Is your mind at fault for your chronic back pain

Dr Irengbam Mohendra Singh *

This column is a kind of new prescription to rid people the heebie-jeebies of one of the greatest disabilities and socially superfluous blob of chronic back pain. With zero options to treatment psychotherapy has become a sobering prose. It's based on a book Back to Life by David Rogers, a physiotherapist at the Royal Orthopaedic Hospital in Birmingham, England. His research confirm how thinking patterns affect long-standing low back pain.

Low back pain affects one in 10 people in the world and it increases with age, according to a large study published in 2014 in the Annals of Rheumatic Diseases. It affects almost all people sometime in their life. Because it's triggered by simple things like bad posture, lifting something inappropriately and rarely by serious conditions like the spread of cancer into the back spine. In Britain where I live with a population of 64 million and where people get paid for being off-work (National Health Security Benefit), 10 million working days were lost to back pain in 2014. Nearly half of them were between the ages of 50-65.

While I was practising, it was very difficult to sign off anybody that he was pain free, based on the absence of physical signs. Pain is subjective. What's more, the x-ray picture of the spinal abnormality does not always correlate with the degree of pain the patient describes. More men complained of back pain than women, partly because they had to go out to do heavy jobs. Women as tougher housewives, were more mentally resolute and less weepy.

Humans suffer from low back pain because we aren't built to walk erect on two feet. A horse or a dog will not have low back pain unless the spine is broken. Fossil evidence of 4 million year old 'bipedal' (walking on two feet) extinct human ancestors were now found in Australopithecus fossils in east Africa (Latin, australis = southern; Greek, pithekos = ape) where they migrated from south. This is older than other australopith genus "Homo" like Homo habilis from which modern humans – Homo sapiens sapiens emerged 2 million years ago.

Walking on two feet was accompanied by significant evolution of the spine, such as the curve at the bottom of your spine to absorb shock. This erect posture has left our low back vulnerable to stress as it is without proper support in front, apart from soft abdominal muscles.

The majority of cases of low back pain are sudden (acute) from minor causes, generally labelled as Lumbar strain. They get better within six weeks with mild pain killers (the advice of the traditional bed rest is out of date). If no better in six weeks, it's called subacute (taking longer time), then chronic (much longer). It's when one seeks medical help.

Chronic back pain has many causes eg a slightly distorted spinal curvature, a slowly collapsing vertebra due to thinning of the bones (osteoporosis), a slipped disc (shock absorber between the spine, gradually bulging out). It could be a vertebra slipped out of its normal alignment over the one below (spondylolisthesis) or, ankylosing spondylitis – a form of hereditary arthritis of the spine.

There is a curious disease called Fibromyalgia [Chronic Fatigue Syndrome or Myalgic encephalomyelitis (ME)] , which is more psychological than physical. I've seen a score of them. There are no physical signs. Diagnosis depends on the narrative of the patient about unexplainable pain all over the body with extreme tiredness. They are mostly women, complaining of inability to bend to do household chores.

Chronic low back pain is a leading cause of disability. Until recently, the treatment was fairly routine: strong pain and anti-inflammatory tablets, massage, physiotherapy, electrotherapy -Transcutaneous electrical nerve stimulation [TENS] , acupuncture, and in extreme cases spinal surgery. Most surgeons wouldn't do spinal operations in the UK as they couldn't guarantee success, and as a result patients would opt out of it. A study (2009) published in the British medical Journal found that people with long term back pain showed fewer improvements after spinal fusion surgery than with "cognitive intervention" (psychological counselling) with targeted exercises.

Long-standing back pain remains a cryptic genre where visceral and emotional reaction is the whole point. Here comes David Rogers with 20 years' experience and brainstorm ideas. He has done research and identified psychological and social factors including depression and anxiety that indicate how long the pain would last, and the disability would continue, though pain is nothing to do with physical factors.

He believes thinking patterns affect back pain and there are different techniques that can help. His method is called "biopsychosocial". Its approach is to target not only back pain with traditional exercise or manipulation methods but also using tools from cognitive behavioural therapy [meaning altering patient's thinking process towards his/her disability] .

Though patients surely feel comfortable with physical diagnoses, Rogers is saying that chronic back pain is mostly in the mind. According to him, the technique was first used by a spinal surgeon Gordon Waddell, who in 2016, wrote a detailed review in the journal Oxford Clinical psychology about the beliefs and psychological obstacles that can worsen back pain and hinder recovery. Roger's approach is thus aimed at people whose back pain is persistent despite available treatment.

He devises a programme of three hours every week into two group sessions. Patients are taught simple breathing exercises to manage any anxiety they feel about their back pain along with easy stretches. More importantly, patients are taught to identify their thinking patterns that could be making their pain worse. These include among other things, what they believe their back pain is so disabling that they avoid movement and activity with a tendency to low mood or withdrawing from social interaction.

Roger records: in one study when 85 patients took part in his programme, 73% were taking less or no pain medications when the session ended. Out of these recovering people 92% were still off-medication nine months later. Roger's approach is supported by independent studies elsewhere in the world. This indicates that it may even work as good as spinal surgery.

Many studies of the psychology of back pain shows that "fear of moving" in case you'll cause damage and thus losing self-confidence, causing distress with anxiety and depression, is the usual "thinking style" in people with persistent back pain. This can make back pain worse and persistent.

Low back pain of sudden onset (acute) occurs when muscles or ligaments that fasten and support your low back spine is overstretched or some fibres in them are torn. Ligaments are very tough but they can snap as it often happens on the outer side of your foot (ankle sprain). When this happens, as a protective body mechanism, inflammation (red, hot & swelling) occurs in the area. That causes muscle spasm and pain.

This usually heals (though torn fibres will not join each other again) in about six weeks time, but intermittent flare ups may continue for weeks or months. Long-standing (Chronic) back pain refers to the relentless back pain, often after the initial injury to that tissue has long healed. The usual x-ray of the spine is unreliable. You may require an MRI scan to show the minutiae of the damage or spinal stenosis (patchy narrowing of the bone canal through which is lodged the spinal cord).

When to worry about? When an acute back pain is associated with things like fever (infection of eg kidney), unexplained weight loss (cancer somewhere in the body), swelling or deformity in your back (spinal collapse), pain in the chest (lung cancer), loss of bladder or bowel control (cancer), numbness around your genitals, buttock or back passage (Cauda- equina syndrome – a serious medical condition), it needs immediate assessment.

In short, long-standing back pain has psychological overlay, and it's helpful to stay positive ie you will get better, though it's difficult to be cheerful . Regular exercise such as yoga, walking and preferably swimming is helpful. Taking advice from a specialist pain clinic (usually run by anaesthetists) is very helpful. Support from a Cognitive Behavioural Therapy clinic should be sought if there is one. When everything else fails spinal surgery is recommended.