Welcome back! You can go to the last-viewed section (your bookmark), stay right where you are, or disable this prompt. Links to the bookmark are always available.

We can put a man on the moon, but back pain is just as miserable as ever, and more costly to society than ever. Most information available online is awful.1 There are no miracle cures or back whisperers. Not one popular treatment has ever been shown to work well.2 When we are “shot by the witch,”3 it’s going to run its course like a head cold in most cases, or drag on much longer in a few, and there’s not much anyone can do about it. There is room for improvement, however! We could, at least, not add insult to injury with pointless and expensive testing, therapies, and surgeries that are all about finding and fixing structural problems that are mostly not there, or not the real problem. Despite overwhelming scientific evidence to the contrary, it is still sadly routine for back pain to be seen as a “mechanical” problem, as if the spine is a fragile structure which breaks down.4 There is some truth in that old way of looking at it, but there are many other factors in back pain. It’s hard to treat because “it’s complicated.”

Has nobody noticed the embarrassing fact that science is about to clone a human being, but it still can’t cure the pain of a bad back? ~ Pain, by Marni Jackson, p. 5

1.1

A tragic low back pain myth This pervasive myth of spinal fragility has many unfortunate consequences, such as unnecessary fusion surgeries — a common and routinely ineffective procedure — and low back pain that lasts for years instead of months or weeks. The seriousness of chronic low back pain is often emphasized in terms of the hair-raising economic costs of work absenteeism, but it may well be far worse than that — a recent Swedish study shows that it probably even shortens people lives.5 The stakes are high. “Tragedy” is not hyperbole. Even worse is that good information exists: many medical experts do “get it,” but they have fought a long, losing battle trying to spread the word to their own medical colleagues on the front lines of health care.6 Back pain treatment in the real world is notoriously out of step with guidelines and best practices,7 and the average family doctor is just not educated enough.8 And as if that wasn’t bad enough, doctors who are more interested in back pain are even worse,9 probably because a little knowledge is a dangerous thing. Similarly, experts have particularly struggled to get the word to alternative health professionals — most of whom don’t even read medical journals.10 In this tutorial, you will meet those medical experts and find out what they know and believe and why. Their ideas about low back pain are neither “conventional” nor “alternative” — they simply come from the best minds in the business. The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis). Lorimer Moseley, “Teaching people about pain — why do we keep beating around the bush?” Pain Management. 2012. GO TO TOP • CONTENTS • NOTES

About footnotes. There are 569 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1 and boring reference stuff.2 Try one! About green links. Standard blue links go to other pages on PainScience.com, or on other websites, as expected. But green links go to other sections of this page, like this link to the top of the page, or the links in the table of contents.

1.2

How do so many health care professionals go wrong when they treat low back pain? Why does the myth of mechanical back pain, the premise for so much ineffective treatment, get repeated endlessly on the Internet and in health care offices around the world? (All of these points above will be explained and substantiated in detail further along — these are just the highlights.) Repairing spinal joint “misalignment” is an easy idea to sell, but it’s hard to actually do. Chiropractors often can’t even agree on which joints need “adjusting” — even with only five lumbar joints to choose from.

Poor posture and crookedness is another popular scapegoat — it seems obvious that posture is relevant. Many professionals assume that back pain is some kind of postural problem that you can exercise your way clear of. Unfortunately, the evidence shows that no kind of exercise, not even the most hardcore core strengthening, has any significant effect on chronic low back pain.

The almost magical power of MRI to look inside the back gives both doctors and patients something to point at and blame, but most are unaware that MRI has been proven (many times) to be a lousy diagnostic tool for back pain. The things you see on MRI scans are rarely the real problem — and every radiologist seems to see something different!

I criticize many common practices and beliefs. If you disagree, let me know — I can take it, and I’ve made many changes over the years based on good quality feedback. Orthopedic surgeons (especially American ones) profit handsomely from the most complex low back surgeries (especially spinal fusion), so they are strongly inclined to think of back pain as a mechanical problem in need of physical repair — in spite of piles of scientific evidence to the contrary. This is the best example of how “entire professions appear to depend on the problem remaining unsolved.”11 If all you have is an incredibly profitable hammer …

Sports medicine specialists have great expertise about injuries, so they often assume that back pain involves some kind of damage — but the evidence clearly shows that low back pain often has nothing to do with tissue damage.

Patient education is critical and yet it rarely happens — or happens well enough — because the topic is just too tricky for professionals to be informed well enough to pass their knowledge on. And so education is “always first line but never headline,”12 a major systemic weakness in back pain care.

The power of mind-over-pain has been badly over-hyped by some experts (ironically as a well-intentioned backlash against some of the ideas above). Nowhere is this more glaring than in Dr. John Sarno’s famous books,13 which has convinced countless patients and pros that low back pain is all a mind game … and that’s just going too far. Plus, of course, there are an almost unbelievable number of sketchier treatments for sale, easily marketed to desperate souls. Is low back pain treatment really this much of a mess? Sadly, I believe so.14 I clearly remember graduating clueless myself. If I hadn’t spent many years doing post-grad study of low back pain, I wouldn’t know 98% of what’s in this tutorial. GO TO TOP • CONTENTS • NOTES

Over-rated? Yes, stress is a factor in low back pain, but meditation & yoga are over-rated & inappropriate options for many people. This tutorial explores more practical options.

1.3

The journey to relief begins with better back beliefs July — New section: No notes. Just a new chapter. These are the most important back pain “belief upgrades”: Treatments such as strong medications, injections, and surgery are not effective or necessary in the overwhelming majority of cases.

Low back pain is rarely a serious medical condition, rarely persists, and rarely deteriorates later in life. Even when it does persist, it usually isn’t related to tissue damage, and scans are almost never helpful in diagnosing the cause of back pain.

Pain with exercise and movement is mostly not a useful warning that harm is being done to the spine. Even intense exercise doesn’t cause “wear and tear” damage, and flare-ups don’t mean you’ve damage something and have to rest.

Low back pain is not caused by weak “core” muscles or prevented by strong ones. Each of these contradicts a major myth or two about back pain, and is strongly supported by the science.15 By the end of this tutorial, I hope you’re convinced of each one. But initially? Most people will have trouble swallowing them. Even professionals will — especially the ones whose income depends on denying these. Embracing them, instead of the myth of fragility and all its implications, is half the battle. But it’s really tough when you’re facing intense, chronic back pain. Sure, most acute low back pain fades steadily — up to 90% of it, for uncomplicated cases.16 And so does a lot of so-called “chronic” low back pain!17 But not all. This tutorial is mainly for patients with unusually stubborn low back pain and sciatica, and for the doctors and therapists who want to help. (It’s overkill for new and acute cases.) Even for these really entrenched cases, there is hope… GO TO TOP • CONTENTS • NOTES

An excellent “back facts” infographic from O’Sullivan et al. Examples: getting older is not a cause of back pain, poor posture does cause back pain & scans rarely show the cause.



Click to embiggen.

1.4

The case for hope: some “incurable” chronic low back pain can still be cured While it’s true that most chronic lower back pain will not yield to any popular back pain treatment, it’s also true that some really stubborn “incurable” cases do eventually turn out to be curable. People who believed for years that their pain was invincible have still found relief. Not always, and often not completely — but sometimes any relief is far better than nothing. How can extremely stubborn pain finally ease up? Simple: because many cases weren’t truly stubborn to begin with, despite all appearances. So many health professionals are poorly prepared to treat low back pain that patients can easily go for months or even years without once getting good care and advice . When they finally get it, it’s hardly surprising that some patients finally get some relief from their pain. And it’s always amazing to me how chronic pain can, with the right approach, finally melt away — it’s not common, but it does happen. Lots of people who thought they’d “tried everything” for lower back pain read this tutorial and then write to me and say, “Well, I guess I hadn’t tried everything!” Similarly, many athletes with “career-ending” injuries are far from finished. Bret “The Glute Guy” Contreras, from You’ll Never Squat Again: Numerous powerlifters over the years have come back following ‘career-ending injuries’ to set all-time personal records. Donnie Thompson is the only man to total 3,000 lbs (1,265 lb squat, 950 lb bench, 785 lb deadlift). Many people don’t know this, but several years back Donnie suffered a horrendous back injury and herniated three discs. He could barely walk, but he got out of bed and rehabbed himself every day. Within three months he was back to heavy squatting and setting personal records. Got that? Setting personal records three months following an injury that herniated 3 discs! How could that be? It’s almost like herniated discs aren’t necessarily as scary as everyone seems to think. Hm! I have never met a patient — no matter how experienced or self-educated — who could not gain at least some new insights and new hope from this tutorial.18 GO TO TOP • CONTENTS • NOTES

