Think you’re alone in your struggle with back pain? Think again. Over 80% of people will suffer from back pain at some point in their lives, and Americans spend $50 billion each year trying to get rid of it. Just this year, 3-4% of the entire US population will be temporarily disabled due to lower back pain.
So what’s causing all of this pain in the back?
The first, most obvious answer that comes to most people’s mind is that the pain is caused by a structural problem in the back itself: spinal abnormalities, disc degeneration, herniated discs, and other forms of 'physical proof’ of pain. From what we’ve been taught to believe about pain, this makes sense. However, the research and science behind pain suggests the exact opposite. In summary, it suggests that:
Let’s take a closer look at the data, and answer some questions that may be on your mind.
No, probably not. There is no correlation between lumbar spine abnormalities found in MRIs and back pain. This is not a theory, it is a fact proven by decades of research.
Let’s start by taking a look at this study, designed to test whether employers could use MRI results to screen for risk of lower back pain. Some of the participants experienced lower back pain, others did not. All were given MRIs to check for abnormalities.
If spinal abnormalities were the cause of lower back pain, one would expect that the participants with lower back pain would show evidence of 'abnormal' lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression). On the flip side, participants without lower back pain should exhibit relatively ‘normal' MRI results.
However, that was not the case. 32% of the participants without lower back pain showed ‘abnormal’ lumbar spines, yet no signs of pain. 47% of the participants with lower back pain showed ’normal’ lumbar spines in their MRI results, despite experiencing pain. What’s even more convincing: over the 12-month follow-up period, 13 subjects experienced lower back pain for the first time, yet showed no change in MRI results that could account for the onset of the pain.
Based on these results, the study concluded "There was not a clear relationship between the MRI appearance of the lumbar spine and [lower back pain]."
These results do not exist in isolation: similar conclusions have been drawn for decades. The New England Journal of Medicine published this study in 1994, showing similar results and calling the discovery of bulges or protrusions in people with lower back pain “frequently coincidental." This 2001 study concludes that “the findings on magnetic resonance scans were not predictive of the development or duration of low-back pain.” In this 2006 study, researchers conclude that “the impression obtained from an MRI scan does not determine whether lumbar stenosis is a cause of pain.” Another 2001 study discourages doctors from using the technology at all, citing that receiving radiography of the lumbar spine "is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload."
When we feel pain, we want to find an easy answer about what’s causing it. It’s easy to look at a herniated disc and blame it for the pain. However, as the data suggests, these abnormalities are NOT causing the pain.
Actually, it happens all the time. “Spontaneous Resorption,” as it’s referred to in the medical world, is the expected outcome for the majority of herniated discs. For this reason, most physicians opt for a conservative “wait and watch” approach rather than recommending physical interventions. In 2017, a group of researchers compiled the results of decades of studies on the incidence of Spontaneous Resorption of lumbar disc herniation. Based on the research, they concluded that this applies to roughly 2/3 of all cases.
More research is needed for a definitive answer, but the bottom line is summed up most clearly by Dr. Ian Harris in his book, Surgery: The Ultimate Placebo: "there is very little evidence that spine fusion surgery for back pain is effective for back pain."
Spinal fusion surgery, though growing in popularity and frequency, has only been shown to have a positive effect in very specific conditions. As a team of physicians points out in Spinal-Fusion Surgery — The Case for Restraint, “[spinal fusion surgery’s] efficacy for the most common indications, such as degenerative disk disease, remains unclear.”
Across the bulk of research studies comparing aggressive treatment approaches (like spinal fusion surgery) with non-invasive approaches, studies have shown that all groups get better over time, at roughly equal rates. Even in situations where surgical procedures produce more immediate results, the efficacy of the surgical option generally levels out with other groups around the five year mark.
But surgery isn’t the only placebo - there is evidence that placebo medication, even when openly labeled as such, can lead to positive outcomes for lower back pain. One 2016 study, which compared the outcome of open-label placebo on chronic lower back pain to the outcome of treatment as usual, found that "adding [open-label placebo] to [treatment as usual] resulted in significantly greater reductions in [chronic lower back pain] and pain-related disability than [treatment as usual] alone. The amount of additional pain reduction produced by [open-label placebo] was approximately 30% of baseline pain and disability ratings."
So - the question remains. Can your back pain levels and disability be improved by using surgery and prescription drugs? Maybe. But are those results any more significant than a placebo effect? It’s unclear.
There is evidence that how you feel and your experience of pain is more heavily influenced by non-physical factors. A 2016 study found that "a feeling of back stiffness relates poorly to biomechanical measures of back stiffness” - or in other words, "people with back pain may feel stiff but it seems that this is not because they are objectively stiff.” Given the lack of correlation between MRI results and instances of back pain, this should not come as a surprise. Researchers involved in the study further concluded that “...feelings of stiffness may be a learned concept … for some people, feelings of stiffness may also reflect more complex constructs such as fear of movement."
So what does this mean? Basically, your experience of back pain has almost nothing to do with the physical state of your back. It does, however, involve a complex interplay of other concepts - how you feel about pain, whether you fear physical movement, whether you direct your attention to pain or away from it, and so on. Newer forms of back pain treatment, like mindbody techniques, incorporate these ideas and work to unravel these factors instead of focusing solely on the physical state of the back.
Yes. Studies on various mindbody techniques have resulted in equal, or sometimes greater, pain reduction than physical exercise-based treatments, including: breath therapy, cognitive behavioral therapy, behavioral treatment, mindfulness meditation, loving kindness meditations, expressive writing, and more. However, some of the most significant reductions in pain have come from approaches like Curable’s, which combine several proven mindbody techniques with pain science education. In one such study of patients with chronic back pain, participants experienced a mean average pain decrease of 52%, decreased medication dosages, increased physical health scores, and increased activity levels.
So why do these treatments seem to be effective where purely physical treatments are falling short? Pain and Emotion: A Biopsychosocial Review of Recent Research summarizes this well:
"The burgeoning neuroscience research indicates that pain pathways in the CNS are tightly linked with and influenced by emotions, and such pathways are sensitized both by early painful or traumatic experiences (Goldenberg, 2010) as well as later painful stimulation from peripheral tissues. Psychological research indicates that emotional awareness, expression, and experiencing as well as pain-related emotion modulation play keys roles in the pain experience. Social research indicates that interpersonal factors contribute to the modulation of negative emotions through processes such as interpersonal disclosure and empathy, and these processes also influence pain. These converging lines of research should arm clinicians to educate patients about the important ways that emotions, stemming from relationships and experiences over one’s life and modulated by psychological factors, both influence and are influenced by neural processes that shape the experience of pain."
The bottom line in all of this? Back pain is more complex than what’s happening in your back, and treating the pain through a biopsychosocial approach (like the one Curable offers) can be extremely effective. But don’t take our word for it - read on for incredible stories of recovery from back pain.
Thank you so much for the Curable app, it has been incredibly helpful. My back pain that I have had for 20 years is almost gone. I appreciate everything… Thank you." - Lianne
"The curable service is brilliant. It has been very helpful as I work towards alleviating my chronic pain. I am still somewhat early in the process but am seeing improvements for sure." - Paul
"I am so glad I found this app. I have improved since starting to use it. Thanks for all the work you put into building it." - Lorrie