Tuesday 25 October 2016

Is your mind making your back pain worse?

As new research links our thinking patterns with long-term back pain, our reporter looks at how managing our behaviours - from anxiety to depression - can help us heal

Anna Magee

Published 20/09/2016 | 02:30

Back pain now affects one in 10 people
Back pain now affects one in 10 people

Whether it's a niggling pain that won't budge, or a sudden twinge that becomes excruciating, back problems are a big deal. Lower back pain is now the leading cause of disability in the world, affecting one in 10 people and increasing with age, according to a large study published in 2014 in the Annals of Rheumatic Diseases.

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Until recently, treatment was fairly routine - painkillers, massage, physio, electrotherapy and, in extreme cases, spinal surgery. But, a new approach claims psychological and social factors play a key role in causing and exacerbating back pain and that help for it should start primarily in the mind.

David Rogers, a leading physiotherapist with 20 years' experience, has been practising this psychological approach at the Royal Orthopaedic Hospital in Birmingham for the past six years. In his new book, Back to Life, he brings together a large body of research that shows how thinking patterns affect back pain and different techniques that can help.

"Research has identified that psychological and social factors such as the way patients think about their back pain, as well as depression and anxiety are stronger predictors of long-term pain and disability than physical factors," says Rogers.

He uses a new called 'biopsychosocial' approach which targets back pain not only with traditional exercise or manipulation methods, but also using tools from cognitive behavioural therapy (CBT).

First used by a spinal surgeon called Gordon Waddell who in 2006 wrote a detailed review in the journal Oxford Clinical Psychology about the beliefs and psychological obstacles that can worsen back pain and make recovery from it take longer, Rogers's approach is aimed at people whose back pain is persistent and ongoing.

In the four-week programme (three hours every week in two group sessions) patients learn simple breathing exercises to manage any anxiety they feel about their back pain along with simple stretches.

Patients are also taught to identify the thinking patterns that could be making their pain worse - these include believing that back pain is severely disabling, avoiding movement and activity and a tendency to low mood or withdrawing from social interaction (as many of us do when our back goes).

In one study of 85 patients undertaking Rogers's programme, 73pc were taking less or no medication when it ended and, of those, 92pc were still off their meds nine months later.

Indeed, other studies suggest that such an approach may even work as well as spinal surgery. A study published in the British Medical Journal in 2009 found that long-term improvements in back pain was not better after spinal fusion surgery compared to cognitive intervention with targeted exercises, such as the approach Rogers uses.

In fact, draft NICE guidelines, released in March this year, specifically recommend group-based psychological methods be used alongside physical treatments for back pain, especially in people for whom previous treatments haven't worked.

The psychology of back pain

Fear of moving in case you'll cause damage, having a 'catastrophic thinking' style, losing confidence, distress, anxiety and depression are all key psychological factors that can make back pain worse.

"These present to varying degrees in people with persistent back pain and have been ignored by the medical community," says Rogers. But how?

"When you injure yourself, the pain you experience is a response in a part of the nervous system called the danger alert system," he explains. "It's made up of nerve fibres called neurons and these link our sensors to the spinal cord where they link to our central nervous system."

The danger alert system is your first protection against potential harm, activating when you touch a hot oven or fall over and injure your back, telling your brain: "There's a problem here and you need to do something about it."

Fascinatingly, research has found that when someone has ongoing back pain, often the actual tissues from the initial injury have healed, yet pain persists.

"This is more to do with a dysfunction of the nervous system," says Rogers. "People with back pain are often given some threatening information at the point of diagnosis about the results of their MRI scans, their future and their ability to work," says Rogers.

"Psychologically, that keeps their danger alert system in protective mode, generating fear, avoidance, stress and anxiety that sticks around, long after their actual injury has gotten better."

This is because such threatening information activates the 'fight or flight' stress response system in the brain, so you stay in 'high alert' with more muscle tension and tightness, priming you for a bad episode of pain.

"In this stressful bodily state a patient can get a severe case of back pain from a relatively small movement.

"It explains why two people can get the same injury but one person's episode can last so much longer, be more severe or keep coming back," says Rogers.

It also explains why back pain can often flare up when there are other stressful events going on in someone's life, such as divorce or bereavement - when muscles can tense - and is the reason why breathing exercises feature highly on his programme.

Change your thinking

Some thoughts could be making your back pain worse, for example, during a flare-up, thinking: 'I'll never get over this, I need to get to A&E now.' "This thinking can exacerbate pain and thwart recovery," says Rogers.

He suggests first trying 7-11 breathing: breathe in for a count of seven and out for a count of 11 for five to 10 minutes. This immediately relaxes the nervous system. Then add some very gentle stretches such as the cat cow from yoga, or gentle rolling of the spine with bent knees ensuring you don't hold your breath.

During an episode of lower back pain, the muscles go into a protective spasm and these two techniques can relax the body enough to stop the pain from worsening or from going into cramp.

Try replacing 'catastrophising' thoughts with 'This will pass eventually' and 'I've been here before, it will get better soon.' Another unhelpful behaviour is avoiding exercise and activity because you're worried about doing more damage, Rogers says.

"A large body of evidence now suggests stretching, yoga and gentle cardiovascular exercise such as walking and swimming can be great help."

* 'Back To Life', by David Rogers and Dr Grahame Brown, €20.55, is published by Vermilion

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