The Low Down on Low Back Pain
 "It Does Not always Mean Tissue Damage"

Just when does Acute low back pain become Chronic?

By G Rieger

Posted June 11, 2014

Last Updated Septemberl 4, 2017

Low back pain and its accompanying work related disabilities are epidemic and getting worse every day.  It is clear that understanding the latest pain research is a crucial factor in improving the current state of low back pain care.  It is the goal of this article to open a dialogue that helps individuals with both acute and chronic pain to improve their understanding of the latest research.  It is hoped that a clear understanding of current research will help individuals experiencing back pain communicate productively with their health care providers.

One of the most important points to make about low back pain is that it is rarely the result of serious injury or disease.  Your spine is designed to be strong and is in no way mechanically fragile.  Pain and the severity of tissue damage are not a direct correlation, think about the last time you had a paper cut.  How long does a person have to be in pain before acute back pain becomes chronic back pain?

Before this question is tackled it may be significantly more productive to discuss some ingrained beliefs about back pain held by both patients and medical practitioners alike.  It may be hard to fathom that our medical communities have been perpetuating these back pain myths for decades.  It is a little known and well documented condition that physicians receive very limited education and information on musculoskeletal pain.  The emphasis on pain research has shifted in recent years and as a result our institutions of higher learning have begun to move toward evidenced based teaching and treatment protocols. (1)  

The number one low back pain myth is that once a person experiences back pain they will continue to experience back pain throughout the duration of their life.  The current research shows that most low back pain will resolve itself when left unhampered. (2)  The research shows that back pain improves rapidly over the first few weeks and will continue to improve over the next several months. (13) (7) (8) (9)  A few simple conservative behavioral changes can assist an individual with the sudden onset of back pain to improve consistently over a several months without the intervention of a medical practitioner. 

Most people who suffer from acute onset low back pain will be able to resume their normal activities within a couple of days. (3)  (4)  The rare occurrence of severe injury resulting in back pain coupled with the following symptoms should be met with immediate medical care.

  • Pins and needles accompanied with numbness and weakness in both legs
  • Reoccurring unsteadiness on your feet.
  • Severe pain that continues to get worse over several weeks
  • Recent difficulty passing or controlling urine
  • A significant recurrent change in sensation along the spinal column and around the genitalia

Most people who suffer from acute onset back pain will be able to resume their normal activities within a couple of days to weeks. (2)  (5)  It is rare for there to be a severe injury with significant mechanical injury without some form of impact trauma such as auto accident, fall, sport or work related impact. The following behavioral adjustments can help resolve the onset of subacute pain without medical intervention:

  • Stay active: although pain may make your normal activities a bit harder, we now know that movement will help to reduce pain and returning to a regular schedule of normal daily activities for the individual as soon as possible will result in less pain. (6) (7)(8)(9)(10)(11) (12)
  • Hurt should not be correlated to harm, hurt does not equate to increased tissue damage  especially when it comes to low back pain. (14)
  • It may be necessary to modify your activity in some way, but it is essential to return to your normal routine as soon as possible. (4) (11)
  • It is favorable to return to work as soon as possible, work related modification of duties may be required for a while to facilitate recovery. 
  • Avoid prolonged periods of bed rest, bed rest is not a treatment and prolonged immobility can make you worse.
  • Prolonged immobility will result in muscle and joint weakness, loss of physical fitness is a crucial factor in prolonged pain. (10) (12) (14)  
  • Statistical analysis shows that low back pain unlike other areas of acute pain does not tend to respond well to the application of cold.  Moist heat has been shown to provide temporary relief.  Every body is unique and it is best to try both to establish how you respond to cold or heat.  It has been shown statistically that contrasting cold and heat therapies can produces higher rates of relief.  It is recommended to reduce the length of cold application to the low back for better results.
  • Regular  exercise can help prevent the occurrence or reoccurrence of acute low back pain. If you are like most people it is best to discover what forms of weekly and daily exercise that you truly enjoy.  Sticking to an active routine of outdoor activities for a minimum of 21 days can facilitate a lifestyle change that will support physical fitness and reduce the likely hood of reoccurring back pain. (8)

Another common myth about back pain is that one should stay still and rest as much as possible.  Mobility is a key to reducing non-specific back pain and provide back pain relief. (10) Although sleep is necessary for the body and restorative body processes take place during normal sleep cycles, staying in bed all day to help back related pain is no longer recommended. Research studies have shown that 95% of all reported back pain is classified as non-specific by health care providers. (17)  It is very unusual for physicians to identify a cause for non-specific back pain.  It is extremely rare for x-rays, MRI's or CT scans to actually identify tissue injury that can be classified as the cause of the pain, especially when no specific accident or event is related to the onset of pain. (16) (18) (19) (20) (21) (22) (23)    

An important understanding is that it is not necessary to identify the cause of low back pain for it to improve and for lifestyle changes, moderate exercise and physical, bodywork and massage therapies to assist and treat low back pain. (24)  The most amazing realization that has come through current research is that the duration of back pain can be related to how different individuals relate to pain. (26) (27) (28) (29) (30)  Yes that is right how each person relates to, cops with or endeavors to avoid pain has shown to play a significant role in the duration of back pain. (25) (29) (30) (31)  Your beliefs about pain can and will affect your recovery from low back pain.

