5 Back Pain Myths
What’s real?
Back pain is a prevalent issue that affects millions of people worldwide. However, there are numerous myths surrounding the causes and treatments of back pain that can lead to misinformation and confusion. In this blog post, we will debunk some of the most common back pain myths to help you better understand this widespread issue and how to effectively manage it.
Five common back pain myths:
A Weak Core or Under-Active Core Muscles can Directly Cause Back Pain
Bad posture can directly cause back pain
Spinal and pelvis adjustments realign my spine
Back pain is an indicator of damage
Bending over with a flexed spine is bad for my back
Myth 1
A Weak Core or Under-Active Core Muscles can Directly Cause Back Pain
This is a popular theory that can be traced back to some research studies in the 90s which showed people with back pain used their ‘core/trunk’ muscles differently. They showed that the deep abdominal muscles ‘switched on’ slower than in people without back pain (Hodge and Richardson 1996). While it sounds feasible that a ‘weak’ or ‘delayed’ core leads to spine instability and back pain, it’s important to interpret these findings with caution and not draw such strong conclusions to them when still, 30 years later, there is not enough research to support this claim.
Currently, the best evidence shows that:
Those with back pain often have ‘increased’ stability, possibly due to the feeling of needing to ‘protect’ their back (Ross et al. 2017, Griffioen et al. 2020)
People with back pain who did core strengthening exercises got better, but their abdominal muscle timing ‘did not change’ (Vasseljen et al 2012)
Core strengthening exercises help back pain but no more than any other exercise (Hayden et al 2021)
Back pain is complex and influenced by many factors, including but not limited to: Physical load, general health, previous experiences, fear of movement, and also worry due to being told that you have a weak core! Your spine is strong and robust, back pain is a normal and common occurrence, stay positive and keep moving!
Myth 2
Bad posture can directly cause back pain
Posture is a frequent topic of debate for patients, clinicians, media and society as a whole. The common belief is that back pain can be caused by sitting, standing or bending ‘incorrectly’. However there is an absence of strong evidence that can support this claim, not from a lack of trying too. Countless studies show that there is no clear relationship between posture and pain (Swain et al 2020)
Currently, the best evidence shows that:
There is no difference in pain levels for different posture types, whether that be those with a stooped back, arched back, flat back or those who stand upright at attention
Differences in posture are a fact of life. There are natural variations in spinal curvatures (kyphosis, lordosis, scoliosis etc) and NONE are strongly associated with pain
Posture can often reflect our beliefs and mood at that period of time. Posture can give insights into someone’s mood, emotions and body image
The best posture is a comfortable one! This varies between individuals and exploring different ones including those avoided can be helpful and provide symptoms relief
Sitting for long periods is not inherently dangerous, nor should it be completely avoided. However, moving and changing position regularly can be helpful and being physically active is important for your health!
Your spine is strong, robust and adaptable! They are capable of moving and loading in a variety of positions, and it should be trusted to do so!
Taken from (Slater et al 2019)
Posture is simply one piece of the puzzle that is pain. However there are many, many more important things that you should consider and address instead, including sleep, stress and physical activity. So our advice? Move more and move often! Sit up straight for a bit, slouch for a bit and understand that your back is more strong and robust than you might think!
Myth 3
Spinal and pelvis adjustments realign my spine
Lots of people are fascinated by spinal manipulations. They are a form of treatment for back pain that therapists can use where a high velocity thrust is performed, this movement is often associated with a crack or a pop. A study by Demoulin et al (2018) showed that around ¾ of people believe that the ‘crack’ you hear when receiving spinal adjustments (much like cracking your knuckles) is the sound of joints or bones being moved, re-aligned or adjusted. Clinical research demonstrates that this is sound is actually rather caused by the build up of bubbles in the joint fluid (Kawchuk et al 2015) and that it is not putting anything back into place (Marcon et al 2019).
Why is this such an issue?
The problem with this difference in narrative arises as the notion of our joints and bones being needed to be ‘adjusted’ or ‘moved’ back into place can lead to the perception that our spine is fragile, when in reality it is extremely robust. Poor beliefs around back pain can have potential negative consequences and health outcomes, we as clinicians need to educate and promote better narratives around back pain. This is not to say that spinal or pelvic adjustments can’t provide a small, short lasting effect on pain, it is just no more effective than any other form of recommended treatment for low back pain (de Zoete 2021).
Myth 4
Back pain is an indicator of damage
A common question we get asked as physiotherapists is should I get a scan with my back pain?
90-95% of the time our answer will be no, as it is not recommended nor indicated as per our practice guidelines, with the vast majority of symptoms that people may present to us with. This may seem odd, however there are actually very good reasons for it. Getting a scan early in the recovery from non life threatening back pain can in fact worsen or prolong the pain, as well as increase the likelihood of developing chronic low back pain in the future (Hall et al. 2021).
How can this happen?
