Lower Back Pain In The Past
The first record we have of treatment for lower back pain is on 3500 year old papyrus, it is a document that gives a tantalising and partial account of treating a patient with lower back pain using physical therapy. It is widely known that bonesetters have operated down the ages in many cultures to this very day. Bonesetters were lay people with a family tradition of treating pain and injuries in the same way that some families had a tradition of baking or changing horseshoes. Yogic traditions, Ayurvedic medicine, tradition Chinese medicine and no doubt even shamanic traditions may well have had input in the lives of people who suffer with lower back pain also.
We don’t know how much success the ancient traditions had with treating lower back pain historically. There is a long standing trend for medical practitioners to openly disregard the validity of pre-pharmacological and pre-surgical healing methods, but we don’t actually know has worked and what hasn’t. What we can now say with certainty however is that the essence of many pre medical methods is being found to have a good deal of efficacy. Many treatments previously disregarded as quack-esque have emerged from the data and from vast quantities of present day anecdotal evidence as being of significant value. Any downside of whatever successes the ancient healers had most likely came from their lack of scientific knowledge.
It is unclear even how much of an issue lower back pain was in pre-industrial and pre-agricultural societies, there is some circumstantial evidence that it may not have been recognised as a condition unto itself. For all we know in harsher and more ‘primitive’ times some combination of factors conspired to create less lower back pain; life was possibly lead in a way that lower back pain was not given much thought. Modern research has certainly shown that there are cultures alive today that suffer from essentially a zero instance of disability related to lower back pain, a stark contrast to the epidemic of serious back pain we have in the Western world.
The last 500 years or so of lower back pain treatment is far more well documented, and as such far more transparent. In Europe we have been on a journey of gradually diminishing superstition in relation to our treatment of lower back pain. Unfortunately our realisations regarding the nature of lower back pain and the body have in part lead to a series of major mistakes in how we have managed it, some of these mistakes have left us with major challenges to this very day. From a positive perspective we have learned a great deal, we now know a lot about the ‘anatomy’ involved with lower back pain (mostly the spine) and we have also learned how not to treat it.
How NOT To Treat Lower Back Pain – What We Have Learned
Treating Lower Back Pain With Bedrest
One of the most significant medical lower back pain treatment trends during the 20th Century was bed rest. After World War 2 the specialty of orthopaedics, who’s main area of expertise was in treating significant trauma and deformities made huge gains in popularity and influence. Their influence enabled them to make somewhat of a ‘land grab’ and claim back pain as part of their scope of practice. Unfortunately for the growing number of lower back pain sufferers in our society the orthopedists had ‘decided’ that bed rest was the most important part of treatment for lower back pain.
What we now know from extensive research and somewhat bitter experience is that bed rest as a prescription for lower back pain is just about as bad as it gets. This is because not only does it not help, it has the capacity to break the first rule of healthcare, by making the situation significantly worse.
Patients who lie flat on their back for weeks at a time suffer from a loss of core strength, a loss of mobility in their spines and an increase in depressive brain chemistry. Our modern understanding of lower back pain has revealed that in essence these are 3 of the very worst things that can happen to a back pain sufferer. During the latter part of the 20th Century bedrest prescriptions converted countless cases of lower back pain into tragic and painful disabilities.
Treating Lower Back Pain With Surgery
Another major medical trend during the 20th Century was the widespread and enthusiastic use of surgery to try and reduce lower back pain. Spinal fusions, laminectomies, discectomies sacro-iliac joint fusions and numerous other procedures were performed in great numbers. Along with bedrest this was another outcome of the rise in popularity of certain specialties, namely orthopaedics and surgery. Once again, unfortunately for the unsuspecting public they were being exposed to a series of wild guesses made on mass with the sharp end of a knife.
What we now know from a volume of data and again somewhat bitter experience is that surgery is only useful to a very small number of disc patients who have stubborn and severe nerve pressure. These people are not true lower back pain sufferers, they are people with spinal disc disorders. What this amounts to historically, is untold thousands of people suffering terrible fates after being operated on for simple mechanical lower back pain. Fortunately, by the mid 1950’s a clear thinking sub-group of orthopedic specialist began to speak out, claiming that disc surgery ‘had left more tragic human wreckage in its wake than any other surgical procedure in history’. And the rest is history.
