There’s a lot of debate about what causes low-back pain, and a lot of misconceptions. Despite their best efforts, even doctors often don’t have an accurate understanding of low-back pain.(1)
After listening to this episode, you’ll understand why most low-back pain treatments and prevention strategies don’t work. In the next episode, you’ll learn what treatments might help.
Click the Player to Listen:
“Quite a Stretch” by Paul Ingraham
“Yoga and stretching for low back pain damned with faint scientific praise” by Paul Ingraham
Other Listening Options
**Armi Legge:** In 1997, about 21% of the population experienced severe back and neck pain. In 2005, just eight years later, that number had risen to almost 25%, along with an additional $1,400 in medical spending per person. For a health condition that’s growing this fast and adding millions of dollars in healthcare spending, you would think we would have a pretty good idea of how to treat it. Unfortunately, that’s not the case with most doctors. One study found that around 82% of medical graduates “fail to demonstrate basic competency in musculoskeletal medicine.”
The reason for the sharp raise in back pain and not because we haven’t been trying to find a solution. The medical community has been trying. Unfortunately, as with any large field of scientific research, mistakes are going to be made that make it even harder to find the correct treatments. In the first installment of this two-part series, you’ll hear from a science journalist named Paul Ingraham on the top five low back pain myths.
You’ll learn whether or not your spine is as fragile as many people say, if biomechanical problems like leg length discrepancies are as much of a problem as they’re often made out to be, if poor posture is the cause of back pain, if stretching will help reduce back pain, and much more.
My name is Armi Legge and you’re listening to episode one of Impruvism Radio, the podcast that uses science to help you become more awesome. Before we get into our topic today, I’d like to remind you that links to the studies we mention appear on your iPod or music playing device as you listen. You can also find a list of selected references and other things we mention on this episode on the show notes for this episode on impruvism.com/lowbackpainpodcast.
Remember, if you like what you hear on this show and you want more information like this, you should navigate to impruvism.com, enter your email address on the box on the right side of the page and click submit. After you do, you’ll get free updates whenever we publish a new article or podcast.
Paul, what are the top five myths about low-back pain?
**Paul Ingraham:** The top five are very hard to pick but I can give you two good ones. It’s hard to rank them. It’s hard to decide what the mythiest myths would be.
The number one has to be that the spine is fragile and degenerate, that it easily breaks down and that is the basic cause of pain. That’s a meta-myth, an umbrella myth. There are a lot of sub myths underneath that. In some ways it’s maybe unfair to call it a myth because there are not very many healthcare professionals who would tell a patent, “Your low back is fragile and degenerating and that’s why you’re in pain.” But that idea nevertheless gets communicated to patients in all kinds of ways. There are a bunch of other myths that all contribute to that one overriding myth, that it’s a structural problem. You’re hurting because you’re breaking down.
**Armi Legge:** Would you mention a few other sub-myths that go along that and the other conceptions that people build around the idea that our backs are these fragile little sticks that might break at any moment?
**Paul Ingraham:** Sure. That’s pretty much the whole game right there, breaking it down into its pieces. Let’s talk about those scary spine models first.
Most people have seen in doctors’ offices and chiropractors offices, a little model of the low back. It particularly gets trotted out if you have a back pain problem. It’s also just sitting there in the background. There’s usually a little, red rubber or plastic exploded disc squirting out from between a couple of vertebrae. That model is basically a visualization of one hypothesis of what causes back pain, but that specific ideology of back pain is really in the minority.
Very few cases of back pain are actually caused by exploding, squirting, slipped intervertebral discs, yet the models are extremely prevalent. They’ve been sitting on healthcare professionals’ shelves for decades. They cost probably $80-$150. They’re just kinda standard operating equipment. Most healthcare professionals buy one. They sit there, physically perpetuating the myth and constantly communicating that idea that this is something that happens to spines, exaggerating it.
Again, every healthcare professional who’s remotely up on their low back pain science knows there’s a lot of back pain that isn’t caused by herniated discs, but those scary spine models keep right on communicating that message. It’s extremely difficult not to be mentally affected by that imagery. It’s almost impossible, in fact, to look at one of those models and not have a pessimistic and concerned reaction. “What if that’s happening to me?” The realty is that happens to very few people. This segues into the next myth.
Even when it does, even when there are identifiable structural problems, they are routinely not painful. So that’s an interesting one. You can scan the heck out of people, find all kinds of interesting, visible, biomechanical problems with them and those problems just don’t line up with actual symptoms and pain very well at all. At the extremes they do. If you’ve got an actual, seriously herniated disc, chances are you’re going to have some pain, but there’s this huge, messy, gray area in the middle where lots and lots of people have minor and even moderately herniated discs and no pain at all.
We could say the next myth is that structural problems cause pain. They don’t. It’s some kind of crazy alchemy with other factors. There is other stuff going on. There’s something else that has to combine with it in order to end up with pain. That’s where back pain really starts to get interesting.
I think any clinician who has spent any amount of time working with low-back pain patients shouldn’t be able to avoid realizing this. You see patients who get a completely clean bill of health. Their scans are clean, they have good posture, they’re fit. They seem like people who shouldn’t have a problem, yet they do. And vice versa. You get messed up people who are completely fine.
