Stop doing THIS if you want your lower back pain to improve!

Stop doing THIS if you want your lower back pain to improve!

Crap, I have lower back pain

How did I do this

Why did this happen to me

Is this permanent 

What happens next 

Will it ever go away 

Is my back never going to be the same

Will I be able to do what I love 

Lower back pain… It’s an emotional rollercoaster. For some of us, it is a constant battle to encourage ourselves that our lower back pain will get better and facing the harsh reality of the actual pain. This is a common issue, and research indicates that up to 4 in 5 people will experience lower back pain during their lifetime (Rubin, 2007). That statistic is staggering, and highlights the need for good information regarding lower back pain. 

Lower back pain can occur from sport, lifting something too heavy or even during random occurrences that happen bending over to do something trivial. What does happen following the onset of lower back pain can be a flood of emotion, anxiety, worry and anger. Then, the sudden flurry of how did I do this, what should I do, how can I prevent lower back pain from happening to me, why me…? 

The Golden Rule

Our number one rule for dealing with any back pain is: 

Do Not Worry. 

Lower back pain happens, and is a natural occurring part of life. Do not get hyper focused on the cause and the pathology of your lower back pain. Even experienced health practitioners are unable to diagnose you and deduce the exact anatomical reasons for your lower back pain. Investigations may be warranted in SOME situations, but are rarely necessary. What we want to make sure is we: 

  1. Take a deep breath 
  2. Calmly analyse the situations and rule out red flags
  3. Use immediate pain relief strategies to get you going through your day
  4. Plan and formulate a structured program for long-term pain management and prevention
  5. Keep calm and keep moving!

Often following onset of lower back pain, our muscles will seize up. We will stress and worry about whether the next move we make will hurt our back. Good thing is, any movement you do is unlikely to cause any harm to your lower back (provided you don’t have any red flags). Instead, all kinds of movement is much more beneficial and can have fantastic effects on your pain and functional movement. 

The One Big Myth

However, there is one myth in particular that can be damaging to your recovery and refuses to die. That is: 

You must keep your back straight when you lift. 

But in today’s world of modern science and medicine, is this actually relevant? Will you break your back if you lift from the ground with a bent back? 

First things first… Slipped discs and broken backs are terms of the old. There’s now more than enough evidence to suggest that even with a “broken back” you could also have very little pain or issues. Even the MRI results that you receive is usually insignificant in establishing the link to your lower back pain. Instead, we should be focusing on aspects of your life including your physical activity levels, psychological barriers or even variables such as home or work stress. 

What does the research say? 

There is a large plethora of research to support the notion that lower back pain is not increased when bending your lower back while lifting (Nolan et al., 2018; Saraceni et al., 2020; Swain et al., 2020) . With no consistency of evidence that support the belief that lifting with a straight back is safer, why is it recommended?

In fact, the implementation of lifting advice in health care HAS NOT resulted in reduced lower back pain in occupational environments.

Saraceni et al. (2020

Well it seems that for many health professionals, previous experience and negative beliefs of lower back pains drives these recommendations (Nolan et al., 2018). Fortunately, with the advent of new research healthcare practitioners are steadily becoming informed. So why is this important?

Negative Beliefs and Lower Back Pain

Well, your lower back pain can improve by reducing the amount of factors that we need to worry about. Particularly, when considering the link between the severity of lower back pain AND negative beliefs (Urquhart et al., 2008). In a study of 506 participants, it was found that negative beliefs were associated with high pain intensity of those with lower back pain (Urquhart et al., 2008).

Through the use of a negative beliefs questionnaire, they were able to establish which individuals had poor perceptions of their lower back pain. An example of a negative beliefs questionnaire is the Fear Avoidance Belief Questionnaire (FABQ). Which includes questions such as:

  • I should not do physical activities which (might) make my pain worse
  • My work makes or would make my pain worse
  • I do no think that I will be back to my normal work within 3 months

 What should we be worrying about? 

