physicians and the American Pain Society “strongly” recommend that doctors avoid trying to diagnose back pain with MRI and X-rays unless symptoms persist and/or include severe neurological problems. For my report when the guidelines were announced, see MRI and X-Ray Often Worse than Useless for Back Pain BACK TO TEXT

29. Gina Kolata for the New York Times:

The pitchers were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says.

And …

“It is very rare for an M.R.I. to come back with the words ‘normal study,’ “ said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. “I can’t tell you the last time I’ve seen it.”

No kidding. I’m not sure I’ve ever had a conversation with someone about their MRI that didn’t involve speculating about the significance of something the scan revealed.

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30. Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients. Arch Intern Med. 2009;169(10):972–981. PainSci #55430.
“Well-established guidelines indicate that rapid or advanced imaging is not beneficial in the absence of specific complicating features,” and imaging is “rarely indicated, even for elderly patients.”

In spite of that, however, this large study of 35,000 (!) patients with low back pain found that almost 30% were given a X-ray or MRI within 28 days. Black and older patients received less rapid imaging, which probably indicates that a lot of imaging is driven by a profit motive: that is, it’s sold to more affluent clients.

“Patients may consider imaging reassuring, and those with higher socioeconomic status may be more successful in obtaining testing in this context. However, in contrast to generally underused services such as diabetic monitoring, more rapid or advanced imaging for low back pain may not benefit patients and may result in harm.”

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31. Carey TS, Garrett J, Project NC. Patterns of ordering diagnostic tests for patients with acute low back pain. Ann Intern Med. 1996 Nov 15;125(10):807–14. PubMed #8928987. PainSci #57065.
From the abstract: “Radiography is commonly used as a diagnostic test for patients with acute back pain.”

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32. Swedlow A, Johnson G, Smithline N, Milstein A. Increased costs and rates of use in the California workers’ compensation system as a result of self-referral by physicians. N Engl J Med. 1992;327:1502–6. PubMed #1406882.
From the abstract: “Of all the MRI scans requested by the self-referring physicians, 38 percent were found to be medically inappropriate…”
Self-referring physicians are physicians sending patients to pain clinics or imaging facilities that they own: that is, referring patients to themselves (“you need to buy more testing from me”). BACK TO TEXT

33. Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed #11172169. “ …imaging is often unnecessary.” BACK TO TEXT

34. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb;373(9662):463–72. PubMed #19200918.
“Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems,” but this review of six studies of the subject clearly concludes that they really should not do that. It simply does no good, but it does waste resources and scare patients. As long as there are no signs of a serious underlying condition, “lumbar imaging for low back pain … does not improve clinical outcomes.”

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35. Chou R, Qaseem A, Owens DK, Shekelle P; for the Clinical Guidelines Committee of the American College of Physicians. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med. 2011 Feb;154(3):181–189. PubMed #21282698.
From the abstract: “…evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. … In this area, more testing does not equate to better care.” Emphasis emphatically mine.

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36. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811–6. PubMed #25430861. PainSci #53872. Signs of degeneration are present in high percentages of healthy people with no symptoms… even young people. For instance, asymptomatic disc degeneration is present in 68% of 40-year-olds. Painless disc bulges are present in 40% of 30-year-olds. The authors concluded: “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.” BACK TO TEXT

37. Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed #11172169. “ …disk and other abnormalities are common among asymptomatic adults.” BACK TO TEXT

38. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72(3):403–408.
The authors found that 22% of pain-free adults under 60 had herniated disks. A whopping 93% of asymptomatic volunteers over 60 had signs of disk degeneration.

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39. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69–73. PubMed #8208267. PainSci #56640.
The authors found 28% of healthy adults with no low back pain had a herniated disk, and 52% had a disk bulge! They conclude: “On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.”

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40. Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology. 1998;209(3):661–666.
This research found that an incredible 40% of asymptomatic adults had herniated disks, and 72% had signs of degeneration. The mean age of the sample was just 35.

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41. Stadnik TW, Lee RR, Coen HL, et al. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology. 1998 Jan;206(1):49–55. PubMed #9423651.
29 of 36 asymptomatic people nevertheless had “bulging disk and focal disk portrusion.” From the abstract: “Annular tears and focal disk protrusions on MR images ... are frequently found in an asymptomatic population.” Indeed, these researchers found that a whopping 81% of pain-free adults had bulging disks, and an equally amazing 56% of them had annular tears (ripping of connective tissue near the disk).

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42. Borenstein DG, JW O’Mara SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects. Journal of Bone & Joint Surgery (American). 2001;83:1306–1311. PubMed #11568190.
In 1989, 21 of 67 perfectly healthy people, with no history of back pain, were scanned with MRI, and found to have “an identifiable abnormality of a disc or of the spinal canal.” Such findings are surprising, but perhaps the effect of such abnormalities is delayed: how were they doing a decade later? The research team followed up with 50 of the original subjects.

Their backs looked somewhat worse — more of the same — but only 21 of them had developed back pain, and not the same 21 that had abnormalities in ‘89. Only 12 of them had any findings on their original scans (and some of those were trivial).

The authors therefore concluded that “the findings on magnetic resonance scans were not predictive of the development or duration of low-back pain” and that “clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.” MRI findings — and the structural abnormalities that they reveal — are essentially meaningless on their own.

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43. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med. 2003 Jun;37(3):263–6. PubMed #12782554. PainSci #56840.
In this study of 31 Olympic athletes with low back pain and/or sciatica, only about half of them had signs of degeneration, bulging, or reduction of disc height.
My point here is that half of them did not have structural problems, in spite of their symptoms. These are elite athletes, not malingerers! If they say they hurt, they hurt. Yet MRI failed to identify a problem in half of them. BACK TO TEXT

44. Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed #11172169. “The association between symptoms and imaging results is weak.” BACK TO TEXT

45. Beattie PF, Meyers SP. Magnetic resonance imaging in low back pain: general principles and clinical issues. Phys Ther. 1998 Jul;78(7):738–53. PubMed #9672546. PainSci #56987.
From the abstract: “Lumbar MRI has a high technical capacity to detect degenerative disk disease, bulging and herniated disks, and distortions in the thecal sac or nerve roots associated with these conditions. The diagnostic accuracy, however, of most lumbar anatomic impairments related to the symptoms of LBP is low or unknown. Although lumbar MRI remains as an excellent tool to study morphology, findings must be related to data from clinical examinations to provide meaningful judgments.”

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46. For several years now, it’s been progressive — maybe almost fashionable — for back pain educators to trash talk imaging the way I am here. But just because we can’t seem to reliably find smoking gun causes of back pain with modern imaging technology does not mean it isn’t there. Physical therapist and researcher Tony Ingram makes this important point in a short evidence-based opinion piece, The back is still important in back pain. BACK TO TEXT

47. Deyo et al report that disc herniations account for about 4% of all back pain, and Sarno argues at length that nearly all disc herniations are incidental to the clinical problem, an sideshow that doesn’t do much except make people anxious. Yet approximately three quarters of the back pain patients that I see have either been “diagnosed” with a disc herniation, or they are concerned about the possibility! BACK TO TEXT

48. Zhong M, Liu JT, Jiang H, et al. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45–E52. PubMed #28072796. PainSci #53529. BACK TO TEXT

49. Kjaer P, Tunset A, Boyle E, Jensen TS. Progression of lumbar disc herniations over an eight-year period in a group of adult Danes from the general population: a longitudinal MRI study using quantitative measures. BMC Musculoskelet Disord. 2016 Jan 15;17(1):26. PubMed #26767364. PainSci #53406.
Impressively, this is “the first study to investigate changes in the size of lumbar disc herniations” over a long period: an 8-year study with multiple MRIs of one hundred and forty herniated discs, from 106 people. It found that disc herniations are mostly quite stable: about 65% got no worse or better. However, 17.5% of intervertebral disc herniations do spontaneously resolve on their own, and only 12.5% got worse. The small remainder of 5% fluctuated.

“Lumbar disk herniation has an uncertain natural history” (Hong). Indeed.

Those numbers are not awesome numbers — herniations do not all magically go away — but I do think they are different and much less discouraging numbers than most people have in their heads.

(No one knows how this works, by the way. Why would a disc herniation spontaneously resolve? Or pop in and out like a gopher? It’s a mystery.)

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50. NEJM.org [Internet]. Hong J, Ball PA. Resolution of Lumbar Disk Herniation without Surgery; 2016 Apr 21 [cited 17 Jun 9].
“Lumbar disk herniation has an uncertain natural history.” UNDERSTATEMENT. Check out these before/after pictures of a disk herniation that solved itself. Look closely where the arrow is pointing. Read the single paragraph description of the case. No scalpels were involved in this recovery. Now, did your concern level about disc herniations just drop 3 notches? Good, mission accomplished. File under “back pain rarely as bad as it feels.”

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51. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ, et al. Magnetic resonance imaging in follow-up assessment of sciatica. N Engl J Med. 2013 Mar;368(11):999–1007. PubMed #23484826. PainSci #54565.
Disc, schmisc: patients with back pain and sciatica recovered about equally well with or without disc herniations visible on MRI. Most (84%) recovered well within a year … and there were actually 2% more good outcomes in the patients with disc herniations! This seems like a surprising result, but it’s what the research has been pointing to for years. The nearly identical stats could be a fluke, of course, but they’d have to be off by a lot to change the reassuring take-home message. Even a 20-point difference, ten times larger than this, would still show that a “slipped disc” confirmed by MRI isn’t nearly as worrisome as most people assume.

Two other notable findings, further emphasizing how uninformative MRI can be: “distinguishing between protrusions and extrusions did not have diagnostic value” and “we did not find a positive correlation between the presence of scar tissue and symptoms.”

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52. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2016 Nov. PubMed #27867079. BACK TO TEXT

53. Peul WC, van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008 Jun;336(7657):1355–8. PubMed #18502911. PainSci #53367. The authors of this paper compared conservative therapy to surgery for sciatica and concluded that, “Neither treatment is clearly preferable.” They argued, “It might therefore be time to shift from the current situation of physicians’ recommendations about the need for surgery (often based on their personal preferences) to patients deciding, with the help of their physician, which treatment strategy is best for them.” BACK TO TEXT

54. Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed #11172169. Deyo’s paper is a tutorial for physicians. He comments in the first paragraph that “ …there is evidence of excessive imaging and surgery for low back pain in the United States, and many experts believe that the problem has been ‘overmedicalized.’” This opinion is supported with references to Carey, Swedlow, and Waddell, among others. North American physicians are looking for mechanical problems, and they are trying to solve them with surgery. BACK TO TEXT

55. There are many ways to demonstrate this. The next few footnotes cover several different angles. However, the most recent and interesting research is a 2008 study in Journal of the American Medical Association that showed that “spine-related expenditures have increased substantially from 1997 to 2005, without evidence of corresponding improvement in self-assessed health status” (see Martin). In other words, a lot of expensive medical care is not helping. This interesting paper was summarized well by Tara Parker-Pope in the New York Times. BACK TO TEXT

56. Not all surgery is ineffective (see Alvarez, for instance, who concludes about a common spinal surgery, decompressive laminectomy, “It is fairly clear, however, that in most patients with clear radiographic and clinical evidence of stenosis, decompressive surgery provides significant relief.”) However, there are conspicuous problems with spinal surgery, chiefly that we must question the rationale of any surgery that is done to correct any of the spinal structural problems that often do not cause symptoms. Until we understand why as many as 40% of adults may be walking around with painless herniated discs (Weishaupt), it seems unwise to assume that a herniated disc is necessarily the cause of any patient’s low back pain — or to operate based on that assumption! BACK TO TEXT

57. Gibson JN, Grant IC, Waddell G. The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. Spine. 1999 Sep 1;24(17):1820–32. PubMed #1048851. From the abstract: “There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management.” BACK TO TEXT

58. Deyo et al, op. cit. “There is no evidence from clinical trials or cohort studies that surgery is effective for patients who have low back pain unless they have sciatica, pseudoclaudication, or spondylolisthesis.” Yet there are, of course, numerous surgical procedures intended to correct other kinds of structural problems presumed to be the cause of back pain. BACK TO TEXT

59. Deyo et al, op. cit. With regards to treating stenosis with surgery (usually regarded as an effective procedure, again see Alvarez), Deyo writes, “Even with successful surgery, symptoms often recur after several years. At four years of postoperative follow-up, about 30 percent of patients have severe pain and about 10 percent have undergone re-operation.” This is supported with references to Atlas as well as another of his own papers, [Deyo 1993]. BACK TO TEXT

60. Vaccaro AR. Commentary and perspective on ‘Low-back pain following surgery for lumbar disc herniation: a prospective study’ by Toyone et al.. Journal of Bone & Joint Surgery (American). 2004. PainSci #56930.
Some important perspective on Toyone et al: “It is important to educate patients that the outcome of disc excision that is performed as a treatment for back pain alone is often unpredictable and that the operation may, in fact, result in a worsening of axial pain.”

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61. The placebo problem is simple: Some (or perhaps even many) successful spinal surgeries are successful not because they’ve corrected a mechanical problem, but because the patient is (extremely) impressed by the seriousness of the procedure and feels unusually optimistic. There will be much more information about this important issue later in the tutorial: see The back surgery placebo problem. BACK TO TEXT

62. Structurally, the spine has at least one distinct advantage over most other musculoskeletal structures in the body: it has a modular design. That is, it is composed of multiple standardized units. Primary spinal functions can be carried out by any significant subset of those units. Unlike your knees, for instance. If you seriously damage a knee joint, you lose all knee function. If you seriously damage a spinal joint, several other spinal joints can produce almost identical spinal function (see the next note). Also, although the spine is complex, evidence abounds that it is actually quite sturdy. Spinal joint dislocations and vertebral fractures are rare, occurring much less often than they do in other parts of the body. Such injuries require enormous physical trauma, like what happens in car accidents — and even then the majority of injuries affect the cervical spine. And no wonder: the spine in general — and the lumbar spine in particular — is an amazing structural compromise between flexibility and stability. Lumbar joints move just enough to give the whole lumbar spine considerable elastic qualities, yet they are entwined so thoroughly that no single lumbar joint moves much at all. And these well-balanced features are strongly consistent with what you’d expect from a structure that has evolved to protect the most crucial of all anatomy, the spinal cord. Lumbar spinal joints are not invulnerable, but they are certainly sturdier than people tend to think they are! BACK TO TEXT

63. Niemeyer T, Bovingloh AS, Halm H, Liljenqvist U. Results after anterior-posterior lumbar spinal fusion: 2-5 years follow-up. Int Orthop. 2004 Oct;28(5):298–302. PubMed #15480660.
Although this research concludes that anterior-posterior lumbar spinal fusion is an effective treatment for chronic low back pain, in my opinion the methodology is poor and the results are unconvincing. My own interpretation is quite different: the surgical procedure may have been irrelevant to the observed improvement in symptoms, which could have occurred without the surgery. However, the results do serve to demonstrate another important point: that the spine is not fragile and it is possible for people who’ve had chronic low back pain to experience an improvement in symptoms in spite of spinal fusion.

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64. This is an interesting one requiring a bit more explanation than just a citation. Its relevance to back pain may not be immediately obvious to the untrained eye. The evidence comes from a 2010 paper in British Journal of Sports Medicine (Hides et al), and appears to be about soccer players and hip muscles. But hips are highly relevant to the low back, particularly these ones — the psoas major muscles are two of the four big columns of muscle that surround and brace the lumbar spine. The research also looked at the quadratus lumborum muscle, which is much more straightforwardly a back muscle.
Researchers used MRI to measure the size of these muscles in 54 Australian Football League players — very serious athletes, these guys — and found that “asymmetry of the psoas and the quadratus lumborum muscles exists in elite AFL players.” I.e., they aren’t “balanced.”

Such asymmetries are widely believed by therapists to be clinically significant. Manual therapists, if they suspected such a distinct asymmetry in muscle mass — and they often do — would enthusiastically and almost unanimously embrace this significant lack of “balance” as a major risk factor for injuries in the region, and certainly as a likely suspect in your back pain. Therefore, they would also almost certainly recommend (expensive, time-consuming) therapy based on this idea: stretching and manipulation for the “over”-developed side, strengthening for the other side, and so on. I have seen patients spend literally thousands of dollars and many months of regular therapy and workouts trying to “solve” muscle imbalances.

However, the researchers also found that “asymmetry in muscle size was not related to number of injuries.” Not. Related. The most imbalanced players were no more likely to have a problem than the most balanced players. End of story. Just another great example of exaggerating the importance of how crooked you are. BACK TO TEXT

65. Maurer M, Soder RB, Baldisserotto M. Spine abnormalities depicted by magnetic resonance imaging in adolescent rowers. Am J Sports Med. 2011 Feb;39(2):392–7. PubMed #20889986.
Rowers often experience abnormalities of the lumbar spine as a result of their sport, but those abnormalities are not strongly associated with symptoms.

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66. Fox AJ, Lin JP,, Pinto RS, Kricheff II. Myelographic cervical nerve root deformities. Radiology. 1975 Aug;116(02):355–61. PubMed #168615.
Although this was a study of the cervical spine, its findings are certainly relevant to the back as well. Paraphrasing, Sarno (p21) writes: “… even large growths in the neck, such as benign tumours, produce no pain.” From the abstract: “Good correlation between specific features of root deformities and clinical significance could not be demonstrated.” In other words, nerve root deformity itself does not constitute a nerve root problem. If a deformed nerve root works and doesn’t hurt, it’s not a problem!

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67. Luoma K, Vehmas T, Raininko R, et al. Lumbosacral transitional vertebra: relation to disc degeneration and low back pain. Spine. 2004 Jan 15;29(2):200–5. PubMed #1472241.
From the abstract, “Lumbosacral transitional vertebra increases the risk of early degeneration in the upper disc,” yet “transitional vertebra is not associated with any type of LBP.”

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68. Magora A, Schwartz A. Relation between low back pain and X-ray changes 4: Lysis and olisthesis. Scand J Rehabil Med. 1980;12(2):47–52. PubMed #6451925.
From the abstract, “No direct relation between sacralization, partial or complete, and LBP was found.”

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69. Magora A, Schwartz A. Relation between the low back pain syndrome and x-ray findings 2: Transitional vertebra (mainly sacralization). Scand J Rehabil Med. 1978;10(3):135–45. PubMed #151915.
From the abstract, “No relation between prelysis and lysis, and low back pain was found. Lysis seemed to be associated with a higher severity of low back pain. All the subjects with olisthesis suffered from low back pain.”

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70. Magora A, Schwartz A. Relation between the low back pain syndrome and x-ray findings 3: Spina bifida occulta. Scand J Rehabil Med. 1980;12(1):9–15. PubMed #644614.
From the abstract, “It is concluded that spina bifida occulta does not play a causative role, does not cause a proneness to LBP and does not influence the chronicity of LBP.”

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71. Splithoff AJ. Lumbosacral junction; roentgenographic comparison of patients with and without backaches. JAMA. 1953 Aug 22;152(17):1610–3. PubMed #1306922.
This is one of the earliest examples of research showing poor correlation between structural problems and back pain. Sarno summarizes in Mind over Back Pain (p23): “Splithoff compared the occurrence of nine different abnormalities of the lower end of the spine in patients with and without back pain. He concluded that patients without backache demonstrated structural aberrations just as frequently as patients with back pain.”

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72. Buchbinder R, Osborne RH, Ebeling PR, et al. A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures. N Engl J Med. 2009 Aug 6;361(6):557–568. PainSci #55333.
This is one of a pair of 2009 papers (see also Kallmes et al) presenting strong evidence that there is “no beneficial effect” to stabilizing fractured spines with injections of bone cement (vertebroplasty), a common and yet apparently dubious procedure. That evidence is backed up by major reviews published since (Buchbinder 2015, Stevenson 2014), but some contrary evidence has also been published (Shi 2012, Klazen), and it is possible vertebroplasty works better for some kinds of patients.

Nevertheless, it’s a major comeuppance for a seemingly straightforward surgical fix that should have been tested more carefully long ago. And if stabilizing the spine with cement doesn’t resolve symptoms, it strongly suggests that instability wasn’t the problem to begin with. The rationale for vertebroplasty has always been cave-man simple: Ooog. Verteba [sic] busted. Hurt. Thag make bone stronger. Inject glue. Ugh. Supposedly these fractures are painful because the spine is unstable — hardly an unreasonable assumption — and therefore stabilizing them will help. Except it didn’t!

(See more detailed commentary on this paper.)

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73. Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V. Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. Eur Spine J. 2015 Jun;24(6):1289–95. PubMed #25833204.
It is widely believed that spondylolysis (SL) and/or isthmic spondylolisthesis (IS) cause low back pain. If so, individuals with these conditions should be more prone to back pain (duh). This paper reviewed other studies looking for that association. They found 15 adequate studies. None of them detected an association between SL/IS and LBP. The authors speculate that the two apparent benefits of treatments may just be “due to benign natural history and nonspecific treatment effects.” They suggest that “traditional surgical practice… should be reconsidered.”

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74. 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. Sarno is the only expert I know of who argues that spondylolisthesis and stenosis do not cause low back pain even when they are obviously present: “I have had a number of patients with this abnormality and have found in each case that the patient also had TMS . In every case the pain was eliminated by proper treatment for TMS, suggesting that spondylolisthesis was not the cause” (p25). This is followed by a “dramatic case history.” With regards to stenosis, “ …it has been my experience this ‘abnormality’ is rarely responsible for leg or back pain” (p27). For my part, for now I accept that these two conditions may cause pain, but not inevitably. New evidence supports this opinion — see the next note! BACK TO TEXT

75. Haig AJ, Tong HC, Yamakawa KS, et al. Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Archives of Physical Medicine & Rehabilitation. 2006 Jul;87(7):897–903. PubMed #16813774.
In this study, about 150 people were assessed for back pain in different ways, including MRI, but “radiologic and clinical impression had no relation.” In other words, there was no useful similarity between evaluation of the patient with MRI, and evaluation by examination and taking a history. “The impression obtained from an MRI scan does not determine whether lumbar stenosis is a cause of pain.” Since MRI does in fact identify narrowing of the spinal canal, and this is the whole basis of diagnosing spinal stenosis with MRI, these results also strongly imply that a narrowed spinal canal does not (alone) cause back pain.

