What are the Real Back Pain Facts?

Low back pain is the leading cause of disability worldwide, it costs billions in lost productivity and has become more expensive and burdensome on healthcare systems.

An episode of back pain can be extremely uncomfortable, this is often accompanied by anxious thoughts and worries about the meaning of the pain and how serious the “damage” in the spine may be. Unfortunately, the magnitude of the back pain experience is often a poor reflection of what the underlying issue is (i.e., a LOT of pain doesn't always equal a lot of damage). It is common for relatively trivial movements or insults to the spine can trigger an episode of extreme pain, and in many cases, there does not seem to be an initiating traumatic event related to the onset of pain.

These observations in clinical practice often render a picture that does not match the expected mechanistic causes we often attribute to back pain (i.e., heavy lifting). As clinicians we often explain this away using a model of poor strength or a lack of muscle protective reactivity that induced a sudden loss of control resulting in a strain or sprain. However, if we look at the science, we see an intriguing complex picture that makes up our understanding of the actual “causes of back pain” – and it’s not simple.

So, what “causes” back pain?

Despite significant advances in our ability to scan and investigate the inner workings and mechanisms within the body, we have not discovered a “gold standard” method of identifying the cause of back pain. Research informs us that up to 90% of back problems are “non-specific” – in other words, we cannot reliably identify the cause of back pain in up to 90% of cases.

This does not mean that back pain is not “real” or may have a specific cause, it simply means that it is more complex than just having “weak core”, "glutes that don't fire" or "something out". Research tells us that back pain is multifactorial, involving physical/mechanical, social, and psychological influences. It is uncommon that back pain emerges solely because of injury, there are often individual psychological and social complexities at play.

MRI and the pitfalls of relying on scans to identify the “cause of back pain”

When back pain is severe, we tend to want to know what’s wrong and how we can fix it. Doctors often rely on MRI scans to find this out. MRI scans are incredibly detailed and sensitive, often highlighting several “abnormalities” or areas of “damage or degeneration”. Whilst this may seem a useful way of finding out what’s going on, the pitfall of this knowledge is not knowing whether this so called “damage” is the actual cause of the pain.

Why is it difficult to identify the cause of back pain if we can see inside the body?

Studies have shown us that pain free people also have damage, degeneration, and abnormal findings seen on MRI - Yep, that’s right, many of us without back pain have "abnormal, damaged or degenerative spines”.

A large illustrative population study recently demonstrated that pain free individuals (between the ages of 20 and 80 years of age) have abundant abnormal findings on MRI scans. This study also highlighted that younger people can have significant changes seen on imaging, hence, these findings are not always a cause for concern or only seen in old people. So called “degenerative” findings are therefore common throughout adult life and are not always associated with pain.

Table 1 Ref – Brinjikji et al. (2015)

This could be likened to wrinkles or grey hair, we don’t look at these things as a disease (we may not like them, but we accept them as part of life), similarly with degenerative changes, we shouldn’t over emphasise or make a disease out of a normal process.

This all gets a little confusing I know (I work with this every day). The important thing to remember is that humans are complex, and pain is complex, and much like an emotion is very dependant on the individual in the context of their life experiences and their unique world. It also illustrates that a person is not a “machine”, we are dynamic, complex creatures with multiple systems interacting within a complex world (that has physical, social, and psychological context).

I often liken back ache to a headache, when we get a headache we usually don't immediately think we have broken something or have a brain tumour. Instead we may take a paracetamol or sleep it off. We call it a headache, and we get on with it. However, with back pain we're on this quest to find out what is wrong and give it some fancy name. Historically, the medical label for back pain was "lumbago", which simply means back ache - perhaps its time to move back to a time when we labelled things as they actually are.

For some reason we have now complicated back pain and made it into this catastrophic disease, when quite simply back ache is a common feature or symptom of being a human!

Why MRI scans can be harmful

Studies highlight the potential influence of imaging and future pain and disability. These studies found the early use of imaging for back pain resulted in increased disability, poorer perceived outlook, increased healthcare expenditure and a greater chance of back surgery.

Another recent study demonstrated that patients that were given a complex report of their MRI results were more likely to have an increase in psychological worry and long term disability. Similarly, patients given a diagnosis that indicated their imaging results were normal and in keeping with age had improved outcomes and were less likely to require long term management. This study also showed that clinicians reading these reports were more inclined to recommend surgical intervention based on the report findings rather than how the patient presented.

So, what does this mean?

