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The Mind Game In Low Back Pain

How back pain is powered by fear and loathing, and greatly helped by rational confidence

1,000 words, published 2007, updated Jul 1st, 2013
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

EXCERPT This article is a summary of one key concept in SaveYourself.ca’s ridiculously detailed tutorial about low back pain.

One of my chronic low back pain patients reported that he’d had a brief relapse after a hard fall on his tailbone. He was playing hockey and got slew footed (tripped). Over the course of the evening, his back seized up into a nasty imitation of previous episodes. Fortunately, by the next morning he had recovered — a testament to his progress.

Many people with back pain are essentially living in that over-reactive, seized-up state — their back reacts to just about everything like that. What was a temporary setback for my client is a continuous reality for someone who has a more serious chronic low back problem. Either that, or they have a “hair trigger” back that may be fine most days, but gets set off by nearly any provocation.

Many people with chronic back pain are essentially living in that over-reactive, seized-up state.

Two key underestimated factors in low back pain

There are two key differences between someone whose back reacts to everything like this, and someone who only reacts to more serious stresses and also recovers more quickly:

Time and time again, it is the people who buy into the idea that their back is structurally unsound who get a case of “fraidy cat back” and react to every challenging stimulus as though it were a lumbar cataclysm — they fear and loathe their own backs.1

It is those who have some confidence that their spine is basically a sturdy structure who are relatively immune to stressful incidents.2

It can take an enormous amount of de-programming to convince people that their backs aren’t actually fragile, disaster-prone structures. Mental habits are incredibly strong, and all the more so under stress. When we are in pain, we are likely to revert to the most familiar thought patterns. This is why I place such a strong emphasis on the “mind game” in low back pain treatment. It’s not that back pain is “all in your head” — it’s not; there absolutely is pain in your back — but it is very much affected by what’s in your head.

ZOOM

Model of doom and gloom

Lumbar spine models like this almost all show a herniated disc. Some go a step further and show discs slipped so far they’ve completely left the spine!

Here’s pain researcher Lorimer Moseley making this point in a great TED talk. He’s talking about how pain is always worsened when you believe that there is danger … and plastic models of slipped discs are much too persuasive.

Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on it’s own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

Don’t miss that video. So good.

Greg House on false positives

It is almost impossible emotionally to see anything that looks “bad” on an X-ray or MRI and not worry about it. It’s also almost impossible to get a completely healthy-looking scan of anyone. TV’s Dr. Greg House has commented on this…

House: Give him a whole body scan.

Cameron: You hate whole body scans.

House: Because they’re useless. You could probably scan every one of us and find five different doodads that look like cancer.

House, Season 1, Episode 17, Role Model, written by Matt Whitten

Or low back pain. And yet most visible defects are clinical red herrings, about as worrisome as a birthmark, and signify nothing at all except the power of modern medical technology to scare you silly if you aren’t armed to the teeth with confident knowledge to the contrary.

I provide numerous examples from the scientific literature elsewhere, but one of the best examples is the most personal: my wife suffered an extraordinary fracture of her spine, and has a lot of titanium and unevenly healed bone in her back today … but minimal back pain. If you can be more or less pain free with that going on your back, you can rest assured that a little joint degeneration is not the cause of severe back pain.

Greg House: one of my critical thinking heroes.
(Cameron ain’t too shabby at it either.)

Greg House: one of my critical thinking heroes.
(Cameron ain’t too shabby at it either.)

The science has my back

Time and time again, the most respected medical experts in low back pain have emphasized the importance of psychological factors in low back pain, instead of the scary-looking things that show up on scans. “

For instance, consider the case of Dr. Richard Bogduk, a mainstream physician, a man who is much more inclined to criticize a fringe theory than to champion one: and yet Dr. Bogduk believes that the most important thing a health care professional can do to stop acute back pain from becoming chronic is to “treat the patient nice and convincing him that there is nothing so horribly wrong.”3

In 2009, the American Pain Society published new guidelines for low back pain interventions, and their first recommendation — top of the list — was that “rehabilitation emphasizing cognitive-behavioral approaches should be considered”4 — and “cognitive-behavioral approaches” is basically doctor talk for “treat the patient nice and convince him that there is nothing so horribly wrong.”

Low back pain is not all in your head … but it is affected by your head

The mind game in low back pain is so important not because it’s a psychosomatic condition, but because the psychological element is a powerful lever. The mind game is a way to break vicious cycles — just as it has the power to negatively influence back pain, what you think and feel also has the power to help back pain.