There is emerging evidence that loading of the lumbar spine may be a risk factor for the risk and persistence of lower back pain (Saraceni et al., 2020). Essentially what this means is:

  • Heavier objects to lift = more stress on lower back

The natural response for most people would be to avoid lifting heavy objects. However, what do you do when lifting heavy objects is your job? In these situations, avoiding lifting is impossible and another solution is required. A simple principle can be applied when identifying these issues, and is one primarily built on the principle of “load tolerance.”

Take these two case studies for example:

Case Study 1

  • John initially came in complaining of lower back pain during a lifting task of his workplace equipment ~20kg. John started off lifting the bar (20kg) for the deadlift exercise in the gym. Initially he is hesitant, and lifting the 20kg bar was heavy and difficult to complete.
  • Over the next few weeks, John improves his strength and is able to lift progressively more and more weight. 12 weeks later, John is able to lift 60kg for the deadlift exercise in the gym. Now when John warms up for his session, the 20kg bar is now warmup weight and he does not need to be mentally focused or ready to complete this exercise.
  • This is because John has built up “load tolerance,” and now has 40kg off leeway from his heaviest attempts to complete his warm-up deadlifts. Now when John goes to work, lifting the 20kg equipment is significantly easier.

Practical Takeaways 

Have no fear, because… Unless you have clearly identified red flags that warrant immediate medical attention, your lower back pain will get better. While not having a straight back doesn’t have evidence to support its utility from any normal lifting motions, doing whatever feels comfortable for you and what will let you go through daily life is the most important.

However, we must learn to limit the amount of negative connotations and thoughts we have associated with lower back. As negative mental status can lead to detrimental outcomes in lower back pain.

References 

  • Nolan, D., O’Sullivan, K., Stephenson, J., O’Sullivan, P., & Lucock, Mi. (2018). What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskeletal Science and Practice, 33, 35 – 40.
  • Rubin, D. (2007). Epidemiology and Risk Factors for Spine Pain. Neurol Clin, 25(2), 353 – 71
  • Saraceni, N., Kent, P., Ng, L., Campbell, A., Straker, L., & O’Sullivan, P. (2020). To Flex Or Not to Flex? Is There A Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 50(3), 121-130. 
  • Swain, C., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312. 
  • Urquhart, D. M., Bell, R, J., Cicuttini, F. M., Cui, J., Forbes, A., & Davis, S. R. (2008). Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women
Beware of this uncommon and dangerous ankle sprain…

Beware of this uncommon and dangerous ankle sprain…

Many of us roll our ankles throughout our lives. An ankle sprain seem to be a common occurrence in life. Whether that be through playing sport, recreational hobbies like hiking or even just stepping off the sidewalk wrong… It’s a natural and normal part of our lives.

However, one specific ankle sprain requires more attention that most. If it’s managed poorly, it could have profound effects on your livelihood and outcomes in the future. 

Case Study: Poor Management of a Ankle Sprain

The history: 

A ~30 year old female suffered an ankle sprain after being intoxicated and stepped off the sidewalk poorly.

  • Initially thought it was a simple ankle sprain – Basic RICE principles (rest, ice, compression and elevation) applied 
  • Doctor review after 2 weeks when it wasn’t getting better.
  • X-ray was performed that ruled out all fractures 
  • The doctor provided pain medication and told her to rest her ankle.
  • Physiotherapy consultation at 4 week mark due to worsening ankle pain

The examination:

  • Ankle felt unstable and had increased laxity on testing
  • Was unable to pivot on foot due to pain
  • Decreased ability to put weight on foot and walk
  • Decreased balance on affected foot
  • Pain in the middle of ankle on touch
  • Positive physiotherapy stress tests including: Side-to-side, external rotation and weight bearing lunge test

The treatment: 

Immediate referral to a new GP, which created a cascade of events including:

  • Emergency X-Ray and MRI which revealed a Syndesmosis injury with tibiofibular diatasis (which the previous GP missed)
  • Referral to orthopaedic specialist from GP
  • Immediate booking for ankle surgery to stabilise the ankle joint
  • Surgery performed and referred to physiotherapy for routine post-op care.

