Chronic Back Pain: The Rabbit Hole Of Research, Ideas, Philosophy and Winging It
Welcome to the rabbit hole that is chronic back pain, I'm going to dive off into different tangents, avenues and directions. It's a long one but I hope you enjoy it. Part research and part personal opinions. Back pain is heavily debated and is treated in so many different ways it can be confusing for a patient to know what to do. Get yourself a cup of tea and take a dive to see your options, what to avoid and what might suit you best. This is not a cure to back pain but a discussion on what is out there, how I feel about the industry and where it is heading. This is an honest review about my own views and personal journey.
Back pain affects most of us at some point in our lives, I myself a Chiropractor, have had back pain, neck pain and shoulder issues. I have spent many years of my youth running around like a lunatic, I’ve had falls, the martial arts I did gave me a six-month neck injury and a nasty fall down the stairs all because my new socks were too slippy for the stairs which gave me six months of agony hell!
Back pain is complex and is not just a mechanical issue  it's not always straightforward and thanks to science and pain science, in particular, we are discovering so many back pain myths and misconceptions. Let's do a case of a patient (made up but a very common presentation)
“Jenny is a 46-year-old female, a nurse for the last 15 years, lots of heavy lifting, she works night shifts so sleeps during the day. 18 months ago she lifted a patient into their bed as she did not have a pulley to hand, a few hours later she noticed an ache in the central part of her lower back. It stayed a sharp type of pain for a few weeks and then subsided to a dull ache. This dull ache is a 6/10 nearly consistent ache, no real pain at night, a little stiff in the morning and pretty much eases as the day goes along, towards the end of the day her pain increases and stays with her until she goes to sleep. Jenny reports that she thinks she may have caused a serious injury because it is not getting better, not even with Naproxen, Co-codomol or paracetamol, or heavy and very addictive opiates prescribed by her GP. Jenny is afraid to bend forward because it hurts her, she does a little exercise and grabs food on the go. Her mother is currently very ill and is looking after her when she has time and is not working. She has no medical issues and is otherwise healthy.”
A typical case for a Chiropractor, physio, osteo, GP, massage therapist, acupuncturist, naturopath, hypnotherapist or surgeon. What do you think is going on? Do you think all of her back pain is purely from lifting that one patient? What other factors could aggravate her back pain?
Let me bullet point them:
Stress is a biological and psychological response, on a cellular level many things are going on. A stressor results from a perceived threat, in this case, back pain. When this perceived threat is triggered, a part of the brain called the hypothalamus (it releases hormones) is activated. When
this happens another part of the brain is activated called the pituitary gland along with another gland called the adrenal medulla which sits on top of the kidneys. Now we could go much further into pathophysiology and neurophysiology but we want to keep this simple! Cortisol is the main hormone that affects us in the long term. It creates tension in the body, mental fog, fatigue, weakness and long-term stress is believed to create more widespread issues like heart disease and diabetes. It's possible that stress alone can cause back pain due to the increased tone of the muscular system, this tightness can be interpreted as pain by the brain during movements such as bending forward.
Sub-optimal sleeping patterns:
Poor sleep is linked to the above, without a good nights rest we have low energy, think more negatively , become less active which can lead us to eat convenience food, this can lead to obesity and new more serious problems. Am I catastrophising? Yes, but it happens so it needs to be addressed. Sleep can lower life satisfaction which in turn, stop us from doing the things that we need to do to help ourself's. It's proven that lack of sleep can result in stress  and vice versa which is just as important as they go hand in hand.
Linked to the above, a poor diet means that we are not getting enough of the good stuff to run our bodies at an optimal level. We need things like Vitamin C, D and E, Magnesium, phosphates and an abundance of other proteins to keep our bones, joint's and muscles healthy. When we run on processed foods, sugar, alcohol and bad fats it might be having an effect on out soft tissues . Also, a poor diet can lead to increase stress levels . You will notice all of these bullet points are linked together.
Lack of Exercise:
Have you ever heard the phrase motion is lotion? I use it all the time, in fact, I rarely sit for longer than 20 minutes at a time. The reason being is we start to stagnate when sitting for long periods. We get less blood flow to go around our body, it makes us sluggish and unmotivated and can create a low mood. Put all of these together and it can create an unmotivated feeling stopping us to do the things we need to help ourselves. Some research though shows that there is no link between low activity levels and back pain  but research does show that it's great for back pain .
