Specific Causes of Back pain

Specific causes of back pain: some ideas from European Guidelines for the management of Chronic non specific back pain (2004)

There is  little relationship  between  low back pain symptoms, pathology  and radiological findings.

In 85% of people (Deyo 1988), pain has no relationship  to any time of physical abnormality.

*4% of people seen with low back pain in primary care have compression fractures

*1% have a neoplasm (Deyo et al 1992).

*5% develop at least one vertebral fracture in 4 years (Kado et al 2003).

Spondylarthropathies have been reported to occur at a rate of 0.8 to 1.9% of the general population (Saraux et al 1999).

Spinal infections are rare, and chronic spinal infections are particularly rare. Infectious diseases of the spine should be considered if the patient has fever, has had previous surgery, has a compromised immune system, or is a drug addict.

Spondylolysis and spondylolisthesis are often classified as non-specific low back pain because a considerable proportion of patients with such anatomic abnormalities are asymptomatic (Soler and Calderon 2000)

Back and leg pain after surgery represent a major problem addressed at specific conferences for failed back surgery.

Failure rates range from 5-50%. Based on a failure rate of 15%, it was estimated that 37500 new patients with failed back surgery syndrome would be generated annually in the US (Follet and Dirks 1993).

One of the causes that is consistently reported in the literature includes poor patient selection (Goupille 1996, Van Goethem et al 1997).

“This means that patients with non-specific back pain are operated on for radiologically diagnosed disc bulging, herniation or degeneration, which turn out not to be responsible for their pain.”

  • References
    1. Andersson HI, Ejlertsson G, Leden I, Rosenberg C (1993) Chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization. Clin J Pain, 9(3): 174-82.
    2. Balague F, Troussier B, Salminen JJ (1999) Non-specific low back pain in children and adolescents: risk factors. Eur Spine J, 8(6): 429-38.
    3. Barash HL, Galante JO, Lambert CN, Ray RD (1970) Spondylolisthesis and tight hamstrings. J Bone Joint Surg Am, 52(7): 1319-28.
    4. Bressler HB, Keyes WJ, Rochon PA, Badley E (1999) The prevalence of low back pain in the elderly. A systematic review of the literature. Spine, 24(17): 1813-9.
    5. Cassidy JD, Carroll LJ, Cote P (1998) The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine, 23(17): 1860-6; discussion 7.
    6. Deyo RA (1988) Measuring the functional status of patients with low back pain. Arch Phys Med Rehabil, 69(12): 1044-53.
    7. Deyo RA, Rainville J, Kent DL (1992) What can the history and physical examination tell us about low back pain? Jama, 268(6): 760-5.
    8. Dickson RA, Stamper P, Sharp AM, Harker P (1980) School screening for scoliosis: cohort study of clinical course. Br Med J, 281(6235): 265-7.
    9. Ebbehoj NE, Hansen FR, Harreby MS, Lassen CF (2002) [Low back pain in children and adolescents. Prevalence, risk factors and prevention]. Ugeskr Laeger, 164(6): 755-8.
    10. Follet KA, Dirks BA (1993) Etiology and evaluation of the failed back surgery syndrome. Neurosurgery Quarterly, 3: 40-59.
    11. Goupille P (1996) Causes of failed back surgery syndrome. Rev Rhum Engl Ed, 63(4): 235-9.
    12. Hestbaek L, Leboeuf-Yde C, Manniche C (2003) Low back pain: what is the long- term course? A review of studies of general patient populations. Eur Spine J, 12(2): 149-65.

Is an MRI for you

Clients with bad backs clutch onto their MRI scans . Often they are of no value. There is little correlation with  disc degeneration and pain. Most people have  a bit of disc degeneration.

MRI’s are often ordered by doctors for patients as placebo’s

But for those who  want a bit more insight into  MRI magic, here is the best lay persons description I can find. Focus on slides  61-63.

As this slide show says, “ask specific questions”

Experiment with Bracing?

One of the biggest confusions in “back pain” is the role of  abdominal muscles.

For years hard working doctors and researchers have attempted to assess the role and value and ideal type of abdominal engagement and training methodology. At the same time fraudsters and  charlatans have always sought to promote  and mystify the actions of an obscure muscle

There are 3 things you can do with your abs if you are standing up in a neutral position ( we need to talk about this concept too!)

1) You  can suck them in
2) You can “tighten” them where they are
3) You can “bear out”

Ill discuss these ideas in painful depth else where.

and now the research begins

Im actually very good at fixing backs. I look at them as a back pain sufferer, a fitness instructor, a massage therapist, a sports person , a hypnotist and an avid student of the many techniques and idea  published  both  in hard copies and on the internet.

