Chronic Pain from the Brain
Move your body to heal. Don’t heal your body to move.
In other words, if you are nursing an acute injury such as lower back pain then you should be staying as active as possible. Bed rest for back pain is the worst thing that you can do for acute back pain. We now know that prolonged bed rest for back pain actually decreases muscle tone which may lead towards altering the mental state of how we perceive pain later on down the road if the problem isn’t fixed during the acute stage.
When we are bending to lift something, whether light or heavy, studies have found that flexing your lumbar spine during this activity puts your spinal discs at an extreme risk for an injury like a bulge or herniation. Sure, your discs may not get injured on the first 100 times that you bend but that repetitive bending is placing an undue amount of stress our spinal discs. This stress can in turn weaken the supporting soft tissues around our spine increasing the risk for an injury.
As a health care provider, I’ve seen countless numbers of ways that people injure their backs. One may think that acute back pain is only related to lifting objects greater than 25 pounds but in all reality, it doesn’t take much weight to throw out your back.
Stress builds up in our body in many different fashions. Our lives can also be very stressful. It’s easy to forget about our health as we take care of our families or become overindulged in our work. From work place stressors to physical stresses, it’s hard not to get easily emotional from internal or external stressors. Prolonged mental stressors may facilitate internal illnesses like stomach ulcers while prolonged physical stressors may facilitate micro-trauma to our backs. Preventing these stressors lead to a healthier, pain free life.
Here’s how it works. Many people walking around casually today may not realize that they may have a lumbar disc bulge or even a herniation that is causing their back pain. Studies have shown that the severity of a disc herniation does not correlate to the amount of pain that people can experience. In other words, a lumbar disc prolapse may cause severe and intractable back pain while a clinically more concerning lumbar disc extrusion may be a asymptomatic. MRI findings are not reliable as a guided measure of pain. MRIs act merely as a compass that point us in the direction of why pain is occurring.
Back pain is often generated by inflammation caused by intradiscal pressure that is pressing on the outer layers of our spinal discs, the posterior annular fibers. These annular fibers have pain receptors that signal to our brain that inflammation is occurring which may cause pain. It’s our job as humans to alleviate that pressure and ease the inflammation.
Moving our bodies to heal is great but smartly moving our bodies to heal is optimal. This is where things get tricky. Many people are numb to the concept of bending your knees to lift. For practical reasons, let’s leave that silly adage to our parents or personal trainers to harp on us about daily.
Bending while keeping a neutral spine is paramount. Repetitive bending without using a neutral spine greatly increases our chances of aggravating the spinal discs which will cause inflammation, pain and so on.
Now that we have a better understanding of how back pain occurs, how do we share this message with the world?
It’s simple. If you feel like you look weird while you are bending to lift then you are probably lifting the right way. Basic tasks such as brushing your teeth or lifting a toilet seat up, while this may not cause pain 9 out of 10 times, is still increasing your risk of injuring the spinal discs.
Let’s visit a scenario that occurs daily. A guy injures his lower back so after his symptoms persist for 3 days without finding any relief from over the counter anti-inflammatory medications, he goes to the ER to get some answers.
After he receives lumbar x-rays, he is told by the medical staff to rest, take anti-inflammatory medications, and follow up with their doctor if symptoms don’t ease in one week.
So why did the ER tell him to rest and take anti-inflammatories for back pain? Great question! Our health care model is fractured and is happy with providing bandages for a problem rather than finding a solution to fix injuries.
What comes next after that acute now chronic back pain sufferer is out of work and on disability 5 years later - the wild whirlwind of chronic pain and depression which an estimated 32 million Americans suffer from daily. These people feel that there is little to no hope to live a pain free life. This is where all health care providers should enter in as a guiding light to change how these people perceive pain.
Pain Education Through Healing
All health care providers who treat pain should empower both acute and chronic pain suffers with the best clinical advice which encourages them to stay active while avoiding pain provoking movements. The patient must understand how their pain occurs. In other words, if the patient has a flexion intolerant spine then they should be coached on using the hip hinge motion like we previously discussed.
Lorimer Mosley, a clinical profession from the University of South Australia, said that “the biopsychosocial model rejects the biomedical model because the biomedical model is not concerned about the person. But, it does not reject the role of structural, biomedical, and functional disturbance of body tissue as powerful drivers of protection.” In other words, health care providers who treat pain are constantly relying on each other to help to treat the same person for multiple ailments.
A chiropractor can’t treat depression and your typical medical doctor can’t provide spinal manipulation or physical therapy exercises during a casual appointment. So how do we as health care providers interlock arms together and address the chronic pain epidemic together?
Positive Reinforcement
We need to empower our patients. In the United States, mental health disorders and back pain respectively are the #1 and #2 causes of disability. These 32 million people who perceive their chronic pain condition as an incurable disease are often accompanied with a medical history of biopsychosocial disturbances.
Avoid fearful language such as degenerative disc disease or pain from arthritis. Instead, communicate in a way that’s more relatable like telling them why they have arthritis and how to prevent the degenerative process from accelerating. In all reality, the majority of adults over the age of 40 have some noticeable degenerative changes in their spine. Arthritis is nothing more than gray hair of the spine. It’s part of our natural aging process. We should treat the body and the brain equally.
Administering the appropriate outcome measure provides an in-depth look at a patient’s pain perception. The Neck Disability Index (NDI), Fear‐Avoidance Beliefs Questionnaire Work subscale (FABQ‐W), and Keele STarT Back scale all provide this baseline. These screenings are designed to make treatment plan outcome goals more relatable and achievable.
The Need
We, as health care providers who treat pain, need to be more open, up front and compassionate for our patients who want to feel better. We must explain to our patients that feeling better starts with them gaining confidence that their body can heal. If they think their chronic pain will be with them for eternity then positive reinforcement becomes paramount for care.
Mental health is a sensitive type of conversation but it is necessary one. Our role of being the best health care provider that we can be goes further beyond what we were physically trained to do. Empowering our patients to understand that they can feel better emotionally and physically will further advance chiropractic in the eyes of the public.
Josh Slomkowski, DC
Dr. Slomkowski is the clinic director at Hometown Spine & Sport outside of Pittsburgh, PA. Since graduating the University of Pittsburgh (2010) and NYCC (2013), Dr. Slomkowski has developed his office with cutting edge chiropractic and rehabilitation based services. He continues to pursue certifications in soft tissue and physiotherapies.
References:
Harvard Health Publications: "Depression and Pain." National Institute of Mental Health: "Depression and Chronic Pain."
What Biopsychosocial Factors are Associated With Work Ability in Conservatively Managed Patients with Cervical Radiculopathy? A Cross‐Sectional Analysis https://onlinelibrary.wiley.com/doi/10.1002/pmrj.12177
Adams, Michael A., et al. “Effects of Backward Bending on Lumbar Intervertebral Discs.” Spine, vol. 25, no. 4, 2000, pp. 431–438., doi:10.1097/00007632-200002150-00007.