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Need better low back pain information? The bark of low back pain is almost always worse than its bite. Find out why! In as much detail as you can stand!
Need better low back pain information?

The bark of low back pain is almost always worse than its bite. Find out why.

Updated the day before yesterday! What’s new?

Save Yourself from
Low Back Pain!

AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS

Low back pain myths debunked and all your treatment options reviewed

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.


Welcome to the internet’s sanest source of information about low back pain. This is more than a web page: it’s a full-length book, a level-headed guide to a controversial subject for patients and professionals. It is not a sales pitch for a miracle cure system. It’s heavily referenced, but it isn’t dry and boring. It has got some important ideas — underestimated factors — about the nature of back pain, but it won’t try to convince you that all back pain comes from a single source. It’s “just” a detailed tour of the topic, the myths and misconceptions, and the best (and worst) treatment ideas available. There’s about 68,000 words ahead, so get comfortable.

Since I first started treating patients with low back pain, a decade ago, there has been an explosion of free information about it available on the internet — a mess of poorly written and oversimplified articles. It used to be that you had to actually go to a doctor or buy a book to get inadequate information about low back pain. Today, all the classic low back pain myths are available to anyone with a few moments at a computer.

Much of the information that you can find out there is just plain wrong.1 For instance, despite overwhelming scientific evidence to the contrary, almost all sources of information about low back pain incorrectly portray it as a “mechanical” problem, as if the spine is a fragile structure which breaks down and causes pain. This is based on many common misconceptions about how backs work, and how pain works.

About footnotes. There are many footnotes in this document. If you click on them, more information will “pop up” right in front of you. Try this one!2 The page will not reload, and you will not lose your place.

A tragic low back pain myth

This myth of “mechanical” failure of the low back has many unfortunate consequences, such as unnecessary fusion surgeries, and low back pain that lasts for years instead of months.

Even more tragic is that good information exists: there are plenty of medical experts who “get it” (the doctors doing the actual research). But they have fought a difficult battle trying to spread the word to their own medical colleagues on the front lines of health care. In 2010, a report in Archives of Internal Medicine showed that, even many years after the publication of excellent guidelines for low back pain care, family doctors still don’t follow them:

Usual care provided by general practitioners for low back pain does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time.

Williams et al, Archives of Internal Medicine, 2010

Experts have particularly struggled to get the word to alternative health professionals — most of whom don’t even read medical journals.3

In this tutorial, you will meet those medical experts, and find out what they know and believe and why. Their ideas about low back pain are neither “conventional” nor “alternative” — they simply come from the best minds in the business.

What would Adam & Jamie do? You know, if they were doctors?

How can you trust this information about low back pain?

I’m inspired by the MythBusters approach: I question everything and I have fun doing it. (No explosions, alas.) I assume that anything that sounds too good to be true probably is. I make no big promises, I do not claim to know the one true cause of anything, and I am not selling a treatment system or my own services. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 200 footnotes), and I link to the original sources so you can check them yourself.

Dr. Richard Deyo, low back pain expert

Don’t take my word for it …

Take this guy’s word for it. Dr. Richard Deyo has been busting myths about low back pain for longer than I’ve been alive.

Dr. Nikolai Bogduk, low back pain expert

Or this guy’s word. Dr. Nikolai Bogduk has authored dozens of scientific papers about low back pain. He also questions and challenges many common beliefs about low back pain, and is one of the expert sources this tutorial relies upon.

Dr. Siegfried Mense, muscle pain expert

Or this guy’s. Dr. Siegfried Mense is the world’s foremost expert in muscle pain. He is the author of the most current and authoritative text on that subject, and one of this tutorial’s most important sources.

And so it is not necessary for you to take my word for anything — you can take the word of the many low back pain medical experts that I quote, and the hard evidence that their opinions are based on. My own credentials are somewhat beside the point. My professional experience as a Registered Massage Therapist certainly helps me understand and write about low back pain, but what really matters is that I refer to and explain recent scientific evidence.

How do so many health care professionals go wrong when they treat low back pain?

Why does the myth of structural back pain get repeated endlessly on the internet and in health care offices around the world?

Is professional care for low back really this dodgy? I believe so. I clearly remember graduating clueless. If I hadn’t spent ten years doing post-grad studying low back pain, I still wouldn’t know 98% of what’s in this document. All of the points above — and many more — will be explained and supported in great detail below.

