Tag Archives: back pain treatment

26Jul/16

Back pain

Back painIn today’s Daily Mail Good Health section an article boldly claims that an ingenious new approach to back pain could transform your life. This is indeed a big statement to make about one of the largest ‘public health’ issues — chronic pain and depression are the top 2 global health burdens.

The authors describe the biopsychosocial model for pain (BPS) that incorporates factors relating to the biology, psychology and sociology of pain. This is the model claimed for most modern pain services, although whether all are fully addressed in an integrated manner is a separate point. It is good for the BPS model to gain some air time as it is certainly a step forward in the right direction compared to the dominant biomedical model that would suggest we need to look for a structural or pathological reason for pain. For anyone with even a basic knowledge of pain, the biomedical model will be deemed outdated and lacks any use for understanding persistent pain. This is simply because pain cannot be explained by a structure or pathology.

For the first time, perhaps ever (in my memory), I was delighted to read about danger signals rather than pain signals in the public press. This is a vital piece of information as we do not have pain signals or pain centres, instead we have a biological system that detects salient events and orientates our attention — termed the salience network by Giandomenico Iannetti and colleagues. Conjoining this model with current models of consciousness, AI and brain (e.g. predictive processing) and you are getting somewhere near a very, very good way of thinking about pain. Of course we have some way to go yet and need to be careful about how we frame the current knowledge in terms of existing data.

There are many biological and behavioural changes that occur when we have back pain and other on-going pains. We change with every moment as every moment is unique. We feel that we are the authors of our own inner dialogue and this often means drifting into the past or future, becoming embroiled with what has been (as far as we can recall) and what may be, but of course neither actually exist despite the embodied sense we have in that moment. Keeping a close eye on what is in front of us, also known as being present, helps us to see what is really happening versus a story that we construct. By regularly thinking about a painful event in the past, we can easily ‘prime’ or sensitise this moment. Equally by anticipating pain or projecting ourselves forward by imagining that a movement will hurt, we change our way of moving and the sense of our body as anxiety and tension emerge. This is one of the reasons why awareness of one’s own breathing helps.

An important aside: It is important to clarify here that although we talk about the mind, thinking and emotions in relation to pain, the actual experience of pain emerges in the person and is felt in the body or the space in which the body should reside (for many biological reasons). The notion that pain is in the brain or in the head is nonsense. And, we are more than a brain.

Turning one’s attention to breathing means that you are being aware of this moment, now. There are other important ways of cultivating this skill, which allows you to think clearly about what action you can take to create a new experience, a better experience that takes you towards your desired outcome. Additionally, on the out-breath we naturally relax as the parasympathetic nervous system increases its activity. This is opposite to the sympathetic that is involved with protection in the face of perceived threat. And this is really what pain is all about.

In the face of a predicted perceived threat, we can feel pain as part of a whole person defence strategy. There is no pain system. Instead systems that have a role in protection: musculoskeletal system, sensorimotor system, immune system, endocrine system, autonomic system. Then consider how systems support each other as they are all integrated: the gastrointestinal system’s role in providing nutrients to energise the other systems — consider how many people with persisting back pain also have digestion issues as their resources are diverted away from digestion and towards protect. So, more threat to ‘me’ (the self — that’s a huge area to discuss alongside consciousness), more pain. Less threat to me, less pain. How often will a person report an increase in pain when they perceive to be in a threatening situation. The beauty of this is ‘perception’, because we can change it. So in changing our perception of threat we can change our pain. We are designed to change so we can use this biological advantage and with practice become good at it. Remember, pain and injury have a poor or absent relationship — consider phantom limb pain. There is no body part yet there is most certainly pain.

Our understanding of pain has moved on enormously over the past ten years. We are in a very exciting time now as we draw upon many areas of science and philosophy to advance this knowledge, asking new questions and gathering new data. The biomedical model is not sufficient and the BPS model has been a useful step forward but now we need to think about pain in terms of a public health issue. People need practical ways of overcoming their pain moment to moment, coaching themselves so that increasingly they generate their own better and better experiences driven by internal messages as they motivate themselves to a healthier life. This is the reason for my term ‘Pain Coach’ as the individual becomes their own coach using continuously updated thinking and actions to get better, overcome pain and resume a meaningful life.

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11Jun/15

Stiff low back. Why?

Have you got a stiff low back? Stiffness is often part of the picture of low back pain. Why is this?