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76. Akhaddar A, Boucetta M. Dislocation of the Cervical Spine. N Engl J Med. 2010 May 20;362(1920). PainSci #55145.
A case report (and disturbing X-ray) of a traumatic cervical spine dislocation, notable for being mostly asymptomatic: just torticollis and limited motion, but no pain, weakness or altered sensation. That such a serious injury can have so little impact on a person is quite interesting!

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77. Moon SJ, Lee JK, Seo BR, Kim SH. Traumatic subluxation associated with absent cervical pedicle: case report and review of the literature. Spine. 2008 Aug;33(18):E663–6. PubMed #18708921.
This paper describes the case of a man who developed severe neck and shoulder pain after a fall. It turned out that a part of one of his neck vertebrae was entirely missing, since birth (“a relatively uncommon developmental anomaly”). The fall subluxed the joint substantially. Although painful, the lack of neurological symptoms is surprising — and more evidence that nerve roots are not easily pinched.

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78. College of Physicians and Surgeons of the Province of Quebec. The scientific brief against chiropractic. The New Physician, Sep 1966. BACK TO TEXT

79. Deyo., op. cit. “Cancer, compression fractures, spinal stenosis, and aortic aneurysms become more common.” BACK TO TEXT

80. Deyo., op. cit. “Low back pain affects men and women equally, with onset most often between 30 and 50 years.” BACK TO TEXT

81. Robinson GE. A combined approach to a medical problem: The Canadian Back Education Unit. Can J Psychiatry. 1980 Mar;25(2):138–42. PubMed #6447538.
This Canadian study of 2200 people with back pain showed a surprising distribution of ages: back pain after age fifty is much less common than it is between thirty and fifty. Back pain in the teens and twenties is rarer still.

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82. Could it be that young people get more back pain because they are more active and more likely to injure themselves? Perhaps, but there are some problems with this theory. Mainly, few back injuries occur during common athletic activity — I can’t recall a single case of back pain in my office that started with a clearly identifiable trauma during running, swimming, cycling, or skiing. It’s usually something more like “I was lifting my baby daughter,” which, as far as I know, is a problem for both parents and grandparents. BACK TO TEXT

83. Hadjipavlou AG, Tzermiadianos MN, Bogduk N, Zindrick MR. The pathophysiology of disc degeneration: a critical review. Journal of Bone & Joint Surgery (British Volume). 2008 Oct;90(10):1261–70. PubMed #18827232. From the abstract: “There is no clear evidence indicating whether ageing in the presence of repetitive injury or repetitive injury in the absence of ageing plays a greater role in the degenerative process.” BACK TO TEXT

84. Here’s the raw data from Harkness. The data in the graph is averaged and smoothed.

age

men

women

18–24

0.0%

5.6%

25–34

1.7%

5.7%

35–44

8.6%

9.8%

45–54

15.2%

13.2%

55–64

7.1%

7.5%

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85. Battié 2009, op. cit. BACK TO TEXT

86. Deyo., op. cit. “Perhaps 85% of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis …” Yet we also know that about 70% of back pain diagnoses made by physicians are “strain” or “sprain”! Deyo goes on to say that “Strain and sprain have never been anatomically or histologically characterized, and patients given these diagnoses might accurately be said to have idiopathic low back pain.” In other words, between 70 and 85% of low back pain is unexplained — yet is routinely attributed to familiar-sounding injuries without any evidence that this is the case. Doubleplusungood! BACK TO TEXT

87. Baron R, Binder A. How neuropathic is sciatica? The mixed pain concept. Orthopade. 2004 May;33(5):568–75. PubMed #15067505.
Sciatica is poorly understood. From the abstract: “The incidence of each pain component in chronic sciatica as well as validated diagnostic tools to identify them remain unknown.”

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88. Patients get told this a lot, but there are many reasons to doubt that the sacroliac joint is a cause of pain nearly so often. The pain may not have anything to do with the sacroiliac joint. I believe it’s more likely to be the adjacent “Perfect Spot No.12” — a common and irritating trigger point in the upper reaches of the gluteus maximus. In my clinical experience, many or most low back pain clients with an alleged sacroiliac joint problem have no such problem that I can detect, but do have this sensitive spot in the neighbouring muscle. I’ll explain more about this important trigger point below. BACK TO TEXT

89. Bogduk N. What's in a name? The labelling of back pain. Medical Journal of Australia. 2000;173(8):400–401. PainSci #56046. BACK TO TEXT

90. Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007 Oct;16(10):1539–50. PubMed #17566796. PainSci #55023. BACK TO TEXT

91. In other words, if you have a really crappy disc that is actually the source of pain, an MRI might help to spot that — but the MRI could easily also show what looks like a problem but actually isn’t, or completely miss a disc that is a problem. BACK TO TEXT

92. Maigne JY, Cornelis P, Chatellier G. Lower back pain and neck pain: is it possible to identify the painful side by palpation only? Ann Phys Rehabil Med. 2012 Mar;55(2):103–11. PubMed #22341057. PainSci #54321.
Researchers tested two (presumably expert) examiners to see if they could detect the painful side of the neck or back by touch alone, 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 — only slightly better than chance.

The results are underwhelming. Although they did a little better than just guessing, the results suggest that it’s difficult even for expert examiners to detect the location of neck and back pain by touch. Plus, they were attempting to detect only the side of pain. Imagine how much worse their performance would have been if they had had to identify the location more precisely, or if the pain could have been anywhere or nowhere. So they barely passed the easiest possible test — and probably would have failed a harder one and done no better than guessing.

An obvious weakness of the study is that only two therapists were tested, so the results are inconclusive. One would still hope for a better detection, though, even from less-skilled therapists.

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93. The tests were primarily “Revel’s criteria:” 5 or more of 7 clinical characteristics defined by Dr. Revel. I’d list them, but … they don’t diagnose anything! BACK TO TEXT

94. The kinds of tests that we’re talking about here are mostly what we call “special orthopedic tests,” most of which are “provocation tests” — basically, trying to make the body hurt by moving and poking the body in creative ways to determine what hurts and why. It’s an art as much as it’s a science, and a great many such tests have proven to be unreliable due to a wide range of flaws — most conspicuously the distressingly wide range of methods, skills, and wisdom with which they are applied and interpreted. Just one example: Cattrysse showed that two of three popular tests for a serious condition of instability in the upper cervical spine showed “no tendency” to get the same results when performed by different clinicians (while the other test was only “somewhat” reliable). And such tests done in “real life” will rarely be done as carefully or formally as they are done in a controlled scientific study, and if the tests can’t be shown to be reliable even there … well, don’t expect them to be all that informative on the front lines of patient care! For this reason, I have dramatically scaled back my use of orthopedic tests over the years, taking even the most obvious findings from the most apparently simple tests with a grain of salt. BACK TO TEXT

95. Bogduk N. Management of chronic low back pain. Med J Aust. 2004;180(2):79–83. BACK TO TEXT

96. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009 May;34(10):1066–1077. PubMed #19363457. PainSci #55429. BACK TO TEXT

97. Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015 Dec;36(12):2394–9. PubMed #26359154. BACK TO TEXT

98. BackSitPro.com [Internet]. McGill S. There is no such thing as “non-specific back pain”; [unknown] [cited 17 Apr 23]. BACK TO TEXT

99. In medical writing, it’s super important to be humble, and to remind readers of uncertainties — and they are thickest in this part of the book. The clinical importance of muscle pain is unproven. Although several experts have been suggesting it for a long time, we’re a long way from having a bunch of scientific papers to back up the claim. Right now it’s more like circumstantial evidence in a court room — emotionally compelling, but not rigorous. I believe that muscle dysfunction explains a lot more of low back pain than is usually suspected, but certainly not all of it. And just because structural problems are exaggerated doesn’t mean they don’t exist at all. BACK TO TEXT

100. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392–9. PubMed #25477053.
Quintner, Cohen, and Bove argue that the common picture of trigger points as lesions in muscle and soft tissue, spelled out most formally in Gerwin 2004, is “flawed both in reasoning and in science,” and that treatments (e.g. massage, needling) based on that idea produces results “indistinguishable from the placebo effect.” They believe that all of the biological evidence put forward over the years (like Shah 2008) is critically flawed in one way or another, while other evidence leads elsewhere, and so the old picture of trigger points “remains conjecture in the face of conflicting data.” They also point out that the theory is inappropriately treated like an established fact by a great many people.

Not even these fierce critics of trigger points deny that people have pain that seems to come from their muscles. But if it’s not coming from the muscle, where is it coming from? They briefly discuss two other ideas of their own: inflamed nerve fibres, and referred pain and tenderness from deeper structures. They do not thoroughly explore or defend either idea.

Neuritis is undoubtedly worth investigating, but it requires us to believe that nerve axons are routinely inflamed for no apparent reason, which doesn’t seem much different than the theory it is supposed to replace. The evidence cited to support it is just as limited as the evidence for trigger points, if not more so (just a few papers, all from the authors themselves, or their research colleagues).

The proposal of “referred pain and tenderness” from deeper tissues with unspecified troubles and/or “altered central nociceptive mechanisms” is imprecise. We know that these mechanisms probably exist, but there is not a jot of evidence that they have anything to do with the subjective experience of “muscle pain.” This is just a proposal to look somewhere other than the integrated hypothesis.

This paper is an abridged version of a much more detailed argument laid out in a chapter of an extremely expensive textbook: see Quintner.

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101. Quintner et al concede that people experience pain and sensitivity that seems to be in muscle tissue. The pain is real, and the need for an explanation and effective treatment is real:

This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.

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102. This point is based entirely on my own clinical observations as a massage therapist. Although I’m not aware of any hard data that can support it, it doesn’t seem any more necessary than it does to argue that cats like sunny windowsills. It’s obvious to any massage therapist: by far the most common client complaint is aching in the low back, and they practically all have clearly defined (“just a little higher!”) sensitive spots in their lumbar muscles. I’ll speculate a bit about why this might be below. BACK TO TEXT

103. I’m often asked what I think of a treatment that supposedly has a “100% success rate.” Or any percentage over 90, really. It’s the same answer, every time: hyperbolic treatment claims in health care are bollocks (and are almost always part of a sales pitch). Most painful problems are not really one problem. Perfect treatment results are nonsense due to co-morbidities & multiple overlapping etiologies alone. Nothing can treat everything. In fact, nothing can treat anything reliably. BACK TO TEXT

104. This is an estimate, of course, and there is no way for it to be anything else. Low back pain is not like pregnancy, where you’ve either got it or you don’t: there is incredible variety in back pain, from subtle unreported chronic low back pain with a single minor cause, to complex acute episodes with a dozen contributing factors, to severe traumatic injuries — and the range of attitudes about back pain is just as wide. I know a story about an elderly farmer who fell off his roof and was forced by his children to see the doctor, where they discovered that he’d not only fractured his back, but done it at least three times previously without diagnosis or treatment or even complaining! However, the 95% figure is, I believe, a fair estimate. It’s extrapolated from various sources, like Deyo (see Note 41), and clinical experiences reported by Sarno. It also matches my own experience. Basically, I propose (as does Sarno) that the 70-85% of the “unexplained” back pain that Deyo acknowledges is actually mostly caused by muscle, and then I go further than that and argue that a significant fraction of the remaining cases of back pain are so seriously complicated by muscle pain that they would be trivial without it. That brings the total up to something like 95%. BACK TO TEXT

105. Evans RW. Book review of Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment. N Engl J Med. 2001;344(13):1026–1027. PainSci #57200.
This is an excellent review of an important text, Muscle Pain: Understanding its nature, diagnosis and treatment, that every physical therapist should read. I particularly appreciate the review for its credible acknowledgement that, “Low back pain is of myofascial origin [in many cases].” Naturally, the text he is referring to thoroughly defends the same idea.

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106. The MS hug is a collection of nasty symptoms caused by spasms in the intercostal muscles, often experienced long before diagnosis. Although the feeling of a tight band around the chest is the classic symptom, many patients also just experience widespread pain in the chest wall. BACK TO TEXT

107. Graven-Nielsen T, Mense S, Arendt-Nielsen L. Painful and non-painful pressure sensations from human skeletal muscle. Experimental Brain Research. 2004 Dec;159(3):273–83. PubMed #15480607.
This study attempted to determine if painful and non-painful pressure sensations from muscles actually exist (which is surprisingly controversial). In this study, even with anaesthetized skin, subjects could still feel pressure and painful pressure. Muscle probably does know when it’s being poked!

(See more detailed commentary on this paper.)

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108. Many organs and tissues in the body are miraculously “busy” and complex, but muscle is characterised by particularly extreme and highly energetic performance, routinely functioning at the limits of what biology will allow, to the point where it’s often injured by the sheer intensity of its metabolic activity. See Post-Exercise, Delayed-Onset Muscle Soreness. BACK TO TEXT

109. 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. 75. BACK TO TEXT

110. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999. BACK TO TEXT

111. Shah JP, Danoff JV, Desai MJ, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89(1):16–23. PubMed #18164325.
This significant paper demonstrates that the biochemical milieu of trigger points is acidic and contains many pain-causing metabolites. For much more information about this, see Toxic Muscle Knots.

(See more detailed commentary on this paper.)

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112. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004 Dec;8(6):468–75. PubMed #15509461.
Until further notice, the most popular provisional explanation for the trigger point phenomenon is the “expanded integrated hypothesis.” It was first presented in this 2004 paper by Drs. Robert Gerwin, Jan Dommerholt, and Jay Shaw. It’s harrowingly detailed and technical. (Read it just below, if you dare!) When abridged and oversimplified, the “expanded” part is largely lost — it was mostly just filling in some details missing from the original integrated hypothesis (“a possible explanation”), which was put forward by Travell and Simons in the second edition of the Big Red Books in 1999, which was in turn an elaboration on the energy crisis hypothesis that debuted in the first edition in 1981. This has been a work-in-progress for quite a while.

Here’s a careful translation of the expanded integrated hypothesis:

Under some circumstances, muscular stresses can cause patches of poor circulation, which results in the pooling of noxious metabolic wastes and high acidity in small areas of the muscle. This is both directly uncomfortable, but also causes a section of the muscle to tighten up and perpetuate a vicious cycle. This predicament is often called an “energy crisis.” It constitutes a subtle lesion. TrPs research has largely been concerned with looking for evidence of a lesion like this.

And here’s the integrated hypothesis fully spelled out. Brace yourself!

It can be hypothesized that the activating event in the development of the TrP is the performance of unaccustomed eccentric exercise, eccentric exercise in unconditioned muscle, or maximal or submaximal concentric exercise that leads to muscle fiber damage and to segmental hypercontraction within the muscle fiber. Adding to the physical stress of such exercise is hypoperfusion of the muscle caused by capillary constriction, which results from muscle contraction. Capillary constriction is increased by sympathetic nervous system adrenergic activity. The resultant ischemia and hypoxia adds to the development of tissue injury and produces a local acidic pH with an excess of protons. Acidic pH results in inhibition of acetylcholinesterase activity, increased release of CGRP, and activation of ASIC on muscle nociceptors. Acidic pH alone (in the absence of muscle damage) is sufficient to cause widespread changes in the pain matrix. However, the breakdown of muscle fibers results in the release of several proinflammatory mediators such as SP, CGRP, K+, 5-HT, cytokines, and BK that profoundly alter the activity of the motor endplate and activity/sensitivity of muscle nociceptors and wide dynamic-range neurons. Motor endplate activity is increased because of an apparent increase in the activity of ACh. This apparent increase in effectiveness is caused by several factors that include an increase in the release of ACh that is mediated by CGRP, presynaptic motor terminal adrenergic receptor activity, and by AChE inhibition caused by CGRP￼and acidic pH. AChRs are up-regulated through the action of CGRP, creating more docking sites for ACh, thereby increasing the efficiency of binding to the receptor. The taut band results from the increase in ACh activity. Miniature endplate potential frequency is increased as a result of greater ACh effect. Release of BK, K+, H+, and cytokines from injured muscle activates the muscle nociceptor receptors, thereby causing tenderness and pain. The presence of CGRP drives the system to become chronic, potentiating the motor endplate response and potentiating, with SP, activation of muscle nociceptors. The combination of acidic pH and proinflammatory mediators at the active TrP contributes to segmental spread of nociceptive input into the dorsal horn of the spinal cord and leads to the activation of multiple receptive fields. Neuroplastic changes in dorsal horn neurons occur in response to continuous nociceptive barrage, causing further activation of neighboring and regional dorsal horn neurons that now have lower thresholds. This results in the observed phenomena of hypersensitivity, allodynia, and referred pain that is characteristic of the active myofascial TrP.

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113. Dommerholt J, Gerwin RD. A Critical Evaluation of Quintner et al: Missing the Point. J Bodyw Mov Ther. 2015 Apr;19(2):193–204. PubMed #25892372. In this response to criticism, Dommerholt and Gerwin freely admit we still don’t really know what’s going on, with statements like “A distinct mechanistic understanding of this disorder does not yet exist” and “…there has never been a credible anatomic pathology associated with myofascial TrPs” and several more. They seem to mind the uncertainty. They know they’re working with “just a theory.” BACK TO TEXT

114. PS Ingraham. Trigger Point Doubts: Do muscle knots exist? Exploring controversies about the existence and nature of so-called “trigger points” and myofascial pain syndrome. PainScience.com. 11998 words. BACK TO TEXT

115. Sarno’s 1999 summary of TMS goes like this: “To summarize, most neck, shoulder and back pain is due to TMS [same as MPS — PI], a harmless physical disorder of the muscles and nerves that is most immediately due to reduced blood circulation to these tissues. This circulatory abnormality results from constriction of the small blood vessels that feed the involved tissues ....” (Sarno) BACK TO TEXT

116. Gunn CC. Neuropathic Myofascial Pain Syndromes. 3rd ed. Lippincott Williams & Wilkins; 2001. “The function and integrity of all innervated structures are contingent on the flow of nerve impulses in the intact nerve to provide a regulatory or ‘trophic’ effect. When this flow (probably a combination of axoplasmic flow and electrical input) is blocked, innervated structures are deprived of the trophic factor which is necessary for the control and maintenance of cellular function. ‘A-trophic’ structures become highly irritable and develop abnormal sensitivity or supersensitivity according to Cannon and Rosenblueth’s Law of Denervation ... The importance of disuse supersensitivity cannot be overemphasized. When a nerve malfunctions, the structures it supplies become supersensitive and will behave abnormally. These structures over-react to many forms of input, not only chemical, but physical inputs as well, including stretch and pressure.” BACK TO TEXT

117. We know that these mechanisms probably exist, but there almost no specific evidence that they have anything to do with the subjective experience of “muscle pain.” Quintner et al. are mainly just proposing to look somewhere other than the integrated hypothesis. BACK TO TEXT

118. It’s more all-encompassing, more thoroughly considered and studied, and has fewer puzzling loose ends. Travell and Simons and those that continued their work have simply been at it for longer and did more and better homework. Knowing Travell and Simons’ work is crucial for any serious manual therapist. I think Gunn’s explanation for muscle pain is interesting and well-conceived, and he presents excellent evidence, but it simply hasn’t got the explanatory scope that Travell and Simons offer. Sarno’s case for pain caused solely by ischemia seems relatively simplistic, much less substantive, and likely to be only partially verifiable — and it’s dubious how he’s still promoting it, many years after MPS was established as a much more powerful theory. And Quintner, Cohen, and Bove, despite all their chops, just have nothing but an interesting idea so far. BACK TO TEXT

119. Some possibilities:

- Maybe our civilization’s sedentariness, postural habits, and often-cruddy ergonomics predispose us to it. I don’t really buy it (lots of evidence points away from it), but I have to acknowledge it as a possibility.

- Although the spine is not particularly fragile, it may nevertheless be over-protected in various ways by the nervous system because it houses the spinal column.

- The back may suffer from an excess of trivial pain because of the strain of bipedality (or perhaps only in combination with lack of exercise; see Natural Imperfection).

- The back may be a psychologically convenient place to conceal the symptoms of stress (I’ll get deep into this idea below).

- It may be just an accident of anatomy that relatively large patches of muscle can be deprived of adequate circulation by stress-induced vasoconstriction of a few blood vessels — there are other “design problems” like this in the human body. (This is from Sarno.)

Or maybe a little of everything!

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120. Bewyer DC, Bewyer KJ. Rationale for treatment of hip abductor pain syndrome. Iowa Orthop J. 2003;23:57–60. PubMed #14575251. BACK TO TEXT

121. For example, a common example is a trigger point in the origin of the gluteus maximus muscle, at the anterior margin, just slightly below and to the right of the PSIS, a prominent bump of bone in the low back. This is a patch of pure muscle with nothing but hip bone underneath it. The sciatic nerve is at least five centimetres away on the surface, and two or three deep. Yet pressure here with the tip of a baby finger regularly reproduces the symptoms of sciatica: vivid, shooting pain through the buttock and upper hamstrings (and sometimes much further). Occasionally people describe pain in their toes and ankles with amazing specificity — on the opposite side. This is not nerve pain! BACK TO TEXT

122. Davies C. The trigger point therapy workbook: your self-treatment guide for pain relief. 1st ed. New Harbinger Publications; 2001. p. 24. BACK TO TEXT

123. For a detailed example from my own experience with injury, see Into the Fire. BACK TO TEXT

124. Unhealthy muscles are vulnerable and more likely to be strained; they are also less responsive, increasing the risk of sprains. An inadequate supply of oxygen to damaged tissues can make recovery drag on and on. Oxygen-deprived nerves will complain loudly about irritations that would be trivial if they were healthy. Arthritis pain that would be minor without MPS can be excruciating in combination with it, and the arthritis itself can be accelerated. BACK TO TEXT

125. Gunn CC, op. cit. Dr. Gunn provides an excellent example of how soft-tissue dysfunction can make a bad situation worse: “Ironically, neuropathy itself contributes to degenerative conditions (including spondylosis!). Neuropathy degrades the quality of collagen, causing it to have fewer cross-links; it is therefore markedly frailer than normal collagen …” BACK TO TEXT

126. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence. Pain. 1993 Mar;52(3):259–85. PubMed #7681556.
From the abstract: “Peripheral tissue damage or nerve injury often leads to pathological pain processes, such as spontaneous pain, hyperalgesia and allodynia, that persist for years or decades after all possible tissue healing has occurred.”

