Dr. Howard Schubiner is board-certified in pediatrics, adolescent medicine, and internal medicine. He was a full time professor at Wayne State University for 18 years and now works at Providence Hospital in Southfield, MI. He is the founder of the Mind Body Clinic and the co-author of several of my posts on the Neurophysiological Disorder.

Neurophysiological Disorder is news to a surgeon

I am a surgeon. Like all surgeons I am focused on finding a source of pain that I can fix. When this happens, my patient is happy. When I make my patient happy, I’m the hero, and that makes me happy. Not finding an exact cause of your pain is almost as frustrating for me as it is for you. The Doctor is Missing Something

Neurophysiological Disorder (NPD)

Dr. Schubiner presented recent neurological research demonstrating that the brain has a quality called neuroplasticity, the ability to create new nerve pathways in response to life events. When you learn to ride a bicycle or play the piano or swing a golf club, your brain cells develop new neural circuits that are connected to your body. They consist of millons of nerve cells. What most doctors do not know is that pain can be caused by these learned embedded circuits. Even when there is no tissue damage in the body, such as a tumor, fracture, or infection these connections can cause real physical pain.

Emotional Pain = Physical Pain

Recent research done in Pittsburgh has shown that the brain can create pain which is identical to the pain of a physical injury. We have also learned that an emotional insult is processed in exactly the same way in the brain as a physical injury (Kross). We now know that stressful life events and our emotional reactions to them can cause severe pain. Treating this type of pain with pain medications, injections, or surgery is usually not effective. These treatments often leave the patient extremely frustrated and depressed. However, when the true cause of the pain is recognized, these pathways can be reversed by programs utilizing NPD principles. Dr. Schubiner’s book Unlearn Your Pain outlines one process. This website is also another resource along with the book Back in Control. The key is using tools that create alternative neurological detours.

Your brain can generate pain

The notion that all pain has an identifiable structural source overlooks several key points:

• Soft tissue injury can occur at a level that is below the sensitivity of any diagnostic test.
• Tissues can be irritated without being torn—another undetectable injury. The irritation occurs through inflammation, which is a chemical, not mechanical, source.
• There is no routine diagnostic test to specifically tell us that the nervous system is “short circuiting” from the Neurophysiological Disorder.We do know that if a “functional MRI” (which shows what part of the brain is “active”) was performed on a patient who suffers from NPD, then the pain parts of the brain would light up.

Fibromyalgia

We enjoy treating NPD – especially chronic pain

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I believed that pain was always structural–I was wrong!!

During my first five years of practice, it was my assumption that if a patient had experienced low back pain for six months, then it was my role to simply find the anatomic source of pain and surgically solve it. I was diligent in this regard. The test I relied on most heavily was the discogram. The discogram is a test where dye is injected into several discs in the lower back; if the patient’s usual pain was produced at a low injection pressure, it was considered a positive response. The only patients I did not fuse were those who did not have a positive response or had more than two levels that were positive. I performed dozens of low back fusions and felt frustrated when I could not find a way to surgically solve my patients’ low back pain.

I have a physiatrist friend, Jim Robinson, who is a strong supporter and contributor to the DOC Project. From 1986 to 1992, we both served on the Washington State Worker’s Compensation clinical advisory board and helped set standards for various orthopedic and neurosurgical procedures. Our discussions were based on this assumption that there always is an identifiable “pain generator.” That means there was always some anatomical problem generating a pain impulse and we need to discover it to save the problem. It was just a matter of figuring out what test is the best one to discern it. We did not think in terms of structural versus non-structural sources of pain. We knew about the role of stress, but did not fully appreciate how large a role it played in altering the body’s chemistry and perception of pain.

BTW, our original concept of a “pain generator” was wrong. The only place in the body where pain is felt is in the brain. Sensory input has to be first interpreted by the nervous system and if a certain threshold is exceeded, your brain sends out a pain signal that indicates danger and your body will respond with an appropriate action to keep you safe. A bone spur has no inherent capacity to generate pain.

Structural problem

I define a structural lesion as one that is distinctly identifiable on an imaging test, which correlates with the patient’s symptoms. An example would be a ruptured disc pinching a nerve that causes pain down the leg. A ruptured disc between the fourth and fifth lumbar vertebrae will cause pain down the side of the leg. This is the pathway of the fifth lumbar nerve root. A ruptured disc between the fifth lumbar and first sacral vertebra will cause pain down the back of the leg, which is the pattern for the first sacral nerve. If in either of these two examples the pain was going down the front of the leg, it would not be considered the cause of the pain because that is the path of the fourth lumbar nerve root and it does not match.

