Is chronic back pain all in the mind?

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backache library INDEPENDENT NEWSPAPERS Backache can be the referred result of mental stress

London - No one, it seems, is immune from back pain. It was reported recently that the Queen had to pull out of an investiture ceremony because of the problem.

She has apparently suffered from excruciating back pain for years - in 2006, she was laid up for several weeks with sciatica (pain caused by pressure on the nerve that runs from the lower back down the legs). The miserable fact is that 80 percent of us will suffer from back pain at some point, and for many it becomes a long-term problem.

Most will see their GP, then take painkillers and anti-inflammatories, and somehow get on with their lives. Some eventually get an X-ray or MRI scan that may confirm structural damage or wear and tear, and surgery may be offered as an option.

However, despite huge advances in diagnostics and surgical techniques, many people with back pain are never completely free of pain. An estimated 1.6 million Britons develop chronic back pain each year and, for around half of them, studies show the pain is disabling.

There is a wide acceptance among pain specialists that when pain drifts from an acute, short-term problem into a chronic one, psychological factors come into play - often making the pain much worse.

In fact, under guidelines from the National Institute for Health and Clinical Excellence (NICE), physiotherapists treating long-term back pain are meant to incorporate some of the principles of cognitive behavioural therapy into their treatment plan, educating patients about the role the mind can play in exacerbating their problem - for instance, using relaxation and breathing exercises.

But a new book by Nick Sinfield, a physiotherapist, goes one step further. Sinfield argues that while our attitudes certainly make pain worse, when it comes to chronic pain, emotional tension is almost certainly the actual cause of the problem in the first place.

“Medical professionals are trained to see back pain in terms of injury or damage to the spine,” he says. “When they treat a back-pain patient, they immediately start looking for explanations that fit a diagnosis.

“They use machines designed to show them every nook and cranny of your nervous system, bone structure and musculature, so they can pinpoint the exact location of the physical abnormality that’s causing you to suffer.

“Because the pain is physical, people look for a cause that’s physical. Unfortunately, this ignores the most common reason for back pain.”

This, he says, is stress and tension, which can come from a number of areas in our lives - from family conflicts to stress at work, or even unrealistically high expectations of ourselves.

“This emotional stress expresses itself in painful physical tension - most commonly in the soft tissues in the neck, the top of the shoulders and shoulder blade, the lower back and the outside of the buttocks,” Sinfield explains.

“I am convinced that failure to address the mental and emotional factors associated with chronic back pain is one reason why treatments based on physical assessment alone have repeatedly failed to provide a permanent cure.”

This is also, he says, why X-rays and MRI scans seldom correlate to patients’ symptoms.

But what about the scan that showed you had a worn-out disc, you ask?

Sinfield is quite firm about this: “Most of us have structural abnormalities in our backs, but those structural abnormalities don’t necessarily cause back pain. Almost all spinal abnormalities are harmless.

“Take ruptured or herniated discs. Our discs often wear out by the time we are 20. It’s a perfectly normal and harmless part of the ageing process, and an inevitable effect of gravity.

“But ask any doctor whether abnormalities in the structure in the back cause pain, and they will say: ‘Yes.’ Yet when you ask why the incidence of back pain has increased rapidly over the past 30 years, they don’t have an answer.

“The reality is these physical abnormalities were prevalent long before MRIs and other diagnostic tools were invented. What has changed is the number of patients being diagnosed.”

The problem, argues Sinfield, is that treating “perfectly normal, degenerative changes in our spine as abnormal and painful conditions” makes us anxious and fearful.

In turn, we treat our backs as fragile, delicate structures prone to damage and “require endless instructions on how to sit, stand, bend, work and lift”.

“People also often misdiagnose themselves, or accept a mistaken diagnosis that attributes their back pain to an injury that occurred long ago that suddenly flares up again,” he adds.

As a result of all this, we become anxious about our backs, says Sinfield. And that anxiety is creating what he calls Tension Related Pain (TRP). This is where a slow accumulation of anxiety and stress over many months, even years, can cause the arrangement of muscles, nerves, tendons and ligaments to tighten and change - restricting blood and oxygen supply.

“Muscles deprived of oxygen can build up deposits of lactic acid, triggering pain, spasm, tingling or numbness,” he says, adding that this pain can easily be confused with the pain that caused the back problem in the first place.

All this prevents patients from recognising that pain is harmless muscle tension which, he says, can be dissipated through exercise (to stretch and build muscle, boosting blood and oxygen flow), relaxation and knowledge. Knowledge means learning to stop worrying about your pain, and thinking about the impact of emotions on your health.

