SaveYourself.ca •Sensible advice for aches, pains & injuries
 
[Picture of a healthy low back.]

Got low
back pain?

Back pain’s bark is usually much worse than its bite.

Save Yourself from Low Back Pain!

Low back pain myths debunked and all your treatment options reviewed

91,000 words, updated Jul 11th, 2014 — What’s new?
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

Welcome to one of the Internet’s saner sources 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 the tone is often light, like this footnote about being “shot by the witch.”1 I will offer you some important ideas — underestimated factors — about the nature of back pain, but I will not try to convince you that all back pain comes from a single cause or cure. It’s “just” a detailed tour of the topic, the myths and misconceptions, and the best (and worst) treatment ideas available.

Since I first started treating patients with low back pain in 2000, there has been an explosion of free information about it 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.23 That’s hardly surprising, but even professional guidelines are often misleading.4 For instance, despite overwhelming scientific evidence to the contrary, most sources of information about low back pain for patients incorrectly portray it as a “mechanical” problem, as if the spine is a fragile structure which breaks down and causes pain.5 This is based on many common misconceptions about how backs work, and how pain works.

I am a science writer & amateur athlete in Vancouver, Canada. I’ve been writing about low back pain for over a decade, in part to understand & manage my own chronic pain problems, including rare but nasty episodes of back pain. ~ Paul Ingraham
About footnotes. There are 322 footnotes in this document. Click to make them “pop up” without losing your place. There are two types: interesting extra content, and boring reference information.1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.
Try one!

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 or weeks. The seriousness of chronic low back pain is often expressed in terms of the hair-raising economic costs of work absenteeism, but chronic musculoskeletal pain may well be far worse than that — a recent Swedish study shows that it probably even shortens people lives.6 The stakes are high. “Tragedy” is not hyperbole.

Even more tragic is that good information exists, and not just here in this book: many medical experts do “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 mostly excellent guidelines for low back pain care, family doctors still don’t pay much attention to 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, “Low back pain and best practice care: a survey of general practice physicians,” 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.7

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.

The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).

Teaching people about pain — why do we keep beating around the bush?, by Lorimer Moseley, pp2–3

How can you trust this information about low back pain?

I question everything and I have fun doing it. I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of low back pain. 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 330 footnotes here), and I always link to the original sources.

You don’t need to take my word for anything — you can just take the word of the many low back pain medical experts that I quote,8 and the hard evidence that their opinions are based on. At the same time, I am realistic about the limits of the science, much of which is pretty junky.9 My own credentials are somewhat beside the point. My decade of professional experience as a Registered Massage Therapist does help me understand and write about low back pain, but what really matters is that I refer to and explain recent scientific evidence, but without blindly trusting it.

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?

  • Repairing spinal joint “misalignment” is an easy idea to sell … but it’s hard to actually do! Chiropractors often can’t even agree on which joints need “adjusting” — even with only five lumbar joints to choose from.
  • Poor posture and crookedness is another popular scapegoat — it seems obvious that posture is relevant. Many professionals assume that back pain is some kind of postural problem that you can exercise your way clear of. Unfortunately, the evidence shows that no kind of exercise, not even the most hard-core core strengthening, has any significant effect on low back pain.
  • The almost magical power of MRI to look inside the back gives both doctors and patients something to point at and blame, but most are unaware that MRI has been proven (many times) to be a lousy diagnostic tool for back pain. The things you see on MRI scans are rarely the real problem.
  • Orthopedic surgeons (especially American ones) profit handsomely from the most complex low back surgeries (especially spinal fusion), so they are strongly inclined to think of back pain as a mechanical problem in need of physical repair — in spite of piles of scientific evidence to the contrary. If all you have is an incredibly profitable hammer …
  • Sports medicine specialists have great expertise about injuries, so they often assume that back pain involves some kind of damage — but the evidence clearly shows that low back pain often has nothing to do with tissue damage.