Stiffness is a conscious experience–a feeling that we sense, interpret and then label as ‘stiff’, usually describing difficulty moving a body part. And just like any other conscious experience, there are the embodied dimensions as well as cognitive and emotional elements: how does it feel? What does it mean for me? Hence to think about stiffness is to think about the body-body systems that create the feeling and meaning.

Stiff low back: there are three common types of stiffness that are addressed in different ways.

  1. Stiffness from actual shortening of the muscles and their compounding tissues
  2. Stiffness from muscles being told to be ‘on’
  3. Stiffness from changes at the joint

Stiffness from actual shortening occurs due to sustained positions or repeated positions being held so that the tissues change in their length. In so doing, there is less freedom of movement at the joints. This tends to gradually worsen as time progresses, with less and less movement at the joint causing further shortening. Regular movement, nudging into the limitation is key in overcoming this aspect of stiffness along with manual treatment that gives you the experience of movement into that part of the range. The manual treatment must sit alongside your understanding of what is happening and why this therapy is being applied, otherwise ‘top-down’ influences can interfere with success (see next section).

Stiffness from muscles instructed to be ‘on’ by the brain is part of the way that the body protects. Otherwise called guarding, the body-brain’s continual planning, expectation, anticipation and desire are embodied, responding to the environment and the context of the situation at that moment. Within our consciousness, different experiences seemingly appear and then fade away as others emerge. Stiffness and pain are no different in this respect, however they may emerge repeatedly in response to normal situations that pose no actual threat. But, due to the sensitive state and vigilance to the environment, non- or low threat stimuli are now interpreted as potentially dangerous and therefore the body responds. The first we know about this is the pain or tightening — the stiff low back. The pain and stiffness are motivators for us to take action, both in thought and behaviour. These thoughts and behaviours seek to reduce the threat and therefore reduce the pain (pain emerges in the person as a result of a perceived threat) and how the body is responding with it’s natural armour, the muscular system. As the need for defence diminishes, so the muscle tension eases and movement improves.

What reduces the threat and muscle tension?

  • Relaxation–this is a skill to learn
  • Mindfulness
  • Understanding pain and knowing that you are ‘safe’
  • Motor imagery

Changes at the joints can, but not always, affect the quality of movement. It is not a given that if your joints show arthritic change, movement will be problematic. Many people have arthritis but suffer no pain or stiffness. Whether you feel pain and stiffness or not is determined by many inter-related factors: e.g./ genetics, gender, past experience, beliefs, expectations, the environment; also known as pain vulnerabilities that all have an underpinning neurobiology that is becoming increasingly understood.

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28Oct/14

Top 5 back pain myths

Welcome to my top 5 back pain myths. What are these you may ask?

Around pain and in particular back pain, there are many phrases and explanations used to try to educate the patient. These have been handed down through the generations and can appear to be logical. Fortunately, the science has moved on and we know better.

Here are 5 common beliefs that have been challenged:

**I have not included the myths of core stability because this has been well documented previously. Pulling in your abs does not solve the complexity of back pain, especially chronic back pain.

1. Bending is dangerous

2. Discs slip

3. Nerves are trapped

4. Pain comes from facet joints, discs etc

5. Low back pain is in isolation to everything else in your life.

Comments below:-

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1. Bending is normal. Sure it can hurt when the back is being protected, and when we have back pain the muscles are guarding and this can reduce the amount of movement. In the acute phase, most positions and movements hurt, but this is protection and it is meant to be unpleasant in order to motivate action. Moving little and often, changing position and breathing all help to keep blood and oxygen flowing.

2. Discs are not actually discs and they do not go anywhere. Yes they can be injured like any other tissue. They can bulge and affect the local environment, and they can herniate, triggering a healing response — both can hurt because protection is initiated. The fact that there are so many nerve endings around the area mean that sensitivity can arise in a vigorous manner. Again, this is a normal if highly unpleasant experience. Remember that a 1/3 of the population have such changes in their spine but without any pain. The body as a whole must rate the situation as threatening for it to hurt.

3. Nerves do not get trapped. Local swelling and inflammation can sensitise the nerves meaning that they send danger signals. There is not too much room either, so if there is swelling or a bulge, this can affect blood flow to the nerve itself and cause sensitivity to movement and local chemical changes. Again, this can happen without pain as well, so it is down to the individual’s body systems and how they respond. Understanding, gradually moving and breathing can all help ease you through this phase.