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127. Maté G. When the body says no: the cost of hidden stress. Alfred A. Knopf Canada; 2003. BACK TO TEXT

128. The history of the biology of stress is much like that of research into soft-tissue pain — a handful of determined doctors have worked to educate their uninformed colleagues and the public. They have tried to teach us that stress, obvious and otherwise, can cause and significantly complicate pain and illness. For instance: Dr. Hans Selye, a Canadian who virtually invented the study of stress, has written some 30 books and more than 1,500 articles on stress and related problems, including Stress without Distress (1974) and The Stress of Life (1956). Dr. Selye died in 1982 in Montreal, where he had spent fifty years studying the causes and consequences of stress. Another notable example is Dr. Dean Ornish (see Dr. Ornish’s Lifestyle Program), whose ideas about the connection between heart disease and stress were once considered heretical but are now mainstream. There are many more contemporary examples, including both Sarno and Maté, already cited here. Unfortunately, their efforts to educate other professionals have largely been ineffective, and to this day … “Most doctors are uncomfortable with medical conditions that have a psychological basis.” (Sarno). BACK TO TEXT

129. Here’s the rationale for the connection between stress and MPS, jargon included. It’s plausible that emotional stress can cause and sustain any or all of at least three of the pathophysiological processes hypothesized as causes of soft-tissue pain: (1) stress may directly result in brain-mediated vasoconstriction of arterioles in the postural musculature, resulting in chronic ischemia (Sarno’s hypothesis); and/or (2) stress may directly result in brain-mediated hyperexcitability of motor neurons, or indirectly by muscular guarding and armouring, causing chronic muscle spasm and tissue fluid stagnancy (Travell/Simons); and/or (3) stress may cause reflex loop stagnancy indirectly via muscular guarding and armouring. In other words, stress makes you clench your blood vessels and muscles, and/or makes you hold yourself tighter and more defensively, resulting in either overexcited or dulled nerve stimulation. And other mechanisms may be involved as well. This is all speculation! I can’t emphasize strongly enough that no one really knows. But these are sensible guesses in many ways. BACK TO TEXT

130. Croft PR, Papageorgiou AC, et al. Psychologic distress and low back pain: Evidence from a prospective study in the general population. Spine. 1995 Dec 15;20(24):2731–7. PubMed #8747252.
From the abstract: “Symptoms of psychologic distress in individuals without back pain predict the subsequent onset of new episodes of low back pain.”

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131. Waters SJ, Keefe FJ, Strauman TJ. Self-discrepancy in chronic low back pain: relation to pain, depression, and psychological distress. J Pain Symptom Manage. 2004 Mar;27(3):251–9. PubMed #15010103.
From the abstract, “Results showed that self-discrepancies [stress] can be reliably assessed in patients with persistent [back] pain.”

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132. Carragee EJ, Chen Y, Tanner CM, et al. Provocative discography in patients after limited lumbar discectomy: A controlled and randomized study of pain response in symptomatic and asymptomatic subjects. Spine. 2000 Dec 1;25(23):3065–71. PubMed #1114581. This complex study of a diagnostic procedure for the low back incidentally observed: “Patients with abnormal psychological profiles [i.e. people who are under a lot of stress and not coping well] have significantly higher rates of positive disc injections than either asymptomatic volunteers or symptomatic subjects with normal psychological screening.” (Manchikanti did research to clarify this and seems to conclude differently, but he used a narrower definition of a positive test result.) BACK TO TEXT

133. 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. 58. “I did a survey of a large group of patients with TMS [same as MPS — PI] and found that 88 percent had a history of one or more of these conditions [psychophsyiological disorders such as heartburn, ulcer, gastritis, hiatus hernia, colitis, spastic colon, migraine, hives, eczema, hay fever, asthma]; 28% had experienced four or more during their lives ...” Sarno also writes, referencing Fassbender, that “They obtained biopsies from the muscles of patients with back pain and studied the tissue under the electron microscope … they found changes in muscle cells that suggested oxygen deprivation.” BACK TO TEXT

134. Holmes TH, Wolff HG. Life Situations, Emotions and Backache. Psychosom Med. 1952;14(1):18–33.
Sarno writes of this paper: “Subsequently I found another paper, written by Drs. Holmes and Wolff, both well-known pioneers in the study of pain, that related life situations, emotions and backaches. From this paper came the idea that reduced blood circulation might be the physical basis for [low back pain].”

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135. SSRI anti-depressant medications probably do not work as advertised (see SSRI Antidepressants Are Not Medicine), but many patients do report a reduction in anxiety and depression, probably due to placebo. Therefore, if the root cause of most back pain is stress-induced MPS, then one would expect SSRIs to have erratic benefits for back pain, probably more so for people who were depressed to begin with, which is exactly what Deyo et al report: “Antidepessant-drug therapy is useful for the one third of patients with low back pain who also have depression. There is conflicting evidence regarding patients without clinical depression.” He goes on to say that “tricyclic antidepressants may be more effective,” which is interesting because tricyclic anti-depressants, although considered obsolete by the psychiatric community, are more straightforwardly sedative and have fewer side effects than the “fancier” modern SSRI anti-depressants. Therefore the tricyclics could be expected to have a more straightforward beneficial effect on stress-induced back pain. BACK TO TEXT

136. Maté G. When the body says no: the cost of hidden stress. Alfred A. Knopf Canada; 2003. p. 28–9. “Medical thinking usually sees stress as highly disturbing but isolated events such as, for example, sudden unemployment, a marriage breakup, or the death of a loved one. These major events are potent sources of stress for many, but there are chronic daily stresses in people’s lives that are more insidious and more harmful in their long-term biological consequences. Internally generated stresses take their toll without in any way seeming out of the ordinary. … While nervous tension may be a component of stress, one can be stressed without feeling tension.” BACK TO TEXT

137. Pérez-Aisa MA, Del Pino D, Siles M, Lanas A. Clinical trends in ulcer diagnosis in a population with high prevalence of Helicobacter pylori infection. Aliment Pharmacol Ther. 2005 Jan;21(1):65–72. PainSci #57160.
From the article: “This study agrees with previous reports that suggest that the prevalence of peptic ulcer disease has decreased significantly over the last decade in western countries …. The reasons for this decline are not clear ….”
Of course, the idea that ulcers are in decline because they have become a less psychologically fashionable/acceptable expression of nervous tension is pretty far out in left field. I do think it’s plausible enough to mention here, and potentially consistent with some well-documented strangeness in other conditions. Both carpal tunnel syndrome and the common cold, for instance, have been shown to have frankly baffling epidemiological characteristics, strongly suggesting that they are affected by psychosocial factors beyond our current understanding. Most doctors would dismiss all of this, though, and agree with the Pérez-Aisa et al. that “a decrease in the prevalence of Helicobacter pylori infection might be the main reason” for the decrease in ulcers. BACK TO TEXT

138. Weren’t ulcers proved to be caused by a bacteria? That they were. Helicobacter pylori was famously hunted down in 1983 by Australian scientists Barry Marshall and Robin Warren. Although its link with ulceration was initially met with much skepticism, science came around relatively quickly — convinced by evidence, just like it’s supposed to work. By the mid-90s it was widely accepted that H. pylori infection causes ulcers, and Marshall and Warren got a Nobel prize in 2005 (acceptance speech).

But! Most people infected with the bacterium have no symptoms, and there are many variables that determine the severity of the infection and whether or not it leads to ulcer. Stress is one of those factors (see Guo et al. and Jia et al.). Thus ulcer is very likely both an H. pylori infection and a “stress-sensitive” condition.

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139. Carlesso LC, MacDermid JC, Santaguida PL, Thabane L. A survey of patient's perceptions of what is "adverse" in manual physiotherapy and predicting who is likely to say so. J Clin Epidemiol. 2013 Oct;66(10):1184–91. PubMed #23856189. Here’s a bit of evidence that back pain makes people nervous and leads to more back pain: in this Canadian survey, low back pain patients were much more likely (51%) to report some kind of unpleasant reaction to therapy than patients with a problem anywhere else in the body, suggesting that back pain makes people nervous. (And/or that actual harm from therapy is more common. But I’m betting on “nervous.”) Also, back pain patients who expected to be “sore” after therapy were somewhat less likely (8.5%) to report a serious reaction. BACK TO TEXT

140. The idea that some clinical approaches to back pain are actually making back pain worse seems to emerge inevitably from the circumstantial evidence. Bear in mind that iatrogenic illness (illness caused by physicians) is not a new or unusual concept. In 2000, an American presidential task force labelled medical errors a “national problem of epidemic proportions.” The stats need perspective (see Quack Word #20), but they are real. And it’s a short leap from those stats to the research showing that elaborate diagnostic imaging is over-prescribed by doctors who own MRI facilities (Swedlow) and that back pain surgeries are much more common wherever there are more surgeons — not because they are answering a need, mind you, but because they are creating it. Medical care in the UK is just as technological as it is in the United States, but they do a lot fewer back surgeries in the UK. Why? It’s probably not because they are primitive … BACK TO TEXT

141. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed #20961685. PainSci #54851.
Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.

For a much more detailed summary of this paper, see Central Sensitization in Chronic Pain.

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142. TheConversation.com [Internet]. Moseley L. Pain really is in the mind, but not in the way you think; 2013 Jul 20 [cited 14 Jan 6].
In this not-too-technical article, the endlessly quotable Lorimer Moseley summarizes the role of the mind in chronic pain, especially low back pain.

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143. This is actually a really common and exasperating general patient communication problem: trying to reassure in the short term by saying that certain drastic steps won’t be taken until later. It’s all well and good in the short term, but as the implied or stated deadline approaches … yikes! Health professionals, please: don’t “reassure” your patients by telling them that they “probably” won’t have to deal with the scary stuff until some deadline. BACK TO TEXT

144. Costa Ld, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009 Oct;339:b3829. PubMed #19808766. PainSci #55422.
ABSTRACT

OBJECTIVES: To describe the course of chronic low back pain in an inception cohort and to identify prognostic markers at the onset of chronicity.

DESIGN: Inception cohort study with one year follow-up.

SETTING: Primary care clinics in Sydney, Australia.

PARTICIPANTS: The study sample was a subcohort of an inception cohort of 973 consecutive patients presenting to primary care with acute low back pain (<2 weeks' duration). 406 participants whose pain persisted for three months formed the inception cohort of patients with chronic low back pain.

MAIN OUTCOME MEASURES: Outcomes and putative predictors measured at initial presentation, onset of chronicity (study entry), and follow-up at nine and 12 months. Recovery was determined from measures of pain intensity, disability, and work status. The association between potential prognostic factors and time to recovery was modelled with Cox regression.

RESULTS: Completeness of follow-up was 97% of total person time for all outcomes. The cumulative probability of being pain-free was 35% at nine months and 42% at 12 months and for complete recovery was 35% at nine months and 41% at 12 months. Of the 259 participants who had not recovered from pain related disability at entry to the chronic study, 47% had recovered by 12 months. Previous sick leave due to low back pain, high disability levels or high pain intensity at onset of chronicity, low levels of education, greater perceived risk of persistent pain, and being born outside Australia were associated with delayed recovery.

CONCLUSION: More than one third of patients with recent onset, non-radicular chronic low back pain recover within 12 months. The prognosis is less favourable for those who have taken previous sick leave for low back pain, have high disability levels or high pain intensity at onset of chronic low back pain, have lower education, perceive themselves as having a high risk of persistent pain, and were born outside Australia.

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145. 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. 27–8.
Reaching for a traumatic explanation for back pain can become quite absurd. When a minor trauma seems to be the cause of back pain, MPS is inevitably the more significant problem, or even the cause of the incident in the first place. Sarno writes ...

In 1978 I surveyed a group of a hundred TMS [same as MPS — PI] patients with regard to how their pain started .... Sixty percent reported that when the pain began it was not associated with a physical incident ... However, all of those patients tried to recall something physical that had happened, sometimes going back twenty or thirty years, because they thought there had to be such an incident, since everything they had heard about back pain related it to an injury and a structural problem. It was clear from their histories that there could be no possible relationship between those remote physical incidents and the onset of pain.

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146. Stretch of the erector spinae muscle group, the big columns of muscle on either side of the spine, are limited by the bony and ligamentous structure of the spine: you can only arch your back so far. The gluteus maximus is surprisingly long and lanky, and you can only flex your hip so far before your thigh hits your belly. And so on. These examples and several more are discussed in The Unstretchables: Eleven major muscles you can’t stretch (no matter how hard you try). BACK TO TEXT

147. Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther. 2010 Mar;90(3):438–49. PubMed #20075147. PainSci #55283. BACK TO TEXT

148. In particular, the big columns of muscle on either side of the spine should feel quite smooth, and the top edge of the gluteus maximus is a long, well-defined diagonal line  show across the top of the buttocks. BACK TO TEXT

149. Acetaminophen (Tylenol) seems to produce mixed results which do not indicate much one way or the other. The psychoactive drugs (anti-depressants, alcohol, marijuana, amphetamines, opioids, benzodiazapenes) often seem to help, but the emphasis is on seem, because they affect mood more than anything else: “It is my impression that ‘pain-killing’ drugs improve the patient’s mood rather than take away the pain.” (Sarno) Muscle relaxants do not work very well at all (substantiated later in the tutorial), so their success or failure is also disappointingly uninformative. BACK TO TEXT

150. Any kind of sensory boat rocking seems to have the potential to do this. I suspect that the shift reflects a change in the brain’s assessment of what tissue concern is the most worrisome, a change in pain priority. It’s as though the body is trying to say, “Now that you’ve scratched the itch on the right, could you please scratch it on the left?” This phenomenon seems to occur much more with the pain that is close to the centre of the body. For instance, I’ve never encountered a case of pain in the forearm switching to the other arm after some treatment. BACK TO TEXT

151. Take all generalizations with a grain of salt, of course: obviously, not every person with back pain is like this. But I can tell you that I have yet to meet a back pain victim who was slovenly, selfish, laid back, and underemployed! BACK TO TEXT

152. 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. 58. “I did a survey of a large group of patients with TMS [same as MPS — PI] and found that 88 percent had a history of one or more of these conditions [psychophsyiological disorders such as heartburn, ulcer, gastritis, hiatus hernia, colitis, spastic colon, migraine, hives, eczema, hay fever, asthma]; 28% had experienced four or more during their lives ...” BACK TO TEXT

153. Heat is reassuring, and comfort is a universal analgesic — it will take the edge of most kinds of pain. Once again the mind game is particularly relevant for back pain: because back pain is so often complicated by anxiety, the soothing power of heat seems to work particularly well on low back muscle pain. BACK TO TEXT

154. Definitely not always. Temperature sensitivity is variable in fibromyalgia patients. Some are cold sensitive! Other are sensitive to either extreme. But heat-sensitivity is a strong theme. BACK TO TEXT

155. Clay FJ, Newstead SV, Watson WL, et al. Bio-psychosocial determinants of persistent pain 6 months after non-life-threatening acute orthopaedic trauma. J Pain. 2010 May;11(5):420–30. PubMed #20439055. Researchers kept tabs on 168 patients who suffered non-life-threatening orthopaedic injuries. 54% reported persistent pain six months after the injury and 87% reported that this pain interfered with their normal work activities. Bet you it’s worse for back pain specifically! BACK TO TEXT

156. This is an interesting feature of human nature that I have observed since grappling with a psychophysiological illness myself (see A Short Story: Slow growth syndrome, oxandrolone and the pathologization of my height). That is, the more we suffer, the more we are likely to continue to suffer — and consequently, sometimes people will actually reject opportunities to heal. In part this is due to a justified cynicism, especially if someone has already been through many failed therapies. But it is probably mainly because we are creatures of habit. If we were the kind of person who could easily break out of a pain-causing pattern, it probably wouldn’t have happened in the first place! For more information about this idea, see Why Do We Get Sick? BACK TO TEXT

157. In contrast, the small minority who really do have a major spinal problem that might cause pain, regardless of trigger points, are affected differently: some of them, having been struck down with pain independently of their attitude, respond to the idea mainly with hope and optimism. “Really?” they will say. “Do you really think even some of this pain might be caused by muscle? Would relaxation help?” Tragically, I must actually persuade these clients that their back pain is serious! It’s all backwards! BACK TO TEXT

158. Nederhand MJ, Hermens HJ, Ijzerman MJ, Groothuis KG, Turk DC. The effect of fear of movement on muscle activation in posttraumatic neck pain disability. Clinical Journal of Pain. 2006 Jul-Aug;22(6):519–525. PubMed #16788337.
This study of whiplash patients showed that muscle tone is inhibited, not increased, let alone spasmed. “It is likely that the decrease in muscle activation level is aimed at ‘avoiding’ the use of painful muscles.”

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159. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000. p. 259. “The old concept of a pain-spasm-pain cycle does not stand up to experimental verification either from a physiologic point of view or from a clinical point of view. Physiologic studies show that muscle pain tends to inhibit, not facilitate, reflex contractile activity of the same muscle ... In 1989, Ernest Johnson, editor of the American Journal of Physical Medicine, summarized overwhelming evidence that the common perception of muscle pain being closely related to muscle spasm is a myth and that the myth has been strongly encouraged by commercial interests.” BACK TO TEXT

160. Spasm could be fairly evenly distributed, but probably not so much that it would fool experienced massage therapists. Most back pain is strikingly one-sided, and it’s unlikely that related spasming would be tidily symmetrical. BACK TO TEXT

161. Belavý DL, Quittner MJ, Ridgers N, et al. Running exercise strengthens the intervertebral disc. Scientific Reports. 2017 Apr;7:45975. PubMed #28422125. PainSci #53606. BACK TO TEXT

162. Maigne R. Manipulation of the spine. In Basmajian JV (ed): Manipulation, Traction and Massage, Baltimore: Williams & Wilkins. 1986. BACK TO TEXT

163. Hertling D, Kessler R. Management of common musculoskeletal disorders. 3rd ed. Lippincott; 1996. p574. Darlene Hertling clearly elucidates Maigne’s ideas about MIDs, with reference to the thoracic spine. Likely the idea can be sensibly applied to other sections of the spine as well. BACK TO TEXT

164. Where is muscle pain? Compared to facet joints, the anatomical location of the source of muscle pain is like trying to find a smoke signal in the fog. We aren’t even sure if there is such a thing as as a discrete painful lesion in muscle (other than bruises). Even if there is, they aren’t easy to reliably locate. BACK TO TEXT

165. Let me explain “wee little nerves” with a bit more jargon for my professional readers: the nerves in question here are the medial branches of the dorsal ramus nerves that innervate the facet joints. BACK TO TEXT

166. Falco FJ, Manchikanti L, Datta S, et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician. 2012;15(6):E839–68. PubMed #23159978.
This small 2012 review concluded that the “evidence for cervical medial branch blocks is fair.” Unfortunately, “fair” is a ridiculous word to use when summing up a “body” of evidence based on one trial (no matter how good) and one prospective evaluation. They also granted “fair” evidence for radiofrequency neurotomy based on just one randomized controlled trial (and a few almost meaningless observational studies).

Evidence for two other cervical joint interventions was “limited” by comparison! Indeed.

In my opinion, they did not find enough of any kind of evidence about anything to draw any conclusions whatsoever.

This paper is very similar to Manchikanti et al, regarding the thoracic spine (again involving some of the same researchers).

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167. Atluri S, Datta S, Falco FJ, Lee M. Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. Pain Physician. 2008;11(5):611–29. PubMed #18850026.
A review of barely adequate scientific literature on thoracic spinal joint interventions, but some of what they found was promising: good (Level I or II-1) for both diagnostic and therapeutic nerve blocks. But the number of papers on this topic really is extremely small: even years later, Manchikanti 2012 only reviewed a handful. The optimistic conclusion here is not resting on much.

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168. Datta S, Lee M, Falco FJ, Bryce DA, Hayek SM. Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician. 2009;12(2):437–60. PubMed #19305489.
This review of diagnosis and treatment of lumbar facet joints found very little, a “paucity of published literature,” but what they did find seemed to be positive: good evidence for diagnostic nerve blocks, and fair when using them for treatment. Notably, Staal concluded that the literature was too scanty to conclude anything.

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169. Wasan AD, Jamison RN, Pham L, et al. Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: a prospective cohort study. BMC Musculoskelet Disord. 2009;10:22. PubMed #19220916. PainSci #55303. “Psychiatric comorbidity is associated with diminished pain relief after a MBB injection performed with steroid at one-month follow-up.” BACK TO TEXT

170. Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov;140(1):239–43. PubMed #18786763.
In this small, unusual study, six patients with low back pain were asked to draw their perceptions of their back and spine. For comparison, a group of ten patients with no recent back pain were asked to do the same exercises. They were encouraged to “draw what it feels like” rather than how it actually looked.

“All the patients, and none of the controls, showed disrupted body image of the back” on the same side and level as the pain. For instance, they did not have a clear sense of the outline of their trunk.

Most intriguingly, patients with back pain on just one side illustrated vertebrae deviated towards the painful side (without any obvious actual deviation).

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171. French SD, Green S, Forbes A. Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low-back pain. J Manipulative Physiol Ther. 2000 May;23(4):231–8. PubMed #10820295. BACK TO TEXT

172. Cooperstein R, Lucente M. Comparison of supine and prone methods of leg length inequality assessment. J Chiropr Med. 2017 Jun;16(2):103–110. PubMed #28559750. PainSci #52779.
Assessments of leg length are common, both with the patient lying down or standing. Either could be reliable, but in this test they did not agree with each other. Two chiropractors with more than 30 years experience each assessed the same few dozen patients, and agreement between their results when they felt confident in them was “perfectly nil.“ Despite the widespread and confident use of each method, this test clearly suggests that at least one of them is unreliable, but it’s also entirely possible that both of them are.

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173. Grundy PF, Roberts CJ. Does unequal leg length cause back pain? A case-control study. Lancet. 1984 Aug 4;2(8397):256–8. PubMed #6146810.
This classic, elegant experiment found no connection between leg length and back pain. Like most of the really good science experiments, it has that MythBusters attitude: “why don’t we just check that assumption?” Researchers measured leg lengths, looking for differences in “lower limb length and other disproportion at or around the sacroiliac joints” and found no association with low back pain. “Chronic back pain is thus unlikely to be part of the short-leg syndrome.” Other studies since have backed this up, but this simple old paper remains a favourite.

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174. Morgenroth DC, Shakir A, Orendurff MS, Czerniecki JM. Low-back pain in transfemoral amputees: is there a correlation with static or dynamic leg-length discrepancy? Am J Phys Med Rehabil. 2009 Feb;88(2):108–13. PubMed #19169176.
“There were no statistically significant differences between the pain and no pain groups in terms … [any kind of] leg length difference.” Amputees are a special population, and (obviously) not necessarily representative of back pain in non-amputees. And yet, if leg length differences mattered to back pain in general, they would probably be more common in the amputees with pain.