Who is this low back pain tutorial for?

This tutorial is useful for virtually any patient, almost regardless of the type of back pain you have. It is particularly ideal for people frustrated by low back pain and sciatica that seems more serious and stubborn. Some safety information is provided below for those rare cases that may be caused by disease.

Most acute low back pain does go away. Better still, so does a lot of so-called “chronic” low back pain!4 When you don’t recover, your therapeutic options — things like surgery for a herniated disc — cause uncertainty and alarm that is unnecessary and harmful in its own right.

This tutorial is useful for people who like to understand their problems. It is unlike any other product you can find online about low back pain. Once again, there is no miracle cure here. I am not going to tell you that there is some other product or service that you have to buy in order to recover from low back pain. The only purpose of this document is to empower you with low back pain information, to present and interpret the science about low back pain in an interesting and readable way.

When you’re done, you’ll know more about your back than most professionals — quite a lot more! (Not that this is saying much — most chronic low back pain patients have already discovered that few general practitioners know much about back pain.5) I have spent many years assembling this information from hard study, professional experience, and your stories and feedback. I update the tutorial regularly, always adding new and better information as new scientific research is published.

But I will not just tell you what you want to hear. Understanding low back pain as well as possible is enormously helpful, but it will not necessarily lead to a cure. Unfortunately, some low back pain really cannot be fixed — a few people live with it for their entire lives.

Has nobody noticed the embarrassing fact that science is about to clone a human being, but it still can’t cure the pain of a bad back?

Pain, by Marni Jackson, p5

And yet …

Some cases of “incurable” chronic low back pain can still be cured!

While it’s true that some lower back pain just cannot be fixed, it’s also true that many “incurable” cases do turn out to be treatable. People who believed for years that their pain was incurable can still get relief. Not always, and often not completely — but sometimes even partial relief is far better than nothing. How can this be? So many health professionals are poorly prepared to treat low back pain that patients can easily go for months or years without good care and advice. When they finally get it, it’s hardly surprising that some of those patients finally get some relief from their pain.

Patients can easily go for months or years without good care and advice

And it’s always amazing to me how chronic pain can, with the right therapy, just suddenly end — it’s not common, but it does happen. There are people who thought they’d “tried everything” for lower back pain who read this tutorial and then write to me and say, “Well, I guess I hadn’t tried everything!”

I have never met a patient — no matter how experienced or self-educated — who could not gain new insights and new hope from this tutorial.

Is this going to be one of those “it’s all in your head” theories about low back pain?

Absolutely not!

Low back pain can certainly be sensitive to emotional state, just like an ulcer gets worse when you’re stressed. But both are real physical problems! All of this will be discussed in detail, and it’s important, but this is not a tutorial about treating back pain through psychoanalysis and stress relief! Yoga and meditation are good tools for those who enjoy them, but they are not required.

A weakness in Dr. John Sarno’s (otherwise interesting) writing about back pain6 is that he tends to give patients the idea that recovery from low back pain is all a mind game. It’s not! Chronic pain is never quite that simple.

Is stress-relief over-rated as a low back pain therapy? Probably. Stress is a <em>factor</em> in low back pain, but meditation and yoga are over-rated and inappropriate options for many people. This tutorial explores more practical options.
Over-rated?

Yes, stress is a factor in low back pain, but meditation and yoga are over-rated and inappropriate options for many people. This tutorial explores more practical options.


“What if there’s something really wrong in there?”

“How do you know I’m not seriously hurt?”

“Could it be cancer? A tumor?”

You’re not paranoid if they really are after you! The most dangerous thing about writing a tutorial intended to reassure low back pain patients is the unnerving possibility that I might occasionally reassure someone who should not be reassured. I’m happy to say that reassurance is almost always appropriate. It’s actually important — even therapeutic — to understand that most back injury feels worse than it is. This is what much of this tutorial is devoted to explaining and proving.

However, in rare cases low back pain may be an early warning sign of cancer, infection, autoimmune disease, or spinal cord injury. Most such ominous causes of low back pain also cause other distinctive signs and symptoms and are likely to be diagnosed correctly and promptly. If you are aware of these “red flags,” you can get checked out when the time is right — but avoid excessive worry before that.