Ankle Sprain: Syndesmosis

For the more astute clinicians or health practitioners, many would know that I’m immediately referring to a syndesmosis injury – otherwise known as a high ankle sprain. This case was poorly managed, as the follow-up with the doctor should have included further investigation. Especially because the ankle pain wasn’t resolving. Usually, recommendations should be made to see a physiotherapist before a doctor for most simple ankle sprains. 

Unfortunately for this individual, had the right assessments been completed and monitored over weeks, a surgery would have been avoided. The individual would have been able to recover in a earlier time period and eventually would have returned to her daily gym and sport routine. 

Epidemiological data suggests as many as 1-2 out of 10 people will suffer a syndesmosis ankle sprain (Williams & Allen, 2010). Although it’s an injury that largely occurs in athletic populations, there have been many cases – like the one above – where syndesmosis injuries happen in every day life.

The Basics: Anatomy 

The syndesmosis joint comprised of a few structures, primarily: 

  • Distal tibia and fibula 
  • The ‘syndesmosis’ itself (interosseous tibiofibular ligament connecting the fibula and tibia together) 
  • The many ligaments supporting it (anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL) and transverse tibiofibular ligament (TTFL)).
Basic outline of anatomy of the ankle syndesmosis.
Basic outline of anatomy of the ankle syndesmosis.

In a syndesmosis sprain; we are worried about the connection between the two shin bones (tibia and fibula) being pushed apart. Disruption of the ligamentous structures holding these bones can cause the ankle to have excessive movement and mobility through the bones. This is extremely detrimental to all facets of life including walking, running and any form of lower limb exercises. Therefore, recommendations to stay away from excessive weight and pain is imperative, as it allows the ligaments to heal back into it’s natural positions. 

Long-term complications including chronic ankle instability and recurrent ankle sprains can arise if this is not treated properly. Other long term complications can include chronic pain in the ankle, loss of strength and range of motion in the ankle. 

Common Signs of a High Ankle Sprain

  • Mechanism of injury (The how of the injury): Forceful external rotation of the ankle (knee turns outwards relative to the ankle)
  • Swelling around the middle and outer edges of the ankle
  • Tenderness directly over the middle of the ankle
  • Positive physiotherapy stress tests, including: external rotation , fibular translation and squeeze test

Therefore, the following few symptoms are indicators you should get your ankle checked ASAP by a qualified health professional:

  1. Pain that increases when your knees go past your toes (i.e lunging, up stairs) 
  1. Pain with pivoting on foot
  1. Your ankle feels loose and unstable 
  1. Unable to point your toes 
  1. Unable to put full weight on ankle

Timeline for Recovery for the Syndesmosis Ankle Sprain

The following guidelines for recovery are based on the recommendations suggested by Williams & Allen (2010). These are only ‘guidelines’ and do not reflect the recovery that you or anyone else may experience. A host of individual factors can influence the speed in which you recover back to your baseline and must be considered in any injury.

First 6 weeks – Protecting the Ankle

  • A combination of moonboot / crutches to reduce weight bearing and protect ankle
  • Gentle ankle movement exercise to reduce stiffness
  • Prevention of re-injury
  • Pain management, including: medication, ice or heat therapy and gentle massage

Progression to next stage when: Able to fully put weight onto affected leg and walk stairs and uneven ground with minimal discomfort.

6 – 12 weeks – Normalising walking and movement

  • Gait retraining
  • Calf and foot strength exercises 
  • Balancing exercises such as single leg stands, tandem stance.
  • Ankle stretches and range of motion exercises (pain free) 

Progression to next stage when: Hopping and running has minimal discomfort.

