Why your chronic lower back pain has nothing to do with a herniating disc – from a physical therapist - Be My Healer
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chronic low back pain

Why your chronic low back pain has nothing to do with a herniating disc

From a physical therapist

​My new patient is sitting on a treatment table with a piece of paper in his lap.

"My pain is worse this week. I'm afraid it's that disc again. ​You know, they took an MRI 6 years ago and found a herniated disc in my back. I've been having back pain since then. You wanna see the imaging report? I still have it."

This scenario is all too familiar for those I have treated in the past with chronic low back pain. The concern about the relationship between the disc pathology and lower back pain is a tricky subject. In this post, I will help you to figure out: how likely (or unlikely) is a herniated disc causing the chronic pain you feel in your  ​lower back. 

Does a herniated disk causes pain?

high risk job

Do you think this is an absurd question? Not so fast!

In 1994, a study published in the prestigious New England Journal of Medicine by Jenson et al took low back MRIs of 98 pain-free individuals. The imaging result revealed that 52% of this imaging demonstrated a disc bulge and 27% demonstrated disc protrusion (which is more severe). They even found one that had full blown disc extrusion. 

Here's a another study.

​Dr. Norbert Boos did a study in 1995, where he gathered 46 "high-risk" pain-free individuals and took their low back MRIs. "High risk" means that all these people had had jobs that required them to perform frequent bending, lifting, twisting, vibration and etc. The results indicated that 76% of this high-risk group of individuals had at least one disk herniation on their MRI. 13% of these herniation were considered "severe". 17% of the results had signs of nerve compression and 4% were even marked as "severe compromise". In a more general sense, 85% of the MRI results in this study qualified for a diagnosis of Degenerative Disc Disease (DDD). 

Yet, these people had NO PAIN!!!!​ 

The take-away message up to this point: things are not that straightforward.​

​Okay, what about those who have a lot of pain from a bulging or herniating disc?

What does acute disc herniation feel like?​

Acute disc herniation can occur with a sudden improper load of the lumbar spine. You may have twisted your back during soccer coaching, picked up a heavy rock(this story came up quite often), or over-did yourself in the yard. The symptoms may happen immediately. More oftenly, people start to experience a dramatic increase in pain a few hours after their incident, and symptoms normally worsen over the course of the following 48 hours.

disc herniation

You are likely to feel a combination of some of the following symptoms:

  • ​Screwdriver stabbing pain in low back, focused on one side. (The disc is likely to herniate to one side only).
  • Pain worsen with bending, especially both on the way down and on the way back up.
  • Significant pain increase when there is an increase in abdominal pressure, such as trying to sit up from a lying position, bowel movements, coughing, etc.
  • Severe stiffness in the morning, difficult getting out of bed.
  • Standing feels better than sitting. (however, prolonged standing or sitting will worsen this pain. Frequent gentle change in position to relief pain)
  • SCIATICA! Yes, I used this word here because people recognize it. In other words, nerve pain and symptoms are often part of acute lumbar disc herniation. This includes leg numbness, tingling, weakness or pain, often with highly sensitive buttocks. 

​Acute disc herniation, like a stab wound or a broken bone, will hurt and may even disable you temporarily. However, it normally heals and people go on with their lives. How does acute back pain becomes chronic low back pain? Now, this is more complicated.

What's a more prevalent course of development for chronic lower back condition?

Here is a weird analogy. Because it is weird, I hope it can be memorable as well.

Danger of nuclear explosion

I once watched a documentary about the physical effects of nuclear bomb.

The most immediate and impressionable part of the bomb is the explosion, the fire, the mushroom cloud and the deafening BANG.​ Almost simultaneously, the explosion creates a shockwave of air pressure. This effect is called the blast. The x-ray-heated air blasts off in all directions, traveling at speed faster than sound, tearing down most buildings and structures within a 1 mile radius.

The shockwave carried fireballs, setting anything flammable on fire, forming a firestorm, spreading and consuming, covering the damaged area of a 2-mile radius.

The most talked about effect of the nuclear bomb was the radiation. The bomb created an air bust, carrying the radiation into the atmosphere. Some of the radiation was then spread and taken away by wind. The coverage and damage of the radiation over years and generations was tragic and shocking. Yet, this is not the end of story.

​After witnessing the power and deadliness of the weapon, the world was drenched in fear. This fear of world destruction, and the entity possessing this weapon stirred the world conflicts and politics for decades after the initial event that we remembered. 

