I was recently contacted by a reader who wanted my advice with regards to low back pain from a herniated disc. This is a highly interesting, complex, and often misunderstood topic. Many people suffer from low back pain. Thats why I decided to write bigger article about it.
What I will do is I will share the main three ideas I will always address when I work with someone with low back pain, especially if it is from a herniated disc. In the scope of this article I cannot go into specific therapies. I might write separate articles on these. For the scope of this article let us focus on some overarching concepts that are in my opinion incredibly important to understand and embrace for every patient.
Over the years I had several athletes who suffered low back pain, and some of those had herniated discs. In 10 years I did not have a single case that did not get better. To be fair though, my patient population is comprised mainly of very growth oriented characters with a „I will take care of it“ mindset. I usually do not work with patients that want to stay passive and outsource their health and well-being to me. So that makes it easier for them and me.
I myself had a terrible case of disc herniation. I had herniations at three levels in my lower back and it was so bad that I was not able to lift my leg at all. What you see in the picture is the furthest I could swing my leg out without a sharp, shooting pain all the way from my back to my toes. I had disturbed sensation all the way down to my toes, I could not feel the side of my right leg, and at one point I was not able to walk without a limb. The pain was excruciating. There was almost no position that was painfree. Sitting hurt, walking hurt, standing hurt. Only lying down in certain positions felt good. So I moved less. I moved less and less. Because everything hurt. I went to the most well-known clinic for back pain in Germany. The did all the state-of-the-art diagnostics on me. They did CT-controlled injections and prescribed me orthotics for my shoes. Nothing changed. No one at this clinic, nor any other doctor I visited for my back pain, told me about these three concepts.
It was not until I actually applied these three concepts to my daily life that I actually got better. I got up and found ways to move more. I started to not overthink things and I started doing things that felt right FOR ME. So to all people out there with back pain : I feel ya! But I can really give you hope. There is a way out. It is not a straight line, but rather a bumpy road with ups and downs, but there is a way out.
For some people it is enough to understand these three concepts and they intuitively find ways to put their bodies into a position where they are able to heal. Two of these concepts are also the reason why I will NOT go into the anatomic structures and what exactly happens in a disc herniation. It is not important to know the anatomy to be able to heal, and actually -as we will learn- it can be quite counterproductive to know the anatomy if you want to heal.
Concept #1 : A herniated disc can spontaneously recover
When I was working in Qatar I was working mostly with Sports Physicians from either UK or Australia. That was in 2014 and at that time I already recovered from my own back pain journey which lasted from 2009-2012. Other than German Sports Physician, the Sports Physicians from Australia received specialty training in Sports Medicine for at least 4 years and when we worked together in Qatar they offered a refreshing perspective to patients with bulging discs I did not know of from German Doctors at that time.
When a patient was diagnosed with a herniated disc the Australian Docs would say things like : „You will be fine, it is only a herniated disc.“
The confidence with which they said that was astounding and gave the patients a lot of hope. They would explain to me that the scientific literature on this and their experience gives them this confidence. At this point in time I was working with athletes for almost 6 years and I had the same experience. I have had many athletes with disc problems in the teams we worked with, but I found that with the right type and dosing of movement they can be fairly easy controlled.
What not many doctors would tell you is that a herniated disc can spontaneously recover completely without any interventions. In 2001 a study in the Journal of Orthopaedic Surgery performed an MRI every 3 months on 42 patients with herniated discs. Within 12 months in 88% of those patients the herniated mass was reduced by over 50%.
Check out this image from a Case Study that has been published in the scientific literature. See the white circle on the right picture? Thats the spinal cord. The normal spinal cord. Then see this black thing on the left thats pushing on the spinal cord? Thats a bulging disc. Well the first picture was taken when the patient came in with severe back pain. The second picture is only some months later. The disc herniation is completely gone. The herniation „dried away“ like a plum. Thats the metaphor my Australian friends gave me to describe what happens there. There are more mechanisms behind this spontaneous recovery than „drying out“, but it is a good way to picture it. So a herniated disc is NOT permanent. We’d like to think that the only way to resolve a bulging disc is surgery, but this could not be further from the truth. With the right movement and nutrition, a bulging disc will resolve on its own. If you actually compare the effects of surgery vs. conservative therapy (no surgery), there is no advantage to surgery when it comes to pain or function at two years after the surgery.
