“Findings such as disk height loss and disc bulges are common in individuals without low back pain.”
Disc bulges, degenerative joint disease, spinal stenosis, can all be a result of living with gravity. We have gravity acting as a compression force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. We can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you is exactly what causes your back pain.
“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”
What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates a screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC study group), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patient’s physical complaints.
“Our results indicate that depression is a strong predictor of who will subsequently report low back pain than baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times as likely to have back pain compared with those who do not report depression.”
There is obviously a psychosocial component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.
“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and root contact may also be risk factors for future low back pain.”
In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.
The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.