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175. Chuter V, Spink M, Searle A, Ho A. The effectiveness of shoe insoles for the prevention and treatment of low back pain: a systematic review and meta-analysis of randomised controlled trials. BMC Musculoskelet Disord. 2014 Apr;15:140. PubMed #24775807. PainSci #53612.
The evidence available on this topic — so far, such as it is, just a few small trials — suggests that insoles or foot orthoses do not prevent or treat back pain, which is hardly a surprise. Technically the evidence is just inadequate and inconclusive, but the absence of any benefit in the small trials done so far is damning.

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176. Cambron JA, Dexheimer JM, Duarte M, Freels S. Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2017 Apr. PubMed #28465224.
This trial tested the efficacy of shoe orthotics and chiropractic treatment for chronic low back pain. 225 patients were divided into three groups: a wait-list control group got no care at all, another group received custom, and a third group got custom orthotics plus chiropractic and massage treatment. The authors reported positive results up: “Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared to no treatment.” But no differences after 12 weeks! And that’s even with an unfair advantage…

Wait-list groups are a crappy control. They suffer from “frustrebo” — poor outcomes caused by disappointment of knowing that you are not getting any treatment (see Power). This is a major flaw. As Dr. Stephen Ward tweeted, “Waiting list control, schwaiting list control.”

The lack of a true placebo control is a deal-breaker here, especially put in the context of other studies of orthotics for back pain, which are negative (e.g. see Chuter). Without replication, I think this study’s results can be dismissed as an outlier attributable to a flawed design and a high risk of bias.

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177. Richter RR, Austin TM, Reinking MF. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis--critical appraisal and commentary. J Athl Train. 2011;46(1):103–6. PubMed #21214358. PainSci #53613.
A review of studies of foot orthoses to treat overuse injuries of the lower limb with a mostly negative conclusion: “no difference between custom and prefabricated foot orthoses” and “the evidence was insufficient to recommend foot orthoses (custom or prefabricated).” (One thin ray of light was that the evidence supposedly supports the use of foot orthoses to prevent a first injury… but, even if true, hardly anyone seeks out orthoses before they develop an overuse injury. And why would they be good only for a first injury? Makes no sense, therefore likely not true.)

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178. Fahrni WH, Trueman GE. Comparative Radiological Study of the Spines of a Primitive Population With North Americans and Northern Europeans. J Bone Joint Surg Br. 1965 Aug;47:552–5. PubMed #14341078. PainSci #53604. BACK TO TEXT

179. Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther. 2002 Sep;32(9):447–60. PubMed #12322811.
From the abstract: “Among all the factors tested, endurance of the back extensor muscles had the highest association with LBP. Other factors such as the length of the back extensor muscles, and the strength of the hip flexor, hip adductor, and abdominal muscles also had a significant association with LBP. It appears that muscle endurance and weakness are associated with LBP and that 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 LBP.”

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180. Murrie VL, Dixon AK, Hollingworth W, Wilson H, Doyle TA. Lumbar lordosis: study of patients with and without low back pain. Clin Anat. 2003 Mar;16(2):144–7. PubMed #12589669.
This study showed that there was no difference in lumbar curvature between people with and without low back pain, and no difference in lumbar lordosis between people of different ages or in people with and without pain.

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181. Nakipoğlu GF, Karagöz A, Ozgirgin N. The biomechanics of the lumbosacral region in acute and chronic low back pain patients. Pain Physician. 2008;11(4):505–11. PubMed #18690279.
This study show no difference in thoracic kyphosis (hunchback curve), lumbar lordosis (low back curve) and sacral inclination between people with acute low back pain and chronic low back pain.

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182. Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008;31(9):690–714. PubMed #19028253.
This review of more than 50 studies found no association between measurements of spinal curves and pain. The authors’ conclusion was decisive: the evidence “does not support an association between sagittal spinal curves and health including spinal pain.” One can cherry pick the data for a few studies that show some minor correlation, but it averages out to nothing to write home about.

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183. Certainly this happens. For instance, in cases of clear trauma, the lordotic curve may change quite radically — that’s simply the body adapting to an unpleasant situation, seeking the position of greatest safety. BACK TO TEXT

184. Whitcome KK, Shapiro LJ, Lieberman DE. Fetal load and the evolution of lumbar lordosis in bipedal hominins. Nature. 2007;450(7172):1075–1078. BACK TO TEXT

185. Quick refresher course in natural selection. (I think about evolutionary mechanisms relevant to health care every day, but most people don’t, so you might appreciate a quick reminder of how this works!) If you die before you can breed, your genes don’t get passed on to your children, and such features steadily get “bred out” of the species. Biological features that make you more likely to succeed at procreating will get passed on to your children and become more and more common in the species over time. Whitcome’s research suggests that women with weaker spines, over the aeons, often failed to successfully carry their babies to term because the strain was debilitating. BACK TO TEXT

186. Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther. 2002 Sep;32(9):447–60. PubMed #12322811. BACK TO TEXT

187. Wright LJ, Schur E, Noonan C, et al. Chronic pain, overweight, and obesity: findings from a community-based twin registry. J Pain. 2010 Jul;11(7):628–35. PubMed #20338816. BACK TO TEXT

188. In a short article for Body In Mind, Neil O’Connell, a UK low back pain researcher, does a wonderfully curmudgeonly job of summarizing the history of core strengthening:

Core stability is an interesting case. It divides opinion and yet stands as one of the preeminent models for treating back pain through rehabilitation. In the mid-nineties a rehabilitation movement was created, born from the experimental observation that deep abdominal and paraspinal muscles are altered in their activation patterns in patients with back pain. Those early experiments and subsequent ones gave the model plausibility but, for me, what was more fascinating than the phenomenon of altered trunk muscle function was the phenomenon of a clinical dogma thrusting its way relentlessly through the therapy world. From this fair but limited data, enthusiastic entrepreneurs and self-elected authorities duly sprinted with the ball, creatively developing detailed treatment approaches with strict and specific rules that far exceeded the actual data. “Contract this muscle but not that one, definitely not that one” or “move like this, not like that”, spreading the empirically unsubstantiated (but potentially harmful?) concept to therapists and patients alike of spinal segmental instability, wherein poorly controlled vertebral segments shear excessively resulting in pain. You too could have the answer to treating back pain as long as you attend these 5 sequential courses at $$$$ a pop. Colleagues were falling over each other to buy the equipment needed to apply this model that had been accepted as gospel, from not-too-pricey pressure biofeedback cushions to very-pricey-indeed real time ultrasound imaging devices and the rehabilitation philosophy of the long-late Joseph Pilates experienced a remarkable resurrection. As a case study into how new treatment approaches are adopted in our profession it is perhaps second to none. Maybe the model was correct – we couldn’t know at that time, but in my early clinical career core stability came to dominate thinking as an accepted truth way before we had a good answer about whether it worked.

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189. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review. Phys Ther. 2009 Jan;89(1):ptj.20080103. PubMed #19056854. PainSci #56118. BACK TO TEXT

190. Bray H, Moseley GL. Disrupted working body schema of the trunk in people with back pain. Br J Sports Med. 2011 Mar;45(3):168–73. PubMed #19887441.
If someone is suffering from low back pain, is it possible that they are less accurate in making left/right trunk rotation judgements? Apparently so. The researchers concluded: “Chronic back pain is associated with disruption of the working body schema [mental picture] of the trunk. This might be an important contributor to motor control abnormalities seen in this population.”

But it’s very important to note that the arrow of causation could swing back and forth like a compass in an MRI machine. Is poor coordination causing low back pain? Or is low back causing poor coordination? Or do they just happen to go well together, like peanut butter and chocolate?

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191. Indeed, the observation that patients with low back pain have screwy core stability is the basic fact that launched the entire core fad. BACK TO TEXT

192. Luomajoki H, Moseley GL. Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls. Br J Sports Med. 2011 Apr;45(5):437–40. PubMed #19553222.
This study showed that patients with back pain have decreased tactile acuity and coordination — that is, their sense of touch goes on the blink, and their movement precision is a bit wonky. Touch accuracy is determined by the minimum distance apart that two points of contact can be distinguished: 10mm for a healthy person, but 13mm for those with low back pain. The worse the touch accuracy in a patient, the worse the coordination as well. The authors speculated that “training tactile acuity may aid recovery and assist in achieving normal motor performance after back injury.” That’s quite a leap, but it’s not an unreasonable question to ask (and it could be an example of the potential value of touch therapy for assisting with normalizing a patient’s sense of self).

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193. Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010 Aug;213(Pt 15):2582–8. PubMed #20639419. PainSci #55265. BACK TO TEXT

194. Braddom RL, Spitz L, Rivner MH. Frequency of radiculopathies in motor vehicle accidents. Muscle & Nerve. 2009 Apr;39(4):545–7. PubMed #19260059.
This fascinating study of almost 25,000 patients showed that “pinched nerves” (nerve root impingement, radiculopathy) are fairly rare in the general population — only 6% actually had it in the neck, and only 12% in the low back — and barely any more common in people who’ve had car accidents. You would certainly think that car accidents would cause more nerve root injuries, especially in the neck, but that is precisely what this study did not find. It identified only a small (2%) increase in the neck, and no difference at all in the low back. This is quite a counter-intuitive finding. I think that if you polled health professionals and patients and asked them “Do people who’ve had car accidents have more nerve injury?” you would get a much larger number.

So I get two interesting things out of this straightforward study: first, it’s yet another great example of how the spine is just not particularly fragile or prone to nerve injury; second, it’s terrific evidence that nerve pinches are really pretty rare overall, certainly relatively to what people fear. Yes, 12% is more than 1 in 10 people — hardly rare — but if you believe every patient who says “I have a pinched nerve,” the rate would be about 80%!

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195. The chiropractic profession was founded on the so-called “Big Idea” that all illness is caused by spinal joint subluxation which pinches nerve roots and interferes with the flow of nerve signals through nerve roots. Thus the entire profession is essentially a public education engine for the false idea that nerve roots get pinched a lot. In fact, not only do nerve roots rarely get pinched, it’s extremely difficult for them to get pinched. BACK TO TEXT

196. ScienceBasedMedicine.org [Internet]. London W. The Straw Protocol: A Chiropractor’s Aggressively Promoted Neuropathy Treatment; 2015 Mar 2 [cited 15 Mar 3]. BACK TO TEXT

197. Torun F, Dolgun H, Tuna H, et al. Morphometric analysis of the roots and neural foramina of the lumbar vertebrae. Surgical Neurology. 2006 Aug;66(2):148–51; discussion 151. PubMed #16876606. This was exasperatingly hard data to find for some reason, and the paper abstract begins by saying so: “There have been few anatomic studies on the foramina and roots of the lumbar region….” This is in a 2006 paper! Hardly ancient. BACK TO TEXT

198. Takasaki H, Hall T, Jull G, et al. The influence of cervical traction, compression, and spurling test on cervical intervertebral foramen size. Spine (Phila Pa 1976). 2009 Jul;34(16):1658–62. PubMed #19770608. BACK TO TEXT

199. Sari H, Akarirmak U, Karacan I, Akman H. Computed tomographic evaluation of lumbar spinal structures during traction. Physiother Theory Pract. 2005;21(1):3–11. PubMed #16385939. BACK TO TEXT

200. Ebraheim NA, Liu J, Ramineni SK, et al. Morphological changes in the cervical intervertebral foramen dimensions with unilateral facet joint dislocation. Injury. 2009 Nov;40(11):1157–60. PubMed #19486975.
Researchers dislocated neck joints in corpses to measure the effect on the size of the intervertebral foramina. (Interesting chore!) Dislocation made the spaces quite a bit larger, indicating that any nerve root pain associated with these injuries “is probably due to distraction rather than due to direct nerve root compression.”

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201. This is particularly the case if a professional asks leading questions. Unfortunately, I made exactly this mistake with her. Rather than say, “How does it feel?” which might have elicited a variety of adjectives, I was too focused on finding out if her pain was nerve pain, and I asked, “Does it feel electrical?” Lacking the intimate familiarity with the lexicon of pain imagery that I possess, my client probably reached for this word like a life preserver, lacking a handy adjective of her own: “Why, yes, ‘electrical’ sounds just right to me.” This is the problem with leading questions. BACK TO TEXT

202. My therapist readers might reasonably ask: is it possible that the pressure on the side of the hip was causing a reactive contraction in the piriformis muscle, resulting in an impingement of the sciatic nerve … and fooling me? Yes, this is possible. But I doubt it. This patient did not have a twitchy piriformis, as so many people with piriformis syndrome do. She was relaxed, optimistic, and not in much pain — already about 50% recovered. I find it unlikely that her piriformis muscle could be that prone to spasm at this stage. Nor could I palpate any reactive spasm in the piriformis during treatment, not even when prodding the piriformis directly. It tolerated stretch well and was not even particularly high-toned at rest. BACK TO TEXT

203. Sekharappa V, Amritanand R, Krishnan V, David KS. Lumbosacral transition vertebra: prevalence and its significance. Asian Spine Journal. 2014 Feb;8(1):51–8. PubMed #24596605. PainSci #54202.
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, 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%). The study also identified a “definite causal relationship” with degeneration of the disc above the LSTV.

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204. Porter NA, Lalam RK, Tins BJ, et al. Prevalence of extraforaminal nerve root compression below lumbosacral transitional vertebrae. Skeletal Radiology. 2014 Jan;43(1):55–60. PubMed #24310344. BACK TO TEXT

205. Apazidis A, Ricart PA, Diefenbach CM, Spivak JM. The prevalence of transitional vertebrae in the lumbar spine. Spine J. 2011 Sep;11(9):858–62. PubMed #21951610. “Although LSTV's role in low back pain remains controversial, our study has shown that, when the same criteria are used for classification, prevalence among the general population and symptomatic patients may be similar.” BACK TO TEXT

206. Lauder TD. Musculoskeletal disorders that frequently mimic radiculopathy. Phys Med Rehabil Clin N Am. 2002;13(3):469–485. PubMed #12380546.
From the abstract: “Treatment of concomitant musculoskeletal disorders in patients with radiculopathy improves patient satisfaction and outcomes.”

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207. Slow- and moderate-intensity compression of most healthy nerves is completely painless, while unhealthy or injured nerves can easily be irritated by light pressure or even brushing of the skin. Of course, if you hit a healthy nerve hard enough, it will zing! Your “funny bone” is the most obvious example: the ulnar nerve at the elbow is all too easy to smash against a backstop of bone! But ordinary pressures on most nerves really does not cause any significant pain, I promise — I press on nerves all the time. So this raises an important question: why would nerves ever hurt if they haven’t actually been traumatized? If an injured nerve hurts, it’s probably because it’s ischemic (oxygen-starved) or irritated by other abnormal tissue chemistry. See Kobayashi, Wilson, and Mackinnon. (The next three notes …) BACK TO TEXT

208. Kobayashi S, Shizu N, Suzuki Y. Changes in nerve root motion and intraradicular blood flow during an intraoperative straight-leg-raising test. Spine. 2003 Jul 1;28(13):1427–34. PubMed #12838102.
Kobayashi et al surgically examined blood flow to a lumbar nerve root while the leg was in a painful position. (They peeked into twelve backs with a history of symptomatic disk herniations and nerve pain.) They found that “the intraoperative reverse straight leg raise test showed that the hernia compressed the nerve roots, and that there was marked disturbance of gliding, which was reduced to only a few millimeters,” and “during the test, intraradicular blood flow showed a sharp decrease [40 to 98%] at the angle that produced sciatica.”

Intriguing. It’s probably the physical distortion of the nerve root that caused the loss of circulation, and the combination of the two that was painful. Successful treatment seemed to back this up: “After removal of the hernia, all the patients showed smooth gliding of the nerve roots during the second intraoperative test, and there was no marked decrease in intraradicular blood flow.”

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209. Wilson CB. Significance of the small lumbar spinal canal: cauda equina compression syndromes due to spondylosis 3: Intermittent claudication. J Neurosurg. 1969;31:499–506. PubMed #5351760.
From the abstract: “Compression of the microvasculature of the lumbar nerve roots, resulting in ischemia, is believed to be a major contributing factor in the development of neurogenic claudication.”

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210. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002 May;18(2):231–41. PubMed #1237102.
From the abstract: “Both ischemic and mechanical factors are involved in the development of compression neuropathy.” In other words, mechanical factors only — just being pinched — probably does not cause nerve pain.

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211. Jayson MI. The role of vascular damage and fibrosis in the pathogenesis of nerve root damage. Clin Orthop Relat Res. 1992 Jun;(279):40–8. PubMed #1534723. It “appears likely that venous obstruction with resultant hypoxia is an important mechanism leading to nerve root damage.” BACK TO TEXT

212. Costigan M, Belfer I, Griffin RS, et al. Multiple chronic pain states are associated with a common amino acid-changing allele in KCNS1. Brain. 2010 Sep;133(9):2519–27. PubMed #20724292.
Mark your calendars: 2010 was the year researchers confirmed a gene as “one of the first prognostic indicators of chronic pain risk,” doubling or tripling the odds that a low back pain patient will recover in a timely fashion from nerve root injury. Screening for this gene is not yet something that is clinically available, but it probably will be someday, and then you will know: the universe really does hate you.

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213. The threat wasn’t immediate, but more of an emergency in slow-motion. She was actually asymptomatic at the time of the surgery. However, her organs were already compressed, and the situation would only get worse and more difficult to repair. BACK TO TEXT

214. In my experience, patients with pronounced scoliosis have less anxiety about whatever pain they have, probably because it has an obvious cause. They understand it, they are more resigned to it, and they are less worried about the future of it. This lack of anxiety might actually account for a great amount of the difference in suffering between a patient like Becca and people with more acute and “scary” low back pain. BACK TO TEXT

215. Karachalios T, Sofianos J, Roidis N, et al. Ten-year follow-up evaluation of a school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion for the screening of scoliosis? Spine. 1999 Nov;24(22):2318–2324. BACK TO TEXT

216. Known as the Valsalva maneuver, it’s just a blocked but forced exhalation.  Sticking your thumb in your mouth like a cork and then blowing strongly without releasing air will increase your abdominal pressure. BACK TO TEXT

217. By far the most common location is the sacroiliac region near the superior portion of the iliac crest. It’s so common that they are sometimes called “episacroiliac lipomas.” Other common locations: upper back, shoulders, and abdomen. But they are extremely common in the low back, so much so that you’d be hard pressed to find anyone over 40 who doesn’t have one or two. BACK TO TEXT

218. Probably of the cluneal nerves, especially the superior cluneal nerve, which emerges from the deep tissues of the lumbar spine, passes through tiny holes in the thoracolumbar fascia, and then over the ridge of the sacroiliac crest. They innervate the skin of the buttocks, so most likely mild cluneal nerve impingement would cause a minor superficial pain in the ass. BACK TO TEXT

219. Erdem HR, Nacır B, Özeri Z, Karagöz A. [Episacral lipoma: a treatable cause of low back pain]. Agri. 2013;25(2):83–6. PubMed #23720083. BACK TO TEXT

220. Bicket MC, Simmons C, Zheng Y. The Best-Laid Plans of "Back Mice" and Men: A Case Report and Literature Review of Episacroiliac Lipoma. Pain Physician. 2016 Mar;19(3):181–8. PubMed #27008292. BACK TO TEXT

221. Erdem et al claim that lipomas are “tender.” This is a blatantly incorrect generalization about lipomas — I’ve palpated hundreds of them, and almost no tender ones at all, and even the few tender ones are not very tender. They also declare that lipomas are a “significant” cause of back pain, which is clearly going too far. So there are real reasons to question their judgement. BACK TO TEXT

222. 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. There is a great deal of back pain science to review, but the authors of this review found that shockingly little of it was worth their while: just 34 acceptable studies out of a 1031 candidates, and even among those “trial quality was highly variable.” Their conclusions are derived from only the best sort of scientific experiments: not just the gold-standard of randomized and placebo-controlled tests, but carefully choosing only the “right” kind of placebos (several kinds of placebos were grounds for disqualification, because of their known potential to skew the results). They do a good job of explaining exactly how and why they picked the studies they did. BACK TO TEXT

223. It’s not that the science hasn’t been done yet, though in a few cases the “more study needed” cliché does apply. Most of these treatments have now been studied enough to know. BACK TO TEXT

224. What if a treatment only works well for just the right sort of patients? This is the popular “sub-grouping” criticism of back pain science so far (and a common form of advanced special pleading by advocates for unproven therapies). Unfortunately Machado et al did not find a pattern of superior results from careful subgrouping, and concluded that the evidence is contradictory at best — even after the most productive decade of back pain science in history. It’s also been shown that “the credibility of subgroup claims in back pain trials is usually low” (see Saragiotto 2016, Saragiotto 2017). BACK TO TEXT

225. Another objection: “Some authors have argued that the small effects of treatments for acute non-specific low back pain are a consequence of the favourable natural history …. The theory is that, at the conclusion of treatment in trials, control groups have improved substantially and so there is not ‘room’ for large treatment effects.” I think there are some rather glaring logical problems with this idea, but hard data is more convincing: Machado et al found that this “does not seem consistent with the data” and not only is there “room” for treatment effects, “There seems to be considerable scope for large treatment effects but how this can be achieved at present is unclear.” No kidding. BACK TO TEXT

226. Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010;(7):CD002014. PubMed #20614428.
This review of the results of dozens of scientific studies shows that behavioural therapies for low back pain have generally been failing the “impress me” test. It is possible that behavioural therapy is more effective for a certain kind of patient. However, if so, apparently there are not enough of those kinds of patients, or the effect is not big enough, to have any discernible effect on the average results of experiments. If evidence of a benefit is being “washed out,” it is being washed out rather easily. Behavioural therapy might work, a little, for some, but scraps of efficacy hardly seem worth fighting over. See Neil O’Connell’s erudite analysis.

