Low Back Pain Part 1 (Harmful Myths)

I'm kicking off the Advanced Academy blog off with an Irish Times interview that I did in November 2016, with extremely capable journalist, Caroline Foran, The interview only skirted on some of the issues, check back next month for part 2.
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First published in the Irish Times Health supplement Nov 2016

Sitting up straight – one of many myths about lower back pain

There's a lot of false information about how to treat back pain, one of our most common ailments

Caroline Foran interviews Terry Christie, Physical Therapist and award winning health Science lecturer.

According to various international reports, lower back pain – or LBP, as it’s more conveniently referred to – is the single most common musculoskeletal condition we now face. With a staggering 58-84 per cent of adults set to experience this debilitating affliction at one or several points their lives, looking after one’s back remains not only a top priority among individuals but a significant burden on national health services too.

Today, thanks in large part to our predominantly stationary lifestyles (for which we’ll blame the desk job) and our skewed, 21st-century posture (perhaps we can blame endless social media scrolling for that one), certain companies are now making serious investments in the area of ergonomics. More than ever before, such back health rhetoric has become hot property.

What’s concerning, though, is that despite its ubiquity, there seems to exist a lot of shared misconceptions surrounding LBP, examples of which might include not sitting with crossed legs or the idea that core strengthening exercises are essential for staving off back pain.

While an awareness of our backs is certainly important, it’s crucial that we have the right information, otherwise what we think we know and never stop to question becomes ultimately counterproductive. So what is helpful and what is not? What are we doing wrong? And given the reality that only about 1 per cent of back pain is actually dangerous, are we worrying unnecessarily?

Interestingly, how you think and feel about back pain plays a crucial role in getting to that elusive pain-free point, yet this more holistic aspect of pain management remains relatively untouched in public discourse. Our attitudes and beliefs – both that of the patient and the doctor or therapist – are considerably more significant than we may think. Here, with the help of Terry Christie, a physical therapist and award-winning health science educator, we endeavour to debunk the various myths surrounding LBP and explore the growing realm of back pain psychology.

Problematic

For reasons not yet clear, LBP is particularly problematic in Ireland, especially when compared to the UK. A one-day survey found that at any one time, 22 per cent of Irish respondents were attending their GP for the management of LBP. While this figure might not immediately shout “national health epidemic”, across the pond it’s a mere 9 per cent.

One of the main driving forces behind our regular visits to the GP or physical therapist is the fear that we’ve done irreparable damage to our backs, explains Christie. “This is one of the most common misconceptions. And then there is an added assumption that they either need to have something ‘clicked back into place’ or that their core is too weak and they need to work on holding more tension in their muscles. In reality – and in the scientific literature – neither of these approaches have been shown to provide relief for long-standing back pain.

“On a psychological level, people can tend to treat pain in the back as somehow different to pain elsewhere in the body. For example, if you had to lift a lot of boxes yesterday, and your arms were very sore when you woke up today, you’d probably rationalise that your muscles had been given a workout that they weren’t accustomed to and that it would settle down itself in a day or so, no harm done.

“In contrast, if it was your back that became very sore this morning, the experience might be quite different. You might worry that you’ve damaged something in your back or you might have heard about ‘slipped discs’ from a friend and the thought of wear and tear might begin to concern you. The fact of the matter remains that the vast majority of back pain is actually benign and requires little intervention to resolve itself.”

Nevertheless, the experience for the sufferer can feel quite different, which, Christie believes, can be easily correlated with our growing fear of back pain.

How we think about back pain and the language used to describe it has changed in more recent decades, allowing for this newly emerging argument among leaders in physical science that perhaps our growing concern and awareness of LBP is more counterproductive than anything else.

Unnecessary tests

“In the past, we simply got a back strain or lumbago and we would reduce strenuous activities for a day or two and then got back to normal. During the mid-90s, however, it became more common to get imagery scans on the spine and there is evidence that this led to a cascade of unnecessary tests and ineffective treatments based on these imaging findings,” says Christie.

