Common Misconceptions about Chronic Back Pain

The MRI can see what is causing my pain.

False–Go back to what we think is causing your pain–the pain sensors and the spinal cord amplifying or getting short-circuited. MRIs can be helpful to see either medium or larger nerve fibers, but the microscopic pain sensors are too small to be seen by an MRI. Painful muscles don’t look different than non-painful muscles. While most numbness, tingling, and funny sensations come from tiny unmyelinated nerve fibers that are scattered within our muscles, tendons, joints, and soft-tissues.

My discs are bulging and that’s what is causing my pain.

False–Many have been told that their pain is coming from disc bulges or tears that look abnormal on their MRIs. Despite what you may have been told about your spine, research shows that chronic back pain frequently does not correlate with the structural abnormalities that may appear on MRIs. Many people with disc degeneration, tears, and bulging discs are able to lead pain-free and active lives. Recently researchers have concluded that an annular tear “had no clinical significance.”

MRI machines are more sensitive now in detecting even slight abnormalities in the water content of the discs. Because of the lack of water in some discs, doctors may say that your discs are “bulging” or even “leaking.” We like to describe the intervertebral disc as being like 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, like a jelly donut does. Many normal age-related factors can increase the likelihood that disks will bulge:

  • Being overweight
  • Performing physically demanding work
  • Having a history of smoking

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, many of us without back pain will have 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, fewer physicians now believe that back pain comes from disc injury. Our spines have the ability to adapt to new environments and activities. Studies have shown that the disc actually benefits from increased physical loading and gradually adapts as joints, bones, muscles, tendons, and ligaments do.

Researchers found that handling heavy loads, bending, twisting, and working in awkward postures, including 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 they do not cause disc degeneration to become rampant. Heavier weight, greater lifting strength, and 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 doctors cite as pain coming from a disc. However, there are growing doubts that disc degeneration is a major cause of lower 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 evidence on spinal fusion treating degenerative disc disease was weak.

At a spine surgery conference, 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. Researchers in Washington state have reported dismal results in injured workers who have undergone spinal fusion for chronic back pain.

I injured my disc lifting something heavy at work. That is why my disc is bulging.

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. Some people feel that repeated stresses of vibrations while driving in a truck or sitting in a car can be damaging to the discs. If it were true that these repeated cycles of activity lead to advanced disc degeneration, then researchers should find that marathon runners would have the worst disc degeneration or osteoarthritis, but they do not. In fact, it is possible that repeated activity cycles may actually improve the discs’ hydration or nutrient delivery and preserve them.

Actually, people who sit at work more frequently have back pain. There are numerous reasons why this occurs, including not being able to engage in a consistent exercise program. Sitting, bending forward, or even changing positions are all activities that require the back muscles to contract repeatedly. Muscles that don’t have sufficient endurance would be expected to fatigue after prolonged sitting or similar activities.

Performing routine activities like bending forward to pick up a pencil or object at work are not likely to cause a disc to rupture. Some feel that just because the pain started at a specific time or with a specific maneuver, this maneuver caused their pain. This is another misunderstanding and is not true.

Unless you undergo significant trauma to your spine, like being thrown out of a moving vehicle, the human spine is capable of absorbing a lot of energy without being damaged. Just look at professional football players being tackled repeatedly or weight lifters exposing their spines to incredible loads. It is much better to try to focus on returning to your usual physical activities rather than finding fault in a particular activity.

Another error in associating the timing of something that breaks with fault can be compared to driving your 10-year-old car around a parking lot and your axle breaks suddenly. Just because your car broke at that particular time does not make the axle wear the fault of the parking lot’s owner. As most people know, if you drive a car that is more than 10 years old, you may be at risk for mechanical breakdowns. By the time we develop chronic pain, our bodies have usually had several decades of wear before the first sign of back pain occurs.

In addition, if one has neglected routine maintenance for many years, (such as maintaining a healthy weight, diet, and exercise habits) it makes the occurrence of these problems even more likely. Some individuals unfortunately perpetuate these misunderstandings by avoiding that particular parking lot or refusing to drive anymore because of fear that a similarly catastrophic event may occur.

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 all of our muscles. You certainly could have strained some of the very deep and important “core” muscles in the spine with an incident at work, but depriving those muscles of regular activity 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 of the regular exercise they need in order to repair themselves. This is why keeping our muscles at their best flexibility, strength, and endurance is so critical if you have a physically demanding work situation.

Population studies have shown increased death rates and increased chronic disease complications when people are taken away from their usual social environment, colleagues, and role or identity in life. Similarly, people who think they are not capable of working in society often become repeat patients, endlessly attending medical appointments.

Back pain often leads to permanent impairment of disability.

False–Surprisingly, the most important predictor of chronic, disabling pain is not related to how bad or abnormal an MRI looks, 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. Physicians are trained to detect slight physical findings or see abnormalities on imaging tests. These subtle findings are not good indicators of the people who develop 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 than from medications, pain injections, or surgery.

