THE NAME OF THE BEAST
How we describe back pain
Back pain is described in many different ways. It's common to say that back pain is the result of a slipped disc, a misaligned spine, a pinched nerve, or a crooked joint. Broadly, these are simple ways of explaining complicated phenomena. These names are useful because they make difficult things easy to talk about, but in simplifying things, some of the nuance is lost. Sometimes, this nuance can mean the difference between one diagnosis and the other, so it's useful to discuss and explore the different ways we talk about back pain. This is also useful because in understanding the true nature of a condition, we best prepare ourselves to deal with it. With this in mind, we'll discuss three common misnomers for back pain and what they actually mean.
I have worked with patients who have described their back pain as being the result of a "slipped disc." They have told me that the disc in their spine is out, that it has slipped out, or that it has become pushed out. These statements can be half-right at best, and dangerous at worst.
The spine has discs in it - this much is correct. The discs are fluid-filled cushions that sit between the bones of the spine, which are called the vertebrae. The vertebrae are bony and hard, and have a central hole which allows the spinal cord to travel in a protected tunnel. This system is best understood like a stack of Oreo cookies; the vertebrae are the biscuits and the discs are the filling, inbetween the hard biscuits. The discs are filled with fluid and have a tough, fibrous outside, which allows them to deform and bear the weight of the body as we move through different postures and perform different activities. Sometimes, due to wear and tear, trauma, or illness, the fibrous outside becomes weakened and the fluid filling can bulge or spill out of their container. This is called a Herniated disc. When a disc herniates, it can bulge against the spinal cord, or against the spinal nerves as they leave the protective tunnel of bone in the spinal canal, which is the proper name given to the tunnel of bone that contains the spinal cord. This bulging produces pain.
This is basically what your spine is.
Discs do not slip. They are not like hockey pucks that can shoot out of their positions if pushed or pinched just right. The discs of the spine, properly called intervertebral discs, are pockets of fluid in tough containers, which themselves are held in a scaffold of muscles and tissues within the spine itself to improve their stability and their durability. However, this durability diminishes over the span of our lives, and this stability can be lost with age. In this way, the discs can become bulged or herniated, and cause pain.
Remember: discs may bulge, and discs may press. Discs do not slip.
Patients have reported that their spines have been diagnosed as "misaligned." This can refer to a broad range of issues depending on who has made the diagnosis. Some professionals say that spinal misalignment is because of postural changes. This has already been discussed in previous blog posts. Other professionals claim that spinal misalignment is when a specific bone or joint is not optimally aligned, and which needs to be manipulated back into place. These statements cause confusion, and so it's best to address this.
The spine is an incredibly interesting piece of anatomy. It needs to be tough and protected because it contains the spinal cord, the spinal nerves, and is the primary weightbearing structure for everything above the pelvis. In addition to this, it needs to be flexible, to allow us to adopt different postures throughout the day with a minimum of discomfort. The spine must also be durable, resistant to shocks and awkward postures, and be able to resist these forces over days, weeks, months, and decades of life. To achieve this, the spine is made up of hard tissues like bones and cartilage, scaffolded by soft yet firm tissues like ligaments, and held in position by muscles which cross the length and breadth of the spine as well as which anchor the spine to other bones. It is exceptionally difficult to misalign the spine unless there is a traumatic or disease-based process that degrades one or all of these components. Like our bodies, our spine changes throughout our lives, and the way it works changes too.
The important thing is this: unless you have been struck in the back, had something heavy dropped on your head, or experienced traumatic separation of the spine sections, the spine cannot be misaligned. Changes in posture can change the way that spinal muscles work to keep the neck, shoulders, legs and arms in working position over time, but this is easily addressable through exercise and activity adjustment. Postural assessment plays an important part in any physiotherapy treatment, but postural changes are easily effected by means of activity and environment setup as well as gentle exercise.
This is spinal misalignment. The best person to see about this is a surgeon.
Remember: the spine does not become misaligned in a short time period without trauma. The spine can become misaligned as a result of a catastrophic physical injury, in which case physiotherapy may refer you to an appropriate specialist. It is exceptionally rare that individual bones become misaligned or mispositioned and thus require repeated realignment.
Patients state that their pain is caused because of a pinched nerve. This conclusion has been reached as a result of googling, or with the assistance of another professional. However, the treatment someone gets after receiving this diagnosis sometimes doesn't line up. It's also important to define WHAT specifically is pinching on the nerve.
A pinched nerve occurs when too much pressure is applied to a nerve by surrounding tissues, such as bones, cartilage, muscles or tendons. This pressure disrupts the nerve's function. This is because nerves are physical tissues which rely on bloodflow and continuity. If a nerve is "Pinched" it can cause pain at the site of constriction or further down. This introduces one element of complexity: is the pain primary pain or referred pain, and does the patient know the difference between the two? Next, how is the nerve being constricted. Is it due to muscular tension surrounding the nerve, is it due to local inflammation, is it due to bony or joint irritation or weardown, is it due to poor oxygen delivery? There are so many dimensions to diagnosing and treating nerve-related injuries that simply stating that a problem is due to a "pinched nerve" eliminates the explanatory power that helps people navigate the course of their rehabilitation.
Nerves may become compressed between two muscles that are inappropriately tense. This happens often in back pain when muscular spasm results in compression of the nerve root as it leaves the spine. Nerves may be compressed by bulging (not slipped!) intervertebral discs, and this may cause pain. Nerves may become compressed between the vertebrae (the Oreo Biscuits) or from other bones.
This has nothing to do with the article. Please enjoy the crab.
Remember: A pinched nerve is never the full answer. A nerve has to be constrained by something, and that something is what needs to be treated.
So why spend so much time discussing all of this? The simple answer is that the language used to discuss pain and the conditions that cause pain can also be used to empower the patient during the course of their care. To reduce a complicated clinical presentation to a simple statement eliminates not only the nuance needed to explain the problem to the patient, but also eliminates the opportunity to explain the problem to the patient. Every time someone is injured, there is an opportunity to educate and empower the patient to understand more about how their body works and use this understanding to improve the quality of their life. The gap between someone's understanding of their problem and the clinician's understanding of the solution is an opportunity to empower the patient, or to make them dependent on the clinician.
Empowering the patient improves their life. Dependence enriches the clinician and contributes to a dialogue where knowledge about health is obscured and limited. Healthy people are those who know more about their bodies, and it is the clinician's role to be an educator in this regard.
So what does this mean for you? Ask your clinician questions! Ask them to explain more! Get them to draw diagrams and arrows! If you leave your appointment without knowing more about your body, your clinician hasn't done their job!
Would you like to know more? Book an appointment with us, or call us to tee something up.
We look forward to seeing you in clinic.