Chronic Back Pain: Common misconceptions

I injured my disc lifting something heavy at work. That’s why my disc is bulging.
multiple vertabrae
FALSE. Researchers are now rethinking the whole concept that serious low back pain comes from minor trauma or structural damage to the spine or discs.10 MRI machines are so sensitive now in picking up slight abnormalities in water content of the discs. Because of the lack of water in some of discs, doctors may say that your discs are “bulging” or even “leaking”. We like to explain the intevertebral disc as being a large jelly donut. During our teenage years, we have a lot of water in the discs. As we age over the next several decades, the water gradually decreases. As the height of the disc decreases, the ends tend to sag and “bulge” out the side, not unlike that in a jelly donut. Many normal age-related factors increase the likelihood that the discs will bulge like increasing age, being overweight, performing physically demanding work, and even a history of smoking.
My “degenerated” disc is causing my pain.

FALSE. Disc degeneration is a normal process. In fact, the blood supply to our discs was the best when we were teenagers. Every year afterwards, the blood supply to the disc decreases. By the time we turn 40 years old, many of us even without back pain will have some radiographic evidence of disc degeneration. This process is completely normal. Unfortunately, many doctors in the past inadvertently linked the normal process of disc degeneration with pain. In fact, now fewer physicians believe that back pain comes from disc injury. Our spines have a tremendous capability to adapt to new environments and activities. Studies have shown that the disc actually benefits from increased physical loading and gradually adapts just as joints, bones, muscles, tendons, and ligaments do.

Researchers found that physically handling heavy loads, bending, twisting, and working in awkward postures and driving in vibrating vehicles were NOT associated with accelerated disc degeneration. These activities may have led to back pain due to insufficient muscle flexibility, strength, or endurance, but do not cause disc degeneration to become rampant. Heavier weight, greater lifting strength, heavier work all seemed to slow the process of disc degeneration and may even protect the lumbar discs from degenerating.

Discogenic pain is the term some physicians cite as pain coming from a painful disc. However, there are growing doubts that disc degeneration is a major cause of low back pain. Before, doctors felt that fusion surgery or disc replacement was successful in treating this type of pain. The Centers for Medicare and Medicaid Services found that the evidence on spinal fusion12 to treat degenerative disc disease was “weak”. At a recent spine surgery conference,13 surgeons were asked about their recommendations. Fewer than one quarter of the surgeons felt that disc degeneration was a major cause of low back pain. Only 1 out of 100 would have opted for fusion surgery and only one would have chosen disc replacement.

Because I have back pain, I should stay away from work

FALSE. We lose muscle strength and endurance much faster than we can regain it. Being off work deprives our bodies of physical activity for our core muscles. You certainly could have strained some of the very deep and important “core” 14 muscles in the spine with an incident at work, but depriving those muscles from the regular activity that you have done every day at work is a step in the wrong direction. Being able to take it a little easier while your muscle rebuilds itself is advisable, but long leaves from work deprive these deep muscles that need regular exercise they need in order to repair themselves.

Even when going back to work, many people fear that they will “re-injure” themselves. Recurrence of back pain does not necessarily mean you re-herniated a disc or are doing any more damage to the spine. “Hurt is not Harm.” Many of our core abdominal, back, and buttock muscles that were painfully short and deconditioned are exactly the muscles that we need to use during our regular day to day activities. This is why keeping our muscles in their best flexibility, strength, and endurance is so critical if you have a physically demanding work situation.