1.5

“What if there’s something seriously wrong in there?” April — COVID-19 update: Added information about headaches as a symptom of COVID-19. “How do you know I’m not seriously hurt?” “Could it be cancer? A tumor?” You’re not paranoid if they really are after you! Only about 1% of back pain has a nasty cause,19 and only a few of those are really scary. But it happens. Andy Whitfield, star of Spartacus, thought he just had back pain from his intense gladiatorial training. In fact, he had a tumour. It killed him in 2011. The most dangerous thing about trying to reassure low back pain patients is the unnerving possibility that I might reassure someone who should not be. But reassurance is almost always appropriate. Most back injury feels worse than it is — its bark is worse than its bite. But how do you know if you’re the exception? Can you recognize the early warning sign of cancer, infection, autoimmune disease, or spinal cord injury? These things often cause other distinctive signs and symptoms, and so they are usually diagnosed promptly. If you are aware of these red flags, you can get checked out when the time is right — but please avoid excessive worry before that. The rule of thumb20 is that you should start a more thorough medical investigation only when three conditions are met: it’s been bothering you for more than about six weeks the trend is strongly negative — the pain is severe and/or not improving, or even getting worse there is at least one other red flag (see below) And there are also two rare situations where you shouldn’t wait several weeks before deciding the situation is serious … significant numbness around the groin and buttocks and/or failure of bladder or bowel control if you’ve had an accident involving forces that may have been sufficient to fracture your spine This free article explains in more detail (including a list of red flags) and is strongly recommended to anyone who feels nervous: When to Worry About Low Back Pain And when not to! What’s bark and what’s bite? Checklists nd red flags and non-scary possible explanations for alarmingly back pain ~ 4,000 words In all other cases, you can safely read this tutorial first. For instance, even if you have severe pain or numbness and tingling down your leg, you can safely read this first. Or, even if you have an obviously severe muscle tear from trying to lift your car or something, you can safely start here — rest and read. Your back is not as fragile as you probably think, and understanding why is a great starting place for healing in nearly all cases of low back pain. Don’t confuse threat and risk. Working at the edge is a risk. But then again, so is walking out your front door. ~ Cory Blickenstaff, PT Is back pain a symptom of COVID-19? (Or other common infections?) Back pain is not specifically a prominent feature of COVID-19. However, infections always lower our pain thresholds, and so all common aches and pains are more likely to be triggered or aggravated by any systemic infection — but perhaps COVID-19 more than most, simply because it’s unusually good at causing widespread body aching,21 and backs are included in that. But back pain doesn’t stand out any more than any other common locations for aching or soreness (with the exception of headache, which occurs in 8–14% of cases.2223). So, if you were already at risk of a flare-up of back pain, it could emerge during any infection, exposed like a rock that is only visible at low tide. GO TO TOP • CONTENTS • NOTES

Part 2 Low Back Pain Diagnosis Your low back is not fragile! Most of what is supposedly “wrong” with spines is nonsense Spines haven’t changed in the last century,24 and yet modern civilization suffers from a great plague of low back pain.2526 The real causes of most back pain are obscured by medical mythology and misunderstanding.27 Before I discuss what kind of things do cause low back pain, it’s important to talk about what does not cause it. In this section, I will challenge the mythology in just a few paragraphs, supported by dozens of references to the best scientific information available. Most people — and most health care professionals — believe that back pain is usually caused mainly by structural problems, either injury or degeneration of the spine. This idea is not supported by the scientific evidence.28 Indeed, just the opposite is more the case: “The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).”29 When structural problems are exaggerated, you also get a plague of bogus explanations and solutions based on that. Spines do degenerate, but not for the reasons most people think they do: genetics is by far the biggest factor in degeneration,30 not your posture, your office chair or mattress, your core stability, or anything else that low back pain sufferers have taught to blame their pain on. The idea that the spine is fragile is an unjustified but deeply held belief, based on ignorance of a complex subject and on an obsolete mechanical view of biology that has dominated medical thinking for centuries. I do worry there is a combination of side effects and unnecessary treatments and labeling people as being fragile when they’re really not. The combination of those kinds of things may actually be in some cases doing more harm than good. Dr. Richard Deyo, low back pain expert31 Ignoring expert recommendations from their own colleagues,32 doctors order too many fancy tests (especially MRI or “magnetic resonance imaging”)3334353637 to try to find evidence of mechanical failures — yet we know that doing such tests does not lead to better results,38 may even cause harm,39 usually shows problems in people with no pain,40414243444546 and shows no problems in people who do have pain!474849 None of these mean that the cause of pain can’t still be lurking in the spine — it could be.50 But either causes of back pain that can actually be imaged are surprisingly rare, or hard to spot, or both. Medical care for the Jetsons? For many years now, MRI scans have been the ultimate in futuristic medicine. But while these machines are miraculous in some ways, they can be worse than useless for diagnosing low back pain & studies show that doctors recommend way too many of them … especially when they profit from it. The overdiagnosis of slipped discs in particular With and without MRI, disc herniations is the most overdiagnosed cause of back pain, probably one of the most overdiagnosed problems in the history of medicine. They are feared by patients way out of proportion to their frequency or severity.51 Herniation severity does not correlate well with pain in the first place, but they definitely can’t be the cause of the trouble when they just go away on their own. Once a spinal disc has “slipped,” it seems like it’s in a biomechanically awkward situation and can’t recover any more than a broken window can reassemble itself. And yet “slipped” discs usually un-slip! This is called “resorption” — a nifty back trick that most people are unaware of (including too many healthcare professionals still). Most herniations, roughly 60%, just go away, some of them surprisingly quickly, like a snail tucking back into its shell, according to about a dozen studies.52 Not only that, but it’s actually the worst ones that are the most likely to resolve on their own!53 One of the best of those studies tracked herniations for eight years, finding that only 12% got worse.54 You can see a good example of resorption in these reassuring before/after pictures (follow link in footnote).55 And here’s another eyebrow-raiser: a study in New England Journal of Medicine showed that people with back pain and herniations actually recovered slightly better than those with “normal” discs!56 For every disc that recovers completely, more probably resolve enough to relieve a key symptom. And yet it is almost impossible emotionally to see anything that looks “bad” on an X-ray or MRI and not worry about it. And it’s also almost impossible to get a completely healthy-looking scan of anyone! TV’s Dr. Greg House has commented on this … House: Give him a whole body scan. Cameron: You hate whole body scans. House: Because they’re useless. You could probably scan every one of us and find five different doodads that look like cancer. ~ House, Season 1, Episode 17, Role Model, written by Matt Whitten But even Dr. House wasn’t cynical enough: radiologists can’t even spot the same red herrings. If you send the same patient to get ten different MRIs, interpreted by ten different radiologists from different facilities, you will get ten markedly different explanations for her symptoms. A 63-year-old volunteer with sciatica allowed herself to be scanned again and again and again for science57 — a sting operation. The results were all over the map. The radiologists cooked up forty-nine distinct “findings.” Sixteen were unique; not one was found in all ten reports, and only one was found in nine of the ten. On average, each radiologist made about a dozen errors, seeing one or two things that weren’t there and missing about ten things that were. That’s a lot of errors, and not a lot of reliability. The authors clearly believe that some MRI providers are better than others, and that’s probably true, but we also need to ask the question: is any MRI reliable? This would be laughable if it weren’t so tragic. Or like low back pain. And yet, most visible defects are clinical red herrings, about as scary as a birthmark, and signify nothing except the power of modern medical technology to scare you silly if you aren’t armed to the teeth with confident knowledge to the contrary. Greg House: one of my critical thinking heroes.

(Cameron ain’t too shabby at it either.) Continuing on the theme of over-medicalization of back pain, doctors also prescribe too much surgery and too many drugs,5859 even though we have evidence that these approaches to the problem routinely have disappointing results.606162636465 Even when surgery appears to work, the benefits may often be due to placebo effect rather than correction of a significant problem.66 Many years before when I had serious back pain from a sports injury, the surgeons said they would explore my spine and “figure it out.” Out of frustration I had impulsively opted for the procedure. They ended up fusing the vertebrae. It left me debilitated. In hindsight, I blamed myself more than the surgeons. I had pressed them for a solution when in fact none was apparent because the cause of the pain was obscure. ~ How doctors think, by Jerome Groopman The truth is that your back is not fragile — it is a strong, adaptable structure.67 Multiple spinal joints can be fused without causing pain or loss of function.68 The big muscles around the spine can be quite asymmetrical with no ill effect.69 The spine can heal from injuries as well as any other part of the body, and can adapt well to significant mechanical failures — study after study has shown that people also can have significant spinal degeneration, deformities, and injuries without any pain.70717273747576 There is even strong and recent evidence that structural stability is not a critical factor in the pain of collapsed vertebrae — stabilizing those bones with injected cement doesn’t make them recover any faster, as surgeons had reasonably assumed for decades.77

2.1

Even serious structural problems in the low back are often painless Even spondylolisthesis and stenosis — true dislocations of vertebrae, and narrowing of the tube that your spinal cord lives in — may not be the primary cause of pain in many cases.78 Until relatively recently in history, almost everyone (except John Sarno79) assumed that spinal stenosis was painful. It’s spinal-canal narrowing! Ouch! Right? That’s gotta hurt! This is an MRI scan of a severe spondylolisthesis — a dislocation of the lowest lumbar joint. This patient has never had low back pain. But in 2006, Haig et al published truly surprising evidence that spinal stenosis often does not hurt.80 In this study, about 150 people were assessed for back pain either with MRI alone or just with physical assessment. MRI can certainly detect narrowing of the spinal canal, but on the basis of MRI alone, doctors could not identify which patients were hurting, because many of the people who had stenosis did not have pain. These results also strongly imply that a narrowed spinal canal does not (alone) cause back pain. Or consider the striking case of one of my own clients. The picture is an MRI of a grade III (i.e. “bad”) spondylolisthesis, a type of dislocation — her fifth lumbar vertebrae is basically falling off her sacrum, slipping down and forward. It is approximately 50% displaced. The degree of structural deformity seems to be extreme, almost disastrously so. One wonders, how can such a person even walk? It’s got to be painful, right? Incredibly, this middle-aged client was not a back pain client. She sought my assistance for a minor foot problem! She had never had significant low back pain in her life: only occasional minor episodes. As if that were not surprising enough, she also had severe scoliosis. This is not an isolated case of a serious but painless dislocation; there are other case studies of relatively asymptomatic dislocation and deformity.8182 I discuss them in more detail in an article about spinal manipulative therapy. Of course, spondylolisthesis, spinal stenosis, and other extreme anatomical situations probably can cause pain. Stenotic pain, for instance, is responsible for the characteristic forward stoop of many elderly persons — because stenosis causes pain when you straighten up, it forces its victims to bend forward to escape it. So it’s certainly a real problem. But it’s also terribly interesting and informative that they cause so much less pain (or other problems) than anyone previously thought. GO TO TOP • CONTENTS • NOTES