Fear of movement/Avoidance behaviour:
I see it every day in my office, people who have been in pain for a long time report of avoiding certain movements because it hurts. This makes sense, total sense to me and the patient. Unfortunately, it creates more issues. As we lose movement, muscles get tighter, more sensitive and people generally feel things get really painful. Many feel stiffer in the mornings because as they are walking and moving things ease up and become less painful as the day goes along.
This is a big one, our beliefs shape our whole being, the phrase “we are what we think” rings very true. Many athletes have mental tuning by specialists to train their brains to overcome their own limiting beliefs, and it works wonders and creates new world records and unbelievable feats! Many chronic back pain patients feel they are broken, that they will have pain for the rest of their lives, lost hope, “I cannot bend forward”, “if I take more drugs the pain will go for a bit”, people often think there is something really serious going on that the hospital, doctors, scans and blood tests have missed. They often think “what if” they missed something. Because of the lack of acceptance, the pain continues because they have been consumed by thinking about the pain. I bet if there was a loud crash of breaking plates in the kitchen then the likelihood of them forgetting about their pain momentarily is highly likely. A recent development in the physio world called cognitive functional therapy is helping people overcome their beliefs about back pain . Similar to CBT (cognitive behavioural therapy – anxiety, panic, depression) but aimed at back pain patients. By challenging our belief system on pain we stand a much better chance of ridding back pain once and for all.
This is a tricky one because no one wants to be told that the pain someone is experiencing is in their head. In fact, this is poor advice, not true and can create disability, make the patient feel useless, inferior and helpless. I have a patient that was born with a scoliosis (a curvature of the spine) in her lower back, mid back and neck when she was 13 doctors told her that she would end up in a wheelchair. What do you think this does to one's mindset? Luckily for her, she thought NO!, I will never be in a wheelchair, this lady is now 83 and has lived a normal life ever since. Her attitude and way of thinking let her live the way she wanted to, has children, a husband and lives a very happy life. Some people are less fortunate. Illness behaviour in many cases is where people keep going to the GP for things that are creating fear. For example a little twinge in the chest cavity that happened once. A person with illness behaviour may become very concerned and feel that it could be something that is potentially dangerous. Most likely it is trapped wind, a muscle spasm or something completely benign. This can lead to strained relationships between patients and doctors. Illness behaviour is like a hypersensitivity to normal bodily sensations, It's not uncommon for people with chronic pain to do the same thing. A new twinge or a different type of pain can lead someone to seek further assistance, and wanting constant reassurance that nothing serious is going on. This can also lead to many scans such as X rays and MRI's. If you look for something hard enough you will probably find it. Research now shows that MRI's and X rays are a poor diagnostic tool for low back pain . Also surgery is out of the window unless there are serious neurological issues that are increasing in severity.
Blimey, you might say, reading all of that puts a real downer on back pain! It does but also we need to go into it with as much detail as possible so we can understand it, help people overcome it and try to re-educate that it is much an emotional experience as well as physical.
If it hurts it must be broken, split or torn?
Something that has been coming to light over the last few years is that chronic pain is not related to the measure of tissue damage . This means that commonly with chronic conditions, there is no tissue damage. Huh? If it hurts there must be something nasty in there or my back is broke? Um pretty much no! OK so does that mean it's all in my head and I’m imagining it all? Again no not at all, the pain people experience is very real! When some people have exhausted all other avenues they often end up at a specialist to be told we can't find anything Jim so it's all in your head. Try not thinking about it (which can actually help), unfortunately, that does no good to one's psyche as we mentioned. Anxiety is common with back pain because they now they feel like this pain is for life like a constant stone in their shoe and sadly a lot of cases can lead to unemployment, social anxiety, depression and even linked to a shorter lifespan .
Where Does The Rabbit Hole Go?
It sounds rather bleak but chronic back pain is the leading cause of disability . BUT and it's a big but, we now know so much more, we can educate more and with a combination of advice, education, treatment and more movement we can get people the relief people are looking for. Yes, some cases will not go completely but for some, having just a little relief from back pain can make a huge difference to someone’s life. So we really are not too sure how deep the rabbit hole is. We now have many groups, niches, gurus, philosophies, techniques, specialists and holistic therapies doing their best to help people with their pain. One issue I personally see now is that the difference of opinions leads to research warfare, dogma and even bitterness between the very people who are all trying to do the same thing. This can be very confusing for a practitioner who wants the best for their patients. Below are some of the groups with differences in opinions.