You are much likelier to feel better if you know that:

Tip of the low back pain iceberg!

This has been a brief introduction — the tip of an iceberg — to a central idea in low back pain therapy. There is a great deal more to learn. Most back pain patients can’t begin to really assimilate and make use of this perspective without much more persuasion. You need a mountain of persuasive evidence. That mountain of evidence exists in the form of my extremely detailed low back pain tutorial. One of the only criticisms I’ve ever received about this tutorial was, “It’s overwhelming. It’s overkill. You had me in the first few sections.” I can live with that criticism!


Fresher, mintier low back pain information!

SaveYourself.ca’s low back pain tutorial is hardly the only source of information about low back pain — but it may be the most refreshing. Relentlessly sensible. Highly readable and reliable. Without ever resorting to claims of a miracle cure, it debunks junky back pain theories with crystal clear scientific explanations (backed up by 326 footnotes). Get perspective and insights on dozens of self-treatment options. Roll your eyes along with the experts at all the back pain mythology out there. Ships with a free copy of SaveYourself.ca’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Notes

  1. Zusman. Belief reinforcement: one reason why costs for low back pain have not decreased. J Multidiscip Healthc. 2013. PubMed #23717046.

    Why is back pain still a huge problem? Maybe this: “It is extremely difficult to alter the potentially disabling belief among the lay public that low back pain has a structural mechanical cause. An important reason for this is that this belief continues to be regularly reinforced by the conditions of care of a range of ‘hands-on’ providers, for whom idiosyncratic variations of that view are fundamental to their professional existence.”

    Well said. If only I could edit it, though, I would say that it is difficult to alter that belief in anyone, patient or professional. The belief isn’t just reinforced by the practices of manual therapists, it’s the reason for them.

    BACK TO TEXT
  2. Vibe Fersum et al. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. European Journal of Pain. 2013. PubMed #23208945.

    Statistically and clinically significant results for a back pain treatment? Pinch me!

    Classification-based cognitive functional therapy (CB-CFT or just CFT) for low back pain is a “body/mind approach to understanding and managing this complex problem” that “targets the beliefs, fears and associated behaviours” of patients — what I have called the “confidence cure” for many years. The big idea of CFT is that back pain does not necessarily have anything to do with a damaged or degenerated back, and the cycle of pain and disability can be broken by easing patient fears and anxieties.

    CFT was tested on 62 patients with moderate back pain, and compared to 59 who were treated with manual therapy and exercise. Three months and a year later, the CFT group was much better off: a 13-point boost on a 100-point disability scale, and 3 points on a 10-point pain scale. Those are not amazing results, but enough to be considered clinically significant, and they beat manual therapy and exercise handily (those patients improved by only 5.5 and 1.5 points on the same scales). CFT was “more effective at reducing pain, disability, fear beliefs, mood and sick leave at long-term follow-up than MT-EX.” As the authors put it for BodyInMind.org, “Disabling back pain can change for the better with a different narrative and coping strategies.”

    There were some blemishes on the study methods, but nothing dire; its results can be safely regarded as “promising” while we wait for replication from bigger studies.

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  3. Jackson. Pain, pp120–1. “Although [Nikolai] Bogduk has a reputation for having all the answers and being a bit of a ‘needle jockey’ who travels everywhere with his little vial of painkilling bivucaine, his presentation in Vienna surprised his colleagues. Instead of talking up the latest surgical intervention, he spoke about addressing the patients’ fears and anxieties, and ‘getting inside their heads.’ He emphasized that what was most important was to first eliminate ‘red-flag conditions’ that might be (but probably weren’t) causing the back pain, and then to reassure the patient that the back would most probably get better and not worse. He still believed in judicious painkilling, but what was more important in treating back pain, he had found, was communication and reassurance. Preventing acute [back] pain from turning into chronic pain was often a matter of ‘treating the patient nice and convincing him that there is nothing so horribly wrong.’” BACK TO TEXT
  4. Chou et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009.

    A review of 161 randomized trials of low back pain interventions by the American Pain Society, concluding with eight recommendations, such as emphasizing cognitive-behavioral approaches and avoiding several historically popular interventions such as provocative discography, facet joint corticosteroid injection, prolotherapy (repeated injections of irritant material to stimulate an inflammatory response), intradiscal corticosteroid injection, or vertebral disc replacement. For patients with persistent radiculopathy, the APS recommends considering epidural steroid injection, surgery and spinal cord stimulation.

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