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last updated 10 days ago, Jan 29th, 2010
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 (qualifications)
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 60,000 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. 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 misconceptions about how backs work, and how pain works.
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. They’ve particularly struggled to get the word to alternative health professionals — most of whom don’t even read medical journals.
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. I say “I don’t know” when I don’t know and I say “I’m guessing” when I’m guessing. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 180 footnotes here), and I link to the original sources so you can check them yourself. I hang out with doctors. I study harder than I ever did in school. Much harder.
Some of my favourite sources
I spend a lot of time on PubMed, and I cite from the best sources whenever possible, like The Cochrane Collaboration and The New England Journal of Medicine and PLoS Medicine.
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.
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.
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?
- For chiropractors and massage therapists, the idea of fixing back pain by repairing “crookedness” and “misalignment” is an easy idea to sell … but it’s hard to actually do! Chiropractors can’t even agree with each other which joints need “adjusting” — with only five lumbar joints to choose from.
The idea of fixing back pain by repairing “crookedness” and “misalignment” is an easy thing to sell
- Physiotherapists often treat back pain as kind of postural problem which can be corrected by therapeutic exercises. Unfortunately, the evidence shows that no kind of exercise, not even “core strengthening,” has any significant effect on low back pain.
- In the opinion of medical specialists, most doctors in general practice are not prepared to diagnose and treat low back pain. In particular, they rely much too heavily on MRI scans, unaware that MRI has been proven (many times) to be a poor diagnostic tool for back pain.
- Orthopedic surgeons profit handsomely from the most complex low back surgeries (spinal fusion), and so they tend to think of back pain as a mechanical problem — in spite of the scientific evidence.
- Sports medicine specialists have great injury expertise, and so they often assume that back pain involves some kind of damage — but, once again, evidence clearly shows tissue damage has little to do with back pain.
I’ve worked hard to provide much, much better information about low back pain than is generally available online, or anywhere — not just more of it, but better researched and referenced, and presented in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it.
If you’ve been struggling with a tough case of low back pain, I think this tutorial will feel like a “good find”!
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
Who is this low back pain tutorial for?
Attention physicians & therapists
This tutorial is written for both patients and professionals. It includes detailed analysis of recent research that you won’t find in any textbook, and the document is crafted to suit any skill level. For instance, user-friendly footnotes add an optional layer of detail. See my reading guide for professionals.
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!1 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 a problem, because 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 family doctors — 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.2) 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. It is a document that virtually anyone can learn from, both patients and health care professionals.
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.
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, can suddenly just 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.
Don’t take my word for it!
This tutorial proposes an unconventional and unproved explanation for most back pain: that it is almost always mainly a muscle problem, and not a spinal, structural, or postural problem as diagnosed by most front-line health care professionals. Many doctors object to this idea, but the ones that matter — the most credible medical experts — actually taught it to me.
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 interpret and cite good science.
Everything written here is thoroughly supported by references to scientific articles, heavyweight medical expertise, and copious explanatory footnotes. There are about 170 more of those in the 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 pain3 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.
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 is not ominous, and is not nearly as serious it feels. 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 not worry excessively before that.
The rule of thumb4 is that you should start a more thorough medical investigation only when three conditions are met:
- it’s been bothering you for more than about 6 weeks
- it’s severe and/or not improving, or actually getting worse
- there is at least one other “red flag” (see below)
And there are also a couple situations where there’s no need to wait several weeks before deciding the situation is serious …
- significant numbness around the groin and buttocks and/or failure of bladder or bowel control
- 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:
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.56 Yet the real causes of most back pain are obscured by medical mythology and misunderstanding.7 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 evidence8 — 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
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I have to — it’s required by law to prevent fraud. However, Big Brother is not watching my customer database, and I have no use for your personal information. If you want, just fill in fake contact information. People do it all the time! I do need a real email address, or you won’t get a receipt.
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No, there is no actual book. I sell online access to pages on SaveYourself.ca, just as scientific journals sell access to their articles — this is known as a “document-access” business model. You buy the right to visit the tutorial online for 90 days. Until you pay, it’s impossible to get to. While you have access, you can read the tutorial online. To preserve your purchase, you can print the tutorial, or save it as a webarchive file (instructions available to customers).
I’d rather read a book. Will you be publishing a book?
Almost certainly, but not for a while yet. For now I prefer to sell access to webpages. They are simply a better product: cheaper to produce, update, and deliver.
Do I have to download anything? Is there a PDF?
No, there is no file to download and store. There are several issues with PDFs: they are hard to update, glitchy and unreliable, difficult for some beginners to use, and more. Tutorials in the form of webpages are the superior product.
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An eBoxed set is a bundle of all eight eBooks about pain problems for sale on this website, ideal for professionals, keen patients and anyone who wants more for less. Purchased individually, they would run you about $160, but the set is only $79.50 — a savings of $80.
Benefits include the savings, a full-year subscription, and inexpensive renewal forever.
Want only 5 tutorials? No problem. Just let me know which ones you’d like.
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Plus …
- Free second tutorial! When you buy this tutorial, you will also get Save Yourself from Trigger Points and Myofascial Pain Syndrome! — a $1995 value. The low back pain tutorial makes the case that trigger points are a major factor in low back pain. However, trigger point therapy is not an easy skill to master — and it’s an enormous subject. SaveYourself.ca publishes a separate tutorial about trigger point therapy. It’s offered as a free, essential companion to the low back pain tutorial. As a pair, they give you everything you need to know about helping most cases of low back pain.