* The pain science guys:
Some amazing books and research are out and coming out on pain science, I use it and know many other chiropractors that have never even heard of it or would not want to use it. But also, many patients are not interested and do not want it. This could be because they have had hands-on treatment for years and believe that is the right treatment for them. Some people want a massage or anything that is hands-on rather than being educated about how their thoughts a partly to blame for their pain. I think the education part is paramount, unfortunately, with any change, there is resistance. Not just with patients but in the therapy industry as a whole. I really think pain science is the way forward for now as it has the best research. But the problem with research is it's always going to change. Five years from now the new back pain cure could be chewing on some grass from your back garden, who knows!
* The manual therapy guys:
A mechanical approach, one leg is longer than the other which is throwing out your pelvis and causing your back pain. Or your back has an increased arch which is causing excess strain on your back. The implementation of acupuncture, electric massager’s, gadgets and massage waxes are in the mix. Spinal manipulation, stretching and active release techniques release muscle tension, get the joints moving and reduces pain levels, or does it? I think it does but I am biased and have been doing this since I qualified three years ago. Some therapists believe manual therapy causes dependency and a biomechanical approach is outdated and pretty much rubbish. I disagree and I am allowed to because I am biased! Some people are unethical and others are ethical. I believe touch is a powerful thing if I had spent my so far short career treating people and none of them actually got any benefit I would have quit soon after I qualified. Luckily 95% of my patients (yes I audit myself) get great results and tell their friends and family. For me, the only pitfall is the people who are more worried about lining their pockets.
* The Anti-manual guys
Massage is bad, spinal manipulation is bad, if you touch anyone then it is bad. Anti-manualists are very research heavy which is fine but I have found they like to belittle anything that is not congruent with the latest research. If I have a patient that comes in with a three-year history of a neck issue and I give it a good click and they are pain-free for the next three months it is still bad because the evidence for neck manipulation is not great. Damn, I should stop now and throw in the towel.
* The unethical guys:
I don't like these, the people who use scare tactics, create fear and make a lot of money. They are pretty much the opposite of the pain science guys by using damaging terminology like “Mrs Jones you have a crumbling spine”. If a practitioner tells you that you need treatment three times a week for the next six months, RUN. That's all I need to say...
* The movement guys:
Usually gym rats (I mean it as an endearing term), usually more fit than the average human and use movement as their way of fixing back pain. I think it's a great way to get people moving more and help people challenge their own beliefs about back pain. Again the only limits are that some people want hands-on treatment, or the patient is literally too scared to try it because they have done very little for many years and is too much of a leap. Yes, graded exposure to exercise is the way forward but it is very challenging sometimes for the patient to take those first steps. This is where a good movement guy will implement some good old pain science. The movement guys are generally very positive and absolutely love what they do because it is their way of life. Usually ethical, motivating and positive, a perfect medicine for back pain patients.
*I do a bit of everything guys:
That's me, the equivalent of a therapy socialite. I like to take what I believe to be the best bits of each group and mould it into one (except the unethical kind hssss). I use physio, osteo, massage, movement and pain science techniques. What works for one patient might not work for the next. I feel having as many tools as possible gives the patient the best chance possible. Some chiropractors hate us because they believe it's not true chiropractic. Well I paid for my degree and qualified so I can practice as I like. Now there are many of us practising in what is called patient centred care. It's all about the patient and what is best for them using the best possible evidence. Does every technique I use currently, backed up by hard peer-reviewed literature? No, but my patients get the benefit and I practice in a way that is ethical. I also adopt the BPS (biopsychosocial) model which addresses biology, psychology and social factors.
So there we have it, back pain is not so simple and there is a long way to go. Conflicting research, opinions, philosophies can confuse not just clinicians but patients as well. All we can do is be our best and keep up to date with the current evidence, offer our patients the best advice and work on their own attitudes towards pain in an uplifting and positive way.
This was a long one and could have been another five thousand words but hey we all have a life to get back to.
Best in health
10. Lorimer Moseley, “Teaching people about pain — why do we keep beating around the bush?” Pain Management. 2012.