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227. Vibe-Fersum K, O'Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul;17(6):916–28. PubMed #23208945. Classification-based cognitive functional therapy (CFT) was tested on 62 patients with moderate back pain, and compared to 59 who were treated with manual therapy and exercise. CFT consisting of “reframing the persons’ understanding of their back pain in a person-centred manner, with an emphasis on changing maladaptive movement, cognitive and lifestyle behaviours contributing to their vicious cycle of pain.” Three months and a year later, the CFT group was much better off: a 13-point boost on a 100-point disability scale, and 3 points on a 10-point pain scale. Those are not amazing results, but they’re clinically significant, and they beat manual therapy and exercise handily (those patients improved by only 5.5 and 1.5 points on the same scales). CFT was “more effective at reducing pain, disability, fear beliefs, mood and sick leave at long-term follow-up than MT-EX.” BACK TO TEXT

228. It’s rare to get both in one study: statistical confidence about an effect that’s big enough to be meaningful to patients. In fact, that’s the take-home message from Machado: as of 2009, it had never happened in any study of back pain. (Clarification) Some of the treatment effect sizes in other studies were large enough to be considered clinically significant, but only just. BACK TO TEXT

229. Deep thought alert — it could be that manual therapy and exercise only did as well as they did in this test insofar as they also reduce fear and anxiety. Exercise in particular can build confidence, depending on how it is prescribed and performed. BACK TO TEXT

230. “Proven” would be an exaggeration, but these results can be safely considered “promising” while we wait for replication from bigger studies. And it’s important to note that CFT is a mostly harmless solution, safe and cheap — you can’t go too far wrong with this approach to back pain. BACK TO TEXT

231. 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. p94. BACK TO TEXT

232. Brison RJ, Hartling L, Dostaler S. A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions. Spine. 2005 Aug 15;30(16):1799–807. PubMed #16103847.
This is one of a few studies showing a benefit to education for neck pain specifically. Researchers showed a reassuring educational video to more than 200 patients with “whiplash associated disorders” (i.e. whiplash injuries that become chronic neck cricks), and found that they had less severe symptoms than patients who received no educational intervention. The effectiveness of education probably depends a lot on the type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature found that most such studies are negative (see Haines or Ainpradub), but I believe that there are still reasons to be optimistic about education for pain problems. Above all, it depends on the type and quality of the education! The right education may be effective, and the wrong could even be harmful. The fact that some education has been shown to be beneficial is promising.

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233. Schultz IZ, Crook J, Meloche GR, Berkowitz J, et al. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain. 2004 Jan:77–85. PubMed #14715392.
This study identified factors affecting return-to-work time after an episode of low-back pain. From the abstract: “The key psychosocial predictors identified were expectations of recovery and perception of health change.”

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234. That certainly sounds like “all in your head!” But it’s still not — not in the sense that it’s a psychological problem, imaginary, or psychosomatic. What Lorimer means is that pain is a neurological construct: all pain is “built” by the brain based on an interpretation of incoming signals. We know this very clearly about vision. We know that the raw signals from our eyes are virtually useless until they are turned upside down and backwards, rearranged and color-corrected, and thoroughly processed by the brain until finally we get to “see” something. It’s no different with pain. Every bit of pain that seems to be in our body is actually just an ugly picture painted by our brains — an illusion. BACK TO TEXT

235. Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Man Ther. 2011 Oct;16(5):413–8. PubMed #21632273.
This is an expert opinion piece echoing some of the tenets of the “explain pain” movement (see also: Moseley).

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236. PS Ingraham. Placebo Power Hype: The placebo effect is fascinating, but its “power” isn’t all it’s cracked up to be. PainScience.com. 5941 words. BACK TO TEXT

237. A great example from my mail bag: a young reader with harsh back pain asked me if the answer to his pain is to study yoga. Full time. For a year. In India! I’d say no. Probably not. Unless he’s Indian. Unless studying back pain full-time in India was a genuine dream for him before the back pain, for other reasons. It is not clear that yoga deserves an investment of four hours a week … let alone a complete lifestyle overhaul. BACK TO TEXT

238. People keep writing to me, “Tch tch, Paul, yoga is totally mainstream!” But I disagree. If you live in downtown Vancouver, it’s certainly mainstream. Yes, you can buy yoga mats at Walmart. But I grew up in a small blue collar town, and I can assure you, yoga still seems veeeeery weird to a lot of folks who aren’t living in the throbbing urban centers of our civilization. And there’s plenty of folks who moved to the big city not that long ago. Big Macs are mainstream. Yoga is not. BACK TO TEXT

239. Although alternative medicine is certainly now a substantial industry, it is still dwarfed by the size of mainstream medicine, and its popularity is exaggerated by the people selling alternative services. Acupuncture, for instance, is nowhere near as widely utilized in North America as North American acupuncturists would have us believe. BACK TO TEXT

240. Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Altern Ther Health Med. 2005 Jul-Aug;11(4):44–52. PubMed #16053121.
A study of thirty-six patients with chronic low back pain, comparing physical therapy to meditation (they call it “breathing therapy,” and describe it as “body awareness, breathing, meditation, and movement”), with a follow-up at six months. The benefits of meditation were roughly as good as physical therapy, but modest across the board. The researchers concluded that patients who meditated “improved significantly” and got benefits “comparable to high-quality, extended physical therapy.”

Sounds good, doesn’t it? Unfortunately, there are important caveats: beating physical therapy at treating low back pain is no great accomplishment, because it doesn’t work particularly well, and the benefits of both treatments were statistically signicant but minor (see Statistical Significance Abuse), and roughly consistent with the slow but steady improvement that always occurs, regardless of treatment.

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241. Williams KA, Petronis J, Smith D, et al. Effect of Iyengar yoga therapy for chronic low back pain. Pain. 2005 May;115(1-2):107–117. PubMed #15836974.
Comparing Iyengar yoga therapy to an educational booklet, researchers found that patients who did yoga had less pain and more function up to three months later. However, it is doubtful that those results would compare favourably with any other common treatment method. For instance, in a pair of studies by Sherman et al, yoga was also better than nothing, but not better than conventional exercise therapy or stretching classes.

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242. Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2005 Dec;143(12):849–856. PubMed #16365466. BACK TO TEXT

243. Sherman KJ, Cherkin DC, Wellman RD, et al. A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain. Arch Intern Med. 2011 Oct. PubMed #22025101. BACK TO TEXT

244. The frustrebo effect — a “frustrated placebo” — can be caused by a lack of blinding: everyone knows who is getting what kind of experimental treatment, which means that they can all be biased — skeptical or optimistic or disappointed — and such biases definitely matter in research like this. In this study, the stretching group was probably a frustrebo-free zone, but the reading group was likely afflicted with it at least a little. Those poor souls were consigned to a rather dreary arm of the study, deprived of either a lovely stretching or yoga experience. They might well have reported more negatively and/or actually had slightly worse outcomes … thus creating the illusion of small benefit to both stretching and yoga in comparison. If frustrebo accounts for even a portion of the reported effect of yoga and stretching, that would pull them below the level needed for any clinical significance.

This is actually also the second recent Cherkin back pain experiment afflicted by a likely frustrebo effect. It was also a critical flaw in a 2011 big study of massage for low back pain — and in nearly every other study of massage. I’ll return to this topic in the massage science section.

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245. NYTimes.com [Internet]. Broad W. How Yoga Can Wreck Your Body; 2012 Jan 7uary [cited 14 Jan 6]. BACK TO TEXT

246. What do I mean by “yoga-specific benefits”? That is, benefits that only yoga practitioners get — and not just anyone doing exercise. There are all kinds of non-health-related reasons why you might prefer to do yoga instead of another kind of exercise, just as some people prefer tennis to baseball. But if yoga is to be justified as a healthy regimen above and beyond any other kind of exercise, it has to have measurable benefits that other forms of exercise cannot offer. And those benefits may be minimal. BACK TO TEXT

247. There are people who apologize for yoga? Oh, yes. Seriously. Yoga has many characteristics of a religion, after all. BACK TO TEXT

248. It’s not a perfect article by a long shot. After a too-positive initial review on Facebook, many of my readers pointed out valid science-based criticisms, primarily that Broad relies heavily on anecdotes. In particular, he concludes the piece with a doozy based on pure speculation: that decades of yoga was the direct cause of a severe case of spinal stenosis, which is not a safe assumption at all (stenosis happens, with or without yoga). The worst case scenario is that the article is fear mongering based mostly on a handful of nasty anecdotes without citing much in the way of real risk/benefit data. For instance, for all we know, average yoga injuries per hour may be less than soccer, or even showering ... and we can’t do a real risk-benefit analysis without that information. BACK TO TEXT

249. Oral diclofenac is nasty stuff: it is associated with horrible cardiovascular risks and should probably be banned (McGettigan et al). But the dosage from topical use is much smaller and safer (How risky are NSAIDS?). BACK TO TEXT

250. Pre-emptive rebuttal … before someone tells me, yes, I know we shouldn’t make too much of a study done on rats. But the stakes are low, and that’s the key: an anti-inflammatory gel was not an unreasonable or unsafe thing to try before this evidence, and this just gives it a boost. It makes it more reasonable. BACK TO TEXT

251. Huang ZJ, Hsu E, Li HC, et al. Topical application of compound Ibuprofen suppresses pain by inhibiting sensory neuron hyperexcitability and neuroinflammation in a rat model of intervertebral foramen inflammation. J Pain. 2011 Jan;12(1):141–52. PubMed #20797917. BACK TO TEXT

252. Fascinatingly, these results also demonstrate the importance of some principles of pain science, namely that interactions with the skin can be surprisingly profound for the body. And from that we can also say some nice, reasonable things about why massage therapy might be effective. There’s a lot of scientific innuendo packed into this little study! BACK TO TEXT

253. And there’s only evidence for short term usage! As of 2015, there still wasn’t enough evidence for any conclusions about long-term benefits, or for acute back pain — a shocking deficit, considering the opioid crisis. BACK TO TEXT

254. Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Jul;176(7):958–68. PubMed #27213267. BACK TO TEXT

255. See S, Ginzburg R. Choosing a skeletal muscle relaxant. Am Fam Physician. 2008 Aug;78(3):365–70. PubMed #18711953. PainSci #55418.
From the abstract: “These drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain.”

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256. Khwaja SM, Minnerop M, Singer AJ. Comparison of ibuprofen, cyclobenzaprine or both in patients with acute cervical strain: a randomized controlled trial. Canadian Journal of Emergency Medical Care. 2010 Jan;12(1):39–44. PubMed #20078917.
A new study in the Canadian Journal of Emergency Medical Care compared ibuprofen and a muscle relaxant (cyclobenzaprine or Flexeril) for patients with serious soft-tissue injury in the neck. Groups of about 20 patients received one, the other, or both. Results were statistically identical for all patients. This test showed no benefit to using or adding a muscle relaxant for acute muscle strain in the neck. The study is too small to be powerful, but it certainly shows that there’s no strong advantage to muscle relaxants in a situation where they are often assumed to be an important medication, and the results are consistent with other research results.

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257. Flaten MA, Simonsen T, Olsen H. Drug-related information generates placebo and nocebo responses that modify the drug response. Psychosom Med. 1999;61(2):250–5. PubMed #10204979.
How much does the effect of a medication depend on what you are told about it? Quite a bit, apparently! This strange and fascinating study in Psychosomatic Medicine showed that a muscle relaxant actually increases tension when the patient is told (lied to) that it is actually a stimulant. The false information is so potent — or the drug is so weak — that its intended effect is actually reversed.

It’s like a Jedi mind trick. These aren’t the drugs you’re looking for.

But the reverse was not true: even when told that they were taking a muscle relaxant (and they were), subjects did not actually relax any more than people taking a placebo … and in some cases less!

And there’s more. This study contains many odd gems, such as the bizarre fact that quite a lot more muscle relaxant was found in the blood of people who had been told that the muscle relaxant was a muscle relaxant. It appears that they literally soaked up more of the stuff from the GI tract when they believed that it was a relaxant! And yet it still didn’t actually relax them any more than a placebo.

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258. It is a myth that muscles are paralyzed by anaesthesia and that surgeons have to be extremely careful not to dislocate joints. There is still normal muscle tone with standard anasthesia, and in fact, “There is a constant battle to relax the muscles during some procedures,” explains Dr. Steven Levin [in private correspondence]. “Maybe the newer anesthetics have more curare-like effects, but if they do, they would have to intubate every patient. If the patient is breathing on their own, they have muscle tone! Sometimes, when fixing a fracture or repairing a ligament, the patient must be curarized.”

The curare poison is the only way to truly paralyze muscle for surgery, but it’s used sparingly and specifically: it’s not part of normal anaesthesia, which only stops protective reflexes. “You have to be awfully insensitive not to know when you are exceeding tissue limits,” Dr. Levin says.

Even a supposedly relaxed muscle shrinks about 20% when cut. The tone is mediated by the brain and spinal cord, which is not affected by anaesthesia. Some believe there is some intrinsic regulation of tone — that is, the muscle sets its own tone — but Dr. Levin directly refutes this with some pretty sound logic: “Curare works at the neuro-muscular synapse, so it is the CNS that maintains the muscle tone, including the resting muscle tone (RMT). In my many years of doing surgery, I have never cut a muscle that did not retract unless it was curare-ized (and even then there is some contraction), so the tone has to be a primitive function, maybe some of it spinal, present even in deeply anesthetized creatures.” That’s from this page, a bit hard on the eyes and heavy reading, but neat stuff.

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259. Giannetti BM, Staiger C, Bulitta M, Predel HG. Efficacy and safety of comfrey root extract ointment in the treatment of acute upper or lower back pain: results of a double-blind, randomised, placebo controlled, multicentre trial. Br J Sports Med. 2010 Jul;44(9):637–41. PubMed #19460762. BACK TO TEXT

260. Rathbone AT, Grosman-Rimon L, Kumbhare DA. Interrater Agreement of Manual Palpation for Identification of Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Clin J Pain. 2017 Aug;33(8):715–729. PubMed #28098584.
This review is called a meta-analysis, which is weird, because “only 1 study met inclusion criteria for intrarater agreement and therefore no meta-analysis was performed.” So it was just a regular old review of 6 studies of how much different experts can agree on the location of myofascial trigger points. Lacking adequate data for statistical pooling, they had to “estimate” an agreement score of 𝛋=0.452 — a rather precise etimate! Of the criteria used to determine the location of trigger points, the most reliable were localized tenderness (.68) and pain recognition (.57). Those are actually decent reliability scores, but the authors conclude that “manual palpation for identification of MTrPs is unreliable.” Based on their estimated scores, this is technically correct but a bit misleading: most attempts to detect pathologies in the body are technically “unreliable,” falling well short of a score of κ=1.0 (perfect agreement), but still much better than κ=0 (coin flipping agreement).

And the error bars on those estimates were too large for a confident conclusion anyway.

Therefore, my conclusion is that this review was mostly inconclusive, but actually found evidence that trigger point reliability is probably not all that bad — as compared to most comparable assessment procedures.

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261. Case in point: recently I spent a good ten minutes looking for and missing a trigger point in the tensor fasciae latae muscle on the side of the hip. My client was chatting away happily, and I wasn’t getting all the verbal cues I needed from him. I spent much of that ten minutes assuming that I was basically already there, until I finally got a word in edgewise and asked him what he was feeling. To my mild horror, I’d been barking up the wrong tree. That ten minutes cost him $16, and it was basically completely useless except as “overhead” — more than the usual amount of paid fumbling that is unavoidable in this kind of therapy. My goal as a therapist is to reduce that overhead as much as humanly possible, but there are inevitably some incidents like this, wasted in every other sense. BACK TO TEXT

262. Case in point: after no less than several years of working with a patient regularly, one day we stumbled upon a different approach to her chronic pain that was distinctly more effective. She called me the next day and said, “Wow, that worked better than usual.” That was a couple years ago, and we have been using the new approach ever since, consistently obtaining much better results than anything we saw for the first few years. The innovation also led to direct and clear improvements in her self-treatment methods, to the point where — hallelujah — she has stopped coming to see me regularly, and turns up only once in a while for a little “extra help.” But it took me years of regular therapy to stumble on what is, in retrospect, a minor adjustment in my technique that I could have tested at any point. I estimate that this client paid me something like $8,000 for fumbling around with an approach that was wrong for her. BACK TO TEXT

263. Case in point: many times I have provided what I hope is helpful, expert guidance to patients as they try to work out the problems in their life that may be contributing to chronic pain, whether it’s serious insomnia or a nasty computer workstation. Doubtless most of them would graciously credit me with providing valuable perspective and advice in this endeavour — at least to my face. But I am aware of many who essentially did it all themselves, with only the slightest tweaks and encouragement from me. One patient in particular really did not need me but thought he did: a young man with a particularly uncomfortable work situation. From the start, I encouraged him to tackle the obvious problems on his own — really, how much help does someone need fixing their desk? — but he insisted on paying me to walk him through it. His enthusiasm and determination were infectious, and for a few sessions I took his money and we had animated, detailed conversations about ergonomics and self-care. But soon enough it felt like exploitation. Was I helping him? Sure. Was it worth my fee for a young man earning barely more than minimum wage? Not even close. I “fired” him soon after. BACK TO TEXT

264. In my defense, I had good reasons — just reasons that weren’t easy to explain. For most bogus back pain therapies, there’s not just a lack of evidence, but what evidence exists is negative — an absence of evidence — and a lack of plausibility to boot. By contrast, massage as a basic approach has always had higher plausibility, and what little evidence exists was at least clearly positive. The effectiveness of massage has never been my “pet theory,” but simply a reasonable hypothesis awaiting scientific validation. BACK TO TEXT

265. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2008;(4):CD001929. PubMed #18843627. PainSci #55772. BACK TO TEXT

266. Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015 Sep;9:CD001929. PubMed #26329399. BACK TO TEXT

267. Preyde M. Effectiveness of massage therapy for subacute low-back pain. Canadian Medical Association Journal. 2000 Jun 27;162(13):1815–20. PubMed #10906914. PainSci #56883. BACK TO TEXT

268. Ontario has one of the world’s best education and certification programs for massage therapy. BACK TO TEXT

269. Oppel L. Is massage therapy genuinely effective? CMAJ. 2000 Oct;163(8):953; author reply 953–4. PubMed #11068563. PainSci #52962. Incidentally, Dr. Oppel is an acquaintance of mine, and — more importantly — a super sharp guy with a lot of experience with critical analysis. I place a lot of faith in his judgement. If Lloyd says Preyde’s experiment is critically flawed and actually tells us massage does not work, I am inclined to agree. And inclined to be sad about it. BACK TO TEXT

270. For the record, what I’d like to see is a trial that involves providing at least six twice-weekly one-hour sessions of simplified trigger point therapy. The treatment would consist of a substantial preparation phase of relaxation massage, followed by a trigger point massage based on patient feedback: that is, looking for trigger points by subjective criteria only, which means hunting for spots that the patient thinks are important (sensitive, relevant to their back pain), and then treatment that is simple pressure only, pressing where the patient wants and exactly as hard as they want (the maximum easily tolerable pressure), all entirely dictated by the patient. BACK TO TEXT

271. Most experiments have just tested the effect of simple pressure on trigger points in the middle trapezius, a classic stiff and sore spot, one of the most basic ways you could test trigger point therapy. BACK TO TEXT

272. Most report only minor effects, a couple are clearly negative, and just one (Aguilera) reports a more robust effect… but based only on a single measurement taken immediately after treatment, which could evaporate within seconds for all we know. BACK TO TEXT

273. Garra G, Singer AJ, Leno R, et al. Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy. Acad Emerg Med. 2010 May;17(5):484–9. PubMed #20536800.
What’s better for neck and back pain — ice or heat? This experiment, conducted at a university-based emergency department, compared the effectiveness of these two common treatments. Everyone studied received 400mg of ibuprofen orally and then thirty patients were given a half hour of either a heating pad or a cold pack.

The researchers concluded that adding heat or cold to ibuprofen therapy did not change the result. Both heat and cold resulted in “mild yet similar improvement in the pain severity.” They recommend that the “choice of heat or cold therapy should be based on patient and practitioner preferences and availability.”

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274. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain — bed rest, exercises, or ordinary activity? N Engl J Med. 1995 Feb;332:351–355. PubMed #http://www.ncbi.nlm.nih.gov/pubmed/7823996. PainSci #56885.
This Finnish study of 180 patients with low back pain found that “continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilizing exercises.” However, the nature of the exercises performed is not described in any detail, even in the complete paper, so not much can be said about exercise for back pain based on this evidence. It is probably safe to say, however, that this is reasonably good evidence that bed rest is less effective than “ordinary activity.”

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275. Vroomen PC, de MC Krom, Wilmink JT, Kester AD, Knottnerus JA. Lack of effectiveness of bed rest for sciatica. N Engl J Med. 1999 Feb 11;340(6):418–23. PubMed #9971865. PainSci #56953.
In this sciatica study, researchers “randomly assigned 183 subjects to either bed rest or watchful waiting” for two weeks and found that “bed rest is not a more effective therapy than watchful waiting.” Nor is it less effective. The results were exactly the same. If that sounds like no big deal, consider the difference in the lives of those patients! Two weeks of bed rest? Compared to two weeks of going about your business!

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276. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated cochrane review of bed rest for low back pain and sciatica. Spine. 2005 Mar;30(5):542–546. PubMed #15738787.
From the abstract: “For people with acute low back pain, advice to rest in bed is less effective than advice to stay active.” There is even “high quality evidence” that bed rest leads to more pain.

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277. Not that golf can’t be hard on the back — it can. It’s just rare for it to be the main mechanism of low back pain. That is, golf isn’t a problem for an otherwise healthy back. BACK TO TEXT

278. Nolan D, O'Sullivan K, Stephenson J, O'Sullivan P, Lucock M. What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskelet Sci Pract. 2017 Oct;33:35–40. PubMed #29078081.
This survey found that about 75% of physical therapists believe that lifting with a straight back is safer… because lifting with a rounded back is more risky. Unsurprisingly, professionals with this opinion also have more “negative back beliefs” (that is, they tend to believe the back is more fragile and vulnerable).

