By Lee Schneider (Physiotherapist)
Seven years ago, I found myself curled up in the foetal position, struggling to eat or drink, with a three-day history of severe and worsening stomach pain. With a quick search of Google I found WebMD. WebMD allowed me to enter my symptoms and then provided a list of possible causes for my pain. At the top of the list of causes was appendicitis and WebMD strongly recommended I check myself in to the nearest emergency department! The medical team at the ED confirmed Dr Google’s diagnosis and my appendix was promptly removed. Without this search, I would have postponed my visit to the hospital, making for a worse outcome. In this situation, Google added value to my healthcare.
Some studies have shown Google to improve health literacy regarding the nature of certain conditions (Kothari & Moolani, 2015). However, consulting Dr Google can also reveal alarming and unfounded diagnoses and explanations that can actually cause harm. There’s even a name for the psychological harm that web-based diagnoses may have, it’s called cyberchondria.
Have you ever had the experience of Google-ing an odd sensation in your body only to find pages and pages of information, mostly concerning, about its possible cause? Low back pain is such a common complaint that I felt many people would be searching the web for answers. Therefore, I wanted to know if Dr Google is a reliable source of information regarding the causes of low back pain. To answer this question, I performed the google search “cause of low back pain” and thoroughly collected information from all of the sites on the first page, compiling a list of Dr Google’s possible diagnoses. This list is given below and any overlapping diagnoses were combined. To fact check Dr Google’s diagnoses I compared them to the most recent scientific information on the topic, sourced from reputable peer-reviewed articles.
Google’s possible causes of low back pain
§ Abnormal spinal curvatures
§ Compression fractures
§ Degenerative disc disease
§ Disc height loss leading to a loss of shock absorption leading to “grinding”
§ Disc injury
§ Extruded disc pushing on nerve roots
§ Facet joint dysfunction
§ Infections of the spine
§ Increased nociceptors (receptors in the body’s tissues that signal for danger)
§ Kidney infections
§ Mechanical stress and strain due to the weight of the upper body
§ Muscle sprains/strains due to sudden movements and poor body mechanics
§ Myofascial pain syndrome
§ Ovarian cysts
§ Ruptured or herniated discs
§ Sacroiliac joint dysfunction
§ Spinal stenosis
Is Dr Google right?
Dr Google’s diagnoses sound rather scary, and if you’ve performed this search yourself you’ve likely come across some of these. But! How reliable is this information? It turns out, it is highly unreliable and potentially quite harmful.
The majority of low back pain is what is called non-specific low back pain. Non-specific meaning it does not relate to a specific cause. When health care professionals say specific cause, they mean problems such as fractures, cancers, inflammatory conditions, neurological issues or infections. Specific causes for low back are actually very uncommon. In fact, specific causes for low back pain make up less than 1% of all possible causes for low back pain! Of the remaining, 5-10% of cases are nerve-related low back pain and a whopping 90-95% of low back pain is non-specific in nature (Bardin, King, & Maher, 2017). Other names in the literature for non-specific low back pain are normal or ordinary low back pain.
Below I’ve made a couple of pie charts, on the right is the actual percentages of specific, non-specific and nerve-related low back pain and on the left, is Dr Google’s percentages. If you rely on Dr Google for your diagnosis you’ll likely assume that your low back pain is due to one of these nasty specific causes, when statistically speaking, it’s probably not. Physiotherapists are trained to treat both non-specific and nerve-related low back pain and are also able to assess you to ensure that your pain is not related to a specific cause.
Dr Google Science
As a side note, you may have been given a diagnosis of, or believe you have based on the information you’ve found thus far, a nerve-related low back pain. This is possible, but it is not all bad and you likely don’t need surgery to fix it. A study in 2016 compared conservative and surgical management of nerve-related low back pain over two years and found that “surgery was not more effective for the treatment of neurogenic symptoms or the improvement of quality of life over the course of the study” (Gugliotta et al., 2016). There are however some important considerations that may have decreased the effectiveness of the conservative management of this study. In a nutshell, management of this type of pain requires interventions that targets the nerve tissue that is sensitized as well as the individual’s sensitivity to movement and stress levels. It appears that the conservative management group did not receive this type of intervention. Furthermore, the conservative group was aware that they were in the conservative management group and were told that they could receive the surgery in the context of conservative management failure. An individual’s beliefs and expectation has a huge impact on their likelihood of recovery. If the conservative group believed they drew the short straw and expected conservative management to fail, then the conservative management is almost destined to fail! Despite these influences there was no difference between the groups. This suggests that conservative management may be superior to surgical management for this issue, provided it is done correctly and with genuine commitment by the person in pain and treating therapist. Lastly, one factor that is often left out of the analysis is the insights that patients get by committing to the process of rehabilitation. By working hard, you increase your movement capacity and movement confidence and gain a better understanding of your body. These insights are better for long-term health. There is no elevator to success, you have to take the stairs.
