3 Myths about Low Back Pain that are stopping your recovery

So far in this 3 part series (of which this is part 3) looking at the PAIN = DAMAGE myth, we’ve come to understand that:

  • Pain is not an accurate indicator of tissue damage
  • Pain is an output of the brain that is projected onto your body
  • The experience of pain is greatly influence by context, such as the language we use to describe our pain
  • Misinformation and untrue beliefs about our health and bodies can lead to an increase in pain

And so if you’re dealing with long-standing pain, then let me give you 3 truths to combat this myth and help you with your own pain:

  1. Your body is fundamentally strong – A lot of you may be familiar with the statistics that come up in Health and Safety and Work, that say when you’re sitting with bad posture or lifting a heavy box with bad posture double the amount of pressure is put on your back. The original research for these statistics was conducted on cadavers – that is people who have donated their bodies to science for experimentation after their death. And so this study confirms something very obvious to me – that dead bodies shouldn’t sit in chairs or lift heavy boxes. Your living tissues are actually remarkably strong and resilient and it’s harder than you think to cause serious damage. And, importantly from that piece of research, even the highest amounts of pressure measured in those cadavers were well within tolerance levels for a living spine. You are not a fragile structure.
  2. Don’t fear movement – it’s a common misconception that bending is bad for your back. And we hear all the time that we have to hold our spine really straight and brace our core before any movement in our back. But honestly, stiffening your back like that is a really unnatural thing to do. On the other hand, there is strong evidence of the many benefits of staying active to reduce pain. In fact keeping mobile, and for many people this would involve staying in work, results in less pain and a faster recovery. So don’t fear movement – “motion is lotion”, as they say.
  3. Your body is healing – think back to last time you had a cat scratch or a paper cut. How long did it take to get better? Would you be surprised if, after a year, it was still bleeding? We are so used to our skin healing and repairing itself, but we often don’t have the same faith in the bits we can’t see, like our joints. But the same immune cells that heal your skin and working all the time to repair all your insides too. And they’re constantly at it – healing and protecting, healing and protecting. So you can have some faith – you are always repairing and getting better.

Now I think that this topic is so incredibly important because a misunderstanding of pain and a fear of our bodies can be a huge burden for the individual. Patients tell me all the time that they’ve stopped doing things that are important to them, because they just don’t trust that their bodies will cope. One patient told me that she felt she had no choice but to have an abortion because of the unbearable strain that a pregnancy would put on her back.

But the impact is not just felt at the individual level. Low back pain and neck pain are both leading causes of time off work in Britain. And the UK, like most other European countries, spends between 2% and 3% of GDP on its treatment. In fact the treatment of persistent pain costs more than diabetes and cancer… combined.

Imagine how this would change if we threw out the pain = damage myth. If instead of spiralling into inactivity and fear we remembered that we are strong and capable of healing. How liberating would it be if we remembered that movement will build our bodies and not break them. And how empowering would it be if we recognised the ability of our brains to control our pain.

Pain – All in Your Head?

Last week we explored the PAIN = DAMAGE myth and saw that:

If the brain feels there is credible evidence of a threat, it will create the experience of pain to protect you. Like that fire alarm sensing smoke or heat, it will sound the alarm. This in essence means that pain is not something that exists IN the body, it is created by your brain and projected ONTO your body.

Now, I just want to pause here and deal with a thought that many of you are having right now. You might be thinking “Are you saying that for some people their pain is in their head?” No. I’m saying that for all of us, 100% of the time, pain is in our heads.

But don’t mis-understand me. What I mean by that is that 100% of the time pain is an output of the brain. What I’m not saying is that, if your pain isn’t driven by tissue damage, then it’s not “real” pain.

If we return to our fire alarm analogy, that fire alarm could be sounding because of a house fire or because of burned toast, but the sound it makes in both those situations is the same. Regardless of what is driving pain, the experience of it is just as real.

And for this reason we must move away from the PAIN = DAMAGE myth. Because if we believe that pain is always an accurate indicator of injury or damage in the body, not only is it untrue, it can actually be very harmful. 

I mentioned last week that this myth could be considered a leading cause of long-standing low back pain. One of the reasons for this is because the language we use when talking about low back pain is often quite scary. When we talk about a slipped disc, a twisted pelvis, a weak core or a spine that’s “out” these can be scary-sounding things, even though they are not life-threatening things at all. What often results from this kind of language is that people become frightened of their own bodies. Thinking back to what we learned last week about pain, we know that stress hormones and your beliefs about your health and your body play a big role in the creation of the pain experience. And so, we see how a vicious cycle could begin. People are frightened, feel more pain, and because they feel more pain they become more frightened.

