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Everything you know about back pain is wrong

Back pain treatment costs more than cancer and diabetes treatment combined - across the world it places a huge burden on people and societies. However, most of these costs are usually related to a small minority of people with back pain. Almost everyone will experience back pain during their life. Thankfully, most people report significant improvement in their symptoms within the first two weeks of an acute episode of pain, with 85 percent of people fully recovered by three months - often without any need for treatment.

Only a very small number of people develop long-standing, disabling problems. Here we look at four aspects of back pain that can confuse people, and identify some strategies that can help manage pain.

Scans for back pain are increasingly used - yet they often do not help Both healthcare professionals and members of the public often want to have a scan on the basis that it might rule out serious conditions, or confirm what exactly is causing the pain. However, scans only show something truly important in a minority (less than 5 percent) of people with back pain.

In fact, there is a suspicion that scans can sometimes make the situation worse. This is because when people have scans for back pain, the scans often show up 'something'. For example, many people have "stuff' on their scans that can sound scary, even if these things are relatively normal and not closely connected to pain. This includes things like bulging discs and degenerated discs, which have a lot in common with grey hair and wrinkles - they are more common as we get older, without being dangerous.

Unfortunately, people with back pain are often told that these things indicate their back is damaged, and this can lead to further fear and distress or lead people with back pain to rush for procedures like surgery when they are not needed. Therefore, you should think twice before getting a scan.

A brief consultation with a healthcare professional (eg GP, physiotherapist) is usually enough to identify if a scan is really needed based on your symptoms and medical history. If you are being sent for a scan, be sure to check with the doctor if that is because you definitely need one right now. You can always decide to go for a scan if needed later on if your back pain has not settled. Finally, remember that if you do get a scan and receive a long report with scary medical terms being used, be sure to check if the things reported are rare and only found in people with back pain.

Physical activities can be painful and frightening - yet refraining from activity is often a bad idea. Back pain can often start with an activity such as lifting, twisting or gardening. When someone is in a lot of pain, resting is an understandable strategy. In the first few days, avoiding aggravating activities may help, similar to pain in any other part of the body such as a sprained ankle. However, there is strong evidence that keeping active and returning to all usual activities gradually is better in the long-term than prolonged rest. Although starting to be active again may be daunting and painful initially, gradually getting back to moving, bending, twisting and activity in general is safe and beneficial in the long run. Therefore, do not panic if you feel sore initially after getting back to activity, as this does not necessarily indicate harm or damage.

Importantly, it looks like there is no exercise or activity that is uniquely 'good' or 'bad' for the back. All forms of activity seem to help - what is important is that you build it up gradually, and stick to it. In this regard, try to select an exercise or activity that you enjoy, can afford and can do at a convenient time and location.

Back pain is not 'all in your head' - yet your thoughts and emotions are important. While back pain can sometimes be related to a specific injury or a sprain, in many cases there is no major trauma or specific incident that caused it. Irrespective of whether there was an initial trauma or not, many other factors can also be involved in delayed recovery from back pain.

This includes issues such as mood, anxiety, fears, poor relationships at work or home, stressful life events and poor sleep. Similar to a headache, you can experience significant pain where the biggest factors are not about damaged tissues, but more related to high stress or poor sleep and how these affect our general health and immune system. If you have been told scary things about your back and your future prognosis, this can lead to even greater levels of tension in your back muscles, which further aggravates back pain.

Nevertheless, being aware of how your thoughts and emotions affect your general health and influence the volume switch for pain is very useful.

Preventing back pain sounds great - yet our attempts so far might be part of the problem. Since back pain is such a disabling and costly condition, a lot of money is spent on trying to prevent it occurring. This is understandable - prevention is better than cure we often say. However, such attempts have mostly failed to help back pain. For example, attempts to reduce physical loads on the back through manual handling training and changing office ergonomics have not reduced pain, disability or absenteeism. In fact, these approaches might have made people unnecessarily worried about everyday tasks such as bending, lifting and sitting.

There are two possible alternatives; First, rather than focusing only on physical factors like posture, ergonomics and manual handling, it is possible that back pain prevention programmes must address more risk factors (eg sleep, mood, stress, anxiety, job satisfaction, general health). More controversially, a second possibility is that primary back pain prevention in itself is unrealistic and maybe even unhelpful. The reason for this is that back pain is - similar to getting tired or becoming sad - a 'predicament of life' in that we don't necessarily like it, but it occurs to almost everybody at some point. What is not common, is not recovering from back pain reasonably quickly. Therefore the time and effort spent on trying to prevent people ever getting back pain might be better spent on ensuring that when people develop back pain that they receive speedy evidence-based advice on what to do.

Kieran O'Sullivan is lead physiotherapist at the Sports Spine Centre at Aspetar Orthopaedic and Sports Medicine Hospital, Qatar and a senior lecturer in Physiotherapy at University of Limerick. His research group provides evidence-based information at
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