The rule of thumb7 is that you should start a more thorough medical investigation only when three conditions are met:

  1. it’s been bothering you for more than about 6 weeks
  2. the trend is negative — the pain is severe and/or not improving, or even getting worse
  3. there is at least one other “red flag” (see below)

And there are also two rare situations where there’s clearly no need to wait several weeks before deciding the situation is serious …

  1. significant numbness around the groin and buttocks and/or failure of bladder or bowel control
  2. if you’ve had an accident involving forces that may have been sufficient to fracture your spine

This free article explains in more detail (including a list of “red flags”), and is strongly recommended to anyone who feels nervous:

SY The Bark and the Bite of Low Back Pain — When you should worry about low back pain, and when you shouldn’t

In all other cases, you can safely read this tutorial first. For instance, even if you have severe pain, numbness and tingling down your leg, you can safely read this first. Or, even if you have an obviously severe muscle tear from trying to lift your car or something, you can safely start here. Your back is not as fragile as you probably think, and understanding why is the best starting place in nearly all cases of low back pain.

Even if you have severe pain, numbness and tingling down your leg, please read this first!

Your low back is not fragile!

Modern civilization suffers from a great plague of low back pain.89 Yet the real causes of most back pain are obscured by medical mythology and misunderstanding.10 Before I discuss what does cause most low back pain, it’s important to talk about what does not cause it. In this section, I will challenge the mythology in just a few paragraphs, supported by over thirty references to the best scientific information available — references you can check for yourself. This is quite different than most sources of information about low back pain for patients, which tend to avoid discussing the evidence.

Most people — and most health care professionals — believe that back pain is usually caused by structural problems, either injury or degeneration of the spine. This is not based on evidence11 — the idea that the spine is fragile is an unjustified but deeply held belief, based on ignorance of a complex subject and on an obsolete mechanical view of biology that has dominated medical thinking for centuries.

End of free introduction to this tutorial

Full access to the rest of this tutorial is available immediately for USD$1995. Click the “Buy Now” button to purchase access, and then continue reading this document immediately.

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Testimonials

Here are some of the nicest things that readers have said about my low back pain tutorial over the years. Thanks everyone!

I have been suffering from lower back pain for the last 5 weeks and found your page to be very informative and interesting. I really can’t thank you enough actually because for the first time I’m really starting to feel like I’m on the right track here.

Glenn Hill, Canterbury, Australia


Thanks to your website, I pretty much got rid of my back problems almost overnight. It’s also fun and thought provoking to read!

Amsterdam Jeroen Strompf, MFA, Screenwriting, Chapman University


First, THANK YOU for this information. You’ve done all the heavy lifting: reading the literature, the studies, et cetera. And you’ve presented all the information in a concise, useful and entertaining format. I have learned a lot from reading these two tutorials, including the miscellaneous articles you have referenced along the way.

Jan Nelson, pharmacist and power yoga practitioner


I bought two of your eBooks last week, and I’m enjoying going through them. Your presentation is excellent. It’s far too early too say, of course, but I think I’ve already begun to benefit from your approach. One of the things I like most about your approach is your respect for “science,” as opposed to “merchandising.” You've put so much into those two eBooks, it's going to take time to do them the justice they deserve.

David Calderisi, Toronto, Ontario

David diligently followed up a month later with the following comment: “By now I’m convinced your research and recommendations are right on the money. Thanks. I’ve recommended you to a few people who, like myself, have had back problems on and off for years. Thanks for having provided such a useful tool.” — Paul

I was just about to buy some “magic cure” book and pay for it when I came across your review of it and decided against it. Then I took the bold step to buy yours instead, although I feared your review was just a ploy to grab business from your competition. But thank God I did! That is the best £10 I have ever spent. In fact, pound for pound, I’ve never purchased anything which has had a greater impact on my physical well being. It was such a relief that you were able to really understand and define exactly what my symptoms were in such detail. Also to be able to visualize the problem and understand what’s going on and why the therapies work is really satisfying. Thank you very much. Your literature is very informative, easy to read and digest. Moreover, it bloody well works. Well done and keep the good work.

Osman Hassan, London


Your low back pain tutorial is refreshing. I’d gotten tired of hearing the same old explanations for my back pain, which are obviously wrong simply because the back pain was around before the things that supposedly caused it! It was nice to read something clear and logical that is actually consistent with my experience.

Jean Gallagher, low back pain sufferer, California


Read 15 more testimonials


One more special testimonial. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

Dr. Jonathon Tomlinson, MBBS, DRCOG,MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.