The research is clear belief systems and pain are related and it is not just patients that have been effected by belief systems and pain. (25) (29) (30) (31) (32)  Medical doctors have developed belief systems about pain from both their personal experience and professional training and careers.  So just where does that leave us, endeavoring to dispel myths about back pain and improve the communication between patient and physicians. (33)

A Big Misunderstanding is that the Level of Pain equates to Tissue Damage 

A big misunderstanding regarding back pain especially of the low back region is that more pain equates to extreme mechanical damage to the spine. (27)  This may seem to be counter intuitive but the evidence is in, the level of pain an individual experiences does not directly correlate to the degree of mechanical or physical damage to tissue.  Most significantly the brain has the ability to modulate or turn down the level of pain an individual experiences.  Even though two distinct individuals may have a similar injury with a similar amount of tissue damage they may not experience the same degree of pain and usually do not.

Pain is interpreted and processed by the brain. The brain is designed to regulate if and how much sensation an individual will experience at any given point in time including pain.  Although we are connected to our parents via our DNA each and every brain is unique.  Pain is experienced by the perceiver.      

There is clear evidence that has established that there are changes in brain activity in individuals with long standing low back pain. (34)  This will be discussed in more detail later on in the article.  Low back pain differs from individual to individual due to many factors one of which is how the individuals brain processes pain. 

This may confuse many readers, there is no significant research evidence that equates bulging or slipped discs to low back pain. (35) (18)  Many individuals have detectable bulging discs and experience no signs of pain.  A recent study conducted with individuals that experienced pain with the presence of a bulging disc concluded that most of these patients saw a reduction of pain over time. (36)  This study also established that many bulging discs will shrink over time without any surgical intervention.   

It is important to realize that the presence of a bulging disc on an x-ray or MRI does not directly indicate that it is the cause of low back pain and more to the point surgery may not only produce no positive change; it may produce increased pain and result in reduced mobility. Studies have shown that a significant patient population does not benefit from back surgery. (37)  It is therefore essential to give sudden onset of acute low back pain time to resolve itself before permanent structural change via surgery is considered. 

Research has established that high levels of stress, anxiety and fear are related to increased low back pain and increased recovery times. (38)  Studies have shown that disabled individuals with low back pain are those who believe that their pain relates to a problem with the structure of their spine. (31)  Yes these conclusion fly in the face of decades of physician and surgeon approved treatment protocols.  It is time that the research and the mind set of the medical community find a common ground and that treatment is based on proven methods and not just weather the treatment is covered by insurance or allowed for under a health care program or plan. 

Just When Does Acute Low Back Pain Become Chronic?

There has been much debate as to just how many weeks it takes for acute low back pain to transition to persistent and chronic low back pain.  The good news is that pain that continues past 6 to 8 weeks does not necessarily indicate that the original injury has not healed or that the pain will be indefinite. (38) (39)  The current research has established that the pain has much more to do with the central nervous system than with specific tissue damage. 

Its important to understand that chronic pain does not mean severe pain or injury it simple translates into pain that has persisted longer than expected and can no longer be referred to as acute.  Pain is intended to help the conscious human to realize that what they are doing has caused damage and to signal the individual to stop doing what they had been doing.  For example if you walked into a modern kitchen and did not know the stove top had just been used you may not be aware that the it is still hot.  Place your hand on the surface and a burning sensation will trigger a reflex to pull your hand away from the hot surface.

When we burn our hand lots of information is sent to the brain to make us take notice of the situation and to respond, the information triggers a reflex.  In other situations lots of information may require a conscious response to stop doing what we had been doing.  All pain experienced by us is produced in the brain not matter where it is felt. 

The really amazing notion is that pain and its expression in our lives depends on multiple factors that are different for each individual.  No two pains are the same.  Although all pain is produced in the brain the other organ systems are also involved in our experience of pain. (40) (41)  We are complex animals and tend to be social, mental, spiritual, as well as physical beings.  Modern research on pain has established that our thoughts and beliefs can amp up a persons sensitivity to pain.

There is a link between emotions and pain which plays a roll in how it persists in or lives.  Our concepts of pain play a roll in the concept of  chronic low back pain.  The moods release biochemical into or blood stream that translate into an expression of pain or sense of well being. (42)  The good news is that we can retrain or beliefs, expressions, and moods to improve or sense of balance.

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