It is amazing to me how we understand in some injuries, that it will heal and we will be fine, while some dysfunctions are being handled as completely catastrophic and final, like it will never be the same again.
Just think about it. What if you twist your ankle today? What would your thought process be? Most likely you will think : „Well fuck. For the next 5-10 weeks I will have to modify my movement, it might budge me for another 3-4 months, but at some point during the next year it will have recovered completely.“ After it has recovered you learn some exercises to prevent you from twisting your ankle again, and then its all good.
But somehow, when we think of a disc herniation, we think of it as final. Its herniated. Thats it. I will always be the one with the herniated disc. But that cannot be further from the truth!
A systematic review of the scientific literature showed that the probability of a spontaneous recovery is between 96% and 13%! The worse the herniation, the higher the chance of spontaneous recovery. For example if the disc is completely broken and the inside of the disc is separated from the disc already, and pressing on the nerve, then the chance of spontaneous recovery is at 96%, while a disc that only slighty bulges, without being broken has only a 13% chance of complete recovery within a few years. A good rule of thumb is „The faster it came, the faster it will go“, or „the more painful and sharp it starts, the higher the chance of it going away soon“. That is very good news, because the severe cases have the tendency to recover themselves fairly quickly, and the not so severe case often do not lead to actual pain. This leads us to the next concept.
Concept #2 : Pain does NOT equal damage
Do you remember the exercises from intelligence tests that went like „If all zips are zits, and all zits are zats, does that mean that all zats are also zips?“
Its kind of like that with herniated discs and back pain. We like to think of it as tied together, but in reality they have nothing to with each other. A herniated disc must be painful right?! And if you have back pain you must have some structural damage in your back right?
Well, its not really like that.
In a classic study from 1990 a research team took 67 individuals, who NEVER had any back pain and had them do MRI’s. These images were evaluated by radiologists who did not know anything about the patients. They only saw the images. It turned out that around 50% of these people had herniated discs. Of those older than 60 years old ALL but one subject had a herniated disc. In the younger part of the study group around 30% of subjects had herniated discs. None of these subjects had back pain. Well, interesting right? A herniated disc does not have to be painful at all!
This same study was repeated by another research team in 1994. Same results. 50% of people without any back pain had herniated discs.
Lets look at it from the other side. How about patients with back pain? Do they all have structural damage in their back?
An interesting study from 2006 took MRI’s from 200 patients without back pain and then left them alone. As soon as one of them came into the hospital for their first episode of severe back pain they did another MRI to find out if they could find changes in the MRI that could explain the back pain. Over the years 51 of the 200 people came into a clinic for back pain. Only 14% of those cases had changes in the MRI. But the majority, 86% of the people with new back pain, did not have any changes to their MRI.
The bottom line is that MRI or CT scans bear close to no relationship at all with pain or functional capacity during daily activities. All studies that look at the relationship between MRI/CT and functional measures showed that the structural damages have nothing to do with the pain that the patients experience. Some have pain without any structural damage (functional pain), and some have no pain at all with severe structural damages. I think it is very valuable to understand that. It is one of the first steps to be able to take healing into your own hands. Is a structurally more damaged back more likely to hurt? Yes of course, but it does not have to! It depends on many factors if it will hurt or not. It depends on your immune system and how much inflammation is being produced. It depends they way you eat, the way you move, and it depends on whats important in your life. We will address this in concept #4.
When it comes to back pain, structural damage found on MRI or CT scans is almost unrelated to pain or functional capacity during daily activities Click To Tweet
Lets now look why it can be valuable to not care about the anatomical structures at all if your goal is become pain free.