Is professional care for low back pain really this dodgy? Sadly, I believe so. I clearly remember graduating clueless myself. If I hadn’t spent many years doing post-grad study of low back pain, I 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 book 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 to be serious and stubborn. Some safety information is provided below about 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!10 When you don’t recover, your therapeutic options — things like surgery for a herniated disc — cause uncertainty and alarm that are unnecessary and harmful in their 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 doctors — quite a lot more! (Not that this is saying much — you have probably already discovered that few GPs know much about back pain.11) I have spent many years assembling this information from hard study, professional experience, and lots of 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 in every case. Some low back pain cannot be fixed — sadly, a few people suffer with it 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 surprisingly treatable. People who believed for years that their pain was invincible have found relief. Not always, and often not completely — but sometimes any relief is far better than nothing. How can extremely stubborn pain finally ease up? Simple: because many cases weren’t truly stubborn to begin with, despite all appearances. So many health professionals are poorly prepared to treat low back pain that patients can easily go for months or even years without once getting good care and advice. When they finally get it, it’s hardly surprising that some 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. Lots of people who thought they’d “tried everything” for lower back pain read this tutorial and then write to me and say, “Well, I guess I hadn’t tried everything!”

Similarly, many athletes with “career-ending” injuries are far from finished. Bret “The Glute Guy” Contreras, from You’ll Never Squat Again:

Numerous powerlifters over the years have come back following ‘career-ending injuries’ to set all-time personal records. Donnie Thompson is the only man to total 3,000 lbs (1,265 lb squat, 950 lb bench, 785 lb deadlift). Many people don’t know this, but several years back Donnie suffered a horrendous back injury and herniated three discs. He could barely walk, but he got out of bed and rehabbed himself every day. Within three months he was back to heavy squatting and setting personal records. Got that? Setting personal records three months following an injury that herniated 3 discs!

How could that be? It’s almost like herniated discs aren’t necessarily as scary as everyone seems to think. Hm!

I have never met a patient — no matter how experienced or self-educated — who could not gain at least some new insights and new hope from this tutorial.12

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 pain13 is that he tends to give patients the idea that recovery from low back pain is all a mind game. It’s not! “The biology of pain is never really straightforward, even when it appears to be.” (Moseley)

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.

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 seriously wrong in there?”

You’re not paranoid if they really are after you!

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

“Could it be cancer? A tumor?”

It’s not likely to be something serious, but it could be. Andy Whitfield, star of the hit TV show Spartacus, thought he just had back pain from his intense training to look the part of a gladiator. In fact, he had a tumour — which killed him in 2011.

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, that its bark is worse than its bite. 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 usually diagnosed correctly and promptly. If you are aware of these red flags, you can get checked out when the time is right — but please avoid excessive worry before that.

The rule of thumb14 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 six weeks
  2. the trend is strongly 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 you shouldn’t 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:

In all other cases, you can safely read this tutorial first. For instance, even if you have severe pain or 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 — rest and read. Your back is not as fragile as you probably think, and understanding why is a great starting place for healing in nearly all cases of low back pain.

Don’t confuse threat and risk. Working at the edge is a risk. But then again, so is walking out your front door.

Cory Blickenstaff, PT

Part 2

Diagnosis

Your low back is not fragile!

Modern civilization suffers from a great plague of low back pain.1516 Yet the real causes of most back pain are obscured by medical mythology and misunderstanding.17 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 patient-focused low back pain information, 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 thinking is not based on evidence.18 Indeed, just the opposite is more the case: “The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).”19 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

Purchase full access to this tutorial for USD$1995. Continue reading immediately after purchase. A second tutorial about muscle pain is included free.

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  • What do you get, exactly? An online tutorial, the size of a small book (91,000 words). MORE
  • Buy more & save 50%! Get a “boxed” set of all eight tutorials for great savings.MORE

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.
 
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Part 2.1

Appendices

Supplements and downloads

Customers are entitled to access some special supplements and downloads. These documents are just as much a part of the tutorial as the included chapters, but they are separated so that they can serve as common resources for other tutorials as well, such as the neck cricks or trigger points books.