However, when ever I fall in love with a theorist, like other practitioners, I go wrong. Of course all practitioners will claim that they assess what they see. I doubt this. We tend to view the world through lenses, and sometimes assume that identifying a problem, precludes the existence of other problems.Otherwise what the point of having a belief. Which Fan of Stuart McGill doesn’t go looking for a flexion based problem?

So, anyway, I was working with a client,and we began the process of fixing by looking at his life style , what he was doing, etc, and basically concluded that his issue was a flexion issue: certainly be benefitted from evaluating his squat form,  developing his hip and shoulder flexibility , grinding out some scare tissue , and building up his core strength and endurance, and realising how much he used his back.

Nevertheless as we came to the 3rd session we realised there was another factor at play. Strangely, like me,  he accepted that he stooped, but we traced his actual injury down to an over extension fault in the squat: he had attempted a squat with his torso bolt up right,  and obtained the extra flexibility the position demanded by over extending, and collapsing at his lumbar curve at the bottom:

so a couple of extra observation, based on his feed back and mine.

1) if you have back issues, the chances are that your perception of your back position if wrong: you simply dont know what the feedback means

2) Is it  possible to tweak your back by over extending and  flexing at the bottom. Yep, you can have both.

So, I started photographing lumbar curves in a toes touching position and noted that quite a lot of people have immobile lumbar areas in flexion: they  flatten, they don”t collapse ( see the montage).  is there a relation hip between the depth and quality of an overhead squat and the position of the lumbar curve in the toe touching position? If you don’t flex your lumbar spin, isn’t coaching you to make a big chest running the risk of an over extension injury. Do we now have a potential easy to do screen.

Im off to photograph lots of overhead squats and toe touches to see if there is some sort of correlation

Bracing sequence: Kelly Starretts sequence

Kelly Starrett suggests an interesting bracing sequence for core stability in his book “Becoming a Supple Leopard”.

1) stand up straight and squeeze your glutes together: leave your pelvis neutral:
2) pull your ribcage down ( a bit). “balance your ribcage over your pelvis”
3) Tight belly ( I think he tries to please the old Suck your tummy brigade here) I say, brace your abs “A la” Stuart McGill. “Push Out”.(I’ll do a specific blog post on this) I think Kelly also mentions Intra abdominal pressure. This I think is an old fashioned blind alley idea : However his core ( excuse the pun) idea is correct: “tighten up your tummy”. He also, correctly talks about being able to breath with a tightened core.
4) set your head in neutral, shoulders down, I’d add the McGill “anti shrug” here to engage the lats. Long arms. Thumbs forward.


if you have back pain you need to learn how to stabilise your spine . One of the hall marks of good stabilisation is the ability to both contract the abdominal wall and breath at the same time. Poor spine stabilisers, in effect, switch between bracing their spines or breathing. In short can you brace your abs ( not suck in!!) and continue to breath?

If not,  train yourself to breath freely while maintaining an isometric  contraction in the abdominal wall.

RED FLAG: Is your back pain “serious”

In many cases, careful management deals with back pain. There is however a species of back pain that  I’ll flag up to you now. The items listed below are “RED FLAG” symptoms which means see your doctor or A & E NOW;  go in and say , “I have back pain symptoms that I think are Red Flag symptoms”

  • fever of 38ºC (100.4ºF) or above
  • unexplained weight loss
  • swelling in the back
  • constant back pain from which there is no position of  ease
  • Chest pain
  • leg pain
  •  a change in toilet patterns
  • numbness or tingling  around your bottom and privates.
  • pain that is worse at night

These are known as ‘red flag symptoms’ and could be a sign of something more serious.

That said, I was checking the NHS  website today (23/7/2020) and it made this  distinction


  • your painkillers are not helping
  • the pain is no better after a month
  • a very high temperature or you feel hot and shivery
  • unexplained weight loss
  • a swelling in your back
  • the pain is worse at night

Go to  A & E or call 999

  • numbness around your bottom or genitals
  • cannot pee
  • lose feeling in 1 or both legs
  • cannot control when you pee or poo
  • got it after a serious accident, such as a car accident

Is sitting a lethal activity? [Research]

A reflection by Crossfit trainer Steven<
Post image for Is sitting a lethal activity? [Research]

Cracking article in the New York Times on research into inactivity, especially related to ‘chair & desk’ culture.

I have been considering for quite a while the idea of a stand up desk, at least at home. My miserable seated posture and the back and neck pain I experience from sitting for hours a day should have been enough to spur me into action. And then I read this:

This is your body on chairs: Electrical activity in the muscles drops — “the muscles go as silent as those of a dead horse,” Hamilton says — leading to a cascade of harmful metabolic effects. Your calorie-burning rate immediately plunges to about one per minute, a third of what it would be if you got up and walked.

Oh dear. Dead horses?

