For Referring Physicians and Healthcare Providers
Many physicians have told us how helpful FixYourOwnBack has been to patients that they referred to the site. For those referred patients, there is a free area that explains the mechanism of injury to the lumbar disc, and some simple self-help instructions on how to manage the disc during activities of daily living. Given the robust literature on the benefit of exercise interventions for back pain, we offer an affordable paid membership ($19.99 per month) which helps organize your patients into clinically proven, safe, exercise progressions. They also receive deeper education on biomechanics and the nature of chronic pain. To give you a better understanding of the information that underpins the FixYourOwnBack site that your patients will be exposed to, read a bit more below. If you’d like to take a look at the membership portion of the site prior to prescribing to your patients, contact me at the email below and I will establish a temporary demo access for you.
In 1994-5, Bogduk, Schwarzer et al produced 3 papers that shed a great deal of light on arthrogenic nociception in chronic low back pain.[1,2,3] Using analgesic joint injections, they determined an estimated prevalence of pain from the lumbar discs, sacroiliac (SI) and facet joints. The graphic below provides that distribution.
The Painful Non-Radicular Disc
The lumbar discs were found to be the origin of pain in chronic low back pain (LBP) in more than 40% of Bogduk et al’s cohorts on average. This number seems in contrast to the statistics that many of us leave medical training with. We are taught that disc extrusion is a relatively rare occurrence (~10%) and infer that the disc is unlikely to be the cause of pain in severe and/or chronic LBP. Bogduk, et al, pointed out that the disc itself can be painful, and indeed is the MOST FREQUENT source of pain in chronic and severe LBP. Said differently, the disc can be the origin of the patient’s back pain well before the nerve roots are affected to produce the radiculitis or radiculopathy commonly referred to as sciatica. Borrowing from earlier authors , Bogduk used the term ‘internal disc derangement’ to describe this type of discogenic pain.
How to Injure a Disc
Research has shown that COMBINED flexion and compression is the quickest way to injure the disc.[5-7] In the injured AND uninjured patient, this is observable as a tendency to hinge excessively in the lumbar spine with forward bending activity. Genetics largely determine how often and how much of this activity can be tolerated before injury occurs.[8-11] The amount of recovery allowed between these episodes of spinal hinging also plays a role in whether load exceeds tissue tolerance. When tissue tolerance is exceeded, injury occurs to the internal lamellae of the annulus of the lumbar disc and progresses outward. These inner layers are free of nociceptive neurons. Pain does not enter the equation until the compromised lamellar layers reaches the well innervated/vascularized outer layers of the disc OR the resultant bulging of the disc produces mechanical pressure on the nerve roots. This latter situation helps to explain the sciatica patient with no back pain, although downstream compression of the sciatic nerve at the piriformis is not an uncommon cause of that presentation in my experience. Interestingly, once enough layers of the annulus have been compromised, innocuous forward bending (picking up a sock, paper clip, etc) with a spinal hinge is often the “straw that breaks the camel’s back.”
The Establishment of the Pain Neuromatrix in the Flexion-Intolerant Disc-Injured Patient
Several lines of research[12-16] suggests that as the damage to the lamellae of the annulus reaches the outer innervated layers, pain nerves follow the vascular elements that migrate into the internal lamellar layers. This sensitizes the disc and the patient may find their functional window of tolerable spinal hinging begins to narrow. At this point even slight loss of the stable neutral spine position can result in pain. As the patient continues the provocative spinal hinging, and feels nociceptive pain more frequently, the ‘wind up’ of the nociceptive neurons associated with the now well-described phenomena of central sensitization begins to occur.[17,18] The hapless patient, unaware of the provocative movement patterns and postures, slowly paints themselves into an inactivity corner because they begin to fear that movement will hurt their back. This adds to the mix the well described fear avoidant behavior that has been shown to be highly correlated with chronic back pain and predictive of poor prognosis.[19-25] The patient often becomes more depressed with this learned helplessness and then becomes a candidate for anti-depressant medications which show well in some studies to help improve perception of pain in chronic back pain.[26,27] We also know from the pain management literature that stimulation of the descending pain inhibition system via activity is a solid, low cost, conservative way out of the central sensitization/chronic pain morass.[28-30] Herein lies the rub…when movement is intermittently painful the patient is strongly reinforced to NOT move.
Here we borrow from the psychology literature on cognitive-behavioral interventions for anxiety and use graded exposure to painless movement. The patient needs to understand the movement fault and then be encouraged to build bridges of successful, pain-free movement to reach their functional goals. This in a nutshell, is the functional rehabilitation paradigm and it represents the foundation of the methods employed here at FixYourOwnBack.com to help a very specific patient subset…those with flexion intolerance and disc injury in the lumbar spine.