  • SUPPLEMENT Does Spinal Manipulative Therapy (SMT) Work? — Adjustment, manipulation, and popping of the spinal joints and the subluxation theory of disease, back pain and neck pain
  • SUPPLEMENT Do Nerve Blocks Work for Neck Pain and Low Back Pain? — Analysis of the science of stopping the pain of facet joint syndrome with nerve blocks, joint injections, and nerve ablation
  • QRG Trigger Point QRG — Quick Reference Guide to Trigger Point Diagnosis and Self-Treatment

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 stories. 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.

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). amazon.com 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.
  • “The Pain Perplex,” a chapter in the book Complications, 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.
  • “Marketing, Money, and Medical Decisions,” a chapter in the book How Doctors Think, by Jerome Groopman MD. Groopman, 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.

Reader Comments

Here is what some readers have said about the low back pain tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!


I have had life-altering low back pain for more than 8 years. I’ve had the fusions at L5-S1. Prior to my first surgery I spent 18 months seeking relief through physical therapy, intense massage therapy, myofascial “release” therapy, a visit to Dr. Sarno himself, injections, dry needling of trigger points and massage from a physiatrist, chiropractic work and more. For years between surgeries I tried core strengthening, acupuncture, PT, more massage, two rhizotomies, and visits to the Mayo clinic and Johns Hopkins’ pain management in-patient programs. So I’ve been through a lot. And your book is the first thing I’ve read that dispassionately and entertainingly dissects all of the options and offers some realistic, pragmatic suggestions. It’s a gift to all back pain sufferers.

— John Ford, veteran of severe chronic back pain


Your tutorial was really important because it gave me confidence that while it hurt, it was probably not serious. I particularly appreciated the idea that the back is not “vulnerable” and discs are not going to pop out every time you exert yourself. So I stayed calm, kept active within limits, and got some massage. In a few weeks, my back felt really good, the referred pain had stopped going down my hips and legs, and things have stayed good even after playing in a tennis tournament.

— John Dunn, Ottawa


I purchased the low back tutorial recently and got the free trigger points one also. Many thanks. They are great! I had already accessed the perfect spot series and have been working on my trigger points. It is very pleasing to have the full discussion on the chemistry and physiology, and I now have a much better idea about the whole ghastly business.

— Leah Brannen, Saskatoon, Canada


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


One more special comment. 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 this tutorial?

This tutorial has been continuously, actively maintained and updated for 10 years now, staying consistent with professional guidelines and the best available science. The first edition was originally published in September of 2004, after countless hours of research and writing while I spent a month taking care of a farm (and a beautiful pair of young puppies) in the Okanagan.

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 79 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Minor update (Jul 11 '14, section #4.21)Added Digital Motion X-ray. See section #4.21, A few more snack-sized reality checks: brief comments on other treatments to avoid.

Minor update (Jul 8 '14, section #3.29)Plugged a good quality microbreaking reminder app See section #3.29, Office work, chairs and ergonomics, and weekend warriorism.

Minor Update (Jul 8 '14, section #2.25)Some relevant humour: added a pretty funny video about a core strengthening product. See section #2.25, Is it core weakness?

New section (Apr 24 '14, section #4.19)A minor topic, but one of the most overdue sections I’ve ever added to the book: I’ve been asked about these devices a lot over the years. See section #4.19, Back bracing and stabilization contraptions (especially inflatable ones).

Rewritten (Jan 8 '14, section #3.28)Cleaned up and modernized, more information, especially a more useful and evidence-based self-treatment tip. See section #3.28, Morning pain and sleep posture.

New section (Jan 1 '14, section #2.11)No notes. Just a new section. See section #2.11, 3 Lessons From an Acute Back Trauma: Joint popping, muscle dominance, and the mind game.

Minor update (Dec 23 '13, section #4.9)Added some great backup from a terrific surgeon blogger — who advocates for the necessity of testing placebo surgeries, exactly as I have in this section for many years. See section #4.9, The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries.

Minor update (Dec 21 '13, section #3.8)Added a (fascinating) footnote about the myth of anaesthetic paralysis. See section #3.8, Pain medications (and even alcohol) can be useful.

Expanded (Dec 20 '13, section #4.13)Added subsection on electroacupuncture. See section #4.13, The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.

Science update (Dec 20 '13, section #3.1)Reporting on the greatest hits of back pain science (Machado 2009, a source of several important points here and in other sections). See section #3.1, So what’s the plan?

Science update (Sep 26 '13, section #3.25)Some science showing that the effect of hamstring tightness on back function/pain isn’t exactly potent. See section #3.25, What about stretching?

Science update (Sep 12 '13, section #4.14)Interpretation of a little junky new science about Pilates. See section #4.14, Core strengthening has failed to live up to the hopes and dreams of therapists and patients.

Comedy update (Aug 13 '13, section #2.8)Added an amusing, extended example from the TV show, The IT Crowd. See section #2.8, Pain and fear, together at last: an even simpler vicious cycle.

Minor update (Jul 20 '13, section #3.5)Added a quote that beautifully expresses the reason for treating chronic pain with … maturity. See section #3.5, Another %!@&*!! personal growth opportunity.

New section (Jul 20 '13, section #2.8)An overdue upgrade! This way pain and fear power each other is now explained much more clearly and thoroughly than before. It’s noteworthy that, with this update, Dr. Lorimer Moseley’s valuable perspective on back pain is now fairly well-represented in this book. See section #2.8, Pain and fear, together at last: an even simpler vicious cycle.

New section (Jun 5 '13, section #4.20)Important new chapter about a hype-hot news item. See section #4.20, The antibiotics for back pain debacle.

New evidence (May 29 '13, section #3.2)Rare good news: the first good quality scientific test of “the confidence cure” had promising results — which is just about the best thing that could have happened to this chapter. See section #3.2, The confidence cure.

Minor update (Apr 4 '13, section #2)Interesting, useful new reference to Barzouhi. See section #2, Diagnosis: Your low back is not fragile!

Minor update (Mar 29 '13, section #3.8)Upgraded risk and safety information about Voltaren Gel. See section #3.8, Pain medications (and even alcohol) can be useful.

New section (Feb 2 '13, section #4.4)No notes. Just a new section. See section #4.4, As if massage wasn’t good enough already!

Major update (Jan 26 '13, section #4)All major professional treatment options now summarized. See section #4, Getting professional help: A consumer’s guide to buying therapy and medical care for low back pain.

New section (Jan 26 '13, section #3.1)New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan. See section #3.1, So what’s the plan?

Major update (Jan 26 '13, section #3)All major self-treatment options now summarized. See section #3, Self-treatment options: How to save yourself from low back pain, or at least avoid getting hurt or ripped off trying.

Edited (Jan 19 '13, section #3.2)Nothing in particular has changed, but it’s definitely a better chapter now. See section #3.2, The confidence cure.

Science update (Nov 10 '12, section #4.13)New reference strongly supporting a key, controversial point. See section #4.13, The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.

Minor update (Nov 2 '12, section #2.23)Added an intriguing quote about evolution and the lack of back pain in hunter gatherers. See section #2.23, Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves.

Science update (Oct 28 '12, section #2.26)Put “foot fear” in context with some reassuring high heels science. See section #2.26, Is it all in your feet? Foot-o-centric low back pain theories.

Science update (Oct 26 '12, section #1.1)Added evidence that the stakes are high with chronic pain: it may even shorten lives. See section #1.1, A tragic low back pain myth.

Minor update (Oct 24 '12, section #3.24)Added a new suggestion for safe, pleasant self-tractioning. See section #3.24, Traction: low back pain on the rack!

New section (Oct 24 '12, section #2.31)No notes. Just a new section. See section #2.31, Back pain and sneezing.