So, what about my slipped disc?
So, we’ve been able to show that Dr Google has far more specific, scary diagnoses than reality. But, what about its description of the causes of non-specific low back pain? The list includes things like degeneration of the discs, disc bulges and protrusions, facet joint irritation, muscle sprains and strains and disc height loss.
Despite what you may have been told, there are no clinical tests available to healthcare professionals to determine a causative link between a pain-sensitive structure and a person’s pain (Hartvigsen et al., 2018). What this means is that in non-specific low back pain, there is no way to know if the pain experienced is due to a facet being irritated, or a disc being herniated, or a vertebrae slipping too far forward, or a nerve root being compressed, or a… you get the idea. Yes, this means that the diagnosis you may have received regarding your low back pain based on scans may not be the whole story. The current recommendation in non-specific low back pain is to avoid sending patients for MRI’s or other scans as they are surprisingly poor at determining the cause of an individual’s pain! Clever researchers at the University of Washington decided to compare the prevalence rates of certain spinal abnormalities in groups of people without pain and what they found was really surprising (Brinjikji et al., 2015). Findings traditionally thought to be the cause of someone’s low back pain were found to be present in really high amounts in people without any pain. The easiest way to show this data is to give you the table from the study, here it is below.
Percentages of pain free individuals that have these imaging findings on their scans.
On the left are the imaging findings and on the right, are numbers representing the percentages of pain-free participants who exhibited these findings on their scans. Most of these percentages are surprising, but some are astounding such as 68% of people in their 40s have asymptomatic degeneration of their spine and 36% of people in their 50s have asymptomatic disk protrusions. Let’s repeat that, one third of 50 year olds have the inner substance of their disk protruding from their spine without any pain! They conclude that these findings on scans are likely normal age-related changes in the spine and are not associated with low back pain. When these findings show up on the scans of people in pain it’s only natural for the treating health care professional to assume cause and effect. That is, you go to a healthcare professional with a sore back, they order a scan of your sore back, they find something that looks odd, and assume that the odd finding is what’s causing the pain. And given the prevalence of these “problems” individually, when you scan the back of someone in pain you’re highly likely to find one of them!
Posture, biomechanics and pain
Another one of the myths of back pain is the need for perfect posture and body mechanics. If you think of the body like a machine then you’ll naturally assume that the parts need to line up perfectly in order for the machine to function. The body is not a machine, sure it has mechanical aspects to it, but it’s a complex biological system! The body as a machine has been the prevailing view in healthcare for too long and many people with low back pain have been given advice on how to modify their posture, strengthen their cores and avoid performing certain movements due to the mechanical strain these movements place on the joints and surrounding structures. Phrases like, “I need to brace through my abdominals as I move or I’ll put my back out” are just plain nonsense as the physical structure of the back is strong and robust and can handle the normal loads we place on it. A compilation of the results of many studies, otherwise known as a systematic review, that looked at the relationship between spinal curves and pain found absolutely no relationship between the two (Christensen & Hartvigsen, 2008). What this means is that it does not matter what shape your spine is, it is unlikely to be the cause of your pain. Another review of studies that looked at people over time to see if the loading of their spine with sport and work had an impact on the development of low back pain found that there was no association between spinal mechanical load and low back pain (Bakker, Verhagen, Van Trijffel, Lucas, & Koes, 2009). These reviews call into question the importance of mechanics when talking about the cause of low back pain.
What is going on then?
The explanation given below is by no means definitive and anyone claiming to have the conclusive truth about the nature of low back pain is too big for their boots. Rather, it introduces a broader explanation of low back pain that will help you understand the issue better.
Low back pain is a symptom and not a disease and the majority of low back pain is short lasting with no or very little consequence, if managed properly. Low back pain, just like any pain, is a complex process involving many different factors. It is not possible to identify a single cause for someone’s pain, not because it’s poorly understood, but because there is never a single cause!
This is where it gets interesting. One of the issues with Dr Google’s diagnoses of the cause of low back pain is that the most important part has been largely overlooked, that is, what is pain?
You may need to put your concentration hat on for this section of the article as it’s highly important, but a little bit challenging to understand at first. Pain is the result of the brain concluding that the painful area of your body requires protection and is actually a highly important body system (Moseley & Butler, 2017). If you are in pain, you engage in certain pain-related behaviours that are advantageous. Such as, you might hold the sore part in social situations to notify those around you that you are in pain and that they should be careful around you. And or, you might reduce your activity and spend some time caring to the sore area if that’s what it needs. If the brain concludes that you need to engage in certain behaviours, it will create the experience of pain to make you do just that! As a side note, the types of behaviours you engage in are largely influenced by your current environment and previous experiences and information regarding pains meaning and consequences. If you are an athlete you may be expected to grin and bear the pain until the off season, whereas your average Joe or Joanna might be expected to visit a GP for some pain medication and rest a while.
