Confusion #1: Imaging or Diagnosis=Symptoms
I can’t express the amount of times I’ve heard, I have a back from a bulged disc I got 10 years ago. Upon further questioning, I usually ask if there was a specific accident which caused the bulged disc and many times the client can’t think of any incident. If this is the case, how do you know the bulged disc is causing your symptoms?
In 1994, the New England Journal of Medicine published a study that showed that when doctors looked at MRIs of 98 asymptomatic backs. Researchers noted the following:
Another study found approximately 1/3 of asymptomatic subjects had abnormalities on MRI. Those under 60 year old, 20% showed a herniated disc. Over 60 years old, 46% had HNP 21% had stenosis.This is only looking at bulged discs and stenosis, many other studies have looked at stenoses, spondlyolysis, etc.
Even athletes show structural abnormalities, but don’t necessarily have low back pain. One study looked at Spanish athletes and found spondlyolysis as an extremely common finding, yet only 50-60% of these athletes had low back.
Everyone knows a friend, who has had unrelenting back pain. To improve this pain, they’ve had every test done on Earth, but no doctor can figure out the cause or they “figure out” the cause, as the imaging doesn’t correlate with the symptoms. This is because our imaging techniques are not perfect and may never be. In fact, the author of one meta-analysis in the New England Journal of Medicine found that 85% of back pain cases have no definitive diagnosis. It kind of makes you wonder if these expensive MRIs causing extra stress are always worth the costs…
Confusion #2: The Location of Pain and the Cause of Pain are the same Thing
I’ve seen many clients who come in with imaging (see above) indicating they have a bulged disc or spondylolysis at L4-L5. Therefore, they expect me to work on this area directly, but I’m tricky, so try to keep up.
After any injury the body tries to protect itself. This is an amazing feature, since the original problem could be at a specific area, then the body intuitively protects itself…pretty cool! However, this protection can go too far and cause compensations and faulty movement patterns. These compensations often times surpass the original injury, resulting in the main source of pain.
I can’t tell you how many times the psoas (a hip flexor) is compensating in low back pain and a diagnosis of spondyloysis. The psoas acts to stabilize the unstable structure (the spine), inhibiting range of motion, causing symptoms. Therefore, improving these compensations are mandatory for improvement. I’ve seen these cases range from poor foot landing causing back pain to impaired hip range of motion causing shoulder pain.
Confusion #3: Avoid Exercise
This confusion stems from the idea and supporting research that suggest minimizing movement will improve low back pain. This was an old thought, now many health care professionals are suggesting exercise for clients with low back pain, so what is the answer? Exercise or not? Well, like all things it depends.
Whether you exercise or not depends on the phase of the injury. For example, if you have inflammation of the discs, exercising (and breaking down muscles, causing inflammation) isn’t the best idea. However, if you simply have some back pain when you touch your toes (a mechanical issue), exercise is likely helpful. Now, these are only a few examples, but overall, it depends!
Confusion #4: Sit-ups will Stabilize the Spine
I have to admit, I was once in the no sit-ups or crunches group, but in retrospect I was wrong, read my piece Dryland Mistakes: Spinal Flexion on SwimmingScience.net. Just like the true/false test you took in high school, whenever you hear absolutes, begin to question the source. Crunches and sit-ups are an effective exercise, if performed with proper form and dosing!
Unfortunately, the second part of this statement is never remembered, but it’s the most important. Therefore, proper sit-ups can help stabilize and build the ship to prevent low back pain. Don’t perform sit-ups if you have low back symptoms, because everyone will have some degree of low back movement during a sit-up. For this, there are much better stabilization exercises like the march (read 5 Most Common Exercises).
Confusion #5: Bending the Knees When Lifting Will Protect my Back
This is another moderately true statement. Proper knee bending and keeping a straight back will protect the low back when lifting. Unfortunately, our society either bends over with the back or shoots their knee forward and bends the back (low back and knee stress)! When picking up a heavy object or doing a squat, the knees do need to bend, but the shins need to remain vertical with the hips moving backwards, moving the chest forward like a seesaw. In this scenario, the glutes activate, while the spine stays straight.
Confusion #6: Strengthening is all you need to do to prevent low back pain
By now you should all know low back pain is multi-factorial and one thing may help and prevent, but isn’t the end-all be-all. It is essential to strengthen while improving proper muscle length and timing. Just proper muscle length and strength will improve most low back pain, but tackling 50 foot waves requires all three all three facets.
Muscle length can inhibit strength. Think about it, if certain muscles are tight they will pull the muscle in a unique position, adding extra stress to specific areas leading to symptoms. These tight muscles can inhibit and weaken muscles which need to work properly to prevent symptoms. If you have inhibited muscles, but only strengthen the weak muscles, you are perpetuating the problem. Don’t feed into this system, take care of muscle strength and length. The solution is not complex, but it isn’t this simple.
Confusion #7: Having a Flexible Low Back is Good
This confusion starts in school elementary school, having kids perform a sit-n-reach to check their hamstring length. Unfortunately, this test looks at low back flexibility and recent studies have correlated low back flexibility with an increased risk of injury. Just think about it, if you have a highly mobile low back then your ship is constructed with wet glue. Many therapists are starting to realize certain body parts must be stable and others mobile to optimize life. The low back needs stability and the surrounding structures (mid back and hips) need mobility. This wet glue hardens to give a stable structure for your ship!
Unfortunately, many myths exist with low back pain, perpetuating the low back pain epidemic. Make sure you don’t sit too much and perform muscle length, strength, and timing exercises for a complete injury prevention protocol!
Dr. John, DPT