Conservative Musculoskeletal Management
Where Exactly Does Back Pain Come from?
"The Intervertebral Disc Is Most Likely
The Cause Of The Pain..."
Dr. Nachemson makes a VERY convincing case when he presents 6 lines of reasoning, supported by 17 references, to support his contention that the intervertebral disc is the most likely source of back pain, including the primary research completed by Smyth and Wright in 1958 (2). Regarding the work by Smyth and Wright, Dr. Nachemson notes:
Was Causing Back Pain.
At the time (1976), claiming the intervertebral disc was capable of initiating pain was new and not only that, Nachemson claiming the disc to be the most probable source of back pain was both surprising AND revolutionary.
remain in the nucleus pulposus
"Clinically, The Concept Of 'Disc Pain'
The posterior longitudinal ligament is innervated by the sinuvertebral nerves and
the anterior longitudinal ligament by branches of the grey rami.
Lateral and intermediate branches of the lumbar dorsal rami supply the iliocostalis
lumborum and longissimus thoracis, respectively.
Medial branches supply the multifidus, intertransversarjj mediales, interspinales,
interspinous ligament, and the lumbar zygapophysial jóints."
systematically identifies those structures that are
potential sources of primary low-back pain."
Adding to the growing momentum of this "disc-pain" concept... In 1987, SPINE published Dr.
Vert Mooney's Presidential Address of the International Society for the Study of the Lumbar Spine. It
was delivered at the 13th Annual Meeting of the International Society for the Study of the Lumbar Spine, May 29-June 2, 1986,
& discomfort. A Chiropractic adjustment opens the joints of the spine and breaks up the unwanted adhesions and helps re-establishes proper joint motion.
stretched ligament, muscle tendon, or joint capsule.
Yet we know that 10% of back 'injuries' do not resolve
in 2 months and that they do become chronic."
a unique relatively avascular tissue found nowhere else in the body - the
intervertebral disc. Is it possible for the disc to obey different rules of damage than
the rest of the connective tissue of the musculoskeletal system?"
"Persistent pain in the back with referred pain to the leg
is largely on the basis of abnormalities within the disc."
Chemistry of the disc is based on the relationship between
mucopolysaccharide production and water content.
"Mechanical events can be translated into chemical events related to pain."
An important aspect of disc nutrition and health is the
mechanical aspects of the. disc related to the fluid mechanics.
"Mechanical activity has a great deal to do with the
exchange of water and oxygen concentration" in the disc.
The pumping action maintains the nutrition and biomechanical function of the
intervertebral disc.. Thus, "research substantiates the view that unchanging posture,
as a result of constant pressure such as standing, sitting or lying, leads to an
interruption of pressure-dependent transfer of liquid. Actually the human
intervertebral disc lives because of movement."
"The fluid content of the disc can be changed by mechanical activity, and the fluid content is largely bound to the proteoglycans, especially of the nucleus."
"In summary, what is the answer to the question of where is the pain coming from in the chronic low-back pain patient? I believe its source, ultimately, is in the disc. Basic studies and clinical experience suggest that mechanical therapy is the most
rational approach to relief of this painful condition."
"Prolonged rest and passive physical therapy modalities no longer have a place in
the treatment of the chronic problem."
This model presented by Dr. Mooney in this paper goes on to discuss:
The intervertebral disc as the primary source of both back pain and referred leg pain. The disc apparently becomes painful because of altered biochemistry, which sensitizes the pain afferents that innervate it.
Disc biochemistry is altered because of mechanical problems, especially mechanical problems that reduce disc movement.
Therefore, the most rational approach to the treatment of chronic low back pain is mechanical therapy that restores the motion to the joints of the spine, especially to the disc.
Prolonged Rest is Inappropriate Management
Additional support for the disc being the primary source of back pain was presented by Dr. Stephen Kuslich in the prestigious journal Orthopedic Clinics of North America in April 1991 (7). The title of his article is:
The Tissue Origin of Low Back Pain and Sciatica:
A Report of Pain Response to Tissue Stimulation
During Operations on the Lumbar Spine Using Local Anesthesia
These authors performed 700 lumbar spine opera€ions using only local anesthesia to determine the tissue origin of low back and leg pain, and they present the results on 193 consecutive patients studied prospectively. Several of their critically important findings for you include:
"Back pain can! be produced by several lumbar tissues, but by far, the most common tissue or
origin was the outer layer of the annulus fibrosis."
"The normal, uncompressed, or unstretched nerve root was completely insensitive to pain."
In summary, these authors found that..
The Outer Annulus Is "THE SITE" Of
A Patient's Back Pain.
Past studies that suggest the disc is not an important source of low back pain because nerve endings "are not present" are clearly and overwhelmingly erroneous when you carefully analyzed the most modern literature.
Documented research at no time has demonstrated irritation of a normal or inflamed nerve root to produce low back pain. Back muscles themselves are proven not to be a source of back pain; in fact, the muscles, fascia, and bone are really quite insensitive for pain. The inflamed, stretched, or compressed nerve root is in fact the cause of buttock, leg pain and sciatica, but not back pain.
Very recently in 2006, physician researchers from
The Japanese researchers note: