Mirror, Mirror, on the Wall: Common Back Pain Misconceptions

Athletes must understand their bodies to maintain overall well-being and performance, especially regarding their backs. However, it’s crucial to acknowledge that misconceptions exist regarding back pain and health. This realization becomes particularly important regarding low back pain (LBP), as misconceptions about cause, prognosis, and treatment efficacy can hinder optimal evidence-based management. Three dominant misconceptions exist surrounding LBP. They include injury labels, misguided imagining, and the relationship between pain intensity and tissue damage.

It is not surprising that there are some misunderstandings about LBP. A simple Google search unearths thousands of supposed causes and equally as many treatments. Despite all this information, low back pain cannot be attributed to any particular cause for most people. This is called non-specific low back pain (NSLBP). 

Labels

Non-specific low back pain is the recommended label for most (90–95%) cases and is defined as low back pain not attributable to a recognizable, known specific pathology. Clinicians base it on a diagnosis of exclusion when they rule out specific pathologies (e.g., cancer, infection, fracture, and cauda equina syndrome). The label is contentious, and when 1093 primary care clinicians were surveyed, almost three-quarters disagreed with the label and reported that it is possible to identify the source of LBP⁽¹⁾. Commonly proposed structural sources of non-specific LBP include the intervertebral discs, facet joints, lumbar ligaments, and lumbar muscles, and diagnostic labels that indicate pathology or damage to these structures include disc bulge, degeneration, arthritis, and lumbar sprain. But like the name NSLBP, these labels are problematic, often leading to unnecessary imaging (we’ll come to that in a bit), or even the label can negatively impact function and performance.

Researchers from the University of Sydney in Australia investigated the effect of different labels on recovery from an episode of low back pain⁽²⁾. They found that those given the label disc bulge, degeneration, and arthritis had a poorer prognosis and were more likely to seek further care. In contrast, those whose back pain was labeled lumbar sprain, non-specific LBP, and an episode of back pain had a good prognosis. 

The effect of labels on recovery is likely related to a person’s beliefs, and specifically their misconceptions. For example, beliefs about the cause, fear of pain or re-injury, and self-efficacy influence how your body interprets danger. A threatening appraisal of pain can induce pain-related fear, leading to avoidance of certain activities and disability. Beliefs are consistently associated with pain- and disability-related measures, with misconceptions frequently considered important drivers of unhelpful behaviors. The specific beliefs related to higher levels of disability and poor outcomes vary. Still, as in the above example, a strong biomedical view of LBP suggests that pain is attributable to tissue damage is associated with more disability and higher levels of pain-related fear. These explanations for LBP are overly simplistic and are a toxic contribution to a sea of confusion among the general public.

Misguided imaging

Another common misconception about LBP relates to the value of imaging. Certain labels may legitimize unnecessary tests (e.g., diagnostic imaging) and ineffective treatments (e.g., facet joint injections and surgeries). Yet evidence indicates that imaging is useful only where suspicion of red flag conditions is high, which is only relevant to a small subgroup of patients. These conditions include the specific causes of LBP mentioned earlier, such as, cancer, infection, inflammatory disease, fracture, and severe neurological deficits, which account for only 5-10% of LBP presentations in primary care⁽³⁾. Degeneration and arthritis describe normal processes that happen as humans age rather than pathological processes requiring further investigation or treatment. There is no evidence that any of these changes cause low back pain; in some cases, they are not even present in people with low back pain, or conversely, they are present in people without low back pain. 

“The misconceptions about back pain can hinder recovery.”

It is true that magnetic resonance imaging (MRI) findings of disc bulges, degeneration, extrusion, protrusion, Modic 1 changes, and spondylolysis are more common in adults with low back pain aged 50 years or younger compared with asymptomatic individuals with no back pain⁽⁴⁾. However, imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age (see table 1)⁽⁵⁾. 

TABLE 1: Prevalence estimates of degenerative spine imaging findings in asymptomatic patients according to age* 

^{*Findings from AJNR Am J Neuroradiol:811-816. (2015)}

Although these studies appear contradictory, the conclusion is that many imaging-based degenerative features are likely part of normal aging. Indeed, imaging will likely show some changes in an athlete’s back structure, but it does not inform clinicians about their pain. It may cause athletes to worry and catastrophize, leading to more pain and disability. At best, these imaging terms provide a convenient explanation for low back pain, something tangible. Still, clinicians must interpret imaging findings in the context of the patient’s clinical condition and, outside of red flags, not rely on them for diagnosis or treatment.

Pain intensity

Finally, many people believe that pain is a reflection of damage. The bigger the pain, the worse the tissue damage. This one is not true, either. Pain is a sign of protection. In the early stages of an injury, pain can accompany tissue damage, but the pain does not accurately reflect what is happening in the body tissues. For example, a paper cut usually produces considerable pain but minor tissue damage. 

Biophysical, psychological, and social factors contribute to pain perception and disability. To produce pain, our brain assesses information from multiple sources, including tissues, environment, emotions, memories, etc. Among these biopsychosocial factors, one aspect considered important with disability and recovery is what people think and believe about their back and associated pain. For example, a belief that LBP is a sign of structural damage and, consequently, the back is fragile, and needs protection is likely to contribute to pain whether or not actual structural damage is present. 

Once clinicians exclude severe pathology, they are recommended to provide education as the foremost intervention for managing pain. Pain education aims to address pain-related misconceptions, allowing individuals to understand their pain better, take greater control of their pain, and make more informed decisions regarding their pain care. Key to pain education is understanding that pain is a biopsychosocial experience, and the context and the associated beliefs will influence how individuals experience it. 

Challenging misconceptions

Pain is a complex experience where things aren’t always as they seem. In fact, in the case of chronic low back pain, which has persisted longer than three months, healing would have occurred if there had been any tissue damage involved when the pain started. After this time, pain is a particularly unreliable indicator of what’s happening in the tissues.

Several very large surveys have investigated people’s level of agreement with statements that researchers consider “myths” about low back pain. The myths about low back pain are common among the general public and clinicians, including physiotherapists. Examples include “If your back hurts, you should take it easy until the pain goes away” and “Everyone with back pain should have a spine x-ray.”

“Biophysical, psychological, and social factors contribute to pain perception and disability.”

Australian researchers investigated the effect of education and graded sensorimotor retraining intervention in people with chronic low back pain⁽⁶⁾. When tested in a sham-controlled, randomized trial, the intervention produced statistical and modest clinically meaningful reductions in pain intensity and several secondary outcomes, including pain-related disability. The change in pain occurred predominantly through changing the beliefs about the consequences of back pain, catastrophizing, and self-efficacy. The results indicate that changing beliefs substantially reduces pain intensity and disability for people experiencing chronic pain.

The misconceptions about back pain can hinder recovery. But the good news; an intervention as simple as delivering accurate, evidence-based education to those experiencing an episode of low back pain reduces fears, worries, and disability. Challenging some misconceptions around LBP can be an essential starting point for recovery.

References

1. Spine: 1022-31. (2004)
2. Eur J Pain: 1532-1545. (2022)
3. BMJ: 372: n291. (2021)
4. AJNR Am J Neuroradiol:2394-9. (2015)
5. AJNR Am J Neuroradiol:811-816. (2015)
6. JAMA; 328-430. (2022)
7. Pain (2023) (in press)