“What the F***?!”

I find myself repeating this phrase over and over in clinic. My patients routinely share laundry lists of beliefs and false information related to back pain. Most of the time these ideas are adopted from the media, friends, and more often than not, medical providers. Most of these adopted beliefs only worsen symptoms and make coping with pain difficult. In my opinion, back pain is a messy and confusing topic. We have a variety of medical providers preaching different “theories,” rather than supported literature and guidelines. This may attribute to the fact that back pain is a 100 billion-dollar a year industry. I hear a lot from my patients. Things like:

 

I have back pain because my alignment is off.

I can’t run, jump or lift because I have degenerative disc disease.

When I bend I feel the vertebrae rubbing together.

I just have to accept my pain because of the damage to my spine.

I was told that I might need a fusion to make my back more stable.

 

Do you see how beliefs like these can influence behaviors and create long-term problems?

 

Instead of crafting patients that are confident to move freely, we do the opposite. Patterns of fear, avoidance, and distress become recurring behaviors in response to pain. These beliefs and behaviors are engrained even deeper with the help of Google (something I am obviously taking advantage of!) and media programs that instill fear instead of hope. In turn, self-doubt grows in performing regular daily activities. People are no longer confident in their abilities to do household chores, socialize, work, and be physically active. All of this because of their pain and beliefs.

 

Most people, when asked, will describe their back as vulnerable or even damaged. We are warned to:

• Not carry bags that are too heavy
• Always maintain a “perfect” neutral posture
• Brace our abdominals with simple activities like tying our shoes and sitting

 

The list goes on and on.

 

If the anxiety in our lives didn’t make us tense enough, we are now told keep our muscles tight with something as simple as picking our noses.

 

Unlearning something always seems to be harder than learning something for the first time. Much of the advice we absorb on a daily basis is not based on any quality literature. It is hearsay that has gained popularity and worsened our ability to relieve pain. Close examination of both short and long term studies provides a good idea of what works well, what works sometimes, and what we really are not sure about.

 

So what do we know?

 

The Low Back Pain Guidelines from the Orthopedic Section of the American Physical Therapy Association (and other independent high quality research studies from a variety of disciplines) encourage medical providers to focus on the way people think. Fear, depression, and distress related to your pain are more predictive of your future outcome than physical factors. For example, being fearful that you won’t be able to return to work due to pain will potentially have a greater impact on your recovery than degeneration or bulging discs on MRI.

 

So how do we change our behaviors?

 

First you need to change your thoughts related to back pain. Peter O’Sullivan has done an amazing job promoting the psychological components of rehabilitation for spine related pain. Topics he continues to reinforce with patients and in his research include the following:

• MRI & X-ray is not predicative of back pain
• Backs are strong
• Movement (bending and twisting) helps reduce stiffness and pain

 

When you understand these concepts, you start to lower fear and anxiety related to your pain. This creates a beautiful start for making long-term improvement.

 

Once you get your brain to relax we go right back to the bread and butter, baby! Yes, I said baby…baby! Change your lifestyle. Risk factors for back pain include:

• Smoking
• Sedentary behaviors (i.e. sitting all day, not exercising)
• Overweight and Obese
• Cardiovascular hypertension
• Sleep deprivation

 

Posture, flexibility, and “the Core” are promoted in the media and with medical providers. However, research is inconclusive on their level of effectiveness. This is not to say that they aren’t helpful. They just are not the silver-bullet for your pain. Your lifestyle and mindset have a much larger impact on how you feel compared to solely relying on:

• Posture: We do not need to sit in a chair like it is the first day of Catholic School. People who have jobs that involve more variety in movement often have less pain. Pain is intensified by sustained static postures. So change positions often.
• Flexibility: Supple hamstrings and psoas muscles alone will not be the cure all if your lifestyle and mindset are not in order. Treating flexibility like a quick fix is like patching your tire, it may help you get some more miles but it won’t be the long-term fix.
• “The Core”: Wait for it… Planks are not the cure all. Yes I said it. I know the jacked guy on YouTube says they fix everything. I also know your PT or surgeon told you that you need to “stabilize” your spine (as if it was a wobbly piece of spaghetti). In reality, muscles around the spine are minimally contracted during activities like standing or walking. In research, training “The Core” has has shown to be no more effective than manual therapy or regular exercise on long-term outcomes. Don’t misunderstand the Rehab Renegade Guys…we love the core, but it is not the cure all. Neither is posture and neither is flexibility. We are a system that is dependent on a strong mind and good lifestyle habits first.

So what does this mean for me?

 

As you start to modify your beliefs and feelings related to pain, work toward lifestyle changes that can help speed up your recovery. Sleep, an active lifestyle, weight loss, and smoking cessation can lead to significant improvements in how you feel and your psyche. Gradually resuming activities that you previously wrote off because of your past beliefs and fears can be the thing that helps you make the quickest improvement in your quality of life.

 

 

OVERVIEW

 

Ok, so some bullet points to tape to your fridge:

• Fear, depression, and distress related to your pain are more predictive of your future outcomes than physical factors.
• False beliefs related to back pain often impede improvements and worsen fear and anxiety.
• Changes in basic lifestyle choices are huge for addressing pain.
• Posture, flexibility, and strength are highly promoted treatment options that should only be considered after psychological and lifestyle factors have been addressed.

 

 

 

1. Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger, Joseph J. Godges (2012). Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 42:4, A1-A57.
2. Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189.
3. Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger, Joseph J. Godges (2012). Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 42:4, A1-A57.