Getting off the couch and accepting low-grade pain may be one of the keys to improved function in back pain.

The intervention that shows the most benefit? Keeping active. Millions of dollars of research to tell us that "motion is lotion, baby." Not as in moving propane tanks or other heavy activity that makes the pain worse, but just keeping moving.

Richard Weber was doing something he has done many times before - tossing his daughter's hockey equipment into the trunk of his car.

But this time, as he twisted, he felt a twinge. Twinges led to pain in his lower back, occasionally shooting down into his buttocks and up to the middle of his back.

Mr. Weber did what a lot of people do for low back pain: he stayed home from work, stretched out on the couch and downed some painkillers. Then, wondering if he might have some disease of the spine, he came to see me.

He was surprised, after I took a medical history and performed a physical examination, at my advice for follow-up tests: none.

Low back pain is ubiquitous. More than 90 per cent of people experience it, with between 25 per cent and 45 per cent of adults suffering repeated bouts. Most back pain is short-lived, though in about 5 per cent of cases the pain lasts longer than 3 months and becomes "chronic."

For the 95 per cent who get better, back pain is an example of an ailment for which, in the vast majority of cases, there is no disease. Most times, even though the pain is very real, there is nothing to see on further investigation.

Back pain doesn't quite fit into the latest-and-greatest form of care that patients and doctors find so seductive: cutting-edge testing and CSI-style sleuthing for pathology. In dealing with back pain in the vast majority of cases, low tech trumps high tech, and an astute history and physical exam are still the most valuable tools.

In back-pain patients, only one in 2,500 X-rays actually detects something that was not suspected on the initial physical exam, according to research by Richard Deyo, a professor of medicine at the University of Washington and a leading low back pain researcher. Three recent studies of early use of MRIs in low back pain showed no improvement compared to patients who had just had a history and physical done.

Many patients are skeptical when told that they don't need to have any tests. Skipping the tests goes against the usual pattern of doctoring: diagnosis, prognosis, treatment. So practitioners do more X-rays than are necessary, partly because it is easier to test than to explain. But the X-rays seem to offer an unintended benefit: patients are reassured, and even if there is a little pain they get off the couch and return to their normal routine.

Getting off the couch and accepting low-grade pain may be one of the keys to improved function in back pain.

In a 2004 study of 134 airport baggage handlers published in the Annals of Internal Medicine, researchers took a different tack by not focusing on the pain itself, but rather on how the workers saw it. Workers went through the same motions that gave them pain, but instead of thinking "this is bad," they were trained to think "this is normal."

The group that focused on functioning normally was laid up for an average of 58 days compared with 87 days for those who didn't get the therapy. The researchers concluded it was a case of mind over matter: if you don't mind, it doesn't matter.

Predictors of worse outcomes, according to other research, are a belief that back pain is harmful and disabling, a fear and avoidance of activity and movement, a tendency to low mood and withdrawal from social interaction and, finally, a belief that passive, not active, treatments are best.

The intervention that shows the most benefit? Keeping active. Millions of dollars of research to tell us that "motion is lotion, baby." Not as in moving propane tanks or other heavy activity that makes the pain worse, but just keeping moving.

In the acute phase, physiotherapy, anti-inflammatory and so-called muscle relaxant medications, self-care exercises, massage and manipulation all seem to provide a marginal benefit in reducing the severity and duration of pain. The success of the interventions may be mostly about their ability to get you moving again.

Ultimately, the paradox of low back pain is that it's real, but almost always there's no disease. The pain has no perfect explanatory model.

This can be tough to accept.

For you, that means back pain is likely going to happen, it's going to hurt, but, like many other things in life, attitude makes the difference.

For me, it's a reminder of the power of fundamentals: a good history and physical, shared decision-making and reassurance.

Michael Evans is an associate professor at the University of Toronto and staff physician at the Toronto Western Hospital.

mevans@globeandmail.com