So an obvious thing that I would ask is that if you’re a healthcare professional, especially if you’re in the manual therapies, stop scaring your patients. We don’t have good evidence that weak cores or twisted pelvises exist in the way that we describe them, much less that they cause pain. But we do have good evidence that the language we use can make patients feel fragile and broken. And this absolutely does contribute to their experience of pain.

Hurt doesn’t always mean Harm

I’m here today to tell you about a huge myth. This myth is about pain and it could be considered a leading cause of persistent low back pain.

Here it is – are you ready?: PAIN EQUALS DAMAGE

On so many levels this feels right to us, doesn’t it? You get an injury, nerves carry pain signals to the brain and you feel pain. But the research has shown us that the experience of pain is so much more complex and nuanced than this and actually it isn’t just about damage at all.

We now know that you can have AN INJURY WITH NO PAIN

Many of us will have had experience of spotting a bruise on our arm or leg and thinking “where did that come from?”. That’s an obvious sign of (albeit minor) tissue damage which didn’t hurt at the time of an injury. I used to see it pitch-side all the time when I was doing first aid at football games. Players would be so involved in scoring that they wouldn’t notice gashes, sprains, strains, or sometimes even fractures, until they actually looked a few moments later. Or how about nosebleeds? They often don’t hurt but they are caused by a ruptured blood vessel in the nose.

Moreover, if you took 100 people with no back pain and scanned them in an MRI machine, 50% of them would have a disc bulge and/or osteoarthritis that is producing no symptoms and absolutely no pain.

We also know that you can have PAIN WITH NO INJURY

Why do we describe the loss of a loved one as heartache? Isn’t it because we get a tangible feeling of pain in our chest in grief? Or if you want a more medical example how about migraines? The pain from migraines is usually very severe. But there’s no damage or injury with a migraine and within a few hours the person has usually fully recovered. So what was all that pain about?

We even know that you can have PAIN WITH NO BODY PART

Some of you may be familiar with phantom limb pain, where a person experiences pain in a limb that isn’t there. Most commonly this is due to amputation but there are actually cases of people born without limbs still experiencing sensations from a limb that never existed. Not only that, but this can be replicated in non-amputees too. In certain research conditions, a person can be made to feel pain in someone else’s body or can be made to feel that kind of deep tingly sensation you get with acupuncture, when acupuncture is performed on a prosthetic limb. Even if they’ve never had acupuncture before.

 

So if you can have an injury with no pain, pain with no injury, or pain without even a body part, then our experience of pain CANNOT just be about tissue damage. 

 

We actually now know that many things contribute to the creation of pain, and it’s all to do with complex interactions of the nervous system. But because neuroscience is complicated I like to think of it like a fire alarm. Because fire alarms don’t actually respond to fire, do they? Their sensors respond to heat and smoke. In the same way there are no pain signals, pain nerves or pain pathways in the body. Receptors on the nerves are sensitive to pressure or stretch, to temperature, to certain chemicals. Now, these things might imply that there was some damage in the area but actually the brain takes a lot of other things into account too. It will take information from sight and sound to work out where you are and what you’re doing. It will assess your mood and the levels of any stress hormones in your blood. It will call on your memory bank to ask if you’ve had this pain before. And it uses your personal beliefs about your body and your health. And using all this information your brain asks one question: “Do I need to protect myself?” 

 

If the brain feels there is credible evidence of a threat, it will create the experience of pain to protect you. Like that fire alarm sensing smoke or heat, it will sound the alarm. This in essence means that pain is not something that exists IN the body, it is created by your brain and projected ONTO your body.

(Stay tuned for the next instalment next week)

Is BMI broken?

Let me tell you about two conversations (and one rude remark) I had recently:

I was discussing an upcoming knee replacement with a neighbour. He is about 5′ 5”, very rotund and in his late 60s, and he said

“They won’t do the surgery until my BMI is lower. They want it below 40. But the thing is, when I was 20 I used to play rugby, and I just don’t think they’re taking into account the muscle on my legs from back then.”

I was telling a friend of mine, who is a personal trainer, about this conversation. His background is in boxing and martial arts, having been county champion about 3 years ago. He now trains athletes and is in excellent shape himself. He’s over 6′ tall and in his early 20s, and he said:

“I went to the GP recently about some symptoms I was having and he said that with my BMI being technically overweight, my issues were down to being too fat. I asked if he was kidding so he asked what I ate. I told him that, because of how I train, I have to eat around 6000 calories a day to maintain my muscle, and he told me I should cut it down to 2000.”

