Low back pain is the leading cause of global disability.
It therefore requires more thoughtful consideration of scientific evidence in comparison to the stories we’ve been sold. Back pain is complex and no one persons back pain is the same as the other. Therefore blanket statements like, “do xyz to cure your back pain” are pointless. The best evidence for treating back pain supports an individualized biopsychosocial approach where the person and their story, history, concerns, health, goals, and support system are all taken into context.
Lately I have been tackling back pain misinformation on social media. Searching for information on google and social media for back pain leaves a lot to be desired. Especially when pain does not always provide an accurate measure of tissue pathology. Here are 8 myths regarding back pain, and the truth to reframe them.
Myth – Sitting is bad for your back
You’ve probably heard that sitting is the new smoking. It’s a bold catchy claim, but is it true?
A sedentary lifestyle has implications for poorer health outcomes. However even when evaluating the evidence on sitting and health, it is insufficient to make specific recommendations in relation to how much sitting time is hazardous.
To make the claim that sitting is the reason for back pain is very reductionistic. Pain is much more multifactorial and individualized.
You may have back pain when you sit, but the act of sitting isn’t the enemy, more so the length of time in one position. So think about how you can sit differently, or change positions more frequently.
Other factors of back pain at work are “low supervisor support, stressful monotonous work, rapid pace work, job insecurity, work-family imbalance, and exposure to hostile work.”
Pain from sitting is more often a signal to do something different. Perhaps the difference that makes a difference extends beyond one’s posture and position.
Myth- Poor posture is the root of back pain
A review of evidence between posture and pain shows that static posture is not a primary factor in low back pain.
This falls in line with the sitting myth. Static positions and postures, whether in sitting or standing have been vilified.
A good majority of my patients, say they believe changing their posture could help their pain. Dismissing this belief is not helpful. So instead we experience movement by changing postures. The important key to understand here, is the word change. Movement change helps the body adapt. Changing posture helps because it makes you move, not because it’s right or wrong.
Back pain doesn’t have a single root cause and even if it did, it wouldn’t be your posture. There is a growing trend toward the death of the postural, structural, biomechancial model of pain. Scientific evidence points far in the other direction toward a more whole person centered approach. For a personal story on this, watch Alexa’s video.
So slouch if it feels good, and stand erect when you want, as long as you move in a variety of ways and often through the day.
Myth-Your spine is fragile and needs protecting
Protecting for injury prevention sounds well and good, but it’s a narrative that states the back is fragile. This is a common story people are told when lifting in the gym with a healthy back; even more so once there’s pain.
Overprotection is a self limiting cycle. A healthier understanding of the spine shows it is strong and resilient. People need to be empowered beyond protective modifications of rehab exercises. You can progress and return to what you love despite years of back pain.
There is also a common misconception that if you don’t have the right mechanics, alignment, muscle intention then you can injure your back. People have been taught to manage back pain by staying safe, and consistent with their rehab exercises. This has created an unnecessary worry that if you do too much, do the wrong move, stop stretching, and stop core strengthening then all the pain and damage will return.
None of it is true.
The spine is extremely strong, adaptable and capable of high loads, forces, and velocities. The back gets stronger the more you use it, and weaker the more you protect it. In fact a disc gets its nutrition from loading and movement.
Loading the spine, as with any other body tissue needs to be progressed over time. The best treatment for back pain is calming symptoms down in the beginning then gradually building the tolerance back up and continuing to progress toward your goals.
Believing the myth that the spine is fragile leads to avoiding activities that may be beneficial and enjoyable. For a personal story on this watch Alana’s video.
Myth – A herniated or bulged disc is abnormal
Your discs are joints. They are pressure detectors and capable of handling load, force, and pressure.
Disc degeneration sounds frightening, but in reality it is a normal age related change, like wrinkles on the skin. Degenerative spinal changes seen on an MRI are extremely common among people without symptoms. In fact 1/3 of 20 year old individuals have a protruded disc and feel fine.
This study with 148 subjects, assessed the prevalence of MRI findings in the lumbar spine. Subjects included those without current low back pain or sciatica and/or those who have never had back pain. The results showed 83% of them had moderate to severe desiccation of one or more discs.
These scan findings are more normal than abnormal.
The belief has been perpetuated that a herniation or bulge is dangerous. This makes people hold on to their scan findings as a reason for their back pain for the rest of their life.
Discs can be an influencer of pain, but they can also heal. It’s not much different than an ankle sprain. They both need movement to help them heal and adapt.
Your physical structure is one piece of the story, not the whole story of back pain.
“Dissociating pain from tissue state and from function is one of the key learnings that come from the emerging science of pain.” Dave Moen
Myth – Core weakness causes back pain
Ah, this one is so engrained in our culture.