Other examples are:

• Bone spurs on one or both sides of the spinal canal with matching leg pain and/or nerve damage
• Central spinal canal constricted by bone or ligaments with one or both legs feeling weak, tired, or painful
• Isthmic spondylolithesis (slippage) with corresponding leg pain.
  • More that 3 mm of back and forth motion on X-ray if only back pain; This would be considered unstable.
• Degenerative spondylolithesis (slippage) AND canal constriction with corresponding leg pain or fatigue
  • >3mm of instability if just back pain; considered unstable.
• Acute compression fracture with fluid on the MRI (indicates bleeding).
• Acute unstable fracture/dislocation
• Tumor
• Infection
• Flatback—whole body tilted forward because the normal curvature of the lower back has been straightened – many causes.
• Scoliosis that progresses over time-just the presence a curve does not count.

Pain problem

Many of you experience pain whose source is not identifiable on any test modern medicine has to offer. When there is no identifiable structural source of your pain, we cannot surgically treat it. But we can still help you and the good news is that you don’t have to undergo the risks of spine surgery.

The only scenario that surgery should be even considered is in presence of an identifiable problem with matching symptoms. Other factors such as the severity of the pain compared to the involved risks must be taken into account. If you can’t see it you can’t fix it.

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You are Not a Machine

“Pain-Generator” thinking takes the human body to be like the body of a car–when there is something wrong with the body, all you need is a good mechanic. The mechanic replaces mechanical parts, and the problem is solved. However, your body is not a machine. There is little resemblance of your body to a mechanical device:

Automobiles are DEAD and do not react to a pain signal. They do not have:

• Pain fibers
• A nervous system that interprets pain signals
• Hormones
• Emotions
• Memories

There is NOTHING in the mechanical world that remotely resembles pain. In fact, serious attempts have been made to reproduce pain in the mechanical world has failed miserably. Yet it is understandable for patients to become focused on finding the physical source of their pain. Your pain problem is solvable once you understand the various aspects of pain and then address ALL of them simultaneously.

• Pain is complicated–it is entangled in an intricate web of mental and physical states. It is a necessary part of being alive and human.

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I look at the source of the pain and it’s receptors in reference to back pain and one’s spine. I also discuss the difference between a structural and non-structural source of the pain. Read more about this topic in discussing structural sources of pain.

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I then spent the last year developing The DOC (Direct your Own Care) Journey. It is a self-directed program that reflects the successful efforts of many patients in breaking free from chronic pain. It has become a more clear process and people are healing more quickly with minimal resources and risk.

“You have degenerative disc disease.”

I regularly saw patients who’d been told that they had “arthritis, bulging discs, herniated discs, bone on bone, ruptured discs or degenerated discs”. They were terrified that they would become increasingly disabled and needed to be especially protective of their spines. Surgeons could be aggressive in pointing out how their lifestyle might become quite limited or they might end up in a wheelchair without surgery.

We know that if you view any body part as “damaged”, you’ll tend to focus on it and the sensations from that area become magnified. Then the next logical step in thinking your spine is “a disaster” is to be worried about becoming paralyzed and again surgeons will often state this. None of this is true. We generally don’t know the exact source of neck/thoracic/back pain (axial pain) most of the time. But we actually do know that the discs between the vertebrae are not the source of chronic pain.

Discs lose water content and become stiffer as we age. Since MRI scans are dependent on the signals created by water, less hydration means less signal and a darker disc on scan. That’s it. That is all it means. It doesn’t mean it’s a source of pain. A more accurate term for this condition would be “normally aging discs” instead of “degenerative disc disease.” It’s not a disease.

You do stiffen up as you age

A less flexible spine doesn’t correlate with a painful spine. There have been multiple studies done in the cervical, thoracic, and lumbar spine demonstrating that there is little correlation between a degenerated, herniated, bulging, or ruptured disc and back pain. (1) For example, if you randomly study 100 people who have NEVER experienced significant low back pain, by age 50, the majority of them have bone spurs, herniated or ruptured discs, disc bulges, or “degenerative disc disease”. By age 65, it approaches 100%.

There was a study done in the 1950’s that showed that after a disc operation, the chance of having low back pain after surgery was less if there was more degeneration of the disc and therefore less motion.

I encountered this scenario daily in clinic. Patients came to me with severe leg pain from a pinched nerve and had no back pain. Yet the x-rays and MRI scan often show that the spine has severe arthritis, degeneration or ruptured discs. I have personally undergone two low back surgeries and my three lower discs are severely degenerated on MRI. Nonetheless, it is my right arthritic knee and hip that slows me down, not low back pain.