LBP sufferers, and particularly those among our nation of worriers here in Ireland, became concerned about terminology such as “degeneration” or “slipped discs”. They may have been told by a friend (or more worryingly, a physical therapist) that their “core muscles weren’t functioning properly or that their spine wasn’t correctly aligned”. The reality, says Christie, is that “when we examine the MRI reports of people who aren’t experiencing low back pain, they look much the same as those who have pain”.

Christie points to research that shows how unnecessary MRI scans can actually have a very negative psychological effect on LBP patients, as this fear of damage can erode some people’s confidence in the strength and resilience of their spine. Furthermore, multiple randomised controlled trials have shown that the early use of imaging for LBP is not actually associated with improved outcomes and may even be harmful to the patient. The American College of Physicians recently reissued guidelines for imaging patients with LBP, emphasising not only the inefficiencies of early imaging but also the potential harms. As rates of MR imaging of the lumbar spine have increased, so too have treatments, including narcotics prescriptions, lumbosacral injections, and spinal surgery, often without benefit. Not only do these treatments result in increased expenditures but, more importantly, they can pose serious risks to the health of the patient.

While LBP can be a debilitating experience for which we crave intervention, should we, perhaps, be more worried about our tendency to worry?

“In one US-based study, between 1992 and 2006 the prevalence of disabling LBP more than doubled,” explains Christie. “These rising rates of disability and pain occurred at precisely the same timeframe as the growth in the popularity of core stabilisation exercises, MRI scans and other interventions such as surgeries and spinal injections.”

Over-treating

Christie is acutely aware that “if we faced a similar increase in any other health condition, we’d realise that we were getting something drastically wrong. Thankfully, this has led to senior researchers now calling for clinicians to ‘back off’ – excuse the pun – on over-treating LBP.

“Given the general fear associated with back pain, it can appear to represent a significant threat to their ability to achieve their future goals. A lot of people are concerned that they may have to give up a sport or that they may not be able to return to work. The reality is quite different, though.”

Christie is quick to remind patients that only a very small proportion of back pain – approximately 1 per cent – is dangerous.

“These cases are readily identifiable by clinical screening strategies. Clinicians are careful to identify cases where ‘red flag’ signs are present or, for example, where nerve root pain has been unremitting for longer than a month. In these cases a more extensive assessment – possibly including MRI and other imaging – is certainly warranted.”

But as for the vast majority of LBP sufferers with whom Christie meets, “they have only minor sprains and strains that have led to their backs becoming very sore and sensitive. I then see the worry associated with back pain leading patients to quit the normal, healthy activities that make them happy. The truth is that you are unlikely to wear out your spine with exercise.”

Furthermore, in a study undertaken in Dublin last year, researchers took before-and-after MR imaging of lumbar spines “and found that following several months of well-programmed free weight training, the participants had improved the health of some important spinal structures. Participants experienced significant reduction in both pain and disability by the end of the four-month programme and no adverse responses were reported. It’s worth noting that the training programme was accompanied by accurate information about back pain, in order to reduce the fear of movement.

“Now this doesn’t mean that you absolutely need to get squatting if you want a healthy back, but it shows that the human spine can respond favourably to lifting and training.”

Back up: Myth Vs Reality

Assumption: “We must stand or sit as straight and upright as possible.”

Reality: “Firstly, there’s no perfect posture that you should remain in for hours. Your body works best when you move so if your back is sensitive, you should try to change things up every 20 minutes or so. Interestingly, it does appear that one factor contributing to some people’s pain is an exaggerated ‘good posture’. You can imagine the type of thing: shoulder blades pulled back, lower back tight together, lower back extended in an exaggerated curve, tummy muscles pulled in tight, and sitting very tall in the chair. I only see this pattern in people who have sore backs. I believe that it’s something that we’ve all learned but I’ve yet to see it help anyone’s back pain. We probably shouldn’t be surprised that this posture doesn’t help. Contracting all your torso muscles can have the effect of increasing compression on your spine and though this is highly unlikely to do damage, it can be very irritating for your back and very tiring for your muscles.

Assumption: “Core strength is the key to reduced back pain.”

