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Busting The Myths Of Lower Back Pain

Lower back pain …... The most common nuisance experienced by man & woman. Being one of the leading causes of disability worldwide, lower back pain will affect eight of every ten people in the UK at some point in their lifetime. The common nature of lower back pain makes it a prime target of myths and tales. If you have suffered from lower back pain, you have probably been told by friends or family to ‘stay in bed and rest’ or ‘get a scan as soon as possible’, both of which are as far from the truth as can be. So in this blog we will be differentiating between the myths and the facts. In most UK healthcare systems, a scan of the lower back isn’t offered straight away. It is only considered if a patient has shown little to no improvements with their pain after 4-6 weeks of Physiotherapy or other form of medical management. The main reason being is that only around 2% of scan results accurately indicate what is wrong with your back. Most people over the age of 40 will have some sort of spinal abnormality such as arthritis or a ‘bulging disc’. Let’s look at an example; Brinjikji, et al., (2014) conducted a systematic review incorporating over 3000 asymptomatic individuals (patients with no lower back pain) and results found that over 50% of individuals between 30-39 years of age had some sort of disc abnormality, which increased to over 90% in individuals over 60. This study suggests that disc and joint changes in the spine are very common and generally part of the natural ageing process. We now know that if the majority of us had lower back scans the results would be far from perfect, but what has research shown about the role of scans on clinical outcomes such as pain and function? Chou, et al., (2009) conducted a systematic review and found that imaging of the lower back does not improve clinical outcomes such as pain, function and quality of life in patients with no serious underlying conditions. Additionally, J.C. Andersen (2011) was able to mirror Chou’s findings and found that immediate imaging (X-ray, MRI scans) also did not improve clinical outcomes in patients with lower back pain. The morale of the story is, if you have lower back pain and are slowly improving with exercises and appropriate pain management under your Physiotherapist/medical professional, forget about a scan! It is unlikely that it will change your treatment plan or improve your clinical outcomes. If anything, this will put a halt to your progress, increasing your recovery time. The best thing you can do is continue to follow your home exercise programme and health care professional’s advice. In recent times, there has been a lot of speculation regarding the role of core strengthening in lower back pain. Like anything in the world of Physiotherapy, there are studies for and against the effectiveness of core stability exercises to improve lower back pain when compared with other interventions. That is why I am not going to highlight specific studies as there will be a conflict of evidence, like most things. However, in 2019, Owen conducted a meta-analysis examining the effectiveness of specific types of exercise on lower back pain. Results found that there is only LOW QUALITY evidence that core stability & control exercises are the most effective form of exercise for lower back pain (Owen, et al., 2019). Moreover, a 2020 systematic review with meta-analysis found that it is the lower quality studies that have overestimated the effect of core stability/motor control exercises on lower back pain (Niederer and Mueller, 2020). Finally, another 2019 review concluded that research studies have made bold claims regarding the effectiveness of core stability exercises without sufficient literature to back it up (Augeard and Carroll, 2019). These recent reviews highlight that still there is no conclusive evidence to suggest that core stability training is better than any other form of exercise in reducing lower back pain, therefore it is unlikely that a weak core alone would be a direct cause of lower back pain. To finish off, a lot of patients feel that as their pain increases, their injury is worsening. Tissue damage DOES NOT positively correlate with the pain we feel. Research has shown that tissue injury results in the release of various chemical mediators (Amaya, et al., 2013). It is these mediators which promote hypersensitivity against different stimuli. In other words, it is the mediators released from damaged cells that provoke pain, not the amount of tissue damage that has occurred. It is important to note that pain is a psychological construct which arises from physiological processes. The consideration of the psychological and social factors is part of the Biopsychosocial approach, which views pain as a result of interactions among biological, psychological and social elements. The pain we feel as humans is dependent on a range of different components other than tissue damage, such as stress and physical activity levels. Uncontrollable factors such as our age and socio-economic status can also influence pain too. For further reading on taking control of your pain or the role of stress on our pain experience, please click the appropriate links. I am hoping this blog has been an insightful read and challenged your views on the myths around such a common, debilitating injury. To summarise, any form of movement within your pain threshold is good and will not be making your lower back injury worse. Moreover, there is insufficient evidence to conclude that a weak core is a direct cause of your lower back pain. In addition to this, it is very unlikely that getting a scan over no scan at all is going to improve your condition in the long term and there are many different factors other than tissue damage which can influence your pain experience, such as physical activity and stress levels. References Amaya, F., Izumi, Y., Matsuda, M. and Sasaki, M., 2013. Tissue Injury and Related Mediators of Pain Exacerbation. Current Neuropharmacology, 11(6), pp.592-597. Augeard, N. and Carroll, S., 2019. Core stability and low-back pain: a causal fallacy. Journal of Exercise Rehabilitation, 15(3), pp.493-495. Brinjikji, W., Luetmer, P., Comstock, B., Bresnahan, B., Chen, L., Deyo, R., Halabi, S., Turner, J., Avins, A., James, K., Wald, J., Kallmes, D. and Jarvik, J., 2014. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 36(4), pp.811-816. Chou, R., Fu, R., Carrino, J. and Deyo, R., 2009. Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 373(9662), pp.463-472. Johnson, M., 2019. The Landscape of Chronic Pain: Broader Perspectives. Medicina, 55(5), p.182. Niederer, D. and Mueller, J., 2020. Sustainability effects of motor control stabilisation exercises on pain and function in chronic nonspecific low back pain patients: A systematic review with meta-analysis and meta-regression. PLOS ONE, 15(1), p.e0227423. Owen, P., Miller, C., Mundell, N., Verswijveren, S., Tagliaferri, S., Brisby, H., Bowe, S. and Belavy, D., 2019. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British Journal of Sports Medicine, pp.bjsports-2019-100886. The Chartered Society of Physiotherapy. 2020. Back Pain Myth Busters. [online] Available at: <https://www.csp.org.uk/publications/back-pain-myth-busters> [Accessed 10 April 2020].

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