2.2

Maybe you’re just getting older? Actually, no … April — More information: Discussed the prevalance of severe back pain in older patients, as a good exception-that-proves-the-rule. You are getting older! But getting older is probably not the reason your back hurts. This is an important clue that back pain often cannot be blamed on structural problems. Many minor structural problems are known to increase steadily with age. Any doctor with some experience knows this. And every person over the age of thirty-five can feel it. This is consistent with the common sense idea that spinal degeneration progresses with age and causes pain. After the age of 40, perfectly normal vertebral columns rapidly become rarer and rarer. It is unusual after that age to see spines without x-ray evidence of aging, including thinning of disks and thinning of articular surfaces. The longer a man lives, the more impressive the radiologic changes in his vertebral column become. College of Physicians and Surgeons of the Province of Quebec83 Yet young people — working people in their thirties and even twenties — routinely get severe back pain in numbers so staggering that they are routinely cited for their economic significance. In fact, there is evidence that people actually get less back pain as they age! Certain types of back pain are relatively absent in the young and become increasingly common with age, especially some of the most severe kinds of back pain — more on these examples below. But those are the exceptions that prove the rule. The overall trend is clear: most typical back pain occurs in the thirties and forties,84 either actually declining in the fifties and sixties,85 or at least not steadily increasing — exactly the opposite of what you’d expect if back pain was mainly caused by the degeneration that we know is occurring!8687 Just look at this camel-hump of a graph of one survey:88 Graph of the percentage of survey respondents who reported low back pain at different ages. That’s a pretty striking hump of low back pain in mid-life … and a surprising decline after that. Not every data set shows it so clearly — I cherry-picked one of the most impressive examples — but even where there isn’t such a clear decline, any decline in pain with age, or even just a lack of increase, is sharply at odds with the conventional wisdom. If low back pain were caused or even much bothered by wear-and-tear on spines, you would not only expect to see more back pain in older people, but worse back pain in older people — much worse. If spines were fragile, and if their fragility was driving low back pain, then the thirty-year-old back pain patient, on average, would be much better off than the sixty-year-old back pain patient. And yet this is decidedly not the case! A great many younger patients with no history of injury suffer from extremely severe pain — pain that is well out of proportion to the degeneration that cannot possibly be significantly afflicting their spines at their age. Degenerating? Although they aren’t immune, older people are actually relatively free of low back pain. It’s the thirty- & fortysomethings that generate the horrifying low back pain statistics. None of this is widely known, but it’s not out in left field. We know that degeneration correlates poorly with pain, and is mostly determined by genetics anyway, and not “primarily through routine physical loading exposures (eg, heavy vs. light physical demands) as once suspected.”89 Although your family doctor may not be aware of this research, he can learn it easily from medical experts, just like I have. For instance, Dr. Richard Deyo of Seattle, one of the world’s foremost medical authorities on back pain, knows full well that back pain is not usually structural, and he’s done much of the research that proves it. In his tutorial for doctors published in the New England Journal of Medicine in 2001, Deyo makes it clear to physicians that only a small amount of back pain has any structural cause, and the rest of it — about 70 to 85% — is just unexplained.9091 The nastiest types of back pain do increase with age Vlaeyen et al. This is the first of several references to this paper in the book. In fact, there are so many that I’m not going to clutter up the footnotes with a dozen “op cits.” From now on, when I refer to this paper, I’ll just link to it from the body text. See this first footnote for a summary/review of the paper. Certain types of back pain are relatively absent in the young and then surge with age. Deyo explains that “cancer, compression fractures, spinal stenosis, and aortic aneurysms become more common.” And Vlaeyen et al emphasized that “if only more severe forms are included, the prevalence steadily increased in individuals ≥65 years of age,”92 based on Dionne et al (which is actually a paper entirely devoted to this question).93 Cancer is a solid example, because it definitely gets more common with age, and it sure can cause severe back pain, so that’s going to drive up the number of cases of nasty back pain in older people. But if you subtract such cases from consideration, then the lack of any clear sign of non-specific back pain worsening with age is even more glaring. Dionne et al. concluded that it’s “unclear” how age affects non-specific low back pain. My opinion is that the absence of clarity is precisely what’s interesting. If aging is bad for backs, why isn’t it clear? GO TO TOP • CONTENTS • NOTES

2.3

Structural problems in the low back are hard to diagnose accurately Even if you have structural problems with your back, and even if they actually are the source of your pain, doctors and therapists have an extremely difficult time accurately identifying where the pain is coming from. Not that it stops them from trying. If I had a buck for every time I heard something like this… “It’s my sacroiliac joint. My physiotherapist told me.” Patients get told this kind of thing a lot. The sacroiliac joint is an especially popular scapegoat (there’s a whole chapter about this later on), but there are many reasons to doubt that the sacroliac joint is a cause of pain nearly so often, such as all the other possible causes of pain, or its legendary toughness: I talked to a trauma surgeon that had been to workshop where they talked about the sacrum being “out of place.” He just said this is ridiculous: we see people who are in motor vehicle accidents with every bit of their body smashed but the sacroiliac joint is intact. It is so strong. Peter O’Sullivan, Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, Australia So patients are routinely given precise pathoanatomical explanations for their back pain, and it always sounds impressive. Sometimes I start to worry that other healthcare professionals might be much smarter than I am, because they seem to be so good at identifying exactly where low back pain is coming from. Nerve blocks numb the nerve supply to a single spinal joint to see if the problem goes away. Provocative discography is the injection of an irritant into a disc nucleus in an attempt to reproduce the patient’s typical pain. Both techniques will be discussed more below. But years of experience and study have taught me that humility about such things is probably wiser. In a 2000 editorial for the Medical Journal of Australia , Dr. Nikolai Bogduk sassily wrote that many diagnoses for low back pain are “illegitimate, inappropriate, or fanciful”94 (italics mine) and explained that there is hope for more precise diagnosis … but only with very specific medical tests, such as nerve blocks and provocative discography. In 2007, the European Spine Journal published the best paper about this so far. This scientific study of about 40 tests-of-testing studies put the claims to the test!95 (Yes, that sentence does actually make sense — I’ve reviewed it carefully. It’s just amusingly tortuous.) Can therapists really pinpoint where low back pain is coming from? Basically, no. At best, testing only modestly increased the odds of correctly identifying the source of pain. “Some diagnostic value” is the strongest positive assessment in the article, and that refers primarily to MRI being used to help confirm a disc as the source of pain (not eliminating it, which they cannot do).96 Massage therapists, rather disappointingly, could not even identify the side of the body that back pain was on by feel alone — despite our legendary reputation for zeroing in on tissue problems with uncanny accuracy.97 Being inaccurate even at finding the side of pain is kind of the palpation equivalent of missing the broad side of a barn in target practice, and rather strongly suggests that, even if there is a structural problem, it doesn’t even show up clearly enough for the “magic hands” of massage therapists! Facet joints are a common scapegoat, but (emphasis mine) “none of the tests for facet joint pain were found to be informative.”98 This makes me cringe, because I “tested” for facet joint involvement frequently during my clinical career. That was a couple minutes of my patients’ time and money wasted every time, to say nothing of the misleading results! And the evidence had existed for years. Yet another great example of how important it is for clinicians to keep up with their journal reading. The effectiveness of common kinds of testing for spinal dysfunction was “at best moderate,” and that was only if multiple tests were used. The tests bombed when tested independently! No one test was any good. Such testing involves a lot of skill and knowledge, so to get even “moderate” results you would also have to have the most competent testing, a top-of-class type of doctor or therapist — rare by definition.99 One would hope that diagnostic tests would produce reasonably unambiguous results which, when tested, would prove to be correct most of the time. Instead what we have is a mess of underwhelming performance not much better than pointing at random anatomy while blindfolded. Hancock et al (cited above) added to the (already large) pile of evidence that “conventional investigations do not reveal the cause of [low back] pain”100 (that’s Dr. Bogduk again). In 2009, the American Pain Society also gave a thumbs down to provocative discography in their official guidelines for low back pain — reducing the number of serious diagnostic options even further.101 You cannot generally trust professionals to identify a structural origin for your pain, even if you have one. Which you probably don’t. GO TO TOP • CONTENTS • NOTES

2.4

Those scary spine models This is a great example of how old ideas in health care persist. And cause problems. As you’ve learned above, although herniated discs do happen, they are less common and much less serious than most patients, doctors, and therapists believe. Meanwhile, several respected medical experts have made strong statements about the extreme importance of reassuring low back pain patients and not scaring them with ominous-sounding diagnoses like “herniated disc.” Such diagnoses are usually wrong — or hopelessly oversimplified at best — and needlessly scare the wits out of patients … which itself is a known risk factor for low back pain. Nervous low back pain patients tend to have more pain for much longer. Model of doom & gloom Lumbar spine models like this almost all show a herniated disc. Some go a step further & show discs slipped so far they’ve completely left the spine! (Hat tip to Dr. Moseley.) And yet it remains nearly impossible for a clinician to buy an anatomical model of the lumbar spine that doesn’t have a little rubber disc bulging ominously from the spine … invariably coloured bright red, just to hammer the point home! It is also nearly impossible for a patient to look at such a model without worrying. That little bulging disc looks bad. Or, God forbid, a disc that has “slipped so far out it’s sitting on its own?” Here’s pain researcher Lorimer Moseley making this point in a great TED talk. He’s talking about how pain is always worsened when you believe that there is danger … and plastic anatomical models of slipped discs are much too persuasive. Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on its own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain. ~ Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33 (I laughed out loud at that, and then cheered. I’ve been bitching about these blasted models for years. Long before I’d ever heard of Lorimer, I’m proud to say.) Such models also undoubtedly also influence professionals. Even if clinicians accept that it’s an oversimplified model, the prominence of herniated discs in most models and anatomical drawings constantly exaggerates their importance. Anatomical models aren’t cheap, and once a clinician has purchased one, it will likely stay in his or her office for years, probably even decades. I’m sure there are probably hundreds of thousands of them in offices around the world that are at least twenty years old, and clinicians are still buying new ones today! And so this is a great example of how hopelessly obsolete clinical ideas persist for years, even decades, after the field has moved on. GO TO TOP • CONTENTS • NOTES

