Ten New Facts About Low Back Pain from BJSM

A recent BJSM editorial set out ten facts about low back pain, along with a visual infographic to make them easy to remember. In my view, the version by Yann Le Meur is clearer, so his image is at the top of the page, and BJSM’s less successful comparison chart follows below, ha.

A quick quiz: how many of the following ideas about back pain do you think are correct?

• Low back pain is a serious medical problem

• Symptoms of low back pain persist and even worsen in later life

• Persistent low back pain is always related to tissue damage

• People with low back pain always need further imaging

• Pain during exercise and activity is usually a warning sign of damage to the spine

• Low back pain is related to poor sitting posture, poor standing posture, and lifting heavy objects

• Weaker core muscles cause low back pain, and strong core muscles prevent it

• Repeated spinal loading causes tissue damage

• Recurring pain happens because of tissue injury

• Treating low back pain with medication, injections, or surgery is effective

If you think none of these are quite right, congratulations, your understanding is already up to date with the latest from BJSM.

The impact of myths and new ideas

There have long been plenty of myths about back pain. These ideas trouble many members of the public, and even some trained or medical professionals. It is understandable that such myths exist, because many of these notions come from linear thinking, lack repeated cross-checking, and have not necessarily been reasoned through and tested scientifically.

In recent years, new research evidence has shown us some ideas that differ from the past:

• Low back pain can be frightening, but most cases are not dangerous

• Low back pain does not become more severe simply because of age

• Persistent low back pain has little to do with tissue damage and is more closely associated with negative thoughts and excessively worried behavior

• Imaging is mostly unhelpful for the prognosis and recovery of low back pain, and abnormal imaging reports can appear in people who are normal and without symptoms

• Progressive exercise is safe and healthy for the spine, and pain during exercise does not necessarily mean the spine is injured

• Poor sitting posture, poor standing posture, and lifting heavy objects do not directly cause low back pain

• Weaker core muscles do not cause low back pain; training the core is a good thing, but excessive tension is counterproductive, and moderate stretching can help

• Most spinal loading movements are safe and can also gradually strengthen the muscles

• Recurring low back pain is mostly related to changes in activity level, stress, and emotions rather than tissue injury

• For long-standing persistent low back pain, medication, injections, and surgery are often not very effective, and other lower-risk options may be considered

The shift in clinical treatment guidelines

Many clinical practice guidelines (CPG) are now entering another era of reform as the number of studies grows, especially for symptoms that are hard to classify and have many treatment options. Nonspecific low back pain is a clear example.

A 2018 Lancet paper pointed out that many past clinical treatment guidelines recommended treatments drawn largely from studies in high-income countries, focused mainly on treatment rather than prevention, and were too costly, while the imaging, medication, rest, injection treatments, and surgery in the guidelines may also have been overemphasized.

A 2020 BJSM systematic review collected 44 clinical treatment guidelines for musculoskeletal joint pain from around the world, of which 11 were of high quality; 4 high-quality papers addressed CPGs for low back pain. For nonspecific low back pain, several key points were noted:

• Do not use acetaminophen alone

• Do not use opioids for pain relief

• Do not use antidepressants, such as SSRIs or TCAs

• Disc replacement is not recommended, and joint fusion surgery is accepted only in certain situations

• Injection treatments should not be used (for example, facet joint, medial branch block, intradiscal injection, and even prolotherapy and trigger point injection)

That’s right, the prolotherapy and other injection methods many people commonly use were also singled out for criticism.

Summary

Research and discussion on low back pain have been very active in recent years, and there is not yet a treatment guideline that convinces everyone. The single question of whether low back pain requires imaging has been debated for a long time. Ask yourself honestly:

• Are you clear on the differences in false positives and false negatives for each imaging test? The numbers and what they mean?
• Are you familiar with the warning signs (red flags) of low back pain conditions, and do you understand the common abnormal disease symptoms?

Opposing imaging just for the sake of opposition, without understanding the process, does not really hold up, because avoiding unnecessary imaging usually depends on being sure that pathological disease and red flag situations have been ruled out.

There are many causes of low back pain and many answers as well. In a future that pursues more evidence, clearer answers should gradually emerge.

p.s. BJSM has been interesting over the past year or two, offering plenty of paradigm-shattering views that challenge everyone’s minds and worldviews. Let’s keep watching.

Further reading

• Spine and low back pain
• Rehabilitation exercise prescription
• Pain management