Concerns regarding news-article titled “Robot shows that it’s not just bending and twisting that causes spinal injuries” that appeared on the ABC website on the 2nd of October, 2018.

Kevin Wernli – BSc. Physiotherapy (1st Class Honours), PhD Candidate.

The original article can be found here. Below are my concerns. 

1. Alarming, nocebic language. Among many misleading imprecisions in the news-article, the use of the term ‘slipped disc’ is particularly disturbing. It is simply not possible for the intervertebral disc to ‘slip out’ like a bar of soap. Granted, discs can herniate, however:

• between 30% and 80% of people without any symptoms have disc herniation’s on MRI (Brinjikji et al., 2015; Kim, Lee, & Lim, 2013).
• More than 80% of herniation’s naturally resolve (Benson, Tavares, Robertson, Sharp, & Marshall, 2010), and
• Imaging findings such as herniation’s are poor predictors of future pain and disability (Jarvik et al., 2005).

The language and metaphors (squeezing a jam donut) used in this news article are inaccurate, misleading and oversimplifications of what is a complex system. This fuels the publics already negative and mistaken perception of the human spine being fragile, vulnerable and easily injured.

The living human spine is an inherently strong, robust and importantly adaptable structure. The study even shows that half of the time, the bones (arguably the strongest structure in the body) failed before the disc did! Meaning that many times the discs were stronger than the surrounding bones – a finding which surprised even the researchers and one that was swiftly overlooked as it did not fit the fear-mongering, nocebic narrative of the news article.

 

2. Does this apply to living humans? There are extensive problems with the generalisability of the results based on the research methodology. The research used deceased human spines with a mean age of 76 years old in a machine (without many of the supporting ligaments, muscles and redundancies that the living human body has). Therefore, substantial caution is needed when translating the findings to the real world. Just like living muscles get stronger with gradual load, there is evidence that living discs are stronger in people that load and bend their back (Belavy et al., 2018; Belavý et al., 2017).

3. A small part of the bigger low back pain picture. Structural abnormalities are a very poor measure of an individual’s pain and disability (Brinjikji et al., 2015; Jarvik et al., 2005) and there are many other factors (such as back beliefs, loading history, stress, sleep, physical activity levels, socio-economic status and mental health conditions) that are arguably more important as they have a significantly stronger relationship with pain and disability (Dankaerts et al., 2009; Darlow et al., 2012; Gabbett, 2016; Gatchel, Peng, Peters, Fuchs, & Turk, 2007; Heffner, France, Trost, Mei Ng, & Pigeon, 2011; Lusa, Miranda, Luukkonen, & Punakallio, 2015; Rabey, Smith, Beales, Slater, & O’Sullivan, 2016).

In summary, there are many people trying to change the narrative around low back pain (the recent Lancet Low Back Series is attest to this), and I find articles like this frustrating as they can undo much of this work and have the potential to cause harmful consequences for those battling with low back pain. 

Thanks to Peter O’Sullivan, JP Caneiro and Jay-Shian Tan for reviewing early drafts of this. 

 

About the author:
Kevin is a physiotherapist currently undertaking a PhD at Curtin University in Perth, Western Australia. His research investigates the relationship between movement, posture and low back pain using wearable sensors. He works under the guidance of Associate Professor Peter Kent, Professors Peter O’Sullivan and Anne Smith, and Dr Amity Campbell. He consults clinically out of Body Logic Physiotherapy in Shenton Park.

 

References:

Belavy, D. L., Quittner, M., Ridgers, N. D., Ling, Y., Connell, D., Trudel, G., & Rantalainen, T. (2018). Beneficial Intervertebral Disc and Muscle Adaptations. Medicine and Science in Sports and Exercise, Publish Ahead of Print. doi:10.1249/mss.0000000000001770

 

Belavý, D. L., Quittner, M. J., Ridgers, N., Ling, Y., Connell, D., & Rantalainen, T. (2017). Running exercise strengthens the intervertebral disc. Scientific Reports, 7, 45975. doi:10.1038/srep45975 https://www.nature.com/articles/srep45975 – supplementary-information

 

Benson, R. T., Tavares, S. P., Robertson, S. C., Sharp, R., & Marshall, R. W. (2010). Conservatively treated massive prolapsed discs: a 7-year follow-up. Annals of the Royal College of Surgeons of England, 92(2), 147-153. doi:10.1308/003588410X12518836438840

 

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A.,

 

Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816. doi:10.3174/ajnr.A4173

 

Dankaerts, W., O’Sullivan, P., Burnett, A., Straker, L., Davey, P., & Gupta, R. (2009). Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model. Spine, 34(15), 1610-1618. doi:10.1097/BRS.0b013e3181aa6175

 

Darlow, B., Fullen, B. M., Dean, S., Hurley, D. A., Baxter, G. D., & Dowell, A. (2012). The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. European Journal of Pain (London, England), 16(1), 3-17. doi:10.1016/j.ejpain.2011.06.006

 

Gabbett, T. J. (2016). The training-injury prevention paradox: should athletes be training smarter <em>and</em> harder? British Journal of Sports Medicine.

 

Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological Bulletin, 133(4), 581-624. doi:10.1037/0033-2909.133.4.581

 

Heffner, K. L., France, C. R., Trost, Z., Mei Ng, H., & Pigeon, W. R. (2011). Chronic Low Back Pain, Sleep Disturbance, and Interleukin-6. The Clinical journal of pain, 27(1), 35-41.

 

Jarvik, J. G., Hollingworth, W., Heagerty, P. J., Haynor, D. R., Boyko, E. J., & Deyo, R. A. (2005). Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine, 30(13), 1541-1548.

 

Kim, S. J., Lee, T. H., & Lim, S. M. (2013). Prevalence of Disc Degeneration in Asymptomatic Korean Subjects. Part 1 : Lumbar Spine. Journal of Korean Neurosurgical Society, 53(1), 31-38. doi:10.3340/jkns.2013.53.1.31

 

Lusa, S., Miranda, H., Luukkonen, R., & Punakallio, A. (2015). Sleep disturbances predict long-term changes in low back pain among Finnish firefighters: 13-year follow-up study. International Archives of Occupational and Environmental Health, 88(3), 369-379. doi:10.1007/s00420-014-0968-z

 

Rabey, M., Smith, A., Beales, D., Slater, H., & O’Sullivan, P. (2016). Differing Psychologically Derived Clusters in People With Chronic Low Back Pain are Associated With Different Multidimensional Profiles. Clinical Journal of Pain, 32(12), 1015-1027. doi:10.1097/AJP.0000000000000363