Today’s blog starts with an example to illustrate how powerful understanding pain can be in improving chronic pain symptoms:
I had a patient this week who had, what she believed to be, low back pain that was the result of a herniated disc. She was a healthcare provider and knew anatomy and physiology very well. X-rays were normal. She was unable to drive more than 8 minutes without excruciating pain. She was concerned about losing her job.
That’s right. Even healthcare providers experience low back pain. I bet that even Dr. Doug Ross (AKA George Clooney), the famous ER doc, experienced back pain after saving children’s lives on television. We’re all human, we all experience injury, and we all fear that our injuries will result in a present or future disability.
So here we were, sitting in a treatment room, discussing the events that led to months of chronic low back pain. After ruling out potential red flags (take a look at our last blog post for red flags associated with the low back), we attempted a quick cat/camel exercise to improve low back mobility. The patient immediately experienced excruciating pain. She sat down and cried. The exercise brought back memories of the exercise class where she first felt her symptoms. She flash-backed to when she couldn’t help her family around the house. She felt weak and defeated.
This was when our pain education began.
We discussed the psychological influence of pain and its effect on her symptoms. We talked about how the brain is on ‘high alert’ because of the previous injury she experienced. Her fears about a potential disc herniation caused subconscious compensatory measures. It became clear that she no longer allowed her low back to move at these segments. It didn’t matter that an exercise in a crawling position is one of the least taxing positions for the low back. She was worried, her back was irritated, and her body responded with intense pain.
Once she demonstrated understanding, we attempted the exercise again. There was tightness during the first few reps, but minimal pain. Motion improved. We performed 30 repetitions, and she reported minimal pain. She attended the following week with minimal pain and no driving restrictions. That’s how powerful understanding pain science can be.
Butler and Moseley write “the concept of increased sensitivity (pain) is often challenging, but this is what happens to some degree in all of us when we are injured. This increase in sensitivity should fade once the damaged structures are under control and/or you fully understand what is going on.” In the previous patient’s case, there was a combination of the two. Irritation of the spine occurred during her exercise regimen, causing pain. Her pain experience was intensified tremendously after fears of a herniated disc controlled her thoughts. This prevented her from performing any activity without pain. Once she understood why low back pain was occurring in a minimally compressive position and her pain reduced.
Again, “Know pain, or no gain.” We know that interventions designed to reduce pain through pain education and mental relaxation techniques are effective in reducing chronic low back pain. (Ostelo et. al, 2009). Understanding that pain is meant to be a “threat system” and that this “threat system” can become over reactive is key to improving symptoms. Bunzil et. al (2016) found that improvement in low back pain symptoms was dependent on patients changing their understanding of pain and recognizing that pain does not always equal damage. Those who were able to properly understand this saw reductions in low back pain, while those who continued to be defined by their pain and adopt a more “pain=damage” mindset did not improve. Here’s a link to the summary.
“Those who continued to be defined by their pain and adopt a more ‘pain=damage’ mindset did not improve.”
Understanding pain is only the first step in your course for recovery. Bunzil et. al. write “belief change is not enough to evoke change. Once you understand pain and what it is designed for, then we must move on to exercises that challenge this mindset. Take a moment out of your schedules to investigate your own pain experience. Explore your thoughts and fears associated with movement. Once you understand this, move on to exercises to challenge the threat system. We will dive into ways to do this more thoroughly in a future blog post. Before that occurs, take a look back to Back pain: the Road to Recovery to begin the movement journey.
Brendan Glackin, DPT, CSCS
Glackin Physiotherapy, LLC
Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K. Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain. Phys Ther. 2016 Sep;96(9):1397-407.
Ostelo Raymond WJG, van Tulder Maurits W, Vlaeyen Johan WS, Linton Steven J, Morley Stephen, Assendelft Willem JJ. Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews. In: The Cochrane Library, Issue 3, Art. No. CD002014.
Schnitzler A, Salenius S, Salmelin R, Jousmaki V, Hari R. (1997) Involvement of Primary Motor cortex in Motor Imagery: a Neuromagnetic study. NeuroImage 6(3), Pg 201-208