Severe degeneration and no LBP

I evaluated an active middle-aged woman with extreme pain down the side of her left leg every time she stood up or walked. She had no pain with sitting or lying down. She was an avid cyclist, runner, and worked out at the gym regularly. She had narrowing around her fifth lumbar nerve root as it exited out of the side of her spine. Every time she stood up, the fifth nerve was tightly pinched. Her spine was one of the worst looking spines I have ever seen in any person of any age. Every disc was completely collapsed and each vertebrae was bone against bone. There was also a moderate amount of curvature (scoliosis). She had absolutely no back pain. She had never had significant back pain. I performed a one level fusion at L5-S1, which relieved the pressure on the nerve. The fusion prevented the opening around her 5th nerve from collapsing when she stood up. Her leg pain is gone and she has been back to full activities for over ten years.

This example is extreme only in the severity of the degeneration of the discs. I see patients routinely who present with severe degeneration of their spines and have only leg or arm symptoms from pinched nerves.

Structural versus non-structural

If you can’t specifically localize the source of pain, it would be considered a non-structural problem. Axia pain almost always considered non-structural since the pain is widespread and there isn’t a reliable method to identify the “pain generator”. Surgery is helpful only for structural problems, when the offending lesion can be identified and the symptoms closely match.

One analogy is that of going to the dentist with a painful cavity. The source of the pain is obvious. By having the tooth repaired or pulled, the problem is solved. But if you present to the dentist with mouth pain and can’t identify the source, you have to be much more careful. Random procedures in your mouth probably won’t solve the pain, since there are so many possibilities. Doing back fusions is about as successful. Most of the discs in the lower back have some degeneration. Even if you thought one of them might be the source of pain, how do you know which one it is? More invasive testing, such as injecting dye into the disc, hasn’t worked out well either.

Stiffer

I recall a Golf Digest article many years ago showing a famous golfer’s swing during his first years on the PGA tour compared to 20 years later. Early in his career he had a beautiful “C” shape of his lower back at the completion of his swing. Twenty years later, his lower back was almost straight throughout all the phases of his swing. None of us are as flexible in our 60’s as we were in our 20’s.

Discs can be the cause of pain in the initial acute phase of an injury. This often occurs in the presence of a relatively normally hydrated disc that has more motion than a degenerated disc. (2) It’s felt that the ring around the perimeter of the disc is partially torn and there’s an irritation of the nerve fibers in the ring that can be quite uncomfortable. Before my first back operation, I would experience severe episodic bouts of low back pain. After the rupture of my L5-S1 disc relieved the internal pressure on the pain fibers in the ring, my back pain disappeared.

Even though discs may cause acute neck/ thoracic/low back pain, they are not the source of chronic axial pain. Chronic pain in any location in the body becomes a neurological issue after six to twelve months. (3)

There are hundreds of thousands of spine fusions being performed annually in the US on degenerated discs for axial pain. The results are predictably poor and people are often worse. (4, 5) Be careful. A spine fusion is a major intervention. You might be making the decision to have surgery performed on a structure that is completely normal for your age. How can that possibly be a good idea? Challenge your surgeon.

References:

1. Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM (1994); 331:69-73.
2. Weber, Henrik. Lumbar disc herniation: A controlled prospective study with ten years of observation. Spine (1983);8:131-140.
3. Hashmi, JA et al. Shape shifting pain: Chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain (2013); 136: 2751 – 2768.

4. Perkins, FM and H Kehlet. “Chronic pain as an outcome of surgery: A Review of Predictive Factors.” Anesthesiology (2000); 93: 1123 – 1133.

5. Carragee, EJ et al. A Gold Standard Evaluation of the ‘Discogenic Pain’ Diagnosis as Determined by Provocative Discography. Spine (2006) 31: 2115 – 2123.

Listen to the Back in Control Radio podcast Degenerative Disc Disease Isn’t a Disease

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It can be difficult for patients to accept that their problem is, essentially, “undetectable” while experiencing so much pain, it seems impossible that so many tests would come up negative. Here are some points to consider.

