Chapter 1
Deficiencies in Current Diagnostic Practices

Decrease in the use of mechanical based diagnostic skills due to an increased reliance on medical imaging. That static images obtained through MRI may not accurately reflect the presence of pain in individuals. Dynamic images, on the other hand, show more movement pathology that can directly relate to pain. That discogenic pain, for example, follows a natural history where the pain is associated with an unstable phase but eventually subsides as the disc becomes desiccated. The pain then shifts to arthritic facet joints. The process is further influenced by central sensitization and patient corrections. This may explain the lack of correlation between medical images and patient symptoms.

MRI impressions or diagnoses are often not linked to the actual cause of pain, leading to incorrect treatments such as surgery. That plain film radiographs may not accurately show actual damage, as they rely on bone displacement which may be masked by periosteum.

The value of images for surgeons is dependent on whether they align with the patient's clinical symptoms. Images only improve outcomes in patients with severe neurological deficits. A comprehensive assessment is more effective in determining the cause of pain than relying solely on images.

Studies on low back pain have found that psychosocial factors, such as job satisfaction, are more important than mechanical factors. However, these studies did not quantify the physical demands of the job, so they were unable to assess the relationship between loading and low back pain.

There are doubts about the connection between the physical demands of a task and musculoskeletal disorders. Instead, he argues that the psychosocial context of work is often associated with such disorders. Additionally, Dr. Hadler states that back pain can be disabling regardless of the weight being lifted, but rather depends on when and how it is lifted. Overall, he suggests that the relationship between work and musculoskeletal disorders is complex and not solely determined by physical factors.

Recent evidence suggests that psychological factors can affect patient behavior, but biomechanics also play a significant role in the development and prevention of low back disorders.

The relationship between pain and biomechanical factors in back pain varies over time. It is important to consider the natural history of back pain in order to fully understand the evidence and accurately assess the relationship between pain, biomechanics, and images. This relationship is complex and specific to each individual.

MRI diagnoses may not accurately determine the cause of pain, leading to incorrect treatments. The value of images for surgeons depends on whether they align with the patient's clinical symptoms. Psychological factors and biomechanics both play a role in the development of low back pain. The relationship between pain, biomechanics, and images is complex and specific to each individual. It is important to consider the natural history of back pain and perform provocative testing to accurately assess the cause of a patient's pain.
Are 85% of Back Troubles of Unknown Etiology?

The article discusses the misconception that most low back injuries have an unknown cause. While some argue that this is due to poor diagnosis or limited expertise, others believe that different medical professionals diagnose based on their specific treatment methods. For example, physical therapists diagnose based on manual therapy while surgeons diagnose based on potential surgical decisions. Some clinicians focus on identifying a specific tissue as the source of pain, while others argue that altered biomechanics can lead to pain in various tissues.

Clinicians use skilled mechanical loading of specific tissues to identify sources of pain or patterns that cause pain. Understanding spine biomechanics is crucial for effective functional diagnoses and developing less painful motion patterns. By reconstructing the instigating mechanical scenario, a general diagnosis can be achieved, allowing for removal or reduction of the cause. However, some patients continue to experience issues because they persist in engaging in the mechanical cause. Familiarity with spine mechanics can address this and reduce the number of undiagnosed back problems.

The practice of treating all patients with a specific diagnosis in the same way has not been successful. Different therapies may be needed depending on the individual patient. It is important to consider the diagnostic criteria before assigning a diagnosis and determining the appropriate treatment.

Tissue-based diagnosis limitations should not undermine the importance of determining the cause of back troubles. Identifying the specific motions, postures, and loads that cause or relieve pain can lead to a precise diagnosis and understanding of spine function.
Diagnosis by Hypothesis Testing

Geoff Maitland introduced the concept of using hypothesis testing to diagnose and treat back pain. This approach involves observing the patient's posture and movements, taking a history to identify potential causes of injury and triggers of pain, and performing tests to support or refute the hypothesis. The information gathered is used to create a plan for corrective and therapeutic exercises. The process also includes functional screens and tests to ensure a functional diagnosis and guide exercise choice and progression. This approach allows for the identification of the specific tissues, motions, postures, and loads that are causing pain, and enables the creation of customized prevention and rehabilitation plans.
Are Most Chronic Back Complaints Rooted in Psychological Factors?

The significance of psychology in chronic back problems is often exaggerated and some doctors blame the patient's mental health instead of addressing mechanical causes. These doctors may dismiss mechanical causes or assume they have been addressed, leading them to label the pain as psychological or blame the patient's noncompliance with therapy.