Science update (Jul 4 '12, section #2.3)Interesting evidence that massage therapists cannot reliably find the side of pain by feel. See section #2.3, Structural problems in the low back are hard to diagnose accurately.

Minor update (Jun 7 '12, section #3.4)Added a fine example of taking yoga very, very seriously as an option. See first footnote in section. See section #3.4, Stress relief and the tyranny of meditation and yoga.

Update (Apr 27 '12, section #3.6)Editing, and several new paragraphs about safety issues. See section #3.6, Yoga and meditation are still an option, of course.

Minor update (Apr 27 '12, section #3.4)Some simple revision for clarity and quality, and a bit more content. See section #3.4, Stress relief and the tyranny of meditation and yoga.

Science (Apr 4 '12, section #4.14)More science, and a few substantial new footnotes fielding common concerns and questions. See section #4.14, Core strengthening has failed to live up to the hopes and dreams of therapists and patients.

Science update (Mar 21 '12, section #2.23)Clarified information about pelvic tilt, and beefed it up with some more science. See section #2.23, Are you crooked? The alignment theories: short legs, pelvic tilts, and spinal curves.

Minor update (Mar 7 '12, section #3.8)Important new, skeptical footnote about the dangers of the powerful narcotic drugs. See section #3.8, Pain medications (and even alcohol) can be useful.

Science update (Dec 16 '11, section #4.14)More evidence of the exercise effects are limited and non-specific. See the paragraph starting “Does spinal function improve…” See section #4.14, Core strengthening has failed to live up to the hopes and dreams of therapists and patients.

New section (Dec 10 '11, section #3.3)No notes. Just a new section. See section #3.3, What is the difference between a ‘confidence cure’ and a mere placebo?

Updated (Dec 1 '11, section #4.5)Added scientific cases studies, examples, pictures and video of true dislocation and abnormal anatomy to help drive home the point that even significant spinal joint dysfunction can be surprisingly harmless … never mind subtle joint problems. See section #4.5, Spinal manipulative therapy (SMT): Adjustment, manipulation, and cracking of the spinal joints.

Minor update (Nov 25 '11, section #2.4)Minor, but fun — a great quote about models of slipped discs, and a good new image to help it along. See section #2.4, Those scary spine models.

Rewritten (Nov 23 '11, section #4.7)Improved and expanded. In particular, intramuscular stimulation (IMS) was “demoted.” I am disillusioned with it and no longer want to promote it without strong caveats. See section #4.7, “Medical” treatment option for trigger points: dry needling (IMS), stretch and spray, and trigger point injections.

Major science update (Nov 3 '11, section #3.6)Detailed reporting on some new yoga science. Significant re-writing of the section ensued. Sometimes new science does not back up my preconceptions: I’ve changed my tune here somewhat. See section #3.6, Yoga and meditation are still an option, of course.

Minor update (Nov 1 '11, section #2)Added a couple great points/quotes from doctors about overuse of MRI, as reported by Gina Kolata for the New York Times. See section #2, Diagnosis: Your low back is not fragile!

New science (Aug 26 '11, section #2.28)I tumbled at random across a fantastic scientific paper about the prevalence of nerve pinches (hint: it’s low). Great stuff! A most welcome addition. See section #2.28, Could you have a “pinched” nerve? The nerve pinch myth.

New section (Aug 26 '11, section #2.17)A key concept covered in the trigger points tutorial long ago, but so relevant to low back pain that I decided it needed to be here as well. See section #2.17, Could it be a vicious cycle of pain-spasm-pain?

New section (Aug 26 '11, section #2.16)This section is a summary of an important concept that’s been available in a free article since late 2008, but it really needed to be emphasized here. See section #2.16, From the frying pan of injury pain to the fire of trigger point pain.

Minor update (Aug 12 '11, section #3.19)A few new paragraphs summarizing an important new study of massage for low back pain with disappointing results. See section #3.19, The evidence for massage.

Minor update (Jul 29 '11, section #1)Added a reference about the poor overall quality of online information about common injuries. See Starman et al. See section #1, Introduction.