Back pain often leads to permanent impairment or disability
FALSE. Surprisingly, the most important predictors of chronic disabling pain are not related to how “bad”or abnormal an MRI looks to the physician, but relate more to how the person responds to their pain. Researchers have identified that people with the highest risk factors for developing chronic pain typically have many psychological stressors including depression and anxiety. They also have more difficulty performing normal day to day physical activities, show non-organic physical signs such as pain with even light palpation or minimal movement, and are in overall poor physical health. Another nationally known spine researcher has said, “The development of chronic disabling low back pain is more about psychology than anatomy.” This can be very surprising to many physicians. Many physicians were trained to detect slight physical findings or see abnormalities on imaging tests. These findings are not good indicators of the people who have the most disabling back pain. Instead, psychological factors seem to be much more predictive of who will need additional services. It is also important to note that the people with chronic, disabling back pain seem to get better more often with counseling, cognitive-behavioral therapy, and exercise programs rather than pain injections and surgery.
Because I have back pain, I will need permanently modified work
FALSE. Reduced lifting programs do not reduce severity or incidence of back pain episodes. Lumbar supports and shoe inserts were also not effective. Only a regular exercise program was found to be effective for preventing back problems. Some researchers are looking at whether our genetic makeup plays a role in controlling our body’s response to pain. The Catecholamine-O-Methyl Transferase gene is thought to play a role in the body’s system of modulating pain. Successful genetic treatments for humans with pain probably won’t be available for several decades at least.
I should rest until my back pain goes away
FALSE. We at the UI Spine Center do NOT agree with this statement. Many other spine specialists, including Dr. James Rainville, a well-known spine specialist in Boston, have said “For individuals with back pain, exercise is therapeutic. It may even reduce the risk of developing further back pain episodes. There is no evidence that exercise places patients at increased risk of harming their backs or accelerating spinal degeneration. We commonly see patients who have muscle soreness after exercise, but this is not a sign that the spine has deteriorated but rather the muscles are repairing themselves.” A failure to exercise has been linked to several chronic diseases including chronic back pain.16 Regular exercise may even have a preventive effect in terms of frequency of back pain and recurrence.
My back pain means I have really significant biological damage or disease
FALSE. In a study of 1200 patients with acute back pain, less than 1% of patients with back pain had a serious condition including a fracture, infection, cancer, or multiple nerve root compressions. Several treatment guidelines17 can identify certain items in your personal history or examination that may lead us to suspect underlying serious medical condition.
X-rays, CT, and MRI can always identify the cause of pain

FALSE. The majority of people with low back pain have problems with poor muscle flexibility, strength, or endurance. Painful, stiff, or weak muscles do not appear any differently on an MRI than a non-painful muscle. Many of the other common abnormalities found on MRI (disc tears, bulging, herniation or degeneration) have not been proven to cause pain. Therefore, we do not recommend MRIs on people who can have their pain so easily reproduced by stretching or activating their muscles unless there are special circumstances.

Some people just want to know what their MRI shows and say they will feel better knowing that they don’t have anything seriously wrong like a tumor, infection, or other abnormality. An interesting research study was done to see whether people who got an MRI early on in the course of back pain did better than those who didn’t get an MRI for their back pain. It was thought that early MRIs could help patients understand their condition better, and make them feel better about their back pain. Many subjects had MRIs that showed annular tears, disc protrusions, endplate changes, and degeneration. Seeing those MRI images led them to have a lesser sense of well-being. The researcher concluded that information supplied by an early advanced imaging test appeared to have a negative impact on patient outcomes, and higher surgery rates might ultimately increase costs.

Another study reported that “Findings on MRI imaging taken within 12 weeks of the start of low back pain are highly unlikely to represent new, clinically significant, structural changes.” These findings have led national physician groups such as the American Pain Society and the American College of Physicians to recommend against routinely obtaining advanced imaging or other diagnostic tests in patients with nonspecific low back pain.

Back pain will usually be cured by medical treatment
FALSE. “Low back pain was recently termed the “most over-treated” condition in the US”20 21 According to the NIH, US spending on back care increased from 1997 to 2005 up to $86 billion dollars which is close to what the country spends on cancer treatment. An article from a 2008 Journal of the American Medical Association reported on “increased back care spending without evidence of corresponding improvement in patient’s health.” Back pain is second only to mental health conditions as a reason for work disability among individuals in their working years.

Clearly back pain is a problem for our entire country and our collective productivity.