The author works at a university clinic and sees patients who have been referred by physicians. These patients are either elite performers or have chronic back problems that have not been resolved by other treatments.
Does Pain Cause Activity Intolerance?

The article discusses the evidence that mechanical tissue overload can cause damage, but the relationship between damage and pain, as well as chronic pain and work intolerance, is difficult to confirm. While there are limited studies that have demonstrated the stimulation of tissues leading to clinical pain patterns, larger studies have not been conducted due to ethical concerns. However, there have been some studies that have shown a link between mechanical stimulation and pain, such as injecting hypertonic saline into spine tissues and experiencing pain. Other studies have also shown the connection between loading, damage, and resulting pain in individuals with osteoporotic vertebral compression fractures caused by a preexisting degenerated disc.

The evidence shows that vertebral disc end-plate fractures are common and caused by mechanical overload. Necropsy specimens also show these fractures in cases of whiplash. Discograms confirmed end-plate fractures and showed that discs with these fractures were more likely to produce severe or concordant pain compared to discs without fractures. This supports the idea that loading causes damage and damage causes pain.

The author suggests that some clinicians dismiss the physical approaches to treating chronic pain in the back. However, the author argues that this dismissal is a disservice to the patient, as athletes in sports medicine often require long-term therapy and can even be forced to retire from their careers due to back injuries. The author emphasizes that chronic pain is not solely a psychosocial concern and physical approaches should not be disregarded.
Inadequacies in Current Care and Prevention

Research shows that many adults with chronic lower back pain rely on narcotics and advanced imaging rather than engaging in formal spine rehabilitation.

The relationship between low back tissue loading and injury risk appears to follow a U-shaped function, meaning that both too much and too little loading can increase the risk of injury. It is important to find the optimal level of activity and loading to strengthen and toughen the back tissues without causing weakening or excessive strain. In order to reduce back pain, it is necessary to match the appropriate activity and its level to find the optimal point on the U-shaped relationship.

The relationship between the intensity and duration of loading and the need for rest periods is complex and subjective. Some studies suggest that certain types of loading do not lead to pain, injury, or disability, while others suggest they do, depending on the measurement of exposure and the optimal level for tissue health. It is also unclear whether there is a clinical difference between tissue irritation and tissue damage. In experiments on human and animal tissues, it has been found that there is a maximum load that can be tolerated before biomechanical changes, pain, and structural failure occur. However, in real life, individuals can experience significant pain at loading levels well below this tolerance due to repeated and prolonged loading. There is evidence to suggest that certain conditions, such as spinal stenosis, may develop over time due to subfailure activity.
Ill-Advised Rehabilitation Recommendations

The failure to accurately present research findings on low back treatment has led to oversimplifications and inadequate treatment practices. Some common recommendations for back health are discussed.

Studies have shown that muscle strength in the back does not predict who will experience back troubles. However, muscular endurance has been shown to be protective. Despite this, many therapeutic programs still focus on strength and neglect endurance. This may be influenced by the athletic world's emphasis on performance enhancement and the use of bodybuilding approaches in rehabilitation. Optimal exercise therapy should prioritize improved health rather than performance enhancement.

The belief that bending the knees during sit-ups is beneficial may be based on clinical wisdom rather than scientific evidence. A study conducted in 1997 found that there is little difference between different knee positions during sit-ups. However, traditional sit-ups can put excessive stress on the lower spine and increase the risk of injury.

The statement that performing sit-ups will increase back health is not entirely true. There is only mild literature support for the belief that fit individuals have less back trouble. Many studies that have examined the role of increased fitness in back health have actually included exercises, such as sit-ups, that can cause back troubles in many people. Sit-ups can cause damage to the back due to lumbar compression and excessive disc annulus stresses. This suggests that the way fitness is increased is critical in determining its impact on back health.

The most common advice to avoid back injury when lifting is to bend the knees instead of the back. However, there is no consensus on whether stooping or squatting is better when lifting, as it depends on various factors such as load dimensions and lifter characteristics.

Discusses the common belief that tight hamstrings and unequal leg length can lead to back troubles. However, it presents evidence that contradicts this belief. Studies have shown that there is little support for the idea that tight hamstrings or unequal leg length cause back pain. Some studies even suggest that reduced hip flexion may not be associated with back pain, but asymmetry between sides may be.

Additionally, leg length inequality only seems to have a link with back pain in extreme cases. The passage suggests that caution should be taken when assessing patients and attributing symptoms, and that further testing should be done to determine the true causes of back troubles.

Discusses the misconception that training single muscles is the most effective way to enhance spine stability. It explains that all muscles can be important for stability, but their importance varies depending on the activity and task. A single approach to rehabilitation will not work for all cases and that different factors need to be considered, such as mobility and joint stability.
Can Back Rehabilitation Be Completed in 6 to 12 Weeks?