2.5

It’s not structure, except when it is: “specific” back pain January — Expanded: Some final elaborations and editing. This topic is now more or less completely addressed, I think. In medical jargon, back pain without a specific explanation is “non-specific” back pain. It’s an odd term, rarely used for other medical conditions. There is no non-specific headache, for instance, even though there probably should be: a headache without a specific explanation is traditionally called a “tension” headache, which is even worse, because it assumes a cause that is routinely wrong. Imagine if we called all puzzling back pain “tension back pain.” Another way of defining it: “non-specific back pain” is what we call it when we literally can’t be any more specific than “it’s back pain!” Chronic low back pain is often classified as non-specific: that is, no organic cause of the pain can be identified, and this happens so much it’s the standard. Even more often, back pain has been blamed on a specific cause prematurely, without actually knowing the real cause — much like assuming that an undiagnosed headache is “tension.” Vast numbers of healthcare professionals default to assuming that undiagnosed back pain is “degenerative,” with variable vehemence, and that problematic assumption is what I’ve mostly focused on so far in this book. The mirror image of that problem is the assumption that there is no specific cause, and that is implied by the label “non-specific back pain.” Rather than simply being unknown, too many people slip into assuming that no specific cause exists. So both of the common ways of labelling and think about back pain are routinely misleading. The other side of the coin: sometimes structure does matters I have devoted several sections to demonstrating that specific, structural causes of back pain are over-emphasized, but not non-existent. Like violent crimes, they are much less common than the news makes people fear, but they do still happen. In 2015, a group of researchers published an excellent pair of papers, one pushing away from mechanical explanations… the other right towards it. The first is cited above: Brinjikji et al looked at a whole lot of MRI pictures of spines, and presented evidence that signs of spinal degeneration are present in amazingly high percentages of healthy people with no problem at all. Good to know. It’s one of the best papers of that sort, highlighting the weird disconnect between back pain and spinal degeneration. But Brinjikji et al didn’t stop there. They published a second paper presenting evidence that degenerative features visible on MRI are nevertheless “more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals.”102 Also good to know! These papers aren’t actually at odds. The collective take-home message of the pair is just a nice, reasonable compromise: degenerative changes matter less than many patients and professionals still assume, and are not an adequate foundation for many popular treatments, but they do still matter. Duh. Importantly, Brinjikji et al also showed that the disconnect between structure and pain is much less striking for some kinds of problems than others. Not many people with intervertebral joint dislocation (spondylolisthesis) are asymptomatic.Some are. But not most. While the majority of people (60%) with bulging discs at age 50 are symptom free, only 14% of 50-year-olds with spondylolisthesis are feeling no pain. It’s amazing that anyone can have a dislocated intervertebral joint and feel fine, but that’s still 85% that do have symptoms. So whether structure matters depends. Some spinal problems matter more than others. Some of them are worse than others. Duh again. A specific example of a specific cause of back pain: neuroma Obviously sources of acute and/or ominous pain like infections, aneurysms, tumours, fractures, and inflammatory diseases are all specific causes of back pain, but they aren’t of much interest here because they are so serious (and usually progressive) that they usually do get diagnosed. They are the kinds of things that mostly qualify as “specific” back pain. But what about specific problems that tend to drag on and never get diagnosed? Are there also specific causes of chronic low back pain that get missed? Yes, of course there are. A friend of mine — let’s call him Alex — suffered for years from relentless back pain before a little tumour was finally discovered: it was benign, but it was growing on a nerve in his back (a “neuroma”), and it had just about ruined him. Neuromas are tumours, but they aren’t the kind that kill you, they just make you miserable. My friend had dropped out of the sport he loved, ultimate, the Frisbee sport, which is how I know him — we had played for years together on a team called Afternoon Delight. Our team logo was a pair of humping unicorns. At his worst, Alex could barely walk. Eventually, after an easy surgery, he was basically completely cured, just like that. Boom. Specific as it gets. Alex had seen many, many healthcare professionals who had failed to diagnose the real problem, thrown up their hands, and chalked it all up to “non-specific back pain.” I know, because I was one of those healthcare professionals. Before the diagnosis, “sensitization” had been a major diagnostic option, a classic non-diagnosis that basically means the problem is a false alarm. Although Alex likely was suffering from the phenomenon of sensitization, it was a sideshow: it was being constantly wound up and sustained by a clear ongoing source of serious irritation in his back. Credit where due: it was a chiropractor who finally suggested the right kind of spinal imaging, which easily identified the neuroma. Once everyone knew it was there, that was the end of any discussions about how strange and unexplained chronic back pain is! He just needed surgery to remove a little blob of uninvited tissue from a nerve root. And that surgery worked immediately and permanently. That’s probably the single clearest example I’ve ever encountered of a specific cause of back pain, without any fine print. The next example is also quite good, but it is not as cut and dried. Another specific example: cluneal nerve entrapment, and another slam dunk surgical fix (maybe) The cluneal nerves pass from the low back and sacrum into the buttocks, just under the skin, and they can get “tangled up” with ligaments and connective tissue on their way (nerve entrapment). The irritation potentially causes low back and leg pain. Most cases are probably relatively minor and are obviously related to a peripheral nerve in distress: that is, some cases probably don’t feel like classic back pain, but back pain with a fairly obvious nervy character (superficial, electrical, with some tingling and other distorted sensation). The location of the pain is probably also a little on the low side, less “back” than sacroiliac joint, butt pain, and a touch of sciatica. But, in 2016, Aota reported on “a case of severe low back pain, which was completely treated by release of the middle cluneal nerve.”103 The patient suffered from nasty “back and buttock pain radiating to both legs” which was “continuous and severe,” and had come on gradually over a decade. She did also have some prominent tingling, however, so neurological involvement was probably always suspected. But she’d been operated on already, a clean miss, a pointless diskectomy, undoubtedly intended to relieve pressure on a nerve root. But her symptoms weren’t coming from a nerve root. She was lucky enough to have a doctor who figured it out and talked her into a surgery I doubt that I would have agreed to: exploratory surgery to identify nerves “entrapped in adhesions.” Freeing it up definitely helped part of the problem, but it didn’t solve it. It took a second attempt to find the main problem, a surgery I would definitely have been reluctant to try myself. But it’s a good thing she did! They found a tiny spot where the nerve passed through a ligament, cut it free, and that was the ticket: she was decisively cured. Which is pretty cool. #1 marks the site of the superior cluneal nerves & where the first surgery freed nerves from “adhesions.” #2 marks the middle cluneal nerve, where the second surgery freed it from entrapment in the ligament. Click to embiggen. That’s about as structural a problem as we can imagine. Tissue in trouble! As physical as tangled sailboat rigging. And yet it is still also completely possible, maybe even likely, that her problem was not the nerve “snag” per se but a biological vulnerability to feeling it. The physical predicament of the nerve may have been like kindling for a fire — a fire that was then lit by something else (and then burned for years).104 Even if that was the case — and it would certainly be fascinating — diagnosing the vulnerability and solving it could well be a lot trickier than just setting the nerve free. No kindling, no fire! Mostly this problem seems as straightforwardly mechanical as your legs falling asleep because a 40-pound terrier won’t get off your lap. There’s “no such thing” as non-specific back pain? Because of cases like neuromas, annular lesions, and cluneal nerve impingement, well-known back pain expert Dr. Stuart McGill has famously argued that there is “no such thing” as non-specific back pain: “there are only those individuals who have not had a thorough assessment.”105 In a podcast interview, he gave the following interesting example: MRIs are static, but when you watch dynamics of spine movement, things really change. The instabilities show up, the micromovements show up. In my last few years at the university, we did fluoroscopic investigations of whiplash patients. These were patients who were rather summarily dismissed by typical medical practice, the radiology reports said “oh, there’s nothing [specific] wrong with you.” Well, when we followed them and watched them move with fluoroscopy, we would see that they could move through the range of motion, and let’s say for example as they passed through 10 degrees of flexion they would get a shot of pain. We would watch and quantify on the dynamic fluoro image a sheer movement of the person’s neck. The legacy of the whiplash was a local joint laxity and instability and that would … cause pain. So here was this poor person dismissed by MRI and yet they had a very specific and quantifiable mechanism to their pain. So you can imagine the cognitive dissonance that person was now in because some medical authority questioned the legitimacy of what they felt every day. Dr. Stu McGill, interview for Evidence In Motion Interesting! Though again, as with the nerve entrapment thing, it’s possible that the problem in such patients was less “mechanical” than it looked, and just as much about a messier vulnerability to irritation. Everyone is easily seduced by the apparent explanatory power of a correlation on MRI. This story seems compelling, but it’s not really any different in principle from the well-established mistake of assuming that a picture of a herniated disc confirms that it’s the cause. The picture is seductive in both cases. A picture is worth a thousand words, but what if the words are lies? Both kinds of pictures seem to scream, “Look at me! I’m obviously the problem!” In one case we know it’s often misleading, so why assume the other is a slam dunk? It is a tighter correlation, but it’s still just a correlation. The causality inference is reasonable, but it ain’t a slam dunk either. Dr. McGill believes a biophysical cause is often there and can be found if we only look hard and smart enough. I admire his confidence! I have no doubt that some back pain mysteries can be solved by a good enough medical Sherlock Holmes. Unfortunately, I also doubt that anyone is actually capable of finding the problem in most cases. I think the evidence is overwhelming that many diagnostic searches for mechanical causes are barking up the wrong tree. A large family of specific possibilities (with one major neglected one) It may well be possible to find a proximate cause “if we look hard enough” (like cluneal nerve entrapment) but those causes are probably often not the only cause. That janky vertebral movement may be the specific trigger for pain, but it’s probably resting on other layers of causation (like biological vulnerabilities like getting inflamed much too easily). I also think it’s obvious that many cases are in turn caused by something else. The true opposite to “non-specific” back pain is probably not a singular specific cause, but multiple causes. One of those causes is, I believe, both extremely common and widely underestimated, something a lot of professionals aren’t even looking for. I think that topic deserves a whole bunch of special attention, and so the next several sections will focus on “muscle pain.” But then I’ll return to a long list of other possible specific causes and factors: muscle strain, spasm, overuse injury, disc herniations, facet joint trouble, subluxation, sacroliac joint dysfunction, aligment problems like short legs, pelvic tilts, obesity, core weakness, foot wonkiness, pinched nerves, scoliosis, and — the last but not least — the spectre of back mice. GO TO TOP • CONTENTS • NOTES

