Low Back Pain: The Truth As We Know It

Do I have your attention? How many times in your search for information on low back pain have you seen statements similar to the ones above? Just take a look at some of the other lenses on Squidoo dealing with low back pain and you will see what I mean.

Let me be the first one to tell you: There is no silver bullet or magic hidden cure for low back pain. Any person or website which tries to convince you that they have the, one and only answer to eliminate back pain is misleading you.

The goal of this lens is to provide you with scientific information on the diagnosis and treatment of low back pain. This lens is not a replacement for medical advice and is meant only to provide the reader with a better understanding of the science behind low back pain.

Throughout this lens you will see small numbers by some of the statements I make. These numbers correlate to particular references which are listed at the end of the lens. These references are scientific article which support what I will be talking about in this lens. I do not expect you to blindly accept what I am presenting on this lens. You should all be critical thinkers and you need to question the validity of any statement that is made on this lens and any other site you use for information. This is called critical thinking and you can learn more about this on other sites. Check out the video "Here Be Dragons" and the pod casts, Skeptoid and the Skeptics Guide to the Universe.

Most people in the United States will experience low back pain in their life. In fact, it is estimated that 70-85% of people will have back pain. (1) The good news is that the vast majority of these people will get better. Less than 10% of these cases last more than one year.(2) As many of you have found in your searches, there are hundreds of treatment approaches for patients with low back. The major reason for the existence of all these treatment methods is that no one really knows what the best treat is for a given individual with low back pain.

I can tell you are very smart, so I am sure you are asking: with all the studies we have addressing low back pain, how can we not know what the best treatment is?

The problem lies in our inability to identify a cause for low back in the majority of people. Nearly 90% of all cases of low back pain can not be accurately diagnosed.(3)

Lots of people get a "diagnosis" for their low back pain. The key is the "accurate" part. Terms like disk herniation or degeneration are often used but in most cases, there is little to no supporting evidence. In many cases, holes can easily be punched through the diagnosis and it can not hold up to scientific scrutiny. We will talk about this more later!

So, if you can not accurately diagnosis or differentiate people with low back pain these individuals are clumped into one large group. When you try a particular intervention on this group you are likely to get very different responses.

Consider this example: Lets say there is a physician and 5 people come into her office with stomach pain. In all her wisdom she decides to remove each of their appendixes. To her dismay the procedure only helps one person. As a result she decides that appendectomies do not consistently work and she vows to never perform one again. In this case, it is easy to see where the physician went wrong. Only 1 of her patients had a problem with there appendix. The other 4 had gall stones, food poisoning, some bad gas cramps and irritable bowl syndrome. No one would expect an appendectomy to help those people. Providing the same treatment to all people who have low back pain also makes no sense. That is why I get so frustrated when I see websites from well meaning back pain sufferers who tell others they have found the answer. Just because a particular treatment worked in their case, does not mean it will help you. Conversely, just because someone did not find benefit in a particular treatment, it does not mean it won't work for you.

If we can not accurately classify patients with low back pain, then we can not predict which treatment is going to be most appropriate for them. Just like if we can not diagnosis a ruptured appendix, then randomly removing the appendix from people with abdominal pain is not going to work very well.

Again, I know you are pretty sharp so you are thinking why is it so difficult to find the right diagnosis for people with low back pain? You may even be thinking that my doctor took an MRI so I know that my pain is from (fill in the blank). Why don't we just get MRIs for everyone and that will solve the problem.
Well there are a few reasons why we have difficulty diagnosing the cause of low back pain:
1. There are lots of structures in the low back that can cause pain (and they are close together)
2. The location of pain is not a very good predictor of the location of the problem.
3. The tests we use to diagnosis low back pain are not very good (and that includes the often highly touted MRI)
4. A person can have structural findings (disk herniation/bulge/protrusion, degeneration, spondylolysesis, bone spurs etc.) and have absolutely no pain.
5. There are probably more reasons but that's all I can think of right now.

The MRI:
Did I just say that MRIs suck? Well that may be a little unfair, but MRIs do not give us the information that we think. Everyday I see people with perfect MRIs who are in a lot of pain and I see people with really bad looking MRIs who are not doing so bad.