Some argue that damaged tissues should heal within 6 to 12 weeks and that long-term work intolerance is mainly due to psychosocial issues. However, this viewpoint overlooks the complexities of spine pathomechanics and the fact that not all patients recover so quickly. Animal studies, particularly on rodent muscle, formed the basis for the belief that tissues heal within this timeframe. However, human patients do not always experience such rapid healing, as evidenced by follow-up studies on certain conditions like whiplash. A systematic review also challenges the notion that most first-time back pain episodes resolve within 6 weeks, as 65% of individuals still reported back pain after 1 year.

Discusses how evidence shows that both mechanical and neurological changes can persist for years after an injury. This includes the loss of motor control, muscle atrophy, and other disorders. This suggests that the changes following an injury are not just a result of healing from visible damage.

  • Specific tissues such as ligaments, for example, have been shown to take years to recover from relatively minor insult.
  • The intervertebral motion units are a complex mechanism that involves various parts that interact with each other. If one part is damaged, it can affect the biomechanics and loading on another part. This can lead to a cascade of biomechanical changes, joint instability, and secondary arthritis over time.
  • Found that vertebral osteophytes are closely linked to end-plate irregularities and disc bulging. These osteophytes are believed to be a result of disc and end-plate trauma, but it takes a long time for them to develop.

Suggest that back troubles are not mechanically based if they linger longer than a few months only demonstrates limited expertise.

Elderly people complain less about back troubles compared to younger people. Research suggests that back troubles are more common in younger years and can last for up to 10 years. Patients with disc herniations who engaged in strenuous activity were still receiving disability benefits after 10 years. However, over time, the pain eventually goes away as the affected joints stiffen.

The belief that damaged low back tissues will heal quickly is not supported by evidence. Long-term problems with the back have a significant biomechanical or pathoanatomical basis. However, having a troublesome back does not mean it will be a lifelong issue.
Should the Primary Goal of Rehabilitation Be Restoring Range of Motion?

The research shows that increasing the range of motion (ROM) in the spine can actually increase the risk of back problems. However, there are still reasons why increasing ROM is a rehabilitation objective. One reason is the need to measure and reduce disability according to the American Medical Association's definition. Another reason is a belief from the athletic world that increasing ROM can improve performance. While this may be true for other joints, it generally does not work for the back. In fact, following athletic principles can hinder successful rehabilitation for back problems.

When Is Surgery Justifiable?

The author is observing that they only see patients who have had unsuccessful back surgeries, and believes that many of them had the surgery too soon. Reviewing their medical records, the author discovered that these patients had received inappropriate treatment and were not given exercises that matched their specific pain causes. As a result, they experienced more pain and were unable to prevent it. Some surgeons may consider patients to have "failed conservative care" simply because a certain amount of time has passed.

Surgery approaches have their own advantages and disadvantages. Fusion surgery has been found to increase arthritis in adjacent segments, while disc replacement surgery has been found to spare them. However, disc replacement surgery can lead to increased degeneration at the level of the replacement due to stress concentrations on the facet. Fusion aims to stop motion and pain, while replacement aims to restore motion and stop pain. There is no clear guidance on selecting the appropriate approach for patients. It is important to note that both approaches can still result in failures.

  • Vertebroplasty is a procedure where cement is injected into a fractured vertebra to relieve pain and restore load-bearing ability
  • Questioned the effectiveness of vertebroplasty in a study on over 70 patients
  • Microdiscectomy techniques aim to reduce tissue disruption for disc herniation and nerve root decompression
  • A trial comparing tubular discectomy with conventional discectomy and found small changes favoring conventional techniques for pain reduction
  • The choice between the two techniques would depend on surgeon familiarity, skill, and patient selection
  • Study pain from spondylolisthesis using three different hardware-based fusion methods and found no difference in outcomes among the approaches

A study followed up with back-injured workers who had surgery compared to those who did not have surgery. After 2 years, more nonsurgical people had returned to work compared to those who had surgery. Reoperations were conducted on a significant number of surgical cases and complications and long-term opioid use were reported. Permanent disability occurred in a higher percentage of postsurgical patients compared to nonsurgical patients. The study suggests that surgery does not guarantee the elimination of back pain and both surgical and nonsurgical patients need to manage their backs.

The effectiveness of surgical techniques can vary greatly from patient to patient. It is important to consider individual responses and not just the average results when interpreting studies. Patient selection is crucial and understanding the factors that contribute to different outcomes will lead to improved results in the future.

