As a well-read physiotherapist with 15 years experience, I know most back pain is nothing serious (ref). I know that the severity and intensity of back pain is poorly correlated with structural damage and pathology (ref). I know that most back pain resolves spontaneously regardless of the treatments and interventions used (ref). I know that imaging for back pain is not necessary for the vast majority and may even be harmful for some (ref).
Yet despite knowing all of this I want to share with you an example of how difficult it is to explain and convince those with back pain of these things, and how bloody scary and frightening an episode of back pain can be. I want to show you how back pain can screw with your mind and convince you that there is something really, really wrong even when you should know better.
This is my own personal story of an episode of severe back pain I had a few years ago and the issues it created. I was reminded of this recently after I was discussing on one of my courses the difficulty and challenges we have as physios in trying to explain pain and reassure patients there is nothing seriously wrong when they are in pain and distress.
So a few years ago I was training in the gym as usual and had just finished my usual weekly deadlift and squat session. All was going well and I thought I would finish off the session with a few sets of kettlebell swings. During my third set of these, I was suddenly and violently struck, hammered, knocked down with a severe, searing, stabbing pain in the left-hand side of my lower back with a sickly white-hot bolt of shooting pain flying down the back of my left leg.
I screamed like a second-rate actress in a budget horror movie, and collapsed to the floor like a felled tree and lay there crumpled on the ground like a cheap discarded suit in an ugly sweaty mess dazed and confused and wondering what the hell just happened. Had I been stealthy attacked by a ninja, or perhaps I’d been a target of a rogue sniper attack? But there was no wounds, no blood, no ninjas standing over me, so what the hell had just happened?
Clearing snipers and ninjas as a reason for my sudden disability I attempted to stand up, but WHAM, FUCK ME… I was struck by another bolt of hot, lancing, searing pain in my back and down my left leg, I let out another squeal like a squashed mouse and down I went again.
This happened about four or five more times before I finally managed to get to my feet, and hobbled out of the gym bent over like the hunch back of Notre Dame, whimpering and wincing with every painful step, trying as best as I could to put on a brave face in front of the other gym users now looking on in a mixture of confusion and amusement.
I attempted to get into my car to drive home but as much as I tried I just could not sit in the seat and drive, so eventually, I had to call my wife to come and pick me up, much to her annoyance. Once home still doubled over, and now cursing and swearing like a drunken sailor, I spent the next few hours trying to get myself straight. But no matter how much I tried to do this, lying on my back, front, side, getting my wife to push and pull me in all directions I just could not, the pain was all consuming.
Eventually I calmed myself down and put my physio head back on and did a self evaluation. 1) Lumbar movement grossly restricted and painful into extension, lateral flexion, and rotation bilaterally, flexion eased symptoms. 2) Dermatomes; no loss of sensation in the lower leg. 3) Myotomes; no gross loss of power in the leg or foot. 4) Bladder and bowel; no issues. 5) Slump test, very +ve for pain the left leg, -ve on the right.
With self-check complete what I should have concluded was that I had an acute episode of mechanical low back pain with no sinister signs that would most likely resolve in around six to eight weeks, and to try and keep myself moving as best I could.
However, what my confused and anxious mind actually concluded was “fuck that Meakins” with this amount of pain and level of disability it clearly means you have suffered a massive lumbar disc herniation, in fact I bet you have probabaly suffered a disc explosion and have nucleus pulpous splattered all over your nerve roots like shrapnel from a bomb blast.
Now I am exaggerating a little here for comic effect, but on reflection my thoughts were not too far from this. I thought I simply must have suffered a serious structural lumbar pathology and my guess was a large disc herniation or sequestration. So long painful story short, my back pain did ease a bit, but after four weeks of debilitating, annoying and worrying pain, and still unable to sit or stand up straight for any length of time, I rather embarrassingly talked myself into getting an MRI for which I paid for privately and have shown below.
Now, as you probably guessed and as you can see there is absolutely NOTHING wrong with my lumbar spine, maybe a slight L5/S1 annular tear/defect, but certainly no herniation! In fact its in remarkably good shape for a man my age with my level of previous of activity and life style. But I still had severe pain, and still was unable to walk far or sit for more than 10 minutes, and I still had leg and buttock pain. Where was this coming from, what was the reason? I don’t know, I still don’t know. All I do know is pain is a confusing complex and worrying condition and poorly associated with structure.
Looking back on this episode I can see that even despite knowing that pain and pathology are poorly correlated, and even though I had no signs of anything sinister, my thinking was so focused on the certainty of some structural damage as a cause for my pain, I couldn’t think or consider anything else, and that’s despite knowing what I know. As predicted however after my scan, in around 6-8 weeks after its onset my pain reduced, my activity returned and I have had no further issues since… However, I’m still not that keen on kettle bell swings anymore!
When I reflect on how I was thinking and feeling during this time it does make me wonder if I could have been convinced by anybody that I didn’t need a scan, and that everything would be ok in a few weeks. Would I have accepted another healthcare professional telling me its ok and to just to keep moving, and give it time?
I doubt it!
This experience highlights to me how scary pain can be, even with a good understanding of it and it’s complexities. This experience also makes me realise the incredibly difficult job we have in trying to explain and reassure people in pain that all is ok when they are scared, confused, disabled, and thinking the worst. If I was unable to convince myself when in pain, I wonder if I am any better in convincing others?
As always thanks for reading