Low back pain (LBP) is extremely common, and is globally ranked as the leading cause of disability in adults (1). LBP is often a source of confusion for healthcare practitioners and patients alike. Where is the pain coming from? Is there a serious issue that needs to be addressed? Fortunately, bouts of pain often resolve on their own with time and appropriate behavioral responses, and the majority of time do not represent a serious underlying pathology. However, too often back pain becomes a chronic problem that begins to impart major impacts on one’s comfort, quality of life, and mobility.
Chronic LBP should be investigated through a biopsychosocial lens, as it is a multifactorial issue that cannot be reduced to one cause. (See our previous blog, A Holistic Approach to Pain Science) There are many factors that can influence the cycle of chronic pain, and among them are cognitive factors- how we think about the pain. How we think about our pain affects how we react and respond to the pain, both on a physiological and a behavioral level. The meaning we assign to our pain can either act as fuel to the fire of chronic pain, or water to dampen its rage.
A danger alarm gone awry
Oftentimes, when it comes to chronic LBP, the bark is worse than the bite. Pain can be considered as a “danger” signal from our nervous system that is indicative of a threat to our safety. However, when pain becomes chronic, part of the problem is in the sensitivity of the danger alarm itself, rather than only issues in the tissues. In chronic pain, learning has time to occur, and this learning is not always helpful. The nervous system begins to amplify pain signals associated with certain activities, and we begin to avoid certain activities, thereby weakening or changing the physical structures that must be used during these activities, creating a negative feedback loop that is consistent with disabling chronic LBP (2).
Consider a home smoke detector. Can you recall the last time you were cooking, and perhaps had the heat just a little too high for a little too long? Tendrils of smoke begin to float up from the pan, and the next thing you know, the smoke alarm is blaring at full blast, causing you to drop everything, turn off the stove, turn on the fan, open the windows, and apologize to your neighbors. While house fires exist and are a huge threat, there was no fire in this case, and the smoke alarm might have caused more of an inconvenience than the smoke itself. Now, imagine that each time this happened, the “sensitivity” dial of the smoke detector turned up just a little bit, the volume of the alarm got a little louder, or perhaps the detector itself somehow started getting closer and closer to the stove. These changes would be maladaptive, and would lead to more situations in which your eardrums get pierced, stress hormones flood your system, and your neighbors start to question your sanity. You might even begin to avoid cooking. Or perhaps you take a more active approach and call a mechanic to help fix some of the issues you are having with the detector.
Cycles of chronic pain can behave in a similar way. Your brain’s pain “alarm” can change overtime, becoming hypersensitive to lower levels of pain input (known as hyperalgesia), or respond by generating pain in situations where normally there would not be pain (known as allodynia). This nervous system plasticity that occurs with chronic pain is known as central sensitization, which is a well-researched phenomenon within pain neuroscience (3). We know that the brain is plastic, and we can learn fear, amplified pain responses, and unhelpful appraisals of our pain. We can also unlearn these maladaptive changes, and begin to relearn safety, comfort, and control.
Changing Your Response to Pain
Amplifications of this danger alarm can occur if we believe that our pain is indicative of severe threats. These beliefs can stem from previous encounters with health care providers, uninformed health messages from society (e.g. our spine is a weak, vulnerable structure), and can even root back to childhood and one’s parent’s responses to pain. If we believe that our pain is not within our control to change, it is more likely to persist.
Try to be with your pain, feeling into it at that exact moment. What is the little person in the control center (your nervous system) trying to communicate? Show your nervous system there is no danger by finding a comfortable, safe environment, slow down your breathing, and engage in some gentle movement of the tissues that are contributing to the distress. Comfort, joy, safety, and pleasure are the opposites of pain, fear, and danger. The sooner you can get yourself into this place, the more likely the smoke alarm will turn off and you will reestablish a state of tranquility.
Asking For Help
In order to make significant, lasting changes to chronic pain, therapeutic interventions are required that we provide at the Wellness Station. A multifactorial, individualized approach is warranted in which bio, psycho, and social issues are addressed. We strive to provide informed care where we can see the intersection between mind and body, the psychological and the structural. Dysfunctional movement patterns are what we look for, and are reflective of protective tension, fear-avoidant behavior, and muscular weaknesses. These patterns may be detected in the way you walk, breathe, bend, reach, turn over in bed, and more. They can also be detected through passive movement, in which we as the therapist move you while you intend to stay relaxed and not help. Addressing these movement patterns are key to bridging the gap between issues in the mind and in the tissues, and will help you make lasting changes in your ability to change and respond to your cycles of pain. While pain is part of being human and it is not realistic to be “pain free”, we can move towards our pain being the occasional pebble thrown into a pond with quickly fading ripples, rather than constant boulders creating tidal waves.
Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team
References:
Vos T, Flaxman AD, Naghavi M et al.. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012;380:2163–2196.
O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther. 2018 May 1;98(5):408-423. doi: 10.1093/ptj/pzy022. Erratum in: Phys Ther. 2018 Oct 1;98(10):903. PMID: 29669082; PMCID: PMC6037069.
Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009 Sep;10(9):895-926. doi: 10.1016/j.jpain.2009.06.012. PMID: 19712899; PMCID: PMC2750819.
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