When does spinal herniation and posture matter? Oh and you still can’t slip a disc
AUTHORS NOTE AND EDITS: Since this post originally came out it has received over 10,000 views and is by far the most popular on this site. I’ve heard some feedback from this and have made some edits, starting with the title. It is WHEN does spinal herniation matter instead of it does not matter. As Jason covers in our interview when an MRI lines up with a symptom it might matter other than that we may be pathologizing something that isn’t a pathology! Furthermore, as a personal trainer it is NOT our job to deal with pain but we still can get a lot out of this piece. We prescribe exercises our clients CAN do and ensure them that they are in a safe, nonthreatening environment. We can assure them that their body is stronger and more capable of what they have been told previously. That these exercises we give, if done correctly (they will be if you’re a good coach) may help with the pain and get our clients moving more often.
“If you’ve ever seen a disc in a cadaver you can’t slip the suckers, they’re immobile, but that’s our language and it messes with your brain”
Not too long ago I was in the gym working on some speed deadlifts. After a set a graduate student, who happened to be a chiropractor as well came over to talk to me. She was concerned about my form (which she shouldn’t be my deadlift is just about one of the only things I can really take pride in). She told me that if I kept deadlifting how I was I would slip a disc.
*max effort deadlift last week- in fact max effort deadlifts by 70+ people which equals 210 max attempts, 0 slipped disc*
This isn’t the first time a fitness professional has predicted a catastrophic injury for me. I’ve written about it before here. A chiropractor has told me that my neck only works at 60 percent capacity by rolling a heat sensor over my neck. A massage therapist once commented on my leg length discrepancy and predicted I would tear my biceps.
Frankly, I’m very very tired of it and how common it is for some fitness professionals to try to predict a specific injury. I’m over the thought process of: “you’re doing this so this injury will happen”.
Correct the person, sure, but don’t make the suggestion of injury. Not only do I think that telling people they’re going to get hurt is a terrible form of fear mongering (the slipped disc chiropractor offered to ‘realign’ me, not a bad business plan I suppose) but it could also have unnecessarily detrimental effects.
Here’s a great video to explain what I mean
People aren’t so delicate that their spine will explode from one or even repetitive flexion cycles, even under tremendous load (although it’s not a good idea to do.)
I am in no way shape or form an expert on this topic, which is why I have interviewed an expert at the end of this piece, but I know that our perception of danger or lack of danger can drastically change how we experience anything.
When I was a sophomore in college, I was in an anatomy and physiology class. We were learning about the heart (and all the things that could go wrong with it). It was a stressful semester and to make things worse on multiple occasions I was waking up with my heart racing. Eventually, it became all I could think about. I convinced myself I had a terrible heart problem. My heart could explode at any moment and my time on this earth was surely limited! Okay, perhaps a bit dramatic.
I finally went to the school nurse who took my blood pressure, it was normal. Next they put sensors on my chest to check my heart rhythm which was also completely normal. Before seeing the nurse my resting heart rate was around 90 bpm. After the nurse had run the test she left the room. I checked my heart rate once again, it was back down in the mid 60’s and the only thing that changed was my perception. I now knew my heart was not on the verge of catastrophic failure. The same idea can be applied to people who are worried about spinal herniations and structural problems.
Eyal Lederman, in “The fall of the postural-structural-biomechanical model” alludes to the emergence of a biopsychosocial model for pain. He states that:
“Being human with a highly evolved nervous system means that the structure is within the awareness. It is also under the influence of our emotions as well as the will and the actions taken. Therefore a person’s cognitions and behavior will have important implications in their recovery from low back pain.” (1)
So if our structure is within our awareness then raising the threat level in the brain can’t be a good thing. Do these herniations of the spine even have relevance? In one longitudinal study on 148 subjects without low back pain it was determined that “69 had never experienced low back pain. There were 123 subjects with moderate to severe desiccation (extreme dryness) of one or more discs, 95 with one or more bulging discs, and 83 with loss of disc height. Forty-eight subjects had one disc protrusion and 9 had one or more disc extrusions” (2). This shows that there is a high prevalence of what one would consider pathological conditions in pain free people.