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279. The evidence on this point is reviewed extremely thoroughly in my low back pain book, but you can also get a good free dose of it from this article: MRI and X-Ray Often Worse than Useless for Back Pain: Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms. BACK TO TEXT

280. Of course things get expontentially more complicated with heavier and/or more awkward objects (sofabeds, patients in a hospital), or working on unstable or uneven surfaces (lugging sofabeds up stairs!). People who move a variety of awkward, heavy things around for a living almost certainly get good at many non-obvious techniques. One of the best examples: lift patients safely (for both patient and nurses) is definitely a complex skill. Again, technique certainly matters… but for most lifting chores, there are just too many variables for there to be any clear “right” way to do it. BACK TO TEXT

281. Hadler NM. Back pain in the workplace. What you lift or how you lift matters far less than whether you lift or when. Spine (Phila Pa 1976). 1997 May;22(9):935–40. PubMed #9152441.
In spite of more than 50 years of concerted effort to diminish task demand, the incidence of compensable back injuries has not wavered. Before we persist for another 50 years in the quest for the "right way to lift," we should consider recent multivariate clinical investigations that suggest alternative approaches. Because task context is at least as important as task content in this regard, it follows that including regional backache under the rubric of "compensable injury" demands reconsideration. Likewise, rather than pursuing the "right way to lift," the more reasonable and humane quest might be for workplaces that are comfortable when we are well and accommodating when we are ill.
“Before we persist for another 50 years in the quest for the ‘right way to lift,’ we should consider…alternative approaches. … The more reasonable and humane quest might be for workplaces that are comfortable when we are well and accommodating when we are ill.” BACK TO TEXT

282. Straker LM. A review of research on techniques for lifting low-lying objects: 1. Criteria for evaluation. Work. 2002;19(1):9–18. PubMed #12454347. BACK TO TEXT

283. Martimo KP, Verbeek J, Karppinen J, et al. Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ. 2008. PainSci #55880. BACK TO TEXT

284. Kuiper JI, Burdorfb A, Verbeek J. Epidemiologic evidence on manual materials handling as a risk factor for back disorders: a systematic review. International Journal of Industrial Ergonomics. 1999 Aug 23;24(4):389–404. PubMed #10569458. PainSci #55881. BACK TO TEXT

285. The International Journal of Industrial Ergonomics paper (which is another analysis of other research), comes to underwhelming conclusions about the relationship between low back pain and heavy lifting at work. Even though “a considerable number of epidemiologic studies investigated the risk of lifting,” the authors obtained “only a moderate insight” into the relationship between lifting and low back pain. Mostly what they found is that the available evidence was of low quality and “inconsistent” and “limited.” BACK TO TEXT

286. Wai EK, Roffey DM, Bishop P, Kwon BK, Dagenais S. Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J. 2010 Jun;10(6):554–66. PubMed #20494816. BACK TO TEXT

287. Ribeiro DC, Aldabe D, Abbott JH, Sole G, Milosavljevic S. Dose-response relationship between work-related cumulative postural exposure and low back pain: a systematic review. Ann Occup Hyg. 2012 Jul;56(6):684–96. PubMed #22356808. BACK TO TEXT

288. Kwon BK, Roffey DM, Bishop PB, Dagenais S, Wai EK. Systematic review: occupational physical activity and low back pain. Occup Med (Lond). 2011 Dec;61(8):541–8. PubMed #21727180. BACK TO TEXT

289. Villumsen M, Samani A, Jørgensen MB, et al. Are forward bending of the trunk and low back pain associated among Danish blue-collar workers? A cross-sectional field study based on objective measures. Ergonomics. 2015;58(2):246–58. PubMed #25374330. BACK TO TEXT

290. Something like this is likely: you’ll hurt your back only if you sloppily lift something heavy and you’re under an extraordinary amount of emotional strain as well — like being miserable at work, perhaps. Or it’s just the seriously sleep-deprived lifters who “tweak” their backs. This is what we mean about lifting not being an independent cause: it almost certainly takes more than a bad lift. BACK TO TEXT

291. Kingma I, Faber GS, van Dieën JH. How to lift a box that is too large to fit between the knees. Ergonomics. 2010 Oct;53(10):1228–38. PubMed #20865606. BACK TO TEXT

292. Dreischarf M, Rohlmann A, Graichen F, Bergmann G, Schmidt H. In vivo loads on a vertebral body replacement during different lifting techniques. J Biomech. 2016 Apr;49(6):890–5. PubMed #26603872. BACK TO TEXT

293. Injury prevention is certainly the main casual reason cited by the average bodybuilder. It gets a bit more complex for serious powerlifters. The reasons I’ve seen (example) are a mish-mash of speculation about perfomance enhancement and/or injury prevention, with a strong common denominator: the belief that belts support the spine. Often the mechanism cited is that this facilitates very high abdominal cavity pressures, which in turn supports the spine anteriorly, which in turn makes it possible to lift heavier loads — “without injury” is stated by some and just implied by others. With loads like that there are only a hair-splitting difference between what can be done and what can be done without hurting yourself. I haven’t read enough to know, but I bet there’s plenty of debate about whether the belts actually help (in a biomechanical way), or if they are a placebo that “just” gives lifters a feeling of safety and confidence — which is exactly like the debate about rehabilitative bracing. BACK TO TEXT

294. Siewe J, Rudat J, Röllinghoff M, et al. Injuries and overuse syndromes in powerlifting. Int J Sports Med. 2011 Sep;32(9):703–11. PubMed #21590644. BACK TO TEXT

295. Kurustien N, Mekhora K, Jalayondeja W, Nanthavanij S. Trunk Muscle Performance and Work-Related Musculoskeletal Disorders among Manual Lifting with Back Belt Wearing Workers. J Med Assoc Thai. 2015 Jun;98 Suppl 5:S74–80. PubMed #26387415. “Low correlation was found between back belt use and work-related musculoskeletal disorders.” BACK TO TEXT

296. Steffens D, Maher CG, Pereira LS, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Jan:1–10. PubMed #26752509. Back belts “do not appear to prevent LBP.” BACK TO TEXT

297. Rohlmann A, Bergmann G, Graichen F, Neff G. Braces do not reduce loads on internal spinal fixation devices. Clin Biomech (Bristol, Avon). 1999 Feb;14(2):97–102. PubMed #10619096.
To determine how much a back brace really braces, German researchers used “telemeterized” implants — steel fixation rods with meters on them! so cyborgy! — to measure the effect of common braces on spinal forces. This is a good experiment. If you have implants stabilizing your spine internally, measuring the stresses on them directly is a pretty clever way of checking to see if an external brace is doing anything.

Three types of braces were examined: Boston overlap brace, reclination brace, and a lumbotrain harness. Unsurprisingly, they found that “none of the braces studied were able to markedly reduce the loads” on the implants. There was some reduction — just not “marked,” nothing to write home about.

More surprisingly, some of their measurements showed that bracing increased loading on the implants! That does seem possible. The spine is an extraordinarily dynamic structure. Somewhat like slouching into a comfortable chair, a brace may actually cause some sloppiness of spinal function, resulting in “resting” on the fixations, rather than using muscle to support and control the spine. That’s just a guess, but it seems like a reasonable one to me.

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298. The world record in 2015 was Eddie “The Beast” Hall’s 463kg lift. That’s 1020 lbs for you Yanks. BACK TO TEXT

299. Siewe 2011, op. cit. “The injury rate is low compared to other sports.” Not nonexistent, of course: “0.3 injuries per lifter per year,” or inury per thousand hours of training. BACK TO TEXT

300. Kingma 2010, op. cit. BACK TO TEXT

301. Clarke JA, van Tulder MW, Blomberg SE, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2007;(2):CD003010. PubMed #17443521. BACK TO TEXT

302. PS Ingraham. Quite a Stretch: Stretching Hype Debunked: Stretching science shows that a stretching habit isn’t doing much of what people hope. PainScience.com. 13797 words. Stretching just doesn’t have the effects that most people hope it does. Plentiful research has shown that it doesn’t warm you up, prevent soreness or injury, enhance peformance, or physically change muscles. Although it can boost flexibility, the value of this is unclear, and no other measurable and significant benefit to stretching has ever been proven. Regardless of efficacy, stretching is inefficient, “proper” technique is controversial at best, and many key muscles are actually biomechanically impossible to stretch — like most of the quadriceps group (which runners never believe without diagrams). If there’s any hope for stretching, it might be a therapeutic effect on muscle “knots” (myofascial trigger points), but even that theory is full of problems. BACK TO TEXT

303. The only part of the quadriceps that can actually be stretched strongly is the smallest part. Thus quadriceps stretching feels like a stretch but actually affects only one slender part of the muscle group. See Massage Therapy for Your Quads for a detailed explanation. BACK TO TEXT

304. Johnson EN, Thomas JS. Effect of hamstring flexibility on hip and lumbar spine joint excursions during forward-reaching tasks in participants with and without low back pain. Arch Phys Med Rehabil. 2010 Jul;91(7):1140–2. PubMed #20599054. BACK TO TEXT

305. Apparently the effect of hamstring extensibility on lumbar motion is trumped when people develop back pain, which could suggest that it’s unimportant to back pain as well. If it was important to back pain, it would probably have a more predictable effect in back pain patients. It’s hardly proof, but this could well mean that tight hamstrings aren’t a driver of back pain. Which in turn would suggest that stretching — even if you could reliably, significantly increase hamstring extensibility — probably won’t have much effect on how back pain patients use their lumbar spines, or how it feels to do so. Interesting side-note: the lack of correlation shown by Johnson et al persisted even after recovery, which is particularly interesting. And also mostly uninterpretable without more information, like how long that effect lasts.

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306. Rebain R, Baxter GD, McDonough S. A systematic review of the passive straight leg raising test as a diagnostic aid for low back pain (1989 to 2000). Spine (Phila Pa 1976). 2002 Sep;27(17):E388–95. PubMed #12221373. BACK TO TEXT

307. Plenty of professionals will nod sagely and claim that, obviously, the hamstrings are not a significant factor in back pain but, in their experience, the psoas is the real culprit. That is possible, and at some point I’ll get into more detail about psoas. Meanwhile, I’m a bit skeptical, of course. Psoas came up earlier in the section Are you crooked? I cited Nourbakhsh et al … who found no connection between back pain and the state of the psoas. BACK TO TEXT

308. I address the topic of morning pain in several places on PainScience.com: back pain, neck pain, headache, and other muscle pains and stiffness are all prone to AM exacerbations, and they all seem to have muscle and spine in common. There could be some biological overlap between those issues and osteoarthritis, which is definitely worse in the morning (and when the barometer is low, which I don’t believe has ever been explained). Morning pain is also a signature symptom of different conditions, like plantar fasciitis and carpal tunnel syndrome. Most repetitive strain injuries are probably worse in the morning, but more obviously so with some than others. No matter how you slice it, there’s just something about sleeping! BACK TO TEXT

309. In particular, morning pain often lacks the characteristics of specific mildly traumatized tissues. And surely people don’t mildly re-injure themselves in exactly the same way, night after night for weeks or months at a time? A habitual problematic sleeping posture might cause that, but it still seems like a lot of morning pain is too predictable even for that. BACK TO TEXT

310. For instance, Lita also asked about a book she’d read, Back Sense, which suggests 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! — but I think that author is indulging in a silly, simplistic mind-body connection theory. I’ve written crankily about this kind of logic elsewhere (see Why Do We Get Sick? or Pain is Weird). It’s a bit of a reach to say that you have 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. BACK TO TEXT

311. The science:

We often worry about lying awake in the middle of the night — but it could be good for you. A growing body of evidence from both science and history suggests that the eight-hour sleep may be unnatural.

Indeed, all the research indicates that humans aren’t actually built to sleep through the night (with the exception of my wife, apparently, who can sleep ten hours without so much as rolling over). The wakeful patch tends to occur between about 2 and 4 am. I discuss this more in my insomnia tutorial.

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312. Hartvigsen J, Leboeuf-Yde C, Lings S, Corder EH. Is sitting-while-at-work associated with low back pain? A systematic, critical literature review. Scand J Public Health. 2000 Sep;28(3):230–9. PubMed #11045756. BACK TO TEXT

313. Lis AM, Black KM, Korn H, Nordin M. Association between sitting and occupational LBP. Eur Spine J. 2007 Feb;16(2):283–98. PubMed #16736200. PainSci #53732. BACK TO TEXT

314. Chen SM, Liu MF, Cook J, Bass S, Lo SK. Sedentary lifestyle as a risk factor for low back pain: a systematic review. Int Arch Occup Environ Health. 2009 Jul;82(7):797–806. PubMed #19301029.
This systematic review of 15 studies, 8 classified as high quality, “confirms that sedentary lifestyle by itself is not associated with low back pain.” Only one of the high-quality studies reported a link.

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315. Bakker EW, Verhagen AP, van Trijffel E, Lucas C, Koes BW. Spinal mechanical load as a risk factor for low back pain: a systematic review of prospective cohort studies. Spine (Phila Pa 1976). 2009 Apr;34(8):E281–93. PubMed #19365237.
This review of 18 studies of risk factors for low back pain confirmed strong evidence of no link to sitting, standing, walking, or common amateur sports; “conflicting” evidence about leisure activitiues like gardening, whole body vibration, hard physical work, and even “working with ones trunk in a bent and/or twisted position”; and no evidence of any quality about sleeping.

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316. My assumption felt safe enough that I never got that sinking “citation needed” itch. I thought I had bigger research fish to fry. There are a lot of things to pay attention to in musculoskeletal medicine. I never even stumbled across the evidence, even though I have delved deep into many closely related topics, such as the absence of a clear link between posture and back pain. BACK TO TEXT

317. Roffey DM, Wai EK, Bishop P, Kwon BK, Dagenais S. Causal assessment of occupational standing or walking and low back pain: results of a systematic review. Spine J. 2010 Mar;10(3):262–72. PubMed #20207335.
Standing and walking probably don’t cause back pain, according to moderate to strong evidence from 18 studies, seven of them high quality. Although still possible, “it is unlikely that occupational standing or walking is independently causative of LBP in the populations of workers studied.”

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318. I’ve been through a long episode of chronic moderate back pain that was almost exclusively aggravated by standing/walking and relieved by taking a load off. When you are completely pain-free in your chair, and in wincing discomfort within five minutes of standing up, consistently for months, it’s pretty easy to assume that “standing causes back pain.” But there’s a big difference between standing aggravating back pain and causing it. BACK TO TEXT

319. Mohseni Bandpei MA, Ehsani F, Behtash H, Ghanipour M. Occupational low back pain in primary and high school teachers: prevalence and associated factors. J Manipulative Physiol Ther. 2014;37(9):702–8. PubMed #25280458.
This survey of several hundred Iranian teachers is not exactly bullet-proof science, but its main finding is probably trustworthy: teachers get a lot of low back pain, and high school teachers get even more than primary school teachers.

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320. We know that long-term voluntary shortening can cause mild contracture (see Csapo et al, which showed that people who wear high heels for years end up with shorter, stiffer calves and Achilles tendons). If trigger points are caused by micro cramps, then it’s highly plausible that chronic trigger points could “set” a bit over time. But that’s also far from proven and even at its worst probably wouldn’t qualify as a true contracture. BACK TO TEXT

321. Kanodia AK, Legedza AT, Davis RB, Eisenberg DM, Phillips RS. Perceived benefit of Complementary and Alternative Medicine (CAM) for back pain: a national survey. J Am Board Fam Med. 2010 May-Jun;23(3):354–62. PubMed #20453181. PainSci #54984. BACK TO TEXT

322. I write about the seductiveness of dot-connecting diagnoses in the article The Not-So-Humble Healer. Both patients and professionals tend to admire a diagnosis that connects seemingly unrelated things. The problem with such diagnoses is that they are usually overconfident. BACK TO TEXT

323. The seeking almost always fail, but the provider rarely admits that. Instead they have a theory, and a solution to sell you. And so a great deal of time and money is spent trying to destroy the alleged cause, often with great fanfare and much “swearing by” for a while as optimism works its magic. BACK TO TEXT

324. Ho KY, Tan KH. Botulinum toxin A for myofascial trigger point injection: a qualitative systematic review. Eur J Pain. 2007 Jul;11(5):519–27. PubMed #17071119.
This 2007 review paper shows pretty clearly that “current evidence does not support the use of Botulinum toxin A (BTA) injection in trigger points [muscle knots].” The truth is never bad news, of course, and I’m going to use this as an example of honouring the evidence even when it irritates me. But damn … this study rocked my boat a bit when I found it in Aug 2009.

For years I was under the impression that Botox injection flipped the switch on trigger points, just turned ‘em off completely, zap, done — no more trigger point until the Botox wears off. That didn’t necessarily make it a good treatment option for patients: it’s invasive, there are risks, it’s difficult to reliably inject the actual trigger point, and so on. But the evidence of the effect of Botox on trigger points was terribly important theoretically, because it showed something vital about the physiology of trigger points. (Botox blocks the release of the neurotransmitter acetylcholine, making it impossible for muscle to contract.) If Botox stops a trigger point, it proves that a trigger point is contractile. If you know how to break a trigger point, then you know how it works. It really helped to push back the scientific darkness around muscle pain.

Only I guess it didn’t!

This paper doesn’t necessarily show that Botox doesn’t do anything to trigger points, or that it has no relevance. (For instance, Botox may do exactly what I thought it did, but it’s so difficult for practitioners to reliably inject it into exactly the right place that it is highly unreliable as a treatment.) But it does mean that it’s effectiveness and significance is no longer certain, no longer reliable. It is, at best, debatable.

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325. Indeed, perhaps to the point of folly! Deyo was the most prominent researcher involved in the deeply flawed 2011 trial of massage that was summarized as positive despite the data being quite unpersuasive (Cherkin). BACK TO TEXT

326. Ernst E. Massage therapy for low back pain: a systematic review. Journal of Pain Symptomology Management. 1999 Jan;17(1):65–9. PubMed #9919867. BACK TO TEXT

327. Wall P. Pain: the science of suffering. Weidenfeld and Nicholson; 2000. p. unknown. BACK TO TEXT

328. Moyer CA. Affective massage therapy. Int J Ther Massage Bodywork. 2008;1(2):3–5. PubMed #21589715. PainSci #54758.
ABSTRACT

Two general effects [of massage, MT] are well-supported by scientific data and widely agreed-upon by MT researchers. Quantitative research reviews show that a series of MT treatments consistently produces sizable reductions of depression in adult recipients. The effects of MT on anxiety are even better understood. Single sessions of MT significantly reduce state anxiety, the momentary emotional experiences of apprehension, tension, and worry in both adults and in children, and multiple sessions of MT, performed over a period of days or weeks, significantly reduce trait anxiety, the normally stable individual tendency to experience anxiety states, to an impressive degree in adults.

Together, these effects on anxiety and depression are the most well-established effects in the MT research literature. They are especially important for us to understand not only for their own sake, but also because anxiety and depression exacerbate many other specific health problems. In other words, it is reasonable to theorize that quite a few specific health benefits associated with MT may actually be “second-order” effects that are a consequence of MT’s “first-order” effects on anxiety and depression.

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329. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Man Ther. 2010 Aug;15(4):355–63. PubMed #20097115. BACK TO TEXT

330. Massage is not a detox treatment. If anything, it’s the opposite! Post-massage soreness and malaise (PMSM) is probably caused by mild rhabdomyolysis (“rhabdo”). True rhabdo is a medical emergency caused by muscle crush injuries. But milder stresses cause milder rhabdo — even just intense exercise can do it. And massage! We know this from a good case study, common exertional rhabdo, and the similarities between PMSM and ordinary exercise soreness. A rhabdo cocktail of waste metabolites and by-products of tissue damage is probably why we feel cruddy after any intense biological stress or trauma — but they can’t be “flushed” away by massage (or by drinking water). See Poisoned by Massage: Rather than being DE-toxifying, deep tissue massage can probably cause a slightly toxic situation in the body. BACK TO TEXT

331. Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev. 2012;9:CD008880. PubMed #22972127. PainSci #54694. BACK TO TEXT

332. Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017 Apr;317(14):1451–1460. PubMed #28399251. This major review in a good journal looks at the results of 26 studies of spinal manipulative therapy (SMT) for fresh cases of back pain (less than six weeks). Fifteen of those studies provided “moderate-quality evidence” of “clinically modest” effects on pain, roughly 10% relief in the short term, “the same as the benefit for nonsteroidal anti-inflammatory drugs in acute low back pain.” BACK TO TEXT

333. Paige et al do seem to present a positive conclusion at first glance: the benefits of SMT are disingenuously summarized as “statistically significant” in the abstract, with no mention of clinical significance (effect size). So the abstract sounds like good news to all but the most wary reader, while deep in the main text the same results are conceded to be “clinically modest,” and even that seems excessively generous. Personally, I need at least a 2-point improvement to consider it “modest.” BACK TO TEXT

334. Although fortunately “no RCT reported any serious adverse event,” it seems that minor harms were legion: “increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.” That’s a lot of undesirable outcomes. BACK TO TEXT

335. That is, such an effect is based on relevant new sensory information from affected tissues being stimulated in a new way, not just expectations. BACK TO TEXT

336. I have noticed a large difference between the methods of physiotherapists in North America and everywhere else. Physiotherapists trained in the UK, Australia, and New Zealand in particular seem to have a much more hands-on approach to therapy, which is almost certainly a better option for low back pain patients. Unfortunately, I don’t really know what physiotherapy is like in other parts of the world — if you know, please send me a note. BACK TO TEXT

337. Zusman M. The Modernisation of Manipulative Therapy. International Journal of Clinical Medicine. 2011 Nov;2(5):644–9. PainSci #54598.
A strong indictment of the persistent use of “passive movement” in physiotherapy, and the disappointing reasons for it: a “now obsolete, structure-based ‘bio-medical’ model” which has “been shown flawed or at least irrelevant.” Unfortunately, the language of the paper is tortuous and clunky, especially the bizarrely overuse of scare quotes and parentheticals. However, I agree completely with its substance, and share the author’s frustration with the state of physical therapy: “The profession needs to be seen to be taking the mature stance afforded by its modern science-based training.”

Research indicates that, despite physiotherapists’ comprehensive training in the basic sciences, manipulative therapy is still dominated in the clinical setting by its original, now obsolete, structure-based “bio-medical” model. This is further inexplicable in the light of evidence that not only the underlying “philosophy” but also several of the fundamental requirements of the clinical process itself which has the structural-mechanical model as its basis, have been shown to be flawed or at least irrelevant. The apparent inability of the profession to fully abandon outmoded “concepts” (and embrace the acknowledged science-based “best practice” biopsychosocial model) may have potentially undesirable consequences for both patients and therapists engaged in the management of (chronic) musculoskeletal pain and disability.