12 weeks + Return to sport or hobbies

  • Reintroduce lateral plane movements 
  • Begin gentle sport specific activities (i.e. agility drills, controlled training drills) 
  • Conditioning and steady-state movement (i.e. jogging and running, jumping rope)

Steadily build on your fitness and strength in the ankle, as well as progress your sport specific activities. When you are able to train pain-free and minimal discomfort, then a return to sport level activity should be warranted.

Caution Signs: 

A few warning signs to be wary of include:

  • Unable to put any weight on your ankle
  • Feeling severe pins and needles in your feet
  • Severe pain that is intolerable

The recommendation to go to the emergency department or your local GP is emphasised. During this stage, you must rule out an ankle fracture otherwise this will have profound long term consequences on your recovery. 

This specific ankle injury can potentially have serious consequences on your long-term ankle function. If you are unsure about the severity of your ankle sprain, please seek professional advice from a healthcare professional. 

Conclusion

This blog post is intended to make the viewer aware that a more serious type of ankle sprain exists. Syndesmosis sprains cannot be managed like a ‘usual’ ankle sprain and can take longer to heal. The main messages for this post are to contact a medical professional if:

  • You exhibit any of the Caution Signs
  • The pain doesn’t seem to be improving
  • You are concerned about your ankle sprain or pain

Like any other injury, syndesmosis sprains can heal. However, proper management and a structured rehabilitation program is necessary to make sure a favourable outcome is made.

References 

  • Bleakley, C. M., McDonough, S. M., & MacAuley, D. C. (2008). Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Australian Journal of Physiotherapy, 54, 7 – 20
  • Physiopaedia. (2020). Tibiofibular Diatasis. Retrieved from: https://www.physio-pedia.com/Tibiofibular_Diastasis
  • Williams, G. N., & Allen, E. J. (2010). Rehabilitation of Syndesmotic (High) Ankle Sprains. Sports Health, 2(6), 460 – 470.
6 Ways to Relieve Your Shoulder Pain Now!

6 Ways to Relieve Your Shoulder Pain Now!

Do you suffer from shoulder pain? 

Does something as simple as lifting the kettle make you cry out in pain? 

Do you feel scared of lifting your arms? 

Do you feel like your shoulders and neck are always tight?

This blog post aims to explain to you why you might be getting your shoulder pain and how we can relieve your pain NOW, but also keep it away for good! Shoulder pain is extremely common… In fact, as much as 20% of the population can be suffering from shoulder pain (Pribicevic, 2012). That’s 1 in 5 people! 

Now the prevalence and especially severity of shoulder pain can have profound economic impacts for the individual and their families (Pribicevic, 2012). This is influenced by a host of factors, including:

  • Age
  • Gender 
  • History of shoulder pain
  • Your occupation / work 
  • Psychological factors 

Diagnosis of shoulder pain

Unfortunately, a rigorous diagnosis cannot be made from the comfort of our own home. However, the good news is that many of these issues have one thing in common – that is they don’t actually matter a whole lot. In fact, the research shows us that many asymptomatic (no pain) individuals have these diagnoses on perfectly healthy and non-painful shoulders. 

A quick google search of shoulder pain may lead you to finding the following terms: 

  • Bursitis 
  • Tendinitis / tendinopathy 
  • Rotator cuff tears
  • Shoulder impingement syndrome 
  • Instability 
  • Arthritis 

The pathological terms such as bursitis or shoulder impingement syndrome have been contested by a plethora of research. The majority of which is written by Jeremy Lewis, a renowned shoulder specialist in physiotherapy management of shoulder pain. Essentially, shoulder pain should not be necessitated by complicated terms and biomechanical principles. Instead, should focus on simpler subject matters like load tolerance, daily activity and strength of the muscles in the shoulder. 

