Reducing Inflammation is a Key to Treating Chronic Back Pain

New research offers hope for millions of sufferers

Why do we experience back pain?

The common belief is we have back pain because of disc herniations and degeneration. It may not be the only cause, but research does suggest 26–42% of all low back pain cases are discogenic, a medical term meaning “caused by the disc.” Yet, a review of 33 studies comprising 3,110 individuals found disc degeneration and herniations are common in people without any back pain.

Of the 20-year-olds without pain, 37% had disc degeneration and 29% had a disc herniation. In the 80-year-old group of people without pain, 95% had disc degeneration and 45% had disc herniation. How can so many people have degeneration and herniations but not pain? What is going on for the 26–42% of low back pain cases that are caused by disc damage?

A recent review of existing research, published in the Journal of Clinical Medicine provides valuable insights. In short, elevated inflammation leads to more disc degeneration and a higher likelihood of experiencing prolonged pain.

Inflammation is a process the body uses to initiate the repair of damaged tissue. When damage occurs, such as the tearing of a muscle or the outer layer of a spinal disc, the body sends special cells to the area to fix the damage. These cells clean away debris, such as dead tissue, and begin the formation of new tissue. During the process, the area often becomes red, swollen, and warm because more blood and helpful cells are flooding the area. As the new tissue matures and strengthens, the inflammation reduces.

The amount of inflammation and the duration of the process differ between people. This is one of the main reasons some people experience back pain and some don’t, even if they both have scary-looking MRIs. So, why do we have different inflammation responses? One reason is the severity of the disc herniation.

Inflammation is the key to back pain

Disc herniations are described in many ways. You will hear lay terms such as “slipped disc” or medical terms such as “disc protrusion.” First, know that discs don’t “slip.” They are not like jelly donuts either, a common analogy that creates a lot of fear and misunderstanding. Instead, a disc is more akin to a truck tire with gum in the middle.

The discs are joints between the bones of your spine. They are essential for spinal stability, alignment, and mobility. The spine is robust and capable of withstanding incredible levels of stress. You can safely lift with a rounded back and pick up heavy objects without causing any damage. In fact, you can enhance your spine, making the bones, muscles, and ligaments thicker and stronger with regular exercise.

As we age, the cellular makeup of the spine changes. These changes alter its properties and ability to withstand stress. How quickly it changes depends on several factors outside of age. Regular exercise and a healthy lifestyle slows the degeneration process. Conversely, metabolic and cardiac diseases, such as diabetes and hypertension, quicken degeneration.

When degeneration occurs, the outer layer of the disc (the tire portion) loses some of its flexibility and becomes easier to tear. Those tears lead to inflammation.

Tears can occur in healthy bodies, sometimes from vigorous physical activity, but they repair quickly. In some people, the tears take longer to recover. As more and larger tears develop, the inner layer (the gum portion) eventually starts to push its way out of the disc. The different medical terms refer to the severity of the herniation. The stage progression goes like this:

bulging > protrusion > extrusion > sequestration

If the herniation presses against a nerve, it can cause pain or numbness and tingling to shoot down the leg. Even if it doesn’t hit a nerve, the inflammation itself leads to pain.

During that inflammation period, when the body is repairing the disc, new nerves and blood vessels are formed. These are important for the repair process but contribute to experiencing pain. The amount of inflammation that occurs and the duration it lasts is not only reliant on the severity of the herniation but also on the overall health of the person.

For example, in physically active adults, the inflammation phase is shorter and less dramatic. Essentially, the body is better at healing. This means their pain experience is often shorter and less intense. In many cases, there is a complete absence of pain despite the MRI showing disc degeneration and herniation.

Unfortunately, according to multiple studies published in JAMA, much of our population does not fall in that category, as physical activity rates are poor, harming their overall health. That poor health speeds up disc degeneration and sows repair. Healing becomes even more challenging when pain is layered in.

Pain is complex

Pain is not just about physical damage. Here is the official definition from the International Association for the Study of Pain (IASP)

“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

Many biological, psychological, and social factors can exacerbate or blunt our pain experience. Our current understanding of pain is referred to as a biopsychosocial model. We don’t simply have ‘pain fibers’ that translate tissue damage into pain. The level of damage does not always correlate with the level of pain we experience either.

Tissue damage plays a large role and it is responsible for most acute pain. If you tear a muscle or break a bone, nociceptive fibers (often incorrectly simplified to pain fibers) are stimulated by local inflammation and trigger a pain cascade, but that is just a part of the complex phenomenon.

As we explored, our health status can impact the severity and duration of the localized inflammatory response. Now let’s layer in the psychological and social factors.

