Spinal pain, more than any other pain we see in clinic seems to induce the most fear and the most intense emotions in general. Perhaps this has something to do with the spine being our centre, an unavoidable part of our daily movements. Perhaps it is also due the horrific, well publicised consequences of severe injury such as paralysis. However I believe that we as a medical community have contributed greatly to the fear that surrounds this incredibly elegant structure. Terms such as “degenerative disc disease” and “slipped disc” conjure horrific images of degradation and in reality, a disc actually never “slips”, it is a misnomer. Back pain, that will effect 8 out of 10 individuals during their lifetime, is mostly self-limiting and does not require extensive medical management.

The Words We Use Are So Important

A study by Darlow et al (2013) clearly demonstrated that when we as clinicians say “chronic” as in “chronic pain” patients hear “two steps from a wheelchair”; when we say “wear and tear”, patients hear “something is rotting away”; and when we say “neurological,” patients hear “death within 6 months, could be a tumour”. Despite this, these are terms so often used in conjunction with scary diagnostic descriptions such as “spondylosis”, “prolapsed intervertebral disc” and “cervical herniated disc”, “disc dessication” and “cervical or lumbar foraminal stenosis”.

We often make the situation worse with investigations

This fear evoking pathway continues with our obsession with investigation. There are indeed times to do an MRI or X-ray. Generally, this is when there are “red flags” such as concerns regarding infection, fracture, tumour, cord compression or neurological symptoms relating to nerve root compression such as numbness or weakness that are progressing over time. Aside from these and specific considerations relating to either auto-immune conditions and perhaps scoliosis monitoring in adolescents there really is little need to be scanning a spine.

Imaging Studies Over Report Pathology and Cause Fear and Unnecessary Treatment

The majority of my patients who I see for either cervical or lumbar pain enter the room and when asked how they can be helped proclaim “well, it all began when I slipped a disc” or “well, I have an L4/5 disc degeneration”. To which I generally reply, sure, “don’t tell me what you’ve been told you have, tell me what you’re feeling, tell me what happened”. This is key, because in reality, most of the time, the structural diagnosis is either irrelevant or only a part of a far wider picture.

Once we are in our 40’s almost 75% of adults with NO SYMPTOMS will have disc degeneration on MRI. 50% of adults with NO SYMPTOMS will have a disc bulge and close to 40% will have “facet joint” degeneration, again, with no symptoms. So why is it when patients with low back pain are sent for MRI’s that suddenly these findings are used to explain their pain, sometimes with very little clinical objective examination performed? In reality, it’s lazy medicine and probably stems from our need as clinicians to give a concrete answer, to be seen as the person with knowledge, because a question has been asked and we would be incompetent to not give clear answer.” The toughest answer, “we don’t know, it could a multitude of factors” is harder to justify, harder to sell and hence we fall back on descriptions of structure which could be irrelevant.” In reality the correlation between MRI findings and low back pain is, wait for it, 10%. More importantly it is found that patients who have MRI’s often have worse outcome regardless of their pathology and this is explained by the fear the follows the structural explanation of their pain (Webster and Cifuentes (2010).

“In reality the correlation of MRI and low back pain is 10% “

Fear creates pain, reduces healing, causes inflammation and movement avoidance and abnormal movement

When patients are stressed, 170 genes relating to inflammation are upregulated (Roy et al, 2005). Stress causes a 40% increase in wound healing times and biases our body towards cell death. Fear and stress also create neurotags, signatures in our brain related to experiences that are stored for future protection so that we don’t hurt ourselves again. These however can even be triggered by situations that don’t actually have the potential to cause harm. The more we hear words that affirm our fears, the stronger these signatures become. Our brain now has the ability to “give us pain” where there is no injury. So now we have a situation where we can have pain with no injury and the stress of it is causing inflammation and delayed healing potential. More than that, as healthcare professionals we often try and give advice that gives us legitimacy justifying our own role in their journey of a patients rehabilitation such as:

“You have a weak core”

“You have weak glutes”

“You are out of alignment”

“Your posture is wrong”

“Your gluts have switched off”

Each one of these deserves its own article however in reality, many patients with ongoing low back pain have “overactive cores”, weak glutes may occur in some individuals but it must be assessed formally and may or may not relate to pain. Alignment varies greatly amongst pain free individuals and more often than not does not need to be and cannot be corrected. There is very rarely a “wrong” posture only a posture that is overly dominant and requires movement and variation to fix. Short term postural changes, I caveat, are often helpful but this does not mean that one posture is “wrong”. Switching “on” muscles implies that they were “switched off” in the first place. This again tends to only occur in the presence of pain and inflammation or neurological injury. The answer is not to try “switching them on” during our activities but instead to reduce pain, inflammation, fear of movement and embark upon a progressive strengthening programme.

So, What is The Answer?

The answer is that a comprehensive evaluation begins the process that considers the patients background, symptoms, objective findings and not only their biochemical, structural and mechanical state but also their psycho-emotional state and belief systems.

Imaging and blood tests should be judiciously used in specific cases but not as a general screening tool. Treatment should consider the multifactorial nature of pain and therefore be highly individualized. There should be a consideration of pathology and structure but also biochemical (inflammatory state), biomechanics but importantly a patient’s lifestyle and psycho-emotional state that may contributing to their injury or pain; this includes, sleep, activity levels, stress and belief systems regarding their condition.

Treatment?

Treatment should be founded upon a careful, sensible and where possible re-assuring explanation of the multifactorial nature of low back and neck pain. Just reducing fear can cause huge changes in the brain of patients with low back pain. In the images below you can see the functional MRI changes in a patient with low back pain on arching backwards before and after a 30minute pain education treatment (Louw et al, 2015) that were accompanied by significant reductions in pain. The top picture shows the patient’s brain at rest, second whilst arching her back prior to treatment and third row whilst arching her back following “treatment”.

Yes, we can use modalities, manipulation, dry needling, taping and other interventions to modulate the nervous system, restore soft tissue length and integrity and use exercise to support the spine and re-establish normal movement patterns, but our first job must be to reduce fear, educate and empower otherwise the rest of the journey becomes incredibly difficult indeed.

References

Darlow, B., Dowell, A., Baxter, G.D., Mathieson, F., Perry, M.,& Dean S. (2013) The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013 Nov-Dec;11(6):527-34. doi: 10.1370/afm.1518. PMID: 24218376; PMCID: PMC3823723.

Roy, S., Kannah, S., Yeh, P.E., et al (2005) Wound site neutrophil transcriptome in response to Psychological Stress in Young Men. Gene expression Vol12 4-6:273-287

Louw, A., Puentedura, E. J., Diener, I., & Peoples, R. R. (2015). Preoperative therapeutic neuroscience education for lumbar radiculopathy: a single-case fMRI report. Physiotherapy theory and practice, 31(7), 496–508. https://doi.org/10.3109/09593985.2015.1038374

Webster, B. S., & Cifuentes, M. (2010). Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. Journal of occupational and environmental medicine, 52(9), 900–907. https://doi.org/10.1097/JOM.0b013e3181ef7e53

Spinal (Neck and Back) Pain – As Doctors and Health Professionals We are Contributing to The Problem.