Spinal surgeries have declined dramatically and are now mostly only even considered in cases of severe sciatic pain. In this new heavily moderated guise surgery is sometimes now of use to those with serious disc related pain that’s unresponsive to non-invasive interventions.
Treating Lower Back Pain With Pills
Pharmaceuticals receive a far more positive review for their role in treating lower back pain than bedrest and surgery, for the most part . In simple terms this is because they are a valuable tool in the short term management of acute lower back pain and even as a ‘stepping stone’ in cases of chronic lower back pain.
It should go without saying that the use of pain medications such as non-steroidal anti-inflammatories, steroid injections, analgesics and opioids for lower back pain rose from nothing to become a billion dollar business during the 20th Century. Thankfully in this case we can at least say with confidence that all these pills and injections did at least reduce the net amount of pain and suffering in those they were prescribed for.
A major downside to the use of pain medications for the treatment of lower back pain has been their toxicity. Non-steroidal anti-inflammatories are associated with many side effects. Steroid injections are associated with many side effects .. Analgesics like aspirin are associated with many side effects. Opioid drugs are associated with many side effects.
The other major downside with pain medications for lower back pain sufferers is that they do not address the underlying physiology of the back pain issue. There is no pill for a weak core of flat feet yet after all.
Pain is a signal that emanates from tissues that are under some form of stress or strain. Treatments that can work on the underlying causes of pain like muscle wasting, misalignments, psychosocial factors and losses of mobility are a fundamentally more honest and accountable way of approaching pain. This is the real issue with using chemical agents to treat bio-mechanical complaints.
Treating Lower Back Pain With Planking Exercises
Thankfully in recent decades there has been an explosion of awareness of the value of movement and exercise for lower back pain sufferers. We now know about the role of the core in relation to back pain, that was big. We are also however in the process of scientifically unpacking the value of movement and general forms of exercise as a whole in managing pain. Of course these observations don’t necessarily mean that all movement and all exercise are beneficial for those suffering with lower back pain.. far from it.
Research has shown conclusively that trunk strength exercises frequently aggravate cases of lower back pain. Strengthening the core in a controlled way on her other hand has a profoundly positive effect on a person’s tendency to suffer lower back pain over time. Performing trunk exercises like planks and sit-ups is not quite the same thing as careful core activation, and we now know it’s not an effective way to tackle lower back pain. Furthermore there is every reason to expect that the wrong kind of trunk exercises can contribute to a worsening of the muscle imbalances that cause lower back pain to manifest in the first place.
What We Know About Lower Back Pain Now
Lower Back Pain Treatment In Our Society
Currently lower back pain in the developed world exists at what is essentially the level of a slow burning epidemic. The National Institute of Neurological Disorders & Stroke estimate that 80% of people suffer with lower back pain during their lifetime.
For reasons that are not clearly understood, there has been an extremely sharp increase in back pain since World War 2. In 1990, a study ranking the most burdensome conditions in the U.S. in terms of their impact on the health of the populations put lower back pain in 6th place. By 2010 lower back pain jumped to third place, with only ischemic heart disease and chronic obstructive pulmonary disease ranking higher.
The management of lower back pain in our current society is essentially 90% pain medications both over the counter and prescribed. The remaining 10% of treatment is made up of manual therapies and exercise prescription and the very occasional surgical intervention.
Quietly along side this messy epidemic of lower back pain, there has been a mass of quality research undertaken by an army of conscientious researchers from multiple disciplines. This research has lead to the adoption of international guidelines on how to manage lower back pain. It’s hallmarks are a move away from surgical interventions, away from bedrest, away from the use of x Ray and MRI as standard diagnostic procedures and away from framing lower back pain as a ‘disease’’ and away from the open ended use of drug therapies. Instead we are moving towards cautious short term use of pharmaceuticals, towards non-invasive manual and manipulation therapies, towards acknowledging the impact of emotional health in chronic pain and perhaps best of all toward exercise and movement.
In the ‘front line’ of lower back pain treatment we live in a world where patients can make their own choices about where they go to seek help. Millions still choose to turn to their family doctors despite the fact that they frequently spend fewer than 5 hours on the entire topic of pain management in their entire training
Others directly seek the help of professionals who have spent many years training in the management of pain like chiropractors, osteopaths, physiotherapists, acupuncturists, neurologists and orthopaedic specialists. The health and fitness industry more recently has a stake in the management of lower back pain also. Countless people essentially seek ‘treatment’ mostly in the form of exercise from their yoga teacher, pilates teacher, massage therapist or physical trainer when they attend sessions. Furthermore as time goes by greater numbers of people are waking up to the emotional and psychosocial components of their lower back pain and seeking the help of cognitive behavioural therapy, biofeedback and the like.