Furthermore in a 1990 study using an MRI on 67 asymptomatic subjects disc herniations were found in 16 subjects and bulging disc were discovered in 54% of subjects under the age of 60 and in 79% over the age of 60. The authors concluded that, “a diagnosis that is based on magnetic resonance imaging… may not be the cause of the patients pain, and an attempt at operative correction could be the first step towards disaster” (5).
Disc degeneration is also questionable as a cause for pain. In one review the author states that, “The relationship between magnetic resonance imaging findings and clinical symptoms in lumbar disc degeneration has also been debated. Although previous studies have identified a high prevalence of lumbar disc degeneration in asymptomatic individuals, these publications represent a narrow subpopulation of individuals” (3).
Pain researching pioneer Ronald Melzack states that, “pain behaviours can be generated or perpetuated by previously conditioned cues in the environment or by the expectation of pain and suffering” (4).
So to me there is a lot of confusion, on one hand I have people telling me to worry about my structure talking about alignment, slipped disc and herniations and on the other hand I’m looking into this biopsychosocial model of pain that tells me that raising the threat level in the brain can actually increase pain and decrease positive recovery outcomes.
I decided that it was time to get some answers, are the things I’ve been told that cause pain (slipped disc/spinal herniation and alignment) really the cause of pain. Physical therapist Jason Silvernail agreed to answer a few of the questions for me:
Justin: Health and fitness professionals, not limited to one specific field, have told me on several occasions that I would slip a disc. I’ve also heard this is physiologically impossible. Is a slipped disc just a poor way of saying disc herniation? Can you shed some light on this topic?
Jason: Well there certainly are a lot of confusing terms out there. I think in addition to the misuse of medical terms by laypeople we have also medical professionals who aren’t using the terms correctly which only confuses things further. It is true that a spinal disk cannot “slip” like a hockey puck sliding out from between two vertebrae. That’s physiologically not possible due to the formation and anatomy of the disk. When people use the phrase “slipped a disk” they are probably referring to a bulge or herniation of the disk, though it’s hard to say for sure. Unfortunately we in medicine haven’t done a very good job of developing and rallying around a good consensus for these terms either! This terminology is based on MRI assessment, so my colleagues in radiology are at the front lines of this issue. As of right now the terminology varies by the reporting radiologist and the country of origin. For example, no one says ‘prolapsed disk” in the United States. Doctors Boo and Hogg have reported a standardized lexicon of degenerative disk problems in the journal ‘Current Problems in Diagnostic Radiology’, Volume 39 Issue 3 in May 2010. As far as I know that is most recent consensus-based scientific document on this issue. I don’t have the full text in front of me at the moment.
Generally a bulging disk, disk bulge or disk protrusion represents a disk whose central gel or nucleus material is pressing against the fibrous outer wall or annulus of the disk causing it to protrude into the central canal (where the spinal cord, related nerves and cerebrospinal fluid are located) or into the foramina (the opening where the nerve root comes out). Generally a disk herniation or extrusion or prolapse refers to a rupture in the fibrous outer wall of the disk (the annulus) with the gel-like nucleus material extruding out into the nearby spaces. Both of these basic types of disk abnormality are found routinely in people with no pain, and the rates go up as you get older. And of course there is often disagreement between various medical specialties and individual experts about which exact term is correct in which case!
Justin: Does spinal herniation really matter? Aren’t their plenty of asymptomatic people with herniated disc?
Jason: Yes there are plenty of people with herniated/prolapsed/extruded disk who have no pain. But that doesn’t mean all disk herniations are irrelevant or ‘incidental findings’ as we say in medicine. The best answer to whether disk problems are related to a person’s pain problem is the very uncertain “IT DEPENDS.” Generally on imaging studies we are looking for what some people call a ‘symptom-defect match.’ We are looking for an abnormality on imaging studies that explains the patient’s symptoms. If we have a close match between the symptoms and the MRI findings, we can feel more comfortable that what we are seeing on the scan might be relevant to the current problem. This is of most use with people who have leg symptoms in addition to their back pain since it allows us to get a sense of what MRI findings make sense. Let me give you an example:
I have had patients with back pain that radiated down their leg to their foot. If their MRI shows a disk herniation or a large disk bulge that touches a nerve root in the lower back on the same side as their pain, I can be somewhat confident that their disk problem might be related to their pain. So in this case if the therapy wasn’t able to help them, we could make a reasonable recommendation for consideration of more invasive care since in this specific case we might have good reason to think there is a specific structure at fault. I probably write referrals to neuro or orthopedic surgeons for these types of problems 3-4 times per year when I worked as a full time clinician. And my caseload was about 50% low back pain. That tells you how rare such a match can be.