New section (Jul 13 '11, section #2.12)More information about an important characteristic of muscle-dominated back pain. See section #2.12, “Out of nowhere”: seemingly random episodes of low back pain.

Major update (Jul 12 '11, section #2.10)Totally renovated section: re-written, reformatted, expanded, upgraded. A few new checklist items were added, most were expanded, and all were clarified. A separate and handier “quick” checklist was added to the existing “slow” checklist. See section #2.10, A trigger point checklist: does this sound like you?

Major update (Jun 19 '11)Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

Minor Update (May 11 '11, section #4.9)Added evidence that spinal fusion surgeries are not just ineffective but often harmful (Nguyen). See section #4.9, The back surgery placebo problem, and how it limits our knowledge of the effectiveness of back surgeries.

Minor update (May 11 '11, section #3.8)Added a fascinating science item about the effect of anti-inflammatory gels on back pain (Huang). See section #3.8, Pain medications (and even alcohol) can be useful.

Minor Update (May 11 '11, section #2.24)Long overdue, I finally added some science to this section, showing that the connection between low back pain and obesity is weaker than it seems (Wright). See section #2.24, Do you really need to lose some weight?

Minor Update (May 5 '11, section #2.25)Added some interesting references about sensation (Luomajoki) and the relationship between back pain and a disrupted “body schema” (Bray). See section #2.25, Is it core weakness?

Upgraded (Feb 17 '11, section #4.5)New artwork from SaveYourself.ca artist Gary Lyons, plus some important new references. See section #4.5, Spinal manipulative therapy (SMT): Adjustment, manipulation, and cracking of the spinal joints.

Minor Update (Feb 17 '11, section #2)Added a fun and informative quote from the TV show House. See section #2, Diagnosis: Your low back is not fragile!

Updated (Jan 12 '11, section #2.2)Added some new evidence about back pain and aging, and a nice new graph. See section #2.2, Maybe you’re just getting older? Actually, no ….

Minor update (Jan 7 '11, section #4.18)Just added a link, but a really great link! The CBC show Marketplace did an amazing job last year reporting on spinal decompression machines. Well worth a look — the show and their show page is probably now the single best source of information on this topic. See section #4.18, Spinal decompression therapy: worth the money and risks?

Minor update (Jan 7 '11, section #2.25)Some editorial cleanup on core strengthening, and I a link to a good summary of recent research. See section #2.25, Is it core weakness?

Like new (Dec 29 '10, section #3.21)Re-written and significantly expanded. See section #3.21, Act normal! Rest minimally and strategically, while maintaining as much normal activity as you can.

New section (Dec 29 '10, section #2.18)No notes. Just a new section. See section #2.18, Could low back pain be an overuse injury?

Major Update (Oct 1 '10, section #2.22)Rewriting and expansion of the Special Supplement on spinal manipulative therapy. See section #2.22, Is there such a thing as a “subluxation”? Can your back be “out”?

Updated (Sep 21 '10, section #2.3)Added a much more detailed description of the Hancock et al study, and in fact turned it into the main substance of this section. See section #2.3, Structural problems in the low back are hard to diagnose accurately.

Updated (Sep 15 '10, section #2)Added a very beefy footnote about some new research showing that muscle imbalance does not result in higher rates of injury. This almost should have been a new section, but I decided to just make it a ginormous footnote — footnotes are there for delving if you want to, that’s the idea! You can read a summary of the research in the bibliography (see Hides et al), but the relevance to back pain is spelled out in detail here. And it’s interesting. See section #2, Diagnosis: Your low back is not fragile!

Upgraded (Aug 25 '10, section #4.13)Section now includes discussion of that bizarre and already infamous paper in the New England Journal of Medicine (see Berman). I also make an important new point: exactly why acupuncture placebos are such a problem for low back pain patients in particular. See section #4.13, The fascinating case of acupuncture, formerly a contender in low back pain therapy, but which has now miserably failed well-designed scientific tests.