Reality: “That has become something of a mantra for a long time now, but it is more myth than reality. The early, small-scale, studies of core muscle function demonstrated a difference in how some people with low back pain used their abdominal and back muscles and this led the rehabilitation community to focus on them as a target for treatment. However, when studies into core muscles were repeated in larger, more robust research, the findings were different. A review of these 15 studies, published in 2014, concluded that neither the size, the activation pattern or the endurance of these muscles had an influence on low back pain or disability. Core exercises, designed to activate specific muscles in the low back and abdomen, have been associated with short-term reductions in pain in some people. When all the trials comparing ‘core stabilisation’ to other exercise, are reviewed, there is no convincing evidence that core exercise is more effective than any other type of exercise for treating back pain. Thus, if your back muscles are feeling tense and sore, it might not be too useful to add even more sustained tension. It also means that if you’ve been unsuccessful in using core stability training to treat your low back pain, it might not mean that your back is untreatable; it’s probably because those exercises don’t provide long-term relief for most people. This 2014 review also suggested that there is a sub-group of people who might actually tense their core muscles earlier than people without back pain, perhaps in anticipation of pain.”

Assumption: “I should be doing pilates for my back.”

Reality: “If you enjoy doing Pilates and if it makes you feel good, then I’d say continue with it. However, if you’re doing Pilates to ‘protect your spine’ or help with longstanding low back pain, there are better approaches available. There have been several clinical trials investigating the effectiveness of Pilates for chronic low back pain. Although it may be better than taking no exercise at all, it’s effects are small and there is no evidence that it’s better for your back pain than any other form of exercise.

Assumption: “Once you hurt your back once it will always bother you for life.”

Reality: “This isn’t really the case. It is true that MRI studies have shown that the human spine will continue to change in shape through the decades. However, LBP is actually less common among older adults than it is among middle-aged individuals.”

Assumption: “There is a proper way to bend down and pick something up.”

Reality: “We still don’t know for sure and, like most things, more research is required to identify the optimal lifting strategies for various tasks. It does appear, however, that the traditional advice to arch your spine back as you lift may not be the optimal way to use your spine. It appears that when lifting from the floor, it is both normal and unavoidable to bend your spine. And contrary to traditional perceptions, lifting with your spine arched backwards may be associated with increased loads on your body and decreased muscular efficiency. As a rule of thumb, if you’re picking up something light, or tying your shoes, you should avoid bracing you back and stomach muscles. For heavier tasks, it may be appropriate to brace yourself to some extent, depending on the situation.”

Assumption: “Sitting with your legs crossed is bad for you.”

Reality: “That’s something that I’m asked frequently. Ironically, I’m usually sitting at my desk with my legs crossed when I’m asked. This could be another example of something that has been termed ‘fragilistic thinking’. It might come from the idea the human spine is delicate and that we have to take great care not to damage it. Now, if activities like yoga and weight training have been shown to be safe for people with back pain, I think that the human spine can survive sitting cross-legged; anyway, it’s more comfortable. Fragilistic thinking is important. though. Nowadays, clinicians are careful not to undermine patients’ confidence in their body. However, there is a residue of misinformation out there so it’s worth assessing the validity of these kind of beliefs.”

What Christie believes to be of huge importance when it comes to effectively treating LBP is understanding an individual’s experience of pain. “Addressing structural/mechanical factors in isolation without considering the whole person is unscientific and provides poor clinical outcomes. In contrast, when we target treatments to benefit the range of factors that contribute to back pain, including lifestyle, beliefs about pain and certain structural factors, the effectiveness of rehabilitation interventions improves dramatically. Very high stress levels, anxiety and depression when combined with low back pain can be very difficult for patients. Again, it’s probably no accident that pain can rear its head at the most inopportune times in one’s life.

“There is also strong evidence that our old friends smoking and obesity are also risk factors. These are both modifiable risk factors and addressing them has the potential to provide multiple health benefits.”

 
Check back next month for part 2; where we’ll go into detail on how to effectively deal with spinal pain,

The original article can be found here;

http://www.irishtimes.com/life-and-style/health-family/sitting-up-straight-one-of-many-myths-about-lower-back-pain-1.2877218

All credit and thanks to Caroline Foran for her excellent work in decoding my ramblings.