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Understanding MRI and disc related low back pain

Bad back? Starting to feel your age and the lower back is suffering because of things done back in your heyday. A scan reports bulging discs or protruding disc in your lower back and a possibly a host of other nasty words you don’t understand. The important thing to recognise from the get go is yes you may be in pain bending over to put your shoes on or have experienced chronic back pain on and off for years but the scan result is not always necessarily the answer to all your questions, pain or problems you’re experiencing. Age isn’t always the determining factor either.

Research[1] shows that almost a third of healthy 20-year-olds have a disc ‘bulges’. The numbers increase with age up to 43% at the age of 80, so just about every second person without low back pain has a herniated disc. Disc bulges are even more common by the way with 84% at the age of 80. So even if your MRI scan does show a bulging disc you should realise that these findings are completely normal, spine degeneration evidence in your scan presents in a great amount of individuals of similar or older age with no back pain or any symptoms. Many imaging-based degenerative features are likely part of normal ageing and unassociated with pain. Pain is complex and cannot be explained by an MRI scan alone.


So whose at risk to back pain or disc herniation?

Suggestive evidence for degenerative changes are that inherited genetics, occupational load exposure, sport exposure and lifestyle/ physical activity have moderate effect on the prevalence[2]. So those in trades or office jobs whom live their life outside of work sedentary on the couch you can expect and increased risk for disc issues. Degenerative features visible on MRI are more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals. Disc related findings can also be associated to low back pain. Studies indicate the prevalence of people with disc findings and no symptoms increased with age. The prevalence of disc bulges in asymptomatic populations ranges from 20% in young adults to >75% in patients older than 70 years of age[3]. Conclusions from this review of literature suggest that the association between disc bulge and low back pain may be more significant in younger adults, which in the general asymptomatic population is much lower. It is possible that the association between disc bulges and low back pain disappears in older populations, in whom the prevalence of this imaging finding is >90% in the asymptomatic population. The problem is that degeneration of the interbody/disc joint in the spine is common both in asymptomatic and symptomatic individuals.

1 in every 6 Australians (16%) have back problems; that’s 4.0 million people. More recently with covid pandemic occurring these numbers have likely risen considerably due to isolation, working from home and inactivity. The national health survey last conducted in 2014-15 found individuals 18 years and over with back problems were 2.5 times as likely to report experience very high levels of psychological distress (8.1%) than those without the condition (3.2%) after adjusting for age[4]. Again, consider the challenges physically and mentally of covid for many individuals and the trend of chronic back pain sufferers increasing as a result. Cognitive factors can account for 30% variability in pain intensity, functional self-efficacy and catastrophizing in chronic low back pain patients. Adjusting for the population group and pain intensity, an additional 32% of variance in disability is also explained by cognitive factors. If individuals have higher levels of functional self belief and lower levels of depression they have less disability[5]. So if our mental health isn’t great or we are struggling psychologically due to different stresses on our life this can also have quite a large impact on our level of pain. Chronic low back pain is shown to have a significant influence on functional capacity or occupation and working activities; cognitive or psychological factors such as stress, depression and or anxiety have a large impact on patient capacity and outcomes[6].

Belavy et al. [7] showed an increased risk for lumbar disc herniations in astronauts after return to earth. Now you’re probably thinking what on earth has an astronaut got to do with my back pain..? They found that the most likely cause was swelling of the disc in the unloaded condition; hence discs need load to stay healthy. Not surprisingly, research [8,9] also shows that physical activity, particularly vigorous activity, and running are beneficial to maintain disc health.


How do we fix it?


Unless there’s some red flags or spinal cord compression to cause for concern surgery is unlikely to be the quick fix some people may be looking for. Important to be mindful of the fact that if you do have severe back pain or referred symptoms down the legs you should consult and discuss with your physio or GP to rule out any serious conditions or red flags we keep an eye out for. Some individuals with disc herniation may suffer from referred pain, numbness or sensations of pins and needles; ‘siatica’ as its been commonly referred to where there is irritation of the lumbar or lower back nerve roots as a result of the disc injury pressing on the nerve. Without surgery, 73% of patients show major improvements in 12 weeks [10]. A systematic review[11] shows that conservative treatment (physiotherapy) and surgery are equally effective after 1 and 2 years. In acute stages to manage symptoms discuss with your GP suitable medications to assist your recovery such as non-steroidal anti-inflammatory drugs.