Following is a set of rules that I compiled that I give to patients considering surgery:
  • The recommendation is to try a virtual surgery game before considering actual surgery for back pain. Many patients mistakenly believe that daily workouts will help their pain, but in reality, it is the exercises that are aggravating their condition. Instead, patients should focus on resting and avoiding activities that irritate their pain. The virtual surgery game simulates the recovery process after surgery, starting with gentle movements and gradually increasing activity levels. This approach has shown positive results in relieving symptoms.
  • Surgery is recommended for neurological issues that significantly affect bodily functions like bowel and bladder control, but not for radiating symptoms such as sciatica. Radiating pain, numbness, and muscle atrophy are signs of nerve root compression. Nerve mobilization techniques have been successful in treating these conditions and should be tried first, but they require expertise and must be performed correctly to avoid worsening symptoms. In stubborn cases, approaches to reduce nerve compression or irritation may also be necessary.
  • Consider surgery in cases of trauma. In such cases, the structure is unstable and needs stabilizing.
  • Advice is to only consider surgery for severe and persistent pain. Patients who have surgery after only three weeks of severe pain tend to have worse post-surgical outcomes.
  • Advice is against blindly accepting a surgeon's claim of being the best. The author has personally witnessed poor work from surgeons who continue to practice. Instead, asking nurses and physical therapists at the hospital for their opinion on which surgeon produces the best results. The head of a department or a speaker at a medical conference is necessarily skilled.
  • Discuss the pain with a surgeon to determine the source of the pain. If multiple tissues are affected or if there is damage at multiple spine levels, the success rate of surgery decreases.
  • Suggests that the term "success" can have different interpretations in medical reports. It could either mean the absence of patient death or a short-term positive outcome after a procedure. However, the focus should be on the long-term success rate in comparison to other options, along with weighing the associated risks and benefits.
  • Warns against new treatments for medical conditions, specifically focusing on various methods used for stiffening discs in the spine. Claims that these treatments have not produced the promised long-term results.
  • Is skeptical of disc replacement as a treatment for spine joint pain. They argue that artificial discs do not mimic the natural movement of the spine, leading to stress on other joints and potentially causing arthritic changes over time.
  • The passage is that before considering surgery as the only option, one should make sure to try all conservative options first. Just because one approach like physical therapy may not have worked, it doesn't mean that it was the best option or that there aren't other conservative options to explore.
  • There is a warning about institutes that claim to provide advice on surgery based solely on viewing medical images. The article emphasizes that pictures alone cannot determine the existence or severity of pain and that a comprehensive clinical assessment is crucial for accurate diagnosis and treatment.

Patient must participate in a preoperative program, if surgery takes place, the patients must engage in a postsurgical rehabilitation program to improve spine-sparing biomechanics and pain-free function.

The author against the notion that back pain is solely a social problem and instead believes that the problem lies within the healthcare system and practitioners. They believe that medical practitioners lack motivation to understand the mechanical causes, appropriate diagnoses, and treatments for back pain due to the financial incentives associated with surgery. The author also criticizes the limited time patients are given for consultations and the reliance on medical images rather than thorough examinations. They assert that a comprehensive understanding of biomechanical function and patient presentation is necessary for effective treatment.
Mechanical Loading and the Process of Injury: A Low Back Tissue Injury Primer

Most back injuries are the result of a series of cumulative trauma, rather than a single event. This misdirection leads to prevention efforts focusing on the wrong event, instead of addressing the true cause of the cumulative trauma.

The purpose of this section is to encourage the consideration of various factors that affect the risk of tissue failure and to encourage the generation of hypotheses about the causes of injury.

Injury occurs when the applied load on a tissue is too much for it to handle. This can range from minor irritation to major tissue failure, causing pain.

A load that exceeds the failure tolerance of the tissue can cause injury. It also mentions that while this is a common description of low back injuries, the author's experience suggests that relatively few low back injuries actually occur in this way.

Injuries during work and sports activities often occur due to repetitive strain on the body from continuous but not overly intense loads. This can result from repeatedly applying low loads or maintaining a sustained load for a long time.

Sustaining stresses over a period of time can result in injury even with a subfailure load. This can happen when the body is in a certain posture for a prolonged period of time, causing the tissues to slowly deform and creep. As the load is sustained, the tissue strength decreases until it reaches a breaking point and injury occurs. This can involve a single tissue or multiple tissues, such as ligaments and intervertebral discs. The resulting microfailure can lead to increased joint laxity and further injury, such as hyperflexion injury.

1. Local instability
2. Injury of unisegmental structures
3. Ever-increasing shearing and bending loads on the neural arch
This laxity remains for a substantial period after the prolonged stoop.