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338. As expressed so well by Zusman above, exercise therapy as usually prescribed for back pain is almost universally focused on “correcting” hypothetical inadequacies, dysfunctions, asymmetries, and so on — all the bogus scapegoats that this book debunks. BACK TO TEXT

339. Many PTs have paid through the nose to create in-office gyms, for instance, and prescription patterns inevitably end up warping in a direction that justifies and pays for the expensive renovations and equipment. Indeed, I once worked in a PT office that was more gym than clinic. Consults were conducted in private, but the overwhelming majority of “treatment” took place in the gym. Naturally this suited a certain kind of client just fine, and I’m not saying it was wrong — it entirely depends on the choices the clinicians make. But how objective could those choices be after spending $100,000 (at least) on a facility like that? It’s exactly analogous to MRI clinic owners recommending too much MRI. BACK TO TEXT

340. Thackeray A, Fritz JM, Brennan GP, Zaman FM, Willick SE. A Pilot Study Examining the Effectiveness of Physical Therapy as an Adjunct to Selective Nerve Root Block in the Treatment of Lumbar Radicular Pain From Disk Herniation: A Randomized Controlled Trial. Phys Ther. 2010 Sep;90(12):1717–1729. PubMed #20864600. PainSci #54993. BACK TO TEXT

341. Maddin WS, Bell PW, James JH. The biological effects of a pulsed electrostatic field with specific reference to hair: Electrotrichogenesis. Int J Dermatol. 1990 Jul-Aug;29(6):446–50. PubMed #2397975. BACK TO TEXT

342. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81–8. PubMed #12110735. PainSci #56845. From the abstract: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.” BACK TO TEXT

343. Louw A, Diener I, Fernández-de-Las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016 Jul. PubMed #27402957. PainSci #53458.
A review of a half dozen high quality tests of four popular orthopedic (“carpentry”) surgeries, all showing a lack of efficacy compared to placebos. As of 2016, this review is the best single academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” It’s also an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.

(See more detailed commentary on this paper.)

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344. Randomized controlled trial. Wikipedia.com. BACK TO TEXT

345. A little bit more detail about this: the gold standard of medical research is the “RCT,” which stands for “randomized, controlled trial.” Surgical studies are usually well-randomized and blinded, but not controlled. Surgeons tend to do RTs… not RCTs. BACK TO TEXT

346. Doctorskeptic.blogspot.ca [Internet]. Skeptic D. Doctor Skeptic: Why placebo surgery is ethical, and necessary; 2012 Nov 29 [cited 18 Jan 18]. BACK TO TEXT

347. Harris I. Surgery: The ultimate placebo. NewSouth Publishing; 2016. BACK TO TEXT

348. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007 May;356(22):2245–56. PubMed #17538084. BACK TO TEXT

349. We can take some comfort here in knowing that the researchers were giving delayed surgery to people who had already been doing poorly without any kind of intervention, and so those people were — sorta — a control group. This is probably why Dr. Deyo called this a controlled study (see Deyo again), even though it isn’t really. Any research methods purist will tell you that you really do have to go all the way with that, because — for all we know — most of those people could have improved quickly after that point regardless of whether or not they had surgery. BACK TO TEXT

350. Schultz 2004, op. cit. BACK TO TEXT

351. Peul WC, van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008 Jun;336(7657):1355–8. PubMed #18502911. PainSci #53367. BACK TO TEXT

352. Nachemson AL. Newest knowledge of low back pain: A critical look. Clin Orthop. 1992 Jun:8–20. PubMed #1534725.
From the abstract: “Psychosocial factors, including insurance benefits, have been demonstrated to be more important than biomechanical workload not only for acute but also for chronic low back pain patients who are unable to work. Orthopedic surgeons must recognize this fact when contemplating operations for patients with ill-defined back syndromes. Rarely are diagnoses scientifically valid, nor is the effectiveness of surgery proven by acceptable clinical trials.”

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353. Gibson JN, Grant IC, Waddell G. The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. Spine. 1999 Sep 1;24(17):1820–32. PubMed #1048851.
This is a valuable review of all “evidence on surgical management for lumbar-disc prolapse and degenerative lumbar spondylosis.” From the conclusions:

There is now strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is considerable evidence on the clinical effectiveness of discectomy for carefully selected patients with sciatica caused by lumbar disc prolapse that fails to resolve with conservative management. There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management.

The claim of discectomy being compared with placebo via chemonucleolysis is dubious, however: as Sarno writes, “The effectiveness of a placebo is directly proportional to the impression it makes on the patient’s subconscious mind ….” I believe it’s fair to say that discectomy makes a greater impression, which is a more elaborate surgical procedure than chemonucleolysis. In other words, just because discectomy seems to produce better results than a procedure that is no better than placebo doesn’t mean that discectomy doesn’t simply produce a stronger placebo effect. We know such things need to be tested, not assumed.

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354. Limbrick DD, Wright NM. Verification of nerve root decompression during minimally-invasive lumbar microdiskectomy: a practical application of surgeon-driven evoked EMG. Minim Invasive Neurosurg. 2005;48:273–277. “Lumbar microendoscopic diskectomy (MED) has gained widespread acceptance as an alternative to conventional open microdiskectomy due to several potential advantages, including reductions in postoperative pain and recovery time.” BACK TO TEXT

355. Nguyen TH, Randolph DC, Talmage J, Succop P, Travis R. Long-term Outcomes of Lumbar Fusion Among Workers' Compensation Subjects: A Historical Cohort Study. Spine (Phila Pa 1976). 2011 Feb;36(4):320–31. PubMed #20736894. BACK TO TEXT

356. Mannion AF, Brox JI, Fairbank JC. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials. Spine J. 2013 Nov;13(11):1438–48. PubMed #24200413.
This interesting paper is a detailed very long-term update — after an average of 11 years! — on the status of hundreds of patients who previously participated in three different trials of spinal fusion and cognitive behavioural therapy for back pain. The results were resoundingly negative: “there was no difference in patient self-rated outcomes between fusion and multidisciplinary cognitive-behavioral and exercise rehabilitation for cLBP.”

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357. Hedlund R, Johansson C, Hägg O, et al. The long-term outcome of lumbar fusion in the Swedish lumbar spine study. Spine J. 2016 May;16(5):579–87. PubMed #26363250. This was a very complicated paper to analyze, to much for a footnote: for the gritty details (~750 words), click the paper title to go to the full bibliography page for this paper. BACK TO TEXT

358. Mannion AF, Brox JI, Fairbank JC. Consensus at last! Long-term results of all randomized controlled trials show that fusion is no better than non-operative care in improving pain and disability in chronic low back pain. Spine J. 2016 May;16(5):588–90. PubMed #27261844. BACK TO TEXT

359. Saltychev M, Eskola M, Laimi K. Lumbar fusion compared with conservative treatment in patients with chronic low back pain: a meta-analysis. Int J Rehabil Res. 2014 Mar;37(1):2–8. PubMed #23820296.
A meta-analysis of lumbar fusion studies with a clear negative conclusion. Although “more study needed” is a bit of a cliché in medical science, these authors believe that it’s “unlikely that further research on the subject would considerably affect this conclusion.”

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360. 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. p35. BACK TO TEXT

361. For example, a review of back pain surgeries (Jacobs et al) found that “fusion showed more favorable results compared to decompression.” BACK TO TEXT

362. Peul 2008, op. cit. BACK TO TEXT

363. Datta 2009, op. cit. BACK TO TEXT

364. Atluri 2008, op. cit. BACK TO TEXT

365. Manchikanti KN, Atluri S, Singh V, et al. An update of evaluation of therapeutic thoracic facet joint interventions. Pain Physician. 2012;15(4):E463–81. PubMed #22828694.
This tiny review was based on extremely limited evidence: just four studies (three non-randomized), and “The only positive studies were of medial branch blocks performed by the same group of authors” (e.g. Manchikanti 2008) … who also happen to be the authors of this review. That doesn’t mean they are wrong, of course, but it’s an important caveat. The word they chose to describe this level of evidence was “fair.” I’m not sure that’s fair! They are mostly just re-reporting the positive results of their own trials.

They also concluded there wasn’t enough evidence about intraarticular injections and radiofrequency neurotomy. They probably should have concluded the same about medial branch blocks!

This paper is very similar to Falco et al, regarding the cervical spine (again involving some of the same researchers).

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366. Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine. 2009 Jan;34(1):49–59. PubMed #19127161.
A review of all kinds of injection therapies for the low back and finding “no strong evidence for or against the use of any type of injection therapy,” which is not as optimistic as Datta 2009.

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367. Manchikanti L, Singh V, Falco FJ, Cash KM, Fellows B. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine. 2008 Aug;33(17):1813–20. PubMed #18670333. BACK TO TEXT

368. Epidural means “around the dura.” This is different than the even deeper injection of anaesthetic into the fluid around the spinal cord itself. BACK TO TEXT

369. Seems obvious, right? You’re bathing a nerve root in anaesthetic! That’s got to be pain relieving! But neurology and pain aren’t simple, and it’s not clear that anaesthetizing the nerve root is necessarily going to have the desired effect. BACK TO TEXT

370. Benyamin RM, Singh V, Parr AT, et al. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009;12(1):137–57. PubMed #19165300. PainSci #55398. BACK TO TEXT

371. See Romero 2015, Berry 2011, Rose 2013 and Storey 2011. BACK TO TEXT

372. You may think, “Yeah, but everything you Google is like that.” But that’s not actually the case — searches for injuries like “iliotibial band syndrome” produce less than 1% as many search results. There truly is a glut of low back pain information! BACK TO TEXT

373. Hartman SE. Cranial osteopathy: its fate seems clear. Chiropractic & Manual Therapies. 2006;14:10. PainSci #56267.
A short but clear, compelling, and strong critique of cranial osteopathy. As an osteopath himself, Dr. Hartman’s opinion carries considerable weight, and he writes well. He concludes that techniques based on the assumptions of cranial osteopathy “should be dropped from all academic curricula; insurance companies should stop paying for them; and patients should invest their time, money, and health elsewhere.”

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374. NICE.org.uk [Internet]. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management; 2016 Nov [cited 16 Dec 21].
For the record, these are all the verboten, “do not offer” treatments in the 2016 NICE guidelines for non-specific chronic low back pain:

- belts or corsets

- foot orthotics, rocker sole shoes

- traction

- acupuncture

- ultrasound

- PENS, TENS, interferential therapy

- paracetamol alone, opioids, antidepressants, anticonvulsants

- spinal injections, disc replacement, spinal fusion

Hardly a complete list, I’m sure, but these are the ones that made it to the current draft. (And yeah, “verboten” is obviously a bit of whimsical hyperbole. This is from something explicitly called “guidelines” after all.)

For more, see this summary of the NICE guidelines.

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375. O'Connell N, Wand B, Goldacre B. Interpretive bias in acupuncture research? A case study. Eval Health Prof. 2009 Dec;32(4):393–409. PubMed #19942631.
This is a discussion of an article about the use of acupuncture for chronic low-back pain. “The authors suggest that interpretive bias has affected reporting, leading to questionable conclusions and advocacy in favor of this form of care that may exceed the evidence. They also suggest that a lack of understanding of research into the placebo effect may have contributed to confusion in the interpretation of these trials.”

For a good related example, see author Neil O’Connell’s criticism of Molsberger et al, a paper that shows a “positive” result from acupuncture but has an absurdly glaring flaw.

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376. van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW. The effectiveness of acupuncture in the management of acute and chronic low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 1999 Jun 1;24(11):1113–23. PubMed #1036166.
In 2000, this The Cochrane Collaboration review of the evidence “did not clearly indicate that acupuncture is effective in the management of back pain” and that “…there clearly is a need for more high-quality randomized controlled trials.” In the years since then, that higher-quality research has had extremely discouraging results.

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377. More about this below, but I’m particularly referring to the infamous case of the 2010 New England Journal of Medicine paper (Berman et al) in which pro-acupuncture authors, writing in a very prominent journal, clearly admitted that “sham acupuncture was as effective as real acupuncture.” BACK TO TEXT

378. Madsen MV, Gotzsche PC, Hrobjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009;338:a3115. Also see my detailed article about the implications of this research, Does Acupuncture Work for Pain?. BACK TO TEXT

379. Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups. Arch Intern Med. 2007;167:1892–1898. PainSci #56004. BACK TO TEXT

380. It’s like this: good acupuncture should affect trigger points, because anything that strongly stimulates trigger points seems to result in some benefit for some patients. Approximately one third of the traditional Chinese acupuncture points are called “pain” points and correspond well with common major muscular trigger points, so presumably the point of needling them is to treat trigger points. If trigger points really are the major factor in most back pain, and if acupuncture typically works for back pain by treating trigger points, then the study by Haake should have shown acupuncture to be more effective than a placebo — and it didn’t. However, it’s most likely that this study of acupuncture was not focused on trigger point release at all, and so no conclusion about trigger points is possible based on this evidence. BACK TO TEXT

381. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May;169(9):858–66. PubMed #19433697. PainSci #54907.
More than 600 participants were either given standard acupuncture treatments or simulated acupuncture. Although this study has been widely reported as if it was a controlled comparison of acupuncture to “standard medical treatment” for back pain, in fact it is not controlled (or blinded), and does not have the power to prove that acupuncture works for back pain.

The apparent difference between real and fake acupuncture they observed was minor. Nevertheless, the authors are excessively friendly to acupuncture and declare it to be “effective” in their conclusion in spite the obvious poverty of the data. In particular, they gloss over the damning implications of their most important finding: what little effect they think they found had nothing at all to do with needle placement. Acupuncture means nothing if needle placement doesn’t matter. The interpretation of Dr. Steven Novella is much more sensible: “The only reasonable scientific conclusion to draw from this is that acupuncture does not work.” For Dr. Novella’s meticulous and expert analysis, see Acupuncture Does Not Work for Back Pain (Part I).

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382. Vas J, Aranda JM, Modesto M, et al. Acupuncture in patients with acute low back pain: A multicentre randomised controlled clinical trial. Pain. 2012 Sep;153(9):1883–9. PubMed #22770838. BACK TO TEXT

383. Sham and placebo acupuncture are similar-but-different. Sham is a retracting needle on an acupuncture point. Placebo is a real needle inserted inaccurately — which the patient doesn’t know unless they are unusually knowledgeable about acupuncture points. BACK TO TEXT

384. Even picking only the best they could find, “trial quality was highly variable.” Machado et al tried to “minimize the possibility of under-estimation of treatment effects” — basically erring in favour of good news — but there was only so much that they could do. For instance, “some placebos may lack credibility, which could cause an over-estimation of treatment effects. Unfortunately, trial reports usually contain insufficient information to judge whether this is a problem, so we could not exclude trials using placebos that are not credible.” It’s almost certain that they reviewed some studies like this, and those would certainly be the ones that would have the best-looking results. BACK TO TEXT

385. Even if it worked, it wouldn’t validate acupuncture — it would validate transdermal electrical nerve stimulation. Prodding people with electricity, oddly enough, might well have effects that have nothing to do with traditional Chinese medicine! Indeed, it’s a well-known quirk of the placebo effect that people have a strong placebo response to all things electrical — they are more impressive. If you compare electroacupuncture to any treatment without that psychologically impressive zapping component, it will come off looking better than it really is (the over-estimation problem described in the last footnote). BACK TO TEXT

386. It’s quite horrifying that all this appeared in The New England Journal of Medicine. But the NEJM does not actually have a great reputation for editorial rigour. (The Last Psychiatrist recently snarked at it, “NEJM: where peer review = spell check”!) This bizarre article, in such a prominent journal, attracted the attention of critics at Science-Based Medicine, of course: both Drs. Crislip and Novella posted about it. Dr. Crislip’s is funny. BACK TO TEXT

387. Liddle SD, David Baxter G, Gracey JH. Physiotherapists' use of advice and exercise for the management of chronic low back pain: a national survey. Man Ther. 2009 Apr;14(2):189–96. PubMed #18375174.
This survey of 600 Irish physiotherapists showed that advice and exercise were the treatments most frequently used for chronic low back pain. Advice was most commonly delivered as part of an exercise programme, and strengthening (including core stability) was the most frequently prescribed exercise type.

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388. One example: O'Sullivan et al found that “specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels,” but … see the next footnote. BACK TO TEXT

389. … O'Sullivan et al did not specify (in their abstract) how much of a statistically significant reduction. When researchers find a good-sized effect, they invariably emphasize it. If they don’t, you can pretty much guarantee it was nothing to write home about. In any event, as you’ll see, the minimal benefits are spelled out by many other studies. BACK TO TEXT

390. That is, the signs of modest benefit that we think we see in some of the research may well be explained away. Most likely there is benefit, but there might well be no benefit that is specifically attributable to core strengthening. That is, what seems to be good news about core strengthening is actually just good news about, say, being more active or confident — which might well happen with any form of exercise, leaving core strengthening without a raison d’être. BACK TO TEXT

391. Miyamoto GC, Costa LO, Galvanin T, Cabral CM. Efficacy of the Addition of Modified Pilates Exercises to a Minimal Intervention in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Phys Ther. 2013 Mar;93(3):310–20. PubMed #23064732.
In this test of Pilates for back pain, patients who did Pilates had “small benefits” compared to those who did not, and six months later even those small benefits were gone. The test had a serious flaw: it neglected to compare Pilates to other any other kind of activity, shamefully sloppy design, fairly junky science. These results only add to the pile of evidence that exercise and therapeutic attention of any kind are probably good for low back pain. It’s only worth reporting these results insofar as they damn Pilates with the faintest possible praise — evidence that Pilates has no special power over back pain.

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392. Unsgaard-Tøndel M, Fladmark AM, Salvesen O, Vasseljen O. Motor Control Exercises, Sling Exercises, and General Exercises for Patients With Chronic Low Back Pain: A Randomized Controlled Trial With 1-Year Follow-up. Phys Ther. 2010 Jul. PubMed #20671099. BACK TO TEXT

393. Paying for eight weekly sessions of training is a greater and more disciplined effort than many people make, and yet it’s still reasonably affordable and achievable — just the sort of therapy that many patients would seriously consider buying and doing. If you can’t make a clear difference with that level of investment, then it’s effectively useless for the vast majority of patients. BACK TO TEXT

394. Childs JD, Teyhen DS, Casey PR, et al. Effects of Traditional Sit-up Training Versus Core Stabilization Exercises on Short-Term Musculoskeletal Injuries in US Army Soldiers: A Cluster Randomized Trial. Phys Ther. 2010 Jul. PubMed #20651013. BACK TO TEXT

395. “But they were all doing some kind of core strengthening!” you might protest. “That doesn’t prove core strengthening doesn’t work.” Right you are, as far as that goes. But this is just one piece of the puzzle, and a good one. Consider that the core strengthening industry tends to put on airs and act like you must do core training and that you do it in a special, technical way for just the right patients (expertly customized). Old-fashioned sit-ups are disparaged as useless and even dangerous. It’s part of the mystique of yoga and Pilates that core strengthening must be an “advanced” process. It is one of the main reasons to pay a physical therapist: the patient believes that there must be some reason for paying $80/hour rather than just doing sit-ups at home! Childs et al undermines core strengthening dogma by showing that it just doesn’t matter how “technical” your core strengthening is. (See also Steiger et al, which is also exactly about this problem. Meanwhile, other studies show that no kind of core strengthening is important.) BACK TO TEXT

396. George SZ, Childs JD, Teyhen DS, et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial. BMC Med. 2011;9:128. PubMed #22126534. PainSci #54506.
Despite good general fitness, soldiers get back pain: do they get less if they train their “core” muscles more in basic training? They should! As the authors note, “Core stabilization has been advocated as preventative.” However, core training “offered no such benefit when compared to traditional lumbar exercise in this trial” — none at all. Although the results might be better with civilians, a good prevention method for us shouldn’t fail completely with soldiers. And although a different, more perfect training program might have worked, even a suboptimal one should have worked at least a little. The null result is therefore significant.

Headlines about the study have focused on the fact that soldiers who got a little extra back pain education reported less back pain over the next two years. (They measured the number of medical follow-ups.) However, it was a minor effect (17% relative risk reduction), and might be due to a fairly obvious (and acknowledged) limitation of the study — the education was “designed to reduce…threat and fear” and may have persuaded soldiers to seek less medical care. Of course, that is a win-win situation, good news either way, whether it was actually preventing back pain, or merely reassuring people and reducing the load on the health care system.

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397. I’d like to elaborate on this important point, for readers who think that soldier science can’t possibly translate to civilians. If core training is even half as good as claimed, it should have a detectable effect, on average, in any reasonably diverse population. The claim has never, ever been: “Works great for everyone! Except soldiers, they shouldn’t bother!” But even if the data is relevant only to soldiers, that’s still interesting. It’s worth testing the core claims in any population with a back pain problem. And if core training has no effect — not just a minor effect, but zero — either it doesn’t work particularly well … or an entire large population had the “wrong” kind of back pain which is not even a tiny bit affected by core training. Which seems rather unlikely. Another way of putting it: if the effect of core training is so minor that it can be completely wiped out simply by using it with the “wrong” population of back pain sufferers, how good can it possibly be? BACK TO TEXT

398. I constantly, routinely encounter the assumption that core strength is both protective and therapeutic. I overheard just such a chat at the gym this morning. I wish I could have recorded it, because it was like it was scripted to be relevant to our conversation here. The trainer was authoritatively and specifically declaring how being fit and strong was not enough, that to protect yourself from back pain you must do specific, “special” core exercises. In other words, he was making the (common!) claim that this study was testing: that a population of reasonably fit people might be at least a little bit protected from back pain by core training. BACK TO TEXT

399. Just as I think it’s implausible that core training would have a significant effect on an ideal population but zero effect on soldiers, I also think it’s unlikely that core training would have a significant treatment effect but zero prevention effect. Are prevention and treatment really so different? Different, yes, but so different that there’s no overlap at all? That you can treat well but get zero prevention effect? Maybe. It’s not impossible. But it seems like a reach to me. BACK TO TEXT

400. Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J. 2011 Nov. PubMed #22072093. BACK TO TEXT

401. Smeets RJ, Wade D, Hidding A, et al. The association of physical deconditioning and chronic low back pain: a hypothesis-oriented systematic review. Disabil Rehabil. 2006 Jun;28(11):673–693. PubMed #16809211. BACK TO TEXT

402. Nadler SF, Malanga GA, Bartoli LA, et al. Hip muscle imbalance and low back pain in athletes: influence of core strengthening. Medicine & Science in Sports & Exercise. 2002 Jan;34(1):9–16. PubMed #11782641. BACK TO TEXT

403. For instance, you might get completely different results from a study of older office workers than a study of young athletes. Perhaps young athletes already have adequate core strength, and so additional training had no effect? By contrast, thirtysomething office workers might have much poorer core strength, and training might have made a big difference. Perhaps. However, consider all the other evidence presented here, none of which shows much sign that core strengthening helps anyone’s low back pain … BACK TO TEXT

404. Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine. 1984 Mar;9(2):106–19. PubMed #6233709.
This study found no correlation between back strength and back problems, but did find evidence that “good isometric endurance [italics mine] of the back muscles may prevent first-time occurrence of low back trouble.”