Unfortunately, he says, “as a result of the powerful and widespread misconception that backs are inherently fragile, most people will reject a diagnosis of TRP. They refuse to believe their pain is not only from a physical cause and they fear a TRP diagnosis somehow reveals them as being emotionally weak.”

These views about the origins of back pain are controversial. But many experts agree that tension can exacerbate long-term pain, even if their explanation for why this happens differs from the one Sinfield proposes.

As Martin Knight, a consultant spine surgeon and medical director of The Spinal Foundation, says: “Increased stress increases tension in the muscles and may cause compression of the disc height or increased protrusion of the discs, which may aggravate pain.”

Other experts argue the link is with nerves, which become “oversensitive” in chronic pain. “In these cases, even the smallest trigger can cause a flare-up or exacerbate pain,” says Dr Rahul Seewal, a consultant in anaesthesia and pain medicine at London’s Chelsea & Westminster Hospital.

In these cases, a pain specialist may prescribe anti-neuropathic drugs - such as gabapentin or amitriptyline - to reduce sensitivity of the nervous system, and some patients may be referred to a psychiatrist to teach them relaxation techniques, such as an increasingly popular form of meditation called “mindfulness”.

But while they might not accept Sinfield’s argument about the emotional roots of pain, experts do accept modern scanning techniques have their failings.

“Pain is very subjective,” says Dr Seewal. “And we do take the patients’ word and absolutely believe the extent to which they are suffering, but scans often show degrees of damage that do not necessarily correlate to the extent of their symptoms at all.”

Scans can have a negative psychological impact on a chronic pain patient, says Philip Conaghan, professor of musculo-skeletal medicine at the University of Leeds and spokesman for Arthritis Research UK.

“We know if you scan and X-ray perfectly healthy people you will see abnormalities,” he says. “Most of us have some degree of wear and tear, and bulging discs, but no pain symptoms.”

However, he says it would be wrong to say pain comes from the psychological impact alone. “Even the smallest changes in spinal pathology can make very big differences in some people’s pain,” he says.

STEPS TO BEAT YOUR ACHY BACK

Nick Sinfield believes anxiety and fear not only lie at the root of chronic back pain, but also impede our recovery from it. For this reason, it’s important to think about pain not just as a physical problem.

Here are his practical steps for beating the problem:

Do you feel anxious?

Ask yourself if your pain makes you anxious. Do you avoid certain activities, positions or exercises in case they hurt?

If you associate certain activities, such as sport, with pain, you can create ‘pain patterns’ that can bring on pain through anxiety and stress.

Are you a perfectionist or competitive? This could mean you put more pressure on yourself and hold more tension in your body.

Every time you feel a twinge of pain, ask yourself whether it might have an emotional root. Try not to worry, and try to ignore the pain.

Try to adopt a positive, hopeful attitude. Feel confident about moving naturally and freely. Get up, move around and be active. This will stimulate blood flow and oxygen to areas of pain.

Muscle sense

Tackle muscle imbalance, which is one of the major causes of back pain. The less we stretch a muscle, the more contracted that muscle becomes (remember the last time you could touch your toes?).

Meanwhile, other muscles overstretch to compensate and become vulnerable to tearing and damage. Our sedentary lifestyle leads to poor posture and muscle imbalance.

As does favouring your right or left side. If you must lead a sedentary lifestyle, sit with a square, straight-on posture, elbows by your sides, neck long and shoulder blades drawn into your spine. Get up once an hour to walk around, and do stretches.

If you always wear a handbag on one side, switch sides frequently - or, even better, use a rucksack.

Don’t slump

Develop postural awareness. Check your posture while sitting and standing in front of a mirror (or ask a friend to check you) and correct any muscle imbalances.

If you tend to slump in your chair, this generally means your lower back is overstretched. As a result, your muscles and joints compensate, causing imbalances throughout the spine and your shoulders to collapse inward, creating tension and pain.

Imagine there is a string attached to the crown of your head and it’s being pulled up tautly. If you sit with your legs crossed to a particular side, it can cause your lower back to curve sideways. So switch sides.

Get stretching

Start regular daily gentle stretching exercises (if you are concerned about this, consult your GP first).

For your lower back, lie on your back on the floor with your knees bent. Slowly bend one knee to your chest, grasping it behind the knee. Hold for 20 to 30 seconds, and repeat three times, alternating legs.

When this is easy, progress to straightening the lifted leg, bringing the foot towards you. Finish by stretching your arms out to the sides, keeping your knees bent and together. Let your legs to roll to one side, hold and return. Repeat eight to ten times, changing sides. Only stretch as far as is comfortable.

Try Pilates

Consider taking Pilates classes - although tell the instructor about your back problems. - Daily Mail

* Now I Can Bend My Back! The Essential Self-help Guide To Back And Neck Pain by Nick Sinfield

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