Now for the rude remark. I was telling my mum about both of these conversations and an extended family member, who is roughly half my height but weighs more than me and recently had open heart surgery, interrupted and said

“These two stupid women…”

(that’s right, she called me and my mum stupid, to our faces)

“…talking about BMI. As long as you’re fit and healthy that’s all that matters.”

I had all these conversations in the space of a week, and it wound me right up!

What is BMI?

BMI stands for Body Mass Index, and it’s calculated using your height and weight. Essentially, it’s a ratio that, depending on your height, will give you an idea of what a healthy weight is for you. This is usually expressed as a range, rather than a fixed number; a BMI of 18.5-25 is considered healthy. Anything under 18 is considered underwieght, above 25 is overweight and above 30 is obese.

These ranges have been shown to be predictive of the risk of developing certain conditions. For example, a higher BMI is associated with a higher risk of osteoarthritis in the lower limbs, insulin resistance, hypertension, diabetes and cardiovascular disease. It is also associated with poorer control of asthma and poorer sleep quality. A lower BMI is associated with a higher risk of fractures, especially in female athletes and the elderly. Both a high and low BMI reduce fertility in different ways.

But, given the conversations above, it seems that no-one trusts BMI any more. Why might this be?

When I was in high school I remember learning about BMI and being told that it didn’t work in sports people, because of their muscle mass. When I was at university I remember a class-mate (who did Power Lifting as a hobby and was extremely muscular but very short) saying that because of his height his BMI didn’t really reflect how heavy he was. I remember at chiropractic college training alongside an Olympic sprinter (who went on to run in the relay team against Usain Bolt) whose BMI technically made him obese. We can all think of examples like this.

What are the limitations of BMI?

When BMI was first devised it was, by necessity, easy to do. In the 1830s there was no easy access to computers or calculators and so clinicians needed a simple formula to quickly assess a patient. There is an argument now that the formula could be updated to make it more complex, but more representative and realistic.

One limitation is the effect of extremes of height. Because weight is divided by height, people who are very short tend to have BMIs that “exagerate thinness”, whilst very tall people will be more likely to be shown as overweight.

Another limitation is that BMI doesn’t take into account what is making up the weight. Muscle is three times denser than fat and not associated with the same health risks we mentioned above. This is why BMI tends to show athletes as overweight when they clearly have low body fat. To a lesser extent bone-density can also affect BMI readings as the quality of the skeleton can’t be assessed in this calculation.

Another limitation that is important, but often overlooked, is that BMI is designed for people who are skeletally and sexually mature, ie. adults. Children need a different measure altogether and for this most healthcare professionals will use a growth chart for height, weight and head circumference.

Can we make BMI better?

Each of these limitations can be addressed to make BMI more accurate. The new formula described below takes into account the effects of extreme height or shortness, to give a more balanced picture:

BMI (metric) = 1.3 x weight (kg) / height (m)2.5

or

BMI (imperial) = 5734*weight(lb)/height(in)2.5

You can try it here.

In order to take into account muscle mass, you can pair BMI with another reading, like body fat %, caliper readings, DXA scanning or waist circumference. Of these, waist circumference is thought to be the most useful, as bulk in this area is much more likely to be fat (or in some cases water) than muscle. It also correlates very highly with disease risk, such as metabolic disorders and cardiovascular disorders. In fact, many scientists argue that a waist-height circumference might be more predictive of cardio-vascular disorders than BMI or waist circumference alone.

However, it’s worth mentioning that if your BMI is over 35, then pairing them with an additional measure has been shown to have no added benefit when it comes to predicting health. If you’re in this category, known as “morbidly obese”, it’s not because of muscle, water or being tall and taking those things into account won’t change the stats on your health.

Best use of BMI

All this is to say that a human body is very complex. Reducing a person to a number without taking the bigger picture into account will never produce good healthcare outcomes. However, there seems to be a mistrust of BMI as a health statistic in the general public which I feel is quite unfounded. BMI does have it’s limitations, true, but these are:

  • generally small
  • only apply to extremes of the populations (elite athletes, the unusually tall or short)
  • can be corrected for with the updated formula mentioned above
  • outweighed by the overwhelming correlation with serious health risks

Let’s not throw out the baby with the bath water. If you’re one of the 95% of people out there who doesn’t fall into an extreme category then BMI won’t tell you everything you need to know about your health – but it’s a darn good place to start.