But my doctor told me I needed an injection…

More relevant perhaps, is the increasingly common shoulder procedures recommended by “shoulder specialists” and doctors. These include subacromial decompressions, rotator cuff repairs and corticosteroid injections to resolve shoulder bursitis. Let’s do a quick 13 reasons why compressed into 3 reasons as to why it’s not relevant: 

  • Subacromial decompression: The relevance of the acromion (You may have heard of acromion types) to rotator cuff pathology of pain is not well supported by research. 
  • Rotator cuff repairs: Over 50% of people over the age of 60 without shoulder symptoms had a partial or full thickness rotator cuff tear 
  • Bursitis: 96% of men who did not have shoulder symptoms, had abnormalities including subacromial bursal thickening, supraspinatus tendinosis and tears and glenoid labral abnormalities. 

Data from Lewis (2016)

So now that we know that the diagnosis is not necessarily important for the shoulder when considering shoulder pain, what should we do then? 

Outlining the six-step process 

1. Short term: Immediate pain relief 

Some of the following immediate pain relief strategies seem very basic, and common sense. These short term pain relief strategies include: 

  • Over the counter (OTC) pain relief (*DISCLAIMER: I am not a doctor, and am in no way recommending you to go get pain relief. Instead, a consultation with your doctor should be made prior to buying any pain relief, especially if you are taking any other medication). 
  • Heat therapy, such as: a heat pack, a hot shower or hot bath 
  • Cold therapy, such as: a ice bath, cold pack or cold shower 
  • Avoiding provocative movements / finding comfortable resting positions

The reason why I don’t have any specific recommendations between ice and heat, is because the effects of both are usually due to preference of the individual. Some do not tolerate ice packs and some do not enjoy the feeling of heat on their shoulders. However, the general precaution is heat should not be applied in the first 72 hours post injury. This is even more important if there is obvious swelling or inflammation around the area, in which case the heat could make the swelling worse. 

The other precaution is: avoiding provocative movements. The first and most important rule is do not avoid all movement. This may seem counter intuitive to some, but is especially important for recovery of all injury. That is because avoidance of movements can have profound effects on your recovery, and also your mental and psychological health. This does not just pertain to the shoulder joint, but to all joints and pain. When considering pain, we must consider the impact of a host of other factors, including psychological and social factors. This is called the “Biopsychosocial Model”, which I have mentioned in a separate post

2. Short term: Self-Massage

Trigger point or self-massage is fantastic for short term pain relief and increasing function in the short term. Usually with any pain, there’s an associated tightness of muscle in and around the affected joint or area. A release of this muscle can provide temporary relief that lasts anywhere from a few minutes, up to a few days. The easiest way to massage is to find a tennis ball, baseball or anything that can help massage your shoulder and then push it into the back of your shoulder blade area: 

Massage can be administered for 3 – 5 minutes, or until tolerated. Be aware that massaging for too long or too hard may lead to bruising or increased soreness around the area.

Self-massage or trigger points of these muscles can make your joint feel much ‘looser’ and provide good pain relief. However, massage does not inherently make your shoulder stronger, more flexible, increase durability or provide any long-term benefits; many times the shoulder pain will return after a short time.  Therefore, we recommend self-massage in conjunction with the next few steps described.

3. Medium term: Stretching 

Stretching of tight muscles around the area may help with additional pain relief. However, similar to the self-massage, stretching only provides moderate short term relief and benefits, and usually your shoulder pain may return once the stretching has ceased or you return to activity.

Shoulder stretches include: 

  • Posterior capsule stretch
  • Pec stretch
  • Overhead stretch

Each stretch should be held for 15 – 30 seconds and should not be pushed into painful areas. Repeat throughout the day as needed or tolerated.

4. Medium term: Movement modification 

Shoulder position while sitting is… important, but at the same time it isn’t. Think of standing in cue for a long period of time – some of us can stand completely still without moving, but most of us need to shift our weight, move side to side, slouch to one side and then the other. That’s a completely normal process of our body, that allows us to have freedom of movement and essentially allows us to keep our joints moving. 