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405. Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther. 2002 Sep;32(9):447–60. PubMed #12322811. BACK TO TEXT

406. Ferreira ML, Smeets RJ, Kamper SJ, Ferreira PH, Machado LA. Can We Explain Heterogeneity Among Randomized Clinical Trials of Exercise for Chronic Back Pain? A Meta-Regression Analysis of Randomized Controlled Trials. Phys Ther. 2010 Oct;90(10):1382–403. PubMed #20671101. PainSci #54919.
ABSTRACT

BACKGROUND: Exercise programs may vary in terms of duration, frequency, and dosage; whether they are supervised; and whether they include a home-based program. Uncritical pooling of heterogeneous exercise trials may result in misleading conclusions regarding the effects of exercise on chronic low back pain (CLBP).

PURPOSE: The purpose of this study was to establish the effect of exercise on pain and disability in patients with CLBP, with a major aim of explaining between-trial heterogeneity.

DATA SOURCES: Six databases were searched up to August 2008 using a computerized search strategy.

STUDY SELECTION: Eligible studies needed to be randomized clinical trials evaluating the effects of exercise for nonspecific CLBP.

OUTCOMES: Of interest were pain and disability measured on a continuous scale.

DATA EXTRACTION: Baseline demographic data, exercise features, and outcome data were extracted from all included trials.

DATA SYNTHESIS: Univariate meta-regressions were conducted to assess the associations between exercise effect sizes and 8 study-level variables: baseline severity of symptoms, number of exercise hours and sessions, supervision, individual tailoring, cognitive-behavioral component, intention-to-treat analysis, and concealment of allocation.

LIMITATIONS: Only study-level characteristics were included in the meta-regression analyses. Therefore, the implications of the findings should not be used to differentiate the likelihood of the effect of exercise based on patient characteristics.

CONCLUSIONS: The results show that, in general, when all types of exercise are analyzed, small but significant reductions in pain and disability are observed compared with minimal care or no treatment. Despite many possible sources of heterogeneity in exercise trials, only dosage was found to be significantly associated with effect sizes.

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407. Which is sciencespeak for “what the hell accounts for the mess of conflicting and underwhelming results for exercise therapy?” BACK TO TEXT

408. Manniche C, Hesselsoe G, Bentzen L, Christensen I, Lundberg E. Clinical trial of intensive muscle training for chronic low back pain. Lancet. 1988 Dec 24:1473–6. PubMed #2904582.
Presents unusually favourable evidence that “intensive dynamic back extensor exercises” reduced pain and improved function in patients with low back pain better than lower intensity exercises or a combination of massage, mild exercise and heat.

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409. Frost H, Lamb SE, Moffett KJ, et al. A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial. Pain. 1998 Apr:273–9. PubMed #9583763.
This study shows a modest benefit to an exercise programme for people with chronic low back pain.
Note that this is consistent with what Ferreira found: that dosage does matter. It probably didn’t matter what exercise these patients did: it mattered that they were “intensive.” BACK TO TEXT

410. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000. p. 214. BACK TO TEXT

411. Lantz CA, Chen J. Effect of chiropractic intervention on small scoliotic curves in younger subjects: a time-series cohort design. J Manipulative Physiol Ther. 2001 Jul-Aug;24(6):385–393. PubMed #11514815.
ABSTRACT

BACKGROUND: Chiropractors have long claimed to affect scoliotic curves, and case studies abound reporting on successful outcomes. No clinical trials exist, however, that evaluate chiropractic's effectiveness in the management of scoliotic curves.

OBJECTIVE: To assess the effectiveness of chiropractic intervention in the management of adolescent idiopathic scoliosis in curves less than 20 degrees.

DESIGN: Cohort time-series trial with all subjects electing chiropractic care. Entry-level Cobb angle was compared with postmanagement curve.

METHODS: Forty-two subjects completed the program of chiropractic intervention. Age range at entry was 6 to 12 years, and patients were included if their entry-level x-ray films revealed curves of 6 degrees to 20 degrees. Participants had adjustments performed for 1 year before follow-up. Full-spine osseous adjustments were the major form of intervention, but heel lifts and postural and lifestyle counseling were used as well.

RESULTS: There was no discernable effect on the severity of the curves as a function of age, initial curve severity, frequency of care, or attending physician.

CONCLUSION: Full-spine chiropractic adjustments with heel lifts and postural and lifestyle counseling are not effective in reducing the severity of scoliotic curves.

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412. Everett CR, Patel RK. A systematic literature review of nonsurgical treatment in adult scoliosis. Spine. 2007 Sep;32(19 Suppl):S130–4.
ABSTRACT

STUDY DESIGN: A formal systematic review of the literature for conservative treatment of adult deformity was performed.

OBJECTIVE: To evaluate evidence for the efficacy and effectiveness of proposed conservative treatment options in adult deformity.

SUMMARY OF BACKGROUND DATA: Adult deformity is a major demographic health issue in the geriatric population in both the United States and the world communities. Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. A prerequisite to surgical intervention is usually failure of all appropriate conservative care. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity.

METHODS: A systematic review of clinical studies; using the key terms of adult or degenerative and scoliosis combined with any of the following: bracing, casting, physical therapy, chiropractic, and injections for treatment. The database inclusions were PubMed, OVID, and CINAHL. Articles were excluded if the primary patient populations were adolescents or the treatment options performed were primarily surgical. The methodology of the studies was graded and the evidence was classified into 1 of 5 levels based on study types. Based on this, a treatment recommendation was determined.

RESULTS: There is indeterminate, Level III/IV evidence on the effectiveness of any conservative care option. Specifically, there is Level IV evidence on the role of physical therapy, chiropractic care, and bracing. There is Level III evidence for injections in the conservative treatment of adult deformity. There is insufficient research for a treatment recommendation beyond Level 2c very weak evidence, but the available literature is supportive of further clinical research in conservative care as a treatment in adult deformity.

CONCLUSION: Conservative care in general may be a helpful option in the care of adult deformity, but evidence for this is lacking. Unfortunately, no treatment option within conservative care has support within the literature as a preferred solution. Basic clinical research at any level would be helpful to further clarify the options.

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413. Not for all patients, but for many: see Gunter and Noble. In both cases, steroid injection was unambiguously beneficial for many patients. BACK TO TEXT

414. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009 May;34(10):1066–1077. PubMed #19363457. PainSci #55429. BACK TO TEXT

415. Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine. 2009 Jan;34(1):49–59. PubMed #19127161. This Cochrane Database review actually concludes that all types of injection therapy are of dubious value, including facet joint injections: “There is no strong evidence for or against the use of any type of injection therapy.” BACK TO TEXT

416. Consider a case which is typically somewhat complicated by trigger points, but still somewhat biased towards facet-o-centric pain: perhaps 30–40% of the pain is caused by trigger points, and the rest by a severely irritated facet joint. Even in this fairly straightforward and facet-o-centric situation, a steroid injection might reduce the facet pain component by only, say, 60% … and possibly temporarily. That still leaves quite a bit of discomfort untouched. And the facet joint will likely become irritated again quite quickly — especially with highly cranky musculature all around it. And this is a pretty straightforward example with no other complicating factors. It’s really no wonder that injection therapy can’t work any miracles for most patients. BACK TO TEXT

417. Peng B, Pang X, Wu Y, Zhao C, Song X. A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain. Pain. 2010 Apr;149(1):124–9. PubMed #20167430. PainSci #55624. BACK TO TEXT

418. Kim SH, Ahn SH, Cho YW, Lee DG. Effect of Intradiscal Methylene Blue Injection for the Chronic Discogenic Low Back Pain: One Year Prospective Follow-up Study. Ann Rehabil Med. 2012 Oct;36(5):657–64. PubMed #23185730. PainSci #54127.
This study provides some encouraging replication of Peng 2010, which had almost shockingly good news for a high quality test of a back pain treatment. Predictably, however, the results here are not quite as thrilling — merely “good” — and the long term results were definitely less promising: “The intradiscal MB injection is a short-term effective minimally invasive treatment indicated for discogenic back pain but it may lose its effectiveness long-term.”

Still good news though.

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419. Dagenais S, Yelland MJ, Del Mar C, Schoene ML. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev. 2007;(2):CD004059. PubMed #17443537. BACK TO TEXT

420. Bear in mind, too, that prolotherapy had a champion, George S. Hackett, MD, and that all the enthusiasm for prolotherapy is largely derived from this one determined doctor. That does not invalidate prolotherapy in itself, but it certainly raises awkward questions in combination with the near perfect lack of compelling evidence. Hackett was a true believer in his therapy and claimed to have given relief to “99%” of his patients — an absurdly high number, completely unsubstantiated by any research ever since. But therapy champions tend to inspire great confidence in their patients, and that is effective even if the therapy is not. What Hackett probably achieved was giving thousands of patients a fantastic basis for a placebo. He wasn’t the first, and he won’t be the last — the history of medicine is already full of such cases of well-intentioned professionals getting so passionate about a plausible therapy that patients get a premium placebo, but researchers never replicate the results. Fascinating stuff. BACK TO TEXT

421. Which is sort of a weird thing to conclude: if it’s not effect when used alone, why would it be effective when used with other therapies? I ask you! BACK TO TEXT

422. Barrett, Stephen. “Axiom Worldwide Sued By Florida Attorney General.” Allegations against Axiom include false claims of an “86% success rate,” FDA approval that never happened, and insurance coverage that doesn’t exist. Axiom’s marketing is so misleading that Florida’s chiropractic regulator disciplined twelve chiropractors for using Axiom’s marketing. BACK TO TEXT

423. Clarke JA, van Tulder MW, Blomberg SE, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2007;(2):CD003010. PubMed #17443521. BACK TO TEXT

424. Schimmel JJ, de Kleuver M, Horsting PP, et al. No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy((R)). Eur Spine J. 2009 May;18(12):1843–50. PubMed #19484433. PainSci #55316.
Regardless of a few modestly positive studies, traction continues to show poor results in other studies, like this 2009 experiment reported in the European Spine Journal: it had a good, rigorous design that showed no difference at all between traction and placebo.

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425. It’s not impossible — irritated tissue might be affected mainly by a particular movement, and external support might help prevent or limit that movement. But these are relatively rare exceptions, not the rule. BACK TO TEXT

426. Giele BM, Wiertsema SH, Beelen A, et al. No evidence for the effectiveness of bracing in patients with thoracolumbar fractures. Acta Orthop. 2009 Apr;80(2):226–32. PubMed #19404808.
Researchers reviewed several studies that have attempted to determine if bracing works in patients with traumatic thoracolumbar fractures. The results? Inconclusive.

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427. Connolly PJ, Grob D. Bracing of patients after fusion for degenerative problems of the lumbar spine—yes or no? Spine (Phila Pa 1976). 1998 Jun;23(12):1426–8. PubMed #9654635.
This research is really just asking two experienced surgeons their opinion on the value of bracing after back surgery (for non-traumatic back problems). They disagree. “Dr. Connolly argues that an external orthosis is advisable in many cases; Dr. Grob feels that the rigidity of internal fixation should be adequate to obviate the need for external bracing.”

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428. Rohlmann A, Bergmann G, Graichen F, Neff G. Braces do not reduce loads on internal spinal fixation devices. Clin Biomech (Bristol, Avon). 1999 Feb;14(2):97–102. PubMed #10619096.
To determine how much a back brace really braces, German researchers used “telemeterized” implants — steel fixation rods with meters on them! so cyborgy! — to measure the effect of common braces on spinal forces. This is a good experiment. If you have implants stabilizing your spine internally, measuring the stresses on them directly is a pretty clever way of checking to see if an external brace is doing anything.

Three types of braces were examined: Boston overlap brace, reclination brace, and a lumbotrain harness. Unsurprisingly, they found that “none of the braces studied were able to markedly reduce the loads” on the implants. There was some reduction — just not “marked,” nothing to write home about.

More surprisingly, some of their measurements showed that bracing increased loading on the implants! That does seem possible. The spine is an extraordinarily dynamic structure. Somewhat like slouching into a comfortable chair, a brace may actually cause some sloppiness of spinal function, resulting in “resting” on the fixations, rather than using muscle to support and control the spine. That’s just a guess, but it seems like a reasonable one to me.

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429. And it’s not like there aren’t other methods that definitely pull vertebrae apart — including a free and easy one, the “seated lumbar pull,” described in the traction section. BACK TO TEXT

430. Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. Eur Spine J. 2013 Feb;22(4):697–707. PubMed #23404353. PainSci #54739. BACK TO TEXT

431. I have edited Dr. Hall’s posts for Science-Based Medicine routinely for years, and once in a while I have an opportunity to correct or caution her about something. In this case, when she posted on this topic, I thought she was a little too positive about it. She replied, “I understand your concerns, but I think I'll leave it as is. It was pretty well done and the authors didn’t claim too much. It’s way better science than most of the stuff we critique, and science will take its due course and either confirm or disprove.” Nothing wrong with cautious optimism! BACK TO TEXT

432. BodyInMind.org [Internet]. O'Connell N. Clean teeth, bad back? Antibiotics for chronic low back pain; 2013 Mar 25 [cited 14 Jan 6]. BACK TO TEXT

433. PubMed Health [Internet]. Antibiotics may help ease chronic back pain; 2013 [cited 14 Jan 6]. BACK TO TEXT

434. From a comment on McCartney. BACK TO TEXT

435. Wood P. Back pain study failed to disclose COI. Rheumatology Update. 2013 May 31. PainSci #54530. BACK TO TEXT

436. McCartney M. Antibiotics for back pain: hope or hype? BMJ. 2013 May 14;346:f3122. PubMed #23674340. PainSci #54557. BACK TO TEXT

437. The Modic Antibiotic Spine Therapy Academy, or MAST Academy, charges £200 ($310) to certify doctors in how to identify and treat modic back pain with antibiotics. Clinicians can alternatively take an online course for £100 ($155). BACK TO TEXT

438. COIs are more common and less of a big deal in science than people think. The purpose of the scientific method is, in part, to correct for COIs because they are inevitable. Where there is science there is funding — such is life — and funding sources affect science in muddy, complicated degrees ranging from not really at all to truly, madly, deeply. Lots of researchers are in a position to profit from positive results, one way or another, and it doesn’t necessarily mean they will do bad science. The worst COIs crop up when researchers stand to profit directly and substantially and there’s minimal oversight and no acknowledgement, as in this case. Dr. Moseley graciously acknowledges the pressures that can lead to this: “It requires a steely resolve to not be seduced by the prospect of CV-enhancing spin. … I wonder how far any of us are from this kind of mistake — a lazy media release, an eager PR manager, an impending promotion. I reflect on the anguish I imagine the authors are feeling right now and the damage this has done to their reputations and I can hear the whispering in my own heart — ‘Careful! That could have been you.’” BACK TO TEXT

439. Because of super bugs. When people take antibiotics, it kills off weaker microbes and often leaves the strongest behind. The problem has apocalyptic proportions. It’s really, truly frightening stuff. Antibiotics are precious medicine that should still be used, but only when absolutely necessary and only correctly — so experimental “maybe this’ll help” antibiotics are completely out of the question. BACK TO TEXT

440. Urquhart DM, Zheng Y, Cheng AC, et al. Could low grade bacterial infection contribute to low back pain? A systematic review. BMC Med. 2015;13:13. PubMed #25609421. PainSci #54222. BACK TO TEXT

441. Wilkens P, Scheel IB, Grundnes O, Hellum C, Storheim K. Effect of Glucosamine on Pain-Related Disability in Patients With Chronic Low Back Pain and Degenerative Lumbar Osteoarthritis: A Randomized Controlled Trial. JAMA. 2010 Jul 7;304(1):45–52. PubMed #20606148. PainSci #55639.
This straightforward and good quality test of glucosamine for low back pain — the first of it’s kind — found no therapeutic benefit by any measure: “Our findings suggest that glucosamine is not associated with a significant difference in pain-related disability, low back and leg pain, health-related quality of life, global perceived effect of treatment.” Although statistically insignificant, disability was actually greater in those who took glucosamine, and “approximately 30% of the patients reported mild adverse events.” They tested 250 adults who’d had low back pain for more than 6 months, and degenerative lumbar osteoarthritis.

Almost 30% of patient had mild side effects, and 10 patients withdrew because of them, but there were no serious problems.

See also Dr. Harriet Hall’s analysis. She writes:

[This study is] well-designed, randomized and double blind, with 250 subjects, a low drop-out rate, a 6 month duration with a one year follow-up, appropriate clinical criteria for improvement (disability, pain, quality of life, use of rescue medications), intention-to-treat analysis, and even an ‘exit poll’ to insure that blinding had been effective, that patients couldn’t guess which group they were in. It used the doses of glucosamine sulfate that had been called for by critics of previous studies. It was done in Norway, where glucosamine is a prescription drug (in the US it is marketed as a diet supplement under DSHEA regulations so there is a greater possibility of dosage variations and impurities); it was independently funded, with no involvement of industry.

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442. Sawitzke AD, Shi H, Finco MF, et al. Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT. Ann Rheum Dis. 2010 Aug;69(8):1459–64. PubMed #20525840. PainSci #54963. This one was a study for knee pain, but was a particularly good-quality study, large and long. Glucosamine’s total failure to treat knee pain certainly does not bode well for its effect on back pain. BACK TO TEXT

443. Milne S, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain. Cochrane Database Syst Rev. 2001;(2):CD003008. PubMed #11406059.
An aging but resoundingly negative review of five tests of TENS for chronic low back pain, finding “no statistically significant differences between the active TENS group when compared to the placebo TENS group for any outcome measures.” The authors concluded there was “no evidence to support the use of TENS in the treatment of chronic low back pain.” See Khadilkar 2008 for a more recent review on exactly the same topic — but still negative.

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444. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008;(4):CD003008. PubMed #18843638.
This is a review of just four trials of TENS for chronic low back pain that were good enough to bother reviewing, and even those four were too messy for a good apples-to-apples comparison (meta-analysis). The conclusions is inconclusive, based mainly on conflicting evidence with regards to pain intensity. A previous review (Milne) was more clearly negative.

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445. Ebadi S, Henschke N, Nakhostin Ansari N, Fallah E, van Tulder MW. Therapeutic ultrasound for chronic low-back pain. Cochrane Database Syst Rev. 2014 Mar;(3):CD009169. PubMed #24627326. BACK TO TEXT

446. von Trott P, Wiedemann AM, Ludtke R, et al. Qigong and exercise therapy for elderly patients with chronic neck pain (QIBANE): a randomized controlled study. J Pain. 2009 May;10(5):501–508. PainSci #55533.
This study of qigong — an ancient Chinese form of therapeutic exercise, similar to taiqi — found that it had no effect whatsoever on chronic neck pain in elderly patients. Qigong has been a popular prescription older clients. It’s full of claims and legends of healing power. I am extremely skeptical of these claims. I saw some neat things in my years of practicing qigong and martial arts, but never anything spooky — just amazing physicality. The results of this study do not surprise me at all: I wouldn’t expect qigong to do much for neck pain, except perhaps a minor benefit from the stimulation of rhythmic movement.

Perhaps more or better qigong would have done the trick: but how much more? Exactly what kind of qigong? The experiment was not perfect, but it’s still useful: if three months of garden variety qigong can’t produce any therapeutic effect for neck pain, it’s probably not worth busting a gut trying to do more and better qigong.

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447. Choi CJ, Knutsen R, Oda K, Fraser GE, Knutsen SF. The association between incident self-reported fibromyalgia and nonpsychiatric factors: 25-years follow-up of the Adventist Health Study. J Pain. 2010 Oct;11(10):994–1003. PubMed #20400378. More smokers have fibromyalgia than non-smokers. The difference was statistically significant in a survey of more than 3000 women. BACK TO TEXT

448. Behrend C, Prasarn M, Coyne E, et al. Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care. J Bone Joint Surg Am. 2012 Dec 5;94(23):2161–6. PubMed #23095839.
This study added to the pile of evidence that smoking is “associated with low back pain, intervertebral disc disease” along with many other medical complications. Their conclusion, after studying the records of more than 5000 patients with “axial or radicular pain from a spinal disorder,” was that there is a “need for smoking cessation programs for patients with a painful spinal disorder.” Very likely both neck and back, of course.

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449. Petre B, Torbey S, Griffith JW, et al. Smoking increases risk of pain chronification through shared corticostriatal circuitry. Human brain mapping. 2014 Oct. PubMed #25307796.
The science here is a bit more complex than I usually deal with, but the punchline is simple enough: “We conclude that smoking increases risk of transitioning to chronic back pain.”

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Table of Contents

Table of Contents

Customer Introduction & Help

Book Introduction

Links to all your books (2)

begins below

updates section

Low Back Pain

Unnamed

updated May 3, 2018

Top of Document

Customer Introduction (Tips & Help)

Start of Book

Legal Stuff & Not-So-Fine Print

Introduction

A tragic low back pain myth

How can you trust this information about low back pain?

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

Who is this low back pain tutorial for?

Some cases of “incurable” chronic low back pain can still be cured!

Is this going to be one of those “it’s all in your head” theories about low back pain?

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

DiagnosisYour low back is not fragile!

Even serious structural problems in the low back are often painless

Maybe you’re just getting older? Actually, no …

Structural problems in the low back are hard to diagnose accurately

Those scary spine models

It’s not structure… except when it is

So then what? The missing muscle piece

There is nothing “just” about muscle

Low back pain is the new ulcer

Pain and fear, together at last: an even simpler vicious cycle

Chronic low back pain is not so chronic: the myth of chronicity

A trigger point checklist: does this sound like you?

3 Lessons From an Acute Back Trauma: Joint popping, muscle dominance, and the mind game

“Out of nowhere”: seemingly random episodes of low back pain

Summary so far …

Other possible causes of low back pain, or “No, my low back pain is really serious …”

Could it be muscle strain? The muscle strain myth

From the frying pan of injury pain to the fire of trigger point pain

Could it be a vicious cycle of pain-spasm-pain?

Could low back pain be an overuse injury?

Could it be a herniated disc?

Facet joint syndrome and MIDs

Diagnostic numbing of facet joints

Is there such a thing as a “subluxation”? Can your back be “out”?

Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves

Do you really need to lose some weight?

Is it core weakness?

Is it all in your feet? Foot-o-centric low back pain theories

Your problem is that you’re having “too much fun”