2.6

So then what? Muscle is the most missing piece of the back pain puzzle So what is going on with most stubborn low back pain? If we have to toss most of the conventional wisdom out the door, what replaces it? If most back pain cannot be attributed a specific pathology, or not one of them anyway, what can we attribute it to? If the usual suspects rarely actually hurt, or don’t hurt that much, then what the heck is hurting so much? I propose that a large percentage of otherwise undiagnosable low back pain is either caused and/or significantly complicated primarily by humble muscle tissue. That is, a lot of low back pain is probably106 muscle pain in the low back. The problem is not the spine, but around the spine. Not pinched nerve root pain, not herniated disc pain, not dislocation or subluxation pain, not arthritic facet joint pain, not torn muscle pain, not even a “muscle spasm.” Not anything specific that is commonly diagnosed (or feared) by patients or professionals. Just the humble muscle “knot” — a poetic and imperfect word for a quirky and controversial clinical entity. The more official word for a muscle knot is a “trigger point,” and a collection of particularly nasty trigger points is often called myofascial pain syndrome (MPS). Trigger points and MPS are important concepts and a major focus in this tutorial because: There are many well-established ideas about trigger points, supported by plenty of interesting scientific evidence slowly accumulating over decades. It’s a half-baked mess,107 but it’s not way out in left field either. For instance …

The existence of unexplained sensitive spots in soft tissue is not in itself a matter for debate. Nearly everything else about them is hotly debated, but not their existence. The fiercest critics of the conventional wisdom concede that we are all studying what people subjectively experience as pain in muscle.108 There may be a great deal about them that we don’t understand, and they may be difficult to diagnose and treat, but they are there, and they have some distinctive properties (properties often observed in back pain).

Trigger points occur in the low back in unusual numbers and severity. Although there are several regions in the body where trigger points are common, the low back seems to by far the most prone to it.109

The clinical importance of trigger points is based on an unholy triple threat: they do not just (1) cause pain, they also (2) complicate any other pain problem, and (3) mimic other pain problems. Trigger points are likely involved to some degree in virtually every case of back pain, regardless of what else is going on. This cannot be said of other factors in back pain. For instance, discs do not herniate in response to muscle pain … but muscle is likely to start to hurting because of disc herniations (and even continue after the herniation resolves).

Best of all, trigger points are a Good News diagnosis because they are mostly self-limiting and treatable, however clumsy and imprecise our methods … because their bark is worse than their bite. They may not be responsible for all back pain, but they are probably responsible for a bunch of it, and responsible for the part of it that we can work with relatively cheaply and safely. But trigger points can bark very loudly. They can be amazingly (frighteningly) painful — much worse and more persistent than an actual injury, probably far more painful than you would ever expect a mere muscle knot to be. This is one of their distinctive properties that is similar to back pain, which is so notorious for causing so much misery without any easily detected tissue trouble. I estimate — opinion and guessing, not science — that about half of all cases of mild to moderate low back pain without any other obvious causes or complications are caused by these sensitive little spots. Most garden variety back pain is probably just some trigger points that got out of hand. The relationship between trigger points and the pain is often so straightforward that the correct therapy is nearly effortless — you find one or two key sensitive spots, stimulate them a bit, and bam, you’re a “miracle worker.” For instance, a woman came to see me complaining that she’d had moderate, chronic back pain for several years. She’d been given several predictable “mechanical” misdiagnoses in that time, especially sacroiliac joint dysfunction, one of the classic back bogeymen. But she had a prominent gluteus maximus trigger point that, when stimulated, caused the same sensation as her symptoms — a deep, sickly, nagging ache in the region of the low back and upper gluteals. In three appointments, years of pain was completely relieved. Bam. “Miracle worker.” She was quite surprised: Just wanted to give you a quick update … my back has been absolutely fine. Unbelievable … or perhaps not, considering what I’ve learned from you! A big thank you for all your help. ~Lois McConnell, retired airline executive, suffered chronic low back and hip pain for a few years I have many stories like that. In almost every such case, the pain was not terrible, but frustrating and persistent for years, then relieved by a handful of treatments. For a manual therapist, it doesn’t get much better than that. I’m shy about writing it down, because skeptics are absolutely correct to be skeptical of such anecdotes. However, this whole idea is not too good to be true: it’s just ordinary good. Working with muscle seems to have given me an opportunity to solve a surprising number of pain problems that would otherwise have defied me … but by no means was I actually working miracles, and failure was also common.110 I’m definitely not bragging that I can fix any case of back pain in three appointments! It’s more like this: “I can improve about 60% of cases of moderate chronic low back pain of a certain type with two to six hours of massage.” Not miraculous, just good. In most of the other half of all cases, trigger points are causing or complicate otherwise relatively minor spinal injuries, like mild muscle strain in a lifting incident. Some such injuries will get better, and some will mark the beginning of a long struggle with trigger points — ultimately, the trigger points are the more stubborn problem. Most chronic back pain would probably be less chronic and less serious if not for the tendency of trigger points to pile on and make everything worse, and create sensations that seem an awful lot like scarier things (nerve pain, chiefly). That leaves only a small fraction — maybe 10%? — of back pain that is more completely mysterious.111 But even in that puzzling remainder, the pain will still usually involve trigger points: they crop up like clockwork near any other major problem, and make a bad situation worse. Therefore, nearly anyone with low back pain probably also has some low back muscle pain. But how could so much pain be primarily caused by “just muscle”? Why would muscles and other tissues get into such an appalling state in the first place? If the back isn’t otherwise fragile, why is the muscle tissue? And why the back in particular? GO TO TOP • CONTENTS • NOTES

About your free companion trigger point tutorial Some things just need to be described over and over again. The clinical significance of muscle pain is one of the most useful ideas this website has to offer. Several PainScience.com tutorials introduce trigger points. Regular readers and boxed set owners may find all the introductions to be somewhat redundant, repetitive, and a lot like reading something over and over again. 😉 But it’s important information for every new reader. I do make an effort to “customize” every discussion of trigger points. This tutorial discusses the basics of trigger points as they relate to low back pain. But don’t forget that customers who purchase this book also have full access to an extremely detailed companion tutorial focusing on trigger points. The Complete Guide to Trigger Points & Myofascial Pain The low back pain tutorial does not assume that you are necessarily going to read the entire trigger points tutorial, or any of it, so there’s enough information about trigger points here to adequately introduce you to the subject. However, if you want to know all about trigger points, then the full trigger point tutorial is the document to read. Your interest in the trigger points tutorial should be proportionate to how much you think trigger points might be involved in your particular case of low back pain.

2.7

There is nothing “just” about muscle While many medical back pain experts will only go so far as an acknowledgement that “no one really knows” what the cause of most low back pain is, some other experts suspect the same thing I do: that muscle may be a major missing piece.112 And it’s not such a strange idea — we are leaving the trunk of the tree of knowledge, but we’re not going too far out on a limb here. Muscle can be a source of major misery, and we know this from the pain caused by an acute cramp, or the less acute (but equally obvious) suffering caused by neuropathic spasticity. An excellent (and rather chilling) example of that is the “MS hug.”113 And yet it’s worth noting that the symptoms of the MS hug are often dismissed or misinterpreted. And for every clinically obvious example, less obvious ones are legion. Muscle is a sensitive114 and volatile tissue,115 but it is also underestimated. Even patients themselves — the people suffering — are often amazed to discover the sensitivity of their own muscle tissue. They feel the pain, but they have no idea how vulnerable the tissue feels until it’s prodded. Even moderate pressure on some muscle tissue can cause strong discomfort. My clients often asked me, “What is that?” (Or they just said a bad word.) People can hardly believe that it’s “just” muscle — that it’s not some more vulnerable anatomy that feels like that. Healthy muscle does not hurt when you gently poke it, but unhealthy muscle sure can! What’s going on? Why would muscle hurt that much? The answer is that muscle tissue is never “just” muscle tissue — there’s a lot of it, it’s biologically complex and chock full of nerve endings, it’s behaviour is highly sensitive to our mental state, and it’s got a difficult and unrelenting job to do. And sometimes muscles get “sick,” and the pain can be agonizing. Dr. John Sarno writes: “ … it is highly unlikely that a structural derangement could produce pain equal in severity to acute muscle spasm [by which he meant trigger points].”116 “Myofascial pain syndrome” was first thoroughly studied by Drs. Janet Travell and David Simons.117 In their explanation of MPS, physical stresses and/or emotional stress triggers a vicious cycle, a trigger is basically a tiny cramp or spasm: a patch of muscle clenches, choking off its own blood supply, resulting in oxygen and nutrient deprivation and stagnant tissue fluids that irritate sensory nerves and perpetuate the cycle.118 Some muscles seem to be more vulnerable to this phenomenon than others — the back muscles most of all. An updated version of this explanation, the “integrated hypothesis,” was spelled out in 2004 by Gerwin et al.,119 and is now the most widely known working theory. And, for the purposes of this book, it’s the theory I will work with — with the understanding that it’s just a theory, it has critics, and it could be wrong. Which Gerwin et al. have acknowledged.120 And which I also freely acknowledge.121 ... an appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points, despite their having been written about in medical journals for over sixty years. ~ The trigger point therapy workbook, by Clair Davies, p. 2 There’s a long, colourful history of arguing about this stuff: many people have tried to label and explain these mysterious patches of icky, achy muscle. The scientific literature was chock-a-block with theories before the ideas of Travell and Simons started to dominate, and there are still many competing theories today. Some examples: In his best-selling book Mind Over Back Pain (and in his more recent Healing Back Pain ), Sarno describes the same problem and calls it “tension myositis syndrome,” attributing it mainly to stress-induced constriction of blood vessels causing oxygen starvation.122

