Probably the most common complaint I have seen in my career as a physiotherapist is low back pain. My understanding of this presentation has changed drastically over the years, and I aim to share some of my thoughts with you, in the hope that you find them useful.
First and foremost: pain is complex
The main message I would like to send is that pain is complex. How we feel pain is dependant on many factors, only some of which fall into the purely biological domain. Pain is impacted by our beliefs, our past experiences, our surroundings, and many other things. Pain is our body’s alarm system. The International Association for the Study of Pain has outlined the definition of pain as “an unpleasant sensory and emotional experience associated with actual or POTENTIAL tissue damage, or described in terms of such damage.” (Merskey & Bogduk, 1994). This means that we can experience pain IN THE ABSENCE of damaging stimuli. This idea alone gives weight to the idea that pain does not equal damage. You can be in a great deal of pain, and have no visible tissue damage. The opposite is also true, you can have a terrible looking MRI scan, but be in no pain and have no loss in function whatsoever.
A real life example to help you to consider this concept: Imagine you are doing something you enjoy, like skiing, or swimming in the ocean, or at a music festival. You might hit something accidentally, and sustain a cut or bruise that you find later and have no idea how you got it. Compare this to when you are having a really bad day, and nothing is going your way, and then you stub your toe; the amount of pain you feel is likely to be drastically different, despite the amount of soft tissue damage being equal.
There are numerous extreme examples of circumstances where people have had immense physical trauma, and no pain, or vice versa.
This it not saying that pain is ‘in your head’. Simply that pain is a product of our brain, and so how we feel it is dependant not only only what is going on at a soft tissue level, but also what is going on in our brains, and in our surroundings. Often, the advice given and words said to people in the early stages of acute low back pain (e.g. you’ve slipped a disc; you might need surgery; you have the spine of an 80 year old; stop going to the gym; stop playing sport; etc) can have disastrous consequences.
This is not only because of the psychological component of pain, but also because we are likely to move and act differently if we believe we have done major ‘damage’ to ourselves. We are likely to stop moving as much, for fear of doing more damage. We are likely to quit exercising, or sitting for prolonged periods at work, or lifting up our children or grandchildren, because we are worried it might be bad for us. We are likely to become hypervigilant about posture and pain, in the belief that we need to be this way in order to protect our backs, when in reality, the opposite is the case.
Often, it is exactly this series of events that leads one to be in chronic pain. An injury occurs, the person is told they have damaged their back and may make it worse if they do it again. They quit doing things they love, grow more anxious, become less active, lose confidence in themselves and their abilities, lose their sense of control over their bodies, and feel they are simply ‘waiting’ until their back gets better, which often, in this scenario, doesn’t happen. While their initial soft tissue damage has likely already healed, the pain persists. In these cases people are often sent on an endless cycle of trying to find out ‘what’s wrong with them’, which never yields a result, as the original catalyst for the pain has largely healed, thus creating the challenge of managing chronic pain.
This is often exacerbated by the fact that the neurological system becomes sensitised in those with chronic pain, meaning that the pain signals are ‘turned up’, or amplified, by their body’s pain feedback system. This is a challenging condition to manage. One of the many drawbacks of our health care system is that despite this being fairly common knowledge, interventions directed at predominantly physical findings for those in chronic pain (e.g. prescription of pain medications, injections, massage, joint mobilisations, even exercise) is fairly near sighted. I will discuss possible management strategies in future posts (within my scope of practice as a physiotherapist only) but I will say that my bias is towards exercise, despite it being a physical modality directed at a biological cause, primarily because it gives the patient back some control and self efficacy, and is less invasive than other treatment options. A simple treatment option with potentially complex mechanisms by which it may be effective.
It is one of my ‘bug bears’ about the medical and physiotherapy professions that often we feed into this fear, asking someone ‘what they have done to themselves’, having a go at people for doing very normal things that they love doing, and generating a general fear of movement. I have had numerous clients come to see me, sheepishly admitting to doing something entirely normal like moving house or lifting a heavy weight or gardening for hours non stop. It is funny that we are so quick to demonise movement, and so quick to tell people to quit doing physical things, when our bodies were designed to move and lift and run and LIVE.
Why this is important specifically for back pain
The most common thing I hear when I see a client with a painful lower back is, ‘I’m really worried I’ve done a disc’. The idea of a disc bulge or herniation being correlated with a terrible injury is one of the most pervasive fallacies in the musculoskeletal realm, considering up to 50% of people aged 30-39 who have NEVER had low back pain have a disc bulge or herniation on imaging (Brinjikji et al., 2014). This number increases every decade.
In fact, there is evidence to show that people who receive an MRI early after feeling low back pain have a WORSE outcome and end up spending MORE money than those who don’t (Webster et al., 2013). This is potentially because being shown a disc injury on MRI is scary and worrying. It is often combined with being told that you have ‘slipped your disc’, and being advised that this can require surgery or lead to life long problems, which can cause the negative decline in function and self worth that I outlined above.
I will say that MRIs do have a place in the management of low back pain, and this role is to rule out sinister pathology. There are very rare instances in which there is an emergency that requires medical attention and in these cases an MRI is necessary to bring it up; however, there are specific red flags that indicate this is required. In the absence of red flags, it is NOT best medical advice to receive a scan. This is supported in the UK’s National Institute for Health and Care Guidelines regarding low back pain best practice management. It is not simply my opinion!
Your ‘diagnosis’ does not define your presentation
Someone with multiple disc bulges all through their lower back can be perfectly pain free, deadlifting heavy, and doing as they please. Someone with no disc injuries can be unable to cough, sneeze, or bend forward without pain. Whether or not you have ‘disc-like’ symptoms is unlikely to be related to the findings on your MRI.
The idea that a disc injury is lifelong, leads to problems later life, needs to be treated extra carefully, requires avoidance of heavy lifting and running, is INCORRECT. While there may need to be modifications made in the short term to aid someone to feel better, there is no reason this needs to spiral out into a long term problem.
Acute low back pain is PAINFUL and feels TERRIFYING
The reason this whole situation is so common with low back pain in particular is because low back pain is PAINFUL. The true 10/10 pains I have seen in my career have been those poor people bent over and hobbling in as a result of their sudden onset lower back pain. I have had it myself. The stereotypical ‘pop’ with instant severe pain across my back so bad I nearly passed out, with leg pain and pins and needles in the weeks following. And it took all my mental energy to reassure myself that what I was going through felt MUCH worse than what it really was!
It is very easy to understand why someone with 10/10 pain walks into their GP’s office crying, and walks out with an MRI and a fear that they are ‘broken’. However, this pain is usually because of the inflammation associated with low back pain (and probably all those other things that affect our experience of pain listed earlier). Most of the time, once the inflammation has gone, the severe, acute pain is much less.
I understand it can feel negligent to not send someone for a scan when they are in such pain, however in the VAST majority of cases, you will get an MRI and be told to ‘wait and see’ if your pain gets better. If it isn’t better in a set timeframe, then more treatment may be warranted. This ‘wait and see’ approach is likely to happen whether you get the MRI or not. The scan does not change the treatment path in the acute phase of low back pain. Considering MRIs are expensive, and associated with worse outcomes, and don’t actually change the treatment in the short term, it doesn’t make sense to get one in those first few weeks of low back pain, in the absence of any red flags.
In my next blog post, I will discuss my personal strategies for managing people with low back pain and some general advice that you may hopefully find useful.