Concept #3 : Your Brain on Pain
In 2013 I went to Boston for the Boston Sports Medicine & Performance Conference. Adriaan Louw from South Africa presented on the „Neuroscience of Back Pain in Athletes“. The first thing he told us was : „The back cannot be painful. Only the head can produce pain, when it feels it is necessary for the organism.“
A simple example : Imagine you walk down a lonely sidewalk, then twist your ankle and fall. Would it hurt? Yeah of course it would hurt. Lets modify this example a bit : Imagine you walk down a sidewalk on a busy street, you twist your ankle and fall on the street. You see a bus approaching at full speed. Would your ankle hurt? Hells no! You would get up and run like a leopard to save your life.
The concept behind this is „The bigger threat wins“. So for example if you feel real fulfilment in your job and your brain values your work and the positive impact it has on your life and the life of others, then this is more important than back pain. Your brain might perceive the threat of not being able to pursue that job as a lot higher than the dysfunction in the back. Then you might not have any back pain. Or maybe only some slight pain when you come back home from work. But what if your brain just hates your work. When it feels it is a waste of time and is of no value to you or society? If your brain feels that going to work will actually destroy your emotional well-being. Well, then the emotional well-being is the bigger threat. Thats why your brain decides to produce pain that keeps you away from work. Then you feel a lot of pain, especially when it is time to work. You will be on sick leave a lot!
We could ramble on and on about the neurochemistry of pain, but I think these couple of examples are enough to give you a slight understanding of pain being a modulating signal by the brain. The brain is optimised for survival. So here is the actual story I want to get to. It is about the brain, our cognition, and how we can modulate pain with our cognition. For better or for worse.
He showed that when a doctor shows a patient an anatomical model of the disc and shows how this disc viciously presses on the nerve and explains in all detail what can go wrong when this disc presses on this nerve too long, the pain of the patient actually increases!
When on the other hand the doctor choses to not educate the patient about the structural damage, but rather educates the patient that there is no connection between structural damage and pain, and that pain is a phenomenon produced by the brain, a warning signal that stands in a much bigger context, then the pain of the patient significantly reduced.
He did many studies on this topic and showed that education on the neurological foundation of pain compared to anatomical education improves not only the pain, but also significantly improves recovery times and pain/recovery after surgery.
So there is no use thinking about the structural damage. Leave that stuff to the doctors or the physical therapist. The only thing you need to care about is what your brain is trying to tell you with the pain. Is your brain trying to get you to move? Is it trying to tell you to change your job? To lose some weight? To get out of a toxic relationship? To wear different shoes? To take more time for yourself? What is your brain trying to protect? What is the bigger threat?
Lorimey Moseley is one of the leading researchers when it comes to the physiological reality of pain. He makes a strong distinction between tissue damage, sensory receptors, and pain perception. Those three things are completely independent of each other. There can be tissue damage with or without sensory reception, with or without pain. There can be sensory reception with or without tissue damage, with or without pain. And of course, there can be pain with or without sensory reception, with or without tissue damage.
He spends his life „explaining pain“ to medical professionals, therapists and patients. The new science and old truths of what pain really is. Pain is not a sign of damage. Pain is a warning signal in a much bigger context.
He likes to re-tell this one story of a patient he once had. A crocodile hunter (thats apparently a normal job in Australia) who had severe backpain, herniated discs in many levels and even disc fusions on several levels. He was in a wheelchair. Professor Moseley explained to him what pain really is. That it is a lot more than a reflection of structural damage. Some years later the crocodile hunter came back to his office. No wheelchair. No pain. Only a small box in his hand with some type of jelly. The crocodile hunter said : „When I first had backpain my doctor pulled out this anatomical model of the spine and told me all about how the bulging disc is like jelly pressing on my nerves and destroying my nerves and producing this pain. This image scared me. After I visited you and you told me that pain has nothing to do with structure I went back to this doctor, took my knife and cut out this piece of bulging disc jelly from his stupid anatomical model and kept in on my drawer as a symbol for my new understanding of pain. Now that I am painfree I want to give this to you!“
When a doctor says things like „Your disc popped out“, „Your back is unstable“, „Your spine is degenerated“ it is not only factually untrue because all things that happen in your body (that are not from catastrophic trauma or accidents) are functional adaptations to the environment and its stressors, but these metaphors also produce a catastrophic image in the patients head, and are proven to increase pain perception.