The Physical Side Of Lower Back Pain – Where Does The Pain Come From?
Based on logic, and based on the limited amount we can know, we must assume that the transition from quadruped (walking on 4 legs) to biped (walking on 2 legs) played a key role in us developing the powerful tendency we have towards suffering with lower back pain. Up until the evolutionary point we made the shift to standing and walking upright the lower spine was essentially a non-weightbearing structure, the exception being those special occasions when our 4 legged ancestors reared up on their hind legs. From that point onward, those same tissues have had to find a way to bear the weight of the entire upper body for a lifetime.
This transition, and the bewilderingly complex changes in skeletal weight distribution and muscle activity may be the primary reason why lower back pain trumps all other pains when it comes to creating pain and disability in modern humans.
Other ‘secondary’ reasons for lower back pain being so prevalent are most likely knock on effects from modern sedentary lifestyles. modern society, modern stress and modern hard surfaces. We lead highly unnatural lifestyles in so many ways, and there can be no doubt our spines suffer the consequences.
Before we dig deeper into the underlying causes it is important that we understand which of the spinal tissues suffer enough to generate pain.
Facet Joints & Lower Back Pain
Facet joints are pairs of small joints the size of knuckles that connect each vertebra to its neighbouring bones. The facet joints sit neatly behind the discs and assist both with weight bearing and with healthy limitation of movements that could damage the spinal cord.
Facets joints are a known cause of lower back pain, they can become stiff, sore and lock up much like any joint that is placed under excessive or prolonged strain. Perhaps unsurprisingly given their role in life (as tiny delicate joints that bear huge amounts of weight) facet joints are prone to developing pain. It is mobilisation of the facet joints that chiropractors are most known for. Facet joint pain is extremely common but does not account for all lower back pain by any means. Patients with pain emanating from inflamed or mildly osteoarthritic facet joints are a subset of lower back pain sufferers who will tend to respond well to the mobilisation of chiropractic adjustments.
Muscle, Fascia & Lower Back Pain
There are many layers of muscle and fascia in the lower back, these form a bewilderingly complex network of movement and support for the spine. The task these muscles and their facial system perform involves a combination of dynamic strength, weight bearing stability, shock absorption and fine protective motor control of the spinal bones.
If muscles are in a complex weakened state or are often subjected to excessive demands over time they become painful and like any other tissue, this leads to muscle pain syndromes. Muscle pain is a profoundly complex and extremely poorly understood phenomena. What we do know however is that most muscle pain develops within the specific and predictable pain points called ‘myofascial trigger points’ that most of us are all too aware of.
Myofascial trigger points are a major cause of back pain and can develop in many different muscle groups. Common muscles that can generate lower back pain include multifidus, quadratus lumborum, lumbar paraspinal extensor muscles and the gluteal insertions. Patients with muscle induced lower back pain will tend to respond well to treatments that target the trigger points like acupuncture and deep tissue release.
Discs & Lower Back Pain
The intervertebral disc is an amazing piece of biological engineering that combines huge amounts of shock absorption with the limited mobility between each pair of bones. It is the combined compression of all these discs that gives the human spine its full flex-ability. Structurally, discs are made up of extremely stiff fibrous outer portion and a gel like fluid centre for ‘suspension’.
If an intervertebral disc becomes weakened and damaged the outer portion known as the annulus can tear, letting some gel bulge or even escape. In the majority of cases this actually happens silently and without significant pain. Most of the people who have had a disc ‘slip’ notice the moment it happens and it is completely painless, many say they felt like something shifted, that it felt strange but not painful. The pain that discs cause is through the irritation of surrounding tissue, particularly the spinal nerve roots. If the disc pushes onto a nerve root, that same person who felt almost no pain when the disc bulged will develop the most severe leg pain imaginable often 24 hours later.
The majority of disc bulges do not require surgery and are better off left alone. Even when surgery is performed (which is sometimes absolutely unavoidable) it generally infers little or no protection from reoccurrence. In many cases a combination of time and gentle non-invasive therapies can be just as helpful.