This is an extreme story and analogy. But we can learn and relate a lot regarding the effect of impact. Any injury to our body is a form of impact, whether it is a broken bone, a torn muscle, or a herniated disc. Locally, this impact of injury will cause a surge of inflammation, swelling and lots of pain signals traveling up to our brain. This dramatic discomfort forces us to rest and load the damaged body part. In the case of a herniated disk, the damaged body part is our spine. 

The secondary effect of injury ​is is targeted at surrounding muscles. All muscles surrounding the injuries will jump into spasm mode in order to protect the injury site. In the case of a herniating disc, this effect translates into unrelenting and widespread stiffness and soreness in the mid-to-low back area, as well as in the buttocks and thighs.

The most global effect of injury is targeting our movement pattern

stop function

In the case of disc injury, the spasming muscles and prolonged bed rest will cause weakening in the large core muscles, forcing other muscles to replace and mimic the function of these core muscles. These "compensating muscles" are not meant for this important role. They are likely not protecting the spine as well as the core muscles can, and are not built with the endurance to do this long-term. In the long-term, the spine will be irritated from poor stability (a lack of core muscle protection) and the compensating muscle will scream in pain from overuse. Over the years, when your disc is no long "the injury," your back will still hurt, not from a herniated disk, but due to this altered mechanical change in musculoskeletal function.

Chronic lower back pain is often composed of:
  • Weak and underused core muscles
  • Overused and painful compensating muscles: 
  • Underprotected and unstable spine
  • Excess loading of spine due to muscle and posture imbalance: lower body cross syndrome

This collection of mechanical problems in lower back increase the risk of additional lower back conditions, such as spinal stenosis, degenerative disc disease, nerve root compression and etc.

Is this unavoidable? Are we doomed to have this? NO!

In fact, the majority of people recover from their herniated disc under two years, regardless of treatment. So, what makes some people's acute back pain turn chronic? This is a highly mystic and debated issue. Some more obvious factors are:

  • ​Lifestyle factors such as: smoking, overweight...
  • Work related factors: sedentary work, back strenuous work
  • Health related factors: diabetic, endocrine system related conditions, digestive/pelvic floor related conditions
  • psychological factors: stress, fear avoidant behaviour, victimization...

Fear Avoidance

Out of all the reasons for one's acute disc injury to become a chronic issue, the one factor that I want to talk about the most is: fear avoidance. Fear avoidance is a mindset, where one is afraid of using the injured body part, fearing the consequence of re-injury, even though the stage of healing has passed the acute, even subacute phase.

"Fear" is a powerful ingredient. ​Fear avoidance is a mindset, where one is afraid of using the injured body part, fearing the consequence of re-injury, even though the stage of healing has passed the acute, even subacute phase.

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Imagine this: you broke your shin bone playing soccer (or you call it football)​. You got x-rayed. You got casted. Three month later, cast off and you are instructed to practice weight bearing and walking. Putting weight through this healing bone is essential because the force will promote cell growth and proper collagen alignment. However, 12 weeks of immobility will result in calf atrophy. As long as you take it slow, stretch and strengthen the calf and entire lower leg properly, you will have yourself a strong limb to run and jump with. 

fear avoidance

However, ​fear avoidant mindset will prevent you from putting weight on the injured leg. Not only does your bone experience a hard time heal properly, the limping and uneven walking pattern will cost multiple joints to take on excessive loads and deteriorate after a while. You will likely decrease overall activity level and settle into a sedentary lifestyle.

People are more familiar with broken bones, thinking it is ridiculous to sit-out in life for a fracture.​ However, disc herniation injury is very similar too. Easing back to activities as soon as you are feeling better is crucial to rebuild those core muscles early on. But things does not always happen that way.

The patient sitting in the doctor's office, being told that they just herniated a disc. The doctor tells the patient that he should rest and avoid bending, twisting, lifting to avoid worsening their situation. ​This is all perfect, except that the doctor forgets to add, that these restrictions are for the acute stage of this injury, not for life. 

So many patient, as long as 20 years after their diagnosis or surgery, are still not bending, lifting, twisting their back at all. Without these movement, there is no capable core muscles to stabilize and protect our spine. In this case, your current chronic low back pain has nothing to do with the herniation disc.

Bottom Line: Were you diagnosed with disc herniation, and even went through surgery? If you have been experiencing pain chronically, and your pain pattern does not match with the symptom of an acute disc herniation, you should take a deep breath and embrace the good news. Your pain may no longer be coming from your disc injury. Core muscle weakness and postural imbalance can be treated conservatively. Keep an open mind, optimistic and determined spirit and find help from physical therapist, massage therapist or other conservative health providers. 

Thank you for reading, and I hope you find this post helpful.

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