Emerging research shows 2/3 of disc bulges spontaneously heal on their own! Many of them within a few months too, not years. So empowering individuals with the knowledge and understanding of their back pain and building confidence in their recovery is just as important as the physical hands on therapy and guidance. At Our Physio this is achieved with graded exercise programs in addition to the hands on therapy to challenge specific movement-related fears such as bending over.


Physiotherapy and exercise are an effective management strategy of back pain; an individual’s beliefs regarding their pain and experiences are also an integral part of their ability to recover [13-15].


Our Physio can provide the guidance you need to recover from your back pain to living happy and healthy.

  • Assessment and diagnosis

  • Education and advice

  • Structured hands on treatment and exercise therapy to facilitate recovery

  • Home exercise prescription

  • Return to pre-injury activity

Assessment and diagnosis for each individuals injury should always be conducted prior to developing a treatment plan with exercise prescription and appropriate progressions. Should you have any further questions or would like to discuss your heel or foot pain with a physiotherapist, please contact Our Physio Central Coast (02) 4339 4475.


References


[1] Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., ... & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American journal of neuroradiology, 36(4), 811-816.

[2]Macedo, L. G., & Battié, M. C. (2019). The association between occupational loading and spine degeneration on imaging–a systematic review and meta-analysis. BMC musculoskeletal disorders, 20, 1-15.

[3] Brinjikji, W., Diehn, F. E., Jarvik, J. G., Carr, C. M., Kallmes, D. F., Murad, M. H., & Luetmer, P. H. (2015). MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: a systematic review and meta-analysis. American Journal of Neuroradiology, 36(12), 2394-2399.

[4] Australian Institute of Health and Welfare. (2020). Back problems. Retrieved 7th February 2023 from https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/back-problems

[5]Woby, S. R., Roach, N. K., Urmston, M., & Watson, P. J. (2007). The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy. European journal of pain, 11(8), 869-877.

[6] Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C., ... & Fanelli, G. (2016). Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research, 5.

[7] Belavy, D. L., Adams, M., Brisby, H., Cagnie, B., Danneels, L., Fairbank, J., ... & Wilke, H. J. (2016). Disc herniations in astronauts: What causes them, and what does it tell us about herniation on earth?. European Spine Journal, 25, 144-154.

[8] Belavý, D. L., Quittner, M. J., Ridgers, N., Ling, Y., Connell, D., & Rantalainen, T. (2017). Running exercise strengthens the intervertebral disc. Scientific Reports, 7(1), 1-8.

[9] Bowden, J. A., Bowden, A. E., Wang, H., Hager, R. L., LeCheminant, J. D., & Mitchell, U. H. (2018). In vivo correlates between daily physical activity and intervertebral disc health. Journal of Orthopaedic Research®, 36(5), 1313-1323.

[10] Vroomen, P. C., De Krom, M. C. T. F. M., & Knottnerus, J. A. (2002). Predicting the outcome of sciatica at short-term follow-up. British Journal of General Practice, 52(475), 119-123.

[11] Jacobs, W. C., van Tulder, M., Arts, M., Rubinstein, S. M., van Middelkoop, M., Ostelo, R., ... & Peul, W. C. (2011). Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. European Spine Journal, 20, 513-522.

[12] Zhong, M., Jin-Tao, L., Jiang, H., Wen, M., Peng-Fei, Y., Xiao-Chun, L., & Xue, R. R. (2017). Incidence of spontaneous resorption of lumbar disc herniation: a meta-analysis. Pain physician, 20(1), E45.

[13] Moseley, L. (2002). Combined physiotherapy and education is efficacious for chronic low back pain. Australian journal of physiotherapy, 48(4), 297-302.

[14] Woby, S. R., Roach, N. K., Urmston, M., & Watson, P. J. (2007). The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy. European journal of pain, 11(8), 869-877.

[15] Smith, C., & Grimmer‐Somers, K. (2010). The treatment effect of exercise programmes for chronic low back pain. Journal of evaluation in clinical practice, 16(3), 484-491.

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