published 4/16/07, updated 9/28/09
The Mind Game In Low Back Pain
How back pain is powered by fear and loathing, and greatly aided or cured by confidence
by Paul Ingraham, Vancouver, Canada MOREclose
Credentials and qualifications
I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.
For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.
Credentials and qualifications
I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.
For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.
EXCERPT This article is a summary one key concept in SaveYourself.ca’s ridiculously detailed tutorial about low back pain.
One of my chronic low back pain patients reported today that he’d had a brief relapse after a hard fall on his tailbone. He was playing hockey and got slew footed. 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 who start back pain treatment with me 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 last night is basically a continuous reality for someone who has chronic low back problems. Either that, or they have a “hair trigger” back that may be fine most days, but gets set off by nearly anything 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:
- The number and severity of muscular trigger points in the region.
- The confidence of the victim that they are not really fragile.
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.
It is those who have some confidence that their spine is basically a sturdy structure who are relatively immune to stressful incidents.
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.
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.
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.”1
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”2 — 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:
- there is no structural problem (or no serious one)
- the “bark” of low back pain is almost invariably worse than it’s “bite”
- you probably won’t need surgery
- stress is a root cause of low back pain and affects it, but doesn’t have to be “eliminated” (which is unrealistic) but can be mitigated
- you probably don’t have to give up playing tennis (or squash, or golf, or whatever it may be)
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!
$1995
Notes
- 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.’” Return to text.
- Chou et al. 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. Return to text.