(and in his more recent ), Sarno describes the same problem and calls it “tension myositis syndrome,” attributing it mainly to stress-induced constriction of blood vessels causing oxygen starvation.122 Dr. C. Chan Gunn of Vancouver calls it “neuropathic pain,” and suggests another explanation: under-stimulated muscle may become extremely sensitive.123 Dr. Gunn’s ideas are also at the heart of one of the most popular and controversial treatment methods, “dry needling”: stabbing trigger points with acupuncture needles, basically! If that sounds painful, you’re right — it can be agonizing.

Quintner, Cohen, and Bove have proposed that the pain is caused by inflamed nerve fibres, and/or “referred pain and tenderness” from deeper tissues with unspecified troubles and/or “altered central nociceptive mechanisms.”124 Not all of these theories can possibly be entirely correct, of course. It’s probably a classic case of holding onto different parts of an elephant. But we’ll proceed with the main working theory.125 So, trigger points are patches of muscle tissue (and perhaps other soft tissues) that is “unhealthy” in some way. Some muscles seem to be more vulnerable to this phenomenon than others — seemingly the back muscles most of all, for unknown reasons.126 They are not only painful to touch, but also spontaneously generate spreading pain and nervous system disturbances to nearby tissues. This spreading is a well-documented phenomenon called “referred pain.” Pain originates in one location, but radiates in surprisingly predictable patterns to other locations. For example, people with low back pain routinely have trigger points that “send” pain into the buttocks and down the legs. These sensations can be extremely similar to pain produced by a pinched nerve, like lumbar nerve roots or the cluneal nerves in the buttocks — often resulting in misdiagnosis.127 In most people with low back pain, trigger points causing these radiating sensations can be located easily. Although the pressure is nowhere near a nerve,128 the spot is sensitive and radiates in a familiar way — clients say things like “it shoots down my legs” and “that’s exactly what my pain is like.” Unsurprisingly, when these trigger points are treated, the “pinched nerve” pain goes away. This is an example of how muscle can be the entire cause of low back pain, even when no spinal injury has occurred — including the cases that scare people, the ones that seem unusually severe, strange, or “nervy.” Massage therapist Clair Davies (famous for his highly readable version of a classic medical text on muscle pain), writes, “Back pain always has a myofascial component, no matter the official diagnosis. Although arthritis, bad discs, and displaced vertebrae come quickly to mind when your back hurts, back pain is very often nothing but referred pain from myofascial trigger points.”129 Or consider the opposite scenario, in which we begin with a genuine injury or mechanical problem: despite the presence of a painful factor other than muscle, it may soon be the least of your worries as trigger points crop up and begin to overshadow the original problem, causing pain that is even worse and more stubborn.130 Indeed, this is a common course of events. It is the nature of trigger points to cause and complicate other low back problems131132133 — to make a bad situation worse! — that makes it the most significant factor in the majority of low back pain. GO TO TOP • CONTENTS • NOTES

2.8

Low back pain is the new ulcer April — Science update: Nice reference supporting the point that true psychosomatic pain is a rare beast. Back pain is probably how some bodies say “no!” Meaning, it is the painful manifestation of an urgent desire and need for change — a reaction to stress. That turn of phrase is borrowed from the title of a book about stress-induced illness by Vancouver physician Gabor Maté.134 Back pain may also be how “the body keeps the score,” another phrase borrowed from a similar book.135 Let me stop the groaning: I know everyone is tired of hearing about the evils of stress, and the last thing anyone with chronic back pain needs is another reason to wonder if you haven’t somehow brought it on yourself. Low back muscle pain is not a basket-case diagnosis. As I’ve already promised, I will not tell you that having back pain means that you are a hypochondriac or that it’s “all in your head,” and I will not recommend meditation and yoga as mind-body treatment (although they might be useful and desirable, they are hardly necessary). These are tired clichés that miss the point. Genuine, pure psychosomatic pain is as rare and exotic as hallucination. While pain may be strongly affected by psychology, even disastrously amplified and prolongued, it is almost never “caused” by it. There isn’t even a pain-specific mental disorder defined for psychiatrists — there used to be, but it was eliminated because it was so problematic. There are so many hard-to-diagnose pathological causes of pain (an unfair share of which are in the back) that the experts judged there was too high a risk of prematurely diagnosing people with a mental disorder when there’s something actually wrong with them.136 The point here is that most pain begins with biological trouble of some kind, but — once it gets going — it gets increasingly sensitive to mental states to varying degrees, much like high blood pressure, heart disease, asthma, or irritable bowel syndrome.137 Spinal pain is generally and seriously vulnerable to mental state. More specifically, myofascial pain syndrome — too many sore spots, associated with too much aching and stiffness, which seems to disproportionately afflict the back — also seems to be tethered to the mind. Stress may be both a root cause and a significant complicating factor in MPS, much as MPS is both a root cause of some back pain and complication of nearly other types of back pain.138 Although it is under-researched, many studies have shown links between stress and low back pain.139140141142 The likely potency of placebo in the treatment of back pain is also telling: nothing works magic on a stress-aggravated condition like optimism! The boiling frog problem Importantly, people routinely do not realize that they are suffering from enough stress to cause trouble. They have clear biological signs of stress — and this is an important premise for what’s coming here. The links between personality type and stress are a little murky and complicated, but they are certainly there:143 Your style, your temperament, your personality have much to do with whether you regularly perceive opportunities for control or safety signals when they are there, whether you consistently interpret ambiguous circumstances as implying good news or bad, whether you typically seek out and take advantage of social support. Some folks are good at modulating stress in these ways, and others are terrible. ~ Robert M Sapolsky, Why Zebras Don’t Get Ulcers , 2004, p. 309. There are two major personality types that not only involve a lot of stress, but some degree of obliviousness to it: The stereotype of the “Type A” personality with its aggressive coping mechanisms, by eagerly tackling fears directly… and by seeing threats where there are none, just in case, which is why it becomes a problem. These people are likely to make a virtue of stress, re-framing it as though it were a good thing, eager to believe that “stress is your friend” (it’s not).144 The stoic, repressive personality — people who feel and act calm and methodical, and genuinely believe that they are, but they are actually conforming intenselyto social norms, and controlling and organizing their lives to the point of suffocation. Dr. Robert Sapolsky: “It can be enormously stressful to construct a world without stressors.”145 Sarno: “one can be stressed without feeling tension” and “there are chronic daily stresses in people’s lives that are more insidious and more harmful [than crises] in their long-term biological consequences. Internally generated stresses take their toll without in any way seeming out of the ordinary”146 (emphasis mine). And then there’s just straight-up avoidance, acting stoic because anxiety is stigmatized and most people want to hide it. It is socially risky to express nervous tension or anxiety — no one wants to be perceived as jittery! It can even be verboten as a self-judgement as well, so people can be pretending for their own sake, trying to fake it until they make it, but peace and harmony never turn up, or rarely. Sometimes the source of tension is not obvious … I recall a young married woman who … denied being tense or nervous … she was known to be a very jolly, easygoing person. Only after a long discussion did she reveal that her strategy for coping with life’s problems was to put them out of her mind. This is a foolproof formula for generating tension. Putting things out of one’s mind doesn’t get rid of them … John Sarno, Mind Over Back Pain, p53 Ulcers were once a socially acceptable symptom of stress. Rather than being a nervous individual, you could be a hardass with an ulcer. But now everyone “knows” that ulcers are stress-induced, whether they really are or not, so ulcers are much less effective as a disguise for emotional stress — and perhaps this explains why the incidence of ulcers has decreased steadily since the 1970s.147 (Aren’t ulcers caused by an infection? Yes, but details.148) Instead, Sarno proposes, North Americans increasingly make back pain into a perfect new “hiding place” for nervous tension: a path of least resistance more than a choice. Because of the widespread belief that backs are fragile, people with back pain are readily seen as victims of biology, instead of stressed out basket cases. Perhaps in time, if the stress-mediated nature of back pain becomes a widespread idea, it won’t be as useful in this way. Psychosomatic disorders are physical symptoms that mask emotional distress. The very nature of the physical presentation of the symptoms hides the distress at its root, so it is natural that those affected will automatically seek a medical disease to explain their suffering. ~ It's All in Your Head, by Suzanne O’Sullivan, 8 A vicious cycle Once an episode of back pain starts, pain itself, immobility, and the fear of more pain become nasty new sources of stress. Thus, back pain can “cause itself.”149 Pain, fear, and immobility constitute an axis of evil, each reinforcing the other. Tragically, medical care for back pain often frightens patient, making the vicious cycle even more vicious: The system generates great fear. I recall a woman who became terrified when she read in a well-known book on the back that if you had a mildly herniated disc and became active too soon it would fully herniate and then require surgery. Another patient was told by the doctor as she left the hospital after refusing surgery, “You will be back in two weeks screaming in pain and begging me for an operation.” Dr. John Sarno, Mind Over Back Pain, p105 Thus a leading cause of back pain may be health care itself,150 in part accounting for the increased frequency of low back pain in modern times and in industrialized nations. More generally, the fear is stimulated by the many common myths and misconceptions about the fragility of spines — which are perpetuated by nearly everyone, not just doctors. Pain, fear & immobility constitute an “axis of evil,” each reinforcing the other & virtually guaranteeing the persistence of low back pain. That’s a nice clear picture, but we can boil it down to something even simpler … GO TO TOP • CONTENTS • NOTES