The same concept applies to your shoulder joints – there is no perfect position at a desk or workplace to “set” your shoulders. Anyone who tells you to sit in one position for hours at a time likely doesn’t listen to their own advice. Instead, posture and sitting position is a RANGE. Movement within that range is important, as it allows for your joints, muscles, ligaments and bones to move. As long as you provide some constant movement, you will find that your shoulder pain will ease quite quickly. That being said, there are some modifications that may feel beneficial to your shoulders while they are sore and painful. 

4a) Desk position

The ideal posture… Forearms on desk, feet firmly planted on the ground, shoulders upright. This seems to be the quote-on-quote, best posture for many individuals.

The “ideal” posture

However, these postures are also absolutely fine and will not cause your shoulders to suddenly break down.

Understandably, when you’re deep in the middle of a project and you’re not paying attention to body position it becomes easy to forget. Fret not! Just keep moving again and using your shoulder joints and you will feel your shoulder start to relax and relieve itself. 

4b) Normal shoulder movement 

The common issue that many individuals have – whether it’s natural or learned – is depressing their shoulder blade down when lifting the arms up.

Keeping our shoulders ‘down and back’ may be harmful to your recovery.

Understandably, many were taught at a young age that good posture meant chest out, shoulders down even when reaching up and out rather than shrugging shoulders. However, this is not exactly a natural movement pattern and isn’t something that our bodies are designed for.

Our scapula’s don’t actually have a anatomical attachment to the back of your ribcage. This allows for a large degree of freedom of movement and is what our shoulders are designed for. So instead of keeping our scapula depressed, we should actively engage in their elevation and movement upward as we also move our arms upwards.

Actively shrugging our shoulders up as we move is normal.

5. Long term: Strengthening your shoulder

Strengthening of your shoulder can also occur in two parts. Namely:

  1. Isolated strengthening of the rotator cuff
  2. General upper body strengthening

The rotator cuff is as the name suggests, muscles that help rotate the shoulder. The primary ones that we focus on are your external rotators, called the supraspinatus, infraspinatus and teres minor. These muscles can be trained through isolated exercises such as:

Rotator cuff specific exercises:

  1. Sidelying external rotation exercise
  1. Sitting external rotation exercise

Please, please, please do not do external rotations in a standing position. Gravity works downwards, and if you do rotations in a standing position, you do nothing to work your rotators as they have no resistance to push again. This is why the exercises are so specific, in order to correctly target the rotators in a movement plane that is challenging.

If you want to do these in a standing position, a cable external rotation is a suitable alternative.

General upper body exercises

These exercises are as they suggest. Performing your normal gym or exercise routine that involves upper body strengthening. As all exercises that involve pushing, pulling involve the rotator cuff to some extent, these exercises are all beneficial in improving the strength and functionality of your shoulder.

If you are still having ongoing pain during certain exercises like the shoulder press or bench press, you can try decreased ranges or pauses at different points. For example:

  1. Shoulder press 
    1. Single arm variations using dumbbells
    2. Slow controlled reps
  2. Bench press
    1. Top half with pause
    2. Bottom half off the rack
    3. Decreased weight 

Long story short, there is no “Best Exercise” for strengthening the rotator cuff, as any upper body strengthening is beneficial in providing stimulus to the muscles.

However, the topics of load management, form and posture will need to be left to another blog post… Otherwise this one will become an essay!

6. Long term: Have no fear! 

Pain relief is fantastic, as it will allow you to feel psychologically and mentally better as well as allow you to do more things physically. Unfortunately, if we only focus on getting rid of our pain every time and not trying to create a long-term solution… This is where you start to get frustrated and angry because it just won’t go away.

Many times, we may be able to get temporary relief from massage, dry needling or any other fancy types of pain modulation. However, if we don’t fix the underlying problem, or the cause that may be exacerbating or worsening your shoulder pain, then it is likely to just return time and time again. 

Luckily for you, shoulder pain can be fixed, we just need to make sure we are on the right direction and pathway to create a situation that will allow it to fix. However, in order to do this, we must consider the solution from multiple directions and not just pain relief.