My favorite great story that I love to tell all these years- the first time I saw this patient, I knew I was going to want this story for a long time. She has a spectacular spondylolisthesis, a dramatic slippage of the L5 vertebrae off of the sacrum is basically falling off. It was incredibly dislocated looking on her MRIs, yet she didn’t come to me for back pain. She had a shoulder problem. Here, you have this amazing physical problem that looks incredible on a scan and she had mild back pain occasionally at worst. So that’s another myth.
**Armi Legge:** So we can recap a little bit, number one is the spine is fragile and easily broken and you often get discs slipped and herniated easily. Number two would be biomechanical problems cause pain, which they usually don’t or at least there is a large discrepancy between the actual problem and the amount of pain that it causes. Now another one that is often perpetuated that I’ve seen a lot is poor posture and crookedness causes low-back pain and you just need to be more conscientious about your posture to improve or reduce your low-back pain. What is the science behind that claim?
**Paul Ingraham:** Oh, there’s no science behind that claim. That’s just a really popular, emotionally appealing concept. It’s been undermined by science steadily over the last 25 years. In particular, the idea of treating back pain with core strengthening has pretty much failed to find any real support in science. Lots of attempts, a few positive studies, but when I say “completely failed,” I mean, at best, it’s damned with faint praise. Even when there are good results, they’re just not that impressive.
The problem with posture is essentially the same as with structure not connecting with pain. With real obvious structural problems, it’s just a smaller version of that. The idea is that poor posture is a structural problem, that poor posture will cause strain on those poor, fragile spinal components and inevitably cause pain, but if you’ve got real, scannable, structural failures and arthritic degeneration and they’re not necessarily causing pain, then the posture one is pretty easy to stop worrying about because it’s comparatively minor.
There are lots of converging lines of evidence showing you don’t have a connection between poor posture and pain and you can’t treat for it. You can’t very effectively change people’s posture and/or it doesn’t do much when you do.
**Armi Legge:** That brings us to the next possible myth. That’s a lack of flexibility. It seems like recommendations to stretch and do core training always go together. Is there any evidence that lack of flexibility, maybe in your hip flexors, causes low-back pain?
**Paul Ingraham:** Yeah, they’re really yin-yang. Those two claims are really intertwined. You could almost just lump them together and say it’s the same thing because the idea that tightness is part of the problem is pretty much always connected to the idea that tightness is pulling you out of alignment. We could cover all of these with the alignment myth, the idea that being crooked is problematic or painful and the recommendation to stretch assumes you can get pulled out of alignment by chronic muscle tension, and more importantly that it hurts and ultimately causes pain and it can be treated by stretching. It’s particularly the last two.
It’s certainly possible that we do have asymmetric and dysfunctional postures because of muscle tension. That’s not particularly controversial. What’s tricker is whether or not it matters. Just like with everything else we’ve said so far, it doesn’t connect with pain very well and treatment is really difficult.
Stretching has, and this is a very unpopular point, I get a lot of flack for this one, but there are a few topics I am better backed up by the science- stretching has just generally failed to show therapeutic value in virtually any context. It is not an effective treatment for back pain. It’s not an effective treatment for much of anything. There is a handful of specific indications where stretching seems to do some good. I’ll lob out a positive example and say the evidence for stretching for plantar fasciitis, a foot problem, seems to be fairly good. That’s really an isolated example. Nobody has ever been cured of their severe chronic back pain by stretching, or very few people at very rate, only a lucky few.
I could use that as a way of getting into the next myth, that there is an effective treatment out there for low-back pain. None of these problems that I write about, none of the tough chronic pain problems would be interesting topics if there was a good magic bullet therapy for them. If there was a treatment that was reliable, that had a strong, positive effect for everyone, everybody would be doing it. It would be widely available and known. It would be the kind of the treatment hill, no problem. The whole reason that low-back pain is such an interesting and difficult topic is because nothing works! The very best treatment options have that damned with faint praise problem.
**Armi Legge:** To recap the five myths, number one would be that our spines are fragile. Number two would be that biomechanical problems often cause pain, which they don’t. Number three would be that poor postering and crookedness cause low-back pain. Number four would be that lack of flexibility or muscle tightness is pulling us out of alignment and causing back pain. Number five would be there is actually a common treatment or cure-all for all forms of low-back pain, which there is not. Would that be correct?
**Paul Ingraham:** Sure, that’s a pretty good list. Did we just do four? Is that four now?
**Armi Legge:** That’s five.
**Paul Ingraham:** That’s five? We’ve got five! Excellent.
**Armi Legge:** Obviously, there are probably far, far more that we could cover, but to just to keep people focused on the basics, that’s a good starting place.
Our listeners are probably wondering what they could do with that and that will be covered in next week’s episode.
Thank you for listening to episode one of Imprivism Radio. Please join us again next week, when we hear from Paul about how to treat what might be the single most common and underrated cause of back pain.
Before you go, you should know about one cure for back pain that works every time: leaving a nice comment and review on iTunes for this podcast.
Okay, not really, but if you enjoyed this podcast and it helped you in any way, leaving a ranking on iTunes is the best way to support the podcast and keep these episodes coming. Just click on the link to iTunes in the show notes for this episode on improvism.com/backpainpodcast. Open the podcast in the iTunes store. Scroll down to where it says “customer ratings” and leave your nice thoughts. Thank you.
1. Stockard AR, Allen TW. Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. J Am Osteopath Assoc. 2006 Jun;106(6):350-5. Abstract: https://pmid.us/16790542 | Full Text: https://goo.gl/O1vvl