• Since people generally keep moving the injured part, the irritation will last a while. Although immobilization may calm it down more quickly, the resulting stiffness can also be a problem.
• Soft tissue pain can occur in any part of the body. Most musculoskeletal pain originates from the soft tissues and the diagnosis is made by the location of the symptoms, what movements make it better or worse, the time of the day, and response to medications.
• Rarely are imaging studies helpful. The problem is manifesting itself at a level below the sensitivity of any diagnostic test.
• Regardless of the source of the pain, it becomes memorized by your brain in about six to twelve months. Then the solution lies in addressing both the soft tissues as well as the nervous system. Soft tissue work alone won’t resolve it.
• Back pain is the most common reason for disability and chronic pain. The reason why is it that it hurts–a lot. The inflammation/ irritation can arise from the fascia, ligaments, tendons and the discs. The worst part it that intense muscle spasms may occur, which is the body’s guarding response. The intensity causes one to worry about the severity of the injury. Often, patients are told that their backs are in bad shape, which isn’t reassuring. The vast majority of the time, patients backs are fine, as the spine normally degenerates with age.
• So, physicians can make an exact diagnosis of the source of low back pain only about fifteen percent of the time. (1) Generally, we do not know the exact cause because of the nature of soft tissue pain.

“No one believes me”

Patients may become frustrated when pain from an “undetectable” injury doesn’t let up. They begin to feel that no one believes them. Unfortunately, this type of injury is far more likely to persist than, say, a broken bone. In the spine, once the soft tissues are irritated, they may stay irritated through normal daily activities, sometimes almost indefinitely. If you severely sprained your ankle and kept re-spraining it on a daily basis, how long would it remain painful? For a long time.  On the other hand, broken bones heal in three to four months. The prognosis for a fractured spine has been shown to be better than the prognosis for a muscle sprain.

My tennis elbow

One of my own muscle/tendon afflictions is tennis elbow. I may set it off when I lift too heavy of a weight at the gym or when I practice my terrible golf swing. I can suffer for six to 18 months with severe pain in either one or both my elbows. It hurts to shake hands, reach up and adjust the lights during surgery, use the surgical instruments, and countless other routine activities. The pain is as severe as any pain I have experienced, and it is persistent. Two years after my last episode, I could still push on the spot on my elbow and slightly feel the irritated area. Yet if I were to have an X-ray, MRI, CT scan, or bone scan of the area, the results would be completely negative. If I were to have a biopsy, there would might be some inflammatory cells in the tendon area. However, since a biopsy would not change treatment, there would never be a need to do one.

Although we often cannot identify the exact structural source of the pain, we do know that pain fibers are being stimulated and are sending messages to the brain. The intensity of the pain may increase if more pain fibers are stimulated or if the sensitivity of the brain increases. The final perception of the pain will depend on how many pain areas that are stimulated in the brain.

Additionally, as mentioned above, chronic pain evolves into a brain disease regardless of the source.

1. Nachemson, A. “Advances in low back pain.” Clinical Orthopedics and Clinical Research (1985); 200: 266-278.

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Sources of pain

With pain in any part of the body, there are potentially three components of the problem:

• Structural problems – identifiable problems with matching symptoms
• Non-structural issues – soft tissues such as ligaments, discs, fascia, etc. that cannot be seen on a test
• The central nervous system is always a factor and can independently create symptoms

The first step is for your physician and you to get a clear idea about whether there is possible structural problem that should be surgically addressed. If there is a correctable problem, then you need to decide whether you pain is severe enough to undergo surgical intervention. If it is, then we have discovered that it is critical to spend a few months optimizing the outcome by normalizing sleep, decreasing anxiety, stabilizing meds, etc. We call this “prehab” or rehab before surgery. If the pain is not severe enough to warrant the risk of surgery or the problem is not structural, then surgery is off the table.

Overview

The DOC program is organized around the following variables:

• Education
• Sleep
• Stress management
• Medications
• Goal setting/vocational issues
• Physical conditioning/ rehabilitation
• Family dynamics

The central nervous system

You might notice that the first five of the categories, either directly or indirectly, affect the central nervous system. Improving sleep will decrease the perception of pain and improve your sense of well-being. Stress is an obvious issue regarding the central nervous system. Everyone has stress and most of us have a lot of it without ever being taught effective stress-management skills. The additional stress of chronic pain is a major problem. Medications are used to decrease the pain on a short-term basis to help improve function. Education and goal setting will decrease your anxiety and frustration.

Physical considerations

Rehabilitation of the soft tissues and general care of your physical health is an important step. However, it is necessary to first calm down the central nervous system before they can be adequately addressed. Otherwise, when painful soft tissues are aggressively manipulated, there will be an exaggerated pain response. What exactly is done within each category is not as important as having ALL of the categories successfully defined and treated. Fighting a forest fire-your pain

You will already have been through many of the treatments that will be described. However, it is the self-directed structured combination of these variables that will make an impact on your pain and quality of life.

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