What’s New In the Low Back Pain Tutorial?

Save Yourself from Low Back Pain! was originally published in September of 2004, after countless hours of research and writing while I spent a month taking care of a farm in the Okanagan. Numerous improvements have been made over the years, but this change log was not started until late March, 2007.

Most links to sections mentioned in the updates will work only for customers. To get access to all sections, purchase the tutorial for $19.95. You’ll receive the full version right away.

Wednesday, July 7, 2010 — Updated the with a summary of a bizarre experiment with muscle relaxants that had quite surprising results.

Monday, July 5, 2010 — Two minor science updates: a thumbs down for transcutaneous electric nerve stimulation (TENS), and a (surprising) thumbs up for comfrey ointment.

Saturday, February 13, 2010 — Added clear evidence that family doctors don’t do a good job with low back pain, and that a myth-busting ebook like this is a pretty important. I was pretty pleased to see this evidence … though it’s sad that back pain care is still such poor quality. See my blog post about it for details.

Friday, January 29, 2010 — Important update: a major new section that finally substantiates one of the most important points of this tutorial with a detailed explanation of … The evidence for massage. There’s some substantial new wordage lately: the total word count for the document is now a meaty 70,000 — solidly book-length now. I think this thing has evolved beyond beyond a “tutorial.”

Saturday, January 23, 2010 — Three significant updates three days in a row! Today a substantially upgraded section about medications, , and a brand new section, .

Friday, January 22, 2010 — A new section covering cheaper and safer methods of tractioning:

Thursday, January 21, 2010 — New section, Spinal decompression therapy is all hype.

Wednesday, November 25, 2009 — Funny, but today I found a way to say some simple things about the power of self-treatment that have been “on the tip of my tongue” for years now. So here’s an nice new section: And it all evolved from writing about an important bit of research, showing that manual therapists cannot reliably diagnose trigger points.

Tuesday, November 24, 2009 — A little extra scientific evidence to make the point “” This new study from the Lancet puts the nail in the coffin of the MRI myth: it’s now just about as busted as a myth can get.

Monday, October 12, 2009 — New section, “,” based on interesting new scientific evidence. The research is explained in a short free article, but I discuss it in quite a bit more more detail here.

Monday, September 28, 2009 — Overhauled all the diagnosis sections — — reorganizing and editing here there and everywhere. Three sections were added or almost completely re-written. In particular, information about nerve blocks was added, and disc herniations are discussed in more detail than before.

Friday, September 25, 2009 — Polished and expanded the section, “.”

Saturday, August 15, 2009 — This morning I stumbled at random across a fantastic new scientific paper about the prevalence of nerve pinches. Great stuff! See “Frequency of radiculopathies in motor vehicle accidents”. It was a most welcome addition to this tutorial’s

Thursday, August 6, 2009 — Added a reference to some really fascinating new research about vertebroplasty — yet more evidence that structural “instability” isn’t actually the main problem in back pain, because “stabilizing” doesn’t actually help. You can read my take on this for free for a while on the front page of SaveYourself.ca.

Friday, July 24, 2009 — The sections on and have been condensed into finely tuned summaries, and link to a new “special supplement” to the tutorial: a separate article covering these topics in much greater detail, accessible to tutorial customers only. As the SaveYourself.ca inventory of tutorials expands, such special supplements will be a useful new way of providing detailed information without repeating it in multiple tutorials. Please think of the special supplement as a part of the tutorial, that just happens to be on another page.

Thursday, July 16, 2009 — Small but good new section “.” Hat tip to Dr. Tarzwell for suggesting this one: I had previously neglected the (obvious) importance of this particular medical speciality for back pain patients.

Tuesday, July 7, 2009 — Important safety update. The section “” has been upgraded, based on a much more careful and thorough translation of the best and most recent medical guidelines, and links out to a new free article with considerably more detail for patients who are concerned about an ominous cause of their low back pain. I’m really happy with this update: for some time now I’ve known that I needed to “cover my butt” with better information about more serious causes of low back pain — they are rare, but they do exist. I was inspired to do so by a case study from a physician I know, who encountered a patient with back pain that was actually caused by a cancer. That story convinced me that it was time to make sure my readers know when to worry about low back pain, and when not to.