Firstly, we should treat the person, not the scan!

Humans are susceptible to the impact of language and images. Perhaps seeing an image of the “damage or degeneration” of your spine increases the likelihood that you will further protect your spine because its “broken”, hence becoming avoidant of activities that may prove useful in back pain recovery. You may also think that the damage cannot be undone, or its only going to get worse as you get older. These “beliefs” can increase the level of vigilance you have around the meaning of your back pain and how serious it may be. Research shows us that people who think too much or ruminate about their back pain tend to develop persistent symptoms.

"The thoughts and concepts you hold about your body are

very important predictors of how you recover"

Humans are sensitive creatures; we live in a world that attempts to solve complex problems with simple solutions. It is important that we do not treat people with blanket rules. The epidemic that is “back pain” is increasing, not decreasing, and this is in part because we have failed to treat the person in their dynamic context.

MRI’s do have their place and are a useful adjunct when a person’s back pain is not resolving or we suspect there is something more sinister going on in the spine (like cancer, or a fracture).

References

1. Brinjikji, W., P. H. Luetmer, B. Comstock, B. W. Bresnahan, L. E. Chen, R. A. Deyo, S. Halabi, et al. "Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations." [In eng]. AJNR Am J Neuroradiol 36, no. 4 (Apr 2015): 811-6. https://doi.org/10.3174/ajnr.A4173. http://dx.doi.org/10.3174/ajnr.A4173.

2. Foster, Nadine E., Johannes R. Anema, Dan Cherkin, Roger Chou, Steven P. Cohen, Douglas P. Gross, Paulo H. Ferreira, et al. "Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions." The Lancet 391, no. 10137 (2018): 2368-83. https://doi.org/10.1016/S0140-6736(18)30489-6.

3. Hartvigsen, Jan, Mark J. Hancock, Alice Kongsted, Quinette Louw, Manuela L. Ferreira, Stéphane Genevay, Damian Hoy, et al. "What Low Back Pain Is and Why We Need to Pay Attention." The Lancet 391, no. 10137 (2018): 2356-67. https://doi.org/10.1016/S0140-6736(18)30480-X.

4. Knezevic, N. N., K. D. Candido, J. W. S. Vlaeyen, J. Van Zundert, and S. P. Cohen. "Low Back Pain." Lancet (London, England) 398, no. 10294 (07/03/2021 2021). https://doi.org/10.1016/S0140-6736(21)00733-9. https://www.ncbi.nlm.nih.gov/pubmed/34115979.

5. Maher, C., M. Underwood, and R. Buchbinder. "Non-Specific Low Back Pain." Lancet (London, England) 389, no. 10070 (02/18/2017 2017). https://doi.org/10.1016/S0140-6736(16)30970-9. https://www.ncbi.nlm.nih.gov/pubmed/27745712.

6. Rajasekaran, S., S. Dilip Chand Raja, B. T. Pushpa, K. B. Ananda, S. Ajoy Prasad, and M. K. Rishi. "The Catastrophization Effects of an Mri Report on the Patient and Surgeon and the Benefits of 'Clinical Reporting': Results from an Rct and Blinded Trials." European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society (03/21/2021 2021). https://doi.org/10.1007/s00586-021-06809-0. https://www.ncbi.nlm.nih.gov/pubmed/33748882.

7. Vos, Theo, Ryan Barber, Brad Bell, Amelia Bertozzi-Villa, Stan Biryukov, Ian Bolliger, Fiona Charlson, et al. "Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 301 Acute and Chronic Diseases and Injuries in 188 Countries, 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013." The Lancet 386, no. 9995 (2015): 743-800. https://doi.org/10.1016/S0140-6736(15)60692-4.

8. Webster, B. S., A. Z. Bauer, Y. Choi, M. Cifuentes, and G. S. Pransky. "Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain." Spine 38, no. 22 (10/15/2013 2013). https://doi.org/10.1097/BRS.0b013e3182a42eb6. https://www.ncbi.nlm.nih.gov/pubmed/23883826.

9. Webster, B. S., and M. Cifuentes. "Relationship of Early Magnetic Resonance Imaging for Work-Related Acute Low Back Pain with Disability and Medical Utilization Outcomes." [In eng]. J Occup Environ Med 52, no. 9 (Sep 2010): 900-7. https://doi.org/10.1097/JOM.0b013e3181ef7e53. http://dx.doi.org/10.1097/JOM.0b013e3181ef7e53.