Ligaments & Lower Back Pain
The lower spine relies heavily on very strong ligaments for support. These ligaments are like big thick straps that bind the bones together and assist the core muscles in their support role.
The ligaments being as strong and fibrous as they are, do not cause a great deal of lower back pain, but they certainly can play a role in chronic lower back pain if they are compromised. There is not a great deal of research data on the role of ligaments in back pain.
In instances of lower back pain that relate to ligament strain, in-depth rehabilitation options that reinforce adjacent muscle support are the options that make most logical sense.
Sacroiliac Joints & Lower Back Pain
The sacro-iliac joints are 2 large weight bearing joints at the very base of the spine. The role of the sacro-iliac joints is to bear weight, and to connect the spine to the pelvis. The sacro-iliac joints are extremely stiff and fibrous joints but they do move, especially under the sort of weight bearing forces they are subjected to when we walk and run.
Like the facet joints, on account of the hard life they lead sacro-iliac joints can become irritated by movement issues and/or injury to some extent. If the sacro-iliac joint becomes inflamed and irritated it we know it can generate lower back pain.
One of the many medical mistakes we made during the 20th C was to begin surgically fusing peoples sacro-iliac joints on mass, this it turns out is not a good idea so we hardly ever do it anymore. Although there are hold outs who claim less invasive versions of this surgery are beneficial. These days gentle mobilisation of the sacro-iliac joints and other non-invasive methods are the way we manage saco-iliac joint pain.
The Physical Side Of Lower Back Pain – What ‘Causes’ The Pain?
When we tending to the wellbeing of our teeth we are only too aware that the cavities themselves are not random and not the whole story, the ‘sugar vs dental hygiene equation’ is the real story and the cavity is just what happens when ‘balance’ is lost. The list of physical pains above, like muscle pain and joint pain, are the same as cavities. If a joint or a muscle becomes inflamed or degenerated enough to cause significant lower back pain there has to be some underlying issue, usually with movement.
The gut is concerned with the movement and absorption of nutrients. The cardio-vascular system is concerned with the dispersal of blood and its constituents. The spinal system is concerned with the mechanics of movement and with providing mechanical integrity. When any of these systems fail it is usually in relation to their primary role, because this is their greatest potential for ‘stress’. Thus when the spinal system runs into trouble, it usually issues with ‘mechanics’ that are the root cause.
We have known for a long time that flat feet and fallen arches can be a major factor in the development of stubborn pain and injury. We usually reserve the term ‘posture’ for the upper body but of course the story of posture alsoe xtends into the hips, legs and feet. When we walk it is essential for the tissues of the spine that fairly correct and neutral alignment is maintained throughout the process of weight bearing. If alignment is lost during weight bearing the joints and muscles of the lower limb may suffer, but so too may the joints and tissues of the spine.
Many lower back pain sufferers show up with uncontrolled and excessive pronation in one or both of their feet, excess pronation causes a great deal of twisting strain in the delicate spinal tissues and can cause significant pain. In our society this issue can be magnified quite dramatically by time spent on concrete, tarmac and paving which provide no natural support to the feet. Over time and repetition on hard surfaces pronation and certain other deviations from normal leg/foot mechanics can lead to irritation and pain in the lower spinal tissues.
Happily the role of the core exercises in preventing lower back pain is essentially common knowledge in our culture now. The heart of this understanding is an acknowledgement that deep stabilising muscles of the trunk provide a complex system of support to the delicate underlying spinal tissues.
The core forms a complex supportive ‘belt’ that maintains pressure throughout the whole abdomen, it offers support to the organs and anchors deep in the spinal system where it provides a massive amount of reinforcement. If the muscles of the core become weak or disorganised it deprives the delicate spinal tissues of the support that they need, in order to function in a manner that is free from damage and irritation.
Human beings are capable of a bewildering number of complicated movement patterns, walking on 2 legs as we do is so complex it takes us about 4 years to master, let alone big wave surfing and professional tennis. The movements that we repeat most often are are very capable of causing back pain, and they should all be examined carefully in those who suffer with stubborn back pain issues.