‘Is sitting a lethal activity’, New York Times, 14 April 2011

Edit: There is also an earlier article with moar science in it: ‘Stand up while you read this!’, New York Times, 23 Feb 2010

Sitting is killing you

An interesting reflection by Crossfit trainer Colin Mennis

No Sit

As I write this I am standing at my kitchen counter as you read this I want you to stand up and even walk around, it could save your life (unless you are outside, then don’t)

Recent studies including some historical reviews of lifestyle changes have concluded that inactivity is killing us. In fact it is regarded in some circles as the most serious threat to our health, more than sugar, fat, smoking and alcohol.  Just take a look these facts:

  1. Sitting for 6 hours a day will increase your chance of death within 15 years by 40% compared to someone who sits less than 3 hours per day. EVEN if you exercise.
  2. Studies have shown obese people sit 2.5 hours more than thin people per day.
  3. Despite more people exercising than ever before obesity has doubled since the 1980’s. Our sitting time has increased by nearly 10%

Studies have discovered some amazing facts about cellular damage due to inactivity. After just 7 hours of sitting we show the first early signs of insulin sensitivity. Our calorific use can drop as low as 1 per minute. Fat fighting enzymes drop by as much as 90%. There is twice as much cardiovascular disease among those with sitting jobs than those with standing jobs.  A great study on the old London buses clearly demonstrated this back in the late sixties comparing the drivers health with the conductors.  And I will repeat exercising regularly will not help you.

As health professionals we advise exercise and eat less and well for weight loss and better health.  Homeostasis, what a pain. Studies have shown that people who take up exercise and/or diet for weight loss become less active throughout their day. They start sitting and lounging around for longer. Yes they can feel overtly tired and feel the need to rest but the body is also working away against your ambitions. It does not like change and you will subconsciously do less and less to maintain the calorie in/out balance. Some people have even been shown to put on weight while dieting because they are burning so few calories!

As health professionals we need to be informing clients and making them constantly reflect on their activity levels during the day.  Maybe add an activity diary to that food diary. Those clever little wrist bands that monitor movement, I thought they were gimmicks, but maybe not? People need to know to stand whenever they can. Configure their desk so they can stand more, use stairs, walk up escalators and stand up when commuting.

I exercise regularly with biking, running, strength and metcon training but none of that will undo the damage caused by the hours on end I sit at my desk or on the tube. So I have made changes, you should too.

Sorensen test

All through our sessions we stress proper squat form: bum back, weight on your heels, lordosis

You have to remember what joint to bend first on your legs when carrying load. You have three joints, which should move first? Think of it this way; whatever joint moves first, takes the whole weight of the move upon it. So think it through: should you move your ankle joint first? Have  a look at that tiny, dainty joint– not really that good a choice. How about getting the infamous injury-prone knee to be the focus of all the stress your body and a bar can generate? Or how about, initially, using your massive hip joint? (a tennis-ball sized joint buried in a secure acetabulum,  supported by a a massive bum muscle. ( And of-course, I’m not saying your bum is too big).

But here’s the “thing”: God knew you would be confused as to which joint to use, so she “flagged it” with a giant arse-shaped “post it note” in case you forgot. This is the joint strong enough to take all the grief when you begin to squat. Hence  we say “bum back” first..

Anyway, lets talk about the  Sorensen Test

The race has always been on to firstly predict,  then inoculate against,  back pain. A test known as the “Sorensen test” based on the work of Hansen in 1964, has been popular since 1984.

According to Demoulin et al 2006  ”The test consists in measuring the amount of time a person can hold the unsupported upper body in a horizontal prone position with the lower body fixed to the examining table”

The test is accepted in its discriminative validity, reproducibility, and safety. However debate continues to surround its ability to predict low back pain. No firm explanation, beyond “women rock” , has been offered as to why “chicks” can hold it longer than guys.

Naturally motivation and discomfort tolerance are confounding factors.

A interesting review is available in PDF form at Isometric back Extension tests: a Review of Literature Maureau et al Journal of Manipulative and Physiological Therapeutics Volume 24 • Number  2001, But in essence,this report says this….(yawn….)

For men, the mean endurance time is 84 to 195 seconds; for women, it is 142 to 220.4 seconds. For subjects with LBP, the mean endurance time range is 39.55 to 54.5 seconds in mixed-sex groups 80 to 194 seconds for men, and 146 to 227 seconds for women” whether thats remotely useful lm not sure, but if you suffer or are prone to lower back pain, (you tend to know by your appalling posture), im going to suggest you move this figure up.

Demoulin C, Vanderthommen M, Duysens C, Crielaard JM.  2006.  Spinal muscle evaluation using the Sorensen test: a critical appraisal of the literature. Joint Bone Spine. 2006 Jan;73(1):43-50.