Like new (Aug 7 '10, section #4.14)Rewritten. I’ve lost track and can’t be bothered to go back into the archives to figure it out for sure, but I think that this section was brand new (but never announced) late in 2009, and then this past week I gave it a substantial upgrade: it is now one of the best-referenced chapters in the book, and it says as much as probably needs to be said on the subject — or more! See section #4.14, Core strengthening has failed to live up to the hopes and dreams of therapists and patients.

New cover (Aug 6 '10)At last! This e-book finally has a “cover.” SHOW

Minor update (Jun 7 '10, section #3.8)Updated with a summary of a bizarre experiment with muscle relaxants that had quite surprising results. See section #3.8, Pain medications (and even alcohol) can be useful.

Minor update (Jun 5 '10, section #4.21)Added a scientific thumbs down for transcutaneous electric nerve stimulation (TENS). See section #4.21, A few more snack-sized reality checks: brief comments on other treatments to avoid.

New section (Jun 5 '10, section #3.9)A surprising scientific thumbs up for comfrey ointment was worth a whole new small section. See section #3.9, Comfrey makes backs comfy, study claims.

Minor update (Feb 13 '10, section #1.1)Added clear evidence that family doctors don’t do a good job caring for patients with low back pain, and that a myth-busting ebook like this is still important. See section #1.1, A tragic low back pain myth.

New section (Jan 23 '10, section #3.32)No notes. Just a new section. See section #3.32, Less than a cure, but better than nothing: short term symptom relief options for low back pain.

New section (Jan 23 '10, section #3.19)An important update: a major new section that goes a long way to substantiating one of the most important points of this tutorial. See section #3.19, The evidence for massage.

Major upgrade (Jan 23 '10, section #3.8)Rewritten and significantly expanded information about medications. See section #3.8, Pain medications (and even alcohol) can be useful.

New section (Jan 22 '10, section #3.24)Having debunked expensive spinal traction using expensive decompression machines, here are some ideas for cheaper and safer methods of tractioning. See section #3.24, Traction: low back pain on the rack!

New section (Jan 21 '10, section #4.18)No notes. Just a new section. See section #4.18, Spinal decompression therapy: worth the money and risks?

New section (Nov 25 '09, section #3.12)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. It all evolved from writing about an important bit of research, showing that manual therapists cannot (reliably) diagnose trigger points. See section #3.12, Limitations of trigger point therapy, and how to take advantage of them.

Notes

  1. Hexenschuss is a German word for back spasm or lumbago, but translated literally it means shot by the witch (hexe = witch and Schuss = shot). Those Germans have a word for everything! Hat tip to reader Richard Moison for teaching it to me. BACK TO TEXT
  2. 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. For example, here’s a good start: In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
  3. I like to kick off a topic with an example of a terrible website about it, just for the chuckle and a teachable moment. ThePain.net is one of the worst I’ve seen: a large, stale, ugly thing by Pekka Palin, MD. There are hours of terrible reading there! Dozens of blandly composed, shallow, rambling, and frequently irrational mini-articles on every imaginable pain subject, all 100% unreferenced, laid out in huge blocks of text without a subheading for many screens (a typographic travesty). There’s soooo much badness, but I really got a chuckle out of this perfectly pointless phrase: “The most common reason for temporary back pain is lumbago.” Now “lumbago” means “back pain” (see the definition of lumbago on Wikipedia), so Dr. Obvious has helpfully explained that the cause of back pain is, er, back pain. The Internet, at your service! BACK TO TEXT
  4. Turns out that the committees that write these things do not necessarily know the science! One of the best reviews of back pain research ever published — Machado 2009, more on this one later — found something really interesting: “treatment recommendations from recent clinical guidelines do not align with the results of this meta-analysis.” In fact, quite a few disproven pain treatments are still cheerfully recommended in otherwise sensible professional guidelines. Eek. BACK TO TEXT
  5. Zusman. Belief reinforcement: one reason why costs for low back pain have not decreased. J Multidiscip Healthc. 2013. PubMed #23717046.

