Conflicting Back Pain Information

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It’s easy to get confused when reading and listening to information about health, wellness, fitness, and exercise. We are often caught in the collision between valid science and pseudoscientific snake oil mumbo jumbo. Even when good research is discussed in the press it’s often reported without nuance by reporters who don’t understand the statistical methodology.

With that in mind, here are three recent articles which overlap in their coverage of back pain. Two reflect the current evidence on back pain. The other, in my opinion, is off the mark and may actually help reinforce back pain and the fear of pain.

Posture has little to do with pain

I like the article titled Are you sitting comfortably: the myth of good posture. I recommend you read it because the sources discuss the current evidence around posture and back pain. Pain researcher Dr. Peter O’Sullivan is one source. He says,

“O’Sullivan says that rather than focus on the right posture, the ability to vary it and shift easily may be more important: ‘While it is appealing to think that if you sit up straight you will not get back pain, this is not supported by big studies across many countries.’ Indeed, while many websites swear that bad posture (usually defined as slumping, leaning forwards or standing with a protruding belly) causes everything from back pain to varicose veins and indigestion, there is no evidence that it causes general health problems.”

“…If you don’t have back pain, then do not give your posture one second’s thought – think about being healthy. Sleep deprivation and stress are more important than the lifting you do. Stress has a strong inflammatory role; it can make muscles tense. Most people don’t get that their back can become sore if they are sleep deprived.”

One thing to think about is the chicken-or-egg paradigm. That is, does “bad” posture cause back pain? (Evidence suggests it doesn’t.) Or could pain force us to adopt a certain type of posture that looks bad? My bet is on the latter. Related to low-back pain misinformation is the fearmongering around the myth of “text neck.”

Misguided treatment

If our concept of what causes back pain is misguided then it’s no surprise that many diagnostic and treatment strategies are ineffective. An article from the BBC titled Many back pain patients ‘getting wrong care’ discusses guidelines from a series of papers written by pain experts for the Lancet, a British medical journal. Several points to consider:

  • Strong drugs, injections and surgery are generally overkill, they say, with limited evidence that they help.
  • Most back pain is best managed by keeping active, they advise.
  • UK guidelines recommend a mix of physical exercise, advice, and support to help patients cope with symptoms and enjoy a better quality of life.
  • Health staff should not treat back pain or sciatica with equipment such as belts, corsets, foot supports or shoes with special soles.
  • They should not offer acupuncture, traction (stretching the back using weights or machines), or electrotherapy (passing electric current or ultrasound waves through the body), says the National Institute for Health and Care Excellence.

My favorite is this list of 10 Things You Should Know About Your Back:

1) Your back is stronger than you may think – the spine is strong and not easily damaged, so in most instances, the pain will be down to a simple sprain or strain.

2) You rarely need a scan.

3) Avoid bed rest and get moving (but avoid aggravating activities).

4) Do not fear bending or lifting – do it in a way that is comfortable, using the hips and knees.

5) Remember that exercise and activity can reduce and prevent back pain.

6) Painkillers will not speed up your recovery.

7) Surgery is rarely needed.

8) Get good quality sleep if you can, because it will help you feel better overall.

9) You can have back pain without any damage or injury.

10) If it doesn’t clear up, seek help but don’t worry – book an appointment to see your doctor or physiotherapist if the pain persists.

Questions about bending and lifting

Lost Art Of Bending Over: How Other Cultures Spare Their Spines comes from National Public Radio. I am a little bit conflicted about it.

The article suggests that we in the US bend forward “incorrectly” and thus we suffer more back pain than agrarian societies where they bend forward “correctly” and thus suffer less back pain. Is this claim true? Do we suffer more back pain than less-developed countries? Do people in other cultures bend forward differently than we do? The article offers no evidence beyond the writer’s casual observations to support the claims. Ironically, the article shows a picture of two rice farmers in Madagascar. One is bent forward “correctly” with a hip hinge, the other is bent “incorrectly” more through the low-back. I’m not sure how to interpret that picture.

My problem with the article is that it suggests there is a wrong way to lift and implies that doing so is a direct cause of back pain. Such fears lead to fear-avoidance beliefs (FABs).  I’ve experienced this phenomenon and I’ve seen it in others.

With FABs, we tend to believe that adopting certain “bad” postures or using “unsafe” lifting strategies will certainly equal pain. As a result, we brace our backs with extreme rigidity and we use a super-strict technique to lift everything from heavy objects down to something small and light like a pair of shoes. The irony of FABs and the resulting extreme diligence is that we are actually at greater risk of incurring more pain. In other words, the fear of pain is more of a problem than the biomechanics of lifting.

Recall that in the first article I discussed, we learned that sitting posture doesn’t relate much to back pain and that in fact emotions and lack of sleep were stronger predictors of back pain. My bet is that we might see a similar dynamic with regard to lifting posture.

Some of the information is useful, specifically the instructions on hip-hinging (a technique I regularly teach to clients) are worth knowing. By using a hip-hinge method to lift things from the ground, you will engage the glutes and hamstrings which are big, strong muscles. The hip hinge should allow a lifter to generate more force so he or she can lift a heavier object. The hip hinge also effectively distributes the forces of the lifting of a heavy object throughout the body rather than concentrating it in one place.

As a counterpoint to my own statement though, look at this. It’s Austrailian strong-woman Sue Metcalf picking up 246 lb. atlas stone with a technique that the NPR article would call unsafe.

I think that if lifting a heavy object, then it’s prudent to use as many muscles as possible to do the job and to generally be careful. Nothing wrong with that. But if bending down to pick up a pen, a shoe, a ball — or possibly a giant atlas stone— and if there’s no underlying acute injury, then we should feel free to move the spine. The spine is comprised of 33 bones, 24 of which are moveable. So why not move them? I wish the press were better at discussing these nuances.

Extra credit

If the problems inherent to bad science interest you, then you might want to pay attention to the words of  Dr. Ben Goldacre, epidemiologist, has to say.