In the pain psychology literature we take liberty with the work of Vlaeyen et al which was well represented in their book Pain Related Fear: Exposure Based Treatment of Chronic Pain. Those authors would just expose the chronic low back pain patient to feared lifting stimulus and omit lifting training so as to avoid safety-seeking behavior. In my clinical practice I have seen this run off of the rails with patients. The patient with a disc injury and fear of lifting, for instance, is negatively reinforced to not lift. In the sustained period of avoidance of lifting, the previously injured structures knit and become tolerant of some loading. However, if the poor quality of movement with lifting is increased in volume or intensity, that person is vulnerable to re-injury. We train our subscribers and our clinical patients like athletes and teach them how to lift and move in ways that are scalable and sustainable. This allows them to practice these movements mindfully like an athlete or martial artist, avoiding the notion of safety-seeking behavior.
A word here is in order about exercise as an intervention in low back pain. Many clinicians saavy to the literature point out that use of “specific” exercises as an intervention in chronic low back pain (CLBP) has not shown to be more successful than recommendations for “general exercise” and activity. A few points are worth noting here:
- Current literature suggests the presence of sub-groups of back pain with different etiologies and characteristics. [32-35]
- Current literature also suggests that specific treatments addressing these back pain subgroups are more successful. [36-44]
- Current literature suggests that when disc injury has progressed to the point of radicular symptoms, McKenzie protocols for endrange extension are highly effective in pain management. [45-48]
- Those studies citing no benefit in specific vs non-specific exercise to address the non-specific clinical entity of CLBP were using a heterogenous cohort comprised of multiple subgroups of CLBP. [49-51]
Noted spine researcher, Stuart McGill, said it well in reference to this phenomenon when he noted that “…a specific intervention that significantly helped only a small percentage of back pain patients in a heterogenous cohort does not mean that that intervention is unsuccessful. Indeed, it means that that intervention is successful for a sub-group of that cohort.”
What Subscribers to Fix Your Own Back Can Expect
Your referred patients have access to free education and videos to help get out of pain, as well as a paid subscription option which offers a progressive exercise plan to help reduce recurring episodes of LBP. They are first walked through a self-adminstered screen to determine whether they indeed have flexion intolerance. If they do, they are educated about the movements that will likely cause them pain and are taught movements that help with their pain when they have it. These movements are borrowed from the work of Robin McKenzie, and help to empower the patient to control their pain with few/no narcotics or doctor visits. All of this educational information to this point is free to your patients and should help most of them to address their pain. McKenzie therapy alone will not cure the functional problem though, because the patient needs to address the movement faults that underlie the condition to address recurrence.
Cheaper Than a Co-Pay
To address the movement faults, motivated patients who subscribe to FixYourOwnBack.com (only $19.99 per month) are coached through hip hinging and lifting strategies to use the powerful gluteal muscles. Common mobility deficits in the hips and thoracic spine that promote excessive hinging in the lumbar spine are addressed with other exercises. Patients are then instructed in bodyweight exercises to begin stabilizing the neutral lumbar spine and are then progressed through successive ‘chapters’ of exercise to groove sustainable, spine-sparing movement patterns in saggital, frontal and transverse planes. The exercise program is organized in a format similar to a college text, with “Chapters” of material covering specific aspects of the flexion intolerant back. Each chapter has Learning Objectives, written material to flesh out those objectives, and a channel of detailed exercise tutorial videos to address those objectives. Subscribers are then presented with an exit test to determine if they are fit to move to the next chapter. Advanced chapters focus on strength, agility and power production with spine sparing strategies, using easily obtainable, inexpensive resistance equipment like dumbbells and kettlebells. The exercises are borrowed from the most progressive and current rehab literature and represents the author’s direct study with many of these individuals and 10 years of successful clinical application to refine the delivery. No obligation or contract is ever applied so subscribers can use the site to meet their needs and then discontinue the service whenever they want.
I am honored to be able to participate in your care algorithm for your patients and truly feel that this approach represented at FixYourOwnBack can make a difference in a very common, and expensive public health phenomenon. Through education, exercise, and empowerment we can help to reduce healthcare costs, and improve the quality of life for many people, with simple interventions that are cost effective and easily implementable. I am available to discuss this further via email, or perhaps by addressing your clinical or educational group directly. Be well!
Phillip W. Snell, DC
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