Fear, depression, anxiety, and past painful experiences can make symptoms worse, as well. Conversely, distraction can lessen pain experiences. Our brain receives a lot of information and filters out what’s important. If we focus on something other than the usual pain, the pain might be less or even gone. But if we pay too much attention to the pain, it can get worse. It’s why you see some athletes play through a game with an ankle sprain without feeling the pain. While hormones, such as adrenaline, can play a role, attention and focus matter too. Conversely, if all you do is think about a painful area of your body, the pain will intensify.

If you have low back pain, how does it affect your life? Every time you put on your shoes, sit in traffic, pick up your kids, or sneeze aggressively you feel pain. Our emotional status and history of pain impact our thoughts and actions, affecting the treatment progression.

These factors are why chronic pain is so prevalent and difficult to treat. When we experience pain for a prolonged period — that is, beyond the duration of normal tissue healing — our nervous system is hypersensitive. Other stressors such as poor or insufficient sleep, poor dietary habits, inactivity, and other medical conditions delay recovery. No pill or surgery will address all of the contributing factors.

How to treat and prevent disc-related back pain.

In short, focus on your overall health. But let’s look at the short and long-game approach. In both cases, activity is your friend and inactivity is one of the worst things for you back.

Research repeatedly shows bed rest does not work for treating pain and medical clinical practice guidelines specifically state to avoid bed rest. That doesn’t mean you shouldn’t modify your activity.

Gradually progress your activity, letting pain be a guide. You aren’t creating more damage if you experience pain. If you have a paper cut and push on it, you aren’t damaging the cut further, you are simply triggering a pain response being stimulating nerves that are affected by inflammation.

Do activities that cause minimal pain but elevate your heart rate. That may be brisk walking, pressing activities in the gym, or swimming. You may be at 25% for one week and then 50% the next, gradually progressing your mobility and strength.

But what about the disc? Should you be worried about the actual herniation, rather than strictly focusing on symptoms?

Sometimes, spontaneous regression happens, in which the disc recovers and the herniation disappears. Over a two-year period, spontaneous regression occurred in 96% of sequestrated discs, 70% of extruded discs, 41% of protruded discs, and 13% of bulged discs, A systematic review in the Journal of Clinical Rehabilitation found. Complete resolution occurred in 43% of sequestrated discs and 15% of extruded discs.

How do you know if you should just wait for spontaneous regression or not? Over my 10 years as an orthopedic physical therapist, I field this question often, and each time I tell my patients it depends on the symptoms.

Medical Clinical Practice Guidelines support conservative treatment as the first-line treatment for disc herniations. If the symptoms do not improve after 3 months, a more robust assessment is needed. That conservative care may be managing it yourself with gradual increases in activity.

If you are unsure about your health or back pain, speak to a healthcare provider. I often recommend starting with physical therapy during the acute stage of back pain, as research demonstrates superior outcomes and fewer medical costs when PT is initiated early.

If you are recommended surgery, get a second opinion. Surgery is an aggressive treatment and often unnecessary. Compared to surgery, conservative care has equal medium and long-term outcomes, and it doesn’t come with the same level of cost of risk. Even if you have chronic pain, conservative care is often best, as surgery is a poor option for chronic pain in most cases. No medication, injection, or surgery will enhance the physical capacity of your body. This brings me to the long game and pain prevention.

Please understand, that injury prevention does not mean a 0% chance of injury. It means the risk is lowered. By nearly every metric, I am healthy and strong but I still have occasional back pain. That’s ok and expected. Seven-hour car trips to the beach, chopping wood for hours in the backyard, and carrying children all day will challenge anyone’s back.

The key is I recover in a normal timeline.

There are many things you can do to improve your overall health including sleeping 7–9 hours a day and eating a lot of plants. I will focus on exercise. Research is clear that exercise, both aerobic and resistance training, is key for metabolic health and controlling inflammation.

There are several health metrics I recommend tracking. I use these for my patients and myself. For cardiac health, keep track of your blood pressure, heart rate, and lipid profile. For your metabolic health, waist circumference, BMI, and A1C or fasting glucose are key. For physical strength, you can use several different metrics that I cover in greater detail here.

You can obtain many of these markers on your own. Getting blood work at a local lab or through your primary care physician can fill the gaps. If you are improving those metrics and they are within the recommended thresholds, you will improve your ability to recover from discogenic back pain.

In general, aim to meet the physical activity guidelines. Achieve at least 75 minutes of vigorous or 150 minutes of moderate aerobic activity a week plus at least two sessions of resistance training. Exceeding these markers can help you enhance muscle mass, strength, and VO2 max to further improve your health.

Your body is resilient and adaptive but it needs proper support.