Here’s a sneak peak of the Table of Contents for the low back pain tutorial…
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 90 days access print or save 100% money-back guarantee exhaustively researched constantly updated reader questions answered 70,000 words 75 sections 171 footnotes all myths & controversies all diagnostic issues all treatment options
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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
Amsterdam Jeroen Strompf, MFA, Screenwriting, Chapman University
Jan Nelson, pharmacist and power yoga practitioner
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
Osman Hassan, London
Jean Gallagher, low back pain sufferer, California
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:
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.
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, Pain medications (and even alcohol) can be useful, and a brand new section, Less than a cure, but better than nothing: thoughts on getting short term symptom relief from low back pain.
Friday, January 22, 2010 — A new section covering cheaper and safer methods of tractioning: Traction: low back pain on the rack.
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: Problems and limitations of trigger point therapy, and how to use them to your advantage. 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 “Your back is NOT FRAGILE!” 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, “Chronic low back pain is not so chronic: the myth of chronicity,” 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 — starting here — 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, “All the treatment options summarized.”
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 section on nerve pain.
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 subluxations and spinal manipulative therapy (SMT) 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 “Physiatry for low back pain.” 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 “What if there’s something really wrong in there?” 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, “A few more snack-sized reality checks: brief comments on other treatments to avoid.”
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 “Prolotherapy: still popular, and for no good reason.”
Saturday, May 16, 2009 — Small new section, based on some persuasive scientific reviews recently published in the journal Spine: “Facet joint steroid injection is not recommended for most patients.”
Saturday, May 16, 2009 — Substantive new section, “Some other real causes of back pain,” 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: “The strange case of scoliosis, which also exists (of course), but is also over-blamed for low back pain” and “Scoliosis cannot be straightened without surgery.”
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: “Appendix C: A great example of how old ideas persist in health care.”
Monday, February 2, 2009 — Some small but important updates to the section, “The fascinating case of acupuncture, formerly a contender in low back pain therapy.” 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, “What about sleeping position and pillowing?”
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 “Reality check: core weakness, core strength.”
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, “What about surgery?” kicking it off with a brand new section about “Surgery for sciatica: mostly underwhelming.” And a large section, “The placebo problem,” 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, “Deal with insomnia.”
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, “Reality check: the structural theories (short legs, outta whack pelvises, and spinal curvature)” and “Reality check: obesity.”
Sunday, November 11, 2007 — Added a table to the section “Reality check: neurophobia!,” 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 “What is the real cause of most low back pain?”, and added a long overdue new section about self-treatment of trigger points, “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 “The fascinating case of acupuncture” 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 “Structural problems are hard to diagnose.”
Tuesday, September 18, 2007 — Confused about whether or not to ice or heat the low back? I just added a new section, “Icing exception: (almost) never ice low back pain.” 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 heating section 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, “The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries.” 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 “About ‘miracle’ back pain cures” 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 “Fear of nerves” and “True nerve problems” sections to bulk up this important subject matter.
August 4, 2007 — Added the “What if you’re broken?” 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, and added the “Yoga and meditation are still an option” 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
- Mind Over Back Pain: A radically new approach to the diagnosis and treatment of back pain, a book by John Sarno (book review). Essential reading for anyone with back pain or neck pain, and for all physicians and physical therapists.
- The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, a book by Clair Davies and Amber Davies (book review). This is an important book: offering hope and practical, effective self-treatment tips to countless people suffering needlessly from pain that doctors have failed to diagnose. Unfortunately, Davies also makes it sound like trigger point therapy can cure anything.
That doesn’t work, of course. But considering the importance of trigger points to virtually all low back pain, this book is a worthwhile investment. - Complications: a Surgeon's Notes On an Imperfect Science, a book by Atul Gawande. Gawande’s entire book is worth reading, but his chapter on pain physiology is certainly the best summary of the subject I have ever read, and a terrific reminder that good writing for a general audience can be just as illuminating for professionals. Anyone struggling with a pain problem should buy the book for this chapter alone, though you are likely to enjoy the whole thing. Much of the chapter focuses on one of the most interesting stories of low back pain I’ve read, and it is a responsible and rational account — although Gawande, like most doctors, seems to be unaware of the clinical significance, or even existence, of myofascial trigger points.
“How Doctors Think,” a chapter by Jerome Groopman MD in the book How Doctors ThinkGroopman, writing from personal experience with chronic back pain and a spinal fusion surgery, discusses back pain as intelligently as any medical expert I’ve come across, but he does so in a way that will fascinate patients. In this chapter, his discussion of back pain is placed in the context of how medical thinking is influenced by marketing and money, giving us a somewhat chilling insiders’ view of the surgical treatment of back pain. And despite the quality of Groopman’s writing and thinking, he is yet another doctor who seems to be uninformed about myofascial trigger points.
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
- 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.
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 numerous studies showing that most doctors do not understand aches and pains. 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 felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”
Return to text.- 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.
![[Cover of Mind Over Back Pain, by Dr. John Sarno]](/resources/images/books/book-sar.jpg)
Dr. John Sarno’s original best-seller about low back pain.
- 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.
- Deyo believes that “Low back pain is second to upper respiratory problems as a symptom-related reason for visits to a physician,” implying that only the common cold causes more complaints. Hart et al put “‘mechanical’ low back pain” in fifth place, and the difference may be due to the fact that Deyo is including chronic low back pain in his estimate. 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 a complementary health care professional about it instead? Return to text.
- 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. 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.
- 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.
- Sarno. Mind Over Back Pain, p27. Return to text.