The interesting thing is that the brain can come to this conclusion that it needs to create pain using many different sources of information. One source of information is nociception. Nociception is information coming from receptors in the body that indicate whether or not the part of the body it supplies is actually being damaged or is at risk of being damaged. They basically signal for potential danger in the body. If you cut your finger chopping potatoes, nociceptors in your finger fire and alert the brain to danger in the area that was cut. Furthermore, if you hold the tip of your finger and slightly bend your finger backwards you may feel an uncomfortable stretch down the front. In this case, nociceptors down the front of your finger are being activated and pain is experienced, but it relates to potential damage and not actual damage occurring. If your brain concludes that the area needs protection, the experience of pain will emerge.
To take things up a notch, the experience of pain can occur without nociception! This means, there doesn’t actually have to be any damage, or threat of damage, for the brain to conclude that it needs to protect the body. That is, the brain can think there is danger when their actually isn’t any.
So, what sources of information, other than nociception, does your brain use to conclude that it needs to protect the back? There are many and they mostly relate to the beliefs and expectations of the damaging nature of certain movements and activities as well as beliefs about the structural capacity of your back. For example, you might have moved the back in a way that you deemed to be threatening like a twist or a flex, or did a lot of work that fatigued the back more than it’s used to. You may have been told by friends, family or well-meaning healthcare professionals that the back is fragile and you should avoid doing certain things or you’ll injure it. You may have been shown scans that show the “abnormalities” discussed above and have come to the conclusion that your back is just “stuffed”. You may have had pain for a while now and feel like there has to be something physically wrong or else it would have gone away! All of these bits of threatening information increase the brains need to protect the back, to the point that normal input from the back can be painful. I’ll repeat that, normal movement in the back can be painful if you believe that your back is damaged and needs protecting. This is why I mentioned that the above diagnoses by Dr Google can actually be harmful. If you read through these conditions and their explanations and conclude that they are relevant to your experience of pain, then that is going to increase your brains need to protect your back, thus increasing the intensity of your pain experience.
This way of looking at pain is not new to pain scientists but it relatively new to the healthcare world. There is currently a massive push in healthcare to help clinicians better explain pain and de-threaten the experience and beliefs about the cause of pain, as it’s one of the most important interventions a patient can receive (Moseley & Butler, 2017). Through knowledge comes power! Any healthcare researcher will tell you that there is a huge gap between the research world and what happens in the clinic. Where Dr Google has really failed in diagnosing the cause of low back pain, is in missing the most important thing of all, what the current understanding of pain is.
This is not to say that there may be something that has been sensitized in the low back. There’s no doubt that we can injure our body and the back is not an exception to the rule. But, it is to say that in the vast majority of cases, knowing the exact part that’s been irritated and worrying that the pain you’re experiencing is causing further damage, is probably the wrong thing to do. Instead, the best thing to do is to keep calm and keep moving.
What can physio do for me?
I believe that physiotherapists have an exciting role to play in this context. Not only can we perform a thorough assessment to learn about the nature of your pain and provide you with all the information needed to better understand your pain and your situation, we are able to guide you towards a greater freedom of movement through careful training and practice.
By gradually introducing movement in a way that is non-threatening, the brain starts to conclude that there is no need to protect the back any more. Alongside this there will be improvements in the physical capacity of the back, and other areas of the body, to perform the types of activities you want to do. In fact, there is a large push for healthcare professionals to get better at promoting activity and movement in their patients with low back pain (Buchbinder et al., 2018).
The opposite of embracing movement is avoiding movement. By avoiding movement, we confirm that something is wrong and protection is needed. This is a phenomenon that people can easily fall victim to called the fear avoidance cycle, I like to call it the rabbit hole (Leeuw et al., 2007). Basically, you feel pain, associate movement with that pain and stop moving. At Inner Focus our aim is to gradually introduce movement into your system, in a way that’s therapeutic and at a pace you are comfortable with, so that your brain learns that it’s ok to keep moving! Once your brain decides its safe, voila! Your pain starts to reduce.
So, in summary, Dr Google may serve an important role in some aspects of healthcare, but it clearly needs an update when it comes to diagnosing the cause of low back pain. There is lots of scary information out there, mostly irrelevant, and this scary information can actually make the problem worse. If you’re worried about your pain, the best thing to do is to speak to a trained professional that can properly assess you and guide you on the right path.
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