Wednesday, July 1, 2009 — Major bibliography update. The SaveYourself.ca bibliography has long been the largest of its kind. It contains an incredible amount of surprisingly readable information about musculoskeletal health science, and it is now possible for visitors to search and sort the bibliography with powerful new features. For instance, every source about low back pain referenced in this tutorial can now easily be displayed in a single search, with a variety of options. See the front page for the announcement of the new features, or visit the bibliography itself.

Saturday, May 30, 2009 — Minor update. Started a new section, “.”

Tuesday, May 26, 2009 — Minor update. Added a solid new reference concerning the overuse of X-ray and MRI.

Sunday, May 17, 2009 — Another new section this morning — a long overdue debunking of prolotherapy, a particularly classic example of a therapy that has failed to prove efficacy after 50 years and numerous fair scientific tests. I recommend the section not just for the useful information, but because it’s quite an interesting topic. See “.”

Saturday, May 16, 2009 — Small new section, based on some persuasive scientific reviews recently published in the journal Spine: “.”

Saturday, May 16, 2009 — Substantive new section, “,” summarizing some common causes of low back pain, such as facet joint dysfunction and injury. Such topics were missing from the tutorial before because they are so hard to diagnose accurately, because professionals and patients alike to over-react to the very idea of them, and because they are almost invariably complicated by muscle pain that becomes more prominent than the original problem. Nevertheless, these problems have a place in the tutorial.

Wednesday, April 1, 2009 — The visual design of the site was upgraded over the past several days. Although this is not an update to the content of this tutorial, it is nevertheless a significant upgrade for all of them — like publishing new editions of books with better typesetting and layout. The new design is even cleaner and reader-friendly; it now looks that good in most web browsers; and pages load as much as 50% faster. Many under-the-hood improvements will make it much easier for me to improve tutorial content. The tutorials are now well-oiled machines of digital publishing goodness, vastly superior to the low-production values of most eBooks. More information about the upgrade is published on the front page.

Sunday, March 15, 2009 — Two completely new and large sections about scoliosis — one section about dubious diagnosis of scoliosis and the exaggeration of the importance of it in low back pain, and another section about how scoliosis is more or less impossible to therapize. Both sections include interesting case studies and lots of great examples of nonsense in low back pain management — this is the most substantial addition to the tutorial in several months. The new sections are: “” and “.”

Friday, February 27, 2009 — Minor update: added/clarified a good reference to the scientific literature regarding acupuncture for low back pain.

Sunday, February 15, 2009 — Added a new appendix to the tutorial today, just something interesting that I couldn’t find a good place for in the main body of the tutorial: “.”

Monday, February 2, 2009 — Some small but important updates to the section, “.” This section still suggested that optimism about acupuncture was justified. Recent scientific evidence has continued to hammer away at acupuncture, and optimism can no longer be justified. You can read about the most recent acupuncture evidence in, Does Acupuncture Work for Pain?.

Tuesday, January 6, 2009 — New section about sleeping factors, “”

Saturday, December 6, 2008 — Physical Therapy just published a new review of a form of therapeutic exercise for the low back (“motor control” training, which is a form of the better known concept of core strengthening), and I’ve integrated it into the tutorial. See the section “.”

Saturday, August 30, 2008 — I published a major upgrade today (by far the largest ever I think). The tutorial gained about 10,000 new words and many miscellaneous improvements. Most of the new content is in the second half of the tutorial. In particular, there are now much more detailed treatment recommendations. Previously, the tutorial leaned too heavily on the idea of the “confidence cure” for low back pain. Even though I do not believe that low back pain is an all-in-your-head problem, some readers may have been left with the impression that the solution is all in your head — which I regret. As important as the confidence cure is, it’s just as important for low back pain patients to have concrete, evidence-based treatment and self-treatment options to pursue (especially treatment options for resolving muscular trigger points in the low back). I’m happy to say that those options are now thoroughly explored. A great deal of content was moved from the trigger points tutorial and adapted specifically for low back pain, and I also spent a lot of time adding miscellaneous practical tips and tricks and re-organizing the entire tutorial. It’s a different e-book! It has the same spirit as before … but with dramatically more practical advice.

Wednesday, June 11, 2008 — Some major upgrades today! This is really where the power of a “web text” really shines, because this new information is based on bleeding edge, just-published science. I finally launched a new major chapter about surgery, “” kicking it off with a brand new section about “” And a large section, “” formerly an appendix, was updated and added to the new surgery section. Other sections about different types of surgery are planned for the relatively near future.