2.9

Pain and fear, together at last: an even simpler vicious cycle The diagram above — the pain-fear-immobility cycle — is one of many similar ways of visualizing what happens in chronic low back pain. For dramatic effect, I’ve cast immobility and muscle dysfunction as the villains: very specific and physical parts of the vicious cycle. Immobility is a problem behaviour, for instance: something you do (or don’t do). That may not be quite right, but describing it in this way is no accident: I want to make it real. Something that implies action. Be more mobile! Keep muscles happy! Immobilization is indeed a common way to show fear, and it’s much easier to work with the consequences of fear than fear itself. And it may well be a particularly important factor in muscle pain. And yet fear itself is actually all we need to keep pain going in that diagram. Immobility is redundant. You don’t need that particular behavioural piece of the vicious puzzle to explain the stubbornness of back pain. You can take immobility out of the picture, and the vicious cycle carries on, powered by fear and pain alone. We tend to assume that the persistence of pain means that there is damage and danger, assumptions that are in themselves direct causes of pain. If your brain thinks that the situation is injurious and dangerous, you will be more pain prone, regardless of whether or not you actually behave fearfully by immobilizing yourself, for instance. (See Woolf151 — a particularly important reference.) Bear with me for a moment for an amusing example. (A bit of a reach, but it’s worth it to get a chuckle out of this difficult subject.) There’s an episode of The IT Crowd that has fun with massage: “Something Happened” (Season 4 Episode 3). Roy has terrible back pain, but he doesn’t particularly want a massage: I’ve never enjoyed having massages. I don’t like being naked in front of strangers, and I can never relax if I think someone might play Norah Jones. ~ Roy, The IT Crowd, “Something Happened” (Season 4 Episode 3) Nevertheless, he gives it a try and he’s actually kind of digging it, until the “something” happens: his therapist concludes the otherwise professional treatment with a quick kiss on the buttock! (News bulletin: this does not actually happen. This is amusing, fanciful satire.) All Finished 0:16 Yes, if you watch Game of Thrones, you have seen that massage therapist before. More seriously (and yet still funny!) is how Roy describes the results of his massage: Did it help? 0:25 Roy attributes the failure to the extreme tension caused by a violating butt kiss — as one does — but there’s a deeper truth here: after a massage that seems to provide great relief at the time, many people do indeed soon end up right back where they started. Despite the nice clichés about feeling relaxed after massage, patients can actually get off the table feeling surprisingly unpleasant, wrung out in a not-so-good way: fragile, vulnerable, and tense. In Roy’s case, it was the kiss on the butt that did it! In real life, therapists of all kinds often unwittingly scare their patients with careless talk of what’s wrong in there, how serious it is, how they need more therapy, and so on, which can leave patients feeling more worried and anxious about their backs than they need to be. And that, in turn, is more than just a side effect: it actually perpetuates the problem. It cannot be said enough: this is not an “all in your head” message. It’s an “all in your brain” message — not psychology, but neurology. Or, as Dr. Lorimer Moseley puts it, “Pain really is in the mind, but not in the way you think.”152 Here’s his description of this more purely neurological vicious cycle: This is where our understanding of pain itself becomes part of a vicious cycle. We know that as pain persists the nociception [danger signalling] system becomes more sensitive. What this means is that the spinal cord sends danger messages to the brain at a rate that overestimates the true danger level. This is a normal adaption to persistent firing of spinal nociceptors. Because pain is (wrongly) interpreted to be a measure of tissue damage, the brain has no option but to presume that the tissues are becoming more damaged. So when pain persists, we automatically assume that tissue damage persists. I think it goes like this: “more pain = more damage = more danger = more pain” and so on and so forth. All of this strongly suggests that anything that reduces fear is probably therapeutic. Reducing the fear part of the equation — not just empty reassurance, but good reasons for genuine, unforced confidence — is a recurring theme throughout the rest of this book. Refusing to be immobilized is probably one of the best strategies (which is why I gave it special focus in the pain-fear-immobilization diagram). The next section is another great example … GO TO TOP • CONTENTS • NOTES

2.10

Chronic low back pain is not so chronic: the myth of chronicity If you’ve had chronic low back pain for less than a year, I’ve got great news for you: your ordeal may soon be over. The window of time that conventionally distinguishes “acute” from “chronic” cases is six to nine weeks. There’s a widespread belief you are doomed to long-term chronic pain if you don’t recover by the end of that period. This is a myth: although chronic low back pain can last many years, there’s no way to know if your case will, because low back pain can disappear at random. You do not disastrously become an impossible case the moment you enter week ten. You’re not likely to catch a doctor actually saying that you’re doomed after week nine. This myth is sneaky: health professionals aren’t stating it directly or erroneously defending it. What they will do is simply fail to reassure their patients during the transition to chronic pain, conveying an attitude of deepening concern and defeatism as the weeks go by, as though you are becoming one of those patients, a “difficult case.” Other professionals may just slightly exaggerate the importance of the transition from acute to chronic. It’s not wrong for health professionals to start taking a case of low back pain more seriously over time — but it is wrong — possibly even tragic — to do so without carefully reassuring the patient. Many health professionals are now educated enough about low back pain that they make a point of reassuring patients with fresh cases that most acute back pain disappears within a few weeks — and that’s great, because it’s true. Unfortunately, many of those professionals simply postpone the alarm to the ninth week. That defeats the purpose of reassurance by undermining patient confidence long before the ninth week. It is not at all reassuring to be told that “most cases go away” if it’s closely followed by “but you’re screwed if it doesn’t!” Patients given these conflicting messages will start worrying about whether or not their pain will go away by the ninth week, with rapidly escalating concern if it doesn’t! Consider a hypothetical patient: our crystal ball tells us that she will recover by week twelve, a somewhat slow recovery, but far from the nightmare of chronicity that a few patients face. Her doctor wisely tries to reassure her that most back pain goes away by the ninth week, but he carelessly tries to emphasize his point by saying that only “serious cases” last longer, so they won’t discuss her surgical options until then. This physician used best practices while simultaneously setting this patient up for severe anxiety.153 How is she going to feel in week eight with symptoms that are still prominent? She doesn’t have the crystal ball. She has no idea that she’s actually going to be just fine very soon. All she knows is that her problem is starting to look serious and surgery will be on the table as an option soon — yikes! Such anxiety could very well change the course of the problem. Such anxiety perpetuates some cases that would otherwise fade away not long after the nine-week “deadline.” And it’s such a shame, because there’s not much more cause for alarm at nine weeks than there is at three weeks. The longer pain lasts, the more likely it is to last even longer: that is a sad truth. But it doesn’t mean that long-term pain is inevitable any more than a slow-healing fracture is never going to heal. Some people just recover more slowly! There is no magic line in the ninth week separating easy cases from difficult ones. In fact, you can have low back pain for three, six, or nine months — technically a “chronic” case — and more than 30% of those patients will still recover by one year. And although there’s no data to support it, it is my experience that chronic low back pain patients often recover at virtually any stage of the problem, even after suffering for many years. These might seem like subtleties, except that we know that low back pain care is already rife with alarmism, and it’s a major problem because patient confidence and expectations are a critical part of rehabilitation. Low back pain patients are in real need of justified confidence, and lots of it, to combat the strong anxiety that is so common. Thankfully, we have good and recent scientific evidence that many patients recover from chronic low back pain — a strong basis for confidence, and some of the most encouraging research I’ve come across in low back pain science in a long time. This evidence was published in 2009 in the British Medical Journal . Australian researchers concluded that the “prognosis is moderately optimistic for patients with chronic low back pain.”154 This evidence is the first of its kind, a rarity in low back pain research, a field where almost everything has been studied to death — and it contradicts the common fear that low back pain that lasts longer than six to nine weeks will become a long-term chronic problem. “Many studies provide good evidence for the prognosis of acute low back pain,” the authors explain. “Relatively few provide good evidence for the prognosis of chronic low back pain.” Their research differs from past studies of chronic low back pain, which tended to focus on patients who already had a well-established track record of long-term problems: in other words, the people who had already drawn the short straw before they were selected for study, and are likely to carry right on feeling rotten. But what if you study fairly new cases of chronic low back pain? How many of them fade away, and how many of them really drag on? Isn’t that what any low back pain patient really wants to know during their first few months of suffering? So these researchers looked at patients who had not recovered from their new cases of chronic low back pain, and found that “more than one third” recovered within nine more months. That’s a pretty good number. So, what’s the Australian connection? Did the people who didn’t recover have anything in common? This study also looked at risk factors, and found some patterns. The patients whose pain just kept going were those who had worse pain, more disability, and more fear (“perceived risk of persistent pain”) — no surprise there. They were also the patients with a history of previous sick leave — not for back pain, but for other things, people who may be unwell. A little more surprising was that they had less education: better educated people recovered more. And my favourite correlation: the patients with persistent pain also tended to be non-Australian. That’s right: native Australians in Australia get less chronic back pain than non-Australians in Australia! Not sure what to do with that information — don’t move to Australia and get low back pain, I guess. Sound medical advice! Yes, of course, that still leaves two-thirds of patients who continue to suffer past the year-mark — and that’s an unfortunate number. However, this is chronic low back pain we’re talking about here! The surprising and promising thing is that so many patients — almost 40% — actually do get better by the one-year anniversary of their pain. These are people who didn’t get better in the first three months, and who would have been told by many doctors that they were officially “chronic” at that point. GO TO TOP • CONTENTS • NOTES

2.11

A trigger point checklist: does this sound like you? There are several classic characteristic signs and symptoms of back pain that is caused mainly by muscle, or back pain with another origin that has come to be dominated by trigger points over time. This section provides a quick checklist to give you a rough idea, plus a slow checklist with more detail. For most people, most of the time, confirming a trigger point diagnosis is simple enough. Check all that apply — if you have more than half of these, and no other apparent explanation for your pain, you probably have a trigger point or two. You have sore spots in muscles.