In order to effectively prevent and intervene in tissue damage, one must understand the complexities of tissue overload, as simple injury prevention approaches often fail.

The goal of injury prevention strategies is to ensure that the body's tissues can adapt to and recover from exposure to load. While exposure to load is necessary for tissue adaptation, it is also important to remove the applied loads to allow for healing and the gradual increase of failure tolerance. Finding the optimal amount of load for maintaining tissue health requires a combination of medical knowledge and understanding of tissue biomechanics. The relationship between tissue loading and injury risk follows a U-shaped curve, where both too much and too little load can increase the risk of injury.

The injury process can be caused by either very high loads or repeated low loads. Therefore, it is important to thoroughly examine the injury and tissue loading history over a long period of time before the injury occurs. Focusing on just one variable, such as the magnitude of a single load, may not accurately predict the risk of injury, especially in different activities.
Excellent Clinicians and Excellent Practice

The author argues that clinicians who dismiss the need for investigating the source of a patient's pain are uninformed and lacking in skills. Understanding the pathways of injury is essential in providing effective medical care. Despite the complexity of finding the exact cause of certain conditions, it is important for clinicians to gather enough evidence through follow-up tests to make accurate diagnoses. The best clinicians operate within an acceptable level of uncertainty and do not believe in nonspecific pain.

Assessment in healthcare requires a combination of art and science, as various variables need to be considered. Clinicians must interpret signs displayed by patients, some of which may be false and require further evaluation. A successful clinician possesses diverse training and tools to determine whether specific exercises or manual tissue work is necessary, or both. They also consider whether pain and symptoms are originating from one source or multiple sources, and whether radiating symptoms are due to nerve tension, compression, or ischemia. It is important for clinicians to differentiate between pain originating from organic tissue and pain that is a neural representation, similar to phantom limb pain. The worst situation is when clinicians fail to address the cause of pain and instead blame the patient for having a psychosocial disorder.
Chapter 1
Epidemiological Studies and What They Really Mean

Definitive experiments are rare in science and medicine, so conclusions are often drawn by integrating evidence from multiple sources. Similarly, lawyers argue cases using circumstantial evidence, hoping that it becomes overwhelming. Researchers adopt a similar approach, gathering and analyzing circumstantial evidence from different perspectives to understand cause and effect. They study variable relationships and mechanisms to form robust and plausible perspectives. This research, along with longitudinal studies, tests causative factors identified in mechanistic studies.

This chapter focuses on the study of associations between variables through different epidemiological approaches. The author acknowledges that some readers may find this chapter boring and suggests skipping it, but also emphasizes that many of these studies have been misunderstood or misrepresented to serve a specific agenda. The author encourages readers to continue reading in order to gain a better understanding of the challenges in building effective injury prevention and rehabilitation programs, appreciate the epidemiological perspective, and understand subsequent approaches for preventing and rehabilitating low back disorders.

This chapter discusses the risk factors for low back trouble, including personal factors and whether they cause or are a result of back troubles. The term personal factors includes things like body measurements, fitness level, motor control ability, and injury history. Low back disorders and work intolerance related to them are referred to as LBDs in this review.

Does Absence of Diagnosis Imply Psychological Cause?

Waddell and colleagues wrote many manuscripts and guidelines on nonorganic signs in patients to support the notion of psychological disturbance overriding any pathoanatomical tissue damage (because none was diagnosed). Yet many of these so-called nonorganic signs are precisely what we will use clinically to detect hypersensitivity to loads that cause pain. For example, a compressive injury often creates pain under very mild compression when the person is in a flexed or slouched posture. Light touch and reported pain in a painful region may indicate a highly centrally sensitized patient. Although the nonorganic signs may be very helpful in defining risk for surgical candidates, we take the position that they do not indicate psychological overlay—in fact, the behavior may be physiologically based. Only a rigorous and complete exam that includes provocative testing could provide evidence to support the diagnostic hypothesis.

Teasell and Shapiro (1998) wrote a nice summary of an extensive experimental literature suggesting that these pain symptoms may indeed have a physiological basis. They reviewed the recent science on the spread of neuron excitability and sensitization of adjacent neurons to explain the sensation of radiating pain in chronic conditions. Changes in neuroanatomy are coupled with biochemical changes with chronic pain. For example, in fibromyalgia patients, numerous studies have shown levels of substance P in the cerebrospinal fluid elevated two to three times over that in controls. Although the nonorganic signs described in Waddell’s papers are important considerations in many cases and are a contribution to clinical practice, strong evidence suggests that many nonorganic signs may not be exclusive of a pathoanatomical mechanism that has eluded diagnosis.