The universe has laws, as an extension of those laws the world of human movement has rules. If movement does not remain within certain parameters of efficiency (correct movement) and magnitude (amount of movement) damage can and does occur, not only by way of major injury but also of slow, subtle wear and tear. A bad postural habit for example can exert strain on the spinal tissues that creeps as slowly and quietly as arterial plaques do in heart disease, only to show up as lower back pain with no fore-warning after 30 years of unseen and unfelt ‘micro-struggle’. The same repetitive truth can rule can apply to poor lifting technique at the gym (for eg.) given enough repetition over enough time.
General Weakness / Lack of Fitness
There are subtle layers of interconnectedness in the body that are not always easy for us to explain or understand.
Smokers suffer with more lower back pain than non-smokers. How and why a habit that primarily damages the lungs manages to impact the spinal pain pathways is not clear. Similarly, without even going near a core exercise, movement in general has a profoundly positive impact on pain levels of back pain sufferers. I can report also from many observations on the front line, that there are many lower back pain sufferers who find that a food intolerance/allergy severely affects their pain.
Despite all the complexity and the uncertainty about how general wellbeing as it relates to lower back pain the basics are pretty clear. If we take better care of ourselves across the board one of the benefits is likely to be less lower back pain.
The Mental & Social Side Of Back Pain
*For some the following will be a wake up call as our cultural belief system hasn’t caught up to modern pain science. It is nonetheless an inescapable fact and common knowledge among pain experts that physical pain has a major ‘psycho-social’ dimension in many cases.
Lifestyle Stress & Lower Back Pain
For some people stress plays a central but relatively superficial role in generating their pain, these people will usually have relatively manageable forms of persistent pain, or pain that comes in more severe but temporary episodes. Truth be told, the majority of people who turn up at clinics seeking treatment for an episode of lower back pain have some kind of recent spike in life stress going on in the background. For these people, acknowledging that stress is a trigger for them is useful, and anything they can do to reduce stress in their life will reduce the amount of pain they experience. Failing that most will find that if they follow through on a quality pain management and rehabilitation program their pain will resolve regardless of any ongoing stress. There are however also those for whom the mental and emotional side plays a far greater role in their pain.
Trauma & Lower Back Pain
Many of us did not lead entirely happy childhoods where we felt consistently safe and nurtured. Many of us as children are highly sensitive to environmental stress. A history of even relatively mild childhood stress and trauma can have a profound effect on the way the adult holds tension in the spine and its supporting muscles.
As a small example of what can be a profoundly sad, serious and complex issue… if you were heavily criticized as a child you may have learned to contract your diaphragm muscles every time you experience uneasiness or anxiety as an adult (as kind of symbolic bracing – protecting front of body gesture). A pattern of this nature can eventually lead to lower back pain by having thrown the activity of the core permanently out of whack. This is because the action of the core muscles is intimately connected to the tone in our diaphragms.
Another and perhaps less complex example is the person who due to the environment they grew up in comes out with the classic hunched shouldered posture of low self esteem. A lifetime of poor posture like that can easily impact back pain in a big way.
It is also obviously the case that trauma experienced by adults can contribute to lower back pain.
Deeper within the nervous system trauma and stress can also impact the way that pain is reported in the central nervous system. In this sense lower back pain that relates to emotional wellbeing can play out invisibly in those who appear to have no postural issues or muscles imbalances whatsoever. How often have you heard of someone with chronic pain being told by their doctors and specialists that there is nothing wrong with them, or that they are imagining their pain? There’s a clue as to one of the many ways that can occur.
Society & Lower Back Pain
Strange as it may seem to our ears, the truth is we now know that the culture and society you are born into has a powerful impact on your likelihood of experiencing serious problems with lower back pain. The way we think and act as groups has a powerful influence over how we deal with pain, and potentially even how our pain is experienced. Our socio-economic status also correlates with chronic pain trends, for reasons we don’t fully understand.
Your beliefs around pain profoundly effect the amount and type of pain you experience, this is the power our minds undoubtedly hold. If you believe a sharp pain in your back is something tearing in your back for example your whole experience of the condition and attitude towards handling it is different from a person who knows the sharp twinges are just unpleasant muscle spasms.
If you live in a society that gives large insurance payments and social support for lower back pain sufferers you are also slightly more likely to develop serious long terms problems too believe it or not. In fairness to all this does not imply dishonesty, its just human nature. It is likely that this would be less of a factor if there was a high quality rehabilitation culture for chronically disabled pain sufferers rather than open ended financial support and minimal high quality rehabilitation, as is the trend.