We know that there is a poor relationship between pain and findings with imaging (MRI, X-ray, Ultrasound etc). Meaning that those with no pain at all can have multiple ‘abnormal’ findings on scans and those with pain can have a ‘perfect’ scan. 30% and 37% of people in their 20s with NO back pain have disc bulges and disc degeneration in their spine, respectively. These figures go to 68% and 50% with people in their 40s (Brinjikij et al. 2015). Using scans to explain back pain reinforces an outdated and incorrect biomedical and reductionist view of where pain comes from. Pain is multifactorial, meaning it is influenced by many, many factors, including but not limited to: Physical load, general health, previous experiences, fear of movement, and also worrying about ‘abnormal’ imaging findings, with really long unfamiliar words, which were probably there before you started experiencing pain. It must be said that scans have their place for the treatment of back pain. They should be used for ruling out red flags, which is only a very small percentage of the time, and a good therapist will be able to assess you and refer where necessary.
Myth 5
Bending over with a flexed spine is bad for my back
Similar to being told ‘you must sit up straight’ otherwise risk back pain, being told to lift with a straight spine to prevent the risk of injury is another commonly misused phrase. It is believed that lifting with a flexed spine can increase the anterior shear forces on spinal discs, increasing the risk of injury. This theory is supported by studies done by well renowned clinicians, which were performed on dead human and animal tissues. These findings can not be simply extrapolated into living human spines. Living human tissues have the capacity to adapt to load, including lumbar muscles, bones and even discs.
The current evidence shows that:
There is no agreement whether an increase in spinal flexion leads to an increase in anterior shear forces, some studies show the opposite (Arjmand et al. 2005)
You cannot avoid spinal flexion even when you try to keep your back in neutral (Holder 2013)
Your spine can adapt, getting stronger with gradual and tolerable load (Belavy et al 2017)
If your spine was not meant to bend it would look like a shin bone! Your spine has lots of moveable joints that were designed to move freely! If you avoid bending your back, you may find it sensitive to that movement when you eventually perform it. So, move more, move often.
Written by Jack Rains
— Physiotherapist, Sydney
References
Hodges, P. W., & Richardson, C. A. (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine, 21(22), 2640–2650.
Ross, G. B., Sheahan, P. J., Mahoney, B., Gurd, B. J., Hodges, P. W., & Graham, R. B. (2017). Pain catastrophizing moderates changes in spinal control in response to noxiously induced low back pain. Journal of biomechanics, 58, 64–70.
Griffioen, M., van Drunen, P., Maaswinkel, E., Perez, R. S. G. M., Happee, R., & van Dieën, J. H. (2020). Identification of intrinsic and reflexive contributions to trunk stabilization in patients with low back pain: a case-control study. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 29(8), 1900–1908.
Vasseljen, O., Unsgaard-Tøndel, M., Westad, C., & Mork, P. J. (2012). Effect of core stability exercises on feed-forward activation of deep abdominal muscles in chronic low back pain: a randomized controlled trial. Spine, 37(13), 1101–1108.
Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., van Tulder, M. W. (2021) Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, Issue 9.
Swain, C. T. V., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312.
Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit Up Straight”: Time to Re-evaluate. The Journal of orthopaedic and sports physical therapy, 49(8), 562–564.
Demoulin, C., Baeri, D., Toussaint, G., Cagnie, B., Beernaert, A., Kaux, J. F., & Vanderthommen, M. (2018). Beliefs in the population about cracking sounds produced during spinal manipulation. Joint bone spine, 85(2), 239–242.
Kawchuk, G. N., Fryer, J., Jaremko, J. L., Zeng, H., Rowe, L., & Thompson, R. (2015). Real-time visualization of joint cavitation. PloS one, 10(4), e0119470.
de Zoete, A., Rubinstein, S. M., de Boer, M. R., Ostelo, R., Underwood, M., Hayden, J. A., Buffart, L. M., van Tulder, M. W., & International IPD-SMT group: (2021). The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis. Physiotherapy, 112, 121–134.
Marcon, A.R., Murdoch, B. & Caulfield, T. (2019) The “subluxation” issue: an analysis of chiropractic clinic websites. Arch Physiother 9, 11
Hall, A. M., Aubrey-Bassler, K., Thorne, B., Maher, C. G. (2021) Do not routinely offer imaging for uncomplicated low back pain British Medical Journal; 372 :n291
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816.
Arjmand, N., & Shirazi-Adl, A. (2005). Biomechanics of changes in lumbar posture in static lifting. Spine, 30(23), 2637–2648.
Holder, L. (2013) The effect of lumbar posture and pelvis fixation on back extensor torque and paravertebral muscle activation. Master of Health Science Thesis Auckland University of Technology
Belavý, D. L., Quittner, M. J., Ridgers, N., Ling, Y., Connell, D., & Rantalainen, T. (2017). Running exercise strengthens the intervertebral disc. Scientific reports, 7, 45975.
Back pain is a prevalent issue that affects millions of people worldwide. However, there are numerous myths surrounding the causes and treatments of back pain that can lead to misinformation and confusion.