Sunday, April 20, 2008 — Integrated new information (in several places in the tutorial) related to the recent Journal of the American Medical Association study showing that increased spending on spinal pain (i.e. expensive surgical procedures especially) has not generally been helping people. See Back Pain Spending Surge Shows No Benefit in the New York Times, or my own summary, Neck and Back Pain Spending Fails.

Friday, January 18, 2008 — Added valuable new section, “.”

Wednesday, January 16, 2008 — Introduced special offer: all low back pain tutorial customers now receive a second, companion tutorial at no charge, Save Yourself from Trigger Points & Myofascial Pain Syndrome! This is a really great deal, and a valuable extension to this tutorial. If you missed this bargain and want to be included, just drop me a line and I will happily grandfather you into the deal.

Tuesday, January 15, 2008 — Edited and expanded a few footnotes for clarity and to add a little more scientific evidence to the pile.

Wednesday, December 19, 2007 — Today I took some existing content and reorganized it into several new “reality check” sections to help readers make sense of the many questionable theories out there about the cause of low back pain. There were many changes throughout, but most of the new content is in two of those sections, “” and “.”

Sunday, November 11, 2007 — Added a table to the section “,” illustrating the differences between nerve pain and trigger point pain. You can also find the same table in the free article Nerve Pain Is Overdiagnosed.

Sunday, October 7, 2007 — Added a good case study example in “”, and added a long overdue new section about self-treatment of trigger points, “.” It’s rudimentary for now, but will soon be expanded, and of course it links to more complete articles elsewhere on SaveYourself.ca.

Friday, September 28, 2007 — Added new section “” based on very interesting new evidence from Archives of Internal Medicine. You can read about some of this for free in the short article Tantalizing Research About Acupuncture For Low Back Pain.

Thursday, September 20, 2007 — Added a new section based on terrific new science from Archives of Physical Medicine & Rehabilitation. See “.”

Tuesday, September 18, 2007 — Confused about whether or not to ice or heat the low back? I just added a new section, “.” The section is short, but it links to another (free) article that just got a bunch of major upgrading, so the details are available to anyone. And I upgraded the along with it.

September 9, 2007 — A new study of back surgery published in New England Journal of Medicine inspired a major expansion and upgrade to the section, “.” Most of this new information is also available for free in the article Getting back surgery sooner is better than getting it later.

August 20, 2007 — Added the substantial “” section, which discusses competitive back pain cure products, and critically reviews a prominent back pain program called “Lose the Back Pain.” Also spent a couple hours starting to seriously upgrade the treatment recommendations. Historically, this article relied too heavily on the idea that simply understanding back pain was significantly therapeutic in itself — that is true, but it’s not the whole story. The process of beefing up other self-treatment advice began today.

August 5, 2007 — Added the “” and “” sections to bulk up this important subject matter.

August 4, 2007 — Added the “” section to make it more certain that no reader with truly ominous back pain symptoms is inappropriately reassured by this article. Most back pain is not as serious as people think — but some back pain really is serious!

June 5, 2007 — “Modernized” 122 footnotes. When I first published this article, it was the first heavily footnoted document I’d published on the internet, and my methods were clumsy, labour-intense, and error-prone. I’ve installed a much more reliable and user-friendly bibliography system on SaveYourself.ca since then, but only just now got around to converting the messy old footnotes into the shiny new kind of footnotes. Hope you like ‘em!

March 25, 2007 — Thoroughly revised all the sections discussing yoga section. This was in response to some feedback from a client who wisely pointed out that I was too critical of yoga and meditation as a back pain treatment. In my eagerness to make it clear to readers that they don’t have to do yoga and meditate, I neglected to mention that it actually is a good option for people who want to practice yoga and meditation. Good point! Thanks, Sandra.

