Debunking 3 Myths About Back Pain
By: Timothy Kwan, Year 2 MscPT Student at U of T; Editor: Nataliya Zlotnikov MSc, HBSc ∙ Estimated reading time: 4 minutes

Is there a recipe for treating back pain?

Whether you are in physiotherapy school, recently graduated, or are a practicing clinician, there is no doubt that there will be many patients who come into your clinic with back pain. However, there is no standardized assessment and treatment plan that works for every patient. 

A plan that may work for one patient may not for another. 

With that in mind, could it be possible that back pain is more complicated than it seems? 

If so, how then do we go about treating our back pain patients? Keep reading as we dispel 3 common myths about diagnosing and treating back pain and provide a few tips to keep in mind for your next patient with back pain.

Myth #1: In order to diagnose low back pain (LBP) patients MUST undergo radiological testing!

A common misconception is that in order to find out about the cause of a patient’s back pain, they must undergo radiological testing such as X-rays or MRIs. 

It has been found that:

“radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain.”

Kendrick et al., (2001) 

Setchell et al., (2017) also found that most people associate their back pain with structures that are “physically defective”. What’s worse, is that 89% of the 130 participants reported learning this information from health professionals!

So what does this all mean?

Well, as health professionals we should be more mindful of choosing what to tell our patients. 

Although clinicians may not intend to frame messages in this way, unhelpful pathoanatomical models can be (mis)interpreted and remembered by patients. This can lead to decreased patient outcomes. 

Tissue deterioration due to natural aging is normal, and since some experience pain, while others do not, the tissue itself cannot be the sole cause of pain.

Myth #2: Back pain is caused by weak “core” muscles and having a strong core protects against future back pain!

There is a large body of evidence correlating low back pain and “weak” core muscle. 

Recently though, a lot of the research has stepped away from focusing on the core, and towards assessing overactivity of the pelvic floor muscles. 

Dufour et al., (2018) assessed 182 women with lower back pain. It was found that 95.3% of the participants had pelvic floor dysfunction, 71% had tenderness upon palpation, or simply overactivity of the pelvic floor, and 66% had weak pelvic floor muscle weakness. 

Dufour et al., (2018) found that of 182 women with low back pain, 

The last percentage is important, as it signifies the high false positive rates of mistreatment. It was also found that: 

“An overactive pelvic floor was more strongly associated with disability compared to weak pelvic muscles.”

So what does this all mean?

If there is such a high rate of false positives in treating weak muscles while not considering overactivity, what is truly the role of working on strengthening those muscles? As clinicians, we should incorporate assessments that screen for both weak pelvic muscles as well as a tender pelvic floor in order to better provide individualized treatments that are more beneficial to patients.

Myth #3: Persistent back pain is always related to tissue damage

Oftentimes, patients believe that the cause of their back pain are musculoskeletal issues, involving tissues of the structures nearby. However, aside from mechanical issues, there are others that can arise. 

Such issues can be explained by incorporating psychological and social factors to see the full picture. 

A common cause of pain that is not mechanical is a term known as central pain mechanisms. This term is another way of saying increased sensitivity of the nervous system. People who deal with central pain mechanisms present with poorer outcomes following local treatments such as electrotherapy, motor control exercises, manual therapy, and surgery. Instead, treatment should pivot towards addressing lifestyle factors that sustain processes of central pain mechanisms like illness beliefs, stress, sleep, physical activity, and diet.

So what does this all mean?

When treating patients with back pain, it is important to incorporate a biopsychosocial approach rather than just a biological one. To determine if central pain mechanisms are present in a patient, a screening instrument called the Central Sensitisation Inventory (CSI) may be used to assess potential psychological and/or social factors. 

If a patient scores greater than 40 out of 100 on the CSI, then they are considered to have central pain mechanisms. In addition, being familiar with the concept of central pain mechanisms may help explain and educate patients on other potential causes of their pain.

What's next?

Based on just these three subtopics, it is evident that back pain is not as simple as most people think, and that clinicians must take a wide variety of approaches to tailor to each and every patient as their stories will be different from each other’s. 

If you want to learn more about how to incorporate a biopsychosocial model in treating patients who are dealing with pain, or other misconceptions regarding back pain, then check out THE Biopsychosocial Bundle which includes courses from:

• Carolyn Vandyken
• Neil Pearson
• Lara Desrosiers
• Lynda McClatchie
• Dr. Sinéad Dufour
• Debbie Patterson

Learn more about
THE Biopsychosocial bundle here 

Works cited list

Dufour, S., Vandyken, B., Forget, M. J., & Vandyken, C. (2018). Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskeletal Science and Practice, 34, 47-53.

Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ. 2001 Feb 17;322(7283):400-5. doi: 10.1136/bmj.322.7283.400. PMID: 11179160; PMCID: PMC26570.

Nijs, J., Polli, A., Willaert, W., Malfliet, A., Huysmans, E., & Coppieters, I. (2019). Central sensitisation: another label or useful diagnosis?. Drug and therapeutics bulletin, 57(4), 60-63.

Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskelet Disord. 2017;18:466.

---

Date published: 16 Oct 2023 
Last update date: 5 July 2024