Common Misunderstandings and Misconceptions Regarding Lower Back Pain and Sciatica
“My spine was out of place and was put back in by the Physio/Chiro.”
Comments such as this are common from those who have received treatment by health professionals and they do nothing but increase fear, anxiety and hypervigilance. This belief that the patient has something structurally wrong with their spine, over which they have no control, often results in dependance on passive therapies. The spine itself is an inherently strong and stable structure and the belief that spinal bones or the sacrum is out of place and in need of manipulation for realignment is inaccurate. There is strong evidence that movements of the sacroiliac joints (commonly manipulated and “re-adjusted” by Chiropractors) is associated with minute movements which are barely measurable with the best imaging techniques available, never mind therapist palpation (Kibsgard, Roise et al 2014).
The lumbar facet joints themselves can also be manipulated and there is radiographic evidence showing increased gapping of the facet joints post manipulations which is associated with the tension release sensation described post treatment. In this case if there are no contraindications to lumbar manipulations an “adjustment” of the lower back can prove beneficial.
It is important to remember that there are conditions whereby the structural integrity of the spine is compromised, however, they are uncommon and include various forms of traumatic spinal bony fractures, spondylolysis and spondylolisthesis. These conditions are obviously contraindicated for manipulations and require various forms of conservative or surgical intervention.
“My friend has had the same pain down the back of his/her legs and says I have sciatica.”
Sciatica is a very general term used to describe referral pain stemming from the lower back region and is felt in the buttock, hamstring and calf region. True sciatica involves compromise of the sciatic nerve which can be due to a disc bulge in the lumbar spine or compression of the sciatic nerve by the piriformis muscle as it passes through the buttock region. Additionally, myofascial referred pain from trigger points within tight muscles can mimic sciatica and give sciatic like symptoms. These muscles can include the quadratus lumborum, gluteus minimus and piriformis.
“I have an acute onset of lower back pain due to a disc bulge and will have back problems for life now.”
There is no denying that the sudden onset of lower back pain due to a disc bulge is both painful and frightening. Not only can there be significant local lumbar pain along with referral pain into one or both legs, there is also the fear that your spine is “wrecked” long-term. Fortunately the recovery rates for acute lower back pain are in your favour with 95% of episodes resolving within 6 weeks of onset. The body is amazing in its ability to heal and in many cases disc bulges do retract to some degree.
“My imaging (MRI or CT) report says I have a minor disc bulge so thats what must be causing my lower back pain.”
There is no doubt that MRI and CT imaging plays an important role in assisting the diagnoses of some lower back pain conditions. However the incidental findings of extensive normal age related degenerative changes are common and unfortunately put the spotlight on many findings that are not related to actual causes of low back pain (O’Sullivan and Lin 2014). Recent research using MRI imaging has shown that in 40 year olds, on average, 68% will present with disc degeneration, 50% with disc bulge/s, 45% with disc height loss, 33% with disc protrusion and 18% with facet joint degeneration (Brinjikji et al 2015). And that is all within the lower backs of individuals who DO NOT experience low back pain. Thats correct! All these findings are present in normal spines who are going through normal age related degenerative changes and who are not experiencing any pain, at the age of 40.
Approximately 1-2% of individuals who experience low back pain actually need MRI for diagnostic purposes and that is those who have fractures, cancers / space occupying lesions or nerve root compressions (O’Sullivan and Lin 2014). It is therefore very important that conclusions of lower back pain are not based purely on imaging results but on relevant bio-psycho-social contributions, comprehensive examinations, accurate clinical reasoning and appropriate management processes.
Brinjikji, W., Luetmer, P.H. Comstock, B., Bresnahan, B.W., Chen, L.E., Deyo, R. A., et al. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.
Kibsgard, T., O. Roise, B. Sturesson, S. Rohrl and B. Stuge (2014). “Radiosteriometric analysis of movement in the sacroiliac joint during a single-leg stance in patients with long-lasting pelvic girdle pain.” Clint Biotech Apr: 29(4): 406-411.
O’Sullivan, P. and I. Lin (2014). “Acute low back pain: beyond drug therapy.” Pain Management Today 1(1): 1-13.