Because I have back pain, I will need permanently modified work.

False–It may be surprising to many that the likelihood that an individual will develop chronic back pain has little to do with actual work requirements. One of the earliest predictors of a reported work injury is a job dissatisfaction or feeling of lack of autonomy in the worksite.

Prior population studies have shown that workers who recently had a poor performance review are also at the highest risk for reporting a work injury. These psychological risk factors are much more predictive of who will develop chronic low back pain rather than actual physical job requirements.

If you are in a job that doesn’t match your physical abilities, you should strongly consider seeking alternative work arrangements. Your employer does not have to find work for you if you cannot perform the essential work duties of your job. Reduced or modified lifting programs also do not reduce the severity or incidence of back pain episodes. Specific types of lumbar supports and shoe inserts have also been proven to be ineffective. Only a regular exercise program was found to be effective for preventing back problems.

If you are involved in a worker’s compensation claim and end up having surgery or permanent structural change to your spine due to a fracture or surgery, then you may need permanent work restrictions. Again, there is a significant difference between hurt and harm.

Those who have had surgery will very likely have increased pain in the future. This pain or hurt does not mean harm to the spine even if the symptoms feel similar to the initial pain. Those who have had surgery should carefully consider whether their post-surgical physical abilities continue to match the requirements of their chosen occupation. Those who are not able to continue their rigorous physical requirements may need to consider that they may be facing the end of their chose occupation or have had a career-ending injury.

Most patients with chronic back pain do not qualify for Social Security Disability because there are usually at least some work activities that can be considered gainful employment. A person who understands the cause of their back pain and is sufficiently motivated to improve their ability to cope with their pain can participate in some form of work, physical, and recreational activities with minimal modifications.

I should rest until my back pain goes away.

False–We at the University of Iowa Health Care do not agree with this statement. Too much rest is the worst thing for a weak, stiff, or painful muscle to have. Activities to get the muscles back to normal are essential.

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. Regular exercise may actually have a preventive effect in terms of frequency of back pain and recurrence.

My back pain means something is significantly damaged or diseased.

False–In a study of 1,200 patients with acute back pain, less than 1 percent of patients with back pain had a serious condition including a fracture, infection, cancer, or multiple nerve root compressions. Several treatment guidelines can identify certain items in your personal history or examination that may lead us to suspect an underlying serious medical condition.

X-rays, CT scans, and MRIs can identify why I hurt.

False–The National Institutes of Health Task Force on Research Standards for Chronic Low Back Pain determined that, “The precise anatomical basis of back pain can only be identified in a small proportion of cases.”

Many spine specialists feel that lumbar spine MRIs are unnecessary in the presence of a good or normal physical examination. Dr. Scott Boden, a well-respected spine researcher once remarked, “‘Let’s get an MRI scan to see if there is anything wrong with the spine’ is the beginning of a dangerous thought process.”

Studies have shown that patients who obtain early MRIs actually have a worse outcome than patients who are simply reassured that there is no significant abnormality in their spine. Another study indicated that only 1 out of 2,500 X-rays of the spine showed anything helpful in determining an individual’s back pain.

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 MRIs (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 easily reproduced by stretching or activating their muscles unless there are special circumstances.

Studies have indicated that more medical care for back pain does not necessarily mean better care. Patients should be careful in requesting an expensive and unnecessary evaluation. Some people may just want to know what their MRI shows and say they will feel better knowing that they don’t have anything seriously wrong such as 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 one. 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 that 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.

My back pain must be curable with some form of medical treatment.

False–Once reassured by your doctors that there is no fracture, infection, tumor, or a sinister medical condition that is responsible for your pain, the next step is to look for whether there are any factors that you can improve your pain.

“Low back pain was recently termed the ‘most over-treated condition in the US.’” According to the NIH, US spending on back care increased from 1997 to 2005 up to $86 billion. This amount is close to what the country spends on cancer treatment. An article from a 2008 Journal of the American Medical Association reported “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. This shows that back pain is clearly a problem for our entire country and its productivity. Dr. Richard Deyo has written an informative book titled “Watch Your Back! How the Back Pain Industry is Costing Us More and Giving Us Less and What You Can Do to Inform Yourself in Seeking Treatment.”

The expectation that passive treatment will cure a person’s back pain is a bad sign. Back pain is not like cancer. You are not dependent upon your physician to prescribe the perfect concoction of chemotherapeutic medications that will destroy rapidly growing cancer cells. Think about your back pain from an activity standpoint.

We want you to think back to the concept that chronic back pain is coming from overactive nerve or pain sensors that are amplified by the spinal cord or brain. Unfortunately, we cannot get into your spinal cord to adjust your pain filters. We also cannot give you any safe prescription medication that will make your muscle flexibility, strength, or endurance get any better.