4. Pain is whole person and involves many body systems that are protecting you. There is no pain system, pain centre or pain signalling. Pain is part of a protective response when the body deems itself to be under threat. We feel pain in the body but the underlying mechanisms are upstream of the body part that hurts. To successfully overcome pain we must go upstream as well as addressing the health of the body tissues.

5. Low back pain is embedded within your lifestyle. It is not separate to how you live — e.g. lack of exercise, postures, work, stress, emotional state, previous experiences, understanding of back pain, gender, genetics, just to name a few. This maybe more complex, but this provides many avenues for overcoming pain.

Suffering with persisting back pain? Have other seemingly different problems such as irritable bowel syndrome (IBS), headaches, migraines, other joint pains, muscular pains, pelvic pain, jaw pain, recurring bladder infections? Contact me today to learn how you can move forward and overcome your pain: 07518 445493

13Jan/14

MRI for back pain – does the report content affect the management?

MRI for back pain –> Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management? This is the question posed by the authors of this recent study, seeking to determine whether adding details about changes seen on an MRI scan in those without symptoms had any impact. The conclusion was: ‘Patients were less likely to receive narcotics prescriptions from primary care providers when epidemiologic information was included in their lumbar spine MR imaging reports’. 

Why may this be?

We can start by saying that jumping down the route of an MRI scan for back pain is not a given, but rather it requires wise thought. The American College of Physicians published a paper in 2011 stating: Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. In other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. Addressing inefficiencies in diagnostic testing could minimize potential harms to patients and have a large effect on use of resources by reducing both direct and downstream costs. In this area, more testing does not equate to better care. Implementing a selective approach to low back imaging, as suggested by the American College of Physicians and American Pain Society guideline on low back pain, would provide better care to patients, improve outcomes, and reduce costs’. 

One immediate issue is that an MRI scan can show structural changes that could be assumed to be the cause of the back pain. On making that assumption, both the clinician and the patient can be pulled down a route of thinking to somehow alter the structure, or remove the tissue will henceforth change the pain. Of course there are many cases of intervention, including surgery, that lead to pain relief. Is it simply because the structure has been removed? The same is true of joint replacement when relief is frequently obtained. However, there are many cases when this does not happen, with pain and other symptoms persisting. We know that this is because pain is not an accurate indicator of tissue damage — see Lorimer Moseley talking about this here. Phantom limb pain is the ultimate example of pain without body.

Including information about common scan findings in people without back pain appears to be a potent message that affects the patient journey. In essence that is what we are seeking to change, the trajectory of the condition and the patient experience, for the better. Cultivating the conditions for the body’s physiology to adapt and develop in such a way as to emerge with healthy function.

What are we doing with this message? Normalising. The key point is the fact that we can have certain changes in the body, in the spine, that do not cause problems. Clearly, the person sitting in the clinic does have a pain problem that needs to be solved, but not necessarily via an MRI scan. If a scan has been taken and shows no serious pathology, this is great news. Having said that, many people describe uncertainty and anxiousness at the lack of a structural explanation for their pain. This is entirely understandable as they have not had their pain explained to them at that time, hence there is no meaning. No meaning creates further worry and this most certainly affects pain.

So, the first point of action once all the information has been scrutinised, is to create a perspective based upon what we know about the body and pain. Describing the pain mechanisms, the underpinning biology that involves many body systems, and the influences upon pain such as fatigue, previous experience, self-analysis of the situation, stress, anxiety, movement and other factors that are all biological. Everything is biological — this is a key data point. A movement, a thought, an emotion; they are all underpinned by brain activity that often creates and colours sensations in the body. We can use the different yet inter-related dimensions of pain (physical – cognitive – emotional) to construct bespoke programmes to tackle both the sources of pain and the influencing factors.

The second point of action is to plan an individual programme that encompasses specific training to re-programme the way in which the body has been working. This sits alongside techniques to develop confidence and awareness of the body, both vital for normal functioning. The patient’s role in this training cannot be over-emphasised, hence why motivational factors, and barriers, must be considered and addressed.

The third point is the monitoring and progression of the training and treatment, sculpting the change in pain and function that is entirely possible once the right conditions have been set for both understanding and action.

The questions regarding MRI and other investigations will continue to be asked and rightly so. We must continually challenge our own thinking about the best route forward for each individual patient. Understandably, patients will continue to expect and hope for the fullest assessment including MRI, the gold standard, and from this we must use the information wisely and objectively, explaining the findings and creating a perspective that makes sense and propels the best possible treatment.