Low back pain is one of the most common complaints we work with in the clinic, so it’s fitting that I write another blog on the subject. This time, we’re going to dive a little deeper into disc related low back pain. This topic resonates with me as I work through some discogenic back pain myself. Many clients in my caseload are working through this “injury” and making their way back to the sports and activities they love.
First: A Disclaimer
Studies have shown that the structural source of back pain can only be identified in less than 10% of cases. I utilize this fact to deter clients from seeking imaging along with research showing how common “pathological” findings are when they aren’t directly correlated to pain. Brinkjikji et al looked at MRIs of 3,110 asymptomatic individuals and found the following:
Disc “degeneration” in 37% of 20 year olds and in 96% of 80 year olds
Disc bulges in 30% of 20 year olds and 84% of 80 year olds
Disc protrusions in 29% of 20 year olds and 43% of 80 year olds
What does this tell us?
Changes to the structure of your discs are normal and may not be associated with your symptoms! I do not need an MRI to diagnose OR decide on a plan of care for you. Additionally, unnecessary MRIs actually cause more harm than good. Not only can you end up getting needless medical treatments, but there is evidence that pathologizing (i.e. identifying a structural abnormality) leads to chronic pain.
Perception of structural deviation leads to feelings of “brokenness” and “needing to be fixed” in order to be “normal” again. However, we already talked about how common disc changes are in asymptomatic people.
That being said, there are some signs and symptoms that lead me to believe that a client (me included) is dealing with disc related low back pain. If a client requests a specific diagnosis, I will tell them my hypothesis, but I am always sure to explain that the research encourages us not to diagnose in such a manner and that disc related low back pain is something that responds well to physical therapy.
Discogenic low back pain can either present in the back only (typically one sided) and/or can present with symptoms down the leg. Symptoms are typically worse in sitting and when bending forward. When less acute, clients may present more with the sensation of “tightness” in the back, as opposed to “pain.” The severity of the symptoms are typically related to the degree to which the disc may be interacting with the nerves and based on how much inflammation is present.
So. Say you present this way and think you may have disc related back pain, what do you do next? Of course, we recommend that you see a performance physical therapist for a full evaluation, but there are some similar themes to rehabilitation for this type of “injury.”
As with neck pain (see my neck pain blog), it is recommended that back pain is treated by placing people into treatment categories. A common category that clients are placed into is direction specific exercise. If symptoms are brought on by flexion activities (i.e. sitting), people often respond positively to extension based movements, like press ups
In very acute, irritable presentations, traction is sometimes the best place to start, and for some adding some lateral movements can be helpful. In these cases, it is necessary to be assessed by a physical therapist to create these more personalized movement programs.
During the rehabilitation process, we also need to work through movements that pump blood flow to the back to decrease symptoms and eventually progress them to back strengthening exercises in order to return to prior level of activity. We know that the makeup of the tissues in the back changes when pain is present, and that the tissues do not go back to “normal” once pain subsides. We need to actively stress the tissues with exercise to get them back to their previous state.
Ultimately, progression of these exercises is very individualized and based on symptom response both during the movement and after. Generally speaking, if an exercise doesn’t cause >3/10 pain during the movement and baseline symptoms aren’t increased the next day, that particular exercise is okay. Some of my favorite exercises for early stage rehab are:
Some of my favorite exercises for mid-late stage rehab are:
As I reflect, I’ve probably had some disc related back and nerve symptoms on and off for a few years. It was in this past year that my symptoms clearly became linked to my back. It started with achy left-sided back discomfort with hinging movements and squatting. This morphed into difficulty with even body weight hinging (i.e. bending over to wash my face) and nerve pain – especially with sitting and prolonged standing, that could travel all the way down to my calf.
The first step was to get my symptoms to calm down. For me that was laying on my stomach, propping up on my elbows, and eventually (when tolerated,) doing full press ups onto my hands multiple times a day. It also meant doing nerve glides to try to decrease the sensitivity of my nerve.
I had to temporarily pause certain movement i.e. full depth squats, rowing, and barbell deadlifts down to the floor. I progressively added movements and assessed my response. For example, one day I did back squats to full depth. I had some discomfort in my left low back during (which is okay) but it caused increased nerve sensitivity the next day. Meaning, back squats to full depth were not yet a great exercise for me, so box squats it was!
Symptoms with this type of “injury” typically fluctuate, so don’t get discouraged if your symptoms don’t always seem consistent. When nerves are involved, changes in sensation are normal. However, let’s talk briefly about symptoms you should take more seriously:
- Progressive neurological changes such as muscle weakness (ex. You stop being able to do a single leg heel raise)
- Rapidly increasing numbness/tingling that you can remove with positional changes, contact a physical therapist immediately to see if you should be referred for imaging.
- Bowel or bladder changes, though not common, is another sign that you should seek medical care immediately.
Woof that was a lot of information!
Essentially what it comes down to is: discogenic back pain is common but responds well to properly dosed physical therapy, patience, and consistency with exercises. Also, it’s one of my favorite things to treat! Reach out with any questions.
Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P, Scott S. The prognostic consequences in the making of the initial medical diagnosis of work-related back injuries. Spine (Phila Pa 1976). 1995 Apr 1;20(7):791-5.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.
Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine (Phila Pa 1976). 1996 Dec 1;21(23):2763-9.