Further Reading

Acknowledgements

This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stores. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Notes

  1. You need to be able to trust that statement. Is “much” information really “just plain wrong”? I will establish this in the sections ahead with a steady supply of clearly explained references to the medical literature that patients can understand and professionals can respect. This extra “layer” of information in easy-to-use footnotes is available for any reader who wants to dig deeper and check my facts. Return to text.
  2. Bold, blue notes contain extra commentary and detailed information, so check them wherever you want to know more. Light gray notes usually contain only bibliographic data and shorter summaries of scientific papers. All the footnotes can also be found in a list at the foot (of course) of the document.
    2323
    bolder, bluer
    more detail, elaborations, asides    		 lighter, grayer
    bibliographic info and summaries
    of scientific papers
    (often “boring,” but not always!)
    Return to text.
  3. I was an alternative health professional myself for many years — a Registered Massage Therapist, trained in Canada (unusually good training standards). Of course, some of my colleagues in alternative medicine were diligent students of medical science. However, in my experience, most were certainly not — indeed, many lack even the most basic knowledge of how medical science works or how to keep current with recent discoveries with clinical implications. Return to text.
  4. There is an anxiety-producing myth that low back pain is serious and chronic if you can’t shake it after the first several weeks, when in fact many people recover just fine after that “deadline.” An entire section below is devoted to the strong scientific evidence about this. Return to text.

  5. Most doctors are well aware that there are serious shortcomings in the medical management of most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”

    Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good recent example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al.

    More generally, the Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers recently showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard et al wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”

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  6. zoom
    [Cover of Mind Over Back Pain, by Dr. John Sarno]

    Dr. John Sarno’s original best-seller about low back pain.

    My original inspiration for this tutorial was Dr. John Sarno’s book Mind Over Back Pain. His more recent Healing Back Pain also has much to offer. For more information about them, see my review. I recommend these books — the more you read, the better your chances of understanding back pain, gaining confidence, and healing permanently. However, as much as I respect Dr. Sarno’s writings and have been influenced by him, there are at least three reasons why this tutorial is better than his books: (1) I make a much more airtight case against the conventional medical myths of back pain than Sarno does; (2) I also build a much better case for the real causes of back pain, heavily referencing more credible sources than John Sarno does; (3) and I offer many more practical suggestions than John Sarno does, instead of focussing exclusively on the psychological factors. Although I have less experience and education than Dr. Sarno, I do have a lot more hands-on experience. So my advice is to read both his books and this one! Return to text.
  7. This is my translation/interpretation for patients of the somewhat more detailed information for physicians published in “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society”. Return to text.
  8. Dr. Richard Deyo, one of the great myth busters of low back pain research, believes that “low back pain is second to upper respiratory problems as a symptom-related reason for visits to a physician” — only the common cold causes more complaints. Hart et al puts low back pain in fifth place (lower because Hart oddly excludes chronic low back pain). Chronic low back pain is usually the kind that this article will examine. Andersson writes: “Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain ….” Indeed, it is almost impossible to measure how much chronic low back pain there is: for every time that acute low back pain is the main reason for a visit to a physician, how many times does a patient mention low back pain as a secondary problem? Or goes to see an alternative health care professional about it instead? (Answer: pretty danged often.) So it’s actually possible that low back pain is the single most common reason that people seek help. Return to text.
  9. Many researchers seem to believe that low back pain is a modern problem. For instance, Waddell writes, “Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic ….” In 2008, Martin et al found that, “The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7%… to 24.7% … 1997 to 2005,” which certainly shows that it is a growing problem, and therefore likely to be worse now than in the past. A Spanish study (Jiménez-Sánchez et al) showed that musculoskeletal complaints (including a great deal of back pain, presumably) increased significantly from 1993 to 2001 (though remained stable in the years after that). Sarno also strongly portrays low back pain as a modern problem in his books. It’s quite hard to say if back pain actually is a modern problem, or whether it just tends to be described as such. Remember that human beings have a strong tendency to sensationalize and dramatize! Return to text.
  10. Nachemson says, “Rarely are diagnoses scientifically valid ….” And Deyo: “There are wide variations in care, a fact that suggests there is professional uncertainty about the optimal approach.” Many other researchers have made this point, but Sarno states it most eloquently: “There is probably no other medical condition which is treated in so many different ways and by such a variety of practitioners as back pain. Though the conclusion may be uncomfortable, the medical community must bear the responsibility for this, for is has been distressingly narrow in its approach to the problem. It has been trapped by a diagnostic bias of ancient vintage and, most uncharacteristically, has uncritically accepted an unproven concept, that structural abnormalities are the cause of back pain” (p111). Return to text.
  11. Sarno. Mind Over Back Pain, p27. Return to text.

There are 187 more footnotes in the full version of the low back pain tutorial. See above for details, or click the “buy” button to buy it now.