Weakness does not cause pain. Strong people have pain and some people are weak and have no pain at all. Blaming weakness for back pain reduces pain down to a protocol and misses the lived experience.
There is no scientific correlation between core weakness and back pain. There was no association between changes in abdominal muscle activation and low back pain.
In fact people with chronic back pain tend to have more tension and stiffness as a protective behavior.
Core stability has also been refuted with research. There is strong evidence that stabilization exercises are not more effective than any other form of active exercise. Thankfully you don’t need much force to have a stable spine. The amount of contraction necessary to stabilize the sine is below conscious control. Exercise is shown to be the most beneficial for back pain but the exercise should be meaningful for each individual and not based on generalized back protocols.
Engaging your core is not bad, but if it is your only strategy, then add variety. Core strengthening is healthy and good so keep loading the core. Just know it is not specifically linked to reducing back pain.
The good news is your back can feel better despite your core getting stronger.
A meaningful well rounded exercise program is ideal.
Myth – Scans will tell you the root cause of your back pain
A question often asked is, “Do I need an MRI before I get treatment for my back?”
No. An MRI or Xray is not necessary because they don’t determine your symptoms. Your history does.
A scan is beneficial if you have had a traumatic incident/accident. They rule out things like tumors and fractures, but do not diagnose pain.
96% of athletes younger than 22 will show “abnormal” changes on an MRI. 52% of 30 yr olds have disc degeneration with no pain or loss of function. 57% of 20-50 year olds have cartilage and ligament tears in their hip but no pain. source – Greg Lehman
Unfortunately searching for what’s wrong with the spine makes people fear their spines, which ironically leads to hypervigilance, sensitization, and disability.
Ninety percent of low back pain is considered non-specific low back pain, because even after all the years of research there is no single root cause found. Back pain in athletes is rather common with 42% prevalence and still this pain is not diagnosed through scans.
The lack of single root cause is not a negative thing. It means, “pain may have an association with structure but the full story is not told by structure.” Peter O’Sullivan
Myth – You must avoid lifting, bending, twisting
You have probably heard, “Squat when you lift.” or “Use your legs not your back.”
I hear it all the time in my workout class.
Instead, research supports exercise variability, not one perfect form, as better means of injury prevention.
Lilting in a variety of ways can prepare the body to accept the load better than forcing one lifting technique.
For acute back pain it may be helpful to modify and change your movement. The problem with avoidance talk however is no one knows how long it’s for, so they keep protecting and keep avoiding.
Consider an athlete who wants to return to sport after back pain. The dynamic positions and movements of their sport must be explored and progressed in order for them to feel safe and confident with returning.
The false narrative of avoidance is also used in pregnancy related back pain. Instead of telling mamas not to bend, lift and twist we should be progressing these movements to make them feel more capable once baby arrives.
The spine needs movement and load to get stronger. Avoiding bending, lifting, and twisting can make one weaker and more sensitive to those movements. This can be scary for people to resume again so work with a provider who makes movement feel safe and reminds you of your capability.
My mentor, Antony Lo, says “train hard, so that life doesn’t have to be.”
Myth – The longer pain persists the more serious the injury
When pain persists your world feels smaller and smaller as capability wanes. You have a harder time experiencing meaningful activity, which then perpetuates pain more and more. Pain interrupts how you experience yourself in your own environment. Quite often it limits your possibilities.
“As we look into the future and take stock of all we know about chronic pain, we find that he most promising treatment approaches don’t involve any chemical inebriation or procedural manipulation. They involve one human being talking to another, helping them realize that the path to relief was within them all along.” Haider Warriach, MD
There is good news for persistent back pain clients, the longer pain persists the less likelihood for structural damage or tissue injury. Rather, back pain is related to all that is going on inside you and around you. It has biological factors, psychological components, and sociological connections.
Non- traumatic musculoskeletal injuries can occur when either a physical or psychological load happens too fast, is too strong, is sustained for too long, or occurs too often.
For athletes with back pain, training load and life load need to be addressed along with tissues. Because “Tissue pathology directly linked with pain is insufficient for assessing and treating musculoskeletal pain.” (Smith, BE et al. BJSM 2019)
Back pain is influenced more from stress, emotions, sleep, physical health, nutrition, training, the immune system, fear, your environment, your support system, and your past experiences than structure alone.
Back pain treatment should always help one see their potential for change and their own agency of control. It should never make one reliant on a provider or treatment technique. Treatment should be guided by the patients goals, values, and personal context.
If you’ve been dealing with persistent back pain and are afraid to return to activity or sport, seek out a professional where movement feels safe and you feel empowered. Contact me.