There are some societies for whom disability from lower back pain is completely unheard of, and there are cultures like yours where it is considered to be a serious issue for society at large. We still have much to learn about this surprising truth.
How We Treat Back Pain Now
A recent review of the international guidelines for managing lower back pain found that there are now officially in an age where we see fairly consistent recommendations for managing stubborn/chronic back pain. While there are definitely some differences from country to country depending on political and cultural factors there is overwhelmingly a consistent picture of how the global pool of back pain research is interpreted. This should be comforting for both back pain sufferers and clinicians alike, because it means there are some relatively trustable map coordinates for those seeking relief.
Unfortunately there is still a major problem with over-utilisation of expensive and often unsafe interventions on a scale that reflects they are not being utilised in line with the international guidelines. A review of recent data documents a 629% increase in Medicare expenditures on spinal cortisone injections; a 423% increase in the use of opioids for back pain; a 307% increase in lumbar MRIs; and a 220% increase in spinal fusion surgery rates. The data available suggests that these increases have not been accompanied by improvements in measurable improvements in patient outcomes or disability rates. Thankfully the problem is far less severe outside the US but the pattern remains an international one.
Chronic Back Pain Treatment Guidelines
Discourage Use Of Modalities (such as ultrasound, electrotherapy)
Treatments like ultrasound and electrotherapy are generally means of stimulating muscle and soft tissue, they have been a staple of the physiotherapy profession for decades.
This recommendation indicates that there is consistent enough evidence to recommend not using electrical and sound based stimuli for chronic lower back pain. Presumably the data contains quite a number of studies that show some worsening of patients back pain with the use of these types of treatments.
Short-Term Use Of Medication/Manipulation.
Medication includes the full spectrum of pain relief pills from over the counter drugs like aspirin and voltaren through to opiods (the latter being near enough a last resort). Manipulation refers to the spinal adjustments most often by chiropractors but also by osteopaths.
This recommendation speaks to the effectiveness of some of our most common, valuable and consistently used means of managing pain in the shorter term. It is essentially encouraging us to use pain medication and spinal manipulation as means to get ourselves out of pain, but not to rely on them for our longer term goals for resolution of our back pain.
Supervised Exercise Therapy
Supervised exercise therapy most often consists of strength and mobility exercises directed primarily at the wellbeing of the core and trunk muscles. The value implied in the supervision component relates to the maximised benefit and minimised risk that comes with professional guidance.
This recommendation is clearly directing us towards the use of exercise and strengthening as key components in our recovery from chronic back pain. It is also letting us know that we are not supposed to go it alone and make up our own exercise routine, but rather have it professionally prescribed and supervised.
Cognitive behavioural therapy
CBT is a form of therapy which helps us make adjustments to our attitudes and behaviors by focusing on the thoughts, images, beliefs and attitudes that we choose. It helps us relate these to the way we behave as a way of dealing with emotional challenges.
The fact that this recommendation now makes it on to the list of international guidelines for managing back pain really shows how far we have come in our understanding of chronic pain. As we mentioned previously, many people are now finding that their chronic lower back pain has a significant mental and emotional component that ‘feeds into’ the pain.
Multidisciplinary treatment refers to treatment that is prescribed by multiple professionals, utilising multiple perspectives, multiple tools and multiple plans of management all directed at the same patient. This could include chiropractors, physiotherapists, osteopaths, rehab specialists (who could also be among the former proefessions), orthopedic specialists and general practitioners.
This recommendation is often of most relevance to those who only go back and forth to their family doctor for advice on their lower back pain. It may also be useful for those who are working with a chiropractor or osteopath who are only treating them with one set of tools or from one perspective. This is a recommendation that lets us know it is better to utlilise multiple perspectives and tools when working on chronic lower back pain.
There is immense value in allowing yourself to be guided by this modern understanding of lower back pain and it’s treatment, it contains much valuable guidance on the road to recovery and relief. The untidy and unavoidable truth however is that the data and the system that generates the data will not generate anything like a comprehensive picture of what is possible for back pain sufferers in our lifetime.
There is so much treatment and rehabilitation out there that works for a great many people but has yet to be captured by research. This means that many lower back pain sufferers find ultimately that to heal they must be willing to colour outside the lines. The best way to do this is with pragmatic clinicians who have the experience and confidence to draw both from what we now ‘know’ scientifically and from what has yet even to be studied, but nonetheless works.