If I have just a patient with low back pain without leg pain, just about anything we might see on the MRI has been found in people without pain, so that pain pattern probably doesn’t lend itself to the ‘symptom-defect match’ concept. Whether I saw a normal spine or a large disk herniation, I couldn’t be at all sure if that had anything at all to do with their pain. I don’t assume it’s irrelevant and I don’t assume it’s the full explanation but that data point by itself just doesn’t help me manage their problem well. This is why many medical groups have come out with guidelines pushing MRI examination of the spine way down the priority list and only if it isn’t resolving otherwise. Early MRI has been proven time and again to lead to higher surgery rates and worse outcomes, so we want to be very careful when we recommend that someone get an MRI of their back. And those same guidelines admit that in 85% of the cases of back pain, we can’t identify a structural reason for the pain.
Justin: I’ve begun some research on why structure doesn’t matter, at least not as much as most people think so (1) why are professionals still talking about it? (2) Is there danger in telling people they should be concerned about their posture? And (3) what should fitness professionals be talking about instead?
Jason: Good questions. People talk about it because in common culture as well as most of medicine, people are still stuck 100% in the ‘postural-structural-biomechanical’ model of pain, without considering other material. Biomechanics and structure matter, but when it comes to pain they are far less important than most people think.
Giving people ideas about their body being ‘broken’ or ‘damaged’ or degenerated is a nocebo (opposite of placebo) that might interfere with their recovery process. Much of my job involves accurate patient education and busting myths about this sort of thing with my patients so they can have an accurate understanding of the science and get back on the track to recovery.
In terms of what fitness professionals ‘should’ be talking about, I’m not as sure about that. I do wish that so many of them would stop trying to offer medical advice or manage medical conditions which I see a fair bit of in online interactions. Many seem envious of the medical providers in a way that doesn’t make sense to me. My wife has an exercise science MS and has worked as a trainer before and she commented that she had a big enough a job trying to motivate and guide people to adopt good health and fitness habits without playing doctor so she confidently deferred all that stuff to medical authorities and put her focus where she could add value for clients. I think nonmedical people like personal trainers and massage therapists can be outstanding coaches and guides to people’s healthy lifestyle and prevention and they have far longer and more lasting influence than I do as a physical therapist with maybe 4-6 visits to treat them and get them back to life.
I would like to see more people in the training and massage communities embrace that kind of guide and coach role rather than so frequently try play doctor and speak beyond their training and expertise. I think trainers like you can have huge long-lasting positive impacts on your clients’ health behaviors and focusing on that seems to me to be where the value is in your community.
Who adds more value for your average client, Bob, who is overweight and inactive and eats a poor diet? Me the DPT who sees them for 4 visits to help with his shoulder pain or you the trainer who has the power to guide him toward lifestyle changes that can lower his chances of developing chronic disease and keep him healthy for years to come? Seems to me good trainers and massage therapists have a lot to be proud of in the services they can offer their clients – and accurate health advice that reinforces what they get from their medical providers is a major item in that list. I hope this helped in that regard!
Justin: Thanks for the advice Jason!
Jason Silvernail DPT, DSc, FAAOMPT
(1)Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. Journal Of Bodywork & Movement Therapies. 15(2):131-138, 2011
(2) Jarvik J. J., Hollingworth W., Heagerty P., Haynor D. R., Deyo R. A. The longitudinal assessment of imaging and disability of the back (LAIDBack) study: Baseline data. Spine (Phila Pa 1976) 15; 26: 1158-66, 2001
(3) Cheung K. The relationship between disc degeneration, low back pain, and human pain genetics. The Spine Journal 10: 958-960, 2010
(4)Loeser J. D., Melzack R. Pain: An overview. The Lancet. 353: 1608-1609, 1999.
(5) Rinkus K. M., Knaub M. A. Clinical and diagnostic evaluation of low back pain. Seminars in Spine Surgery. 20: 93-101, 2008