    To kick of the referencing, here’s the first of many expert opinions and quotes about this, from a 2013 paper by Max Zusman, explaining why low back pain is still such an incredibly costly problem for society:

    It is extremely difficult to alter the potentially disabling belief among the lay public that low back pain has a structural mechanical cause. An important reason for this is that this belief continues to be regularly reinforced by the conditions of care of a range of ‘hands-on’ providers, for whom idiosyncratic variations of that view are fundamental to their professional existence.”

    Well said, but perhaps a bit wordy. Here’s the simple version: patients believe back pain is caused by structural fragility, and careers are built on catering to that belief. I would also say that it is difficult to alter that belief in anyone, patient or professional. This preoccupation with fragility isn’t just reinforced by the practices of many therapists, it’s a major reason reason for them.

    BACK TO TEXT
  6. Jansson et al. Sickness absence because of musculoskeletal diagnoses and risk of all-cause and cause-specific mortality: A nationwide Swedish cohort study. Pain. 2012. PubMed #22421427. BACK TO TEXT
  7. I was an alternative health professional myself for many years — a Registered Massage Therapist, trained in Canada (which has 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 lacked even the most basic knowledge of how medical science works or how to keep current about recent discoveries with clinical implications. BACK TO TEXT
  8. Dr. Richard Deyo, low back pain expert

    Don’t take my word for anything. 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.

    BACK TO TEXT
  9. That’s a huge topic, but here’s one simple example of an extremely common problem with back pain science: control groups that don’t control. Rather than comparing a treatment to a good, carefully selected placebo, most studies use a comparison to a treatment that is allegedly neutral, underwhelming, or placebo-ish. That makes the results hard to interpret: if each works about the same, it could mean that the treatments are equally effective … or equally ineffective! So much back pain science has this problem — or any one of a dozen other weak points — that you can effectively ignore at least 80% of all back pain research, because it’s so far from the last word on anything. Good science is essential to solving these problems, but really good studies are also difficult to design and rare. BACK TO TEXT
  10. 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. BACK TO TEXT
  11. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches and Pains. BACK TO TEXT
  12. Once in a great while some cranky reader (always a guy) writes to tell me, “I didn’t learn anything from your book.” I’m a little skeptical about that, and it’s always tempting to start quizzing! There’s a great deal of information here, including analyses of recent research. Sure, readers who have already done a lot of reading about back pain might already be familiar with a lot of it — but you will know that going in, of course, and you’ll find the nuggets of new information and perspective that any keen reader is always looking for. BACK TO TEXT
  13. [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 1984 book Mind Over Back Pain. (His more recent Healing Back Pain make too many empty promises. See my review.) However, as much as I respect Dr. Sarno’s early work, 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 Dr. Sarno does; (2) I also build a much better case for the real causes of back pain, heavily referencing more credible sources than Dr. Sarno does; (3) and I offer many more practical suggestions than Dr. 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 (and the useful perspective of a journalist). BACK TO TEXT
  14. 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”. BACK TO TEXT
  15. 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 book 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 sees 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. BACK TO TEXT
  16. 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 the rates remained stable in the years after that. Finally, Harkness et al did a nice job in 2005 of comparing rates of musculoskeletal pain (including low back pain) 40 years apart in the northwest of England, and found a large increase. In his books, Sarno also strongly portrays low back pain as a modern problem — though he doesn’t defend it. It’s 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! Harkness pointed out in her study that the appearance of an increase “could be partly explained by the ‘worried well’. The ‘worried well’ are those patients who are concerned about their health, and attend their GP to seek reassurance about their well-being.” This is a great example of how hard it is to really be sure of anything! BACK TO TEXT
  17. 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 it 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). BACK TO TEXT
  18. Sarno. Mind Over Back Pain, p27. BACK TO TEXT
  19. Moseley. Teaching people about pain — why do we keep beating around the bush? Pain Management. 2012. BACK TO TEXT

There are 303 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.


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