MRIs give a very detailed view of the spine. X-rays only show bone where an MRI will show muscle, tendons, ligaments, disks, nerves and so on. The problem is, they can not show pain. It is very normal to have a "positive" MRI. In fact, many people (with or without) low back pain will have a positive MRI. So just because you MRI showed a disk herniation or degeneration or stenosis, it does not mean that these are causing your pain. It also, does not predict what treatments are going to be the most effective for you. It takes a skilled clinician who can correlate the MRI finds with the clinical presentation to determine if the MRI findings are a factor in your pain.

I really hope that you are skeptical of everything I just said about MRI. I have yet to offer you one bit of evidence to support what I just said. Lets see if I can fix that:

A smart guy by the last name of Jarvik decided to take MRIs of 148 people who did not have any low back pain.(4) He found all sorts of things on these MRIs. He found disk herniations and protrusions (some of which pushed on nerves), degeneration, stenosis and lots of other fun things (remember none of these people had pain). He then sat back and chilled out for 3 years. After three years he called back those 148 people and he asked which of them had experienced low back pain in the past three years. Then he went back and looked at their MRIs to see if any of the findings occurred more often in those people who got low back pain. Guess what, they didn't. In fact, the strongest predictor of development of low back pain in this group had nothing to do with the MRI. It was the presence of depression. This Jarvik guy was not the only person who found that MRI results did not correlate well with the presence of low back pain. Here are 3 other studies which found very similar results. (5-7)

A guy named Kleinstuck studied 53 patients with low back pain.(8) He wanted to see if MRI findings predicted whether a person would be helped from conservative care (no surgery). Out of the 53 subjects 89% had severe disc degeneration, 74% had a disc bulge and they had a bunch of other things too. None of these factors had an association with pain or disability after a bout of physical therapy. So that means, the 89% of the people who had severs disc degeneration had just as good a change of doing well with PT as those people who did not have any significant findings on their MRI. Several other studies also found no major correlation between MRI findings and success of conservative care.(9-12)

Lets wrap up all that non-sense
1) People without back pain have lots of nasty stuff on their MRIs
2) Nasty stuff on an MRI does not mean you are going to have back pain in the next 3 years
3) MRI findings do not predict how you are going to respond to conservative treatment

There are times when MRIs are needed and can be very helpful. They are very good at ruling out scary things like cancer and infection. They can also help a surgeon figure out what type of surgery should be performed.

1. Strine TW and Hootman JM, Us national prevalence and correlates of low back and neck pain among adults. Arthritis Rheum, 2007. 57(4): p. 656-65.
2. Maetzel A and Li L, The economic burden of low back pain: A review of studies published between 1996 and 2001. Best Practice & Research Clinical Rheumatology, 2002. 16(1): p. 23-30.
3. Hollingworth W, Todd CJ, and King H, Primary care referrals for lumbar spine radiography: Diagnostic yield and clinical guidelines. Br J Gen Pract, 2002. 52: p. 475-80.
4. Jarvik JG and Hollingworth W, Three-year incidence of low back pain in an initially asymptomatic cohort: Clinical and imaging risk factors. Spine, 2005. 30(13).
5. Carragee E, et al., Are first-time episodes of serious lbp associated with new mri findings. The Spine Journal, 2006. 6: p. 624-635.
6. Carragee E, et al., Discographic, mri and psychosocial determinants of low back pain disability and remission: A prospective study in subjects wiht benign persisten back pain. The Spine Journal, 2005. 5: p. 24-35.
7. Kjaer P, et al., An epidemiologic study of mri and low back pain in 13-year-old children. Spine, 2004. 30(5).
8. Kleinstuck F, Dvorak J, and Mannion, Are "structural abnormalities" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain. Spine, 2006. 31(19): p. 2250-2257.
9. Gilbert FJ, et al., Does early magnetic resonance imaging influence management and improve outcome in patients with low back pain? A pragmatic randomized controlled trial. Health Technol Assess, 2004. 8(17): p. 1-131.
10. Jarvik JG, Hollingworth W, and Martin B, Rapid magnetic resonance imaging vs radiographs for patients with low back pain: A randomized controlled trial. JAMA, 2003. 289:: p. 2810-18.
11. Kendrick D, et al., Radiography of the lumbar spine in primary care patients with low back pain: Randomized controlled trial. BMJ, 2007. 322: p. 400-405.
12. Modic M, et al., Acute low back pain and radiculopathy: Imaging findings and their prognostic role and effect on outcome. Radiology, 2005. 237(2): p. 597-604.

More to come!!