You have sore spots in muscles. Your pain usually occurs in specific areas of your body.

Your pain usually occurs in specific areas of your body. The problem feels more like muscles than joints.

The problem feels more like muscles than joints. The checkboxes are for your visual convenience only. There’s no form here to “submit.” Your pain is primarily dull, aching, and nagging.

Your pain is primarily dull, aching, and nagging. You feel a lot of stiffness as well as pain.

You feel a lot of stiffness as well as pain. Affected areas feel weak and heavy.

Affected areas feel weak and heavy. Stretching is appealing (but not very effective).

Stretching is appealing (but not very effective). Hot showers and baths are usually helpful.

Hot showers and baths are usually helpful. Anti-inflammatory medications don’t really work. And now for the slow checklist. This list is deliberately similar to the slow checklist for myofascial pain syndrome in the trigger points tutorial, but it is customized for back pain. Muscle pain in the back is a different critter than muscle pain in general — many distinctions are made throughout this section. You are bound to have some of these signs, regardless of the cause of your back pain. Roughly less than one third means that trigger points are probably not an important factor in your case. More than two thirds, and you can safely bet that trigger points are either the whole problem or a big part of it. Sensitive under pressure. By definition, trigger points are sensitive patches of soft tissue. If you have a trigger point problem in the back, then your back muscles will be more sensitive to pressure. That is, it will hurt to poke your low back and upper gluteal muscles, compared to muscles in problem-free areas of your body. (These are big muscles, so they may not be sensitive to light pressure — use a medium to firm pressure and check in several locations.)

Sensitive under pressure. By definition, trigger points are sensitive patches of soft tissue. If you have a trigger point problem in the back, then your back muscles will be more sensitive to pressure. That is, it will hurt to poke your low back and upper gluteal muscles, compared to muscles in problem-free areas of your body. (These are big muscles, so they may not be sensitive to light pressure — use a medium to firm pressure and check in several locations.) Feels like muscle! Pain is a difficult sensation to interpret, but trigger points do often feel like a muscle problem. Many small clues can contribute to this subjective impression: a sense of moderate depth (deeper than skin, shallower than bone), for instance, or sensitivity to flexing and stretching. Muscle pain might be much sharper than you expect, but usually it’s dull. If your pain is mostly aching, and nagging, with a strong “stiffness” component — and there are no obvious signs of other kinds of pain, like stabbing or burning or electrical sensations — then muscle may be the source of your troubles.

Feels like muscle! Pain is a difficult sensation to interpret, but trigger points do often feel like a muscle problem. Many small clues can contribute to this subjective impression: a sense of moderate depth (deeper than skin, shallower than bone), for instance, or sensitivity to flexing and stretching. Muscle pain might be much sharper than you expect, but usually it’s dull. If your pain is mostly aching, and nagging, with a strong “stiffness” component — and there are no obvious signs of other kinds of pain, like stabbing or burning or electrical sensations — then muscle may be the source of your troubles. No other obvious cause for pain! And by “obvious” I mostly mean “injury.” One of the simplest ways to diagnose trigger points is simply by elimination: if there is no obvious trauma, then trigger points are more likely. Only a significant and recent accident qualifies as a possible traumatic cause of your back pain: a high-velocity sports injury, falling off a ladder, or a muscle strain while lifting a sofa-bed. Backs are pretty tough — they cannot normally be damaged by subtleties like “twisting the wrong way” or “more golf than usual.”155 There are other reasons pain might persist after healing, but trigger points are a strong possibility.

No other obvious cause for pain! And by “obvious” I mostly mean “injury.” One of the simplest ways to diagnose trigger points is simply by elimination: if there is no obvious trauma, then trigger points are more likely. Only a significant and recent accident qualifies as a possible traumatic cause of your back pain: a high-velocity sports injury, falling off a ladder, or a muscle strain while lifting a sofa-bed. Backs are pretty tough — they cannot normally be damaged by subtleties like “twisting the wrong way” or “more golf than usual.”155 There are other reasons pain might persist after healing, but trigger points are a strong possibility. You have back trauma, but it’s old. Perhaps you really did injure your back … once upon a time. However, backs heal like any other part of your body. If your injury happened more than twelve weeks ago, you have probably more-or-less healed, and any continuing pain that you have is much more likely to be caused by trigger points. (There are other reasons pain might persist after healing, but trigger points are a strong possibility.) This is the “out the frying pan, into the fire” phenomenon, discussed in another section and in a separate article, Muscle Pain as an Injury Complication: The story of how I finally “miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had healed.

You have back trauma, but it’s old. Perhaps you really did injure your back … once upon a time. However, backs heal like any other part of your body. If your injury happened more than twelve weeks ago, you have probably more-or-less healed, and any continuing pain that you have is much more likely to be caused by trigger points. (There are other reasons pain might persist after healing, but trigger points are a strong possibility.) This is the “out the frying pan, into the fire” phenomenon, discussed in another section and in a separate article, Muscle Pain as an Injury Complication: The story of how I finally “miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had healed. You crave stretch. You crave it because trigger points make you feel stiff and stuck. (For contrast, it is not an appealing idea to stretch a damaged spine. The nervous system usually strongly warns you away from that.) When you stretch, it may feel difficult or even as though it amplifies the symptoms — like you are “pulling on the pain” — but it probably also feels somewhat relieving, offering a good pain, like scratching an itch. Similarly, muscle pain tends to make people generally squirmy: not only a craving for stretch, but for movement in general.

You crave stretch. You crave it because trigger points make you feel stiff and stuck. (For contrast, it is not an appealing idea to stretch a damaged spine. The nervous system usually strongly warns you away from that.) When you stretch, it may feel difficult or even as though it amplifies the symptoms — like you are “pulling on the pain” — but it probably also feels somewhat relieving, offering a good pain, like scratching an itch. Similarly, muscle pain tends to make people generally squirmy: not only a craving for stretch, but for movement in general. … but stretch usually fails. Although it seems like a good idea, stretching trigger points usually fails to actually do much good. It’s not a very good treatment. Sometimes it might provide more relief, but most MPS sufferers will be underwhelmed by the benefits of stretching. However, because it does tend to take the edge off, stretch remains appealing. Unfortunately, the muscles typically affected in the low back are biomechanically difficult to stretch,156 so it often feels futile, like trying to scratch an itch you can’t quite reach. Back fear can definitely be a factor here: stretch is also limited by the brain,157 so the anxious back pain patient may not crave stretch simply because of a freaked out nervous system.

Aching, not sharp. Your pain is primarily dull, aching, nagging pain, as opposed to sharp, stabbing, burning, aching. Although nearly any quality of pain is possible, and particularly flared up triggers can get more focal and intense and toothachy, most trigger point pain most of the time is a dull ache. There aren’t many other unclear causes of pain that ache. For instance, arthritis usually has an aching quality, but it’s obviously joint pain.

Aching, not sharp. Your pain is primarily dull, aching, nagging pain, as opposed to sharp, stabbing, burning, aching. Although nearly any quality of pain is possible, and particularly flared up triggers can get more focal and intense and toothachy, most trigger point pain most of the time is a dull ache. There aren’t many other unclear causes of pain that ache. For instance, arthritis usually has an aching quality, but it’s obviously joint pain. Similar pain in areas of the body. Trigger point pain is “patchy,” afflicting some predictable areas of the body, especially the meatier tissues of the trunk (neck, shoulders, upper back, low back, and hips). Other kinds of problems would cause different kinds of pain, or more widespread and uniform pain (like the diffuse all-over sensitivity of the flu, or muscle soreness after unfamiliar exertion, which always affects an entire muscle group uniformly). Trigger points usually afflict just one or two regions of the body at a time (but sometimes more, of course).

Similar pain in areas of the body. Trigger point pain is “patchy,” afflicting some predictable areas of the body, especially the meatier tissues of the trunk (neck, shoulders, upper back, low back, and hips). Other kinds of problems would cause different kinds of pain, or more widespread and uniform pain (like the diffuse all-over sensitivity of the flu, or muscle soreness after unfamiliar exertion, which always affects an entire muscle group uniformly). Trigger points usually afflict just one or two regions of the body at a time (but sometimes more, of course). Abnormal texture. You might be able to feel a lump in your muscle and a hard and ropy texture around it, but then again you might not. This is an unreliable way to diagnose trigger points, but it’s particularly tricky in the back, because there are many normal anatomical structures that feel like bumps and ropy structures, as well as common harmless abnormal structures, especially “back mice” (lipomas, more about them below). However, in some muscles in the area, bumps stand out nicely.158

Abnormal texture. You might be able to feel a lump in your muscle and a hard and ropy texture around it, but then again you might not. This is an unreliable way to diagnose trigger points, but it’s particularly tricky in the back, because there are many normal anatomical structures that feel like bumps and ropy str