Bulging or Herniated Disc
A herniated or bulging disc would by far be the most common answer I receive when I ask patients the question- “what do you understand to be the cause of your pain?” When we are discussing disc related neck or back pain, it is really important that we place the herniated or bulging disc within the broader physiological context from which symptoms emerge. Put simply, the presence of a disc bulge or disc herniation is only part of the story of neck or back pain. It may be a big part of the story, or a small part of story… as time goes by, the bulging or herniated disc should become a smaller part of the story.
We know from some good research that a disc bulge or herniation doesn’t correlate well with the presence of pain i.e. MRI studies of people without any pain repeatedly reveal the presence of degenerative changes in the intervertebral discs. And MRI studies of people who are suffering from back pain do not always reveal a bulging or herniated disc. This is not to say that an injury to the disc won’t be painful- the intervertebral disc is highly innervated, so the nervous system is capable of detecting injury to the disc and mounting a protective response in the form of pain.
What it does mean is that the presence of a bulging or herniated disc, as revealed by an MRI is not a fait accompli with respect to a life of neck or back back pain. Essentially, it is normal to have structural changes to the discs occur… they simply occur as we age. We don’t really know why some people have discs that wear out more quickly or injure more easily than others. It is likely a product of differing genetics and differing environmental factors.
The missing element in this conversation, up until the last 10-15 years has been the concept of neural sensitivity. Our nerve endings and pathways have a capacity to increase or decrease their sensitivity to mechanical and chemical activation. You can read all about neural sensitisation here.
Broadly speaking I would argue that most people with ongoing pain who attribute their pain to a bulging or herniated disc, would probably get a great deal of improvement and perhaps resolution of their pain with education that tidies up their understanding of how pain works, and treatment that addresses the defensive motor patterns that are (probably) sustaining a good portion of their symptoms. Once the muscular guarding and neural sensitivity normalizes, the spine is generally able to move more easily and symptoms tend to diminish. There are of course, a population for whom their disc pathology is the primary driver of their symptoms. Typically though, these patients present with a specific set of symptoms that indicate the need for surgical intervention.
I think it helps to keep in mind that generally, our spines are inherently strong structures… they are tough as nails. An acute injury to the disc, or wear and tear of the disc doesn’t compromise the structural integrity of our spines. Our spines are wrapped in layers of thick ligaments and muscles. A disc injury or wear and tear to the disc doesn’t make your spine unstable. If you’re dealing with recent or acute pain that you understand to be related to a disc problem, you need a good plan to work through the process of getting back to normal without getting to caught up on the popularly held belief that a disc injury necessarily means long terms problems. Similarly, if you have longstanding pain that you attribute to a disc problem, you will probably benefit from some conceptual re-framing of your problem and complementary treatment.
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