Introduction
I was sitting at the kitchen table with a few friends the other day, chatting over a cup of tea. One of the lads was telling us about the goings on at his rugby club, when the topic led to injuries. He began to tell us that he helps out when the lads get knocks, giving massages and perscribing stretches. Now this guy works in an office with no experience in musculoskeletal injuries, so in a nice way we put that to him. His response sums up his knowledge and probably paints a picture of what many people out there may believe. Quote, “Sure I have a few slipped discs in my back which give me trouble now and then, but I can sort it by just popping them back in”.
Im not going to deal with the issue of why an untrained person is prescribing rehab and administering massage, etc. Thats for another day! Instead I would like to deal with the impact of words such as a slipped disc.
You Can’t Slip a Disc
Firstly, you can’t slip a disc. The disc that we hear about is made up of an outer “disc”, the annulus fibrosus with a centre named a nucleus pulposus. This material is not hard, but soft (65%-90% water) with a gel like consistancy. The annulus is made of tough fibrocartliage and the nucleus consists of a hydrophilic mucoid tissue, which in time is replaced by fibrocartliage (Magee, 20o6). This annulus adheres to end plates which in turn attach to the vertebral bodies and hence don’t slip!
When someone talks about a slipped disc what they mean is a disc herination, protrusion, bulge. This is were the nucleus pulposus makes it way to the outside of the annulus. This can in some circumstances be the source of pain as the nucleus sensitises other structures in the area. However, current research suggests that this is not usually the case. A recent study by Mc Cullough et al., (2010) found, on diagnosis through MRI on a pain free population, 56% had disc bulges, 91% disc degeneration, 38% annular tears and 32% had disc protrusions. What this research is telling us is that there are alot of people (you may be one of them) living their daily lives with these types of issues, but have no pain.
Scenario
Now say you lift something heavy in work and hurt your back. It’s stopping you from doing what you normally do and you begin to think it’ll never go away. You go to the doctor/physio/physical therapist. Here is a hypothetical conversation between you and your clinician:
Clinician: Maybe I’ll send you for an MRI “just to get to the bottom of it”.
You: What would an MRI show?
Clinician: It will show if there is any disc bulges/herinations, degeneration, trapped nerves etc.
You: Oh, I’ve heard of that, a friend of mine said it could be a slipped disc.
You go and get an MRI and low and behold it shows a disc bulge at L4-L5 with degeneration at L3 and osteophyte growth around the facet joints. This sounds like pretty scary stuff! However, we know from two paragraphs above that these types of occurances are not good predictors of pain. But had you not read this post you would think that these “anomolies” were causing your pain.
Added to these findings and the reason for this post is the terminology used. A slipped disc in my back sounds like a nightmare. Will I be able to play football, work, swim, cycle go for walks, sit down, sleep etc? How can I, my disc slipped out! Can anyone slip it back in? No = disaster. What am I going to do now, my back is killing me and I need to work to pay my mortgage.
The seed for the potential of long lasting chronic pain was planted in your head from the phrase “slipped disc” and focus on the mechanics of what the MRI has shown compounded it and increased the sensitisation of your pain. These poor choices of words are common place and unhelpful. Other example of this type of terminology are: trapped nerve, pelvis out of alignment, leg length discreprency, knots in your muscles, herination, bulge, facet lock. Just like the expression on our faces when a child falls dictates whether they will laugh or cry, words can have an impact on what we feel.
All these phrases put pictures in our heads that translate to mechanical abnormalities. These pictures form a map in our brain which connect to the pain map already created in our brain when we injured ourselves. Therefore when we think of those words, images flash across our mind and activates the pain map. Not focusing on such words or images and keeping a positive frame of mind will help to desensitise your back and hence reduce your pain. This is only one factor which can heighten the experience of pain. I will address other factors in subsequent posts. Thanks for reading.
Bibliography
Department of Health in human services (2014). Understanding persistant pain. Tasmania: Tasmanian Health Organisation South.
Louw A., Diener I., Butler D., Puentedura E. J. (2011). The effect of neuroscience education on pain, disability, anxiety and stress in chronic musculoskeletal pain. Archives of Physical Medicine Rehabilitation. 92:2041-2056
Magee D. (2006). Orthopaedic Physical Assessment 4ed. Missouri: Saunders Elsevier
Moseley G. L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy. 8:3:130-140
O Sullivan P. (2011). Acute low back pain, Beyond drug therapies. Pain Management Today 1:1: 8-14.
Puentedura E. J., Louw A. (2012). A neuroscience approach to managing athletes with low back pain. Physical Therapy in Sport. 13:123-133
Wong W. S., Lam H. M. J., Chow Y. F., Chen P. P., Lim H. S., Wong S., Fielding R. (2014). The effects of anxiety sensitivity, pain hypervigilance, and pain castrophysing on quality of life outcomes of patients with chronic pain: a preliminary, cross-sectional analysis. Springer. Quality Life Res. 23:2333-2341.
Zusman M. (2013). Belief reinforcement: one reason why costs for low back pain have not decreased. Journal of Multidisciplinary Healthcare. 6: 197-204.
Zusman M. (2011). The Modernisation of Manipulative Therapy. International Journal of Clinical Medicine. 2:644-649
Zusman M. (1988). Structure-orientated beliefs and disability due to back pain. Australian Physiotherapy. 44: 1: 13-20.