Warnings Signs  

Fundamentally, shoulder pain is generally not a concern unless you have the following symptoms: 

  • Severe pins and needles down the arms and into the fingers 
  • Heaviness, throbbing, “feels cold” 
  • Significant loss of strength and ability to grasp or lift objects 
  • If you have had a traumatic event prior to the pain starting 

If any of these signs and symptoms describe your situation, a urgent consultation with your local health practitioner is recommended to identify if you need further referral to the Emergency Department or investigations. 

Conclusions

Shoulder pain can be fixed. All it takes is proper management, understanding the right steps and creating a plan to address it. Hopefully through this blog post you’ve learned the six steps to creating pain free shoulders:

Short term: 

  1. Pain relief 
  2. Self-massage

Medium Term

  1. Stretching
  2. Movement Modification 

Long-Term 

  1. Strengthening 
  2. Have no fear! (Education) 

You’ve also learnt that many of the diagnosis such as bursitis, impingement and rotator cuff tears are not relevant to your outcomes! This has been one of our most comprehensive guides to date for any joint, so I hope you’ve enjoyed the read!

Leave us a comment or share this post with some of your family or friends!

References

  • Lewis, J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, 23, 57 – 68. 
  • Pribicevic, M. (2012). The epidemiology of shoulder pain: A narrative review of the literature. In Pain in perspective. IntechOpen.
The Bizarre Truth About Your MRI for Your Lower Back Pain

The Bizarre Truth About Your MRI for Your Lower Back Pain

Have you ever seen or heard of a family member who had an MRI of their lower back and were told: 

“Your back is degenerative” 

“You have a slipped or bulging disc” 

“Your back is like an 80 year olds” 

Back pain is prevalent, and is increasingly common in members of all ages. It isn’t uncommon to see a 20 year old student experiencing the same debilitating back pain of a person who is 50 years old. Regardless of age, common thoughts that many have following the acute onset of lower back pain is:

Is this permanent 

Will this ever go away

Will I ever be the same

The Initial Fear of Lower Back Pain…

The first point of action for most individuals is to seek our professional healthcare advice, usually from a physiotherapist or a doctor. Unfortunately, there are still many healthcare professionals who will immediately send you off for a scan of your lower back. Then, tell you there’s “nothing that we can do about it until the scans come back.

This leads into a negative spiral as individuals can depend on the results of the MRI scan as a “life or death” diagnosis. Namely, the severity of their lower back pain and their outcome is dependent on the results seen on the scan.

Photo by Adrien Olichon on Unsplash

However, as I have mentioned in my previous lower back pain post, pain is multifaceted and cannot be attributed to only one cause. As I will allude to in a second, there is no supporting evidence that directly links the results of the scan to lower back pain.

Compare the following statements:

  • Individuals who have severe anatomical or pathological change on their MRI can have minimal or no pain, but
  • Individuals that have minimal anatomical or pathological change on their MRI can have severe pain
So what’s the difference and why do some people get pain? 

The Complexity of Pain…

Pain is complex… If you want to see scientific discourse on the ambiguity of pain, I would highly recommending reading this article by Treede (2018). Our understanding of pain is only continuously evolving and there are still many things that we need to learn in order to truly understand “pain.”

“… Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons.”

The interpretation of pain includes cognitive (i.e. our emotional association and relationship with the pain or threat) and social dimensions (i.e. our interaction or lack thereof with family, friends and peers)

Treede (2018)

When assessing pain, tissue pathology and actual injuries are not the only factors that we must consider. In modern healthcare, we commonly have a paradigm which we follow called: The Biopsychosocial Model of Health / Pain. Essentially, the interpretation of pain can be defined in three seperate factors / cateogories:

  1. Biological factors (e.g. physical health, genetics, age etc.)
  2. Social factors (e.g. relationships with family, friends or peers, work or stress issues)
  3. Psychological factors (e.g. depression, anxiety, self-efficacy)

As we know, emotional factors such as stress and anxiety can elevate and heighten our perception of pain. Similarly, if we were taught pain was a very bad sensation when we were young, then naturally we may develop a fearful response to it when it does happen. However, this is outside the realm of this blog post and will be explored further in the future!