“Pain is the output. Nociception is one of the inputs. All of the inputs are evaluated when we’re talking about pain.” Dr. Lorimer Moseley
Understanding the reality of pain perception is about understanding the body is a fluent and adaptive organism navigating in an ever changing environment. The body is NOT a machine. It does NOT play by machine rules. It does NOT degenerate or rust like a machine. It does not need mechanical fixing. This is an old mechanistic and Cartesian body image. I can prove to you that your body is not a machine very simply. Do sprints every Monday. After some months you will be faster. Do the same with your car. Full out sprints every Monday with your car. Your car will not improve. It will not have more horsepower or become faster. It will deteriorate. The body is organic! It will improve if it is stressed. A machine will deteriorate if it is stressed. That is the complete opposite!
The body is an adaptive organism navigating in an ever changing environment. The body is NOT a machine. It does NOT play by machine rules. A machine will deteriorate under stress. An organism will adapt to stress. Click To Tweet
This is the classic Cartesian Image of how pain works. But it is plainly wrong with todays medical insights.
The type of thinking captured in Descartes’ model has led to some amazing advances in clinical medicine. But the evidence against it is now almost as compelling as that against the world being flat.Of course, those sailors who never leave the harbour might hang on to the idea of a flat world. And, in the same way, there are probably clinicians who hang on to the idea of pain equalling tissue damage. I suspect they either don’t see complex or chronic pain patients, or, when they do, they presume that those patients are somehow faulty or psychologically fragile, or, tragically, are lying.Perhaps they can continue to practice without ever leaving the harbour. The problems I want to solve clearly exist on the open seas. – Lorimer Moseley –
It is really important to understand that the neurophysiology of pain is NOT about thinking that „pain is not real“, or „pain is only in the head“, or „you can think your pain away“. It is totally NOT about that. It is about the biology of pain and this concept is especially important when pain tends to become chronic. Especially in chronic pain the brain found it to be useful or of value to produce pain, when there is actually no tissue damage. It was conditioned to pain, because in the bigger context of life it made sense to the brain at that time. And understanding the independency of tissue damage, sensory reception, and pain perception in the brain is an important step to get rid of chronic pain.
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“Thinking that we have a slipped disc has the potential to increase back pain. But what if this piece of knowledge we have stored is inaccurate, just like our notion of a slipped disc? A disc is so firmly attached to its vertebrae that it can never, ever slip. Despite this, we have the language, and the pictures to go with it, and both strongly suggest it can.When the brain is using this inaccurate information to evaluate how much danger one’s back is in, we can predict with confidence that, if all other things were equal, thinking you have a slipped disc and picturing one of those horrible clinical models of a slipped disc will increase your back pain.” Lorimer Moseley
Okay up to here it was about broad concepts and general statistics. Thats the fruitful soil of hope and understanding that will be able to guide anybody experiencing pain or injury on its path to recovery and healing. But what about the statistics? What worth is it TO YOU as an individual to know that up to 96% of discs spontaneously recover. You shouldn’t care. The only thing you should care about is : „How do I become part of the 96% and not of the 4%?“.
And that leads us to individual strategies to optimising your chance of full recovery. I will soon write further articles on specific practical therapies and strategies I use with people who suffer from back pain.
May the FLOW be with you!
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Gerrit Keferstein is a Medical Doctor specialised in Performance & Functional Medicine. He is most known for his work on the optimisation of recovery and adaptation in elite athletes.