Just listened to episode 290 reviewing the recent Huberman podcast and as an avid student of his podcast, would like to offer a video essay in response (runtime is 224 mins). Additionally, I have begun developing a protocol to take individual toe training to the next level, involving a set of tiny pulley systems that I will be putting on Kickstarter. A discount and video series will be available for BBM readers on my Feetfinder account.
Seriously though, great summary on back pain broadly. A few questions:
At 32:45ish you guys mention that 90-95% of patients presenting with low back pain have non-discogenic back pain, but the Australian Low Back clinical care guidelines mention that 90-95% of it is non-pathologically serious low back pain. Is that what was meant, or is only “pathologically serious” LBP considered reliably diagnosable as “discogenic” in nature?
Jordan also mentioned something in passing about herniation increasing the likelihood of low back pain onset. Is there any connection known with how symptoms present with low back pain (aside from the aforementioned “pathologically serious” situations) that changes overall prognosis, management or expected recovery time, such as “sciatica” (radiculopathy or radicular pain)? I.e. the Australian guidelines mention episodic back pain, back pain persisting over time, etc means that the timeline significantly increases for recovery, but I’m not sure how this is related to anything tangible mechanistically (even though the management is probably the same?). They also make allusions there (found also in BBM’s Sciatica article by Charlie) to sciatica symptoms being likely related to the sciatic nerve, but I don’t know what the significance of this is from a treatment or prognostic standpoint.
Does the presence of sciatica imply a “more mechanical” link to nerve impingement or similar, or are the stats pretty much the same for herniation and non-herniation in terms of symptoms (or do we have less “false negatives” with sciatica than we would with a herniation, i.e. “most people who experience sciatica have X MRI findings, even if many people who have X MRI findings have no symptoms”)? I assume its presence doesn’t imply anything more severe, concerning, etc, but I’m not sure I’ve found a concrete answer on this even though it may be right in front of me.
Thanks for the continual good info, constantly referring people to your work and away from expensive gimmicks. Trying to get physios on board too, but it’s difficult to get people away from concrete “pseudo-treatment” to accepting the more abstract nature of the BPS model, even if they “acknowledge” it.
It’s been a while since I have delved into these data, but I would be surprised if fully 10% of back pain is “pathologically serious”. Perhaps my impression of what is truly “pathologically serious” might be skewed, working primarily in an inpatient setting where epidural abscesses, vertebral osteomyelitis, and compressive myelopathy are the things we worry about. Reliably diagnosing “discogenic” back pain is more complex than we’d be able to get into on the podcast, outside of obvious scenarios.
There are certainly scenarios where the nature of symptoms / symptom onset can alter management. This mostly relates to pathologically serious situations. However, in situations of severe debilitating radicular pain, early epidural corticosteroid injections can have an impact on pain in the short term and can be considered, even if they do not change the ultimate prognosis or long-term outcome.
Yes, true radicular pain syndromes typically reflect nerve root involvement in some capacity.
Glad to help. If you are interested in “sciatica” in more detail, highly recommend Tom Jesson’s work.
I don’t think I quoted that particular stat precisely. When I went back to check it, page 14 says diagnosis stats are: -Serious spinal disease (less than 1% in primary care) -Radicular pain or neurogenic claudication (5-10%) -Non-specific (90-95%)
I think Jordan did specifically mention that ~95% was specifically non-discogenic, but maybe getting into the weeds of what this means isn’t really that important, as I assume that even if “discogenic” pain theoretically does exist and is identical to non-specific pain (no notable neurological symptoms), it’s not really a clinically relevant distinction.
There are certainly scenarios where the nature of symptoms / symptom onset can alter management. This mostly relates to pathologically serious situations. However, in situations of severe debilitating radicular pain, early epidural corticosteroid injections can have an impact on pain in the short term and can be considered, even if they do not change the ultimate prognosis or long-term outcome.
Gotcha. I wondered if the presence of “leg pain” without notable neurological symptoms in the presence of ye olde back pain onset changes anything about management, prognosis or timeline, but I missed this bit on page 27: The presence of radicular leg pain alone is not considered a serious pathology in the absence of severe or progressive neurological deficits, and elsewhere it notes that simply the presence of it doesn’t change management. Makes sense re: “severe debilitating pain”, but I suppose it’s heuristically convenient to simply lump this into “severe debilitating pain” with back pain as well for the average person.
Yes, true radicular pain syndromes typically reflect nerve root involvement in some capacity.
Gotcha, but I assume the previously discussed still applies here barring serious neurological impairment or severe debilitating radicular pain, namely in that treatment is largely the same approach over time? Any idea if “leg pain” that’s not true radicular pain occurs in people that present with LBP?
Glad to help. If you are interested in “sciatica” in more detail, highly recommend Tom Jesson’s work.
Thanks, will add it to my reference list. Mostly interested in understanding this broadly, but also being able to disseminate it coherently, as the amount of people with back pain and some degree of leg symptoms I’ve encountered that are very convinced of the “spinal injury” route is pretty high, and almost all have fairly significant chronic psychological stress as a result.
Yes, initial treatment is likely to be similar in most situations.
And yes, leg pain that is not true radicular pain can occur in the context of low back pain, which is why I added that qualifier of true radicular pain syndromes. A lot of people can experience discomfort in the hips, gluteal region, posterior thigh and commonly just refer to any of it as “sciatica” without knowing. Sometimes this is due to other concomitant musculoskeletal issues (like hip OA), vascular pathology (like claudication or thrombosis), etc.
In lieu of another thread:
This was originally intended as general info as I had been experiencing what I thought was referred pain in my glute after a back tweak that’s lasted a few weeks and had some other people ask.
In any case, over the last week I’ve felt a familiar tight pain in my right buttock (sort of central/slightly lateral) that occasionally moves into my lateral hamstring. I first experienced this when doing glute bridges when working with Dr Miles last year, but it sort of went away on its own.
It came back after a week of doing a lot of low bending for work. It’s significantly more painful now, but previously I was able to somewhat avoid sitting on it, etc.
The issue currently is that I’ve got the same pain in my left leg, although this leg feels less painful and more like a vague “burning” on occasion (with tingling on occasion) down my left leg. Discomfort is mostly glute, down lateral hamstring and into top of calf, occasionally. Parathesia is mostly around foot and calf when present.
It hasn’t really been improving, and has gotten worse with periods of sitting when teaching music, etc. Last night was quite uncomfortable and made it very difficult to sleep, regardless if lying on side, stomach, back. Driving made the right side significantly worse.
I’m familiar with the prognostic criteria of this now, and want to be careful of catastrophizing or worrying that it will become chronic, but it’s quite distressing when one can’t sleep or get a chance at recovery. Function is limited, as squatting or hinge patterns produce pain. No neurological deficits as far as I can tell.
What am I looking for in terms of needing to be evaluated, aside from the reg flags you guys mention in articles? Activity seems to mostly make it worse, and there’s no pattern of improvement. I’ve read that pain becoming “centralized” and moving from the leg into the upper posterior region is a “good sign” but I’m not sure how true that is. I also read that if it progresses and becomes more debilitating, evaluation is warranted, but I’m concerned about medical nocebo or attempting to be persuaded into unnecessary treatment. Would book another consult but other pain issues have made work less frequent than it needs to be. Mostly hoping this is all “normal” and on the path to subsiding.
We did not leave anything out in terms of our recommendations here.
Yes, centralization of symptoms with time and/or activity is associated with good outcomes.
I think you know enough about this topic that this is unlikely to be an issue, and could ask the right questions to get the best information & advice from a clinician making recommendations to you.