So What About the MRI?

The interpretation of lower back MRI’s often give you insight into many pathological anatomical changes. The most common of which include:

  • Disc bulge
  • Disc degeneration

Interestingly enough, lower back pain is not actually synonymous with disc pathology. One study from 1990 by Boden and colleagues researched MRI results on 67 volunteers who had no history or current symptoms of lower back pain. What they found was:

  • 20% of people aged 20 – 59 had abnormal scans
  • 57% of people aged >60 had abnormal scans
  • 54% under 60, and 79% over 60 had bulging discs
  • Perhaps most extraordinary, 93% of people aged 60 and older had degenerated discs.
Adapted from Boden et al. (1990)

Let me just repeat that last one for you. 93% of people aged 60 and older had degenerated discs, but had no lower back pain. So you’re thinking, that’s insane. There’s no way that you can have degeneration and bulging discs without pain?

Unfortunately, with our current medical technology, we are unable to directly propose that scan result = pain. The only way that we would be able to attribute or interpret your MRI results to lower back pain is:  

  • If you took a scan directly prior to your injury that showed an absence of any pathological changes
  • If you took a scan directly after your injury that showed a pathological change at the area of your pain

The Slippery Disc

A common fear that many individuals have is “slipped discs.” Fortunately, there’s no scientific literature or reasoning to support discs “slipping.” There’s just too much structural and anatomical stability around the area to allow for a disc to slip. An excellent article written by Dr Jarod Hall titled “Discs don’t slip DAMMIT” outlines these specific concerns and the reasoning behind it.

So if you did have an MRI scan and have been diagnosed with a bulging disc, do not worry! The research shows that a disc can actually REABSORB and present you with a ‘normal’ MRI scan. Yet again another amazing article written by Dr Jarod Hall titled “What if I Told You That……Discs Heal!?!?” talks in detail about the spontaneous healing or “regression” of a bulging disc.

A Word of Caution

As I mentioned in my lower back pain blog post, you need to be aware of any red flags. This includes: 

  • Unexplained weight loss
  • Night pain not relieved by rest
  • Saddle anaesthesia (numbness of the buttocks, perineum and inner surfaces of the thigh)
  • Bowel and bladder incontinence (unable to go) and retention (unable to hold)
  • Drastic changes in strength or sensation in legs
  • Any recent significant trauma
  • Gait / walking abnormalities

Adapted from Ramanayake & Basnayake (2018)

This could be indication that you need to have an emergency consultation with your doctor, or visit the emergency department of your local hospital. Similarly, a trip to your local healthcare professional should be considered if you have ongoing concerns regarding your lower back pain or your condition suddenly deteriorates.

Conclusion

Lower back pain is common amongst all ages, and is something that we need to consider as we grow older and change. The main takeaways from this article can be summarised as follows:

  • Pathological changes on your MRI results DOES NOT equal pain
  • MRI are usually only required to rule out serious, medical emergencies
  • 93% of people aged 60 and older had degenerated discs, but had no lower back pain.
  • Discs cannot slip, but they can bulge. Fortunately, bulging discs are not always painful and can also heal by themselves!

Lower back pain is scary, but hopefully these blog posts will help with your knowledge and understanding of them!

How would you explain this to your friend or family or coworker that had lower back pain?

References 

  • Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. The Journal of Bone and Joint Surgery. American Volume, 72(3), 403–408. https://doi.org/10.2106/00004623-199072030-00013
  • Ramanayake, R. P. J. C., & Basnayake, B. M. T. K. (2018). Evaluation of red flags minimizes missing serious diseases in primary care. J Family Med Prim Care, 7(2), 315 – 318.
  • Treede R. D. (2018). The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. Pain reports3(2), e643. https://doi.org/10.1097/PR9.0000000000000643